Avir at New Braunfels

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 8 Residents (Resident #2) who were reviewed for homelike environment. The facility failed to ensure Resident #2's shower remodeling project was completed and the floor in the resident room was leveled and safe to walk across. This deficient practice could place residents at risk of unsafe living conditions and avoidable accidents. The findings were:Review of Resident #2's face sheet, dated 11/24/25, revealed she was admitted to the facility on [DATE] with diagnoses including unspecified Dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), lack of coordination, weakness, pain in right hip and difficulty in walking. Review of Resident #2's quarterly MDS, dated [DATE], revealed her BIMS score was 15 of 15 reflecting she was alert and oriented without cognitive impairment. Resident #2 was independent for most ADLs and she did not have a fall history. Review of Resident #2's Care Plan, dated 9/25/25, revealed Resident #2 was at risk for falls due to: mild cognitive decline, occasional pain to right hip. Tendency to ambulate without walker, frequently wears flip flops. Approaches included If resident is observed without walker, retrieve it for her and encourage use. Assure walker is within reach at all times as able. Review of the incident/accident log from August 2025 to November 2025 revealed Resident #2 had not had any falls. Observation on 11/20/25 at 5:09 PM in Resident #2's room revealed the shower stall in the restroom was sealed off with plastic. Some of the plastic was coming off. Observation revealed the drywall, and tile had been completely removed. It appeared like the shower was in the process of being remodeled. In the resident room revealed a large area, approximately 2 x 2-foot area, in the middle of the floor that was sunk in. The surface was unleveled and had a lip on one side. There were also brown stains on the linoleum floor under the vanity. The room and restroom smelled like mildew. Observation and interview on 11/21/25 at 3:20 PM with the MS in Resident #2's room revealed the shower room was sealed off with plastic, the floor was uneven in the middle of the resident room and there was a brown stain on the linoleum floor underneath the vanity. The MS stated the facility hired a contractor to remodel 7 resident showers including Resident #2's shower. He stated the contractor backed out and stated he wanted to re-negotiate for more money because he noted additional plumbing problems once he removed the drywall and tile. The MS stated the job came to a halt and in the meantime a new company bought out the facility. The MS stated progress had come to a standstill for about 2 months and the ADM had not asked him to call other contractors to complete the job. The MS stated he had not noticed the uneven surface in the middle of the room and thought the floor had probably been opened to get to the plumbing. He Identified the uneven surface as a trip hazard for Resident #2. He stated the building itself was old and needed a lot of repairs and stated the linoleum was stained throughout the facility. Observation and interview on 11/24/25 at 11:45 AM with Resident #2 revealed she was lying in bed. Resident #2 stated her shower had been under construction for 2 months and 2 weeks. She stated she did not like it but commented, it is what it is, she could not do anything about it. Resident #2 stated I'd rather have my own shower but stated she used the main shower room next door to her room. Resident #2 stated the MS told her they would repair the uneven surface in the middle of the room that was sunk in. She stated she did not have any problems walking over it with her rolling walker and had never had any falls. She stated the stain under the vanity did not bother her. Interview on 11/24/25 at 5:00 PM with the ADM revealed the facility hired a contractor to remodel multiple showers including Resident #2's shower right before the facility was bought out. He stated the contractor decided he wanted to negotiate for more money because it was more work than he realized. The ADM stated the company who bought out the facility was legally pursuing the contractor but stated in the meantime the remodeling project had been at a standstill for a couple of months. The ADM stated they secured/locked all restrooms that were under construction except for Resident #2's restroom because she was adamant she wanted access to the toilet. The ADM stated he understood the restroom was not in homelike condition and Resident #2 should not have to wait 2 months to have access to the shower. He stated he understood it was an inconvenience and at this time he was waiting for the new company to give them the go ahead to secure another contractor. Review of the facility's policy, Resident Rights, revised February 2021, read in relevant part Employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. Review of the facility's policy Maintenance Services, revised December 2009, read in relevant part Maintenance services shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance in federal, state and local laws, regulations and guidelines. b. maintaining the building in good repair and free from hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care 1 of 2 residents (Resident #1) reviewed for PASARR services. The nursing facility failed to submit a completed (NFSS) application to ensure Resident #1 received a specialized motorized wheelchair based on her rehabilitation assessment. This deficient practice could place residents at risk for not receiving specialized equipment and result in the decline in their physical condition. The findings were: Review of Resident #1's face sheet, dated 11/24/25, revealed she was admitted to the facility on [DATE] with diagnoses including severe intellectual disabilities, unspecified lack of coordination, muscle weakness (generalized), other specified disorders of muscles and unspecified Dementia (a general term for declining mental abilities, like memory, thinking, and reasoning, severe enough to disrupt daily life). Review of Resident #1's quarterly MDS assessment, dated 8/30/25, revealed her BIMS score was 0 out of 15 reflecting severe cognitive impairment. Resident #1 was dependent on staff for most ADLs and she used a manual wheelchair for mobility. Review of Resident #1's Care Plan, edited on 11/12/25, revealed focused area of psychosocial well-being with start date of 1/10/24, revealed Resident #1 was identified as PASRR positive related to severe intellectual disabilities and was receiving habilitation coordination and independent living skills training. The NF was unable to submit NFSS forms for habilitation PT/OT/ST or request a CMWC. The approaches were to coordinate care and services with [name of organization]. Review of PASARR Comprehensive Service Plan Form, dated 11/12/25, revealed a PASARR NFSS was completed and Resident #1 was assessed and measured for the use of a CMWC by the DOR, initial date 1/1/25. The verbiage read Patient will require a tilt in space wheelchair with custom back and cushion to support posture. Patient will use her CMWC to improve her out of bed mobility, to participate in her ADL's like dining, recreation activities, mobility within using while maintaining safe sitting posture. [NAME] approved for Medicaid will be available upon certification by the Nursing Facility. The application was denied because they required a hospice plan of care signed by the physician which was not provided by the hospice provider. Telephone interview on 11/18/25 at 1:46 PM with PASARR representative revealed Resident #1 had not received Medicaid services and a CMWC because of the following: The NF was notified and instructed to submit a NFSS Request by a specific deadline but failed to do so. The NFSS Request submittal by the NF was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for the resident. The PASARR representative stated she sent the ADM and the DON an email during September 2025 to remind them they needed to submit the NFSS application because they were out of compliance. Observation and attempted interview on 11/19/25 at 12:15 PM with Resident #1 revealed she was sitting in a manual high back wheelchair at one of the tables in the dining room. Resident #1 did not engage in conversation, did not make eye contact and did not speak. Resident #1 was not interviewable. Further observation revealed Resident #1 was leaning forward in the wheelchair and over the table. Interview on 11/19/25 at 12:30 PM with the DOR revealed Resident #1 was PASARR positive and was also receiving hospice services. He stated during an IDT meeting on 1/1/25 with PASARR he recommended Resident #1 would benefit from a specialized wheelchair that had the capability to tilt in space which would help Resident #1 with positioning in the wheelchair to keep her from leaning forward. He stated he assessed Resident #1 and was responsible for submitting the NFSS application because he was recommending a CMWC. He stated he submitted the application, but it was denied because hospice had not provided him with Resident #1's current plan of care signed by the hospice physician. The DOR stated he talked with several hospice staff including the nurse manager for months requesting a signed plan of care to no avail. The DOR stated he had brought up the issue during morning meetings and stated he explained why the NFSS application was denied. He stated he was not able to order a CMWC for Resident #1. He stated he spoke to a company resource person who recommended that he keep asking hospice to provide the resident's plan of care. The DOR stated he never thought about discussing the issue directly with the ADM, who was his immediate supervisor, in an attempt to have him assist with resolving the matter. Interview on 11/19/25 at 1:00 PM with the DOR and hospice DON revealed the DON stated she had not provided a current plan of care for Resident #1 because they had been waiting for the physician's signature. The Hospice DON stated this had been on-going since at least June 2025. Interview with the DOR revealed it had actually been on-going for about 1 year as of 1/1/25. Interview on 11/20/25 at 8:30 PM with the ADM revealed he did not remember the DOR bringing up the problem he was having in obtaining a physician signed plan of care from hospice for Resident #1. He stated he also did not remember the PASARR representative emailing him about it but stated he called hospice today and they came right over and provided a signed plan of care. The ADM stated in talking with the DOR he realized the issue had been going on for about a year. He stated it should not have taken this long to complete the NFSS and it was Resident #1 who ultimately was at a disadvantage because she was not able to utilize the CMWC to assist her with positioning. Review of the facility's policy PASARR, dated 7/29/25 read in relevant part The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs. 4. Care Planning: Based on the findings of the Level II evaluation, a care plan is developed that may include specialized services or living arrangements tailored to the individual's needs. Collaboration with mental health professionals and Local Authority to ensure continuity of care.

Based on observation, interview and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments, under proper temperature control and labeled in accordance with currently accepted professional principles for 2 (medication cart #1 and medication cart #3) of 4 medication carts reviewed for medication storage. The facility failed to ensure that MC #1 did not have loose unknown NARC medications in the drawer. The facility failed to ensure that MC #1 and MC #3 did not have medications that were undated in the drawer. This failure could put residents at risk for missed medications and/or receiving unidentified medications. An observation and audit conducted on 08/27/2025 at 12:50 PM revealed Med Cart #1 which was stationed on the 50 hall, contained loose and unlabeled medications. The observation revealed half of a white circle tablet loose in the locked narcotics bin. It was identified by INV and LVN G that the medication was not a current medication in the narcotics bin. Med Cart #1 contained undated over the counter medication bottle which should be labeled with a date when opened. An interview was conducted on 08/27/2025 at 1:15PM with LVN G who reported being employed at the facility for 1 year. LVN G stated that she had received training on labeling and dating medications. LVN G stated that they were expected to label the bottle of OTC medications when they opened them. LVN G stated undated and opened medication could negatively affect the residents by the medication not being as effective if it was expired. LVN G stated that loose unaccounted medications could negatively affect a resident by not having the medication available to the resident. LVN G stated the loose narcotic medication could negatively affect a resident for pharmacy delivery. LVN G stated pharmacy orders could be delayed. An observation and audit conducted on 08/28/2025 at 10:05AM revealed Med Cart #3 which was stationed in the men's locked unit, contained undated/unlabeled Vitamin D medications. The medication should have been labeled with a date of when the medication was first opened. An interview was conducted on 08/28/2025 at 10:15AM with LVN F who reported being employed at the facility for 2 months. LVN F stated that they had received training on labeling and dating medications. LVN F stated that the training included ensuring that they checked expiration dates, and whenever a medication was opened, they labeled and dated it. LVN F reported that if medications were not labeled it could negatively affect a resident by the medications not being effective. LVN F stated that a negative effect of loose narcotic medications would be the resident potentially had not received the medication. An interview was conducted on 08/28/2025 at 4:38PM with the ADM who reported working at the facility for 2.5 months. The ADM stated the ADON and DON provided training for labeling/dating medication. The ADM stated that the policy for labeling/dating medications was everything that came from the pharmacy should be labeled already. OTC meds should be dated and labeled when they opened them. The ADM stated the policy for loose medications was that staff should not use them and throw them away. The ADM stated that the med carts were audited by nursing management monthly but there were no formal records to provide. The ADM stated it could negatively affect a resident to have undated meds in the med cart by receiving expired medications. The ADM additionally added it could negatively affect a resident to have loose medications in the NARC drawer by not knowing what the medication is and that it could be contaminated. The ADM stated this could indicate a possibility that a resident did not receive that medication. An interview was conducted on 08/028/2025 at 4:50PM with the DON who reported working at the facility for 3 weeks. The DON stated that the policy for labeling/dating medications was that staff need to have an open date of when they had opened the medications for OTC meds. The DON stated the policy for loose medications was that there shouldn't be any loose pills. The DON stated that pharmacy will audit the med carts once a month but there is no official document to provide. The DON stated it negatively affected a resident to have undated/expired meds in the med cart by the medication could lose their effectiveness. The DON stated it negatively affect a resident to have loose medications in the NARC drawer by the potential that the resident did not receive that particular medication. The DON confirmed that this could potentially be a med error. Record review of a document provided by the facility titled Medication Storage undated, revealed that medications should be labeled, dated and stored in proper areas according to the label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 47 residents (Resident #2) whose care plan was reviewed, in that:<BR/>The facility failed to ensure Resident #2's care plan included insulin<BR/>This deficient practice could place residents at risk of receiving the incorrect care and cause health complications with subsequent illness.<BR/>The findings were: <BR/>Record review of Resident #2's face sheet, dated 04/14/2023, revealed the resident was re-admitted on [DATE] with diagnoses that included: vascular dementia, type 2 diabetes, anxiety and psychotic disturbance. <BR/>Record review of Resident #2's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 08, which indicated moderate cognitive impairment. Further review for Active Diagnoses revealed I2900. Diabetes Mellitus (DM) . checked as a current diagnoses. <BR/>Record review of Resident #2's continuity of care document, dated 04/14/2023, revealed a medication with a start date of 01/30/2023 and a last administered date of 04/12/2023 at 08:21 pm and specifically read Levemir U-100Insulin (insulin detemir u-100)100 unit/mL solution; Once An Evening; 10 units, subcutaneous, Once An Evening, Administer 10 units subcutaneously in the evening for DM 2 HOLD IF BSIS &lt; 100; E11.9 : Type 2 diabetes mellitus without complications.<BR/>Record review of Resident #2's care plan, undated, revealed insulin nor diabetes was not listed as a problem area. <BR/>During an interview and record review on 05/13/2021 at 2:30 p.m., the Regional DON stated insulin was supposed to be on Resident #2's care plan. He stated it was supposed to be care planned when resident was diagnosed (with diabetes), which possibly since this resident was admitted . The Regional DON stated care plans began with the MDS or CCN and then the DON overseas that position. He stated it must have been overlooked. The Regional DON stated the potential harm to resident was a new nurse would not know this resident needed insulin or was diabetic, by just looking at the care plan. He further stated that if the order is in the system, the resident was supposed to be receiving the insulin regardless. <BR/>During an interview on 05/13/2023 at 4:38 p.m., the Administrator stated insulin was supposed to be added to the care plan at on-site of the problem. She further stated anyone in the nursing department has the authority to add items from the orders to the care plans. The Administrator stated that care plans are reviewed during their review date. The Ato the care plan. She then stated the IDT during the team conference ensured that everything was in place starting Administrator did not believe there was a potential harm to resident, being there was an order for the insulin and Resident #2 was receiving the service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #1) reviewed for incontinence care. When CNA-A was providing incontinent and bladder indwelling catheter care to Resident #1 on 07/10/2025, CNA-A did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region), left groin area, right groin area, and scrotum. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #1's face sheet, dated 07/09/2025, revealed Resident #1 was [AGE] years old male, admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnosis of major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), urinary tract infection (infection to the bladder), dysuria (discomfort, pain, or burning when urinating), neuromuscular dysfunction of bladder (the nerve that carry messages back and forth between the bladder and the spinal cord and brain do not work the way they should), and paraplegia (inability to voluntarily move the lower parts of the body). Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident's BIMS was 15 out of 15, which indicated the resident's cognition was intact, and the resident needed to have substantial/maximal assistance (Helper does MORE THAN HALF the effort) to sit to stand and chair to bed transfer, and for toilet transfer, the resident did not attempted due to medical condition or safety concerns. Further record review of the MDS indicated Resident #1 had urinary indwelling catheter and was always bowel incontinent. Record review of Resident #1's comprehensive care plan, dated 03/10/2025, revealed the resident had the care plan regarding how to care for the resident's bladder, indwelling catheter, but there was no care plan regarding how to care for the resident's bowel incontinence. Observation on 07/10/2025 at 9:05 a.m. revealed CNA-A washed her hands with water, put on gloves and a gown, opened the old and dirty brief of Resident #1, then cleaned only the resident's penis with a circular motion. CNA-A did not clean the resident's suprapubic area, left groin area, right groin area, and scrotum. CNA-A cleaned Resident #1's indwelling catheter gently, then rolled the resident to the left side and cleaned the resident's rectal and buttock areas. Further observation revealed CNA-A changed her gloves after sanitizing her hands and put a new and clean brief under the resident, then closed the brief. Interview on 07/10/2025 at 9:17 a.m. CNA-A acknowledged she did not clean Resident #1's suprapubic area, left groin area, right groin area, and scrotum, then she cleaned only Resident #1's penis, indwelling catheter, and buttock areas. Further interview revealed CNA-A said she was very nervous, so she forgot to clean Resident #1's suprapubic area, left groin area, right groin area, and scrotum. CNA-A stated she should have cleaned those areas to prevent possible infection. Interview on 07/10/2025 at 3:45 p.m. the DON stated CNA-A should have cleaned Resident #1's suprapubic area, left groin area, right groin area, scrotum per the facility policy to prevent possible infection. Record review of the facility policy, titled Perineal Care, revised 12/2020, revealed 01/20/2023, revealed B. For a male resident: . (6) Continue to clean the perineal area including the penis, scrotum, inner thighs. (12) Clean the rental area thoroughly, including the area under the scrotum, the anus, and the buttocks, change the cleansing wipe as needed.

Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for residents 1 of 1 secure unit reviewed for activities, in that: <BR/>The facility failed to ensure there were organized activities available to residents. <BR/>The failure placed residents at risk for a diminished quality of life, isolation, and lack of stimulation. <BR/>Findings included: <BR/>During observation of men's secure unit (MSU) on 3/4/2025 at 1:30 PM, the centrally located group activities board was observed to have a large print February 2025 calendar posted with red themed decorations. There were no additional postings to include activities for March on the activities board. On 3/5/2025 as observed at 1:30 PM, the group activities board contained new decorations in a green theme but did not have a calendar or notes of daily or monthly activities. The activities board remained the same during observation on 3/6/2025 at 09:05 AM. No calendars were observed in resident rooms. <BR/>Observation of MSU on 3/4/2025 during times of 4 scheduled events (10:00 AM morning melodies, 11:30 AM coffee and daily chronicle, 2:00 PM mardi gras art, 3:00 PM coffee and chat) did not reveal any formal group activity. During these times, residents were observed sitting quietly in the dining area watching television or resting in their rooms watching television or sleeping.The nursing staff was not aware of any planned activities for the day during brief interview on initial observation of unit on 3/4/2025 at approximately 10:00 AM. <BR/>Observation of MSU on 3/5/2025 during time of scheduled event (10:00 morning melodies) did not reveal scheduled activity occurrence. <BR/>An interview was conducted with CNA B on 3/4/2025 at 11:22 AM. CNA B was asked what helped to prevent residents from having altercations with each other. She answered that the residents played bingo on Monday/Wednesday/Friday and they really liked that activity. She explained that when the residents were busy, it kept them from fighting and getting upset. CNA B was asked if there were any other group activities other than bingo, and she stated that there were no other activities done for the residents, only bingo. CNA B also stated the Activities Director was supposed to come to the unit and do more, but they did not. She explained there was usually a calendar posted but that was not followed. <BR/>An interview was conducted with LVN A on 3/4/2025 at 1:38 PM. LVN A was asked what was being implemented to reduce aggression within MSU, and she stated behaviors were reduced when the residents were kept busy and occupied. LVN A reported that organized activities were rarely hosted within the unit, and the residents sometimes have bingo but that it was inconsistent. She also explained the residents expected bingo on Monday/Wednesday/Friday per the usual routine and would prepare the bingo supplies in anticipation of the event and express disappointment when the event did not occur. LVN A was asked if individual, one-on-one activities ever occur within the residents' rooms, and she said no. LVN A was asked if the residents were ever taken out of the unit to participate in facility-wide group activities, and she responded that the residents would leave MSU when occupational therapy or physical therapy come to get the resident for individual therapy sessions but that nobody ever came to get them for activities. LVN A stated she had voiced her concerns to AD C and ADON D but there were no changes after those conversations. <BR/>During a subsequent interview with LVN A on 3/5/2025 at 09:50 AM, she was asked why she felt like the residents become aggressive with each other and had physical altercations, and she answered that it was because the residents were bored and under stimulated. She continued that they have nothing to do most of the time so they fight with each other. <BR/>ADON D was interviewed on 3/6/2025 at 09:50 AM. ADON D was asked about activities and engagement on MSU. ADON D reported that AD C participates in care plan meetings all day on Tuesday and all day on Wednesday, so his schedule limited the number of activities that he could do on those days. ADON D stated she had absolutely been made aware of staff concerns regarding lack of activities and attributed it to AD C's schedule because he can't be in two places at one time. ADON D was then asked how the activities were performed when AD C was unable to attend, and she stated some of the staff would find things for the residents to do, but not all the staff members would do this. ADON D was asked if the residents on MSU ever participated in facility group activities, and she explained many of the residents could not tolerate the stimulation of large-scale activities, but a few would be picked to participate and integrate with mixed success. <BR/>AD C was interviewed on 3/6/2025 at 1:05 PM. AD C explained he attended just about all of the care plan meetings because the other activities director was new. AD C stated group participation during activities in MSU was pretty decent and the residents required a lot of encouragement for participation. In response to question regarding notification to residents about activities, AD C stated the monthly calendar was often posted on the main activities board around the 5th or 6th of the month because the printing company took several days to print the large print calendar. AD C stated that something was planned every day. AD C was asked how the residents were made aware of activities in that time frame, before the calendar was available. AD C answered that he would go door to door or leave notes. He also said the residents knew that bingo occurred on Monday/Wednesday/Friday and did not usually need reminders for that event. AD C was asked if he did any in-room activities and what types of activities he hosted in an individual environment, for residents who were unable or unwilling to attend group activities. AD C answered that he typically did and that he had session where we talk about current events. He also reported that he would engage in conversations when he was inviting residents to group activities. In response to a question about hosting activities when he was unavailable, AD C explained he would ask the other activities director if she could bring some of the MSU residents to participate in her scheduled events. He also stated he had asked a few of the CNAs to host events in MSU but that it was hard to get them onboard to help you out . I could use a little more support from them . it's not an issue on the women's unit, they'll usually jump in and call bingo or whatever, but not there. AD C said he had brought up his concerns with leadership at the facility and was told that they would see what they could do. AD C indicated residents who did not receive activities could experience sadness, depression, and isolation. <BR/>Record review of group activity attendance and individual activities for 90 day period were requested for review from AD C on 3/6/2025 at 07:48 AM. AD C stated he did not maintain records detailing attendance for group activities or records for individual activities performed. AD C explained his documentation consists of quarterly progress notes written in the EMR during care planning, with no other routine documentation. <BR/>Record review of activity progress notes from February 2024 through March 2025 for Residents #1-6 revealed documentation consistent with AD C's description except that all 6 residents progress notes contained one additional note detailing daily activity for a single date concurrent with on-site investigation time frame. <BR/>Calendars of activities for January-March 2025 were reviewed on 3/7/2025 to confirm that daily activities were planned for MSU residents. <BR/>Facility policy titled Activity Programs revised 2021, states at least two group activities per day are offered on Saturday, Sunday, and holidays and at least four group activities are offered per day Monday through Friday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions including cigarettes for two (Resident #13 and Resident #37) of four residents reviewed for the right to use personal possessions.The facility failed to return the residents personal cigarettes for Resident #13 and Resident #37 on 08/13/2025.This failure could place residents at risk of having their rights infringed upon and could lead to the residents not being able to use their personal cigarettes when resident were off facility grounds.Record review of Resident #13's face sheet, dated 08/27/2025, reflected he was a [AGE] year-old male, who admitted to the facility on [DATE], with diagnoses including Nicotine Dependence (regularly smokes cigarettes), cognitive communication deficit (difficulties in communication stemming from impairments in the cognitive processes), generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about various aspects of life).Record review of Resident #13's quarterly MDS assessment dated [DATE] indicated his BIMS score was a 15, indicating he had intact cognition. Resident #13's functional abilities assessment stated he was coded as a 6 (Independent - Resident completes the activity by themself with no assistance from a helper).Record review of Resident #13's Smoking Evaluation completed on 08/26/2025 indicated Resident #13 had demonstrated ability to safely smoke.Record review of Resident #13's care plan dated 08/13/2025 indicated Resident #13 was a smoker and that Resident #13 was to be a compliant smoker by following the schedule the next 90 days. Resident #13's care plan regarding Psychosocial Well-Being included to observe for signs of adjustment difficulties such as inability to pursue interests or activities, sad or anxious mood, behavioral symptoms.In an interview on 08/26/2025 at 1:00 PM Resident #13 stated that staff were not treating him with dignity and respect, and they were taking away his rights and freedom by not allowing him to have possession of his personal cigarettes when he left the facility at various times. He also stated that the ADM said he would not allow the residents to take their cigarettes off the property unless they were to sign out for good (indicating at discharge). Resident #13 stated that smoking off the property made him feel normal, like he had freedom to smoke and watch people go by and he stated, I will gladly return the items when I come back into the facility.Record review of Resident #37's face sheet dated 08/28/2025, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnosis of congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), hypertension (high blood pressure), mood disturbance (a mental health condition that primarily affects your emotional state and uncontrollable worry about various aspects of life).Record Review of Resident #37's MDS assessment dated [DATE] indicated his BIMS score of 15 indicating resident had intact cognition. Resident #37 ADL assessment stated Resident required Supervision - oversight, encouragement or cueing. Record review of Resident #37's Smoking Evaluation completed on 08/26/2025 indicated Resident #37 demonstrated ability to safely smoke.Record Review of Resident # 37's Care Plan indicated the resident prefers to spend most of her time with their friend outdoors smoking. Resident asks other residents and staff to give her cigarettes and/or money for cigarettes. Resident is to be reminded of smoking policy routinely and PRN.In an interview on 08/28/2025 at 4:40 PM, Resident # 37 stated she was denied her cigarettes when she was signing out of the facility on 08/13/2025. She stated she was with Resident #13 and they asked the hall nurse for their cigarettes because they were going to sign out of the facility for a few hours and they wanted to smoke while they were gone. She stated she did not remember the name of the hall nurse. Resident # 37 stated the nurse said no to her and they then went to the ADM and asked him for their cigarettes to which the ADM said they were not supposed to take their cigarettes with them.In an observation on 08/28/2025 at 1:48 PM of an interaction between Resident #13 and Resident #37 and the DM at the facility's designated smoking site. The DM was supervising 5 resident smokers at the facility's designated smoking area. Residents # 13 and # 37 each demonstrated ability to smoke independently.In an interview on 08/28/2025 at 1:48 an interview with the DM was conducted. The DM stated, she and other staff alternate the smoking monitoring assignments. The DM stated, I told [Resident # 13] and [Resident # 37] that they were only allow 2 cigarettes per smoking session. During the interview the DM stated, Per the Smoking Policy [Resident # 13] and [Resident # 37] and all other residents who smoke are not able to bring their personal cigarettes off the facility grounds. The DM stated, We had smoking policy training on Monday, 08/25/2025 but I forget what they talked about.In an interview with ADON B on 08/28/2025 at 11:22 AM, ADON B stated, I was told by [LVN B] that (Resident # 13 and Resident # 37) requested they be given their personal cigarettes to take off the facility grounds. ADON B stated, I told residents including (Resident # 13 I cannot give the cigarettes to any residents upon signing out of the facility due to the smoking policy. She stated, (Resident # 13) told me that the cigarettes the facility was holding for him were his cigarettes, and he should be able to take them with him when he goes out of the facility. ADON B stated, I said to (Resident # 13 and resident # 37), I'm sorry, but we cannot do that. ADON B stated, I was trained in resident rights; we were all in-serviced was last week regarding resident rights. ADON B gave examples of residents' rights such as residents had the right to make choices, to be provided good care, to make decisions about themselves and to have personal property. When ADON B was asked if a resident's cigarettes were considered personal property, ADON B responded, Yes. ADON B stated, If a resident signs out of the facility they are not allowed to take cigarettes with them. In an interview on 08/29/2025 at 10:24 AM with the DON, she stated that an in-service regarding resident rights was conducted both in person and online and she stated it was mandatory for all staff. The DON stated that smoking assessments and observations of residents were done quarterly, and that smoking assessments and resident trainings were mandatory upon admission if the facility knew they were a smoker. She stated that if they found out later that they smoked, the staff would assess them and train them at that time. The DON stated that residents had a right to possess personal property except for their smoking items because their smoking items were locked up and only given to residents according to the facility smoking policy. She stated that residents who smoked were allowed to smoke with supervision while on the property in designated locations and they were not handed their smoking items other than per the policy and residents were not given their smoking items if they checked themselves out of the facility. The DON stated that they would not want the residents to get burned and that the staff monitored the residents in the smoking areas for their safety. The DON stated that if a resident's care plan indicated they could sign themselves out, go off property, they were not allowed to take possession of their personal cigarettes.In an interview on 08/29/2025 at 11:11 AM, the ADM stated that smoking items were considered personal property. The ADM stated, Residents were required to follow the facility policy regarding smoking locations, posted smoking times and smoking items such as cigarettes and lighters. He stated that he told residents they may take possession of their personal smoking items only when they discharge from the facility. He stated that if a resident left the facility grounds, he or she was 100% responsible for themselves. The ADM stated that the residents had a right to smoke off property but the faciality did not have to give the residents their cigarettes unless they were being discharged from the facility.Record review of the facility's policy titled, admission Smoking Policy reflected, Residents are not permitted to have tobacco products or lighting devices in their rooms or possession at any time except designated smoking times while supervised by center staff member. All tobacco products and lighter devices are to be labeled with resident name and are to be kept at nurses' station in a locked place. Residents are prohibited from sharing or loaning tobacco products to others. Residents who smoke will be further assessed, using the [company's] Safe Smoking Evaluation, to determine the level of supervision required for smoking, or if resident is safe to smoke at all.Review of the facility's policy titled; Resident Rights reflected: The resident has a right to be treated with respect and dignity, including: The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess a resident using the quarterly review (every 3 months) instrument specified by the State and approved by CMS for 1 of (Resident #92) of 5 residents reviewed for quarterly MDS assessments. The facility failed to complete a quarterly MDS assessment for Resident #92 every 3 months (04/19/2025 through 08/22/2025). This failure could place residents at risk of not having accurate assessments completed timely which could result in the residents not receiving necessary care or receiving inappropriate care for their conditions.Findings included: Record review of Resident #92's face sheet dated 08/28/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Alzheimer's Disease (progressive brain disease that causes memory loss and other cognitive impairments), Major Depressive Disorder (mental disorder characterized by a persistent low mood and loss of interest or pleasure in activities), Psychotic Symptoms (collection of symptoms that indicate a disconnection from reality), Cognitive Communication Deficit (problem with communication due to a disruption in cognitive processes), and Muscle Weakness (muscles cannot work with the expected amount of force). Record review of Resident #92's comprehensive care plan dated 06/18/2025 reflected Resident #92 was dependent on staff and was to be offered assistance as needed and verbal encouragement as needed with mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs while encouraging independence. The goals were for Resident #92 to maintain current level of function with assistance in his daily living care needs. Record review of Resident #92's quarterly MDS assessment dated [DATE] reflected a BIMS Score of 3, which indicated several cognitive impairments. Further record review of Resident #92's MDS assessments reflected Resident #92 had a past due open incomplete quarterly assessment dated [DATE]. In an interview on 08/28/2025 at 1:05 PM with the DON, she stated that the facility didn't have an MDS Coordinator in which there was a covering Regional MDS Coordinator conducting MDS assessments for residents. The DON stated that Resident #92's MDS was missed. The MDS was last completed on 04/19/2025 in which the MDS was processed on 08/22/2025, 125 days in total, and 5 days late out of the quarterly assessment timeframe which is 120 days for review. In an interview on 08/28/2025 at with RMDS Coordinator, he stated he had been RMDS trained in which he had been conducting MDSs for residents since 2019. The RMDS Coordinator stated he had not received any MDS in-service or training by this facility. The RMDS Coordinator stated he was hired by a senior living company overseeing the facility in a regional role. The RMDS Coordinator stated he was hired based on his knowledge and previous training experience. The RMDS Coordinator stated there wasn't an MDS coordinator as of August 8, 2025 when he filled in to cover as the RMDS Coordinator taking over MDS duties for the facility. The RMDS Coordinator stated the process for MDS was to complete an initial admission within 14 days, complete MDS assessments quarterly every 3 months per regulations, and complete annual MDS assessments. The RMDS Coordinator stated under certain circumstances, if there was a change of condition when needed, an MDS assessment was completed. The RMDS Coordinator stated Resident #92's MDS was missed due to him not checking back dates for MDS completion dates and it was going to be late regardless if he checked. The RMDS Coordinator stated his plan was since Resident #92 MDS was late, he was going to change it to an annual MDS assessment. The RMDS Coordinator stated Resident #92 wasn't assessed in a timely manner and he honestly didn't notice it until he did an audit sometime last week when at the facility. The RMDS Coordinator stated he wasn't advised by anyone that Resident #92's MDS was late and it's his responsibility to monitor MDSs to meet timeframes. The RMDS Coordinator stated he owns the fact that Resident #92's MDS was missed. The RMDS Coordinator stated his expectations for residents MDS is to make sure they are all in compliance with regulations and completed in a timely manner. The RMDS Coordinator stated his expectations also included following the MDS assessment cycle until the resident discharged . The RMDS Coordinator stated the resident's quality of life such as, Resident #92, could be affected if MDSs were not completed mainly in an indirectly affect towards a resident as the facility would continue providing the services to the resident and not have an updated assessment for the residents current person-centered needs. In an interview on 08/28/2025 at 3:21 PM with the DON, she stated she learned her MDS training prior to being hired within the facility as she had been the DON for 3 weeks. The DON stated the MDS process is to complete an initial MDS assessment, complete a quarterly MDS assessment, complete an annual MDS assessment which is regulations. The DON stated she wasn't able to conduct the MDS assessment since that was the job of the MDS Coordinator or Regional MDS Coordinator that oversaw the facility. The DON stated there had not been any in-servicing and training by the facility. The DON stated since she was hired 3 weeks ago as the DON, there wasn't a MDS Coordinator onsite besides there being a Regional MDS Coordinator. The DON stated Resident #92 wasn't assessed in a timely manner and was missed by the Regional MDS Coordinator. The DON stated Resident #92's MDS should have been monitored by the Regional MDS Coordinator as it's the Regional MDS Coordinator's responsibility to complete initial, quarterly, and annual MDS assessments. The DON stated it's her expectations for residents' MDSs to be completed and entered in timely along with a calendar timeframe as to make sure all MDS assessments was completed during each recurring cycle. The DON stated residents could be negatively impacted or their quality of life could be affected if MDS assessments aren't completed such as, weight loss, wound care treatments, decline in ADL's, and all the resident's needs being provided to by the facility. In an interview on 08/28/2025 at 3:38 PM with the ADM, he stated that he had not been trained on MDS assessments since he was not a nurse. The ADM stated he checked to see if MDS assessments were completed or there was missing information. The ADM stated the RMDS Coordinator managed all the MDS aspects and monitored to make sure they were completed. The ADM stated he wasn't aware of any MDSs being past due for any residents. The ADM stated he did not oversee Resident #92's MDS assessment to have knowledge when it was due or that it was late. The ADM stated there had not been an MDS Coordinator since the beginning of August 2025, and that was when the RMDS Coordinator took over the role. The ADM stated the facility had hired a new MDS Coordinator to help fill the role and assist the RMDS Coordinator with working on residents MDS assessments. The ADM stated if an MDS was not finished, it put things on hold for additional staff to assist with the MDS tasks, and he did not see how it affected residents physically as it would cause issues with the company. The ADM stated Resident #92 was not assessed and was late if it had been over 125 days. The ADM stated the previous the MDS assessment for Resident #92 would continue and default, which the facility would not be able to provide Resident #92 updated treatment to meet the resident's needs. The ADM stated his expectations was that residents' MDS assessments to be completed correctly, timely, and be accurate for the residents. Record review of facility In-services reflected: the facility did not have MDS in-service trainings or education for January 2025 to August 2025. Record review of facility policy for MDS Completion dated 07/2025 reflected the following: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. OBRA Assessment refers to an assessment mandated by the Omnibus Budget Reconciliation Act of 1987, which specifies a Minimum Data Set of core elements for use in assessing nursing home residents. PPS Assessment refers to an assessment used in the skilled nursing facility prospective payment system to classify residents into categories for payment purposes. ARD, or Assessment Reference Date, refers to the specific endpoint in the MDS assessment process (last day of MDS observation period). Comprehensive Assessment refers to the completion of the MDS, Care Area Assessment (CAA) process, and development and/or review of the comprehensive care plan. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. Quarterly Assessment - completed using an ARD no >92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD). Annual Assessment - a comprehensive assessment completed using an ARD no, >366 days from the most recent prior comprehensive assessment and no >92 days from the most recent quarterly assessment (counting ARD to ARD).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 8 residents (Residents #1 and #2) reviewed for accidents hazards and supervision, in that:<BR/>1. On [DATE] at 8:54 a.m., Resident #1 was found outside the facility near a busy two way street near the facility. The facility did not investigate whether Resident #1 had received adequate supervision. Also, the facility did not have a mechanism in place for monitoring the front door to ensure resident supervision/monitoring resulting in Resident #1's elopement.<BR/>2. On [DATE] at 6:45 a.m., Resident #2 was found bleeding from the head from an unwitnessed fall in the Women's Secured Unit. Facility staff were not monitoring the resident's movements and were aware the resident was agitated. Facility's failure to provide adequate supervision resulted in the resident suffering a large subdural hematoma from a fall from a rolling stool in the dining room.<BR/>An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to establish a permanent alarm system for the monitoring of the front door. <BR/>The failure could place residents at risk of experiencing accidents, injuries, and/or death.<BR/>The findings included:<BR/>1. Record review of Resident#1's face sheet, dated [DATE] revealed, the resident was admitted on [DATE] with diagnoses that included: dementia, major depressive disorder, and anxiety. Resident was a male age [AGE]. The RP was listed as a family member.<BR/>Record review of Resident#1's quarterly MDS, dated [DATE], revealed: <BR/>o BIMS Score was 5 (0-5: severe cognitive impairment.) ADLs for transfer was supervision only. ROM listed no impairments.<BR/>Record review of Resident #1's Care Plan dated [DATE], revealed the goals and interventions included: placement in the secured unit due to wandering and/or exit seeking behaviors. An approach documented in the said CP was for Frequent staff rounding and redirection when wandering/exit seeking observed. <BR/>Record review of Resident#1's MAR (medication administration record), dated [DATE] revealed, Psychotropic medications included: Aricept 5 mg 1 tab daily (dementia) and Zoloft 25 mgs I tab daily (depression) and Depakote 125 mgs 1 tab twice per day (dementia). <BR/>Record review of Resident#1's Skin Assessments revealed : (dated [DATE]) revealed: skin intact. <BR/>Record review of Resident #1's Fall Risk Score (dated [DATE]) revealed, a rating of not at risk for elopement. <BR/>Record review of Resident#1's Physician' Orders, dated [DATE] , revealed no specific order for the close monitoring of the resident. <BR/>Record review of Resident #1's Nurse Notes revealed:<BR/> [DATE] at 8:59 a.m., authored by LVN A revealed: the LVN was notified the resident had left the Men's Secured Unit. LVN A and CNA B went outside the facility and saw Resident #1 walking down the street. A visiting family member offered LVN A car transportation to bring Resident #1 back to the facility. The MD and RP were notified of the elopement. LVN A conducted a full assessment of the resident and no injuries found. <BR/>[DATE] at 9:07 a.m. authored by LVN A revealed: Resident #1 put on 15 minute checks for elopement prevention.<BR/>Record review or staff statements date [DATE] revealed:<BR/>CNA B documented : staff became aware of resident missing between the hours of 8:00 am to 9:00 am. CNA B assisted LVN A in returning the resident back to the facility.<BR/>Housekeeping Aide C documented she was in the front room and saw resident leaving to the front door and notified HR Aide D [no time listed].<BR/>HR Aide D reflected: at 8:56 am ([DATE]) she spoke to Housekeeping Aide C and was informed the resident [Resident #1] left through the front door; and notified LVN A.<BR/>Record review of facility's internal investigation packet revealed:<BR/>5 day investigation report was completed and the finding was missing person confirmed. <BR/>In-service on the topics of abuse and neglect and elopement were initiated on [DATE].<BR/>72 hour monitoring sheet was present.<BR/>During a telephone interview on [DATE] at 9:45 AM, a message was left for return call to surveyor. Called returned at 10:00 AM. Housekeeping Aide C stated that she saw Resident #1 leaving the facility and did not follow him or maintain eye contact. Housekeeping Aide C stated she informed HR Aide D about Resident #1 leaving through the front door.<BR/>During an observation and interview on [DATE] at 9:00 a.m., Receptionist E stated in the month of February 2024 she was made receptionist for the front desk [day shift] with the duty to observe residents and visitor movements at the front door. Observation revealed that there was no bell or alarm on the front door that alerted staff when a person entered or left through the front door. Receptionist E stated the door was not monitored on weekends/nights or when she left the front desk. <BR/>During an observation and interview on [DATE] at 10:30 a.m., revealed during while the path Resident #1 took when he was found to be a missing person on [DATE] was walked, with the Administrator, the resident had walked outside the facility's boundary for about 100 feet before being found at a local charity store. There was a busy street with traffic in both directions in the path the resident took on [DATE], and the Administrator stated the resident did not cross the busy street but continued to walk on the sidewalks parallel to the nursing facility. The Administrator stated, fortunately a family member and the former MDS Nurse saw the resident walking down the sidewalk while driving in their respective cars and immediately notified the facility of the resident walking away from the facility. The Administrator stated the facility when notified of the missing person dispatched nursing staff to convince the resident to return to the facility; the resident returned and was placed back in the Men's Secured Unit. The Administrator stated the preventative measures put in place after the incident on [DATE] included: in-service training on abuse/ neglect and missing persons, signs of the doors on the secured units advising all staff and visitors to use the door and check for piggy-backing (residents following visitors or staff), change of door codes, and verification of the census.<BR/>Observation on [DATE] on [DATE] at 10:35 a.m. of Men's Secured Unit revealed there were two signs inside the unit which read: Stop .Please ask for assistance from staff when entering and exiting a secure unit .Please do not let unsupervised residents leave the secured unit unattended. The signs to the entrance of the Men's Secured Unit read: Please ask for assistance from staff when entering and exiting a secure unit. <BR/>During an observation and interview on [DATE] at 11:34 a.m., Resident #1 was in bed in the Men's Secured Unit, alert and oriented to person and place; cleaned and groomed. The resident did not reveal signs of injury, bruises or skin tears, and the resident was ambulatory. The resident stated: I did leave .but do not remember .not sure whether someone saw me leaving .I walked alone when the door opened .no one stopped me .I was going to my house .I did not want to be here .they found me and brought me back .I probably was gone for five minutes .I feel safe here .but I want to be in my house .I have not tried to escape again .if taken to my house I will stay in my house .the door is now locked in the [unit] and I cannot leave .I have not tried to leave again .there is no abuse .no neglect .I just want to be home . <BR/>During an interview with the Administrator and MDS Nurse G on [DATE] at 11:53 a.m., the Administrator and MDS Nurse G revealed the following timeline involving the missing person incident on [DATE]:<BR/>8:55 a.m.: from Nurse progress note authored by LVN A stated Resident #1 had completed eating breakfast and likely followed a visiting person outside the Men's Unit.<BR/>8:55 -8:56 a.m.: Housekeeping Aide C was sitting up front (from interview with the Administrator) and she saw the resident leaving the front door and reported to HR Aide D. [no process/procedure or elopement training was in place at the time of the incident]<BR/>8:56 a.m.: (from written statement authored by HR Aide D) statement made that HR Aide D called the Men's Unit and notified the nurse station and spoke to LVN A.<BR/>8:56 a.m.: (from interview with Administrator) a visitor and the MDS Nurse H (no longer an employee) alerted someone in the facility that the resident was seen away from the facility.<BR/>8:56 a.m.: LVN A and CNA B (no longer an employee) left the facility immediately to retrieve the resident.<BR/>8:57 a.m.: LVN A and CNA B met up with the resident about 100-200 feet and convinced the resident to return (in nurse notes) and accepted a visitor's offer to drive the resident and staff back to the facility.<BR/>8:59 a.m.: Nurse Note authored by LVN A stated that resident was back in the secured unit. <BR/>During an interview with MDS Nurse G on [DATE] at 2:10 p.m., MDS Nurse G stated after the elopement of Resident #1 the 72-hour monitoring order was discontinued on [DATE]. MDS Nurse G stated the resident did not experience any other exit seeking behaviors after [DATE]. MDS Nurse G stated law enforcement was not notified; but the MD, and RP were notified of the elopement.<BR/>During an interview with HR Aide D on [DATE] at 2:48 p.m., HR Aide D stated the statement written on [DATE] was correct. HR Aide D stated she did not maintain eye contact of Resident #1 because she was not sure the person identified by Housekeeping Aide C was a resident of the facility. HR Aide D stated after the training on missing persons the highlight was to follow the person until help arrived. <BR/>During an interview with the ADON on [DATE] at 6:01 p.m , the ADON stated she was told by LVN A that Resident #1 had left the Men's Unit on [DATE]. The ADON stated the code to the Secured Men's Unit might have been given to a regular family member not related to Resident #1 who visited the Men's Unit and the resident had followed someone's family member on the day of the incident. The ADON stated the current practice was for only paid staff to have the secure units' codes and to educate agency nursing staff not to give the code out. The ADON stated, in-service was given and the codes were changed and a door bell was placed in the secured units to announce entering the secured units after the incident.<BR/>Record review of facility's Emergency Procedure-Missing Resident dated revised [DATE] read, .Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety .<BR/>Record review of the facility's Wandering and Elopements policy dated revised [DATE] read, .Adequate supervision will be provided to help prevent accidents or elopements . <BR/>2. Record review of Resident #2's face sheet, dated [DATE] revealed, the resident was admitted on [DATE] with diagnoses that included: dementia, osteoarthritis (weak bones), and agitation and restlessness. Resident was a female age [AGE]. RP was listed as a family member.<BR/>Record review of Resident#2's Care Plan revealed the goals and interventions included: [start date [DATE]] at risk for falls with interventions: assistance, re-direction, safety measures, and monitoring. [[DATE]] additional interventions: proper foot attire, and keep pathway free of obstacles.<BR/>Record review of Resident #2's quarterly MDS dated 11/2023 revealed: BIMS score was 99 (unable to answer questions), transfer was listed as supervision, bed Mobility was listed as supervision, and ROM was documented as no impairments.<BR/>Record review of Resident #2's Fall Risk Score (dated [DATE] ) revealed a rating of high risk for falls.<BR/>Record review of Resident #2's Nurse Note authored by LVN K, dated [DATE], revealed, resident did not sleep well and was agitated all night. At 6:15 a.m. the resident was in the dining area near the trash can and pick-up the trash can and carried it around. The resident was re-directed and sent to her room. Resident returned to dining room and LVN K and CNA J heard and noise and noted resident on the floor lying next to a rolling stool on her right side and blood was noted on the floor. Resident was bleeding from the forehead and pressure was applied to the site. Vitals taken (temp 98.0 (normal), pulse 54 (normal), respiration 18 (normal), Blood Pressure 110/76 (normal), O2 (95% room air-normal). 911 was called. LVN K notified Hospice, RP, and MD of the unwitnessed fall.<BR/>Record review of Resident #2's clinical record revealed, Resident #2 was found on the dining room floor bleeding from the head from an unwitnessed fall on [DATE] at 6:45 AM. Staff members in the Women's Secured Unit were not monitoring the resident's movement in the dining room after the resident displayed agitation and left obstacles in her pathway. Resident #2 was taken by EMS to a local hospital where she was assessed and eventually underwent surgery for a large subdural hematoma with mid line shift (bleeding in the brain creating pressure on one side of the brain). Hospital status post finding revealed a craniotomy (a surgical procedure to remove the subdural hematoma) on [DATE].<BR/>Record review of Resident #2's hospital record dated [DATE] revealed: resident had a large subdural hematoma with mid line shift; placement in ICU; and physical restraint for aggression and behaviors. Status post craniotomy (a surgical procedure to remove the subdural hematoma) on [DATE]. Resident was discharged to another NF on [DATE]. Hospital diagnoses at discharge: SDH and Alzheimer's disease, HTN and history of falls. <BR/>Record review of facility's discharge list dated [DATE] revealed Resident #2 was discharged [DATE] to hospital and did not return. <BR/>Record review of Resident #2's Skin Assessments revealed: (dated [DATE]) laceration to the upper right side of the forehead; no measurements.<BR/>Record review of Resident #2's Fall Risk Score (dated [DATE]) revealed, a rating of high risk for falls.<BR/>Record review of Resident #2's Physician' Orders, dated [DATE] revealed, no specific order for more than routine monitoring the resident's movements in the secured unit. <BR/>Record review of Resident #2's incident report dated [DATE] authored LVN K revealed: unwitnessed fall with injury from fall in dining room involving a rolling stool.<BR/>Record review of facility's Provider Investigation Report dated [DATE] involving the incident on [DATE] revealed:<BR/>Disciplinary action taken against CNA J, LVN K and NA L; all three employees were terminated.<BR/>Rolling stools removed from the Unit.<BR/>Investigation summary: Overall, the allegations did not prove [Resident #2] had an unwitnessed fall with significant injury. [Resident #2] had a laceration to the right side of forehead and was admitted to hospital with a diagnosis of brain bleed (some old and some new) .disciplinary action taken .rolling stools removed .education provided .<BR/>5 day report submitted; finding was inconclusive.<BR/>Start of neuro checks pending EMS arrival from 6:45 AM-7:15 AM.<BR/>Inservice on fall prevention [DATE] for 35 employees in the secured units. <BR/>Record review of three terminated employees' written statements revealed:<BR/>LVN K [hire date [DATE]]: at [DATE] at 6:45 a.m. when resident fell the LVN [K] was standing in front of the nurse's cart away from the resident.<BR/>CNA J [hire date [DATE]]: not present in the dining room when fall occurred; location was at hall near Nurse station.<BR/>CNA L [hire date [DATE]]: not present when fall occurred; location was at the Nurse Station. <BR/>Record review of three terminated employee files revealed: they had received Abuse/Neglect Training and Fall Prevention Training at hiring and also on the day of the incident [DATE]. <BR/>Record review of facility's employee list of dated [DATE] revealed: 13 dedicated staff assigned to the secured units.<BR/>Record review of in-service training on fall prevention started [DATE] to [DATE] revealed 117 employees received the training (100 % completion rate).<BR/>Record review of the facility's Wandering and Elopements policy, dated revised [DATE], read, .Adequate supervision will be provided to help prevent accidents or elopements . <BR/>Record review of facility's Resident Rights policy, dated revised February 2021, read, .rights include the resident's right to .a dignified existence .be free from abuse, neglect, misappropriation of property, and exploitation .<BR/>Record review of facility's Falls-Clinical Protocol policy, dated Revised [DATE], read, .The physician will help identify individuals with a history of falls and risk factors for falling .The staff and practitioner will review each resident's risk factors for falling and document in the medical record .<BR/>During an interview on [DATE] at 11:58 a.m., NP stated she was informed of the unwitnessed fall involving Resident #2 from a rolling stool. The NP stated there were no orders other than routine monitoring of residents in the secured unit.<BR/>During an interview on [DATE] at 12:36 p.m., the Administrator stated his investigation revealed the unwitnessed fall was actually witnessed by the staff hearing the fall. The Administrator stated he terminated all the 3 employees (CNA J, LVN K and NA L) because thy failed to monitor the dining room before breakfast meal which led to Resident #2 falling from a rolling stool. The Administrator stated post incident the interventions put in place included: no rolling stools in the secured unit, an in-service of staff, fall risk assessments for secured unit residents, and updated care plans if necessary. The Administrator stated the timeline of the incident on [DATE] was: unwitnessed fall at 6:45 a.m. EMS arrived at 7:15 a.m.<BR/>During telephone call on [DATE] at 2:13 p.m., Hospice RN stated: hospice was contacted concerning the resident falling in dining room and suffering a laceration to the head requiring a visit to the ER. <BR/>During a telephone interview on [DATE] at 2:21 p.m., the RP stated , .[the resident] was sent to the ER and had to undergo brain surgery .she was hospitalized for one week and put in ICU for the brain bleed .after the hospital stay [Resident #2] was transfer to another NF for three months and then died .I hold [the NF] responsible for the death of [Resident #2]. The RP stated that she was notified of the incident on [DATE]. <BR/>In interviews on [DATE] from 10:00 a.m. to 10:30 a.m. with 5 day shift (6:00 a.m. to 6:00 p.m.) nursing staff (1 LVNs and 3 CNAs) and one other (Activity Tech) in the Men's Secured Unit; also, in the Women's Unit nursing staff (1 LVN and 2 CNAs); revealed: they had been in-serviced on fall prevention in the Secured Units with the highlights of: no rolling stools, no objects that could create hazards or accidents, no wet floors and maintaining supervision of the residents. Further interviews of 5 night staff (6:00 p.m. to 6:00 a.m.) (2 LVNs, 2 CNAs, and 1 MA) revealed they had the latter fall prevention training on maintaining safety in the secured units as well as throughout the facility. <BR/>In interviews on [DATE] from 12:15 p.m. to 12:30 p.m. 15 with day shift (6:00 a.m. to 6:00 p.m.) nursing staff (1 LVN and 1 CNA), 9 therapy staff (day shift) (4 PTAs, 3 OTs, 1 SP, 1 Rehab Tech) and 3 night shift (6:00 p.m. to 6:00 a.m.) included (1 LVN and 1 MA) and 9 other staff (1 Maintenance, 2 HR, and 1 Housekeeping) staff nursing and; further interviews of 5 night staff (6:00 p.m. to 6:00 a.m.) (2 LVNs, 2 CNAs, and 1 MA) revealed they had been in-serviced on fall prevention in the Secured Units with the highlights of: no rolling stools, no objects that could create hazards or accidents, no wet floors and maintaining supervision of the residents; also no fall or accident hazards throughout the facility. <BR/>The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]) <BR/>1. 100 percent completion rate for in-service of 117 paid staff on fall prevention (completed [DATE]). <BR/>2. Immediate Inservice on fall prevention on [DATE] for 35 employees assigned to the secured units. <BR/>3. Termination of the three employees (LVN K, CNA J, and NA L) for failing to provide supervision to Resident #2.<BR/>4. Assessment of resident #2 at time of fall and transferring the resident to the ER.<BR/>5. Neurology checks before the arrival of EMS from 6:45 a.m. to 7:15 a.m.<BR/>6. Assessing the scene of the fall and removing rolling stools.<BR/>7. Notifying the RP, Hospice, and MD of the fall.<BR/>Observation of Women's and Men's Secured Units on [DATE] and [DATE] revealed no rolling stools present or equipment or objects that could create accidents and hazards and adequate supervision.<BR/>During telephone interview on [DATE] at 4:10 p.m., LVN K stated the resident was agitated and moving in and out of resident rooms and eventually found a trash can she carried. LVN K stated the resident was redirected and sent back into her room in preparation for the breakfast meal. LVN K stated the resident was left unsupervised and returned to the dining hall where she found a rolling stool and tried to sit on it a fell. LVN K stated at the time of the incident she was preparing medications for morning dispensing. LVN K stated she was terminated because Resident #2 was left unsupervised. <BR/>During a telephone interview on [DATE] at 4:51 p.m., CNA J stated that Resident #2 was highly agitated on [DATE] and wandered throughout the unit and eventually found a rolling stool where she fell from. At the time of the incident, CNA J stated she was at the nurse station doing documentation. CNA J stated she was terminated for not monitoring Resident #2 on the day of the fall.<BR/>Attempted telephone calls to [DATE] at 3:55 p.m. and 4:00 p.m. to NA L revealed the phone was busy not accepting any calls or messages.<BR/>Interviews with 33 day and night staff (8 LVNs, 9 CNAs, 3 MAs, 9 Rehab staff, 1 Housekeeping, 1 HR, 1 Maintenance, and 1 Activity) on [DATE] from 1:00 p.m. to 2:00 p.m. revealed they had received an in-service on fall prevention with the return demonstration highlights: check on obstacles in the secured units and throughout the facility that could create accidents and hazards. <BR/>The Administrator was notified of an Immediate Jeopardy (IJ) on [DATE] at 6:35 p.m. The Administrator was provided with the IJ Template and a Plan of Removal was requested. <BR/>The facility provided a Plan of Removal which reads as follows: <BR/>Plan of Removal:<BR/>689: Accidents, Hazards, Supervision & Devices<BR/>Date Initiated: [DATE]<BR/>Today's Date: [DATE]<BR/>The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 22 residents (Resident #1) reviewed for adequate supervision.<BR/>All residents residing on the secured unit can be affected by this deficient practice. <BR/>Immediate Action Performed:<BR/>Action: Resident #1 was assisted back into the nursing home, resident was assessed, elopement assessment performed, and care plan updated. Resident was placed on 15 min checks until evaluated by the Psychology provider and medication review and adjustments completed.<BR/>Notified the Administrator, Notified MD, and Responsible Party.<BR/>Person(s) Responsible: Director of Nursing <BR/>Date: [DATE]<BR/>Action: <BR/>- Resident head count performed with all residents residing at [the facility]. No other missing residents identified.<BR/>- Elopement assessment performed on all residents at [the facility]. Any residents residing on the secured unit have elopement assessment, secured unit assessment, orders, consent and care plans in place. <BR/>Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee<BR/>Date: [DATE]<BR/>Action: To prevent future occurrence the facility has-<BR/>Placed signs on the inside and outside of the secured unit doors informing staff, vendors, and visitors to Please do not allow residents to follow you out. <BR/>Secured unit doors codes have been changed, staff aware of the codes, doorbell installed and visitors/vendors will be let in by staff.<BR/>Person(s) Responsible: Administrator, Director of Nursing, and/or Designee <BR/>Date: [DATE]<BR/>Steps to Achieve Compliance:<BR/>Action: Resident #1 was assessed for and further exit seeking behaviors and elopement risk assessment performed. They resident care plan was updated. <BR/>Person(s) Responsible: Director of Nursing <BR/>Date: [DATE]<BR/>Action: Place a staff member, continuously on all shifts at the front door until the Interdisciplinary Team (Including minimum Administrator, Director of Nursing, Assistant Director of Nursing, and Maintenance Director) can implement an alarm or a keypad that would alarm and/or require a code to exit the front door of the center. <BR/>Person(s) Responsible: Administrator, Maintenance Director, and/or Designee <BR/>Date: [DATE]<BR/>Action: Elopement assessments reperformed on all residents. Elopement assessments and Secure Unit assessments will be repeated quarterly, annually and with significant change. The DON will review elopement assessments weekly to ensure they are completed timely. <BR/>Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee <BR/>Date: [DATE]<BR/>Action: Missing Resident & Wandering/Elopement education provided to all staff to include: <BR/>If you note a resident (with emphasis a resident on the secured unit) attempting to exit any door, stay with resident and ensure that they have signed out and/or have appropriate supervision. <BR/>Elopement book has been verified as updated and staff education on location of the elopement book, which includes residents on the secured unit that are at risk for elopement. The Elopement Book will be updated daily with any changes by the Social Worker/designee.<BR/>All employees, including new and temporary, to be educated prior to working their next shift. All newly hired employees will be education during orientation, prior to first scheduled shift The DON/designee will review the next days schedule daily to ensure that any staff scheduled to work on the oncoming shifts have been educated. <BR/>Person(s) Responsible: Administrator, Director of Nursing, and/or Designee<BR/>Date: [DATE] <BR/>Action: Ad hoc QAPI performed with Medical Director to inform of the Immediate Jeopardy template and the facility's action to remove the immediacy. <BR/>Person(s) Responsible: Administrator<BR/>Date: [DATE]<BR/>Verification of Plan of Removal:<BR/>During an observation and interview on [DATE] at 10:30 a.m. the front door was locked and when opened by the Admissions Coordinator, a bell sounded. Observation further revealed that a reception desk was set up with a ledger near the entrance to control traffic and out of the facility. The Admissions stated that her assignment was to monitor traffic during her shift. She stated that the facility was working on a permanent alarm system for the front.<BR/>Observation on [DATE] at 11:26 a.m. of Resident #1 revealed the resident was in the secured men's unit in the dining room socializing with other residents.<BR/>Observation on [DATE] at 12:05 p.m. of Men's Secured Unit had two signs inside the unit that read: Stop .Please ask for assistance from staff when entering and exiting a secure unit .Please do not let unsupervised residents leave the secured unit unattended. The signs to the entrance of the Men's Secured Unit read: Please ask for assistance from staff when entering and exiting a secure unit. The Women's Secured Unit signs read: Please do not allow residents to follow you out .Ensure door is locked behind you . Observation also revealed that the doorbell are operating in both secured units. <BR/>Observation on [DATE] from 2:45 p.m.-2:55 p.m. revealed the location of the elopement books at: station 1, station 2, Men's Secured Unit and the Women's Secured Unit. <BR/>Record review of Resident's Nursing note dated [DATE] at 8:59 a.m. authored by, LVN A revealed the resident eloped from the facility and was missing for about 5 minutes; was assessed and returned to the facility. <BR/>Record review of Resident #1's elopement evaluation on [DATE] revealed high risk for elopement.<BR/>Record review of Resident #1's CP dated [DATE] revealed: the resident was an elopement risk. <BR/>Record review of Resident #1's behavior monitoring dated [DATE] to [DATE] revealed monitoring done and completed; see attachment.<BR/>Record review of Resident #1's Psychology evaluation on [DATE] by [psychiatric company] revealed: medications reviewed and follow-up visits.<BR/>Record review of Resident #1's Medication review done by the NP dated [DATE] revealed: medications reviewed and new order for Aricept 5 mgs once per day at bedtime (dementia).<BR/>Record review of Resident #1's Nurse Progress note dated [DATE] authored by LVN A revealed the MD was notified and the RP.<BR/>Record review of facility's census audit on [DATE] revealed 124 residents were present and no other resident had eloped.<BR/>Record review of sample residents (Residents #3 through #7) revealed elopement assessment was completed on [DATE]. <BR/>Record review of Secured Units' census on [DATE] revealed: Men's was 34 and Women was 22. <BR/>Record review of sample residents in the Men's Unit on [DATE] revealed Resident's clinical record contained the elopement assessment, secured unit assessment, orders, consent and care plan was in place.<BR/>Record review of sample residents in the Women's Unit on [DATE] revealed Resident #8's clinical record contained the elopement assessment, secured unit assessment, orders, consent and care plan was in place. <BR/>Record review of Resident #1's elopement assessment dated [DATE] authored by RN revealed the assessment was present; and resident assessed for high risk of elopement. <BR/>Record review of Resident #1's CP dated [DATE] revealed: the CP was updated and to closely monitor the resident for wandering and elopement. <BR/>Record review of facility's POR binder revealed 117 elopement assessments were present.<BR/>Record review of training on Missing Residents for 117 staff members revealed: 117 signatures were present for 100% completion.<BR/>Record review or email dated [DATE] to Medical Director revealed a discussion on the IJ and the POR. <BR/>During an interview on [DATE] at 12:09 p.m. the DON stated the codes to the locked units had been changed and would be changed every three months unless compromised. The DON stated, Staff were made aware of the codes individually when she made rounds and during orientation. The DON stated that the codes are not given to agency staff or visitors.<BR/>During an interview on [DATE] at 12:43 p.m., the Corporate Nurse stated that corporate headquarters is exploring a permanent solution for the front door monitoring to prevent elopement and tracking visitors.<BR/>During an interview on [DATE] at 12:49 p.m., the DON stated, yes .117 elopement assessments were completed .the resident at risk for elopement resided in the secur[TRUNCATED]

Based on observation, interview and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments, under proper temperature control and labeled in accordance with currently accepted professional principles for 2 (medication cart #1 and medication cart #3) of 4 medication carts reviewed for medication storage. The facility failed to ensure that MC #1 did not have loose unknown NARC medications in the drawer. The facility failed to ensure that MC #1 and MC #3 did not have medications that were undated in the drawer. This failure could put residents at risk for missed medications and/or receiving unidentified medications. An observation and audit conducted on 08/27/2025 at 12:50 PM revealed Med Cart #1 which was stationed on the 50 hall, contained loose and unlabeled medications. The observation revealed half of a white circle tablet loose in the locked narcotics bin. It was identified by INV and LVN G that the medication was not a current medication in the narcotics bin. Med Cart #1 contained undated over the counter medication bottle which should be labeled with a date when opened. An interview was conducted on 08/27/2025 at 1:15PM with LVN G who reported being employed at the facility for 1 year. LVN G stated that she had received training on labeling and dating medications. LVN G stated that they were expected to label the bottle of OTC medications when they opened them. LVN G stated undated and opened medication could negatively affect the residents by the medication not being as effective if it was expired. LVN G stated that loose unaccounted medications could negatively affect a resident by not having the medication available to the resident. LVN G stated the loose narcotic medication could negatively affect a resident for pharmacy delivery. LVN G stated pharmacy orders could be delayed. An observation and audit conducted on 08/28/2025 at 10:05AM revealed Med Cart #3 which was stationed in the men's locked unit, contained undated/unlabeled Vitamin D medications. The medication should have been labeled with a date of when the medication was first opened. An interview was conducted on 08/28/2025 at 10:15AM with LVN F who reported being employed at the facility for 2 months. LVN F stated that they had received training on labeling and dating medications. LVN F stated that the training included ensuring that they checked expiration dates, and whenever a medication was opened, they labeled and dated it. LVN F reported that if medications were not labeled it could negatively affect a resident by the medications not being effective. LVN F stated that a negative effect of loose narcotic medications would be the resident potentially had not received the medication. An interview was conducted on 08/28/2025 at 4:38PM with the ADM who reported working at the facility for 2.5 months. The ADM stated the ADON and DON provided training for labeling/dating medication. The ADM stated that the policy for labeling/dating medications was everything that came from the pharmacy should be labeled already. OTC meds should be dated and labeled when they opened them. The ADM stated the policy for loose medications was that staff should not use them and throw them away. The ADM stated that the med carts were audited by nursing management monthly but there were no formal records to provide. The ADM stated it could negatively affect a resident to have undated meds in the med cart by receiving expired medications. The ADM additionally added it could negatively affect a resident to have loose medications in the NARC drawer by not knowing what the medication is and that it could be contaminated. The ADM stated this could indicate a possibility that a resident did not receive that medication. An interview was conducted on 08/028/2025 at 4:50PM with the DON who reported working at the facility for 3 weeks. The DON stated that the policy for labeling/dating medications was that staff need to have an open date of when they had opened the medications for OTC meds. The DON stated the policy for loose medications was that there shouldn't be any loose pills. The DON stated that pharmacy will audit the med carts once a month but there is no official document to provide. The DON stated it negatively affected a resident to have undated/expired meds in the med cart by the medication could lose their effectiveness. The DON stated it negatively affect a resident to have loose medications in the NARC drawer by the potential that the resident did not receive that particular medication. The DON confirmed that this could potentially be a med error. Record review of a document provided by the facility titled Medication Storage undated, revealed that medications should be labeled, dated and stored in proper areas according to the label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the right to be free from abuse for 6 of 11 residents (Residents #4, #5, #7, #8, #10, and #11) reviewed for abuse as evidenced by:<BR/>1. Facility failed to address that Resident #3 sexually assaulted Resident #4 on 12/14/24.<BR/>2. Facility failed to address that Resident #3 physically assaulted Resident #5 on 12/15/24. <BR/>3. Facility failed to address that Resident #7 reported to CNA B that Resident #3 was sexual inappropriate with Resident #7 on 12/13/2024.<BR/>4. Facility failed to address that Resident #3 was sexually inappropriate with Resident #10 and reported to Social Worker A on 12/16/2024. <BR/>5. Facility failed to address that Resident #11 reported to Social Worker A that Resident #3 was being sexually inappropriate and moved out of Resident #3's room on 12/04/2024. <BR/>6. Facility failed to address that Resident #3 was sexually inappropriate with Resident #8 during the week of 12/08/2024 - 12/13/2024.<BR/>An Immediate Jeopardy (IJ) was identified on 12/19/2024 at 5:10 p.m. The IJ template was provided to the facility on [DATE] at 7:24 p.m. While the IJ was removed on 12/22/2024 at 3:18 p.m., the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of its plan of Removal (POR).<BR/>This failure could place residents in the facility at risk for abuse or harm from other residents exhibiting aggressive behaviors. <BR/>The findings were:<BR/>1. Record review of Resident #3's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 12/15/2024 with diagnoses that included Vascular Dementia (a general term for impaired ability to remember, think, or make decisions), Type 2 Diabetes (a chronic condition that happens when your body can't use insulin properly), Schizoaffective Disorder, Bipolar Type (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), Anxiety Disorder (a feeling of worry, nervousness, or unease) and Depression (a mood disorder that causes persistent feelings of sadness and loss of interest). <BR/>Record review of Resident #3's quarterly MDS assessment, dated 10/09/2024, revealed Resident #3 had a BIMS score of 14, indicating no cognitive impairment. <BR/>Record review of Resident #3's comprehensive care plan revealed the following care plans: 1) [Resident #3] has behaviors in the dining area, during meals, that agitates other residents' r/t he uses vulgar language, racial slurs and talks loudly, start date 11/11/2023. 2) [Resident # wants to express himself sexually and is cognitively intact to choose to have a sexual relationship(s), start date 11/13/2023. 3) [Resident #3] has behaviors while outside smoking that agitates other residents' r/t he uses vulgar language, racial slurs, and talks loudly, start date 11/13/2023. 4) Resident has physically abusive behavioral symptoms of physical aggression directed toward another resident, start date 11/11/2023, end date 02/11/2024. 5) Resident has been heard calling his roommate 'my lover', which upsets the roommate. He stated he calls him that because he believes it to be funny, but he does not consider his roommate to be his lover, start date 11/07/2023. 6) Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by [Resident #3] talks in a loud voice and says inappropriate things to staff and other residents. [Resident #3] tells untrue stories such as the Administrator will buy him gifts. [Resident #3] stated his cigarettes were marijuana. [Resident #3] makes false allegations against staff, start date 11/05/2024. 7) Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by recent behaviors reported by nursing staff: argumentative, refusing to come inside late at night, yelling and cursing at staff, singing and talking loudly in the dining area during meal services, start date 10/17/2023. 8) [Resident #3] was observed engaging in a sexual act with another male resident, start date 10/12/2023. 9) Resident has potential for socially inappropriate/disruptive behavioral symptoms r/t bipolar disorder and anxiety, start date 10/12/2023. <BR/>Record review of Resident #3's December MAR revealed Resident #3 had the following orders: 1) Clonazepam 1mg, 1 tablet, scheduled for 8:00 a.m. and 8:00 p.m. daily for bipolar disorder with a start date of 05/13/2024. 2) Benztropine 1mg, 1 tablet, scheduled for 8:00 a.m. daily for schizoaffective disorder with a start date of 12/15/2024. 3) Cymbalta delayed release 60mg, 1 capsule, scheduled for 7 a.m.-10 a.m. daily for major depression disorder with a start date of 05/06/2024. 4) Gabapentin 400mg, 2 tablets to equal 800 mg scheduled for 8:00 a.m., 2:00 p.m., and 8:00 p.m. for neuropathy pain with a start date of 10/12/2023. 5) Lyrica 50mg, 1 capsule scheduled for 8:00 a.m.-10:00 a.m. and 8:00 p.m.- 10:00 p.m. for pain with a start date of 05/06/2024. 6) Trazadone 150mg, &frac12; tab scheduled for 8:00 p.m. for insomnia. <BR/>Record review of Resident #3 progress note, 12/14/2024 at 11:50 a.m. by LVN A, stated, told in report that DON was not reached. Pt has been very argumentative with staff and other patients all day. <BR/>Record review of Resident #3's progress note, 12/15/2024 at 11:21 a.m. by LVN C, stated, Enter this shift this morning and observed resident very talkative, speaking with other residents and staff loudly, sometimes 15 minutes with kisses and hugs. Administered all medications including PRN Ativan 0.5mg. STAT labs CBC. CMP, UA with C&S. Resident attempted to go outside and sit on the porch but was redirected back inside. Resident required redirection to eat breakfast, sat down to eat 30 minutes later after food was placed on the table. While in dining room [Resident #3] called another resident a bitch because [Resident #3] says the other resident called him a prostitute. [Resident #3] was redirected and continued to eat his breakfast. After resident ate breakfast, he went to his room and laid down. Police here to speak with resident due to an incident that occurred yesterday. Resident is 1:1[supervision] until further notice.<BR/>Record review of Resident #3 prescription order revealed an ordered received by LVN C on 12/15/2024 for Ativan .5mg, 1 tablet, PRN. <BR/>Record review of Resident #3's progress note, 12/15/2024 at 11:53 a.m. by LVN C stated, [lab company] here to do STAT labs, resident refused blood draw d/t police here questioning him on complaint made by another resident. At this time resident is very upset and doesn't want to be bothered. UA was collected earlier today and was sent with tech. Attempted to do a skin assessment, resident refused that as well.<BR/>Record review of Resident #3's progress note, 12/15/2024 at 11:58 a.m. by Agency LVN L stated, This nurse observed resident arguing with another resident. This nurse did not hear what they were saying. This nurse redirected residents successfully.<BR/>Record review of Resident #3's progress note, 12/15/2024 at 1:15 p.m. by LVN C, stated, This nurse was informed resident threatened to kill 'whoever call the police on him.' This nurse called on call for [Resident #3 physician] and spoke with [Nurse Practitioner] and gave orders to send resident to psych hospital. Call placed to [hospital name] to give report, ER nurse made me aware that if resident doesn't meet criteria he will be sent right back. Call placed to EMS requesting resident to be sent out for a psych eval and treat. EMS dispatcher made me aware that since this is a psych transport police will come out first. The police came back inside and stated since resident didn't verbally name someone then they can't do much about it because the person would have to press charges.<BR/>Record review of Resident #3's progress note, 12/15/2024 at 1:36 p.m. by LVN C stated, Resident was sitting outside and came inside once he saw the other resident [representative] enter the building. As the [representative] was leaving with the resident for a oop stay, [Resident #3] began cursing at the resident and [resident representative] while they were leaving and tried walking toward them. Resident was blocked from trying to get the other resident. [Resident representative] exchanged words as well. Resident then proceeds to walk towards the dining room and states to another resident what are the fuck are you looking at mother fucker and hits him. The other resident gets up and attempt to hit him back but almost lost his balance. Residents were separated immediately. Call placed to the police.<BR/>Record review of Resident #3's progress note, 12/15/2024 at 2:55 p.m. by LVN C stated, Resident arrested due to physical assault to another resident and sent to [County Name], [case number]. Police informed this nurse its a Emergency protective order that last for 72 hours if judge approves. Call placed to [resident representative], message left requesting call back, NP on call, Administrator, ADON and DON was notified.<BR/>Record review of a facility document titled 24-hour resident monitoring form used to document the 1:1 supervision for Resident #3, dated 12/15/2024, listed 3 columns for each shift with column 1 -time, column 2-location/room, column 3- staff initials. The form revealed Resident #3 was documented as out front at 12:00 p.m., 12:blank, 12:blank and initialed with CNA A's initials. Resident #3 was documented DR (number) at 12: blank, 1:00 p.m., 1:blank, 1:blank, 1:blank, 2:00 p.m., 2:15, 2:30, 2:45 and initialed with CNA A's initials. <BR/>Record review of a facility document titled Event Report for Resident #3, completion date 12/15/2024 at 2:31 p.m. by LVN C, described the behavior exhibited by Resident #3 as, Resident was sitting outside and came inside once he saw the other resident [representative] enter the building. As the [representative] was leaving the resident for a oop stay [Resident #3] began cursing at the resident and [resident representative] while they were leaving and tried walking toward them. Resident then proceeds to walk towards the dining room and states another resident what are the fuck are you looking at mother fucker and hits him. The other resident gets up and attempt to hit him back but almost lost his balance. Residents were separated immediately. Call placed to the police. The event report revealed Resident #3 exhibited 'anger' and a 'desire to harm others'. The event report section titled Behavioral Symptoms stated Resident #3 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 4 to 6 days, but less than daily. The event report section of behavioral symptoms stated Resident #3 exhibited verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), 1 to 3 days in the last 7 days. The event report section of behavioral symptoms stated Resident #3 exhibited other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds, 1 to 3 days in the last 7 days. The event report stated Resident #3's behaviors put the resident at risk for significant risk for physical illness or injury, significantly interfered with resident care, put others at significant risk for physical injury, significantly intruded on the privacy and activities of others and significantly disrupted the care or living environment. The event report section for interventions for Resident #3 revealed medications were ineffective and non-pharmacological measures taken were redirection and 1:1. The outcome of the non-pharmacological measures used was coded as 'interventions ineffective'.<BR/>2. Record review of Resident #5's undated face sheet revealed he was an [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included Conversion Disorder with Seizures (a functional disorder that causes abnormal sensory experiences and movement problems during periods of high psychological stress), Congenital Malformations of Corpus Callosum-Birth Defect (a condition present at birth when parts of the nerve fibers that connect the right and left sides of the brain are missing), Dementia (a mood disorder that causes persistent feelings of sadness and loss of interest), Unspecified Intellectual Disabilities (a diagnosis for individuals when assessment of the degree of the intellectual disability by means of locally available procedures, is difficult or impossible because of sensory or physical impairments). <BR/>Record review of Resident #5's MDS assessment, dated 11/14/2024, revealed Resident #5 was coded as rarely/never understood on Section B- Hearing, Speech and Vision. Section C- Cognitive Patterns revealed Resident #5 had short term memory problems and Resident #5's cognitive skills for daily decision making were moderately impaired, defined on the MDS as decisions poor, cues/supervision required. <BR/>Record review of Resident #5's comprehensive care plan revealed the following care plans, 1) [Resident #5] has been identified as having IDD PASRR positive status related to unspecified intellectual disabilities and conversion disorder, start date 06/21/2022. 2) Resident has difficulty understanding others R/T impaired cognition, start date 05/27/2022. 3) Resident has impaired cognition R/T Dementia and Congenital malformations of corpus callosum, start date 05/27/2022. <BR/>Record review of Resident #5's progress note, 12/15/2024 at 2:50 p.m. by Agency LVN L stated, Another resident [Resident #3] walked by [Resident #5] and said what the F*** are you looking at and hit [Resident #5] in the left forearm. This was Witness by [MA A].<BR/>Record review of Resident #5's progress note, 12/15/2024 at 3:22 p.m. by Agency LVN L stated, [Physician name] returned call and was notified. Stat x-ray ordered.<BR/>Record review of Resident #5's progress notes revealed a skin assessment was completed on 12/15/2024 at 3:27 p.m. by Agency LVN L and there were no alterations in skin integrity noted. <BR/>Record review of Resident #5's progress note, 12/15/2024 at 9:14 p.m. by LVN F stated, x-ray came to take x-ray at 7:30 p.m. Resident is resting in his room.<BR/>Record review of a document titled event report for Resident #5, completion date 12/15/2024 at 2:59 p.m. by Agency LVN L, revealed Resident #5 was hit in the left forearm by Resident #3. The event report was checked 'yes' to a question of if the incident was witnessed. The location of the incident was marked as 'dining room'. Injury was described as no injury noted. Resident has a small dark green bruise. Treatment was marked 'x-ray ordered'. Action taken was marked 'police notified'. Immediate intervention to prevent reoccurrence stated keep [Resident #3] away from resident. The report revealed Resident #5's resident representative, physician and NP were notified of the incident. <BR/>Record review of Resident #5's x-ray report, date of service 12/15/2024 and faxed date 12/18/2024, revealed no evidence of acute fracture or dislocation in forearm. <BR/>3. Record review of Resident #4's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Schizophrenia (a chronic mental illness characterized by delusions, hallucinations and disorganized thinking), End stage renal disease, and Conversion disorder with seizures (a functional disorder that causes abnormal sensory experiences and movement problems during periods of high psychological stress).<BR/>Record review of Resident #4's quarterly MDS assessment, dated 10/06/2024, revealed Resident #4 had a BIMS score of 15, indicating no cognitive impairment. <BR/>Record review of Resident #4's progress notes, 12/15/2024 at 11:50 a.m. by Agency LVN L stated, Residents [representative] called this morning asking to speak with someone about a grievance. This nurse stated that [admission Coordinator name] the manager on duty was at lunch, that this nurse could take her number and have [admission Coordinator name] call her back. This nurse stated that I was [Resident #4's] nurse today and if I could help her. [Resident representative] then stated that [Resident #4] was sexually assaulted last night. that [Resident #3 first name] asked [Resident #4] to come look at his Christmas tree last night and when [Resident #4] entered the room [Resident #3] shut the door and took his clothes off and started rubbing on [Resident #4]. This nurse took [resident representative] number and stated that [admission Coordinator] would call her back.<BR/>Record review of Resident #4's progress notes, 12/15/24 at 12:01 p.m. by Agency LVN L stated, police have arrived and are getting statements.<BR/>Record review of Resident #4's progress notes, 12/15/24 at 2:05 p.m. by Agency LVN L stated, Resident left with [resident representative] for therapeutic leave.<BR/>Record review of Resident #4's facility document titled event report, completion date 12/16/2024 at 12:22 p.m. by ADON A, described the event as recipient of sexually inappropriate behavior and included a brief description of the incident that stated Resident was invited by another Resident to their room to look at the Christmas tree. Once they were in the room, the other resident then closed the door, pulls his pants down, blocks the entrance to his room door and begins to rub his genitals against [Resident #4]. The event report revealed there were no witnesses to the alleged event and no injuries were noted. Action taken was described as staff re-education, resident re-education, police notified, state notified, Administrator notified, DON notified and listed as immediate intervention implemented that the other resident was placed on 1:1 supervision. <BR/>Record review of Resident #4's Social Service progress note, 12/16/2024 at 4:38 p.m. by Social Worker A stated, [Resident #4] returned from [resident representative] outing in time to smoke outside. SW spoke to him 4: 38PM and he appeared to be doing well. SW expressed sorrow that [Resident #4] was assaulted in that way and that it was no way his fault. We talked about how shocking it is to be put in that situation. He said he was badly shaken up but going home with his [resident representative] really helped. They fed him well and talked to him and gave him his meds. He said he is not traumatized by it but felt that way when it happened. SW assured him that the Resident was arrested and taken to jail and will not be returning and that we are packing up his belongings. I told him [psychiatry company name] would be here to visit with him and I personally contacted them to be sure they were coming. He thanked me for coming to talk to him. I told him to reach out anytime he needed to talk. I also offered additional counseling if he needed it and he told me he was good.<BR/>4. Record review of Resident #7's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Myopathy (a muscle disease) and Atherosclerosis of coronary artery bypass graft (surgical operation to bypass arteries in the heart). <BR/>Record review of Resident #7's MDS assessment, dated 07/31/2024, revealed Resident #7 had a BIMS score of 15, indicating no cognitive impairment. <BR/>5. Record review of Resident #8's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Pulmonary Fibrosis (a disease in which the lungs become scarred and damaged causing difficulty in breathing), Anxiety (a feeling of worry, nervousness, or unease) and Depression (a mood disorder that causes persistent feelings of sadness and loss of interest).<BR/>Record review of Resident #8's MDS assessment, dated 09/15/2024, revealed Resident #8 had a BIMS score of 12, indicating moderate cognitive impairment. <BR/>6. Record review of Resident #10's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Hemiplegia (paralysis of one side of the body), Anxiety (a feeling of worry, nervousness, or unease), Depression (a mood disorder that causes persistent feelings of sadness and loss of interest), Schizoaffective Disorder, Bipolar Type (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), and Chronic Post-Traumatic Stress Disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress and anxiety). <BR/>Record review of Resident #10's MDS assessment, dated 11/19/2024, revealed Resident #10 had a BIMS score of 15, indicating no cognitive impairment. <BR/>Record review of a facility document titled Safe Survey for Resident #10, dated 12/16/2024 by Social Worker A, revealed a question Has any staff/resident approached you in a way that made you feel uncomfortable? Social Worker A wrote Friday-[Resident #3] came to my room the other day. He said he has a 'female part' down there (he pointed to his penis). He said his 'asshole is his pussy'. He told me I would like him better than [girl's name]. [Resident#10] told him 'I'm not doing that shit'. He bent over and showed me his butthole. He told me if I told anyone he has rights and the right to be gay. Last Monday he tried to give me a kiss (he walked into my room). That's sexual harassment. He is gay and he can be gay all he wants. He uses his gayness as a crutch. He ate all my cookies, he sat there and ate them. He offered my money. Can you keep him away from me?<BR/>7. Record review of Resident #11's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes (a chronic condition that happens when your body can't use insulin properly) and Mild Intellectual Disabilities (a neurodevelopmental condition that affects adaptive and cognitive potential).<BR/>Record review of Resident #11's MDS assessment, dated 09/07/2024, revealed Resident #11 had a BIMS score of 13, indicating no cognitive impairment.<BR/>Record review of a facility document titled Safe Survey for Resident #11, dated 12/16/2024 by Social Worker B, revealed a question Has any staff/resident approached you in a way that made you feel uncomfortable? Social Worker B wrote yes but I don't know if he is no longer here, from what I heard. Resident #11 told the head nurse/reported it when it happened. The survey also revealed a question has any staff/resident approached you about any sexual advances or remarks or anything that would cause you concern? and Social Worker B wrote yes, same as above. Happened last week then they moved me to a different room and then I heard he wet to jail. He told the head nurse when it happened. It was his former roommate, [Resident #3].<BR/>During an interview with the Administrator, 12/16/2024 at 10:40 a.m., the Administrator stated Resident #3 and Resident #4 were not in the facility. The Administrator stated Resident #4 was out on pass with his resident representative and Resident #3 was in jail because Resident #3's behavior continued to escalate and there was another incident that resulted in Resident #3 being arrested.<BR/>During an interview with the Administrator, 12/16/2024 at 11:00 a.m., the Administrator stated he was notified on the morning of 12/15/2024 around 9 a.m. by the Admissions Coordinator that Resident #4 reported to the Admissions Coordinator that Resident #3 allegedly asked Resident #4 to go to Resident #3's room to look at his Christmas tree on 12/14/2024 at approximately 5 p.m. to 6 p.m. Resident #4 reported that he went to Resident #3's room and when he entered the room, Resident #3 closed the door to the room, dropped his pants, rubbed his bare bottom on him and made him uncomfortable and attempted to kiss him. The Administrator stated, when he was notified of the allegation, he began an investigation and reported the incident to HHSC and the police were notified by Resident #4's resident representative before the Administrator had a chance to contact them. The Administrator stated the police arrived around 10:14 a.m. on 12/15/2024 to interview Resident #3 and Resident #4 and after the interviews, Resident #4's family took him out on pass from the facility. The Administrator stated after Resident #3 was interviewed by the officers, Resident #3 came out of his room and started threatening to beat people's asses and wanted to know who called the police on him and then looked at another resident and said, 'what are you looking at' and then hit the other resident. The Administrator stated the police were still outside at the time and came back in the facility and arrested Resident #3 and took him to jail. The Administrator also stated the police took an article of clothing from Resident #4 to see if there was any DNA from Resident #3. The Administrator stated Resident #3 had exhibited behaviors in the past and had a couple of reportable incidents after he admitted to the facility. The Administrator stated Resident #3 had a sexual encounter with a resident that was reported but both residents were consenting and after we investigated it, it was unsubstantiated. The Administrator stated Resident #3 had a resident-to-resident physical altercation right after he admitted last year, but there were no injuries. The Administrator stated Resident #3 had been on hospice services and was declining for part of the year but had recently improved and graduated off of hospice and said Resident #3 was on psychiatric services and his medication had been effective. <BR/>During an interview with the Admissions Coordinator, 12/16/2024 at 11:40 a.m., the Admissions Coordinator stated she arrived at the facility for manager of duty around 6:30 a.m. on 12/15/2024. The Admissions Coordinator stated Resident #3 asked her to go see his room and his decorations when she arrived and she went down to his room. Upon noticing that Resident #3 had decorated the whole room, the Admissions Coordinator stated she made a comment to him about how nice the room looked but if he gets assigned a roommate, he would have to take down the decorations on the other side of the room. The Admissions Coordinator said he got upset and poked me on the right upper arm and said 'no, you have to give me thirty days' notice first' in a real agitated voice. The Admissions Coordinator displayed a round dime size bruise on her right upper arm and stated that the bruise was from Resident #3. The Admissions Coordinator stated she tried to redirect Resident #3 to go to breakfast but he stated he was just going to stay in his room. The admission Coordinator stated she took residents who smoke outside on a smoke break around 7 a.m. and Resident #4 was late to the smoke break and appeared tired and upset. The Admissions Coordinator stated she asked Resident #4 if he was ok and he stated he was tired and could not sleep the night before and agreed to go to her office to talk to her after the smoke break. The Admissions Coordinator stated around 8 a.m., Resident #4 went to her office and told her Resident #3, on 12/14/2024 around 5 p.m., asked Resident #4 to go see his room and how he decorated it and to see his Christmas tree. Resident #4 said Resident #3 then shut the door behind him, dropped his pants, rubbed his naked ass on him and then tried kissing on him as he was trying to get out the door. Resident #4 said Resident #3 told Resident #4 that since Resident #4's family member had died 3 months ago, he did not need to be heterosexual. The Admissions Coordinator stated Resident #4 said he was able to get around Resident #3 and leave the room and stated he told a nurse what happened but could not describe the nurse and stated he did not know who it was. The Admissions Coordinator stated the 2 nurses that work the shift are his favorites so I don't know how he could not remember who it was, I think his times could be off because he knows the nurses. The Admissions Coordinator stated she notified the Administrator of the allegations made by Resident #4. The Admissions Coordinator stated between the hours of 8 a.m. and 9 a.m. on 12/15/2024, Resident #3 was observed being agitated and being rude to residents and staff in the dining room, insulting people, and calling people fat. The Admissions Coordinator stated staff continued to redirect Resident #3 and he returned to his room and then the police arrived around 10:15 a.m. to talk to Resident #3 and Resident #4. The Admissions Coordinator stated 2 officers went to talk to Resident #3 and she could hear Resident #3 screaming and yelling in the room. Other officers went to talk to Resident #4 for about 30 minutes and took some articles of clothing. The Admissions Coordinator stated she asked an Officer what was going to happen once they leave from Resident #3's room because he was agitated, and they said they would investigate to see if they would issue a warrant for sexual assault. When the officers exited from Resident #3's room, the Admissions Coordinator witnessed Resident #3 walking behind the officers and yelling fuck you, you pigs. I used to be a male prostitute, I know my rights, I'm getting a lawyer. The Admissions Coordinator stated a CNA was assigned to sit with Resident #3 1:1. Resident #4's resident representative called and said they would be coming up to the facility to take Resident #4 out on pass and the nurse was notified and then Resident #3 was overheard yelling I will fucking kill whoever called the police on me at the nurses station. The Admissions Coordinator stated she notified the Administrator of the behavior and notified the police who were still outside of the facility. The police reentered the facility and told the Admissions Coordinator that Resident #3 could not be arrested for the statement since it was not directed toward a specific named individual. The Admissions Coordinator stated she told the CNA who was providing 1:1 with Resident #3 around 1:30 p.m. to take Resident #3 out front to get some air while the Admissions Coordinator was going to take the residents, including Resident #4, outside on the smoking patio for a smoke break. The Admissions Coordinator stated she was outside with the residents on a smoke break for about 5 - 10 minutes and was notified that Resident #3 physically hit Resident #5. The Admissions Coordinator stated she was told by a nurse that Resident #4's resident representative entered the facility and Resident #3 started calling Resident #4's representative a faggot or gay and Resident #5 laughed so Resident #3 hit him on the forearm. The Admissions Coordinator stated she notified the Administrator of the physical altercation; police were notified and she had to leave the facility for a personal appointment before the police arrived and arrested Resident #3. The Admissions Coordinator stated she was unsure how Resident #3 was able to physically assault Resident #5 while he was on 1:1 supervision and stated, I am not sure how Resident #3 was able to get close enough to Resident #5 to be able to hit him and stated I was upset when I got home and was afraid he was really going to hurt someone.<BR/>During[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 9 residents (Resident #9) reviewed for misappropriation and exploitation, in that:<BR/>The facility did not prevent Resident #9's personal belongings from being lost when he discharged to the hospital. <BR/>This failure could affect residents and their responsible party by preventing them from having access to their personal effects and belongings. <BR/>The findings included:<BR/>Record review of Resident #9's face sheet, dated [DATE], revealed the resident was admitted on [DATE] with diagnoses that included: dementia, anxiety, and mood disorder. The resident was a male age [AGE]. The RP was listed as a family member.<BR/>Record review of Resident #9's quarterly MDS, dated [DATE], revealed the resident had BIMS score of 01 (severe cognitive impairment).<BR/>Record review of facility's discharge list, dated [DATE], revealed Resident #9 expired in the facility on [DATE] under hospice care. <BR/>Record review of Resident #9's Nurse Note dated [DATE] authored by LVN M reflected: Progress Note: Resident was pronounced dead at: [DATE] 10:46 PM. Further review revealed Resident #9's RP was notified of the resident's death. The resident's personal effects were documented as, none, and not sent to the RP or the Mortuary. Also, the said note reflected, No, Personal effects secured for release at a later time .<BR/>During a telephone interview on [DATE] at 1:50 p.m., Resident #9's RP stated the facility, never returned [to her the resident's] property after his death . Resident #9's RP stated she remembered the resident's belongings included six different blankets and all the resident's clothes.<BR/>During a telephone interview with LVN M on [DATE] at 2:28 p.m., LVN M stated no inventory was done on Resident #9's belongings at admissions or at discharge. LVN M stated, no personal effects, belonging to Resident #9 were returned to the family or the RP. LVN M stated the admitting nurse and the discharge nurse were responsible for inventorying the resident's personal belongings.<BR/>During an interview with the DON on [DATE] at 3:15 p.m., the DON stated at admission a nursing staff member inventoried what personal items the resident brought into the facility. The DON stated the procedure for Resident #9 was to do a paper inventory; but as of [DATE] the inventory was not done or located in the EMR. The DON stated when new items were brought into the facility, the inventory sheet was supposed to be updated and signed by nursing staff. The DON stated at discharge the personal items were supposed to be inventoried by a nursing staff and the items are to be given to the resident or the RP. Regarding Resident #9, the DON stated, signatures are not captured and noted in the progress notes; in other words, no inventory of Resident #9's personal belongings was done by nursing staff either at admission or discharge. The DON repeated the facility could not find an inventory sheet involving Resident #9 done at admissions or discharge.<BR/>Record review of facility's Transfer or Discharge Documentation dated revised [DATE] reflected, .When a resident is transferred or discharged from the facility, the following information will be documented in the medical record .Disposition of personal effects.<BR/>Record review of the facility's Admitting the Resident: Role of the Nursing Assistant policy dated revised February 2022 read, .Assist with Inventory of the Resident's Personal Effects .<BR/>Record review of facility's Resident Rights policy dated revised February 2021 reflected, .be free from abuse, neglect, misappropriation of property .<BR/>Record review of the facility's Abuse, Neglect, and Exploitation dated revised [DATE] read, The facility will provide protection for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property.<BR/>Review of the facility's electronic forms did not reveal the presence of any electronic form addressing inventory of personal belongings at admissions or discharge of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 8 residents (Residents #1 and #2) reviewed for accidents hazards and supervision, in that:<BR/>1. On [DATE] at 8:54 a.m., Resident #1 was found outside the facility near a busy two way street near the facility. The facility did not investigate whether Resident #1 had received adequate supervision. Also, the facility did not have a mechanism in place for monitoring the front door to ensure resident supervision/monitoring resulting in Resident #1's elopement.<BR/>2. On [DATE] at 6:45 a.m., Resident #2 was found bleeding from the head from an unwitnessed fall in the Women's Secured Unit. Facility staff were not monitoring the resident's movements and were aware the resident was agitated. Facility's failure to provide adequate supervision resulted in the resident suffering a large subdural hematoma from a fall from a rolling stool in the dining room.<BR/>An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to establish a permanent alarm system for the monitoring of the front door. <BR/>The failure could place residents at risk of experiencing accidents, injuries, and/or death.<BR/>The findings included:<BR/>1. Record review of Resident#1's face sheet, dated [DATE] revealed, the resident was admitted on [DATE] with diagnoses that included: dementia, major depressive disorder, and anxiety. Resident was a male age [AGE]. The RP was listed as a family member.<BR/>Record review of Resident#1's quarterly MDS, dated [DATE], revealed: <BR/>o BIMS Score was 5 (0-5: severe cognitive impairment.) ADLs for transfer was supervision only. ROM listed no impairments.<BR/>Record review of Resident #1's Care Plan dated [DATE], revealed the goals and interventions included: placement in the secured unit due to wandering and/or exit seeking behaviors. An approach documented in the said CP was for Frequent staff rounding and redirection when wandering/exit seeking observed. <BR/>Record review of Resident#1's MAR (medication administration record), dated [DATE] revealed, Psychotropic medications included: Aricept 5 mg 1 tab daily (dementia) and Zoloft 25 mgs I tab daily (depression) and Depakote 125 mgs 1 tab twice per day (dementia). <BR/>Record review of Resident#1's Skin Assessments revealed : (dated [DATE]) revealed: skin intact. <BR/>Record review of Resident #1's Fall Risk Score (dated [DATE]) revealed, a rating of not at risk for elopement. <BR/>Record review of Resident#1's Physician' Orders, dated [DATE] , revealed no specific order for the close monitoring of the resident. <BR/>Record review of Resident #1's Nurse Notes revealed:<BR/> [DATE] at 8:59 a.m., authored by LVN A revealed: the LVN was notified the resident had left the Men's Secured Unit. LVN A and CNA B went outside the facility and saw Resident #1 walking down the street. A visiting family member offered LVN A car transportation to bring Resident #1 back to the facility. The MD and RP were notified of the elopement. LVN A conducted a full assessment of the resident and no injuries found. <BR/>[DATE] at 9:07 a.m. authored by LVN A revealed: Resident #1 put on 15 minute checks for elopement prevention.<BR/>Record review or staff statements date [DATE] revealed:<BR/>CNA B documented : staff became aware of resident missing between the hours of 8:00 am to 9:00 am. CNA B assisted LVN A in returning the resident back to the facility.<BR/>Housekeeping Aide C documented she was in the front room and saw resident leaving to the front door and notified HR Aide D [no time listed].<BR/>HR Aide D reflected: at 8:56 am ([DATE]) she spoke to Housekeeping Aide C and was informed the resident [Resident #1] left through the front door; and notified LVN A.<BR/>Record review of facility's internal investigation packet revealed:<BR/>5 day investigation report was completed and the finding was missing person confirmed. <BR/>In-service on the topics of abuse and neglect and elopement were initiated on [DATE].<BR/>72 hour monitoring sheet was present.<BR/>During a telephone interview on [DATE] at 9:45 AM, a message was left for return call to surveyor. Called returned at 10:00 AM. Housekeeping Aide C stated that she saw Resident #1 leaving the facility and did not follow him or maintain eye contact. Housekeeping Aide C stated she informed HR Aide D about Resident #1 leaving through the front door.<BR/>During an observation and interview on [DATE] at 9:00 a.m., Receptionist E stated in the month of February 2024 she was made receptionist for the front desk [day shift] with the duty to observe residents and visitor movements at the front door. Observation revealed that there was no bell or alarm on the front door that alerted staff when a person entered or left through the front door. Receptionist E stated the door was not monitored on weekends/nights or when she left the front desk. <BR/>During an observation and interview on [DATE] at 10:30 a.m., revealed during while the path Resident #1 took when he was found to be a missing person on [DATE] was walked, with the Administrator, the resident had walked outside the facility's boundary for about 100 feet before being found at a local charity store. There was a busy street with traffic in both directions in the path the resident took on [DATE], and the Administrator stated the resident did not cross the busy street but continued to walk on the sidewalks parallel to the nursing facility. The Administrator stated, fortunately a family member and the former MDS Nurse saw the resident walking down the sidewalk while driving in their respective cars and immediately notified the facility of the resident walking away from the facility. The Administrator stated the facility when notified of the missing person dispatched nursing staff to convince the resident to return to the facility; the resident returned and was placed back in the Men's Secured Unit. The Administrator stated the preventative measures put in place after the incident on [DATE] included: in-service training on abuse/ neglect and missing persons, signs of the doors on the secured units advising all staff and visitors to use the door and check for piggy-backing (residents following visitors or staff), change of door codes, and verification of the census.<BR/>Observation on [DATE] on [DATE] at 10:35 a.m. of Men's Secured Unit revealed there were two signs inside the unit which read: Stop .Please ask for assistance from staff when entering and exiting a secure unit .Please do not let unsupervised residents leave the secured unit unattended. The signs to the entrance of the Men's Secured Unit read: Please ask for assistance from staff when entering and exiting a secure unit. <BR/>During an observation and interview on [DATE] at 11:34 a.m., Resident #1 was in bed in the Men's Secured Unit, alert and oriented to person and place; cleaned and groomed. The resident did not reveal signs of injury, bruises or skin tears, and the resident was ambulatory. The resident stated: I did leave .but do not remember .not sure whether someone saw me leaving .I walked alone when the door opened .no one stopped me .I was going to my house .I did not want to be here .they found me and brought me back .I probably was gone for five minutes .I feel safe here .but I want to be in my house .I have not tried to escape again .if taken to my house I will stay in my house .the door is now locked in the [unit] and I cannot leave .I have not tried to leave again .there is no abuse .no neglect .I just want to be home . <BR/>During an interview with the Administrator and MDS Nurse G on [DATE] at 11:53 a.m., the Administrator and MDS Nurse G revealed the following timeline involving the missing person incident on [DATE]:<BR/>8:55 a.m.: from Nurse progress note authored by LVN A stated Resident #1 had completed eating breakfast and likely followed a visiting person outside the Men's Unit.<BR/>8:55 -8:56 a.m.: Housekeeping Aide C was sitting up front (from interview with the Administrator) and she saw the resident leaving the front door and reported to HR Aide D. [no process/procedure or elopement training was in place at the time of the incident]<BR/>8:56 a.m.: (from written statement authored by HR Aide D) statement made that HR Aide D called the Men's Unit and notified the nurse station and spoke to LVN A.<BR/>8:56 a.m.: (from interview with Administrator) a visitor and the MDS Nurse H (no longer an employee) alerted someone in the facility that the resident was seen away from the facility.<BR/>8:56 a.m.: LVN A and CNA B (no longer an employee) left the facility immediately to retrieve the resident.<BR/>8:57 a.m.: LVN A and CNA B met up with the resident about 100-200 feet and convinced the resident to return (in nurse notes) and accepted a visitor's offer to drive the resident and staff back to the facility.<BR/>8:59 a.m.: Nurse Note authored by LVN A stated that resident was back in the secured unit. <BR/>During an interview with MDS Nurse G on [DATE] at 2:10 p.m., MDS Nurse G stated after the elopement of Resident #1 the 72-hour monitoring order was discontinued on [DATE]. MDS Nurse G stated the resident did not experience any other exit seeking behaviors after [DATE]. MDS Nurse G stated law enforcement was not notified; but the MD, and RP were notified of the elopement.<BR/>During an interview with HR Aide D on [DATE] at 2:48 p.m., HR Aide D stated the statement written on [DATE] was correct. HR Aide D stated she did not maintain eye contact of Resident #1 because she was not sure the person identified by Housekeeping Aide C was a resident of the facility. HR Aide D stated after the training on missing persons the highlight was to follow the person until help arrived. <BR/>During an interview with the ADON on [DATE] at 6:01 p.m , the ADON stated she was told by LVN A that Resident #1 had left the Men's Unit on [DATE]. The ADON stated the code to the Secured Men's Unit might have been given to a regular family member not related to Resident #1 who visited the Men's Unit and the resident had followed someone's family member on the day of the incident. The ADON stated the current practice was for only paid staff to have the secure units' codes and to educate agency nursing staff not to give the code out. The ADON stated, in-service was given and the codes were changed and a door bell was placed in the secured units to announce entering the secured units after the incident.<BR/>Record review of facility's Emergency Procedure-Missing Resident dated revised [DATE] read, .Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety .<BR/>Record review of the facility's Wandering and Elopements policy dated revised [DATE] read, .Adequate supervision will be provided to help prevent accidents or elopements . <BR/>2. Record review of Resident #2's face sheet, dated [DATE] revealed, the resident was admitted on [DATE] with diagnoses that included: dementia, osteoarthritis (weak bones), and agitation and restlessness. Resident was a female age [AGE]. RP was listed as a family member.<BR/>Record review of Resident#2's Care Plan revealed the goals and interventions included: [start date [DATE]] at risk for falls with interventions: assistance, re-direction, safety measures, and monitoring. [[DATE]] additional interventions: proper foot attire, and keep pathway free of obstacles.<BR/>Record review of Resident #2's quarterly MDS dated 11/2023 revealed: BIMS score was 99 (unable to answer questions), transfer was listed as supervision, bed Mobility was listed as supervision, and ROM was documented as no impairments.<BR/>Record review of Resident #2's Fall Risk Score (dated [DATE] ) revealed a rating of high risk for falls.<BR/>Record review of Resident #2's Nurse Note authored by LVN K, dated [DATE], revealed, resident did not sleep well and was agitated all night. At 6:15 a.m. the resident was in the dining area near the trash can and pick-up the trash can and carried it around. The resident was re-directed and sent to her room. Resident returned to dining room and LVN K and CNA J heard and noise and noted resident on the floor lying next to a rolling stool on her right side and blood was noted on the floor. Resident was bleeding from the forehead and pressure was applied to the site. Vitals taken (temp 98.0 (normal), pulse 54 (normal), respiration 18 (normal), Blood Pressure 110/76 (normal), O2 (95% room air-normal). 911 was called. LVN K notified Hospice, RP, and MD of the unwitnessed fall.<BR/>Record review of Resident #2's clinical record revealed, Resident #2 was found on the dining room floor bleeding from the head from an unwitnessed fall on [DATE] at 6:45 AM. Staff members in the Women's Secured Unit were not monitoring the resident's movement in the dining room after the resident displayed agitation and left obstacles in her pathway. Resident #2 was taken by EMS to a local hospital where she was assessed and eventually underwent surgery for a large subdural hematoma with mid line shift (bleeding in the brain creating pressure on one side of the brain). Hospital status post finding revealed a craniotomy (a surgical procedure to remove the subdural hematoma) on [DATE].<BR/>Record review of Resident #2's hospital record dated [DATE] revealed: resident had a large subdural hematoma with mid line shift; placement in ICU; and physical restraint for aggression and behaviors. Status post craniotomy (a surgical procedure to remove the subdural hematoma) on [DATE]. Resident was discharged to another NF on [DATE]. Hospital diagnoses at discharge: SDH and Alzheimer's disease, HTN and history of falls. <BR/>Record review of facility's discharge list dated [DATE] revealed Resident #2 was discharged [DATE] to hospital and did not return. <BR/>Record review of Resident #2's Skin Assessments revealed: (dated [DATE]) laceration to the upper right side of the forehead; no measurements.<BR/>Record review of Resident #2's Fall Risk Score (dated [DATE]) revealed, a rating of high risk for falls.<BR/>Record review of Resident #2's Physician' Orders, dated [DATE] revealed, no specific order for more than routine monitoring the resident's movements in the secured unit. <BR/>Record review of Resident #2's incident report dated [DATE] authored LVN K revealed: unwitnessed fall with injury from fall in dining room involving a rolling stool.<BR/>Record review of facility's Provider Investigation Report dated [DATE] involving the incident on [DATE] revealed:<BR/>Disciplinary action taken against CNA J, LVN K and NA L; all three employees were terminated.<BR/>Rolling stools removed from the Unit.<BR/>Investigation summary: Overall, the allegations did not prove [Resident #2] had an unwitnessed fall with significant injury. [Resident #2] had a laceration to the right side of forehead and was admitted to hospital with a diagnosis of brain bleed (some old and some new) .disciplinary action taken .rolling stools removed .education provided .<BR/>5 day report submitted; finding was inconclusive.<BR/>Start of neuro checks pending EMS arrival from 6:45 AM-7:15 AM.<BR/>Inservice on fall prevention [DATE] for 35 employees in the secured units. <BR/>Record review of three terminated employees' written statements revealed:<BR/>LVN K [hire date [DATE]]: at [DATE] at 6:45 a.m. when resident fell the LVN [K] was standing in front of the nurse's cart away from the resident.<BR/>CNA J [hire date [DATE]]: not present in the dining room when fall occurred; location was at hall near Nurse station.<BR/>CNA L [hire date [DATE]]: not present when fall occurred; location was at the Nurse Station. <BR/>Record review of three terminated employee files revealed: they had received Abuse/Neglect Training and Fall Prevention Training at hiring and also on the day of the incident [DATE]. <BR/>Record review of facility's employee list of dated [DATE] revealed: 13 dedicated staff assigned to the secured units.<BR/>Record review of in-service training on fall prevention started [DATE] to [DATE] revealed 117 employees received the training (100 % completion rate).<BR/>Record review of the facility's Wandering and Elopements policy, dated revised [DATE], read, .Adequate supervision will be provided to help prevent accidents or elopements . <BR/>Record review of facility's Resident Rights policy, dated revised February 2021, read, .rights include the resident's right to .a dignified existence .be free from abuse, neglect, misappropriation of property, and exploitation .<BR/>Record review of facility's Falls-Clinical Protocol policy, dated Revised [DATE], read, .The physician will help identify individuals with a history of falls and risk factors for falling .The staff and practitioner will review each resident's risk factors for falling and document in the medical record .<BR/>During an interview on [DATE] at 11:58 a.m., NP stated she was informed of the unwitnessed fall involving Resident #2 from a rolling stool. The NP stated there were no orders other than routine monitoring of residents in the secured unit.<BR/>During an interview on [DATE] at 12:36 p.m., the Administrator stated his investigation revealed the unwitnessed fall was actually witnessed by the staff hearing the fall. The Administrator stated he terminated all the 3 employees (CNA J, LVN K and NA L) because thy failed to monitor the dining room before breakfast meal which led to Resident #2 falling from a rolling stool. The Administrator stated post incident the interventions put in place included: no rolling stools in the secured unit, an in-service of staff, fall risk assessments for secured unit residents, and updated care plans if necessary. The Administrator stated the timeline of the incident on [DATE] was: unwitnessed fall at 6:45 a.m. EMS arrived at 7:15 a.m.<BR/>During telephone call on [DATE] at 2:13 p.m., Hospice RN stated: hospice was contacted concerning the resident falling in dining room and suffering a laceration to the head requiring a visit to the ER. <BR/>During a telephone interview on [DATE] at 2:21 p.m., the RP stated , .[the resident] was sent to the ER and had to undergo brain surgery .she was hospitalized for one week and put in ICU for the brain bleed .after the hospital stay [Resident #2] was transfer to another NF for three months and then died .I hold [the NF] responsible for the death of [Resident #2]. The RP stated that she was notified of the incident on [DATE]. <BR/>In interviews on [DATE] from 10:00 a.m. to 10:30 a.m. with 5 day shift (6:00 a.m. to 6:00 p.m.) nursing staff (1 LVNs and 3 CNAs) and one other (Activity Tech) in the Men's Secured Unit; also, in the Women's Unit nursing staff (1 LVN and 2 CNAs); revealed: they had been in-serviced on fall prevention in the Secured Units with the highlights of: no rolling stools, no objects that could create hazards or accidents, no wet floors and maintaining supervision of the residents. Further interviews of 5 night staff (6:00 p.m. to 6:00 a.m.) (2 LVNs, 2 CNAs, and 1 MA) revealed they had the latter fall prevention training on maintaining safety in the secured units as well as throughout the facility. <BR/>In interviews on [DATE] from 12:15 p.m. to 12:30 p.m. 15 with day shift (6:00 a.m. to 6:00 p.m.) nursing staff (1 LVN and 1 CNA), 9 therapy staff (day shift) (4 PTAs, 3 OTs, 1 SP, 1 Rehab Tech) and 3 night shift (6:00 p.m. to 6:00 a.m.) included (1 LVN and 1 MA) and 9 other staff (1 Maintenance, 2 HR, and 1 Housekeeping) staff nursing and; further interviews of 5 night staff (6:00 p.m. to 6:00 a.m.) (2 LVNs, 2 CNAs, and 1 MA) revealed they had been in-serviced on fall prevention in the Secured Units with the highlights of: no rolling stools, no objects that could create hazards or accidents, no wet floors and maintaining supervision of the residents; also no fall or accident hazards throughout the facility. <BR/>The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]) <BR/>1. 100 percent completion rate for in-service of 117 paid staff on fall prevention (completed [DATE]). <BR/>2. Immediate Inservice on fall prevention on [DATE] for 35 employees assigned to the secured units. <BR/>3. Termination of the three employees (LVN K, CNA J, and NA L) for failing to provide supervision to Resident #2.<BR/>4. Assessment of resident #2 at time of fall and transferring the resident to the ER.<BR/>5. Neurology checks before the arrival of EMS from 6:45 a.m. to 7:15 a.m.<BR/>6. Assessing the scene of the fall and removing rolling stools.<BR/>7. Notifying the RP, Hospice, and MD of the fall.<BR/>Observation of Women's and Men's Secured Units on [DATE] and [DATE] revealed no rolling stools present or equipment or objects that could create accidents and hazards and adequate supervision.<BR/>During telephone interview on [DATE] at 4:10 p.m., LVN K stated the resident was agitated and moving in and out of resident rooms and eventually found a trash can she carried. LVN K stated the resident was redirected and sent back into her room in preparation for the breakfast meal. LVN K stated the resident was left unsupervised and returned to the dining hall where she found a rolling stool and tried to sit on it a fell. LVN K stated at the time of the incident she was preparing medications for morning dispensing. LVN K stated she was terminated because Resident #2 was left unsupervised. <BR/>During a telephone interview on [DATE] at 4:51 p.m., CNA J stated that Resident #2 was highly agitated on [DATE] and wandered throughout the unit and eventually found a rolling stool where she fell from. At the time of the incident, CNA J stated she was at the nurse station doing documentation. CNA J stated she was terminated for not monitoring Resident #2 on the day of the fall.<BR/>Attempted telephone calls to [DATE] at 3:55 p.m. and 4:00 p.m. to NA L revealed the phone was busy not accepting any calls or messages.<BR/>Interviews with 33 day and night staff (8 LVNs, 9 CNAs, 3 MAs, 9 Rehab staff, 1 Housekeeping, 1 HR, 1 Maintenance, and 1 Activity) on [DATE] from 1:00 p.m. to 2:00 p.m. revealed they had received an in-service on fall prevention with the return demonstration highlights: check on obstacles in the secured units and throughout the facility that could create accidents and hazards. <BR/>The Administrator was notified of an Immediate Jeopardy (IJ) on [DATE] at 6:35 p.m. The Administrator was provided with the IJ Template and a Plan of Removal was requested. <BR/>The facility provided a Plan of Removal which reads as follows: <BR/>Plan of Removal:<BR/>689: Accidents, Hazards, Supervision & Devices<BR/>Date Initiated: [DATE]<BR/>Today's Date: [DATE]<BR/>The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 22 residents (Resident #1) reviewed for adequate supervision.<BR/>All residents residing on the secured unit can be affected by this deficient practice. <BR/>Immediate Action Performed:<BR/>Action: Resident #1 was assisted back into the nursing home, resident was assessed, elopement assessment performed, and care plan updated. Resident was placed on 15 min checks until evaluated by the Psychology provider and medication review and adjustments completed.<BR/>Notified the Administrator, Notified MD, and Responsible Party.<BR/>Person(s) Responsible: Director of Nursing <BR/>Date: [DATE]<BR/>Action: <BR/>- Resident head count performed with all residents residing at [the facility]. No other missing residents identified.<BR/>- Elopement assessment performed on all residents at [the facility]. Any residents residing on the secured unit have elopement assessment, secured unit assessment, orders, consent and care plans in place. <BR/>Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee<BR/>Date: [DATE]<BR/>Action: To prevent future occurrence the facility has-<BR/>Placed signs on the inside and outside of the secured unit doors informing staff, vendors, and visitors to Please do not allow residents to follow you out. <BR/>Secured unit doors codes have been changed, staff aware of the codes, doorbell installed and visitors/vendors will be let in by staff.<BR/>Person(s) Responsible: Administrator, Director of Nursing, and/or Designee <BR/>Date: [DATE]<BR/>Steps to Achieve Compliance:<BR/>Action: Resident #1 was assessed for and further exit seeking behaviors and elopement risk assessment performed. They resident care plan was updated. <BR/>Person(s) Responsible: Director of Nursing <BR/>Date: [DATE]<BR/>Action: Place a staff member, continuously on all shifts at the front door until the Interdisciplinary Team (Including minimum Administrator, Director of Nursing, Assistant Director of Nursing, and Maintenance Director) can implement an alarm or a keypad that would alarm and/or require a code to exit the front door of the center. <BR/>Person(s) Responsible: Administrator, Maintenance Director, and/or Designee <BR/>Date: [DATE]<BR/>Action: Elopement assessments reperformed on all residents. Elopement assessments and Secure Unit assessments will be repeated quarterly, annually and with significant change. The DON will review elopement assessments weekly to ensure they are completed timely. <BR/>Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee <BR/>Date: [DATE]<BR/>Action: Missing Resident & Wandering/Elopement education provided to all staff to include: <BR/>If you note a resident (with emphasis a resident on the secured unit) attempting to exit any door, stay with resident and ensure that they have signed out and/or have appropriate supervision. <BR/>Elopement book has been verified as updated and staff education on location of the elopement book, which includes residents on the secured unit that are at risk for elopement. The Elopement Book will be updated daily with any changes by the Social Worker/designee.<BR/>All employees, including new and temporary, to be educated prior to working their next shift. All newly hired employees will be education during orientation, prior to first scheduled shift The DON/designee will review the next days schedule daily to ensure that any staff scheduled to work on the oncoming shifts have been educated. <BR/>Person(s) Responsible: Administrator, Director of Nursing, and/or Designee<BR/>Date: [DATE] <BR/>Action: Ad hoc QAPI performed with Medical Director to inform of the Immediate Jeopardy template and the facility's action to remove the immediacy. <BR/>Person(s) Responsible: Administrator<BR/>Date: [DATE]<BR/>Verification of Plan of Removal:<BR/>During an observation and interview on [DATE] at 10:30 a.m. the front door was locked and when opened by the Admissions Coordinator, a bell sounded. Observation further revealed that a reception desk was set up with a ledger near the entrance to control traffic and out of the facility. The Admissions stated that her assignment was to monitor traffic during her shift. She stated that the facility was working on a permanent alarm system for the front.<BR/>Observation on [DATE] at 11:26 a.m. of Resident #1 revealed the resident was in the secured men's unit in the dining room socializing with other residents.<BR/>Observation on [DATE] at 12:05 p.m. of Men's Secured Unit had two signs inside the unit that read: Stop .Please ask for assistance from staff when entering and exiting a secure unit .Please do not let unsupervised residents leave the secured unit unattended. The signs to the entrance of the Men's Secured Unit read: Please ask for assistance from staff when entering and exiting a secure unit. The Women's Secured Unit signs read: Please do not allow residents to follow you out .Ensure door is locked behind you . Observation also revealed that the doorbell are operating in both secured units. <BR/>Observation on [DATE] from 2:45 p.m.-2:55 p.m. revealed the location of the elopement books at: station 1, station 2, Men's Secured Unit and the Women's Secured Unit. <BR/>Record review of Resident's Nursing note dated [DATE] at 8:59 a.m. authored by, LVN A revealed the resident eloped from the facility and was missing for about 5 minutes; was assessed and returned to the facility. <BR/>Record review of Resident #1's elopement evaluation on [DATE] revealed high risk for elopement.<BR/>Record review of Resident #1's CP dated [DATE] revealed: the resident was an elopement risk. <BR/>Record review of Resident #1's behavior monitoring dated [DATE] to [DATE] revealed monitoring done and completed; see attachment.<BR/>Record review of Resident #1's Psychology evaluation on [DATE] by [psychiatric company] revealed: medications reviewed and follow-up visits.<BR/>Record review of Resident #1's Medication review done by the NP dated [DATE] revealed: medications reviewed and new order for Aricept 5 mgs once per day at bedtime (dementia).<BR/>Record review of Resident #1's Nurse Progress note dated [DATE] authored by LVN A revealed the MD was notified and the RP.<BR/>Record review of facility's census audit on [DATE] revealed 124 residents were present and no other resident had eloped.<BR/>Record review of sample residents (Residents #3 through #7) revealed elopement assessment was completed on [DATE]. <BR/>Record review of Secured Units' census on [DATE] revealed: Men's was 34 and Women was 22. <BR/>Record review of sample residents in the Men's Unit on [DATE] revealed Resident's clinical record contained the elopement assessment, secured unit assessment, orders, consent and care plan was in place.<BR/>Record review of sample residents in the Women's Unit on [DATE] revealed Resident #8's clinical record contained the elopement assessment, secured unit assessment, orders, consent and care plan was in place. <BR/>Record review of Resident #1's elopement assessment dated [DATE] authored by RN revealed the assessment was present; and resident assessed for high risk of elopement. <BR/>Record review of Resident #1's CP dated [DATE] revealed: the CP was updated and to closely monitor the resident for wandering and elopement. <BR/>Record review of facility's POR binder revealed 117 elopement assessments were present.<BR/>Record review of training on Missing Residents for 117 staff members revealed: 117 signatures were present for 100% completion.<BR/>Record review or email dated [DATE] to Medical Director revealed a discussion on the IJ and the POR. <BR/>During an interview on [DATE] at 12:09 p.m. the DON stated the codes to the locked units had been changed and would be changed every three months unless compromised. The DON stated, Staff were made aware of the codes individually when she made rounds and during orientation. The DON stated that the codes are not given to agency staff or visitors.<BR/>During an interview on [DATE] at 12:43 p.m., the Corporate Nurse stated that corporate headquarters is exploring a permanent solution for the front door monitoring to prevent elopement and tracking visitors.<BR/>During an interview on [DATE] at 12:49 p.m., the DON stated, yes .117 elopement assessments were completed .the resident at risk for elopement resided in the secur[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 47 residents (Resident #2) whose care plan was reviewed, in that:<BR/>The facility failed to ensure Resident #2's care plan included insulin<BR/>This deficient practice could place residents at risk of receiving the incorrect care and cause health complications with subsequent illness.<BR/>The findings were: <BR/>Record review of Resident #2's face sheet, dated 04/14/2023, revealed the resident was re-admitted on [DATE] with diagnoses that included: vascular dementia, type 2 diabetes, anxiety and psychotic disturbance. <BR/>Record review of Resident #2's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 08, which indicated moderate cognitive impairment. Further review for Active Diagnoses revealed I2900. Diabetes Mellitus (DM) . checked as a current diagnoses. <BR/>Record review of Resident #2's continuity of care document, dated 04/14/2023, revealed a medication with a start date of 01/30/2023 and a last administered date of 04/12/2023 at 08:21 pm and specifically read Levemir U-100Insulin (insulin detemir u-100)100 unit/mL solution; Once An Evening; 10 units, subcutaneous, Once An Evening, Administer 10 units subcutaneously in the evening for DM 2 HOLD IF BSIS &lt; 100; E11.9 : Type 2 diabetes mellitus without complications.<BR/>Record review of Resident #2's care plan, undated, revealed insulin nor diabetes was not listed as a problem area. <BR/>During an interview and record review on 05/13/2021 at 2:30 p.m., the Regional DON stated insulin was supposed to be on Resident #2's care plan. He stated it was supposed to be care planned when resident was diagnosed (with diabetes), which possibly since this resident was admitted . The Regional DON stated care plans began with the MDS or CCN and then the DON overseas that position. He stated it must have been overlooked. The Regional DON stated the potential harm to resident was a new nurse would not know this resident needed insulin or was diabetic, by just looking at the care plan. He further stated that if the order is in the system, the resident was supposed to be receiving the insulin regardless. <BR/>During an interview on 05/13/2023 at 4:38 p.m., the Administrator stated insulin was supposed to be added to the care plan at on-site of the problem. She further stated anyone in the nursing department has the authority to add items from the orders to the care plans. The Administrator stated that care plans are reviewed during their review date. The Ato the care plan. She then stated the IDT during the team conference ensured that everything was in place starting Administrator did not believe there was a potential harm to resident, being there was an order for the insulin and Resident #2 was receiving the service.

Based on interviews and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required. <BR/>The Dietary Manager (DM) did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services.<BR/>This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.<BR/>The findings included:<BR/>Record review of the employee personnel file provided by the facility revealed the hire date for the DM was 03/22/2023. Further review of this personnel file, which included the DM's resume, did not reveal the DM was: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Had similar national certification for food service management and safety from a national certifying body; or (D) Had an associate's or higher degree in food service management or in hospitality; or (E) Had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety management that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. <BR/>Record review of the DM's certification documentation provided by the facility revealed the DM successfully completed the Texas Food Safety Manager Certification Examination, effective 07/26/2023, expiration date 5 years from the effective date.<BR/>Record review of the facility employee files revealed the facility's RD was contracted and not a full-time employee of the facility.<BR/>During an interview on 06/28/2024 at 11:45 AM, the DM stated he was hired by the facility in early 2023, completed a Texas Food Manager's Certification program, received a certificate, and believed this certification met the requirements for the position. <BR/>During an interview on 06/28/2024 at 11:05 AM with the Administrator he stated he understood the Texas Food Manager's Certification was not a national certification and was not the appropriate certification for the position of the DM, and the DM did not meet any of the other qualifying criteria for the position. The Administrator further stated the DM was hired three months prior to his arrival at the facility.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with &sect;2-102.12.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>1. There was a zip-locked bag in the reach in cooler with diced ham that was past its use-by date.<BR/>2. There was an open bag of flour in the dry storage room that was not stored in a closed or tightly covered container.<BR/>3. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime.<BR/>These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.<BR/>The findings included:<BR/>1. Observation on 04/11/2023 at 10:20 a.m. in the reach-in cooler revealed there was a zip-locked bag on a shelf with the words, Diced ham. Also written on the bag was the date 3/23 and OP 3/28.<BR/>Interview on 04/11/2023 at 10:30 a.m. with the DM revealed the dates meant the ham was received by the facility on 3/23/2023 and opened on 3/28/2023. The DM stated that the ham had been in the cooler for 14 days by 04/11/2023 and should have been discarded in accordance with the facility's food storage policy. The DM further stated that any dietary staff member that stores food in the cooler is responsible for ensuring food is properly labeled, dated, and discarded according to the policy, and that failing to discard food in a timely manner could result in foodborne illness. Training on foodservice sanitation and safety was provided on a regular basis by the consultant dietitian.<BR/>2. Observation on 04/11/2023 at 10:35 a.m. in the dry storage room revealed a 25 lb. bag of flour on a shelf. The bag was approximately &frac14; full, and the top of the bag was rolled down. The bag was not closed with any type of fastener, and the bag was not enclosed in a sealed container. <BR/>Interview on 04/11/2023 at 10:41 a.m. with the DM revealed the bag of flour was not sealed, and the bag should have been stored either in a larger bag with a zip lock or a sealed container. The DM further stated that all kitchen staff store food in the dry storage room, and that failing to ensure food was properly sealed could result in deterioration in food quality and potential contamination from pests. <BR/>3. Observation on 04/11/2023 at 10:45 a.m. in the kitchen revealed the tabletop can opener was covered with sticky grime that was black and brown in color. The grime covered the blade portion of the can opener, the adjustable bar, and also surrounded the base that was affixed to the table with screws. <BR/>During an interview on 04/11/2023 at 10:46 a.m. with the DM, the DM stated that the can opener blade, bar and base were covered in sticky grime and should not have been. The DM stated the cooks were responsible for ensuring the can opener and area surrounding the base remained clean and free of debris, and that failing to do so could result in contamination of food from bacteria lingering on the blade and potential foodborne illness.<BR/>Review of facility policy 03.003 revised 06/01/2019 revealed: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Code and HACCP guidelines. 1. Dry Storage. d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators. e. Use all leftovers within 72 hours. Discard items that are 72 hours old.<BR/>Review of facility policy 04.009 Can Opener dated 10/01/2018 revealed, The facility will maintain can openers free of food particles and dirt to minimize the risk of food hazards. Can openers be cleaned after each use. 1. Hand held or table top. a. Remove can opener shank from base. b. Wash shank in sink with warm water and detergent or in the dishwasher. c. Give close attention to the blade and moving parts. d. Rinse in clean, hot water. e. Sanitize with approved sanitizer. Follow manufacturer's instructions for immersion times. f. Air dry. g. Wash base of can opener with clean cloth soaked in warm water and detergent, removing all food particles and dirt. h. Rinse with clean cloth soaked in clear hot water.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, , ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food contact surfaces and utensils shall be clean to sight and touch. <BR/>(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.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 reach-in freezers (Freezer #1) reviewed for essential equipment.<BR/>The facility did not ensure Freezer #1 was in safe operating condition. <BR/>This failure could place the residents at risk of foodborne illness for consuming food not stored at a safe temperature.<BR/>Findings included:<BR/>Observation on 06/25/2024 at 11:28 AM of the analogue thermometer inside Freezer #1 revealed the reading fluctuated between 40 and 42 degrees Fahrenheit. Further observation of several food items in Freezer #1 (two 6.5-lb. containers of sliced strawberries, a sample of biscuit dough from a closed case, and a sealed, uncooked pork loin of unknown weight) were all in a completely thawed state. <BR/>Record review of the temperature log attached to Freezer #1 revealed the temperature of Freezer #1 was 1.4 in the AM on 06/25/2024, 1.5 the PM on 06/24/2024, 1.4 the AM on 06/24/2024, and -1 the PM on 06/24/2024.<BR/>During an interview on 06/25/2024 at 11:29 AM with the DM, who was present during the observation of the analog thermometer's reading, he stated the food items in Freezer #1 were completely thawed. The DM further stated the seal of the door to Freezer #1 was not working properly, he was aware of this situation, and had put in a work order three weeks prior. He last checked on the contents of Freezer #1 on 06/21/2024 and there were no issues.<BR/>During an interview on 06/25/2024 at 11:37 AM with the Corporate RN, she stated all the food in Freezer #1 was thawed and would be discarded.<BR/>Observation on 06/25/2024 at 1:00 PM with the Corporate RN revealed the analogue thermometer inside Freezer #1 displayed a temperature of approximately 40 degrees Fahrenheit and the digital display outside the freezer read 32 degrees Fahrenheit.<BR/>During an interview on 06/25/2024 at 1:30 PM with the Maintenance Director, he stated he was told the middle door gasket on Freezer #1 was not sealing properly 1.5 weeks prior. He ordered the part and it arrived on 06/23/2024. He had not opened Freezer #1 and check the status of the food items inside the freezer because he did not have the key to the freezer. He further stated it was possible the external digital display on Freezer #1 had inadvertently changed from displaying the temperature in Fahrenheit measurements to Celsius measurements, which could occur with machines that had temperature displays. Therefore, recorded temperature of 1.4 on the temperature log would convert to between 34 - 35 degrees Fahrenheit. While this was a safe storage temperature for foods that needed to be kept cold, it still indicated Freezer #1 did not work properly and was not freezing food items.<BR/>During an interview on 06/25/2024 at 1:40 PM with the Administrator, he stated Freezer #1 should not have been used once it was noted the door was not sealing properly.<BR/>Record review of the word order provided by the facility revealed it was placed by on 05/23/2024 by the Maintenance Director and stated: 3-Door Freezer the middle door gasket is coming off and of the doors is not closing right and it's locked all the time and when someone is trying to open with locks on one of the doors stays propped open and temp drops so need a better locking method so door stays closed. Further review of the work order revealed the part was expected on 5/29/2024, it was delayed, and delivered on 06/10/2024. The Maintenance Director changed the status to completed on 06/10/2024 at 12:40 PM.<BR/>During an interview on 06/26/2024 at 2:40 PM with [NAME] E, he stated he reported the problem with the freezer door on Freezer #1 not sealing properly several times to the DM and the Maintenance Director over the past month and was told they were working on it and waiting on parts. He worked the AM shift and [NAME] F worked the night shift. Neither he nor [NAME] F had used any food for residents from Freezer #1 over the past 2 weeks. This freezer is used to store items such as biscuits and ice-cream. The pork loin was excess from a recently served meal and not needed.<BR/>Record review of facility policy 03.003 Food Storage, 2018, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 3. Freezers. a.Store all frozen meats, poultry, seafood, fruits and vegetables, and some dairy products, such as ice cream, in the freezer at a temperature that maintains the frozen state of the foods. h. Place a thermometer inside freezers near the door where the temperature is warmest. Check the temperature of all freezers using the internal thermometer to make sure the temperature stays at 0&deg;F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the freezer.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-302.11 Packaged and Unpackaged Food - Protection Separation, Packaging, and Segregation. The freezer equipment should be designed and maintained to keep foods in the frozen state. Corrective action should be taken if the storage or display unit loses power or otherwise fails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review the facility failed to immediately inform the resident's responsible party and physician when there was a significant change in the resident's physical, mental or psychological status for one resident (Resident #1) reviewed for notification of change of condition, in that:<BR/>The facility failed to notify Resident #1's responsible party and physician when Resident #1 sustained a burn injury after spilling hot coffee on himself.<BR/>The non-compliance was identified as past non-compliance. The non-compliance began on 08/28/2023 and ended on 09/01/2023. The facility had corrected the non-compliance before the survey began.<BR/>This failure placed residents' caregivers at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE]. His diagnoses included Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), viral pneumonia (an infection caused by a virus that causes inflammation in one or both of the lungs), chronic kidney disease, vascular dementia (dementia caused by problems in the blood supply to the brain, resulting from a cerebrovascular disease), and diabetes mellitus type II (an endocrine diseases characterized by sustained high blood sugar levels).<BR/>Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS could not be conducted as the resident was rarely/never understood and could not answer questions. Further review of this MDS revealed Resident #1 total assistance for eating with one person assistance. <BR/>Record review of Resident #1's Care Plan, dated 05/21/2021, revealed, Eating amount of assistance: One person assist. Further review revealed the resident's care plan did not state whether it was total or extensive assistance. <BR/>Record review of LVN A's progress note in Resident #1's EMR dated 08/28/2023 at 5:43 a.m. revealed: Resident was in dining room being assisted with coffee but dropped the cup when taking a drink. Redness to right side of abdomen and mid right arm.<BR/>Record review of Resident #1's EMR revealed the next note referring to the accident was on 08/31/2023. LVN A documented: Post coffee burn to right flank now with two open areas. Large open area measures 4 cm x 3 cm and smaller one measures 1.5 cm diameter. Dry dressing applied and secured with tape. Will make wound care aware of changes. There was no documentation Resident #1's RP, physician or NP were notified of the accident anywhere in Resident #1's EMR.<BR/>Interview on 11/09/2023 at 9:11 a.m. with CNA C stated she brought Resident #1 a cup of coffee in the dining room before the breakfast meal, as was the resident's routine. He picked it up, went to take a sip, and spilled it on himself. As soon as it happened, CNA C put her hand under his shirt to keep the liquid from causing any additional injury, wheeled the resident to his room, changed him, brought him back to the dining room, and reported the incident to LVN A. CNA C stated the resident had never demonstrated difficulty holding a cup prior to this incident. <BR/>Telephone interview on 11/08/2023 at 1:08 PM with LVN A stated she was informed of the incident by CNA C the morning of 08/28/2023, who was standing next to Resident #1 and saw the incident occur. LVN A said she did a skin assessment on Resident #1 and reported the incident to LVN B, the incoming day nurse. LVN A was off the next two days. Upon returning to work on 08/31/2023, LVN A called the resident's physician and spoke with the on-call service, who stated they would have the physician call the facility. <BR/>Interview on 11/09/2023 at 12:29 PM with Resident #1's NP stated she was told about the incident days after it happened.<BR/>Interview with the DON on 11/08/23 at 3:45 PM, the DON stated LVN A did not contact her, the ADON, the administrator, Resident #1's RP or Resident #1's physician/NP about the incident when it occurred and she was not made aware of the incident until 08/31/2023. All the notifications were made on that date. The DON stated LVN A believed notifying the incoming nurse was all she had to do. The DON stated LVN A had been a CNA at the facility for several years and received her nursing license within the last year, and LVN A had been trained multiple times on notification procedures when there was a significant change in a resident's condition prior to the incident. <BR/>Record review of training records provided by the facility revealed LVN A received training on Notification to NPs on 7/25/2023. The flyer attached to the sign-in sheet stated: Notify Nurse Practitioner of vital signs out of parameters or changes in condition every time.<BR/>Record review of LVN A's Clinical Skills evaluation dated 05/09/2023 revealed LVN A demonstrated competency in: 7. Resident Care Procedures f) Recognizes abnormalities; documentation; reporting.<BR/>Record review of the Job Description for Licensed Vocational Nurse, revised 05/20/2021, provided by the facility, revealed: Essential Functions/Primary Duties: .communicate with residents, family members, other interdisciplinary team members and management regarding resident status.<BR/>Record review of facility policy Accidents and Incidents - Investigating and Reporting, revised July 2017, revealed, 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom.<BR/>The facility completely corrected the deficient practice and provided as evidence the following:<BR/>- Record review of a copy of the self-report made to HHSC with investigation of the incident dated 08/31/2023.<BR/>- Record review of Quality Assessment Performance Improvement Committee documents related to the incident dated 08/31/2023 and attended by Administrator, DON and Medical Director. <BR/>- Record review of the facility's new policy regarding communication of documentation (attached to sign-in rosters dated 09/01/2023). Further review of the pokicy revealed: <BR/>- During the morning clinical meeting when reviewing documentation from the previous 24 hours, the ADON <BR/>and DON will text regarding important information that needs to be added to a nurse note such as provider <BR/>or responsible party notification.<BR/>- We ask that throughout the day you add the information to the resident chart.<BR/>- During the 3:30 stand down meeting, the ADON and I will review to be sure the missing information has <BR/>been added. <BR/>**Everyone does a great (job) documenting (in) the progress notes. The missing piece is usually the <BR/>notification.**<BR/>- Notify and document provider of blood glucose &gt;70 seems silly but it is what the physician asked us to do<BR/>- Notify and document for any blood sugar out of parameter<BR/>- Document and notify provider of all changes in condition including skin especially burns<BR/>- DOCUMENTATION PROTECTS YOU<BR/>- LVN A was suspended the day she received the counseling, on 08/31/2023<BR/>- Record review of sign in rosters for inservices on: Accidents/Incidents, Investigation and Reporting Burn/Skin Issues/Change of Condition, Safety & Supervision of Residents with evidence that all staff received the training dated 9/1/2023. Training conducted by DON and ADON.<BR/>- Record review of employee memorandum for LVN A detailing her failure to report change of condition to supervisor, physician and to notify responsible party; LVN A's suspension and education on failure to report dated 08/31/2023. Memorandum signed by DON and LVN A.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 7 residents (Reident #1), reviewed for care plan revisions, in that:<BR/>Resident #1's care plan was not revised a total of four times changes were made to the MDS specific to eating assistance.<BR/>This deficient practice could place residents at risk for lack of coordination of services and confusion as to eating assistance.<BR/>The finding included: <BR/>Record review of Resident #1's face sheet, dated 11/30/23, and EMR revealed the resident was admitted on [DATE] with diagnoses that included: Alzheimer's disease (primary) (progressive mental deterioration), abnormal gait and mobility, lack of coordination, stroke affecting right side of face; and hospice. Further review revealed the resident was a male; age [AGE], Advanced Directive was DNR, and the resident's Responsible Party was listed as a family member.<BR/>Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS could not be conducted as the resident was rarely/never understood and could not answer questions. Further review of this MDS revealed Resident #1 total assistance for eating with one person assistance. <BR/>Record Review R#1's MDS for four time periods reflected:<BR/>MDS-07/26/23: Eating was total one person. <BR/>MDS-4/26/23: Eating was limited one person assistance. (staff does about 25%) <BR/>MDS-1/30/23: Eating was limited one person assistance. (staff does about 25%) <BR/>MDS-12/20/22: Eating was extensive one person assistance. (staff does about 50%-75%) [changes to the MDS were not captured in the CP dated 5/31/23]<BR/>Record review of Resident #1's care plan, dated 5/31/21, Resident #1's ADL reflected Eating amount of assist: One Person Assist [CP did not state whether it was total or extensive assistance]<BR/>During an interview on 11/30/23 at 11:10 AM, the Administrator stated the timeline was as follows:<BR/>- 5/31/21 Resident #1's care plan for ADL reflected, Eating amount of assist: One Person Assist.<BR/>- 7/06/23 Resident #1's MDS (quarterly) reflected, one person total assistance for eating.<BR/>- 8/28/23 in the morning Resident #1 spilled coffee on self not being assisted by CNA C.<BR/>- 8/30/23 Resident #1's MDS (significant change) reflected extensive assistance X1 (one person) <BR/>- 8/31/23 Resident #1 discovered with blisters: MD, RP, and Hospice notified. HHS report submitted.<BR/>- 9/06/23 Resident #1's care plan was revised to read, Eating assist with meals as needed.<BR/>During an interview on 11/30/23 at 12:23 PM, RN K (ADON) stated total assistance was defined as the person doing the feeding assistance, they provided 100 % of weight bearing, meaning the resident was not involved in the weight bearing. RN K (ADON) stated prior to the incident on 08/28/23, Resident #1 was total assistance in eating. RN K stated that extensive assistance meant that the staff provided the assistance in 50-75% of the weight bearing. Resident #1 was changed to extensive after the incident on 8/28/23. RN K stated Resident #1's care plan prior to the incident reflected Resident #1 was helped with eating/drinking. RN K further stated after the incident Resident #1's care plan was revised for eating was assist with meals as needed versus the MDS, dated [DATE], which documented for Resident #1 as extensive. RN K stated Resident #1's record contained no evidence or information which indicated the resident was independent in eating at the time of the incident.; nor was the CP revised. <BR/>During an interview on 11/30/23 at 1:00 PM, the Rehab Director stated a review of the Rehab notes for Resident #1 for the past year revealed there were no referrals to rehab involving feeding assistance; nor a referral for PT, OT, or SP; nor was a change to the care plan made by the Rehab department.<BR/>During an interview on 11/30/23 at 2:16 PM, LVN G (MDS) stated Resident #1's MDS dated [DATE] was coded that Resident #1 was total dependence one person for eating. LVN G added that there was a coding error in the MDS and the code for Resident #1 should have been extensive assistance with one person assistance. LVN G stated the CP dated 5/31/21 was not revised.<BR/>During an interview on 11/30/23 at 4:24 PM, CNA C stated Resident #1 feed himself and she had worked with the resident for over one year. CNA C stated the resident's eating requirement was extensive which meant that he was able to do some eating tasks with staff assistance. CNA C did not respond to the question as to whether she knew Resident #1's eating code by checking the resident's MDS, care plane, or checking with the charge nurse; nor was she aware of any revisions to the resident's care plan.<BR/>Record review of facility's Care Area Assessments policy, revised November 2019, read: . Document interventions on the care plan. <BR/>Record review of facility's Care Plans policy, dated December 2020, read: . care plans are revised as information about the residents and the residents' conditions change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 8 residents (Residents #1 and #2) reviewed for accidents hazards and supervision, in that:<BR/>1. On [DATE] at 8:54 a.m., Resident #1 was found outside the facility near a busy two way street near the facility. The facility did not investigate whether Resident #1 had received adequate supervision. Also, the facility did not have a mechanism in place for monitoring the front door to ensure resident supervision/monitoring resulting in Resident #1's elopement.<BR/>2. On [DATE] at 6:45 a.m., Resident #2 was found bleeding from the head from an unwitnessed fall in the Women's Secured Unit. Facility staff were not monitoring the resident's movements and were aware the resident was agitated. Facility's failure to provide adequate supervision resulted in the resident suffering a large subdural hematoma from a fall from a rolling stool in the dining room.<BR/>An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to establish a permanent alarm system for the monitoring of the front door. <BR/>The failure could place residents at risk of experiencing accidents, injuries, and/or death.<BR/>The findings included:<BR/>1. Record review of Resident#1's face sheet, dated [DATE] revealed, the resident was admitted on [DATE] with diagnoses that included: dementia, major depressive disorder, and anxiety. Resident was a male age [AGE]. The RP was listed as a family member.<BR/>Record review of Resident#1's quarterly MDS, dated [DATE], revealed: <BR/>o BIMS Score was 5 (0-5: severe cognitive impairment.) ADLs for transfer was supervision only. ROM listed no impairments.<BR/>Record review of Resident #1's Care Plan dated [DATE], revealed the goals and interventions included: placement in the secured unit due to wandering and/or exit seeking behaviors. An approach documented in the said CP was for Frequent staff rounding and redirection when wandering/exit seeking observed. <BR/>Record review of Resident#1's MAR (medication administration record), dated [DATE] revealed, Psychotropic medications included: Aricept 5 mg 1 tab daily (dementia) and Zoloft 25 mgs I tab daily (depression) and Depakote 125 mgs 1 tab twice per day (dementia). <BR/>Record review of Resident#1's Skin Assessments revealed : (dated [DATE]) revealed: skin intact. <BR/>Record review of Resident #1's Fall Risk Score (dated [DATE]) revealed, a rating of not at risk for elopement. <BR/>Record review of Resident#1's Physician' Orders, dated [DATE] , revealed no specific order for the close monitoring of the resident. <BR/>Record review of Resident #1's Nurse Notes revealed:<BR/> [DATE] at 8:59 a.m., authored by LVN A revealed: the LVN was notified the resident had left the Men's Secured Unit. LVN A and CNA B went outside the facility and saw Resident #1 walking down the street. A visiting family member offered LVN A car transportation to bring Resident #1 back to the facility. The MD and RP were notified of the elopement. LVN A conducted a full assessment of the resident and no injuries found. <BR/>[DATE] at 9:07 a.m. authored by LVN A revealed: Resident #1 put on 15 minute checks for elopement prevention.<BR/>Record review or staff statements date [DATE] revealed:<BR/>CNA B documented : staff became aware of resident missing between the hours of 8:00 am to 9:00 am. CNA B assisted LVN A in returning the resident back to the facility.<BR/>Housekeeping Aide C documented she was in the front room and saw resident leaving to the front door and notified HR Aide D [no time listed].<BR/>HR Aide D reflected: at 8:56 am ([DATE]) she spoke to Housekeeping Aide C and was informed the resident [Resident #1] left through the front door; and notified LVN A.<BR/>Record review of facility's internal investigation packet revealed:<BR/>5 day investigation report was completed and the finding was missing person confirmed. <BR/>In-service on the topics of abuse and neglect and elopement were initiated on [DATE].<BR/>72 hour monitoring sheet was present.<BR/>During a telephone interview on [DATE] at 9:45 AM, a message was left for return call to surveyor. Called returned at 10:00 AM. Housekeeping Aide C stated that she saw Resident #1 leaving the facility and did not follow him or maintain eye contact. Housekeeping Aide C stated she informed HR Aide D about Resident #1 leaving through the front door.<BR/>During an observation and interview on [DATE] at 9:00 a.m., Receptionist E stated in the month of February 2024 she was made receptionist for the front desk [day shift] with the duty to observe residents and visitor movements at the front door. Observation revealed that there was no bell or alarm on the front door that alerted staff when a person entered or left through the front door. Receptionist E stated the door was not monitored on weekends/nights or when she left the front desk. <BR/>During an observation and interview on [DATE] at 10:30 a.m., revealed during while the path Resident #1 took when he was found to be a missing person on [DATE] was walked, with the Administrator, the resident had walked outside the facility's boundary for about 100 feet before being found at a local charity store. There was a busy street with traffic in both directions in the path the resident took on [DATE], and the Administrator stated the resident did not cross the busy street but continued to walk on the sidewalks parallel to the nursing facility. The Administrator stated, fortunately a family member and the former MDS Nurse saw the resident walking down the sidewalk while driving in their respective cars and immediately notified the facility of the resident walking away from the facility. The Administrator stated the facility when notified of the missing person dispatched nursing staff to convince the resident to return to the facility; the resident returned and was placed back in the Men's Secured Unit. The Administrator stated the preventative measures put in place after the incident on [DATE] included: in-service training on abuse/ neglect and missing persons, signs of the doors on the secured units advising all staff and visitors to use the door and check for piggy-backing (residents following visitors or staff), change of door codes, and verification of the census.<BR/>Observation on [DATE] on [DATE] at 10:35 a.m. of Men's Secured Unit revealed there were two signs inside the unit which read: Stop .Please ask for assistance from staff when entering and exiting a secure unit .Please do not let unsupervised residents leave the secured unit unattended. The signs to the entrance of the Men's Secured Unit read: Please ask for assistance from staff when entering and exiting a secure unit. <BR/>During an observation and interview on [DATE] at 11:34 a.m., Resident #1 was in bed in the Men's Secured Unit, alert and oriented to person and place; cleaned and groomed. The resident did not reveal signs of injury, bruises or skin tears, and the resident was ambulatory. The resident stated: I did leave .but do not remember .not sure whether someone saw me leaving .I walked alone when the door opened .no one stopped me .I was going to my house .I did not want to be here .they found me and brought me back .I probably was gone for five minutes .I feel safe here .but I want to be in my house .I have not tried to escape again .if taken to my house I will stay in my house .the door is now locked in the [unit] and I cannot leave .I have not tried to leave again .there is no abuse .no neglect .I just want to be home . <BR/>During an interview with the Administrator and MDS Nurse G on [DATE] at 11:53 a.m., the Administrator and MDS Nurse G revealed the following timeline involving the missing person incident on [DATE]:<BR/>8:55 a.m.: from Nurse progress note authored by LVN A stated Resident #1 had completed eating breakfast and likely followed a visiting person outside the Men's Unit.<BR/>8:55 -8:56 a.m.: Housekeeping Aide C was sitting up front (from interview with the Administrator) and she saw the resident leaving the front door and reported to HR Aide D. [no process/procedure or elopement training was in place at the time of the incident]<BR/>8:56 a.m.: (from written statement authored by HR Aide D) statement made that HR Aide D called the Men's Unit and notified the nurse station and spoke to LVN A.<BR/>8:56 a.m.: (from interview with Administrator) a visitor and the MDS Nurse H (no longer an employee) alerted someone in the facility that the resident was seen away from the facility.<BR/>8:56 a.m.: LVN A and CNA B (no longer an employee) left the facility immediately to retrieve the resident.<BR/>8:57 a.m.: LVN A and CNA B met up with the resident about 100-200 feet and convinced the resident to return (in nurse notes) and accepted a visitor's offer to drive the resident and staff back to the facility.<BR/>8:59 a.m.: Nurse Note authored by LVN A stated that resident was back in the secured unit. <BR/>During an interview with MDS Nurse G on [DATE] at 2:10 p.m., MDS Nurse G stated after the elopement of Resident #1 the 72-hour monitoring order was discontinued on [DATE]. MDS Nurse G stated the resident did not experience any other exit seeking behaviors after [DATE]. MDS Nurse G stated law enforcement was not notified; but the MD, and RP were notified of the elopement.<BR/>During an interview with HR Aide D on [DATE] at 2:48 p.m., HR Aide D stated the statement written on [DATE] was correct. HR Aide D stated she did not maintain eye contact of Resident #1 because she was not sure the person identified by Housekeeping Aide C was a resident of the facility. HR Aide D stated after the training on missing persons the highlight was to follow the person until help arrived. <BR/>During an interview with the ADON on [DATE] at 6:01 p.m , the ADON stated she was told by LVN A that Resident #1 had left the Men's Unit on [DATE]. The ADON stated the code to the Secured Men's Unit might have been given to a regular family member not related to Resident #1 who visited the Men's Unit and the resident had followed someone's family member on the day of the incident. The ADON stated the current practice was for only paid staff to have the secure units' codes and to educate agency nursing staff not to give the code out. The ADON stated, in-service was given and the codes were changed and a door bell was placed in the secured units to announce entering the secured units after the incident.<BR/>Record review of facility's Emergency Procedure-Missing Resident dated revised [DATE] read, .Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety .<BR/>Record review of the facility's Wandering and Elopements policy dated revised [DATE] read, .Adequate supervision will be provided to help prevent accidents or elopements . <BR/>2. Record review of Resident #2's face sheet, dated [DATE] revealed, the resident was admitted on [DATE] with diagnoses that included: dementia, osteoarthritis (weak bones), and agitation and restlessness. Resident was a female age [AGE]. RP was listed as a family member.<BR/>Record review of Resident#2's Care Plan revealed the goals and interventions included: [start date [DATE]] at risk for falls with interventions: assistance, re-direction, safety measures, and monitoring. [[DATE]] additional interventions: proper foot attire, and keep pathway free of obstacles.<BR/>Record review of Resident #2's quarterly MDS dated 11/2023 revealed: BIMS score was 99 (unable to answer questions), transfer was listed as supervision, bed Mobility was listed as supervision, and ROM was documented as no impairments.<BR/>Record review of Resident #2's Fall Risk Score (dated [DATE] ) revealed a rating of high risk for falls.<BR/>Record review of Resident #2's Nurse Note authored by LVN K, dated [DATE], revealed, resident did not sleep well and was agitated all night. At 6:15 a.m. the resident was in the dining area near the trash can and pick-up the trash can and carried it around. The resident was re-directed and sent to her room. Resident returned to dining room and LVN K and CNA J heard and noise and noted resident on the floor lying next to a rolling stool on her right side and blood was noted on the floor. Resident was bleeding from the forehead and pressure was applied to the site. Vitals taken (temp 98.0 (normal), pulse 54 (normal), respiration 18 (normal), Blood Pressure 110/76 (normal), O2 (95% room air-normal). 911 was called. LVN K notified Hospice, RP, and MD of the unwitnessed fall.<BR/>Record review of Resident #2's clinical record revealed, Resident #2 was found on the dining room floor bleeding from the head from an unwitnessed fall on [DATE] at 6:45 AM. Staff members in the Women's Secured Unit were not monitoring the resident's movement in the dining room after the resident displayed agitation and left obstacles in her pathway. Resident #2 was taken by EMS to a local hospital where she was assessed and eventually underwent surgery for a large subdural hematoma with mid line shift (bleeding in the brain creating pressure on one side of the brain). Hospital status post finding revealed a craniotomy (a surgical procedure to remove the subdural hematoma) on [DATE].<BR/>Record review of Resident #2's hospital record dated [DATE] revealed: resident had a large subdural hematoma with mid line shift; placement in ICU; and physical restraint for aggression and behaviors. Status post craniotomy (a surgical procedure to remove the subdural hematoma) on [DATE]. Resident was discharged to another NF on [DATE]. Hospital diagnoses at discharge: SDH and Alzheimer's disease, HTN and history of falls. <BR/>Record review of facility's discharge list dated [DATE] revealed Resident #2 was discharged [DATE] to hospital and did not return. <BR/>Record review of Resident #2's Skin Assessments revealed: (dated [DATE]) laceration to the upper right side of the forehead; no measurements.<BR/>Record review of Resident #2's Fall Risk Score (dated [DATE]) revealed, a rating of high risk for falls.<BR/>Record review of Resident #2's Physician' Orders, dated [DATE] revealed, no specific order for more than routine monitoring the resident's movements in the secured unit. <BR/>Record review of Resident #2's incident report dated [DATE] authored LVN K revealed: unwitnessed fall with injury from fall in dining room involving a rolling stool.<BR/>Record review of facility's Provider Investigation Report dated [DATE] involving the incident on [DATE] revealed:<BR/>Disciplinary action taken against CNA J, LVN K and NA L; all three employees were terminated.<BR/>Rolling stools removed from the Unit.<BR/>Investigation summary: Overall, the allegations did not prove [Resident #2] had an unwitnessed fall with significant injury. [Resident #2] had a laceration to the right side of forehead and was admitted to hospital with a diagnosis of brain bleed (some old and some new) .disciplinary action taken .rolling stools removed .education provided .<BR/>5 day report submitted; finding was inconclusive.<BR/>Start of neuro checks pending EMS arrival from 6:45 AM-7:15 AM.<BR/>Inservice on fall prevention [DATE] for 35 employees in the secured units. <BR/>Record review of three terminated employees' written statements revealed:<BR/>LVN K [hire date [DATE]]: at [DATE] at 6:45 a.m. when resident fell the LVN [K] was standing in front of the nurse's cart away from the resident.<BR/>CNA J [hire date [DATE]]: not present in the dining room when fall occurred; location was at hall near Nurse station.<BR/>CNA L [hire date [DATE]]: not present when fall occurred; location was at the Nurse Station. <BR/>Record review of three terminated employee files revealed: they had received Abuse/Neglect Training and Fall Prevention Training at hiring and also on the day of the incident [DATE]. <BR/>Record review of facility's employee list of dated [DATE] revealed: 13 dedicated staff assigned to the secured units.<BR/>Record review of in-service training on fall prevention started [DATE] to [DATE] revealed 117 employees received the training (100 % completion rate).<BR/>Record review of the facility's Wandering and Elopements policy, dated revised [DATE], read, .Adequate supervision will be provided to help prevent accidents or elopements . <BR/>Record review of facility's Resident Rights policy, dated revised February 2021, read, .rights include the resident's right to .a dignified existence .be free from abuse, neglect, misappropriation of property, and exploitation .<BR/>Record review of facility's Falls-Clinical Protocol policy, dated Revised [DATE], read, .The physician will help identify individuals with a history of falls and risk factors for falling .The staff and practitioner will review each resident's risk factors for falling and document in the medical record .<BR/>During an interview on [DATE] at 11:58 a.m., NP stated she was informed of the unwitnessed fall involving Resident #2 from a rolling stool. The NP stated there were no orders other than routine monitoring of residents in the secured unit.<BR/>During an interview on [DATE] at 12:36 p.m., the Administrator stated his investigation revealed the unwitnessed fall was actually witnessed by the staff hearing the fall. The Administrator stated he terminated all the 3 employees (CNA J, LVN K and NA L) because thy failed to monitor the dining room before breakfast meal which led to Resident #2 falling from a rolling stool. The Administrator stated post incident the interventions put in place included: no rolling stools in the secured unit, an in-service of staff, fall risk assessments for secured unit residents, and updated care plans if necessary. The Administrator stated the timeline of the incident on [DATE] was: unwitnessed fall at 6:45 a.m. EMS arrived at 7:15 a.m.<BR/>During telephone call on [DATE] at 2:13 p.m., Hospice RN stated: hospice was contacted concerning the resident falling in dining room and suffering a laceration to the head requiring a visit to the ER. <BR/>During a telephone interview on [DATE] at 2:21 p.m., the RP stated , .[the resident] was sent to the ER and had to undergo brain surgery .she was hospitalized for one week and put in ICU for the brain bleed .after the hospital stay [Resident #2] was transfer to another NF for three months and then died .I hold [the NF] responsible for the death of [Resident #2]. The RP stated that she was notified of the incident on [DATE]. <BR/>In interviews on [DATE] from 10:00 a.m. to 10:30 a.m. with 5 day shift (6:00 a.m. to 6:00 p.m.) nursing staff (1 LVNs and 3 CNAs) and one other (Activity Tech) in the Men's Secured Unit; also, in the Women's Unit nursing staff (1 LVN and 2 CNAs); revealed: they had been in-serviced on fall prevention in the Secured Units with the highlights of: no rolling stools, no objects that could create hazards or accidents, no wet floors and maintaining supervision of the residents. Further interviews of 5 night staff (6:00 p.m. to 6:00 a.m.) (2 LVNs, 2 CNAs, and 1 MA) revealed they had the latter fall prevention training on maintaining safety in the secured units as well as throughout the facility. <BR/>In interviews on [DATE] from 12:15 p.m. to 12:30 p.m. 15 with day shift (6:00 a.m. to 6:00 p.m.) nursing staff (1 LVN and 1 CNA), 9 therapy staff (day shift) (4 PTAs, 3 OTs, 1 SP, 1 Rehab Tech) and 3 night shift (6:00 p.m. to 6:00 a.m.) included (1 LVN and 1 MA) and 9 other staff (1 Maintenance, 2 HR, and 1 Housekeeping) staff nursing and; further interviews of 5 night staff (6:00 p.m. to 6:00 a.m.) (2 LVNs, 2 CNAs, and 1 MA) revealed they had been in-serviced on fall prevention in the Secured Units with the highlights of: no rolling stools, no objects that could create hazards or accidents, no wet floors and maintaining supervision of the residents; also no fall or accident hazards throughout the facility. <BR/>The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]) <BR/>1. 100 percent completion rate for in-service of 117 paid staff on fall prevention (completed [DATE]). <BR/>2. Immediate Inservice on fall prevention on [DATE] for 35 employees assigned to the secured units. <BR/>3. Termination of the three employees (LVN K, CNA J, and NA L) for failing to provide supervision to Resident #2.<BR/>4. Assessment of resident #2 at time of fall and transferring the resident to the ER.<BR/>5. Neurology checks before the arrival of EMS from 6:45 a.m. to 7:15 a.m.<BR/>6. Assessing the scene of the fall and removing rolling stools.<BR/>7. Notifying the RP, Hospice, and MD of the fall.<BR/>Observation of Women's and Men's Secured Units on [DATE] and [DATE] revealed no rolling stools present or equipment or objects that could create accidents and hazards and adequate supervision.<BR/>During telephone interview on [DATE] at 4:10 p.m., LVN K stated the resident was agitated and moving in and out of resident rooms and eventually found a trash can she carried. LVN K stated the resident was redirected and sent back into her room in preparation for the breakfast meal. LVN K stated the resident was left unsupervised and returned to the dining hall where she found a rolling stool and tried to sit on it a fell. LVN K stated at the time of the incident she was preparing medications for morning dispensing. LVN K stated she was terminated because Resident #2 was left unsupervised. <BR/>During a telephone interview on [DATE] at 4:51 p.m., CNA J stated that Resident #2 was highly agitated on [DATE] and wandered throughout the unit and eventually found a rolling stool where she fell from. At the time of the incident, CNA J stated she was at the nurse station doing documentation. CNA J stated she was terminated for not monitoring Resident #2 on the day of the fall.<BR/>Attempted telephone calls to [DATE] at 3:55 p.m. and 4:00 p.m. to NA L revealed the phone was busy not accepting any calls or messages.<BR/>Interviews with 33 day and night staff (8 LVNs, 9 CNAs, 3 MAs, 9 Rehab staff, 1 Housekeeping, 1 HR, 1 Maintenance, and 1 Activity) on [DATE] from 1:00 p.m. to 2:00 p.m. revealed they had received an in-service on fall prevention with the return demonstration highlights: check on obstacles in the secured units and throughout the facility that could create accidents and hazards. <BR/>The Administrator was notified of an Immediate Jeopardy (IJ) on [DATE] at 6:35 p.m. The Administrator was provided with the IJ Template and a Plan of Removal was requested. <BR/>The facility provided a Plan of Removal which reads as follows: <BR/>Plan of Removal:<BR/>689: Accidents, Hazards, Supervision & Devices<BR/>Date Initiated: [DATE]<BR/>Today's Date: [DATE]<BR/>The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 22 residents (Resident #1) reviewed for adequate supervision.<BR/>All residents residing on the secured unit can be affected by this deficient practice. <BR/>Immediate Action Performed:<BR/>Action: Resident #1 was assisted back into the nursing home, resident was assessed, elopement assessment performed, and care plan updated. Resident was placed on 15 min checks until evaluated by the Psychology provider and medication review and adjustments completed.<BR/>Notified the Administrator, Notified MD, and Responsible Party.<BR/>Person(s) Responsible: Director of Nursing <BR/>Date: [DATE]<BR/>Action: <BR/>- Resident head count performed with all residents residing at [the facility]. No other missing residents identified.<BR/>- Elopement assessment performed on all residents at [the facility]. Any residents residing on the secured unit have elopement assessment, secured unit assessment, orders, consent and care plans in place. <BR/>Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee<BR/>Date: [DATE]<BR/>Action: To prevent future occurrence the facility has-<BR/>Placed signs on the inside and outside of the secured unit doors informing staff, vendors, and visitors to Please do not allow residents to follow you out. <BR/>Secured unit doors codes have been changed, staff aware of the codes, doorbell installed and visitors/vendors will be let in by staff.<BR/>Person(s) Responsible: Administrator, Director of Nursing, and/or Designee <BR/>Date: [DATE]<BR/>Steps to Achieve Compliance:<BR/>Action: Resident #1 was assessed for and further exit seeking behaviors and elopement risk assessment performed. They resident care plan was updated. <BR/>Person(s) Responsible: Director of Nursing <BR/>Date: [DATE]<BR/>Action: Place a staff member, continuously on all shifts at the front door until the Interdisciplinary Team (Including minimum Administrator, Director of Nursing, Assistant Director of Nursing, and Maintenance Director) can implement an alarm or a keypad that would alarm and/or require a code to exit the front door of the center. <BR/>Person(s) Responsible: Administrator, Maintenance Director, and/or Designee <BR/>Date: [DATE]<BR/>Action: Elopement assessments reperformed on all residents. Elopement assessments and Secure Unit assessments will be repeated quarterly, annually and with significant change. The DON will review elopement assessments weekly to ensure they are completed timely. <BR/>Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee <BR/>Date: [DATE]<BR/>Action: Missing Resident & Wandering/Elopement education provided to all staff to include: <BR/>If you note a resident (with emphasis a resident on the secured unit) attempting to exit any door, stay with resident and ensure that they have signed out and/or have appropriate supervision. <BR/>Elopement book has been verified as updated and staff education on location of the elopement book, which includes residents on the secured unit that are at risk for elopement. The Elopement Book will be updated daily with any changes by the Social Worker/designee.<BR/>All employees, including new and temporary, to be educated prior to working their next shift. All newly hired employees will be education during orientation, prior to first scheduled shift The DON/designee will review the next days schedule daily to ensure that any staff scheduled to work on the oncoming shifts have been educated. <BR/>Person(s) Responsible: Administrator, Director of Nursing, and/or Designee<BR/>Date: [DATE] <BR/>Action: Ad hoc QAPI performed with Medical Director to inform of the Immediate Jeopardy template and the facility's action to remove the immediacy. <BR/>Person(s) Responsible: Administrator<BR/>Date: [DATE]<BR/>Verification of Plan of Removal:<BR/>During an observation and interview on [DATE] at 10:30 a.m. the front door was locked and when opened by the Admissions Coordinator, a bell sounded. Observation further revealed that a reception desk was set up with a ledger near the entrance to control traffic and out of the facility. The Admissions stated that her assignment was to monitor traffic during her shift. She stated that the facility was working on a permanent alarm system for the front.<BR/>Observation on [DATE] at 11:26 a.m. of Resident #1 revealed the resident was in the secured men's unit in the dining room socializing with other residents.<BR/>Observation on [DATE] at 12:05 p.m. of Men's Secured Unit had two signs inside the unit that read: Stop .Please ask for assistance from staff when entering and exiting a secure unit .Please do not let unsupervised residents leave the secured unit unattended. The signs to the entrance of the Men's Secured Unit read: Please ask for assistance from staff when entering and exiting a secure unit. The Women's Secured Unit signs read: Please do not allow residents to follow you out .Ensure door is locked behind you . Observation also revealed that the doorbell are operating in both secured units. <BR/>Observation on [DATE] from 2:45 p.m.-2:55 p.m. revealed the location of the elopement books at: station 1, station 2, Men's Secured Unit and the Women's Secured Unit. <BR/>Record review of Resident's Nursing note dated [DATE] at 8:59 a.m. authored by, LVN A revealed the resident eloped from the facility and was missing for about 5 minutes; was assessed and returned to the facility. <BR/>Record review of Resident #1's elopement evaluation on [DATE] revealed high risk for elopement.<BR/>Record review of Resident #1's CP dated [DATE] revealed: the resident was an elopement risk. <BR/>Record review of Resident #1's behavior monitoring dated [DATE] to [DATE] revealed monitoring done and completed; see attachment.<BR/>Record review of Resident #1's Psychology evaluation on [DATE] by [psychiatric company] revealed: medications reviewed and follow-up visits.<BR/>Record review of Resident #1's Medication review done by the NP dated [DATE] revealed: medications reviewed and new order for Aricept 5 mgs once per day at bedtime (dementia).<BR/>Record review of Resident #1's Nurse Progress note dated [DATE] authored by LVN A revealed the MD was notified and the RP.<BR/>Record review of facility's census audit on [DATE] revealed 124 residents were present and no other resident had eloped.<BR/>Record review of sample residents (Residents #3 through #7) revealed elopement assessment was completed on [DATE]. <BR/>Record review of Secured Units' census on [DATE] revealed: Men's was 34 and Women was 22. <BR/>Record review of sample residents in the Men's Unit on [DATE] revealed Resident's clinical record contained the elopement assessment, secured unit assessment, orders, consent and care plan was in place.<BR/>Record review of sample residents in the Women's Unit on [DATE] revealed Resident #8's clinical record contained the elopement assessment, secured unit assessment, orders, consent and care plan was in place. <BR/>Record review of Resident #1's elopement assessment dated [DATE] authored by RN revealed the assessment was present; and resident assessed for high risk of elopement. <BR/>Record review of Resident #1's CP dated [DATE] revealed: the CP was updated and to closely monitor the resident for wandering and elopement. <BR/>Record review of facility's POR binder revealed 117 elopement assessments were present.<BR/>Record review of training on Missing Residents for 117 staff members revealed: 117 signatures were present for 100% completion.<BR/>Record review or email dated [DATE] to Medical Director revealed a discussion on the IJ and the POR. <BR/>During an interview on [DATE] at 12:09 p.m. the DON stated the codes to the locked units had been changed and would be changed every three months unless compromised. The DON stated, Staff were made aware of the codes individually when she made rounds and during orientation. The DON stated that the codes are not given to agency staff or visitors.<BR/>During an interview on [DATE] at 12:43 p.m., the Corporate Nurse stated that corporate headquarters is exploring a permanent solution for the front door monitoring to prevent elopement and tracking visitors.<BR/>During an interview on [DATE] at 12:49 p.m., the DON stated, yes .117 elopement assessments were completed .the resident at risk for elopement resided in the secur[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that licensed nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety for 2 of 29 licensed staff (LVN A and LVN B) reviewed for competent staff, in that:<BR/>1. The facility failed to ensure LVN A completed an incident report and notified Resident #1's RP and physician after he sustained a burn incident. <BR/>2. The facility failed to ensure LVN B documented care provided to Resident #1 in his EMR.<BR/>The non-compliance was identified as past non-compliance. The non-compliance began on 08/28/2023 and ended on 09/01/2023. The facility had corrected the non-compliance before the survey began.<BR/>These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety.<BR/>The findings included:<BR/>1. Record review of Resident #1's face sheet, dated 11/08/2023, and EMR revealed a revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), viral pneumonia (an infection caused by a virus that causes inflammation in one or both of the lungs), chronic kidney disease, vascular dementia (dementia caused by problems in the blood supply to the brain, resulting from a cerebrovascular disease), and diabetes mellitus type II (an endocrine diseases characterized by sustained high blood sugar levels).<BR/>Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS could not be conducted as the resident was rarely/never understood and could not answer questions. Further review of this MDS revealed Resident #1 total assistance for eating with one person assistance. <BR/>Record review of Resident #1's Care Plan, dated 05/21/2021, revealed, Eating amount of assistance: One person assist. Further review revealed the resident's care plan did not state whether it was total or extensive assistance. <BR/>Record review of LVN A's progress note in Resident #1's EMR dated 08/28/2023 at 5:43 a.m. revealed: Resident was in dining room being assisted with coffee but dropped the cup when taking a drink. Redness to right side of abdomen and mid right arm. Further review of the resident's EMR revealed there was no record of an incident report related to this incident and no documentation that the DON, Resident #1's RP or physician had been notified of the incident.<BR/>Telephone interview on 11/08/2023 at 1:08 PM with LVN A revealed she was informed of the incident the morning of 08/28/2023 by CNA C, who was standing next to Resident #1 and saw the incident occur. LVN A stated she did a skin assessment on Resident #1 and reported the incident to LVN B, the incoming day nurse. LVN A stated she was off the next two days and upon returning to work on 08/31/2023, LVN A stated she called the resident's physician and spoke with the on-call service, who stated they would have the physician call the facility. LVN A stated she completed the incident report on 08/31/2023.<BR/>Interview on 11/08/2023 at 3:45 PM with the DON revealed LVN A should have reported the incident to her supervisor, either an ADON or the DON and completed the incident report before leaving the facility on 08/28/2023 and failed to make the notifications and complete the report. The DON stated the incoming nurse would have expected her to do the incident report. The DON stated LVN A did it on 8/31/2023 when she reported the incident to LVN B. The DON further stated LVN A was put on a performance improvement plan for failure to report the incident to the appropriate individuals and she was counseled. The DON stated LVN A was upset and tearful she did not do the right thing for the resident. The DON stated when LVN A reported the incident to the incoming nurse, LVN A thought that was all she had to do. The DON stated LVN A has had training on the responsibilities of a nurse that specified documentation and reporting prior to the incident.<BR/>Interview on 11/09/2023 at 10:38 a.m. with ADON D stated LVN A told her about the incident on 08/31/2023, days after it had happened, and she (ADON D) told the DON. ADON D stated she knew LVN A pretty well, both as a CNA and a nurse and LVN A was a new nurse and was learning. ADON D stated when questioned LVN A cried and said over and over, I told LVN B. ASNO D stated the severity of the incident was made very clear to LVN A, that she needed to report this incident to us, the resident's RP and physician. ADON D staed tt was a hard lesson LVN A would not forget.<BR/>Interview on 11/09/2023 at 12:29 PM with Resident #1's NP revealed she was told about the incident days after it happened.<BR/>2. Record review of Resident #1's EMR revealed the note referring to Resident #1's burn incident after the initial note was dated 08/31/2023 at 5:32 a.m. LVN A documented: Post coffee burn to right flank now with two open areas. Large open area measures 4 cm x 3 cm and smaller one measures 1.5 cm diameter. Dry dressing applied and secured with tape. Will make wound care aware of changes. Further review revealed there was no other documentation in the resident's progress notes about this incident.<BR/>Telephone interview with LVN B on 11/08/2023 at 5:03 p.m., LVN B stated she was informed of the incident by LVN A. LVN B stated she used a hydrophilic wound dressing on Resident #1's burned area, and then placed a bandage with soft tape on the area. LVN B stated she did not document the care she provided to Resident #1 because, That side of the building had a million blood sugars I had to check before breakfast, so I did not document the treatment. I know I should have. LVN B stated she did not return to work at the facility until 08/31/2023.<BR/>Interview with NP E on 11/09/2023 at 12:29 p.m., NP E stated she was informed about Resident #1's burn after it happened. NP E stated when she saw Resident #1, the wound was healing well and the staff had been treating it before they told her. NP E further stated, Whatever they did, they did a good job. There was no infection, it was healing well.<BR/>Interview with wound NP F on 11/09/2023 at 12:23 p.m., wound NP F stated nurses could use triad hydrophilic cream without a prescription if they had it on hand for burns, though they preferred if the nursing staff contacted the wound care team.<BR/>Interview with the DON on 11/10/2023 at 10:55 a.m., the DON stated there was no documentation of the care Resident #1 received on his burn wound from the time of the injury on 08/28/2023 until 08/31/2023 and there should have been. The DON stated LVN A also did not complete an incident report at the time of the injury, and this should have been done before she ended her shift. The DON further stated ADON D was responsible for ensuring nurses completed all mandatory training. The DON stated in-person training was provided monthly and was also available online. <BR/>Record review of LVN A's Clinical Skills evaluation dated 05/09/2023 revealed LVN A demonstrated competency in: 7. Resident Care Procedures f) Recognizes abnormalities; documentation; reporting.<BR/>Record review of the Job Description for Licensed Vocational Nurse, revised 05/20/2021, provided by the facility, revealed: Essential Functions/Primary Duties: .communicate with residents, family members, other interdisciplinary team members and management regarding resident status.<BR/>Record review of facility policy Accidents and Incidents - Investigating and Reporting, revised July 2017, revealed, 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom.<BR/>Record review of facility policy Guidelines for Charting and Documentation revised April 2012 revealed: Personnel authorized to record data. 4. Nurses/Nursing Assistants. Purpose. The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to care, signs, symptoms, etc., and the progress of the resident's care; 2. Guidance to the physician in prescribing appropriate medications and treatments; 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident; 4. Nursing service personnel with a record of the physical and mental status of the resident; 5. Assistance in the development of a Plan of Care for each resident; 6. A legal record that protects the resident, care providers, and the facility. General Rules for Charting and Documentation. 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc. as well as routine observations. 5. Chart as often as the need arises. 6. Document assessments, interventions, treatments, outcomes, etc.<BR/>The facility completely corrected the deficient practice and provided as evidence the following:<BR/>- Record review of a copy of the self-report made to HHSC with investigation of the incident dated 08/31/2023.<BR/>- Record review of Quality Assessment Performance Improvement Committee documents related to the incident dated 08/31/2023 and attended by Administrator, DON and Medical Director. <BR/>- Record review of the facility's new policy regarding communication of documentation (attached to sign-in rosters dated 09/01/2023). Further review of the policy revealed: <BR/>- During the morning clinical meeting when reviewing documentation from the previous 24 hours, the ADON <BR/>and DON will text regarding important information that needs to be added to a nurse note such as provider or <BR/>responsible party notification.<BR/>- We ask that throughout the day you add the information to the resident chart.<BR/>- During the 3:30 stand down meeting, the ADON and I will review to be sure the missing information has been <BR/>added. <BR/>**Everyone does a great (job) documenting (in) the progress notes. The missing piece is usually the notification. <BR/>**<BR/>- Notify and document provider of blood glucose &gt;70 seems silly but it is what the physician asked us to do<BR/>- Notify and document for any blood sugar out of parameter<BR/>- Document and notify provider of all changes in condition including skin especially burns<BR/>- DOCUMENTATION PROTECTS YOU<BR/>- LVN A was suspended the day she received the counseling, on 08/31/2023<BR/>- Record review of sign in rosters for inservices on: Accidents/Incidents, Investigation and Reporting Burn/Skin Issues/Change of Condition, Safety & Supervision of Residents with evidence that all staff received the training dated 9/1/2023. Training conducted by DON and ADON.<BR/>- Record review of employee memorandum for LVN A detailing her failure to report change of condition to supervisor, physician and to notify responsible party; LVN A's suspension and education on failure to report dated 08/31/2023. Memorandum signed by DON and LVN A.

Based on interview and record review, the facility failed to in accordance with professional standards and practices, maintain clinical records that are complete and readily accessible for 2 of 6 residents (Resident #1 and Resident #2) reviewed for medical records. <BR/>1. Resident #1 medical record was missing Physician Visit Notes, or Non-physician practitioner (NPP) Visit Notes since 09/20/2022.<BR/>2. Resident #2 medical record was missing Physician Progress Notes, or NPP Visit Notes since 10/18/2022.<BR/>This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors or delays in care and treatment.<BR/>The findings included: <BR/>Record review of Resident #1's face sheet, dated 05/04/2023, revealed an admission date of 06/07/2022 and a latest return on 02/12/2023 with diagnoses including: acute respiratory disease, vascular dementia, and a personal history of transient ischemic attack (a brief, stroke-like attack that resolves itself). The resident had a recent history of transfer to the local hospital.<BR/>Record review of Resident #1's electronic medical record (EMR) on 05/04/2023 revealed the presence of physician or nurse practitioner (NP) progress notes with dates of service: 07/29/2022, 08/15/2022, and 09/20/2022. Physician or NPP progress notes were missing from the EMR following the 09/20/2022 visit.<BR/>Record review of Resident #2's face sheet, dated 05/04/2023, revealed an admission date of 10/03/2022 with diagnoses including: cerebral aneurysm (a bulging blood vessel in the brain), hypertension, and personal history of transient ischemic attack and cerebral infarction (disruption in the brain's blood flow).<BR/>Record review of Resident #2's EMR on 05/04/2023 revealed the presence of a physician progress note, date of service 10/18/2022. Physician or NPP progress notes were missing from the EMR following the 10/18/2022 visit.<BR/>In an interview with Staff A on 05/08/2023 at 11:30 a.m., record request submitted for a copy of the most recent Physician or NPP Visit Notes for Resident #1 and Resident #2.<BR/>In an interview with the ADON on 05/08/2023 at 4:13 p.m., the ADON revealed that there has been a big issue with documents not being uploaded since the company removed the medical records staffing position. She confirmed that the physician notes should have been obtained from the physician's office and uploaded into the EMR to ensure staff have access to them. The ADON revealed that she was waiting for the physician's office to fax over copies of the requested Physician or NPP Visit Notes for Resident #1 and Resident #2.<BR/>In an interview with the ADMIN on 05/08/2023 at 4:51 p.m., the ADMIN revealed that the duties for maintaining the medical records had recently been reassigned to the facility ADONs. The ADMIN revealed that there had not been any known effects of not have the physician or NPP visit notes updated in the EMR due to the physicians' offices being easy to contact over the phone for staff.<BR/>Record review of investigator's HHSC email on 05/08/2023 at 6:04 p.m. revealed the facility ADMIN received the requested Physician or NPP Visit Notes for Resident #1 and Resident #2 via an email from the NP on 05/08/2023 at 5:58 p.m.<BR/>Record review of CMS Appendix PP State Operations Manual &sect;483.70(i) Medical records last revised 02/03/2023, revealed In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete . (iii) Readily accessible . The medical record must contain- .(v) Physician, nurse, and other licensed professionals progress notes.

Based on interview and record review, the facility failed to in accordance with professional standards and practices, maintain clinical records that are complete and readily accessible for 2 of 6 residents (Resident #1 and Resident #2) reviewed for medical records. <BR/>1. Resident #1 medical record was missing Physician Visit Notes, or Non-physician practitioner (NPP) Visit Notes since 09/20/2022.<BR/>2. Resident #2 medical record was missing Physician Progress Notes, or NPP Visit Notes since 10/18/2022.<BR/>This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors or delays in care and treatment.<BR/>The findings included: <BR/>Record review of Resident #1's face sheet, dated 05/04/2023, revealed an admission date of 06/07/2022 and a latest return on 02/12/2023 with diagnoses including: acute respiratory disease, vascular dementia, and a personal history of transient ischemic attack (a brief, stroke-like attack that resolves itself). The resident had a recent history of transfer to the local hospital.<BR/>Record review of Resident #1's electronic medical record (EMR) on 05/04/2023 revealed the presence of physician or nurse practitioner (NP) progress notes with dates of service: 07/29/2022, 08/15/2022, and 09/20/2022. Physician or NPP progress notes were missing from the EMR following the 09/20/2022 visit.<BR/>Record review of Resident #2's face sheet, dated 05/04/2023, revealed an admission date of 10/03/2022 with diagnoses including: cerebral aneurysm (a bulging blood vessel in the brain), hypertension, and personal history of transient ischemic attack and cerebral infarction (disruption in the brain's blood flow).<BR/>Record review of Resident #2's EMR on 05/04/2023 revealed the presence of a physician progress note, date of service 10/18/2022. Physician or NPP progress notes were missing from the EMR following the 10/18/2022 visit.<BR/>In an interview with Staff A on 05/08/2023 at 11:30 a.m., record request submitted for a copy of the most recent Physician or NPP Visit Notes for Resident #1 and Resident #2.<BR/>In an interview with the ADON on 05/08/2023 at 4:13 p.m., the ADON revealed that there has been a big issue with documents not being uploaded since the company removed the medical records staffing position. She confirmed that the physician notes should have been obtained from the physician's office and uploaded into the EMR to ensure staff have access to them. The ADON revealed that she was waiting for the physician's office to fax over copies of the requested Physician or NPP Visit Notes for Resident #1 and Resident #2.<BR/>In an interview with the ADMIN on 05/08/2023 at 4:51 p.m., the ADMIN revealed that the duties for maintaining the medical records had recently been reassigned to the facility ADONs. The ADMIN revealed that there had not been any known effects of not have the physician or NPP visit notes updated in the EMR due to the physicians' offices being easy to contact over the phone for staff.<BR/>Record review of investigator's HHSC email on 05/08/2023 at 6:04 p.m. revealed the facility ADMIN received the requested Physician or NPP Visit Notes for Resident #1 and Resident #2 via an email from the NP on 05/08/2023 at 5:58 p.m.<BR/>Record review of CMS Appendix PP State Operations Manual &sect;483.70(i) Medical records last revised 02/03/2023, revealed In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete . (iii) Readily accessible . The medical record must contain- .(v) Physician, nurse, and other licensed professionals progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents are free of significant medication errors for 1 (Resident #1) of 5 residents reviewed for safe administration of medications, in that:<BR/>Resident #1's order for levothyroxine was not entered by nursing staff during her initial admittance and upon readmission to the facility. Resident #1 was not given twenty-four doses of levothyroxine for her diagnosis of hypothyroidism as ordered by a physician, as a result, Resident #1 was hospitalized with a myxedema coma.<BR/>This failure resulted in identification of an Immediate Jeopardy (IJ) situation; an IJ was identified on 03/30/2023. The IJ template was provided to the facility on [DATE] at 10:48 a.m. While the IJ was removed on 03/31/2023 at 2:37 p.m., the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope of a pattern until interventions were put in place to ensure residents' physician orders were accurately entered into the medical records system. <BR/>This deficient practice could affect all residents who receive medication from the facility and place them at risk for adverse reactions, decline in physical health, hospitalization, or death.<BR/>The findings were: <BR/>Record review of Resident #1's face sheet, dated 03/31/2023, revealed the resident was initially admitted the facility on 02/09/2023 with diagnoses including: hypothyroidism, unspecified dementia, and hyperkalemia. <BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed a staff assessment of memory was completed with short-term and long-term memory problems. <BR/>Record review of Resident #1's care plan as of 03/31/2023, revealed goals: Resident's needs/wants will be met at all times and Resident will experience no complications.<BR/>Record review of Resident #1's hospital discharge orders, dated 02/06/2023, revealed levothyroxine (a drug to treat hypothyroidism) 200 micrograms daily was prescribed.<BR/>Record review of Resident #1's clinical record from the facility revealed the resident was re-hospitalized from [DATE] to 02/20/2023. <BR/>Record review of Resident #1's hospital discharge orders, dated 02/20/2023, revealed the resident received levothyroxine during her hospital stay and was prescribed levothyroxine 100 micrograms daily upon discharge. <BR/>Record review of Resident #1's order summary, dated 03/31/2023, revealed the physician order for levothyroxine was not included in her list of medications upon admission on [DATE] and was not included in her re-admission medication list on 02/20/2023. <BR/>Record review of Resident #1's medication administration record, dated 03/31/2023, revealed the resident was not administered levothyroxine while in the facility from 02/09/2023 to 02/13/2023, and was not administered levothyroxine while in the facility from 02/20/2023 to 03/13/2023. <BR/>Further review of Resident #1's clinical record from the facility, dated 03/13/2023, revealed .resident was put on [an oxygen] mask at 2 [liters] due to residents [oxygen saturation at 70%] .resident was observed moaning as if in pain, her skin was yellowish in color, increased lethargy, and unable to communicate with staff. [Nurse Practitioner] stated to send to [Emergency Room] to be evaluated for possible [pneumonia]. <BR/>Further review of Resident #1's clinical record from the facility revealed the resident was re-hospitalized again from 03/13/2023 to 03/20/2023.<BR/>Record review of Resident #1's hospital records from 03/13/2023 to 03/20/2023 revealed the resident was diagnosed as having a myxedema coma, defined by the National Institute of Health as, a rare life-threatening clinical condition in patients with longstanding severe untreated hypothyroidism (ncbi.nlm.nih.gov/books/NBK279007 updated 04/25/2018, accessed 04/05/2023). Further review revealed the resident had a TSH (thyroid stimulating hormone) level of 139 with approximately 5 being the upper range of an acceptable level. <BR/>During an interview with LVN A on 03/29/2023, LVN A stated she was new to the facility at the time of Resident #1's admission and had inadvertently left out the resident's physician order for levothyroxine while entering Resident #1's admission orders from the hospital. During the same interview, ADON B stated the facility protocol for new admissions was for an ADON to check the admissions entries the day after an admission had occurred and stated he did not perform this check following Resident #1's admission because he did not have time. LVN A and ADON B confirmed that all of Resident #1's hospital discharge orders should have been added to the resident's facility medical record and were not added due to an oversight. LVN A confirmed she had not been directed by a physician or nurse practitioner to exclude levothyroxine from Resident #1's medication list.<BR/>During an interview with LVN A on 03/29/2023, LVN A confirmed she had completed Resident #1's readmission on [DATE] and had restarted the original, incomplete medication list from the time of the resident's admission which left out the discharge order for levothyroxine. LVN A confirmed she had not been directed by a physician or nurse practitioner to exclude levothyroxine from Resident #1's medication list.<BR/>During an interview with the Nurse Practitioner on 03/29/2023 at 4:20 p.m., the Nurse Practitioner stated she had reviewed a clinical record for Resident #1 which indicated that the resident was being treated with the medication hydrocortisone for the condition of adrenal insufficiency and she believed this course of treatment was related to the resident's thyroid condition. The Nurse Practitioner stated she did not recall which record she had reviewed. The Nurse Practitioner further stated she had not seen any of Resident #1's clinical records from the resident's two hospitalizations and if she has known that the resident was being treated in the hospital with levothyroxine for hypothyroidism, she would have continued with that treatment in consultation with the hospital. The Nurse Practitioner stated she relies on the information entered in the facility medical records system to know what hospital discharge orders are given for each resident. The Nurse Practitioner further stated she had referred Resident #1 to an endocrinologist, a thyroid specialist. <BR/>During an interview with the facility's consultant Pharmacist on 03/29/2023 at 4:36 p.m., the consultant Pharmacist stated the potential harm of a resident not receiving levothyroxine as prescribed was not having the medication at a therapeutic level, and confirmed that a myxedema coma could be the result of not having received levothyroxine as prescribed. <BR/>During an interview with the DON on 03/29/2023 at 4:45 p.m., the DON stated she had spoken with the Nurse Practitioner regarding Resident #1's treatment and stated it was her belief that the Nurse Practitioner chose not to continue the hospital order of levothyroxine for hypothyroidism and instead was pursuing hydrocortisone for adrenal insufficiency as the course of treatment. <BR/>Record review of Resident #1 facility medication list as of 03/21/2023 revealed the resident was prescribed levothyroxine 100 mcg daily. <BR/>Record review of Resident #1's clinical record from the facility revealed labratory results, dated 03/29/2023, which indicated the resident's TSH level was 42.761 with a desired range of .450-5.3. <BR/>On 03/30/2023 at 10:48 a.m. the Administrator was notified of the Immediate Jeopardy (IJ) situation for the above failure, a completed IJ template was provided, and a Plan of Removal was requested. <BR/>The following Plan of Removal submitted by the facility was accepted on 03/30/2023 9:09 p.m. and included:<BR/>Colonial Manor respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on 03/30/2023 for F760. Plan submitted on 03/30/2023 at 3:15pm.<BR/>Immediate action taken for resident affected:<BR/>Resident #1 was readmitted from the hospital on [DATE] and discharge orders were received and transcribe to the admitting orders for Levothyroxine 100mcg per gastric tube QD. This order was <BR/>verified with the nurse practitioner by the admitting nurse. The DON notified the physician of the medication error on 3/29/2023 at 3:05 pm and labs were ordered for a CBC, CMP, TSH and Lipids. These <BR/>were drawn by the lab at 8:11pm. The facility is waiting on results. <BR/>Resident identified to have been affected by the alleged deficient practice:<BR/>The Director of Nursing and Clinical Resource Nurse immediately completed a review of all residents that have been admitted or readmitted in the last 90 days to ensure that hospital discharge records are available in the Documents tab in Matrix and that all discharged orders have been transcribed correctly on the orders and the hospital discharge orders and the admitting orders have been reviewed with the physician. Completed 03/30/23<BR/>Residents with the potential to be affected by the alleged deficient practice:<BR/>During the above thorough review the facility identified 27 residents who were admitted /readmitted in the last 90 days. The facility found no other medication omissions on the admission orders. <BR/>Systemic Measures:<BR/>1. <BR/>The Director of Nursing/designee including the ADON/Weekend RN Supervisor will review new admissions/readmissions on a daily basis to ensure that hospital discharge orders are available in the Documents tab in Matrix and that the discharge orders are transcribed accurately in the admission orders and the hospital discharge orders and the admitting orders have been reviewed with the physician. The results of these daily reviews will [sic] reported to the QAPI committee for no less than 90 days<BR/>2. <BR/>Training: Will be completed as follows:<BR/>a. <BR/> All licensed nurses will be trained by the Director of Nursing/designee including the ADON/Weekend RN Supervisor on reviewing hospital discharge orders in the Documents tab of Matrix, transcribing orders to the admission orders in Matrix and reviewing these with the attending physician for approval prior to their next scheduled shift. Completed 03/30/2023. <BR/>b. <BR/>All licensed nurses will be trained by the Director of Nursing/designee including the ADON/Weekend RN Supervisor to document the review of these orders and approval by the physician in the progress notes prior to their next scheduled shift. Completed 03/30/2023<BR/>c. <BR/>The Director of Nursing/designee including the ADON/Weekend RN Supervisor will train all newly hired nurses upon hire on reviewing hospital discharge orders in the Documents tab of Matrix, transcribing orders to the admission orders in Matrix and reviewing these with the attending physician for approval prior to their next scheduled shift. Completed 03/30/2023. <BR/>d. <BR/>The Director of Nursing/designee including the ADON/Weekend RN Supervisor will review the schedule daily and will train any agency nurses prior to the start of their shift on reviewing hospital discharge orders in the Documents tab of Matrix, transcribing orders to the admission orders in Matrix and reviewing these with the attending physician for approval. Completed 03/30/2023. <BR/>e. <BR/>The Director of Nursing/designee including the ADON/Weekend RN Supervisor will be trained by the Clinical Resource Nurse on the Clinical Morning Meeting and review of new admissions/readmissions to ensure hospital discharge orders are uploaded into the Documents tab, admitting orders are transcribed accurately and the physician has reviewed these and approved the orders. Completed 03/30/2023. <BR/>f. <BR/>The facility Medical Director and their providers will be trained by the Administrator on location of hospital discharge records in Matrix. Completed 03/30/2023.<BR/>Quality Assurance Performance Improvement: <BR/>On 03/30/2023 the Quality Assessment and Performance Improvement committee members to include, the Medical Director, Administrator, and Director of Nursing, Clinical Resource Nurse and Clinical Company Leader met to review and approve this plan. The Committee will meet weekly until the findings of immediate jeopardy are abated.<BR/>The results of the Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Date of Correction: 03/30/2023.<BR/>Plan of Removal verification included the following:<BR/>Record review of facility training document, Staff Re-education, dated 03/30/2023, revealed, The charge nurse will review the orders with the physician on new and readmits. The charge nurse will enter the medications ordered by the physician in the electronic medical record. The ADON or designee will review previous medications for readmissions, hospital orders, and medication list to review that all medications ordered are listed .<BR/>During an interview with ADON B on 03/30/2023 at 4:02 p.m., ADON B stated he had worked at the facility for four years, confirmed the facility provided an in-service training regarding medications and the admission/readmission process. ADON B stated that a nurse manager will double check all new admissions and readmits to ensure all hospital orders are entered correctly, the physician is notified, and that lab orders entered into the electronic medical records. As a nurse manager, ADON B stated he had given his personal phone number to all members of nursing staff and encouraged them to call him in the event they had a question with admissions or any other facility procedure. <BR/>During interviews with fifteen members of nursing staff between 03/30/2023 at 4:36 p.m. and 03/31/2023 at 11:23 a.m., including agency staff, facility staff, LVNs, RNs, and nurse managers, all nursing staff members confirmed they had received the in-service training and were able to verbalize understanding of the training materials.<BR/>The Administrator was informed the Immediate Jeopardy was removed on 03/31/2023 2:37 p.m. The facility remained out of compliance at actual harm that is not immediate jeopardy with a scope of a pattern until interventions were put in place to ensure residents' physician orders were accurately entered into the medical records system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 6 resident (Residents #44 and, #114) reviewed for privacy, in that:<BR/>1. LVN X did not completely close Resident #44's privacy curtain while providing wound care for the resident.<BR/>2. LVN A did not completely close Resident #114's privacy curtain while providing colostomy care for the resident.<BR/>This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.<BR/>The findings include:<BR/>1. Record review of Resident 44's face sheet, dated 04/13/2023, revealed an admission date of 10/03/2022, with diagnoses which included: Cerebral aneurysm (weak spot in an artery of the brain that bulges out), Hypertension (High blood pressure), Depression (feeling of severe despondency), Hyperlipidemia (too much lipids (fat) in the blood), Anxiety (a feeling of worry, nervousness or unease) <BR/>Record review of Resident #44's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 9, indicating moderate impairment. Resident #44 required extensive assistance and was always incontinent of bladder, frequently incontinent of bowel and was coded at risk for pressure ulcer.<BR/>Observation on 04/13/23 at 09:56 a.m. revealed LVN X provided wound care for Resident #44, LVN X did not pull the curtains completely around Resident #44's bed to offer privacy to the resident during care. The privacy curtain was too short to completely surround the bed and an area was left open during care Resident #44's wound was on the knee and the resident's pants had to be pulled down. The opened area was large enough the resident could be seen through it.<BR/>During an interview with LVN X on 04/13/2023 at 10:18 a.m., LVN X confirmed the staff was supposed to provide complete privacy during care and completely close the privacy curtain. She confirmed the bed and resident were partially uncovered. She confirmed receiving training about privacy during care. <BR/>During an interview with the Housekeeping Supervisor on 04/13/2023 at 11:05 a.m., the Housekeeping Supervisor revealed housekeeping changed the curtain every month or when they were soiled or broken. But she could not know if they needed replacement unless the nursing staff would tell her. <BR/> 2. Record review of Resident 114's face sheet, dated 04/14/2023, revealed an admission date of 12/08/2022 and, a readmission date of 12/21/2022, with diagnoses which included: Type 2 diabetes mellitus (blood glucose, also called blood sugar, is too high), Legal blindness (poor visual perception), Colostomy status (opening in the belly (abdominal wall) that's made during surgery. It's usually needed because a problem is causing the colon to not work properly), Hypertension (High blood pressure), Cirrhosis of liver (late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions).<BR/>Record review of Resident #114's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 8, indicating moderate impairment. Resident #114 required limited assistance, was always continent of bladder and. had a ostomy (a surgical procedure that creates an opening in the abdominal wall)-<BR/>Observation on 04/13/23 at 12:13 p.m. revealed LVN A provided colostomy care for Resident #114, LVN A did not pull the curtains completely around Resident #114's bed to offer privacy to the resident during care. The end of the bed was left open during care Resident #114's ostomy site and abdomen were exposed and could have been seem by someone opening the room's door. <BR/>During an interview with LVN A on 04/13/2023 at 12:25 p.m., LVN A confirmed the staff was supposed to provide complete privacy during care and close completely the privacy curtain. She confirmed the bed and resident were partially uncovered. She confirmed receiving training about privacy during care. <BR/>During an interview with the Administrator and Regional Nurse on 04/14/2023 at 3:00 p.m., the Administrator confirmed the curtain should have been closed during care to provide privacy. The Administrator confirmed the staff received training on resident rights. The facility did annual skill checklists with the staff. The ADON did spot checks on different staff to check their knowledge and skills. <BR/>Review of the facility's policy titled Residents rights guidelines for all nursing procedures, dated 10/2010, revealed, For any procedure that involves direct resident care, follow this steps: [ .] f. Close the room entrance door and provide for the resident's privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 47 residents (Resident #2) whose care plan was reviewed, in that:<BR/>The facility failed to ensure Resident #2's care plan included insulin<BR/>This deficient practice could place residents at risk of receiving the incorrect care and cause health complications with subsequent illness.<BR/>The findings were: <BR/>Record review of Resident #2's face sheet, dated 04/14/2023, revealed the resident was re-admitted on [DATE] with diagnoses that included: vascular dementia, type 2 diabetes, anxiety and psychotic disturbance. <BR/>Record review of Resident #2's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 08, which indicated moderate cognitive impairment. Further review for Active Diagnoses revealed I2900. Diabetes Mellitus (DM) . checked as a current diagnoses. <BR/>Record review of Resident #2's continuity of care document, dated 04/14/2023, revealed a medication with a start date of 01/30/2023 and a last administered date of 04/12/2023 at 08:21 pm and specifically read Levemir U-100Insulin (insulin detemir u-100)100 unit/mL solution; Once An Evening; 10 units, subcutaneous, Once An Evening, Administer 10 units subcutaneously in the evening for DM 2 HOLD IF BSIS &lt; 100; E11.9 : Type 2 diabetes mellitus without complications.<BR/>Record review of Resident #2's care plan, undated, revealed insulin nor diabetes was not listed as a problem area. <BR/>During an interview and record review on 05/13/2021 at 2:30 p.m., the Regional DON stated insulin was supposed to be on Resident #2's care plan. He stated it was supposed to be care planned when resident was diagnosed (with diabetes), which possibly since this resident was admitted . The Regional DON stated care plans began with the MDS or CCN and then the DON overseas that position. He stated it must have been overlooked. The Regional DON stated the potential harm to resident was a new nurse would not know this resident needed insulin or was diabetic, by just looking at the care plan. He further stated that if the order is in the system, the resident was supposed to be receiving the insulin regardless. <BR/>During an interview on 05/13/2023 at 4:38 p.m., the Administrator stated insulin was supposed to be added to the care plan at on-site of the problem. She further stated anyone in the nursing department has the authority to add items from the orders to the care plans. The Administrator stated that care plans are reviewed during their review date. The Ato the care plan. She then stated the IDT during the team conference ensured that everything was in place starting Administrator did not believe there was a potential harm to resident, being there was an order for the insulin and Resident #2 was receiving the service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to follow menus for 1 of 1 resident meals (lunch meal on 04/11/2023) reviewed for menus in that:<BR/>1. Residents on a regular diet were served lunch items on 04/11/2023 that did not reflect what was on the menu.<BR/>2. Residents on modified diets were served lunch items on 04/11/2023 that did not reflect what was on the menu.<BR/>These failures could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss.<BR/>The findings included: <BR/>1. Observation on 04/11/2023 at 10:15 a.m. in the dining room revealed the lunch meal posted for that day was: Cheeseburger, French Fries, Tomato/Lettuce/Pickles/Onion, Hot Spiced Apples, Iced Tea or Punch and Water. There was no weekly menu posted.<BR/>Record review of the current week's menu provided by facility labeled, Week 5 revealed the lunch meal scheduled for Tuesday, 04/11/2023, for residents on a regular diet was: Pot Roast, Roasted New Potatoes, Sliced Carrots, Herb butter Roll, Banana Pudding. The consultant dietitian signed the menu.<BR/>During the Resident Council Meeting on 04/12/2023 from 9:30 a.m. to 10:30 a.m., all twelve residents in attendance denied requesting a cheeseburger meal every Tuesday. The residents claimed they received cheeseburgers every Tuesday and also every Saturday and they were not happy about the lack of variety.<BR/>Interview on 04/11/2023 at 10:30 a.m. with the facility's Ombudsman revealed the Ombudsman was at every Resident Council meeting and this request was never mentioned by any resident at any meeting.<BR/>During an interview on 04/11/2023 at 10:30 a.m. with the DM and [NAME] W, both the DM and [NAME] W stated that the Resident Council had decided that they wanted cheeseburgers for lunch every Tuesday.<BR/>Review of the minutes from the Resident Council Meetings for the months of January, February and March 2023 revealed there was no mention of requesting hamburgers or cheeseburgers for lunch every Tuesday.<BR/>2. Record review of the current week's menu provided by the facility labeled, Week 5 revealed the lunch menu scheduled for Tuesday, 04/11/2023, for residents on a pureed diet, was: Pureed Pot Roast, Pureed Roasted New Potatoes, Pureed Herb Butter Roll, Pureed Banana Pudding Dessert. The consultant dietitian signed the menu.<BR/>During an interview on 04/11/2023 at 10:40 a.m. with the DM, when asked what the residents who had a physician's order for a pureed diet would receive for lunch that day, the DM stated residents on a pureed diet would receive pureed cheeseburgers for the lunch meal.<BR/>Record review of the Diet Order Report 3/11/2023 - 4/11/2023 revealed that Residents #48, #57 and #63 had diet orders from their physicians that read: Regular with Puree Texture.<BR/>Observation of lunch service on 04/11/2023 from 12:25 - 12:35 p.m. revealed Resident #57 was served a plate with pureed food. On Resident #57's plate was a scoop of food that was brown in color, a scoop that was off-white in color, and a scoop that was bright red in color. Residents #48 and #63 were served similar looking plates with pureed food.<BR/>Review of the meal tickets for Residents #48, #57 and #63 revealed they read: Regular/Puree and listed the following: Entr&eacute;e - &frac12; C PUR Pot Roast; Starch - &frac12; C PUR New Potatoes; Vegetable - 1/3 C PUR Carrots; Bread - &frac14; C PUR Herb Butter Roll; Dessert - &frac12; C PUR Banana Pudding [NAME]. <BR/>During an interview on 04/11/2023 at 1:30 p.m. with CNA I, CNA I stated that the scoop of pureed red food on Residents #48, #57 and #63's plates was not carrots, and that it was pureed stewed tomatoes. Sitting at the same table were residents served stewed tomatoes in their unpureed form, and the color of the tomatoes on those plates matched the color of the pureed stewed tomatoes.<BR/>During an interview on 04/11/2023 at 12:40 with the DM, he stated he believed the residents on pureed diets would be served pureed cheeseburgers for the lunch meal and he did not know they would be served pureed pot roast, pureed potatoes, and a pureed vegetable. The DM further stated that he did not speak with the consultant RD about the change in menu.<BR/>Record review of facility policy 01.0007 Menu Substitutions, revised 06/01/2019, revealed, 1. The menu will be served as written unless an emergency situation arises. 2. If a specific item is not available, the cook will consult with the Nutrition & Foodservice Manager or consultant RD regarding an appropriate substitution. If the Nutrition & Foodservice Manager or dietitian is not available, the cook will refer to the Menu Substitution Guide included in this section and their approved diet manual. 3. All substitutions will be made in accordance with the Menu Substitution Guide to ensure that the meal is well-balanced and adequate. 4. All changes to the menu will be recorded on the Menu Substitution Approval Form. 5. The consultant RD will review the Menu Substitution Approval Form on each visit to determine trends in substitutions and accuracy of substitutions so that appropriate training can be provided if needed. 6. The dietitian will initial off the Menu Substitution Form after review. The Menu Substitution Form will be retained with dated menus for a 12-month period.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>1. There was a zip-locked bag in the reach in cooler with diced ham that was past its use-by date.<BR/>2. There was an open bag of flour in the dry storage room that was not stored in a closed or tightly covered container.<BR/>3. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime.<BR/>These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.<BR/>The findings included:<BR/>1. Observation on 04/11/2023 at 10:20 a.m. in the reach-in cooler revealed there was a zip-locked bag on a shelf with the words, Diced ham. Also written on the bag was the date 3/23 and OP 3/28.<BR/>Interview on 04/11/2023 at 10:30 a.m. with the DM revealed the dates meant the ham was received by the facility on 3/23/2023 and opened on 3/28/2023. The DM stated that the ham had been in the cooler for 14 days by 04/11/2023 and should have been discarded in accordance with the facility's food storage policy. The DM further stated that any dietary staff member that stores food in the cooler is responsible for ensuring food is properly labeled, dated, and discarded according to the policy, and that failing to discard food in a timely manner could result in foodborne illness. Training on foodservice sanitation and safety was provided on a regular basis by the consultant dietitian.<BR/>2. Observation on 04/11/2023 at 10:35 a.m. in the dry storage room revealed a 25 lb. bag of flour on a shelf. The bag was approximately &frac14; full, and the top of the bag was rolled down. The bag was not closed with any type of fastener, and the bag was not enclosed in a sealed container. <BR/>Interview on 04/11/2023 at 10:41 a.m. with the DM revealed the bag of flour was not sealed, and the bag should have been stored either in a larger bag with a zip lock or a sealed container. The DM further stated that all kitchen staff store food in the dry storage room, and that failing to ensure food was properly sealed could result in deterioration in food quality and potential contamination from pests. <BR/>3. Observation on 04/11/2023 at 10:45 a.m. in the kitchen revealed the tabletop can opener was covered with sticky grime that was black and brown in color. The grime covered the blade portion of the can opener, the adjustable bar, and also surrounded the base that was affixed to the table with screws. <BR/>During an interview on 04/11/2023 at 10:46 a.m. with the DM, the DM stated that the can opener blade, bar and base were covered in sticky grime and should not have been. The DM stated the cooks were responsible for ensuring the can opener and area surrounding the base remained clean and free of debris, and that failing to do so could result in contamination of food from bacteria lingering on the blade and potential foodborne illness.<BR/>Review of facility policy 03.003 revised 06/01/2019 revealed: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Code and HACCP guidelines. 1. Dry Storage. d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators. e. Use all leftovers within 72 hours. Discard items that are 72 hours old.<BR/>Review of facility policy 04.009 Can Opener dated 10/01/2018 revealed, The facility will maintain can openers free of food particles and dirt to minimize the risk of food hazards. Can openers be cleaned after each use. 1. Hand held or table top. a. Remove can opener shank from base. b. Wash shank in sink with warm water and detergent or in the dishwasher. c. Give close attention to the blade and moving parts. d. Rinse in clean, hot water. e. Sanitize with approved sanitizer. Follow manufacturer's instructions for immersion times. f. Air dry. g. Wash base of can opener with clean cloth soaked in warm water and detergent, removing all food particles and dirt. h. Rinse with clean cloth soaked in clear hot water.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, , ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food contact surfaces and utensils shall be clean to sight and touch. <BR/>(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.

Based on interview, and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 13 of 23 staff (CNAs E, F, G, H, I, J, K, L, and LVNs N, Q, and ST, PT, and OT, reviewed for training, in that:<BR/>The facility failed to ensure that 13 of 23 staff (CNAs E, F, G, H, I, J, K and LVN's N, Q, and ST, PT, OT staff had completed their mandatory QAPI annual training.<BR/>This failure could place residents at risk for care by CNA, LVN, and therapy staff who have been insufficiently trained while working in the facilit<BR/>The findings included:<BR/>Record review of the annual CNA, LVN, and therapy staff training information revealed that: CNA E (hired-11/1/18), CNA F (hired-5/5/20), CNA G (hired-8/2/20), CNA H (hired-11/1/18), CNA I (hired-11/1/18), CNA J (hired-11/1/18),CNA-K((hired- 11/1/18),CNA-L(hired-3/3/20), LVN N (hired-5/28/19), LVN-Q (hired-2/20/19), and ST (hired-9/1/20), and PT (hired-9/21/20) and OT (hired-3/15/22) had not completed their mandatory QAPI annual training<BR/>During an interview with the HR Coordinator on 4/14/23 at 11:00am the HR Coordinator stated that there was not a record of a annual QAPI training for CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA-K, CNA-L, LVN-N, LVN-Q, ST,,PT,, and OT The HR Coordinator stated that she was not aware of any facility policy that addressed the QAPI training requirement for staff.<BR/>During an interview with the Administrator on 4/14/23 at 12:55p.m., the Administrator stated that she was not aware of a record of a annual QAPI training for CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA-K, CNA-L, LVN-N, LVN-Q, ST,,PT,, and OT The Administrator stated that she was not aware of a QAPI training program held by the facility for the identified staff. <BR/>Record review of the facility policy titled In-service Training Program Nurse Aide revised in May 2019 stated that all personnel are required to attend regularly scheduled in-service training classed.

**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 diseases and infections for 1 of 5 residents (Resident #1) observed for infection prevention. <BR/>The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-A provided peri and catheter care for Resident #1.<BR/>This deficient practice could place residents at-risk for spread of infection.<BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 01/30/2025 revealed she was a [AGE] year-old woman, with an initial admission date of 04/04/2024, with re-admission on [DATE] and with diagnoses which included: Non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain); Gastrostomy status (presence of surgically created opening in stomach through which a feeding tube can be placed); Pressure ulcer of right hip, stage 4 (a severe wound that extends deep into tissue potentially with bone or muscle exposure on hip); Pressure ulcer of left buttock stage 4; and Neuromuscular dysfunction of bladder (condition where bladder muscles and nerves do not function properly). <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Further review revealed Resident #1 was assessed as having an indwelling catheter. <BR/>Record review of Resident #1's Active Orders dated 01/30/2025 revealed a orders which included:<BR/>- <BR/>Enhanced Barrier Precautions start date 06/25/2024.<BR/>- <BR/>Foley Catheter: Provide catheter care every shift start date 01/26/2025.<BR/>- <BR/>Wound treatment Order: Location: Right Hip Clean with Normal Saline/Wound Cleanser Apply .QD/PRN start date 01/29/2025.<BR/>Record review of Resident #1's Care Plan dated 12/18/2024 revealed a Problem of General which included I require enhanced barrier precautions due to the following: I am at increased risk of a MDRO acquisition due to having a wound, edited 07/22/2024. This problem area included the following interventions:<BR/>- <BR/>A sign will be posted on my door that says, 'contact nurse before entering room'.; and<BR/>- <BR/>PPE will be available (including gowns/gloves/face shield or goggles) will be available right outside my room, in the shower room.<BR/>Observation on 01/30/2025 at 10:30a.m. revealed there was no sign of any type on or outside the door to Resident #1's room, and there was no supply of PPE available outside the door/room. Further observation revealed CNA-A put on gloves, but did not put on or wear a gown while performing peri-care and foley care for Resident #1.<BR/>During an interview with CNA-A on 01/30/2025 at 10:43 a.m., CNA-A stated that she did not know what Enhanced Barrier Precautions (EBP) were and had not heard that term before. When Surveyor described what the Enhanced Barrier Precautions were, CNA-A stated that they did that during COVID, but not now. CNA-A stated she had received training in infection control and they get annual training, but did not recall ever having received training on EBP.<BR/>During an interview with the DON on 01/30/2025 at 10:50 a.m., the DON stated that there should have been an EBP sign on or just outside Resident #1's door, as well as a supply of PPE available outside her door. The DON further stated that the CNA should have worn both a gown and gloves while providing peri-care and foley-care to Resident #1, but also confirmed that EBP were not included in the training provided to staff. The DON stated she viewed this as an opportunity for improvement and was taking immediate action to in-service all the staff on EBP and providing needed signage and PPE supply. The DON stated that not using Enhanced Barrier Precautions could cause the spread of infection.<BR/>Record review of facility policy titled Enhanced Barrier Precautions revised 4/1/2024 revealed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistance organisms. Further review revealed An order for enhanced barrier precautions will be obtained for residents with any of the following: 1. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. Central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. Review of the section titled Implementation of Enhanced Barrier Precautions revealed Make gown and gloves available immediately near or outside of the resident's room . and PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .which include: Providing hygiene .changing briefs or assisting with toileting .Device care or use: central lines, urinary catheters, feeding tubes .<BR/>

**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 diseases and infections for 1 of 5 residents (Resident #1) observed for infection prevention. <BR/>The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-A provided peri and catheter care for Resident #1.<BR/>This deficient practice could place residents at-risk for spread of infection.<BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 01/30/2025 revealed she was a [AGE] year-old woman, with an initial admission date of 04/04/2024, with re-admission on [DATE] and with diagnoses which included: Non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain); Gastrostomy status (presence of surgically created opening in stomach through which a feeding tube can be placed); Pressure ulcer of right hip, stage 4 (a severe wound that extends deep into tissue potentially with bone or muscle exposure on hip); Pressure ulcer of left buttock stage 4; and Neuromuscular dysfunction of bladder (condition where bladder muscles and nerves do not function properly). <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Further review revealed Resident #1 was assessed as having an indwelling catheter. <BR/>Record review of Resident #1's Active Orders dated 01/30/2025 revealed a orders which included:<BR/>- <BR/>Enhanced Barrier Precautions start date 06/25/2024.<BR/>- <BR/>Foley Catheter: Provide catheter care every shift start date 01/26/2025.<BR/>- <BR/>Wound treatment Order: Location: Right Hip Clean with Normal Saline/Wound Cleanser Apply .QD/PRN start date 01/29/2025.<BR/>Record review of Resident #1's Care Plan dated 12/18/2024 revealed a Problem of General which included I require enhanced barrier precautions due to the following: I am at increased risk of a MDRO acquisition due to having a wound, edited 07/22/2024. This problem area included the following interventions:<BR/>- <BR/>A sign will be posted on my door that says, 'contact nurse before entering room'.; and<BR/>- <BR/>PPE will be available (including gowns/gloves/face shield or goggles) will be available right outside my room, in the shower room.<BR/>Observation on 01/30/2025 at 10:30a.m. revealed there was no sign of any type on or outside the door to Resident #1's room, and there was no supply of PPE available outside the door/room. Further observation revealed CNA-A put on gloves, but did not put on or wear a gown while performing peri-care and foley care for Resident #1.<BR/>During an interview with CNA-A on 01/30/2025 at 10:43 a.m., CNA-A stated that she did not know what Enhanced Barrier Precautions (EBP) were and had not heard that term before. When Surveyor described what the Enhanced Barrier Precautions were, CNA-A stated that they did that during COVID, but not now. CNA-A stated she had received training in infection control and they get annual training, but did not recall ever having received training on EBP.<BR/>During an interview with the DON on 01/30/2025 at 10:50 a.m., the DON stated that there should have been an EBP sign on or just outside Resident #1's door, as well as a supply of PPE available outside her door. The DON further stated that the CNA should have worn both a gown and gloves while providing peri-care and foley-care to Resident #1, but also confirmed that EBP were not included in the training provided to staff. The DON stated she viewed this as an opportunity for improvement and was taking immediate action to in-service all the staff on EBP and providing needed signage and PPE supply. The DON stated that not using Enhanced Barrier Precautions could cause the spread of infection.<BR/>Record review of facility policy titled Enhanced Barrier Precautions revised 4/1/2024 revealed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistance organisms. Further review revealed An order for enhanced barrier precautions will be obtained for residents with any of the following: 1. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. Central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. Review of the section titled Implementation of Enhanced Barrier Precautions revealed Make gown and gloves available immediately near or outside of the resident's room . and PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .which include: Providing hygiene .changing briefs or assisting with toileting .Device care or use: central lines, urinary catheters, feeding tubes .<BR/>

**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 diseases and infections for 1 of 5 residents (Resident #1) observed for infection prevention. <BR/>The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-A provided peri and catheter care for Resident #1.<BR/>This deficient practice could place residents at-risk for spread of infection.<BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 01/30/2025 revealed she was a [AGE] year-old woman, with an initial admission date of 04/04/2024, with re-admission on [DATE] and with diagnoses which included: Non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain); Gastrostomy status (presence of surgically created opening in stomach through which a feeding tube can be placed); Pressure ulcer of right hip, stage 4 (a severe wound that extends deep into tissue potentially with bone or muscle exposure on hip); Pressure ulcer of left buttock stage 4; and Neuromuscular dysfunction of bladder (condition where bladder muscles and nerves do not function properly). <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Further review revealed Resident #1 was assessed as having an indwelling catheter. <BR/>Record review of Resident #1's Active Orders dated 01/30/2025 revealed a orders which included:<BR/>- <BR/>Enhanced Barrier Precautions start date 06/25/2024.<BR/>- <BR/>Foley Catheter: Provide catheter care every shift start date 01/26/2025.<BR/>- <BR/>Wound treatment Order: Location: Right Hip Clean with Normal Saline/Wound Cleanser Apply .QD/PRN start date 01/29/2025.<BR/>Record review of Resident #1's Care Plan dated 12/18/2024 revealed a Problem of General which included I require enhanced barrier precautions due to the following: I am at increased risk of a MDRO acquisition due to having a wound, edited 07/22/2024. This problem area included the following interventions:<BR/>- <BR/>A sign will be posted on my door that says, 'contact nurse before entering room'.; and<BR/>- <BR/>PPE will be available (including gowns/gloves/face shield or goggles) will be available right outside my room, in the shower room.<BR/>Observation on 01/30/2025 at 10:30a.m. revealed there was no sign of any type on or outside the door to Resident #1's room, and there was no supply of PPE available outside the door/room. Further observation revealed CNA-A put on gloves, but did not put on or wear a gown while performing peri-care and foley care for Resident #1.<BR/>During an interview with CNA-A on 01/30/2025 at 10:43 a.m., CNA-A stated that she did not know what Enhanced Barrier Precautions (EBP) were and had not heard that term before. When Surveyor described what the Enhanced Barrier Precautions were, CNA-A stated that they did that during COVID, but not now. CNA-A stated she had received training in infection control and they get annual training, but did not recall ever having received training on EBP.<BR/>During an interview with the DON on 01/30/2025 at 10:50 a.m., the DON stated that there should have been an EBP sign on or just outside Resident #1's door, as well as a supply of PPE available outside her door. The DON further stated that the CNA should have worn both a gown and gloves while providing peri-care and foley-care to Resident #1, but also confirmed that EBP were not included in the training provided to staff. The DON stated she viewed this as an opportunity for improvement and was taking immediate action to in-service all the staff on EBP and providing needed signage and PPE supply. The DON stated that not using Enhanced Barrier Precautions could cause the spread of infection.<BR/>Record review of facility policy titled Enhanced Barrier Precautions revised 4/1/2024 revealed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistance organisms. Further review revealed An order for enhanced barrier precautions will be obtained for residents with any of the following: 1. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. Central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. Review of the section titled Implementation of Enhanced Barrier Precautions revealed Make gown and gloves available immediately near or outside of the resident's room . and PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .which include: Providing hygiene .changing briefs or assisting with toileting .Device care or use: central lines, urinary catheters, feeding tubes .<BR/>

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 2 of 4 shower rooms observed for environment, in that: <BR/>The facility failed to ensure potential hazards were locked up in two communal shower rooms.<BR/>This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment.<BR/>The findings were:<BR/>During an observation, on a side table against the wall in a communal shower room near station 1, and interview on 03/09/2023 at 5:55 a.m., LVN A confirmed observing razors (located in a rolling plastic cart), cleaning solution and shaving cream in an unlocked communal shower room. Further observation revealed LVN B put cleaning solution and shaving cream in the shower room closet and locked it up. LVN A and LVN B rolled the plastic cart, with razors in it, to the other communal shower room, where the door locked. <BR/>During an observation, in an unlocked closet in the communal shower room located in the women's memory care unit, and interview on 03/09/2023 at 6:01 a.m., LVN C confirmed observing razors and shaving cream in the unlocked closet of the shower room. LVN C stated the potential harm to resident was death. <BR/>During an interview on 03/09/2023 at 6:57 a.m., the Administrator stated yes, razors and shaving cream was supposed to be locked up away where residents do not have access to it. The Administrator stated the potential harm to residents was harming themselves. The Administrator stated nursing assistants were responsible for making sure those items were locked up. <BR/>During an interview on 03/09/2023 at 10:15 a.m., the Administrator stated the facility did not have a policy for hazards in unlocked shower rooms.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 2 of 4 shower rooms observed for environment, in that: <BR/>The facility failed to ensure potential hazards were locked up in two communal shower rooms.<BR/>This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment.<BR/>The findings were:<BR/>During an observation, on a side table against the wall in a communal shower room near station 1, and interview on 03/09/2023 at 5:55 a.m., LVN A confirmed observing razors (located in a rolling plastic cart), cleaning solution and shaving cream in an unlocked communal shower room. Further observation revealed LVN B put cleaning solution and shaving cream in the shower room closet and locked it up. LVN A and LVN B rolled the plastic cart, with razors in it, to the other communal shower room, where the door locked. <BR/>During an observation, in an unlocked closet in the communal shower room located in the women's memory care unit, and interview on 03/09/2023 at 6:01 a.m., LVN C confirmed observing razors and shaving cream in the unlocked closet of the shower room. LVN C stated the potential harm to resident was death. <BR/>During an interview on 03/09/2023 at 6:57 a.m., the Administrator stated yes, razors and shaving cream was supposed to be locked up away where residents do not have access to it. The Administrator stated the potential harm to residents was harming themselves. The Administrator stated nursing assistants were responsible for making sure those items were locked up. <BR/>During an interview on 03/09/2023 at 10:15 a.m., the Administrator stated the facility did not have a policy for hazards in unlocked shower rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were discarded before the expiration date for 2 medications stored in 1 of 2 medication rooms observed for medications. The facility failed to ensure that Med room [ROOM NUMBER] did not have expired OTC medications in the drawer/room.The failures could result in residents receiving ineffective, expired medications which could be harmful. An observation and audit were conducted 08/28/2025 at 10:21 AM of Med room [ROOM NUMBER] which was located in the main lobby revealed that inside a mini fridge were expired insulin and Bisacodyl. The insulin had an expiration date of 08/21/2025. The Bisacodyl had an expiration date of 04/29/2025. An interview was conducted on 08/28/2025 at 4:38PM with the ADM who reported working at the facility for 2.5 months. The ADM stated the ADON and DON provided training for labeling/dating medication. The ADM stated that the policy for labeling/dating medications was everything that came from the pharmacy should be labeled already. The ADM stated it could negatively affect a resident to have expired medications by the potential for the medication to lose some of its potency. The ADM stated this could indicate a possibility that a resident did not receive that medication. An interview was conducted on 08/28/2025 at 4:50PM with the DON who reported working at the facility for 3 weeks. The DON stated that the policy for labeling/dating medications was that staff need to have an open date of when they had opened the medications for OTC meds. The DON also stated that the policy for expired medication is that they should not be in the cart and should have been removed. The DON stated that pharmacy will audit the med carts once a month but there is no official document to provide. The DON stated it negatively affected a resident to have undated/expired meds in the med cart by the medication could lose their effectiveness. Record review of a document provided by the facility titled Medication Storage undated, revealed that medications should be labeled, dated and stored in proper areas according to the label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were discarded before the expiration date for 2 medications stored in 1 of 2 medication rooms observed for medications. The facility failed to ensure that Med room [ROOM NUMBER] did not have expired OTC medications in the drawer/room.The failures could result in residents receiving ineffective, expired medications which could be harmful. An observation and audit were conducted 08/28/2025 at 10:21 AM of Med room [ROOM NUMBER] which was located in the main lobby revealed that inside a mini fridge were expired insulin and Bisacodyl. The insulin had an expiration date of 08/21/2025. The Bisacodyl had an expiration date of 04/29/2025. An interview was conducted on 08/28/2025 at 4:38PM with the ADM who reported working at the facility for 2.5 months. The ADM stated the ADON and DON provided training for labeling/dating medication. The ADM stated that the policy for labeling/dating medications was everything that came from the pharmacy should be labeled already. The ADM stated it could negatively affect a resident to have expired medications by the potential for the medication to lose some of its potency. The ADM stated this could indicate a possibility that a resident did not receive that medication. An interview was conducted on 08/28/2025 at 4:50PM with the DON who reported working at the facility for 3 weeks. The DON stated that the policy for labeling/dating medications was that staff need to have an open date of when they had opened the medications for OTC meds. The DON also stated that the policy for expired medication is that they should not be in the cart and should have been removed. The DON stated that pharmacy will audit the med carts once a month but there is no official document to provide. The DON stated it negatively affected a resident to have undated/expired meds in the med cart by the medication could lose their effectiveness. Record review of a document provided by the facility titled Medication Storage undated, revealed that medications should be labeled, dated and stored in proper areas according to the label.

**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 diseases and infections for 1 of 5 residents (Resident #1) observed for infection prevention. <BR/>The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-A provided peri and catheter care for Resident #1.<BR/>This deficient practice could place residents at-risk for spread of infection.<BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 01/30/2025 revealed she was a [AGE] year-old woman, with an initial admission date of 04/04/2024, with re-admission on [DATE] and with diagnoses which included: Non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain); Gastrostomy status (presence of surgically created opening in stomach through which a feeding tube can be placed); Pressure ulcer of right hip, stage 4 (a severe wound that extends deep into tissue potentially with bone or muscle exposure on hip); Pressure ulcer of left buttock stage 4; and Neuromuscular dysfunction of bladder (condition where bladder muscles and nerves do not function properly). <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Further review revealed Resident #1 was assessed as having an indwelling catheter. <BR/>Record review of Resident #1's Active Orders dated 01/30/2025 revealed a orders which included:<BR/>- <BR/>Enhanced Barrier Precautions start date 06/25/2024.<BR/>- <BR/>Foley Catheter: Provide catheter care every shift start date 01/26/2025.<BR/>- <BR/>Wound treatment Order: Location: Right Hip Clean with Normal Saline/Wound Cleanser Apply .QD/PRN start date 01/29/2025.<BR/>Record review of Resident #1's Care Plan dated 12/18/2024 revealed a Problem of General which included I require enhanced barrier precautions due to the following: I am at increased risk of a MDRO acquisition due to having a wound, edited 07/22/2024. This problem area included the following interventions:<BR/>- <BR/>A sign will be posted on my door that says, 'contact nurse before entering room'.; and<BR/>- <BR/>PPE will be available (including gowns/gloves/face shield or goggles) will be available right outside my room, in the shower room.<BR/>Observation on 01/30/2025 at 10:30a.m. revealed there was no sign of any type on or outside the door to Resident #1's room, and there was no supply of PPE available outside the door/room. Further observation revealed CNA-A put on gloves, but did not put on or wear a gown while performing peri-care and foley care for Resident #1.<BR/>During an interview with CNA-A on 01/30/2025 at 10:43 a.m., CNA-A stated that she did not know what Enhanced Barrier Precautions (EBP) were and had not heard that term before. When Surveyor described what the Enhanced Barrier Precautions were, CNA-A stated that they did that during COVID, but not now. CNA-A stated she had received training in infection control and they get annual training, but did not recall ever having received training on EBP.<BR/>During an interview with the DON on 01/30/2025 at 10:50 a.m., the DON stated that there should have been an EBP sign on or just outside Resident #1's door, as well as a supply of PPE available outside her door. The DON further stated that the CNA should have worn both a gown and gloves while providing peri-care and foley-care to Resident #1, but also confirmed that EBP were not included in the training provided to staff. The DON stated she viewed this as an opportunity for improvement and was taking immediate action to in-service all the staff on EBP and providing needed signage and PPE supply. The DON stated that not using Enhanced Barrier Precautions could cause the spread of infection.<BR/>Record review of facility policy titled Enhanced Barrier Precautions revised 4/1/2024 revealed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistance organisms. Further review revealed An order for enhanced barrier precautions will be obtained for residents with any of the following: 1. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. Central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. Review of the section titled Implementation of Enhanced Barrier Precautions revealed Make gown and gloves available immediately near or outside of the resident's room . and PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .which include: Providing hygiene .changing briefs or assisting with toileting .Device care or use: central lines, urinary catheters, feeding tubes .<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, in that: <BR/>Resident #276's baseline care plan did not include her prescribed diet, food allergies, or code status. <BR/>This deficient practice could result in newly admitted residents receiving improper care. <BR/>The findings were: <BR/>Record review of Resident #276's face sheet, dated 06/28/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Type 2 diabetes mellitus without complications, Gastro-esophageal reflux disease without esophagitis, and Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding. <BR/>Record review of Resident #276's clinical record as of 06/28/2024 revealed her initial MDS had not yet been completed. <BR/>Record review of Resident #276's care plan, dated 06/27/2024, revealed her prescribed diet, food allergies, and code status were not included. <BR/>Record review of Resident #276's physician orders, dated 06/24/2024, revealed, Diet: Regular diet. Texture: regular Fluid Consistency: thin allergic to eggs Special Instructions: allergic to eggs lactose intolerant, can not eat food with seeds. Further review revealed, Code status: Full Code. <BR/>During an interview with MDS/LVN A on 06/26/2024 at 12:50 p.m., MDS/LVN A stated the baseline care plan includes showering, diet, and shows staff what needs to happen until we get comprehensive [care plan] in. MDS/LVN A further stated that no specific staff member was responsible for creating baseline care plans, and that the task was a team effort of floor nurses, ADONs, the DON, and MDS nurses. <BR/>During an interview with LVN/ADON J on 06/28/2024 at 10:21 a.m., LVN/ADON J confirmed Resident #276's baseline care plan did not include her prescribed diet, food allergies, or code status. LVN/ADON J stated these elements of the baseline care plan included information necessary to meet the resident's basic needs. LVN/ADON J confirmed she had created Resident #276's baseline care plan, stated the missing information should have been included, and the deficient practice was an oversight. <BR/>During an interview with the DON on 06/28/2024 at 1:15 p.m., the DON stated the facility had been using a template to create the baseline care plans that did not include prescribed diet, food allergies, or code status. The DON stated she would change the baseline care plan template to include prescribed diet, food allergies, or code status and would expect staff to include the missing information in the future. <BR/>Record review of the facility policy, Care Plans - Baseline, revised December 2016, revealed, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 2 of 4 shower rooms observed for environment, in that: <BR/>The facility failed to ensure potential hazards were locked up in two communal shower rooms.<BR/>This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment.<BR/>The findings were:<BR/>During an observation, on a side table against the wall in a communal shower room near station 1, and interview on 03/09/2023 at 5:55 a.m., LVN A confirmed observing razors (located in a rolling plastic cart), cleaning solution and shaving cream in an unlocked communal shower room. Further observation revealed LVN B put cleaning solution and shaving cream in the shower room closet and locked it up. LVN A and LVN B rolled the plastic cart, with razors in it, to the other communal shower room, where the door locked. <BR/>During an observation, in an unlocked closet in the communal shower room located in the women's memory care unit, and interview on 03/09/2023 at 6:01 a.m., LVN C confirmed observing razors and shaving cream in the unlocked closet of the shower room. LVN C stated the potential harm to resident was death. <BR/>During an interview on 03/09/2023 at 6:57 a.m., the Administrator stated yes, razors and shaving cream was supposed to be locked up away where residents do not have access to it. The Administrator stated the potential harm to residents was harming themselves. The Administrator stated nursing assistants were responsible for making sure those items were locked up. <BR/>During an interview on 03/09/2023 at 10:15 a.m., the Administrator stated the facility did not have a policy for hazards in unlocked shower rooms.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 2 of 4 shower rooms observed for environment, in that: <BR/>The facility failed to ensure potential hazards were locked up in two communal shower rooms.<BR/>This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment.<BR/>The findings were:<BR/>During an observation, on a side table against the wall in a communal shower room near station 1, and interview on 03/09/2023 at 5:55 a.m., LVN A confirmed observing razors (located in a rolling plastic cart), cleaning solution and shaving cream in an unlocked communal shower room. Further observation revealed LVN B put cleaning solution and shaving cream in the shower room closet and locked it up. LVN A and LVN B rolled the plastic cart, with razors in it, to the other communal shower room, where the door locked. <BR/>During an observation, in an unlocked closet in the communal shower room located in the women's memory care unit, and interview on 03/09/2023 at 6:01 a.m., LVN C confirmed observing razors and shaving cream in the unlocked closet of the shower room. LVN C stated the potential harm to resident was death. <BR/>During an interview on 03/09/2023 at 6:57 a.m., the Administrator stated yes, razors and shaving cream was supposed to be locked up away where residents do not have access to it. The Administrator stated the potential harm to residents was harming themselves. The Administrator stated nursing assistants were responsible for making sure those items were locked up. <BR/>During an interview on 03/09/2023 at 10:15 a.m., the Administrator stated the facility did not have a policy for hazards in unlocked shower rooms.

Based on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 days calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 7 resident (Resident #423) reviewed for Comprehensive Assessments and timing. <BR/>The facility failed to ensure an MDS Assessment for Resident #423 was completed within 14 days after admission. <BR/>This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.<BR/>Findings include:<BR/>Record review of Resident #423's face sheet dated 04/13/2023, revealed an admission date of 03/15/2023, <BR/>Record review of Resident #423's medical record revealed as of 04/14/2023 no admission assessment MDS had been completed.<BR/>Interview with the MDS Coordinator on 04/14/23 at 2:52 p.m. revealed the time frame for an initial MDS to be completed was 14 days from admission and the Comprehensive Assessment within 21 days of admission. She stated she was the only MDS for the facility and had fallen behind with her assessment. She revealed she used the RAI manual as reference and she had electronic access to the manual. <BR/>Interview with the Administrator on 04/14/2023 at 3:00 p.m. revealed the Administrator was aware the MDS coordinator needed help with the assessments for the facility and the facility was trying to hire another MDS nurse. <BR/>Record review of the mds-3.0-rai-manual-v1.17.1_October_2019 revealed The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: -this is the resident' s first time in this facility, OR -the resident has been admitted to this facility and was discharged return not anticipated, OR -the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge.