THE VILLA AT MOUNTAIN VIEW

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #154) reviewed for elopements.<BR/>The facility failed to ensure Resident #154 did not elope from the facility's back door on 04/19/24. Resident #154 was found on the street attempting to go to the gas station across the street from the facility that was located directly off a busy highway. Resident #154 had suffered a skin tear to his arm . <BR/>The noncompliance was identified as past noncompliance. The IJ began on 04/19/24 and ended on 11/01/24. The facility had corrected the noncompliance before the survey began. <BR/>This failure could placed residents at risk of serious injury or death.<BR/>Findings included:<BR/>Review of Resident #154's Face Sheet, dated 05/13/25, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 11/20/24.<BR/>Review of Resident #154's Quarterly MDS Assessment, dated 02/28/24, reflected he had a BIMS score of 04, indicating severe cognitive impairment. His MDS indicated he did not have any behaviors of wandering and that he utilized a wheelchair to ambulate. His active diagnoses included depression (feelings of severe despondency and dejection) and bipolar disorder (a mental health condition characterized by significant mood swings).<BR/>Review of Resident #154's Care Plan, dated 05/14/25, reflected the following: <BR/>Problems: [Resident #154] is at risk for wandering as evidenced by: Dementia/Alzheimer's .Interventions: Observe location each shift and prn .Report any attempts to exit the facility to IDT, family & MD as indicated and record in the clinical record .Place a wanderguard bracelet on [Resident #154] if attempt to leave out the facility [sic] .[Resident #154] requires a Wander Guard Bracelet [sic] and is at risk for injury from wandering in an un-safe enviornment [sic] .Interventions: Monitor for placement q shift, monitor for proper functioning q 24 hours .<BR/>Review of Resident #154's Elopement Risk Assessment, dated 11/01/24, reflected the following : 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK, A) Patient is cognitively impaired AND .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .Comments: Shows no signs of elopement.<BR/>Review of Resident #154's Elopement Risk Assessment, dated 06/27/24, reflected the following: 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .<BR/>Review of Resident #154's electronic health chart revealed there were not any other elopement risk assessments completed. <BR/>Review of Resident #154's Clinical Notes Report reflected the following: <BR/>- <BR/>pt left the facility and was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. She is getting me some coffee'. [sic] pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix written on 04/19/24 at 9:24 PM by RN G<BR/>- <BR/>At this time resident remains in bed, no s/s of pain and or discomfort noted. Resident noted to be resting on and off, but resident remains in bed and no attempts to get out of bed or facility noted at this time. All safety measures met. Written on 04/20/24 at 12:33 AM by LVN H<BR/>- <BR/>Resident was brought to nurses station by reception informed [sic] that resident pushed door open trying to go outside call [sic] placed to [the NP]. Notified of resident attempt to go out of front door [sic]. N/O may apply Wander guard for safety. Call to [Resident #154's Family Member] at [phone number] notified of attempt to go out of front door will be [sic] placing a wander guard to lower extremity. foe [sic] safety reason. stated'thank You' [sic] written by LVN I on 07/26/24 at 11:39 AM.<BR/>Review of an Accident/Incident Report, dated 04/19/24, reflected the following: <BR/>Person in charge- account of occurrence: pt left the facility was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. she is getting me some coffee'. pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix. Completed by RN G .<BR/>Interview on the phone on 05/12/25 at 10:53 AM with Resident #154's Family Member revealed Resident #154 left the facility in November 2024. Resident #154's Family Member said Resident #154 used a wanderguard bracelet while at the facility which she said was not necessary because the resident as far as she knew he never tried leaving or left the facility. <BR/>Interview on the phone on 05/13/25 at 2:06 PM with RN G revealed she no longer worked at the facility and could not remember the incident from April 2024.<BR/>Interview on the phone on 05/13/25 at 2:24 PM with CNA J was unsuccessful as she did not answer. CNA J was working on 04/19/24 and was assigned to Resident #154. <BR/>Interview on 05/13/25 at 2:30 PM with RA K revealed she was not here when Resident #154 eloped from the facility on 04/19/24 but she heard he had left through the back door of the facility near where the dumpsters were at. RA K said Resident #154 had a wander guard placed on his leg after this incident happened. RA K said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. RA K said she was in-serviced regarding elopements and wandering residents. RA K said she knew to immediately report to the nurse if she noticed a resident began to wander or make an attempt to elope from the facility. RA K said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. <BR/>Interview on 05/14/25 at 8:50 AM with LVN I revealed she cared for Resident #154 but had no idea about his elopement on 04/19/24. LVN I said she remembered Resident #154 had a wander guard bracelet because he had a tendency to wander around the facility. LVN I said if a resident began to have wandering or elopement behaviors it should be reported to her so that she may complete an elopement assessment on the resident. LVN I said she currently had residents who used a wander guard bracelet because they were at risk of wandering or eloping. LVN I said as the nurse she checks those identified resident's wander guard bracelets every shift for placement and functioning. LVN I said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. LVN I said she was in-serviced regarding elopements and wandering residents. LVN I said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. <BR/>Interview on 05/14/25 at 11:45 AM with LVN H revealed she could not recall anything about Resident #154's elopement on 04/19/24. LVN H said if a resident began to have wandering or elopement behaviors it should be reported to her so that she may complete an elopement assessment on the resident. LVN H said she did not currently have residents who used a wander guard bracelet because they were at risk of wandering or eloping. LVN H if she did care for a resident who used a wander guard bracelet, as the nurse she would check them every shift for placement and functioning. LVN H said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. LVN H said she was in-serviced regarding elopements and wandering residents. LVN H said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 1:07 PM with CNA L revealed he did not know about Resident #154 elopement from the facility on 04/19/24. CNA L said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. CNA L said he was in-serviced regarding elopements and wandering residents. CNA L said he knew to immediately report to the nurse if he noticed a resident began to wander or make an attempt to elope from the facility. CNA L said he knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 1:18 PM with CNA M revealed she had only been at the facility for four weeks. CNA M said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. CNA M said she was in-serviced regarding elopements and wandering residents. CNA M said she knew to immediately report to the nurse if she noticed a resident began to wander or make an attempt to elope from the facility. CNA M said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 3:15 PM with the DON revealed she was in training in April 2024 when Resident #154 eloped from the facility so she did not have any details about it. The DON said she recalled when they had to put a wander guard bracelet on Resident #154 because he would stand up and try to walk towards the doors and set the alarms off to the doors. The DON said with the wander guard bracelet, if Resident #154 got too close to the door the door alarm and the wander guard alarm would both go off and scare Resident #154 so he would back away from it after that. The DON said Resident #154 was easily redirectable but was exit seeking while he tried to find his family. The DON said Resident #154's family was not happy with him having the wander guard bracelet and did not believe the resident required one. The DON said when a resident eloped from the facility she expected staff to get them back inside right away and report to the Administrator and her about what happened. The DON said when the elopement code was activated she also expected her staff to do a sweep of the facility to ensure all residents were in house and safe. The DON said after the resident was safe the facility would investigate to see how they eloped from the facility and that would be corrected. The DON said staff should know to be supervising residents and watching them to make sure they did not leave and if they heard an alarm going off they should make sure they are responding to them. The DON said a number of things could happen to a resident if they eloped from the facility, depending on the weather it could be too cold or hot so they could die, or be hit by a car since there's a busy street behind the facility. The DON said staff were trained and in-serviced regarding resident elopements recently. The DON said when a resident was admitted and had elopement or wandering behaviors the facility would complete an elopement assessment on them and if a wander guard bracelet was necessary to keep them safe one would be placed. The DON said all staff knew to immediately report any new behaviors of a resident wandering or making elopement attempts.<BR/>Interview on the phone on 05/15/25 at 9:20 AM with the Previous Administrator was unsuccessful as she did not answer.<BR/>Interview on the phone on 05/15/25 at 9:21 AM with the Previous DON was unsuccessful as he did not answer. <BR/>Interview on 05/15/25 at 10:10 AM with the Administrator revealed she was not yet employed by the facility on 04/19/24 when Resident #154 eloped from the facility. The Administrator said she was not informed about the elopement either when she arrived to the facility. The Administrator said since she was not at the facility on 04/19/24 she had no details about what happened. The Administrator said Resident #154 had tendencies to wander and exit seek and his family was upset about him having to wear a wander guard bracelet. The Administrator said Resident #154 was always at the doors of the facility trying to leave. The Administrator said Resident #154 was always setting off the door alarms and the wander guard system alarms. The Administrator said Resident #154 was easily redirectable away from the doors, however. The Administrator said Resident #154 should not have been able to elope from the facility back in April 2024. The Administrator said she expected all staff to frequently monitor all residents who were at risk of eloping/wandering and to ensure they each were inside and safely in the facility. The Administrator said if a resident had been identified as being at risk of eloping/wandering a wander guard bracelet was placed on them. The Administrator said each resident's nurse would be responsible for checking the wander guard bracelet's placement and functioning each shift. The Administrator said the Maintenance Director checked each door every week to make sure that the wander guard system was working as well. The Administrator said the staff were provided with training on elopements because the facility had other residents elope back in November 2024. The Administrator said if a resident was able to elope from the facility they were at risk because it was not safe outside the facility. The Administrator said she expected staff to report when a resident eloped from the facility. <BR/>Interview and observation on 05/15/25 at 12:53 PM with the Maintenance Director revealed he was notified of Resident #154's elopement back in April 2024 but he could not recall any of the details. The Maintenance Director said if Resident #154 eloped from the back door of the facility near the dumpsters it would have been the door near the therapy gym at the end of the 400-hallway. Observation of the door at the end of the 400-hallway revealed it had a wander guard system alarm on it and the door was locked and required a code to turn the alarm off. Observation of the door being pushed open revealed an alarm went off and staff would have to enter the code in to the keypad to turn the alarm off. The door led out to a small parking lot that had the facility's dumpsters off to the left side and a gas station could be seen across the street. In front of the gas station was a busy highway as well. The Maintenance Director said he checks to make sure the wander guard system was working on each of the exterior doors once a week and documents that on his check off sheet. <BR/>The facility implemented the following interventions:<BR/>Review of an in-service roster, dated 11/01/24, and titled Staff in-services initiated the following: .elopement policy . reflected 108 staff's signatures. <BR/>Review of the facility's policy, dated January 2024, and titled Elopement Response Protocol reflected: 1. Conduct a thorough search of the Facility and its grounds .8. A complete head to toe nursing assessment must be completed upon return of the Patient [sic].<BR/>The Administrator was informed of the PNC IJ on 05/15/25 at 12:42 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five (Resident #1, #2, #3, #4, and #5) of fifteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, #2. #3, #4, and #5's rooms was in a position that was accessible to the residents on 08/12/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #1 Record review of Resident #1's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness, hemiplegia (paralysis of one side of the body), and hemiparesis (weakness on one side of the body). Record review of Resident #1's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 09/01/2025, reflected the resident had a severe impairment (the resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 05. The Quarterly MDS Assessment indicated that the resident required maximal assistance for dressing, bed mobility, and transfer. Record review of Resident #1's Comprehensive Care Plan, dated 09/23/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and interview on 10/09/2025 at 9:32 AM revealed Resident #1 was in her bed, awake. It was observed that the resident's call light was on the resident's side table and was not within reach. When asked where her call light was, the resident looked at her side and said she could not find her call light. Resident #2 Review of Resident #2's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting. Review of Resident #2's Quarterly MDS Assessment, dated 07/14/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 13. The Quarterly MDS Assessment indicated that the resident required moderate assistance for dressing, bed mobility, and transfer. Review of Resident #9's Comprehensive Care Plan, dated 09/10/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and interview on 10/09/2025 at 9:36 AM revealed Resident #2 was in his wheelchair, awake. It was observed that the resident's call light was on the floor behind his side table. He said the call light was behind his side table for some time. Resident #3 Review of Resident #3's Face Sheet, dated 10/09/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting. Review of Resident #3's Quarterly MDS Assessment, dated 08/14/2025, reflected the resident had severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated that the resident required moderate assistance for dressing, bed mobility, and transfer. Review of Resident #3's Comprehensive Care Plan, dated 09/30/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. An observation on 10/09/2025 at 9:39 AM revealed Resident #23 was in his bed with eyes closed. It was observed that the resident's call light was on the floor under his bed. Resident #4 Review of Resident #4's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting. Review of Resident #4's Quarterly MDS Assessment, dated 09/26/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated that the resident required maximal assistance for dressing, bed mobility, and transfer. Review of Resident #4's Comprehensive Care Plan, dated 09/23/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and an attempted interview on 10/09/2025 at 9:43 AM revealed Resident #4 was in her bed, awake. It was observed that the resident's call light was on the floor. When asked where her call light was, the resident did not answer. Resident #5 Review of Resident #5's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and abnormalities of gait. Review of Resident #5's Quarterly MDS Assessment, dated 09/01/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated that the resident required supervision for dressing, bed mobility, and transfer. Review of Resident #5's Comprehensive Care Plan, dated 09/24/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and an attempted interview on 10/09/2025 at 9:47 AM revealed Resident #5 was sitting at the side of her in her bed. It was observed that the resident's call light was on the floor under a walker. When asked where her call light was, the resident did not reply. During an observation and interview on 10/09/2025 at 9:57 AM, CNA C stated the call lights should be with the residents at all times because the call lights were used by the residents to call the staff if they needed something or if they needed help. She said without the call lights, the residents might fall if they tried to do things by themselves or might get mad because they cannot get hold of anybody. She said the call lights were for all the residents, whether independent or dependent residents. She went inside Resident's #1's room, took the call light from her side table, and placed it where Resident #1 could reach it. She then went to Resident #2's room and pulled his call light from behind the resident's side table and placed it where the resident could reach it. She then went to Resident #3's room and took the call light from the floor. She also did the same for Resident #4 and Resident #5. She said she went to the residents' rooms to change them but did not made sure that the call lights were with residents when she left their rooms. She said she would a round on her assigned hall to check the call lights. In an interview on 10/09/2025 at 10:31 AM, LVN B stated call lights should be with the residents in case they needed to call the staff because they needed to be changed, needed pain medications, or needed a refill of water. She said the CNAs and herself were responsible in making sure the call lights were with the residents. She said she did not notice the call lights were not with the residents when she checked on them. In an interview on 10/09/2025 at 11:19 AM, ADON A stated call lights should be with the residents at all times because the call lights were their lifeline. He said the residents used the call lights to call the staff if they were in distress or just needed a refill of water. He said the call lights were for independent or dependent residents. He said an independent resident might be having a heart attack and no one would know because the call light was not within reach. He said all the staff were responsible in checking if the call lights were with the residents and the expectation was for the staff to make sure the call lights were with the residents every time they left the rooms. He said an in-service had been going around and that he would coordinate with the DON to randomly check if the call lights were with the residents. In an interview on 10/09/2025 at 11:28 AM, the DON stated the expectation was for the staff to make sure the call lights were with the residents at all times. She said the call lights were used by the residents to call the staff if they needed something. She said residents might try to go to the bathroom by themselves because she had no way to call the staff that might result to a fall and injuries. She said all the staff were responsible for the call lights, including her. The DON said an in-service was already initiated and she would monitor the staffs' compliance about call lights. In an interview on 10/09/2025 at 11:48 AM, the Administrator stated the staff should make sure the call lights were with the residents before they leave the room. She said, for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said without the call light the residents might feel helpless. She said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said the DON already started an in-service about call lights. Record review of the facility's In-Service Training Report, dated 10/09/2025, reflected Call lights should be always be withing residents' reach/ability to push button/activate call light. Use clip for positioning. Everyone has the ability/responsibility to pick up call light and make sure it is in residents reach at all times. Record review of the facility's policy entitled Answering the Call Light 2001 MED-PASS, Inc. revised October 2010 reflected Purpose: The purpose of this procedure is to respond to the resident's requests and needs . General Guideline . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the resident had the right to personal privacy and confidentiality of his or her personal and medical records for 1 (Resident #1) of 6 residents reviewed the Privacy of medical records. <BR/>1.LVN D failed to notify FM 1 after Resident #1 had an unwitnessed fall and complained of back pain on 04/06/25 at 2:50 am. The nurse notified FM 2 who was not on the face sheet. <BR/>2.RN E failed to notify FM about Resident #1's transfer to the hospital after he fell with abnormal x-rays of his back on 04/06/25 around 3:26 pm. The nurse notified FM 2 who was not on the face sheet.<BR/>These failures could place residents with fall incidents or abnormal radiology reports at risk of a delay in prompt medical decisions, which could result in a decline in a resident's health and psycho-social well-being. <BR/>Findings included:<BR/>Record review of Resident #1's admission MDS Assessment completed on 04/02/25, by MDS M revealed Resident #1 was an [AGE] year old male who admitted to [This Facility] on 03/25/25 with a BIMS score of 09 (Moderate Cognitive Impairment). He was dependent (2 person helpers did all assist) with toileting, showering/bathing, lower body dressing and putting on footwear. And partial to moderate assist with bed mobility and transfers. He was occasionally incontinent with bladder and always incontinent with bowel. His active diagnoses were medically complex conditions and he was diagnosed with atrial fibrillation, HTN, BPH, diabetes, hyperlipidemia, metabolic encephalopathy, acute pancreatis without infection, diverticulitis of small intestines without perforation or abscess. He had a history of falling within the past month. And based on Braden and clinical assessment he was at risk for pressure injuries and had 1 or more pressure injuries, <BR/>Record review of Resident #1's Care Plan dated 04/08/25 for bladder incontinence related to confusion and impaired mobility, 03/31/25 Pressure Ulcer and enhanced barrier precautions implemented related to pressure ulcer. And 04/06/25 risk for falls. <BR/>Record review of Resident #1's Face Sheet dated 04/08/25 revealed only one FM listed [FM 1] as the Responsible party and Resident #1 was the alternate contact. (FM 2 was not listed). <BR/>Record review of Resident #1's Nurse Progress notes by LVN D dated 04/06/25 at 2:37 am revealed, Resident was found on the floor in his room next to his bed while CNA was making rounds. resident is unable to verbalize what happened. We were able to put resident back into the bed, when asked if he had injured himself, he pointed to his low back. neuro-checks were initiated and within normal limits, vital signs Temp 97.9-Blood Pressure-146/80-Respirations 16-Saturations 97% Room Air. Call To MD/NP received new orders for X-ray for lumbar spine and bilateral Lower Extremity. Family, DON/ADON informed. will continue to monitor condition.<BR/>Record review of Resident #1's Nurse Progress notes by LVN D dated 04/06/25 at 4:02 am revealed, XR (x-ray) requested for Lumbar Spine and Bilateral Hips.<BR/>Record review of Resident #1's Nurse Progress note by RN K dated 04/06/25 at 11:13 am revealed, Resident continues neuro checks due to recent fall. No pain or discomfort noted. Patient resting in bed. respirations even and unlabored. Medications given per orders.<BR/>Record review of Resident #1's Nurse Progress note by RN E dated 04/06/25 at 3:36 pm revealed, x-ray of spin and bilateral hip results received provider hotline called, reviewed results with NP H, order to send to ER for evaluation. Responsible party made aware.<BR/>Record review of Resident #1's Nurse Progress note by RN E dated 04/06/25 at 6:52 pm revealed, FM 2 was in the facility on day shift, made aware of resident's fall and pending x-ray by day shift staff, FM 2 exited the facility, FM 2 called the facility multiple times, left note with the receptionist for charge nurse to call him back to follow up on Resident #1's pending x-rays, this charge nurse called FM 2 back and FM 2 stated I came to visit Resident #1 a few hours ago, I was informed that Resident #1 fell and there were pending x-rays, are the results available yet? this charge nurse stated the x-ray results had been received and the NP was made aware of the results and the NP wanted to send the resident out for further evaluation, FM 2 said ok, he will come in and pick up a few things for Resident #1 such as his wallet and a few other items Resident #1 may want, FM later came into facility, this charge nurse informed FM that resident was transported to hospital for further evaluation pending x-ray results. <BR/>Record review of Resident #1's Nurse progress note by RN E dated 04/06/25 at 9:35 pm revealed, Resident returned from [The Hospital] with no new orders, np made aware FM made aware @ (at) phone # (number). <BR/>Record review of Resident #1's Change of condition completed by unknown staff dated 04/06/25 at 6:55 pm revealed, this change started 04/06/25 this afternoon. Resident's vitals were taken that were normal and he had an abnormal spine x-ray. The Resident Representative Notification was blank and there was not a signature on who completed this form. <BR/>Record review of Resident #1's Radiology Report dated 04/06/25 revealed, PROCEDURE: SPINE 1V SPECIFY LEVEL Status: Final, Reason for Study: M54.50 LOW BACK PAIN, UNSPECIFIED, SPINE 1V SPECIFY LEVEL: FINDINGS: Moderate L1 and mild L2-L3 vertebral body compression demonstrated. The age of the compression is indeterminate. Vertebral bodies show degenerative osteophytic spurring and narrowing of disc spaces. The bones appear diffusely demineralized. L5-S1 anterior fusion hardware present. No comparison study is available. CONCLUSION: Abnormal spine. Consider more sensitive imaging evaluation with CT/MRI as clinically directed.<BR/>Record review of Resident #1's Incident Report dated 04/06/25 at 2:15 am revealed, Resident was found on the floor next to his bed by CNA. No apparent injuries. Resident Unable to give Description, Vital signs taken, complete body assessment completed and neuro-checks initiated. MD/NP Called received order for XR((X-rays) of bilateral lower extremities and lumbar spine. No injuries noted at the time of incident, bedridden, oriented to person, pain aid 4 (moaning/groaning, facial grimacing, distressed), confused, incontinent, gait imbalance, impaired memory. Responsible party, DON and DR/NP notified. <BR/>Record review of Resident #1's Hospital Record dated 04/06/25 4:26 pm revealed, He admitted for abdominal pain and fall. At 4:43 PM Resident #1 is an [AGE] year-old male with a PMHx of HTN, a-fib, acute ischemic Left middle cerebral artery stroke, pancreatitis, and diabetes mellites who presents to the Emergency Department via Emergency Medical Service from a nursing home status post a fall yesterday evening. Per nurse relaying EMS, nursing home staff noticed the patient had an Altered Mental Status after falling out of bed yesterday evening. Per patient, he has bad back pain, left lower quadrant abdomen tenderness, and has vomited an unknown number of times recently. History of present illness and review of system limited secondary to chronic aphasia. CT scan of abdomen and pelvis with no abnormal findings. Radiology report from nursing home conducted at 1:00 pm today shows L1-L3 compression, unknown if acute or chronic. No acute changes on hips/pelvis x-ray. Pt has extensive cardiac history and history of stroke. The Lumbar findings were seen on prior imaging studies. Patient escorted from Emergency Department via stretcher accompanied by Ambulance service. Patient being taken back to the [The Facility]. Intravenous line removed by this RN. Discharge papers and face sheet given to transport team. No belongings left in room on pt departure. This RN attempted to call nursing home to let them know pt (patient) is coming back, no one responded.<BR/>Interview on 04/09/25 at 1:48 pm, FM 1 stated he did not get a call about Resident #1 falling from the facility staff last Sunday 04/06/25. He stated FM 2 visited Resident #1 and was given the information about him falling and going to the hospital. He stated FM #2 called him around 4:30 pm telling him about Resident #1 falling and went to the hospital Sunday 04/06/25. He stated on 04/06/25 around 6:00 pm he went to the facility to get more information and they said they did not know where he was and finally the lady said Resident #1 was at the hospital. He stated they called him Sunday 04/06/25 at 10:30 pm saying Resident #1 had returned from the hospital and the nurse was not able to say what the hospital results were. He stated the nurse said he was okay and that it was abnormal but he was not sure what was abnormal. He stated he asked when did Resident #1 fall and was told by RN Weekend Supervisor F he fell last night. He stated some 15 &frac12; hours later they told FM 2 not on the face sheet about his fall and hospital transfer. He stated RN Weekend Supervisor F said Resident #1's fall was reported to her and they needed to resolve his concern about not being notified of Resident #1's fall and hospital transfer. He stated the weekend supervisor said she would call the DON and Administrator about this issue. He stated to this day he's not been explained as to how his father fell and what was abnormal. <BR/>Interview on 04/09/25 at 3:58 pm, CNA G stated on 04/06/25, she overheard Resident #1 had a fall on a previous shift and then he went to the hospital. She stated FM 1 was at this facility wanting to know about the fall and said no one had contacted him from this facility that he had gone to the hospital. She stated Resident #1 returned around 9:00 pm on 04/06/25. <BR/>Interview on 04/10/25 at 9:55 am, the DON stated on 04/06/25 this past weekend, She stated Resident #1 fell and x-rays showed he had a lumbar spine that looked abnormal. She stated he was sent to the hospital and returned from the hospital and they confirmed the lumbar spine was a preexisting diagnosis. She stated RN E reached out to FM 2 and not FM 1 who was the responsible party. She stated she was not sure how she got confused, because she should have called FM 1 on the face sheet. She stated FM 1 spoke to the weekend supervisor about the matter. She stated she had not spoken to the staff about ensuring they spoke to the right family member but planned to do. She stated they planned to talk to the staff this upcoming Friday about incident reporting, notifications, and call outs. She stated RN Weekend supervisor F talked to RN E to try to figure out why she did not do the communication correctly. She stated after reviewing with RN E the notification on face sheet, RN E said she thought she had the right person. She stated she had not had a chance to speak to RN E because the State Surveyor came to the facility. She stated she had been tied up and was not aware FM 1 had not been updated about Resident # 1's hospital visit. <BR/>Interview on 04/10/25 at 10:41 am, the Administrator stated she thought FM 1 had a concern on the weekend of 04/06/25 about FM 2 being notified instead of him. She stated FM 2 visited Resident #1 and was told by the nurse he fell and was waiting for the x-ray results. She stated Resident #1 went to the hospital and had no complaints about why Resident #1 was sent to hospital and result afterwards. She stated on 04/06/25 at 2:37 am, Resident #1 was found on floor, in his room and the resident was unable to say what happened. She stated according to the nurses notes, the nurse called the Dr/NP and family. She stated she had no complaints from FM 1 about not being aware of Resident #1 falling, abnormal x-ray and transfer to the hospital. She stated he was sent back the same day 04/06/25 and there were no issues with informing FM 1 about the details of his hospital visit and fall that she was aware of. <BR/>Interview on 04/10/25 at 11:45 am, ADON A stated FM 1 said a few days ago Resident #1 went to the hospital and he was not informed. She stated FM 1 should have been informed because he was listed as the Responsible party. She stated she reviewed Resident #1's chart and FM 2 was not on it but FM 2 was in Resident #1's room visiting on 04/06/25. She stated she addressed this issue with RN E making sure they informed the right people on the face sheet because the RP needed to be notified for change of condition. She stated not being sure if FM 1 was notified of Resident #1 falling. She stated if the nurse called and left a message she should have called again then let upcoming nurse know to keep calling and go to next person on face sheet. She stated in Resident #1's case there was not a second contact person but RN E assumed FM 2 was the RP. She stated they planned to have a training with all staff to ensure no one was contacting the wrong person. She stated she was not aware of FM 1 complained about not being notified of the hospital visit findings. She stated the staff were supposed to call the RP to let them know the resident returned and outcome of hospital stay. <BR/>Interview on 04/11/25 at 10:59 am, Doctor J stated his NP H received the notice about Resident #1 fell and x-rays were ordered 04/06/25. She stated PA I was notified about the abnormal x-rays on 04/06/25 and sent the resident to the hospital. He stated Resident #1 fell out of bed and had bad back pain and had some vomiting. He stated he blood pressure and labs were fine and other vitals were fine and at the hospital he had a normal CT of his abdomen/pelvis. He stated Resident #1 had a diagnoses of diverticulitis and arthritis. He stated Resident #1's lumbar L1 and L2 were also negative and was sent back to this nursing facility the same day. <BR/>Interview on 04/11/25 at 12:42 pm, LVN D stated she worked the 300 and 400 halls and on 04/06/25 around 1:30 or 2:30 am, Resident #1 fell. She stated the CNA told her he was on the floor and after he was assessed he was assisted back into his bed. She stated Resident #1 said he had pain and pointed to his lower back then she called NP H and she ordered x-rays for his lumbar and bilateral hips. She stated she called FM 1 but he did not answer and got a voice mail and she left a message to call [This Facility]. She stated FM 1 did not call back and she did not try to call FM 1 back, then she left at 6:15 am. She stated she documented he fell and she initiated neuro checks because he had an unwitnessed fall. She stated Resident #1 was on his back on the floor, between the 2 beds, he was lying flat on the floor with his knees up. She stated she found out later he was taken to the hospital for irregular x-rays. <BR/>Interview on 04/11/24 at 1:24 pm, the Administrator stated they were trying to solve FM 1's complaints and they could not drop the ball again. She stated they had a meeting with FM 1 today 04/11/25 and FM 1 was giving them another opportunity to make things right for Resident #1. She stated not contacting the RP could potentially lead to the resident's needs not being met. She stated the DON was responsible for ensuring the change of condition process was done properly. She stated they were handling the issue with RN E and she was going to be written up and counseled, because she did not follow appropriate protocol. She stated FM 1 said when he came to the facility 04/06/25 to find out more information RN E was arguing with him that she had call him and he said no she did not call him. She stated RN E should have verified she spoke to the RP. She stated she was not aware LVN D did not call FM 1 after Resident #1 fell <BR/>Interview on 04/11/25 at 10:09 am, RN E stated last Sunday 04/06/25 LVN K told her Resident #1 fell and neuro checks were needed. She stated FM 2 had visited earlier that day 04/06/25 and he found out about the fall and pending x-ray. She stated Resident #1 was in a little bit pain of pain of his lower back she told him he's going to the hospital for abnormal x-rays and he said okay. She stated she called NP H and got the order to send Resident #1 to the hospital for an evaluation. She stated Resident #1 was sent to the hospital around 3:00 pm or 4:00 pm because he had an abnormal lumbar x-ray. She stated FM 2 contacted her but she had not had the opportunity to call anyone yet, then she returned FM 2's call to follow-up with the x-ray result and told him what was going on and the resident was going to the hospital. She stated later that evening FM 1 said he was the RP and she responded she was unaware of that. She stated she normally looked at the face sheet to see who the RP was but did not in this case. She stated FM 1 wanted a follow-up on Resident #1's fall and x-ray results and she told him that she did not know the residents well on the 400 hall. She stated she was told FM 1 was the only RP Resident #1 had and to only contact him. She stated the DON told her to look at the resident's face sheets before talking to anyone about the residents. She stated the RP was upset and she apologized for not looking at the face sheet and not contacting him first. She stated around 10:00 pm Resident #1 returned back to the facility with no new orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles for two (100 and 200 halls Nurses Medication Carts) of the four medication carts and one medication room reviewed for labeling and storage.<BR/>1. The facility failed to ensure insulin vials were dated after they were opened. <BR/>2. The facility failed to ensure expired insulins and medications were removed from the cart and medication room.<BR/>The failure could place residents at risk of receiving medications that were ineffective due to not labeling with opening dates and removing the expired medications. <BR/>Findings included:<BR/>Observation on 03/08/23 at 7:40 AM of Hall 200 Medication Cart with LVN C revealed one Lantus insulin vial was opened, partially used, and not labeled with the open date.<BR/>Interview on 03/08/23 at 7:52 AM with LVN C, who was the Charge Nurse, revealed she knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed in the cart. She stated she knew she was supposed to check her cart to ensure insulins were labeled and dated, but she did not check that morning. She stated the risks of not putting the open date was that a nurse would not know when the insulins expired, and the insulins might not be effective leading to residents having high blood sugar readings. She stated she was trained on labeling and dating medications.<BR/>Observation on 03/08/23 at 8:18 AM of Hall 100 Medication Cart with RN B revealed 3 insulin vials, to include two Lantus, one Humalog and NovoLog flex pen, that were opened and partially used with no open date. There was also Novolin insulin vial and Novolog insulin vial was opened, partially used, with the open date of 02/06/23 and 02/07/23.<BR/>Interview on 03/08/23 at 08:22 AM with RN B, who was the Charge Nurse, revealed she knew short-acting insulin pens and vials were good for only 28 days. She stated she knew it was all nurses' responsibility to check the cart each shift for expired medication. She stated she was aware there were insulins with expired dates and others with no open date in her cart, but she forgot to discard them. She stated the risks of not checking the cart and removing expired medications was the insulin would not be effective, blood sugars would not be controlled, and the resident could get brain damage. She stated she had done training on medication labeling and storage and removal of expired medications.<BR/>Interview with the DON on 03/08/23 at 8:50 AM revealed it was her expectation that staff date the insulin pens/vials once they pulled them from the refrigerator. She stated if the staff were not putting the opening dates on the insulin pens and vials that required an open date it placed residents at risk of receiving expired medication, having reactions, and the medication being ineffective leading to high blood sugar levels. She stated her expectation was once a resident's order had been discontinued the staff should remove the medications/insulins from their carts. She stated it was the responsibility of all nurses to check their halls cart each shift. She stated it was the responsibility of the ADON to monitor the carts and the medication storage for the expired insulins/medications and labeling once a week, but she was new to that position. She stated she had done training with nurses on expired medications which included instructing them to remove the expired medications, placing expired medications in the destruction boxes, and labeling medications with an open date when they opened medications and insulins.<BR/>Interview with the ADON on 03/08/23 at 4:42 PM revealed it was her responsibility to monitor the carts for expired medications and auditing the carts to ensure the nurses were putting open dates when they opened medications. She stated she last checked the carts in February 2023, since she has been busy covering position for two ADONs. She stated she had done training with nurses on checking the carts for expired medications and labeling with open dates when they opened medications and insulins.<BR/>Observation on 03/09/23 at 8:49 AM of the Medication Room with ADON revealed 9 Heparin vials with expiry dates of 08/22 (August 2022).<BR/>Interview with the ADON on 03/09/23 at 8:58 AM revealed it was her responsibility to check and monitor the medication room for expired medications weekly and ensuring they are labeled. She stated she had checked the medication room [ROOM NUMBER]/08/23, and she thought she missed the expiry dates on those heparin vials. She stated they were supposed to be put in the destruction box. She stated the risk of keeping expired medication in medication room was that residents could be administered expired medication which could be ineffective.<BR/>Interview with the DON on 03/09/23 at 9:56 AM revealed it was the responsibility of the ADON to check the medication room weekly for labeling and expired medications. She stated failure to check could lead to nurses administering expired medications to residents that would be ineffective. <BR/>Review of the facility's Storage of Medicationpolicy, dated November 2020, reflected: <BR/> .4.insulin-date after opening.<BR/>Insulin vials and pens are good x28days after open<BR/>Levemir vial and pen is good for x42 days after open.<BR/>Medication room.<BR/>Log discontinued medications for destruction<BR/>Audit over the counter medications stores.<BR/>Review of the Lantus Prescribing Information from the manufacturer, revised December 2020, reflected in-use, opened Lantus can be kept for 28 days either refrigerated or at room temperature. The manufacturer's prescribing information reflected: .The LANTUS vials you are using should be thrown away after 28 days, even if it still has insulin left in it <BR/>Review of the Humalog Prescribing Information from the manufacturer, revised April 2020, reflected: .Do not use your Pen past the expiration date printed on the Label or for more than 28 days after you first start using the Pen Throw away the HUMALOG Pen you are using after 28 days, even if it still has insulin left in it.<BR/>Review of the Novolog Prescribing Information from the manufacturer, revised February 2023, reflected: <BR/> .PenFill cartridges in use:<BR/>&middot; <BR/> Store the PenFill cartridge you are currently using in the insulin delivery device at room <BR/>temperature below 86&deg;F (30&deg;C) for up to 28 days. Do not refrigerate.<BR/>&middot; <BR/> The NovoLog PenFill cartridge you are using should be thrown away after 28 days, even if <BR/>it still has insulin left in it

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to immediately inform his or her authority, the resident representative(s) when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention and when a need to transfer or discharge the resident from the facility for 1 (Resident #1) of 6 residents reviewed for Change in condition. <BR/>1.LVN D failed to notify FM 1 after Resident #1 had an unwitnessed fall and complained of back pain on 04/06/25 at 2:50 am. <BR/>2.RN E failed to notify FM about Resident #1's transfer to the hospital after he fell with abnormal x-rays of his back on 04/06/25 around 3:26 pm.<BR/>These failures could place residents with fall incidents or abnormal radiology reports at risk of a delay in prompt medical decisions, which could result in a decline in a resident's health and psycho-social well-being. <BR/>Findings included:<BR/>Record review of Resident #1's admission MDS Assessment completed on 04/02/25, by MDS M revealed Resident #1 was an [AGE] year old male who admitted to [This Facility] on 03/25/25 with a BIMS score of 09 (Moderate Cognitive Impairment). He was dependent (2 person helpers did all assist) with toileting, showering/bathing, lower body dressing and putting on footwear. And partial to moderate assist with bed mobility and transfers. He was occasionally incontinent with bladder and always incontinent with bowel. His active diagnoses were medically complex conditions and he was diagnosed with atrial fibrillation, HTN, BPH, diabetes, hyperlipidemia, metabolic encephalopathy, acute pancreatis without infection, diverticulitis of small intestines without perforation or abscess. He had a history of falling within the past month. And based on Braden and clinical assessment he was at risk for pressure injuries and had 1 or more pressure injuries, <BR/>Record review of Resident #1's Care Plan dated 04/08/25 for bladder incontinence related to confusion and impaired mobility, 03/31/25 Pressure Ulcer and enhanced barrier precautions implemented related to pressure ulcer. And 04/06/25 risk for falls. <BR/>Record review of Resident #1's Face Sheet dated 04/08/25 revealed only one FM listed [FM 1] as the Responsible party and Resident #1 was the alternate contact. (FM 2 was not listed). <BR/>Record review of Resident #1's Nurse Progress notes by LVN D dated 04/06/25 at 2:37 am revealed, Resident was found on the floor in his room next to his bed while CNA was making rounds. resident is unable to verbalize what happened. We were able to put resident back into the bed, when asked if he had injured himself, he pointed to his low back. neuro-checks were initiated and within normal limits, vital signs Temp 97.9-Blood Pressure-146/80-Respirations 16-Saturations 97% Room Air. Call To MD/NP received new orders for X-ray for lumbar spine and bilateral Lower Extremity. Family, DON/ADON informed. will continue to monitor condition.<BR/>Record review of Resident #1's Nurse Progress notes by LVN D dated 04/06/25 at 4:02 am revealed, XR (x-ray) requested for Lumbar Spine and Bilateral Hips.<BR/>Record review of Resident #1's Nurse Progress note by RN K dated 04/06/25 at 11:13 am revealed, Resident continues neuro checks due to recent fall. No pain or discomfort noted. Patient resting in bed. respirations even and unlabored. Medications given per orders.<BR/>Record review of Resident #1's Nurse Progress note by RN E dated 04/06/25 at 3:36 pm revealed, x-ray of spin and bilateral hip results received provider hotline called, reviewed results with NP H, order to send to ER for evaluation. Responsible party made aware.<BR/>Record review of Resident #1's Nurse Progress note by RN E dated 04/06/25 at 6:52 pm revealed, FM 2 was in the facility on day shift, made aware of resident's fall and pending x-ray by day shift staff, FM 2 exited the facility, FM 2 called the facility multiple times, left note with the receptionist for charge nurse to call him back to follow up on Resident #1's pending x-rays, this charge nurse called FM 2 back and FM 2 stated I came to visit Resident #1 a few hours ago, I was informed that Resident #1 fell and there were pending x-rays, are the results available yet? this charge nurse stated the x-ray results had been received and the NP was made aware of the results and the NP wanted to send the resident out for further evaluation, FM 2 said ok, he will come in and pick up a few things for Resident #1 such as his wallet and a few other items Resident #1 may want, FM later came into facility, this charge nurse informed FM that resident was transported to hospital for further evaluation pending x-ray results. <BR/>Record review of Resident #1's Nurse progress note by RN E dated 04/06/25 at 9:35 pm revealed, Resident returned from [The Hospital] with no new orders, np made aware FM made aware @ (at) phone # (number). <BR/>Record review of Resident #1's Change of condition completed by unknown staff dated 04/06/25 at 6:55 pm revealed, this change started 04/06/25 this afternoon. Resident's vitals were taken that were normal and he had an abnormal spine x-ray. The Resident Representative Notification was blank and there was not a signature on who completed this form. <BR/>Record review of Resident #1's Radiology Report dated 04/06/25 revealed, PROCEDURE: SPINE 1V SPECIFY LEVEL Status: Final, Reason for Study: M54.50 LOW BACK PAIN, UNSPECIFIED, SPINE 1V SPECIFY LEVEL: FINDINGS: Moderate L1 and mild L2-L3 vertebral body compression demonstrated. The age of the compression is indeterminate. Vertebral bodies show degenerative osteophytic spurring and narrowing of disc spaces. The bones appear diffusely demineralized. L5-S1 anterior fusion hardware present. No comparison study is available. CONCLUSION: Abnormal spine. Consider more sensitive imaging evaluation with CT/MRI as clinically directed.<BR/>Record review of Resident #1's Incident Report dated 04/06/25 at 2:15 am revealed, Resident was found on the floor next to his bed by CNA. No apparent injuries. Resident Unable to give Description, Vital signs taken, complete body assessment completed and neuro-checks initiated. MD/NP Called received order for XR ((X-rays) of bilateral lower extremities and lumbar spine. No injuries noted at the time of incident, bedridden, oriented to person, pain aid 4 (moaning/groaning, facial grimacing, distressed), confused, incontinent, gait imbalance, impaired memory. Responsible party, DON and DR/NP notified. <BR/>Record review of Resident #1's Hospital Record dated 04/06/25 4:26 pm revealed, He admitted for abdominal pain and fall. At 4:43 PM Resident #1 is an [AGE] year-old male with a PMHx of HTN, a-fib, acute ischemic Left middle cerebral artery stroke, pancreatitis, and diabetes mellites who presents to the Emergency Department via Emergency Medical Service from a nursing home status post a fall yesterday evening. Per nurse relaying EMS, nursing home staff noticed the patient had an Altered Mental Status after falling out of bed yesterday evening. Per patient, he has bad back pain, left lower quadrant abdomen tenderness, and has vomited an unknown number of times recently. History of present illness and review of system limited secondary to chronic aphasia. CT scan of abdomen and pelvis with no abnormal findings. Radiology report from nursing home conducted at 1:00 pm today shows L1-L3 compression, unknown if acute or chronic. No acute changes on hips/pelvis x-ray. Pt (patient) has extensive cardiac history and history of stroke. The Lumbar findings were seen on prior imaging studies. Patient escorted from Emergency Department via stretcher accompanied by Ambulance service. Patient being taken back to the [The Facility]. Intravenous line removed by this RN. Discharge papers and face sheet given to transport team. No belongings left in room on pt departure. This RN attempted to call nursing home to let them know pt (patient) is coming back, no one responded.<BR/>Interview on 04/09/25 at 1:48 pm, FM 1 stated he did not get a call about Resident #1 falling from the facility staff last Sunday 04/06/25. He stated FM 2 visited Resident #1 and was given the information about him falling and going to the hospital. He stated FM #2 called him around 4:30 pm telling him about Resident #1 falling and went to the hospital Sunday 04/06/25. He stated on 04/06/25 around 6:00 pm he went to the facility to get more information and they said they did not know where he was and finally the lady said Resident #1 was at the hospital. He stated they called him Sunday 04/06/25 at 10:30 pm saying Resident #1 had returned from the hospital and the nurse was not able to say what the hospital results were. He stated the nurse said he was okay and that it was abnormal but he was not sure what was abnormal. He stated he asked when did Resident #1 fall and was told by RN Weekend Supervisor F he fell last night. He stated some 15 &frac12; hours later they told FM 2 not on the face sheet about his fall and hospital transfer. He stated RN Weekend Supervisor F said Resident #1's fall was reported to her and they needed to resolve his concern about not being notified of Resident #1's fall and hospital transfer. He stated the weekend supervisor said she would call the DON and Administrator about this issue. He stated to this day he's not been explained as to how his father fell and what was abnormal. <BR/>Interview on 04/09/25 at 3:58 pm, CNA G stated on 04/06/25, she overheard Resident #1 had a fall on a previous shift and then he went to the hospital. She stated FM 1 was at this facility wanting to know about the fall and said no one had contacted him from this facility that he had gone to the hospital. She stated Resident #1 returned around 9:00 pm on 04/06/25. <BR/>Interview on 04/10/25 at 9:55 am, the DON stated on 04/06/25 this past weekend, She stated Resident #1 fell and x-rays showed he had a lumbar spine that looked abnormal. She stated he was sent to the hospital and returned from the hospital and they confirmed the lumbar spine was a preexisting diagnosis. She stated RN E reached out to FM 2 and not FM 1 who was the responsible party . She stated she was not sure how she got confused, because she should have called FM 1 on the face sheet. She stated FM 1 spoke to the weekend supervisor about the matter. She stated she had not spoken to the staff about ensuring they spoke to the right family member but planned to do. She stated they planned to talk to the staff this upcoming Friday about incident reporting, notifications, and call outs. She stated RN Weekend supervisor F talked to RN E to try to figure out why she did not do the communication correctly. She stated after reviewing with RN E the notification on face sheet, RN E said she thought she had the right person. She stated she had not had a chance to speak to RN E because the State Surveyor came to the facility. She stated she had been tied up and was not aware FM 1 had not been updated about Resident # 1's hospital visit. <BR/>Interview on 04/10/25 at 10:41 am, the Administrator stated she thought FM 1 had a concern on the weekend of 04/06/25 about FM 2 being notified instead of him . She stated FM 2 visited Resident #1 and was told by the nurse he fell and was waiting for the x-ray results. She stated Resident #1 went to the hospital and had no complaints about why Resident #1 was sent to hospital and result afterwards. She stated on 04/06/25 at 2:37 am, Resident #1 was found on floor, in his room and the resident was unable to say what happened. She stated according to the nurses notes, the nurse called the Dr/NP and family. She stated she had no complaints from FM 1 about not being aware of Resident #1 falling, abnormal x-ray and transfer to the hospital. She stated he was sent back the same day 04/06/25 and the facility had no issues with FM 1 about the details of Resident #1's hospital visit and fall that she was aware of. <BR/>Interview on 04/10/25 at 11:45 am, ADON A stated FM 1 said a few days ago Resident #1 went to the hospital and he was not informed. She stated FM 1 should have been informed because he was listed as the Responsible party. She stated she reviewed Resident #1's chart and FM 2 was not on it but FM 2 was in Resident #1's room visiting on 04/06/25. She stated she addressed this issue with RN E making sure they informed the right people on the face sheet because the RP needed to be notified for change of condition. She stated not being sure if FM 1 was notified of Resident #1 falling. She stated if the nurse called and left a message she should have called again then let upcoming nurse know to keep calling and go to next person on face sheet. She stated in Resident #1's case there was not a second contact person but RN E assumed FM 2 was the RP. She stated they planned to have a training with all staff to ensure no one was contacting the wrong person. She stated she was not aware of FM 1 complained about not being notified of the hospital visit findings. She stated the staff were supposed to call the RP to let them know the resident returned and outcome of hospital stay. <BR/>Interview on 04/11/25 at 10:59 am, Doctor J stated his NP H received the notice about Resident #1 fell and x-rays were ordered 04/06/25. She stated PA I was notified about the abnormal x-rays on 04/06/25 and sent the resident to the hospital. He stated Resident #1 fell out of bed and had bad back pain and had some vomiting. He stated he blood pressure and labs were fine and other vitals were fine and at the hospital he had a normal CT of his abdomen/pelvis. He stated Resident #1 had a diagnoses of diverticulitis and arthritis. He stated Resident #1's lumbar L1 and L2 were also negative and was sent back to this nursing facility the same day . <BR/>Interview on 04/11/25 at 12:42 pm, LVN D stated she worked the 300 and 400 halls and on 04/06/25 around 1:30 or 2:30 am, Resident #1 fell. She stated the CNA told her he was on the floor and after he was assessed he was assisted back into his bed. She stated Resident #1 said he had pain and pointed to his lower back then she called NP H and she ordered x-rays for his lumbar and bilateral hips. She stated she called FM 1 but he did not answer and got a voice mail and she left a message to call [This Facility]. She stated FM 1 did not call back and she did not try to call FM 1 back, then she left at 6:15 am. She stated she documented he fell and she initiated neuro checks because he had an unwitnessed fall. She stated Resident #1 was on his back on the floor, between the 2 beds, he was lying flat on the floor with his knees up. She stated she found out later he was taken to the hospital for irregular x-rays. <BR/>Interview on 04/11/24 at 1:24 pm, the Administrator stated they were trying to solve FM 1's complaints and they could not drop the ball again. She stated they had a meeting with FM 1 today 04/11/25 and FM 1 was giving them another opportunity to make things right for Resident #1. She stated not contacting the RP could potentially lead to the resident's needs not being met. She stated the DON was responsible for ensuring the change of condition process was done properly. She stated they were handling the issue with RN E and she was going to be written up and counseled, because she did not follow appropriate protocol. She stated FM 1 said when he came to the facility 04/06/25 to find out more information RN E was arguing with him that she had call him and he said no she did not call him. She stated RN E should have verified she spoke to the RP. She stated she was not aware LVN D did not call FM 1 after Resident #1 fell <BR/>Interview on 04/11/25 at 10:09 am, RN E stated last Sunday 04/06/25 LVN K told her Resident #1 fell and neuro checks were needed. She stated FM 2 had visited earlier that day 04/06/25 and he found out about the fall and pending x-ray. She stated Resident #1 was in a little bit pain of pain of his lower back she told him he's going to the hospital for abnormal x-rays and he said okay. She stated she called NP H and got the order to send Resident #1 to the hospital for an evaluation. She stated Resident #1 was sent to the hospital around 3:00 pm or 4:00 pm because he had an abnormal lumbar x-ray. She stated FM 2 contacted her but she had not had the opportunity to call anyone yet, then she returned FM 2's call to follow-up with the x-ray result and told him what was going on and the resident was going to the hospital. She stated later that evening FM 1 said he was the RP and she responded she was unaware of that. She stated she normally looked at the face sheet to see who the RP was but did not in this case. She stated FM 1 wanted a follow-up on Resident #1's fall and x-ray results and she told him that she did not know the residents well on the 400 hall. She stated she was told FM 1 was the only RP Resident #1 had and to only contact him. She stated the DON told her to look at the resident's face sheets before talking to anyone about the residents. She stated the RP was upset and she apologized for not looking at the face sheet and not contacting him first. She stated around 10:00 pm Resident #1 returned back to the facility with no new orders. <BR/>Record review of the Facility's Change in Condition policy undated revealed, CHANGE OF CONDITION Policy: To identify and evaluate a change in condition and notify the Physician and Responsible Party when indicated. A significant change in Resident's status is any sign or symptom that is Acute or sudden onset: - A marked change (i.e., more severe) in relation to usual signs and symptoms - New or worsening symptoms - Examples include but are not limited to the following: cardiovascular, respiratory, behavioral, fall with major injury, infection, dehydration, altered mental status, pressure injury and any other condition based on professional judgment. Procedure: When a change in condition occurs, the Licensed Nurse will: .3. Document date, time Physician, Responsible Party was notified of findings from the evaluation and any new orders obtained . 6. If the Physician chooses to send the Resident to the hospital for further evaluation and treatment, the charge nurse will initiate the transfer process. Evaluation findings will be documented on the communication tool used to transition the Resident to the next level of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the resident had the right to personal privacy and confidentiality of his or her personal and medical records for 1 (Resident #1) of 6 residents reviewed the Privacy of medical records. <BR/>1.LVN D failed to notify FM 1 after Resident #1 had an unwitnessed fall and complained of back pain on 04/06/25 at 2:50 am. The nurse notified FM 2 who was not on the face sheet. <BR/>2.RN E failed to notify FM about Resident #1's transfer to the hospital after he fell with abnormal x-rays of his back on 04/06/25 around 3:26 pm. The nurse notified FM 2 who was not on the face sheet.<BR/>These failures could place residents with fall incidents or abnormal radiology reports at risk of a delay in prompt medical decisions, which could result in a decline in a resident's health and psycho-social well-being. <BR/>Findings included:<BR/>Record review of Resident #1's admission MDS Assessment completed on 04/02/25, by MDS M revealed Resident #1 was an [AGE] year old male who admitted to [This Facility] on 03/25/25 with a BIMS score of 09 (Moderate Cognitive Impairment). He was dependent (2 person helpers did all assist) with toileting, showering/bathing, lower body dressing and putting on footwear. And partial to moderate assist with bed mobility and transfers. He was occasionally incontinent with bladder and always incontinent with bowel. His active diagnoses were medically complex conditions and he was diagnosed with atrial fibrillation, HTN, BPH, diabetes, hyperlipidemia, metabolic encephalopathy, acute pancreatis without infection, diverticulitis of small intestines without perforation or abscess. He had a history of falling within the past month. And based on Braden and clinical assessment he was at risk for pressure injuries and had 1 or more pressure injuries, <BR/>Record review of Resident #1's Care Plan dated 04/08/25 for bladder incontinence related to confusion and impaired mobility, 03/31/25 Pressure Ulcer and enhanced barrier precautions implemented related to pressure ulcer. And 04/06/25 risk for falls. <BR/>Record review of Resident #1's Face Sheet dated 04/08/25 revealed only one FM listed [FM 1] as the Responsible party and Resident #1 was the alternate contact. (FM 2 was not listed). <BR/>Record review of Resident #1's Nurse Progress notes by LVN D dated 04/06/25 at 2:37 am revealed, Resident was found on the floor in his room next to his bed while CNA was making rounds. resident is unable to verbalize what happened. We were able to put resident back into the bed, when asked if he had injured himself, he pointed to his low back. neuro-checks were initiated and within normal limits, vital signs Temp 97.9-Blood Pressure-146/80-Respirations 16-Saturations 97% Room Air. Call To MD/NP received new orders for X-ray for lumbar spine and bilateral Lower Extremity. Family, DON/ADON informed. will continue to monitor condition.<BR/>Record review of Resident #1's Nurse Progress notes by LVN D dated 04/06/25 at 4:02 am revealed, XR (x-ray) requested for Lumbar Spine and Bilateral Hips.<BR/>Record review of Resident #1's Nurse Progress note by RN K dated 04/06/25 at 11:13 am revealed, Resident continues neuro checks due to recent fall. No pain or discomfort noted. Patient resting in bed. respirations even and unlabored. Medications given per orders.<BR/>Record review of Resident #1's Nurse Progress note by RN E dated 04/06/25 at 3:36 pm revealed, x-ray of spin and bilateral hip results received provider hotline called, reviewed results with NP H, order to send to ER for evaluation. Responsible party made aware.<BR/>Record review of Resident #1's Nurse Progress note by RN E dated 04/06/25 at 6:52 pm revealed, FM 2 was in the facility on day shift, made aware of resident's fall and pending x-ray by day shift staff, FM 2 exited the facility, FM 2 called the facility multiple times, left note with the receptionist for charge nurse to call him back to follow up on Resident #1's pending x-rays, this charge nurse called FM 2 back and FM 2 stated I came to visit Resident #1 a few hours ago, I was informed that Resident #1 fell and there were pending x-rays, are the results available yet? this charge nurse stated the x-ray results had been received and the NP was made aware of the results and the NP wanted to send the resident out for further evaluation, FM 2 said ok, he will come in and pick up a few things for Resident #1 such as his wallet and a few other items Resident #1 may want, FM later came into facility, this charge nurse informed FM that resident was transported to hospital for further evaluation pending x-ray results. <BR/>Record review of Resident #1's Nurse progress note by RN E dated 04/06/25 at 9:35 pm revealed, Resident returned from [The Hospital] with no new orders, np made aware FM made aware @ (at) phone # (number). <BR/>Record review of Resident #1's Change of condition completed by unknown staff dated 04/06/25 at 6:55 pm revealed, this change started 04/06/25 this afternoon. Resident's vitals were taken that were normal and he had an abnormal spine x-ray. The Resident Representative Notification was blank and there was not a signature on who completed this form. <BR/>Record review of Resident #1's Radiology Report dated 04/06/25 revealed, PROCEDURE: SPINE 1V SPECIFY LEVEL Status: Final, Reason for Study: M54.50 LOW BACK PAIN, UNSPECIFIED, SPINE 1V SPECIFY LEVEL: FINDINGS: Moderate L1 and mild L2-L3 vertebral body compression demonstrated. The age of the compression is indeterminate. Vertebral bodies show degenerative osteophytic spurring and narrowing of disc spaces. The bones appear diffusely demineralized. L5-S1 anterior fusion hardware present. No comparison study is available. CONCLUSION: Abnormal spine. Consider more sensitive imaging evaluation with CT/MRI as clinically directed.<BR/>Record review of Resident #1's Incident Report dated 04/06/25 at 2:15 am revealed, Resident was found on the floor next to his bed by CNA. No apparent injuries. Resident Unable to give Description, Vital signs taken, complete body assessment completed and neuro-checks initiated. MD/NP Called received order for XR((X-rays) of bilateral lower extremities and lumbar spine. No injuries noted at the time of incident, bedridden, oriented to person, pain aid 4 (moaning/groaning, facial grimacing, distressed), confused, incontinent, gait imbalance, impaired memory. Responsible party, DON and DR/NP notified. <BR/>Record review of Resident #1's Hospital Record dated 04/06/25 4:26 pm revealed, He admitted for abdominal pain and fall. At 4:43 PM Resident #1 is an [AGE] year-old male with a PMHx of HTN, a-fib, acute ischemic Left middle cerebral artery stroke, pancreatitis, and diabetes mellites who presents to the Emergency Department via Emergency Medical Service from a nursing home status post a fall yesterday evening. Per nurse relaying EMS, nursing home staff noticed the patient had an Altered Mental Status after falling out of bed yesterday evening. Per patient, he has bad back pain, left lower quadrant abdomen tenderness, and has vomited an unknown number of times recently. History of present illness and review of system limited secondary to chronic aphasia. CT scan of abdomen and pelvis with no abnormal findings. Radiology report from nursing home conducted at 1:00 pm today shows L1-L3 compression, unknown if acute or chronic. No acute changes on hips/pelvis x-ray. Pt has extensive cardiac history and history of stroke. The Lumbar findings were seen on prior imaging studies. Patient escorted from Emergency Department via stretcher accompanied by Ambulance service. Patient being taken back to the [The Facility]. Intravenous line removed by this RN. Discharge papers and face sheet given to transport team. No belongings left in room on pt departure. This RN attempted to call nursing home to let them know pt (patient) is coming back, no one responded.<BR/>Interview on 04/09/25 at 1:48 pm, FM 1 stated he did not get a call about Resident #1 falling from the facility staff last Sunday 04/06/25. He stated FM 2 visited Resident #1 and was given the information about him falling and going to the hospital. He stated FM #2 called him around 4:30 pm telling him about Resident #1 falling and went to the hospital Sunday 04/06/25. He stated on 04/06/25 around 6:00 pm he went to the facility to get more information and they said they did not know where he was and finally the lady said Resident #1 was at the hospital. He stated they called him Sunday 04/06/25 at 10:30 pm saying Resident #1 had returned from the hospital and the nurse was not able to say what the hospital results were. He stated the nurse said he was okay and that it was abnormal but he was not sure what was abnormal. He stated he asked when did Resident #1 fall and was told by RN Weekend Supervisor F he fell last night. He stated some 15 &frac12; hours later they told FM 2 not on the face sheet about his fall and hospital transfer. He stated RN Weekend Supervisor F said Resident #1's fall was reported to her and they needed to resolve his concern about not being notified of Resident #1's fall and hospital transfer. He stated the weekend supervisor said she would call the DON and Administrator about this issue. He stated to this day he's not been explained as to how his father fell and what was abnormal. <BR/>Interview on 04/09/25 at 3:58 pm, CNA G stated on 04/06/25, she overheard Resident #1 had a fall on a previous shift and then he went to the hospital. She stated FM 1 was at this facility wanting to know about the fall and said no one had contacted him from this facility that he had gone to the hospital. She stated Resident #1 returned around 9:00 pm on 04/06/25. <BR/>Interview on 04/10/25 at 9:55 am, the DON stated on 04/06/25 this past weekend, She stated Resident #1 fell and x-rays showed he had a lumbar spine that looked abnormal. She stated he was sent to the hospital and returned from the hospital and they confirmed the lumbar spine was a preexisting diagnosis. She stated RN E reached out to FM 2 and not FM 1 who was the responsible party. She stated she was not sure how she got confused, because she should have called FM 1 on the face sheet. She stated FM 1 spoke to the weekend supervisor about the matter. She stated she had not spoken to the staff about ensuring they spoke to the right family member but planned to do. She stated they planned to talk to the staff this upcoming Friday about incident reporting, notifications, and call outs. She stated RN Weekend supervisor F talked to RN E to try to figure out why she did not do the communication correctly. She stated after reviewing with RN E the notification on face sheet, RN E said she thought she had the right person. She stated she had not had a chance to speak to RN E because the State Surveyor came to the facility. She stated she had been tied up and was not aware FM 1 had not been updated about Resident # 1's hospital visit. <BR/>Interview on 04/10/25 at 10:41 am, the Administrator stated she thought FM 1 had a concern on the weekend of 04/06/25 about FM 2 being notified instead of him. She stated FM 2 visited Resident #1 and was told by the nurse he fell and was waiting for the x-ray results. She stated Resident #1 went to the hospital and had no complaints about why Resident #1 was sent to hospital and result afterwards. She stated on 04/06/25 at 2:37 am, Resident #1 was found on floor, in his room and the resident was unable to say what happened. She stated according to the nurses notes, the nurse called the Dr/NP and family. She stated she had no complaints from FM 1 about not being aware of Resident #1 falling, abnormal x-ray and transfer to the hospital. She stated he was sent back the same day 04/06/25 and there were no issues with informing FM 1 about the details of his hospital visit and fall that she was aware of. <BR/>Interview on 04/10/25 at 11:45 am, ADON A stated FM 1 said a few days ago Resident #1 went to the hospital and he was not informed. She stated FM 1 should have been informed because he was listed as the Responsible party. She stated she reviewed Resident #1's chart and FM 2 was not on it but FM 2 was in Resident #1's room visiting on 04/06/25. She stated she addressed this issue with RN E making sure they informed the right people on the face sheet because the RP needed to be notified for change of condition. She stated not being sure if FM 1 was notified of Resident #1 falling. She stated if the nurse called and left a message she should have called again then let upcoming nurse know to keep calling and go to next person on face sheet. She stated in Resident #1's case there was not a second contact person but RN E assumed FM 2 was the RP. She stated they planned to have a training with all staff to ensure no one was contacting the wrong person. She stated she was not aware of FM 1 complained about not being notified of the hospital visit findings. She stated the staff were supposed to call the RP to let them know the resident returned and outcome of hospital stay. <BR/>Interview on 04/11/25 at 10:59 am, Doctor J stated his NP H received the notice about Resident #1 fell and x-rays were ordered 04/06/25. She stated PA I was notified about the abnormal x-rays on 04/06/25 and sent the resident to the hospital. He stated Resident #1 fell out of bed and had bad back pain and had some vomiting. He stated he blood pressure and labs were fine and other vitals were fine and at the hospital he had a normal CT of his abdomen/pelvis. He stated Resident #1 had a diagnoses of diverticulitis and arthritis. He stated Resident #1's lumbar L1 and L2 were also negative and was sent back to this nursing facility the same day. <BR/>Interview on 04/11/25 at 12:42 pm, LVN D stated she worked the 300 and 400 halls and on 04/06/25 around 1:30 or 2:30 am, Resident #1 fell. She stated the CNA told her he was on the floor and after he was assessed he was assisted back into his bed. She stated Resident #1 said he had pain and pointed to his lower back then she called NP H and she ordered x-rays for his lumbar and bilateral hips. She stated she called FM 1 but he did not answer and got a voice mail and she left a message to call [This Facility]. She stated FM 1 did not call back and she did not try to call FM 1 back, then she left at 6:15 am. She stated she documented he fell and she initiated neuro checks because he had an unwitnessed fall. She stated Resident #1 was on his back on the floor, between the 2 beds, he was lying flat on the floor with his knees up. She stated she found out later he was taken to the hospital for irregular x-rays. <BR/>Interview on 04/11/24 at 1:24 pm, the Administrator stated they were trying to solve FM 1's complaints and they could not drop the ball again. She stated they had a meeting with FM 1 today 04/11/25 and FM 1 was giving them another opportunity to make things right for Resident #1. She stated not contacting the RP could potentially lead to the resident's needs not being met. She stated the DON was responsible for ensuring the change of condition process was done properly. She stated they were handling the issue with RN E and she was going to be written up and counseled, because she did not follow appropriate protocol. She stated FM 1 said when he came to the facility 04/06/25 to find out more information RN E was arguing with him that she had call him and he said no she did not call him. She stated RN E should have verified she spoke to the RP. She stated she was not aware LVN D did not call FM 1 after Resident #1 fell <BR/>Interview on 04/11/25 at 10:09 am, RN E stated last Sunday 04/06/25 LVN K told her Resident #1 fell and neuro checks were needed. She stated FM 2 had visited earlier that day 04/06/25 and he found out about the fall and pending x-ray. She stated Resident #1 was in a little bit pain of pain of his lower back she told him he's going to the hospital for abnormal x-rays and he said okay. She stated she called NP H and got the order to send Resident #1 to the hospital for an evaluation. She stated Resident #1 was sent to the hospital around 3:00 pm or 4:00 pm because he had an abnormal lumbar x-ray. She stated FM 2 contacted her but she had not had the opportunity to call anyone yet, then she returned FM 2's call to follow-up with the x-ray result and told him what was going on and the resident was going to the hospital. She stated later that evening FM 1 said he was the RP and she responded she was unaware of that. She stated she normally looked at the face sheet to see who the RP was but did not in this case. She stated FM 1 wanted a follow-up on Resident #1's fall and x-ray results and she told him that she did not know the residents well on the 400 hall. She stated she was told FM 1 was the only RP Resident #1 had and to only contact him. She stated the DON told her to look at the resident's face sheets before talking to anyone about the residents. She stated the RP was upset and she apologized for not looking at the face sheet and not contacting him first. She stated around 10:00 pm Resident #1 returned back to the facility with no new orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** tc Based on interviews and record reviews the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and once identified received services to promote wound healing for 1 (Resident #1) of 6 residents reviewed for Wound prevention. <BR/>The facility failed to ensure Resident #1 did not develop a sacral wound after he admitted to this facility on 03/25/25; subsequently on 03/30/25, CNA C did not provide incontinent care to Resident #1 and the nurses or treatment nurses did not provided wound care to his sacral Deep Tissue Injury. And on 03/31/25 he developed an opened sacral wound. <BR/>The facility failed to ensure Resident #1 did not develop a Left heel wound that was discovered on 04/09/25. <BR/>These failures could place all residents at risk of acquiring wounds which could result in pain and infection and cause a decline in the resident's health and psycho-social well- being.<BR/>Findings included:<BR/>Record review of Resident #1's admission MDS Assessment completed on 04/02/25, by MDS M revealed Resident #1 was an [AGE] year-old male who admitted to [This Facility] on 03/25/25 with a BIMS score of 09 (Moderate Cognitive Impairment). He was dependent (2 person helpers did all assist) with toileting, showering/bathing, lower body dressing and putting on footwear. And partial to moderate assist with bed mobility and transfers. He was occasionally incontinent with bladder and always incontinent with bowel. His active diagnoses were medically complex conditions and he was diagnosed with atrial fibrillation, HTN, BPH, diabetes, hyperlipidemia, metabolic encephalopathy, acute pancreatis without infection, diverticulitis of small intestines without perforation or abscess. He had a history of falling within the past month. And based on Braden and clinical assessment he was at risk for pressure injuries and had 1 or more pressure injuries. <BR/>Record review of Resident #1's Care Plan dated 04/08/25 for bladder incontinence related to confusion and impaired mobility, 03/31/25 Pressure Ulcer and enhanced barrier precautions implemented related to pressure ulcer. And 04/06/25 risk for falls. (There was no care Plan for ADL Care). <BR/>Record review of Resident #1's March 2025 MARS Skin Prep Wipes Miscellaneous (Ostomy Supplies) Apply to sacrum topically everyday shift for wound care Cleanse area with Normal Saline or Skin Cleanser. Pat Dry. Apply Skin Prep to affected area. Cover with Dry Dressing -Start Date- 03/27/2025 6:00 am Discontinued Date- 03/31/2025 2:15 pm. Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for PREVENT CLOT-Start Date- 03/25/2025 at 7:00 pm. And on 03/30/25 there were no initials that his wound care treatment had been done. <BR/>Record review of Resident #1's April 2025 MARS revealed, Wound Treatment - Hydrogel with silver everyday shift Cleanse wound to sacrum with Normal Saline or Skin Cleanser. Pat Dry. Apply Hydrogel to wound bed. Cover with Dry Dressing Start Date- 04/01/2025 at 6:00 am. Eliquis Oral Tablet 5 MG(Apixaban) Give 1 tablet by mouth two times a day for PREVENT CLOT -Start Date- 03/25/2025 7:00 pm.<BR/>Record review of Resident #1's Nurse Progress Note dated 03/25/25 by RN N revealed, Skilled Note: Patient admitted to the facility under the skilled care of Doctor J with the DX (Diagnoses)) and HX (History)of Abdominal pain related to pancreatitis, Acute ischemic, Atrial fibrillation, Biventricular implantable cardioverter, Cardiomyopathy, CHF (Congestive Heart failure), Complete AV (Atrioventricular) block due to AV (Atrioventricular) [NAME] ablation, DM (diabetes Mellites) , and HTN. Patient is A/O (Alert/oriented) X 2, Spanish speaker with some understanding of English language. Incontinent of B/B (bowel/bladder), assist x 1 with Adl care. Patient continues on regular diet and regular liquid, skin is intact, no teeth no dentures. No s/s (signs/symptoms) of respiratory distress or pain noted or verbalized, skin warm and dry, bed lowered and call light within reach.<BR/>Record review of Resident #1 Braden Scale for predicting pressure ulcer risk evaluation dated 03/25/2025 at 5:09 pm by RN N revealed, Sensory Perception: No impairment. Moisture: Occasionally moist. Activity: Chairfast. Resident is Slightly Limited: Makes frequent though slight changes in body or extremity position independently. Nutrition: Adequate. Friction and shear: Potential problem. BRADEN Score: 17.0 (at risk). <BR/>Record review of Resident #1's Nurse Progress note dated 03/26/25 at 1:17 pm by RN S revealed, Skilled Note: Day 1/3 new admit. Resident is full code under skilled care of Dr J with the DX and HX of Abdominal pain related to pancreatitis, Acute ischemic, Atrial fibrillation, Biventricular implantable cardioverter, Cardiomyopathy, CHF, Complete AV block due to AV [NAME] ablation, DM, and HTN. Resident is primarily Spanish Speaking but understands some English. Writer introduced self as morning nurse. Full head to toe assessment shows no skin issues. Skin warm to touch dry and intact. Ear audible x2 with minimum wax build-up. Resident denies wearing hearing aids. Nares patent x2. Lips moist. Skin turgor good. No bleeding to gums noted. Teeth within reason. No thrush on tongue. Gag reflex present. Facial muscles present. No jvd (bulging jugular veins) noted. Able to MAEW (moves all extremities well). PT/ST/OT to eval. Denies pain at this time. Lungs CTA (CT angiogram of chest) A&P (anterior and posterior) bilaterally. breathing even and unlabored with no acute distress noted. No sob (Shortness of Breath) noted. No edema noted. PPP (pedal, pulses, palpable) present x4. BS (bowel sounds) present x4 quads. Resident is incontinent of B/B (bowel and bladder). Requires assist x 1 with Adl care such as grooming/transfers/bathing. Able to independently feed self with setup help only on NAS (no added salt) diet, Regular texture, Regular/Thin consistency. VS (vital signs) wnl (within normal limits). Resident orientated to call light/bedside remote. Repositioned for comfort. Care provided in timely manner. Call light within reach. <BR/>Record review of Resident #1's Skin/Wound note dated 03/26/25 at 2:46 pm by Treatment Nurse B revealed, LATE ENTRY: Skin assessment completed. Dry skin to lower extremities and feet, moisturizer applied. Sacral area with purplish discoloration, Dr. notified, initiated wound consult, and wound care. Offloading with pillows, w/c cushion in place. No c/o pain voiced. Called FM 1, unable to leave message. Resident aware of treatment plan, no concerns voiced.<BR/>Record review of Resident #1's Baseline Care Plan dated 03/27/25 by RN S revealed, substantial/maximal assistance with sit to stand, chair/bed to chair transfer and toilet transfer, used a walker and wheelchair, always incontinent with bladder and bowel, used anticoagulants. 4. Skin risk was unchecked for current skin integrity and history of skin integrity issues.<BR/>Record review of Resident #1 Skin/Wound note on 03/27/2025 at 9:42 am by Treatment Nurse B revealed, LATE ENTRY: Skin Issues: New skin Issue. Location: Sacrum. Issue type: Pressure ulcer / injury. Wound was present on admission. Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 6 Width (cm): 6 Depth (cm): 0 Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 0%. Slough: 0%. Eschar: 0%. Exudate amount: None. Exudate type: None. Odor after cleansing: None. Periwound: Attached. Surrounding tissue: Normal in color. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing saturation: None 0%. Cleansing solution: Normal saline. Other primary dressing: SKIN PREP Secondary dressing: Dry. Modalities: None. Additional care: Mattress with pump. Additional care: Nutrition / dietary supplementation. Additional care: Mobility aid(s) provided. Additional care: Incontinence management. Additional care: Repositioning device(s). Skin issue education: Treatment of skin issue. Skin issue notification: Family. Skin issue notification: Provider. Skin issue notification: Wound nurse.<BR/>Record review of Resident #1's Skin Issue progress note dated 03/31/2025 2:10 pm by Treatment Nurse B revealed Skin Issues : Skin Issue: #001: Skin issue has been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure ulcer / injury. Wound was present on admission. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Staged by: Health care provider. Length (cm): 2.5 Width (cm): 6 Depth (cm): 0.2 Undermining: No. Tunneling: No. Epithelial:0%. Granulation: 80%. Slough: 0%. Eschar: 0%. Exudate amount: Light. Exudate type: Serous: clear watery fluid, which is separated from solid elements. Odor after cleansing: None. Other: not applicable. Other wound bed information: INTACT SKIN 20%Periwound: Attached. Surrounding tissue: Normal in color. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Minimal &lt; 25%. Cleansing solution: Normal saline. Other primary dressing: hydrogel with silver Secondary dressing: Dry. Modalities: None. Additional care: Nutrition / dietary supplementation. Additional care: Repositioning device(s). Additional care: Mattress with pump. Additional care: Incontinence management. Additional care: Mobility aid(s) provided. Additional care: Pressure reducing device for chair. Skin issue education: Treatment of skin issue. Skin issue notification: Provider. Skin issue notification: Family. <BR/>Record review of Resident #1's Skin/Wound note dated 03/31/2025 at 2:19 pm by Treatment Nurse B revealed, Seen by wound NP for wound consult in am. Unstageable DTI to sacrum with light serous drainage noted, 20% intact skin. No c/o pain voiced. Tx changed to Hydrogel with silver and dressing daily. R/p present and observed wound, aware of tx plan. Low bed position, call light in reach.<BR/>Record review of Resident #1's Skin/Wound note dated on 04/02/2025 3:08 pm by Treatment Nurse B revealed, Skin issue has been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Unstageable pressure ulcer / injury. Unstageable ulcer due to slough and / or eschar. Wound was present on admission. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Staged by: Health care provider. Length (cm): 2.5 Width (cm): 5.5 Depth (cm): 0.2 Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 40%. Slough: 40%. Eschar: 0%. Exudate amount: Light. Exudate type: Serous: clear watery fluid, which is separated from solid elements. Odor after cleansing: None. Other: not applicable. Other wound bed information: 20% skin Periwound: Attached. Surrounding tissue: Normal in color. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Minimal &lt; 25%. Cleansing solution: Normal saline. Debridement: Sharp. Other primary dressing: hydrogel with silver Secondary dressing: Dry. Modalities: None. Additional care: Pressure reducing device for chair. Additional care: Mattress with pump. Additional care: Incontinence management. Additional care: Nutrition / dietary supplementation. Additional care: Repositioning device(s). Additional care: Mobility aid(s) provided. Skin issue education: Treatment of skin issue. Skin issue notification: Family. Skin issue notification: Provider.<BR/>Record review of Resident #1's Skin/Wound note dated 04/09/2025 at 6:09 pm by Treatment Nurse B revealed, Has skin issue has been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Unstageable pressure ulcer / injury. Wound was present on admission. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Staged by: Health care provider. Length (cm): 2 Width (cm): 4.5 Depth (cm): 0.2 Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 40%. Slough: 40%. Eschar: 0%. Exudate amount: None. Exudate type: None. Odor after cleansing: None. Other: not applicable. Other wound bed information: 20% skin Periwound: Attached. Surrounding tissue: Normal in color. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: None 0%. Cleansing solution: Normal saline. Debridement: Sharp. Other primary dressing: hydrogel with silver Secondary dressing: Dry. Modalities: None. Additional care: Incontinence management. Additional care: Repositioning device(s). Additional care: Mobility aid(s) provided. Additional care: Mattress with pump. New skin Issue. Location: Left heel. Issue type: Diabetic foot ulcer. Wound acquired in-house. Wound is new. Painful: No. Staged by: Health care provider. Length (cm): 0.8 Width (cm): 0.7 Depth (cm): 0 Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 0%. Slough: 0%. Eschar: 0%. Exudate amount: None. Exudate type: None. Odor after cleansing: None. Other: not applicable. Other wound bed information: INTACT SKIN WITH PURPLE/ MAROON DISCOLORATION Periwound: Attached. Surrounding tissue: Normal in color. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing saturation: None 0%. Cleansing solution: Normal saline. Other primary dressing: SKIN PREP Secondary dressing: No secondary dressing applied. Modalities: None. Additional care: Mobility aid(s) provided. Additional care: Repositioning device(s). Additional care: Mattress with pump. Skin issue education: Treatment of skin issue. Skin issue notification: Provider. Skin issue notification: Family.<BR/>Record review of Resident #1's Skin/Wound note dated 04/09/2025 at 6:02 pm by Treatment Nurse B revealed, Seen by Dr. [NAME] in am for wound consult. Sacral wound improved with increased granulation tissue. No sx of infection noted. New area to left heel; intact skin with purple /maroon discoloration noted. New order for skin prep daily. Offloading with pillows, LAL mattress, vitamin therapy continues. No c/o pain voiced. Called R/p FM 1, updated on status of wounds and new orders.<BR/>Record review of Resident #1's four (4)skin assessments by Treatment Nurse B revealed on:<BR/>03/27/25 at 9:52 am Skin issues: New issue - sacrum pressure injury, present on admission, no drainage, Attached: Edge appears flush with wound bed or as a sloping edge. Incontinence management. Skin prep with dry dressing. (6 cm x 6 cm x 0 cm). <BR/>03/31/25 at 2:10 pm Skin issues: Evaluated - sacrum pressure injury, stable, unstageable pressure injury, present on admission, light clear drainage, 20 % skin intact. Incontinence management, Attached: Edge appears flush with wound bed or as a sloping edge. Hydrogel with silver dry dressing. (2.5 cm x 6 cm x .2 cm). <BR/>04/02/25 at 3:08 pm, Skin issues: Evaluated - sacrum pressure injury, improved, unstageable pressure injury, present on admission, light clear drainage, 20% skin intact, incontinence management, Attached: Edge appears flush with wound bed or as a sloping edge, Hydrogel with silver dry dressing. (2.3 cm x 5.5 cm x .2 cm). <BR/>04/09/25 at 6:09 pm, Skin issues:#1. Evaluated - sacrum pressure injury, improved, unstageable pressure injury, present on admission, no drainage 20% skin intact, Attached: Edge appears flush with wound bed or as a sloping edge, Hydrogel with silver dry dressing. 2 cm x 4.5 cm x .2 cm. #2. New issue: Left heel diabetic foot ulcer, in-house acquired, Skin intact with purple/maroon discoloration, Attached: Edge appears flush with wound bed or as a sloping edge. mattress with pump, reposition device. Skin prep. (.8 cm x .7 cm x 0 cm).<BR/>Record review of Resident #1's Wound care Doctor Notes from 03/31/25 to 04/09/25 revealed:<BR/>03/31/25 - Unstageable DTI sacrum undetermined thickness wound size (L x W x D) 2.5 x 6 x 0.2 cm. <BR/>04/02/25 - Unstageable due to necrosis sacrum full thickness wound size (L x W x D) 2.5 x 5.5 x 0.2 cm. <BR/>04/09/25 - (Site 1)Unstageable due to necrosis sacrum full thickness wound size (L x W x D) 2.0 x 4.5 x 0.2 cm. Focus wound exam (Site 2) Diabetic wound of left heel (L x W x D) .08 x o.7 x not measurable cm. <BR/>Record review of Resident #1's Hospital Discharge Record dated 03/25/25 revealed, Hospital Discharge summary dated [DATE] revealed, Primary Discharge Diagnosis: Acute pancreatitis (pancreas inflammation), resolved. Secondary discharge diagnosis: Acute metabolic encephalopathy (Brain Dysfunction), small bowel obstruction (blockage in intestines), diarrhea (loose watery stools), Diverticulitis of descending colon (inflamed or infected colon), Type 2 diabetes (high blood sugar), Essential hypertension (high blood pressure), paroxysmal A-fib (recurrent irregular heartbeat), CVA (Stroke), dilated cardiomyopathy (heart muscle disease), Discharge Disposition: Skilled Nursing Facility. Extremities: normal, atraumatic, no cyanosis or edema, Skin: Skin color, texture, turgor normal, no rashes or lesions. Hospital Problem list: Essential hypertension, benign prostate hyperplasia, paroxysmal atrial fibrillation, chronic anticoagulation, cognitive impairment, cerebrovascular accident, dilated cardiomyopathy, Principal: acute pancreatitis, small bowel obstruction, diverticulitis of descending colon. (There were not any Skin issues, rashes, DTI, or wounds listed). <BR/>Interview on 04/09/25 at 1:28 pm, FM 1 stated there was no report of Resident #1 having any skin issues at the hospital or when he first admitted to [This Facility] 03/25/25, then on 03/29/25 Treatment Nurse B said she discovered Resident #1 had a sacral wound. FM 1 stated when visiting Resident #1 on 03/30/25, Resident #1's clothes and bed was saturated with feces and urine that appeared reddish underneath Resident #1. FM stated he had to get staff to come in to change him and the CNA was not on the hall and they found her working another hall. FM 1 stated on 03/31/25 there was several people in the meeting as a new admission meet and greet and he brought up the sacral wound concern and why was he not notified of Resident #1's wound until 03/29/25. FM 1 said the Administrator tried to say Resident #1 checked in with that wound but FM 1 did not think that was true. FM 1 stated Treatment Nurse B said Resident #1 did not have a sacral wound when he first admitted . FM 1 stated on 03/31/25 he was able to see Resident #1's wound with the wound care NP and Treatment Nurse B in the room. FM 1 stated Treatment Nurse B admitted to him, Resident #1 was not changed the day before on 03/30/25 by CNA C. <BR/>Interview on 04/09/25 at 10:52 am, the Treatment Nurse B stated Resident #1 had a pressure wound. She stated he admitted with a sacral pressure sore that had actually improved. She stated she assessed him the following day after he admitted on [DATE] and he had some purplish discoloration. She stated skin prep was ordered for skin protection. She stated she did skin assessments but his skin was not open until the wound care NP saw him 03/31/25. She stated Resident #1's treatment was changed to hydrogel with silver and dry dressing on 03/31/25. She stated that tended to happen with DTI they were superficial and will open up. She stated the nurse managers had daily standup meetings to discuss who had wounds, the statuses, and interventions to ensure they were on the same page. She stated they met to see if they needed to do something different. She stated Resident #1 initially had a purplish color on his sacral that was fading and granulating with minimum drainage. She stated Resident #1's sacral wound had no odors in the healing phase and he had no pain. She spoke to FM 1 about the wound and he came up to the facility to see the wound and he had concerns about Resident #1 being incontinent and being left wet. <BR/>Interview on 04/09/25 at 3:35 pm, RN N stated he remembered assessing Resident #1 when he first admitted during the evening shift on 03/25/25. He stated he did a head-to-toe assessment of Resident #1 and he did not have any wounds or discolorations anywhere. He stated Resident #1 did not have a sacral wound and he stood on his word. He stated the next day the Treatment Nurse B did the skin assessments for all new admit residents. He stated if the residents skin was not checked regularly they might miss something and the resident's skin might turn to something like a wound. <BR/>Interview on 04/09/25 at 4:15 pm, LVN O stated she worked another hall two weekends ago on Sunday 03/30/25 and FM 1 said for three days he did not feel the staff were checking and changing Resident #1 that often. She stated FM 1 said he noticed the issue of Resident #1 not getting changed on the weekends and weekdays. She stated she had to talk to CNA C that day 03/30/25 who worked a split hall and had a few rooms on the 400 hall. She stated she asked CNA C why was Resident #1 soaking wet. C said she was not sure of Resident #1's care level. She stated she made sure Resident #1 was provided incontinent care, just before the CNA's shift was over. She stated Resident #1 was very soiled with brownish stains underneath him and stated she wrote a note and put it under the DON's door. She stated the note she left was about Resident #1 not being turned and changed and had to send CNA C into the room to do incontinent care on him. She stated she assumed the DON addressed it and did not call the DON about this matter the same day or next day She stated she had not worked at this facility since then and felt she took care of the issue with Resident #1 with getting him changed. She stated FM 1 said thanks so much and he said he was going to mention this issue in the meeting already scheduled for that Monday 03/31/25, with the DON and Administrator. She stated she was not his nurse that day it was LVN T and she was just passing by Resident #1's room and FM 1 stopped her around 1:00 pm. She stated FM 1 wanted Resident #1 changed because he was wet and after seeing the condition of the resident she went to the nursing station where LVN T was charting. She stated she had LVN T go into the room to see the condition of Resident #1 and then he was changed. She stated she did not think Resident #1 not being changed was neglect but it was miscommunication on what the CNA was supposed to do. She stated she told CNA C she still was supposed to check and provide care to Resident #1. <BR/>Interview on 04/09/25 at 4:40 pm, CNA C stated she worked a double shift on 03/30/25 and onetime she worked a split on the 300 and 400 halls on 03/30/25 from 6:00 am to 2:00 pm. She stated she also worked the 500 hall on 03/30/25 from 2:00 pm to 10:00 pm . She stated she never worked the 400 hall and CNA P who normally worked that hall said Resident #1 was continent but he really was not. She stated it was a hard lesson for her to learn and said she checked Resident #1 once before breakfast and lunch and his sheets was not messed up. She stated FM 1 came around 3:00 pm and Resident #1's bed sheets were soaked and a mess they had orange colored urine and bowel movement in his brief. She stated she immediately changed him and she did not see any wounds on him anywhere. She stated she did not look at Resident #1's Plan of Care because she took the word of CNA P telling her he could walk and put his light on when he needed something. She stated she was a new CNA (just certified as a nurse aide) and went by the CNA's word and did not check to see that Resident #1 was incontinent. She stated she had access to the residents records and for now she would make sure she checked everybody to see if they needed incontinent care and toileting. She stated she did not want to base care on what she heard from CNA's and what happened to Resident #1 was a hard lesson to learn. She stated no one talked to her about ways to not ever do that again. She stated she was emotional and apologized about what happened to Resident #1 and FM 1 and they just looked at her and said thank you. She stated she was assigned 14 residents and CNA P worked the other side of hall 400. She stated LVN T was the nurse who worked the 400 hall and she was made aware of the situation. She stated the DON nor Administrator had not spoken to her about this and asked was she in trouble about this. <BR/>Interview on 04/10/25 at 9:55 am, the DON stated the wound care NP visited the residents every Mondays and the wound care Doctor visited the residents every Wednesday. She stated ADON A said Resident #1's son had some concerns about the timeliness of Resident #1's care, about how often he was being changed. She stated FM 1 was explained on the call light process, which was understandable with Resident #1 being new to their facility. She stated she explained to FM 1 how the staffing ratio was different from the hospital. She stated she was not aware Resident #1 was not changed for a long period of time on 03/30/25. She stated ADON A told her FM 1 said Resident #1 was wet, not soaking wet and she stated she did not call FM 1 about his complaint because ADON A said she handled it. She stated what they needed to do moving forward was to check more often on the residents and family about any concerns. She stated they were constantly training the staff on call light response and making sure they followed through on what they needed to do for the residents. She stated she never heard anything about Resident #1 not getting care on 03/30/25. She stated the splitting of halls fluctuated with the census. She stated they planned to have a meeting with FM 1 about his expectations. She stated there were no complaints from anyone about the care CNA C provided the residents. She stated CNA C usually worked the 500 hall and did a really really good job and added she was not sure if she had ever worked the split 400 hall, but she may have. She stated she had no complaints or issues with how LVN T provided care to the residents. She stated LVN T had not reported any issues with Resident #1 on 03/30/25. She stated Resident #1 admitted with a sacral wound and they did not take pictures of the wound when he admitted because the Treatment nurse assessed the residents once they admitted . She stated she was not sure when the Treatment Nurse B assessed Resident #1. She stated Resident #1 admitted with a sacral Deep Tissues Injury but his wound was intact. She stated she was not sure why Resident #1 was not diagnosed with a DTI when he admitted , she would have to ask the Treatment Nurse B . She stated she was not sure when Resident #1 got the sacral wound. She stated his sacral wound started out as a DTI and changed to a pressure wound or that area. <BR/>Interview on 04/09/25 at 10:41 am, the Administrator stated they had a new admission meeting with FM 1 on 04/02/25 about Resident #1's discharge planning. She stated FM 1 brought up an ADL grievance about Resident #1 being wet but not soaking wet. She stated FM 1 said Resident #1 was incontinent and there was delays in his care. She stated they told FM 1 Resident #1 admitted with a darkened area. She stated they told FM 1 the sacral discoloration was under his skin and it was not an open area. She stated after Resident #1 admitted the DTI opened up to a pressure wound. She stated she was not sure why RN N said Resident #1 skin was intact and had no discoloration when he admitted . She stated RN N was not trained in wound care like Treatment Nurse B. She stated she was not sure when the Treatment Nurse B first assessed Resident #1 maybe 03/26/25. She stated as of yesterday 04/09/25 Resident #1's sacral area was an unstageable pressure wound and he had a new diabetic non- pressure heel wound. She stated Resident #1 has had four wound care assessments on 03/27/25, 03/31/25, 04/02/25 and 04/09/25. She stated there were no issues with how often Resident #1 was changed with the exception of 03/30/25. She stated telling FM 1 the staff would be doing frequent rounds from shift to shift and communicate better between the nurses and CNA's. She stated telling FM 1 she had an open-door policy to her about any concerns. She stated no facility was perfect and FM 1 knew he could talk to them about any concerns. She stated she spoke to ADON A and she said she resolved FM 1's concern and all the aides working 03/30/25 were counseled because there was an issue with the assignments that day who worked the 400 hall. She stated now those staff received clarification on what residents they were assigned to care for. She stated the nurses needed to check behind the CNA's to ensure the care was being provided during their shifts. She stated she was not sure of the specifics of FM 1 complaint because ADON B handled it and she stated she was not sure if the nurses had been spoken to about the 03/30/25 incident with Resident #1. She stated there were no complaints with how CNA C and LVN T cared for the residents. She stated CNA C was disciplined about the confusion of her assignment in not providing care to Resident #1 on 03/30/25. She stated she did not talk to CNA C directly because she gave the directive for it to be handled by the ADON A. She stated all the staff knew their expectations and if Resident #1 not getting changed was a mistake or accident did not negate what happened. She stated they were all monitoring CNA C to ensure she was providing proper care to the residents. She stated no one brought to her attention the condition of Resident #1's bed being heavily soaked with bowel and urine because CNA C thought Resident #1 was continent but that was not an excuse she should have checked on him periodically and changed him. She stated Resident #1 was in a facility to get care. She stated they trained the staff about ADL care last Monday 04/07/25. She stated if a resident were left soiled for a long period of time they could have a negative outcome, anything could happened. She stated Resident #1 had care plans for sacral wound, bladder incontinence on 03/26/25, enhanced barrier precaution related to pressure ulcer on 03/31/25, bladder incontinence on 04/08/25.<BR/>Interview on 04/10/25 at 11:45 am, ADON A stated they had an admission meeting earlier this month where all the staff introduced themselves to the new residents and family. She stated FM 1 had concerns about ensuring Resident #1 received appropriate care and they told FM 1 to come to her (ADON A) or other ADON U for his concerns. She stated two days ago FM 1 called her about the timing issue of Resident #1's incontinent care and she told him moving forward she would go out to check and see that Resident #1 was getting care every two hours. She stated she worked some weekends and some nights but not all the time but the charge nurses was also ensuring Resident #1 was being changed timely. She stated FM 1 said he came to visit and Resident #1 was soiled and was concerned with how long it was taking for the CNA's to change him. She stated she reviewed the schedule for 03/30/25 and there was a mix-up of the schedule. She stated CNA G worked the other end of the 400 hall during the 2:00 pm -10:00 shift on 03/30/25. She stated none of the staff reported Resident #1 was soaking wet with bowel and urine and not changed for a long period of time. She stated she was not sure who LVN O was. She stated the staff should have reported if a resident was heavily soaking wet with bowels and urine because of not being changed for a long period of time. She stated Resident #1 should not have been left that long without being changed, LVN T was his nurse 03/30/25 and she did not say anything about this incident either. She stated she spoke to CNA C about what happened and she said the thought Resident #1 was continent and did not provide any incontinent care to him on 03/30/25. She stated she did counseling with CNA C and told her moving forward she needed to make sure everyone was on the same page and knew the right assignment by looking at

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to maintain medical records on each resident that were complete for 1 (Resident #1) of 6 residents reviewed for Medical records. <BR/>MDS L or MDS M failed to add to Resident #1's EMR profile, of him having a sacral pressure ulcer he was diagnosed with on 03/31/25. <BR/>These failures could place residents at risk of not getting appropriate care if the resident's documentation were missing from their medical profile which could cause missed care and treatment resulting in a decline in health and psycho-social well-being. <BR/>Findings included: <BR/>Record review of Resident #1's admission MDS Assessment completed on 04/02/25, by MDS M revealed Resident #1 was an [AGE] year old male who admitted to [This Facility] on 03/25/25 with a BIMS score of 09 (Moderate Cognitive Impairment). He was dependent (2 person helpers did all assist) with toileting, showering/bathing, lower body dressing and putting on footwear. And partial to moderate assist with bed mobility and transfers. He was occasionally incontinent with bladder and always incontinent with bowel. His active diagnoses were medically complex conditions and he was diagnosed with atrial fibrillation, HTN, BPH, diabetes, hyperlipidemia, metabolic encephalopathy, acute pancreatis without infection, diverticulitis of small intestines without perforation or abscess. He had a history of falling within the past month. And based on Braden and clinical assessment he was at risk for pressure injuries and had 1 or more pressure injuries, <BR/>Record review of Resident #1's Care Plan dated 04/08/25 for bladder incontinence related to confusion and impaired mobility, 03/31/25 Pressure Ulcer and enhanced barrier precautions implemented related to pressure ulcer. And 04/06/25 risk for falls.<BR/>Interview on 04/11/25 at 12:14 pm, MDS L stated for the residents new diagnoses she was responsible for ensuring they were added to the residents EMR profile. She stated both ADON's and the DON could also add new diagnoses. She stated she was aware Resident #1 had a sacral wound and just found out while looking at his record he had a new left heel wound . She stated she would add his Sacral wound diagnoses to his EMR profile. She stated when resident's diagnoses were missing from their EMR profile it could cause safety issues and not allow them to care for them properly. She stated it could cause them to not have interventions in place and proper care could be delayed.<BR/>Interview on 04/11/25 at 1:24 pm, the Administrator stated she was not aware of any issues with adding the residents diagnoses to their medical records. She stated the MDS L was not at work last Friday and called out and added they did not have another person designated for adding diagnoses. She stated the resident's diagnoses were needed in the EMR profile to adequately reflect the residents condition. She stated the MDS Coordinator was responsible for adding any new diagnoses to the resident's file. She stated Resident#1 has had the sacral wound for a couple of weeks. <BR/>Record review of the facility's Medical records policy was requested and on 04/11/25 at 3:30 pm, the Regional Nurse Consultant said they did not have one. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 5 residents (Resident #66) reviewed for PASRR assessments.<BR/>The facility did not refer Resident #66 to the appropriate state-designated mental health authority for review when he received a new diagnosis of schizoaffective disorder, bipolar type. <BR/>This failure could place residents at risk of not being evaluated and receive needed PASRR services.<BR/>Findings included: <BR/>Record review of Resident #66's face sheet dated 05/15/25 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #66 was diagnosed with schizoaffective disorder, bipolar type on 04/14/25. <BR/>Record review of Resident #66's MDS Assessment, dated 03/21/25, reflected the resident had an active diagnosis of depression disorder, anxiety disorder, psychotic disorder, non-Alzheimer's dementia and the resident had severe cognitive impairment with a BIMS score of 05.<BR/>Record review of Resident #66's Care plan reflected [Resident #66] currently taking psychotropic <BR/>medication(s) as evidenced by: Major Depressive Disorder, Anxiety/Panic Disorder, psychosis. Goals: [Resident #66] will not experience adverse side effects over the next 90 days. Interventions: Monitor and record any displayed behavior or mood problems.<BR/>Record review of Resident #66's PASRR Level 1 Screening, dated 11/16/21, reflected he did not have a mental illness. PASRR Level 1 screening did not indicate Resident #66 had primary diagnosis of dementia.<BR/>Record review of Resident #66's, 1012 Form (Mental Illness/Dementia Resident Review) dated 11/22/23 reflected: the individual has a primary diagnosis of dementia as define above. The physician signs and dates the form attesting to the dementia diagnosis. Complete Section D and E of the form. -Section D and Section E not completed. <BR/>Interview on 05/15/25 at 2:21 PM, RCC stated Resident #66 had a negative PASRR Level 1. She stated Resident #66 had a primary diagnosis of Dementia. The RCC reviewed Resident #66's medical chart and stated Resident #66 did not have any documentation stating he had a diagnosis of Dementia other than the psych notes. RCC stated Resident #66 had a 1012 form completed on 11/22/23 and stated Resident #66's primary diagnosis was dementia. The RCC stated since the 1012 Form stated a primary diagnosis of dementia it would override any new diagnosis. <BR/>Interview on 05/15/25 at 3:39 PM, the DON stated if a new diagnosis was given to a resident a new PASRR evaluation should be completed. The DON stated to ask RCC for any questions regarding Resident #66's PASRR. <BR/>Follow up interview on 05/15/25 at 4:03 PM, the RCC stated Resident #66's, 1012 Form was not completed correctly. She stated since given a new diagnosis and new 1012 form or PASRR Level 1 should had been completed. She stated the potential risk would be resident being positive for PASRR and would be missing out on PASRR services. <BR/>Record review of facility admission Criteria policy, undated, reflected the following: <BR/>9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding, for 1 of 1 resident (Resident #45) reviewed for enteral nutrition.<BR/>The facility failed to follow physician orders for Resident #45's enteral feeding tube to be flushed with 50 ml of water every 1 hour and feeding with Jevity 1.2 at 55mls/hr.<BR/>This failure could place residents who had gastrostomy tube at risk for fluid deficit and over feeding.<BR/>Findings included:<BR/>Record review of Resident #45's quarterly MDS assessment dated [DATE], reflected the resident was a [AGE] year-old female who was admitted to the facility initially on 09/24/2024 and readmitted on [DATE]. She had diagnoses that included dysphasia (swallowing difficulties). Resident #45's BIMS score was 11 revealing moderate cognition. The MDS further revealed Section K (Nutritional approaches) indicated the resident's nutritional approach was a feeding tube. <BR/>Record review of Resident #45's care plan dated 03/18/25 reflected: Focus: Resident #45 requires tube feeding rule out Dysphagia. Goal: will maintain<BR/>adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: Administer enteral feeding/water flushes as ordered by physician.<BR/>Record review of Resident #45's physician orders, dated 05/05/25, reflected an order for Enteral Feed Order flush feeding tube with 50 cc of water every 1 hour and another Enteral Feed jevity 1.2 at 55ml/hr. via feeding to run continuously.<BR/>Observation and interview on 05/13/2025 at 10:55 AM, revealed Resident #45 lying in bed. Resident #45 was connected to her feeding pump, the Jevity1.2 formula bag was dated 05/13/25 at a rate of 65 mL/hr and the water bag was dated 05/13/25 with a rate of 35ml/hr .<BR/>Observation and interview on 05/14/25 at 10:43 AM with LVN A, who was the charge nurse for Resident #45, revealed Resident #45 was connected to her feeding pump.The Jevity 1.2 feeding rate was set at 65 mL /hr, and the water flush rate was set at 35 mL every 1 hour. She stated she was aware the physician order for the flush was supposed to be 35 mL/hr and jevity 1.2 at 65mls/hr. She stated when she came in the morning, she only checked to ensure the feeding was flowing. She stated she did not check the settings. She stated she knew she was supposed to check the settings, but she forgot. LVN A stated Resident #45 had a g-tube, and the night shift had hung a new formula and water bag. She stated she was not aware that the orders had been changed. She stated failure to follow the physician orders could lead to dehydration and overfeeding that could lead to vomiting and aspiration. LVN A stated she had done training on gastronomy tubes regarding medication and feeding administration.<BR/>Interview on 05/14/25 at 02:30 PM with RN B, who was the charge nurse for Resident #45 on the second shift , revealed she was the one that had connected Resident #45 to her feeding pump on 05/13/25. She stated the feeding rate was set at 65 mL/hr, and the water flush rate was set at 35 mL every 1 hour. She stated she knew she was supposed to check the physician orders before hanging a new bottle of feeding and flushing water, but she did not check. She stated she was not aware that the orders had been changed. She stated failure to follow the physician orders could lead to dehydration and overweight. RN B stated she had done training on gastronomy tubes regarding medication and feeding administration.<BR/>Interview on 05/14/25 at 02:51 PM with ADON N, revealed he was responsible of putting new orders given by dietician on the electronic records. He stated his expectation was for nurses to check orders before they hang the feeding bottle and the water flushes. He stated it was his responsibility to monitor nurses and ensure the pumps were set with the correct orders. He stated he had not been to Resident #45's room since the orders were changed. He stated the potential risk would be dehydration and weight gain. He stated he could not recall any in-service on g tube feeding administration.<BR/>Interview with on 05/15/25 at 01:22pm with Regional Dietician she stated her expectation was nurses to carry out orders as given and follow instructions . She stated she changed the orders on 05/05/25 and she notified the ADON. She stated the risk of not following the orders would be dehydration and weight gain.<BR/>Interview on 05/15/25 at 03:29 PM, the DON revealed she expected the nurses to follow physician and dietitian orders. The DON stated she also expected the nurses to set feeding pumps per the orders and check orders regularly for changes. The DON said the person responsible to ensure orders were followed, were nursing staff and ADON N. The DON said that ADON N was responsible to ensure orders were followed by nursing staff through audits and ensure the orders matches with the feeding and the flushes on the pump . She stated failure to follow the physician orders could lead to dehydration and weight gain. She stated she had done training with staff in April on g tube feeding and medication administration. <BR/>Record review of the facility's training records for medication administration including tube feeding, dated April 13 2024, reflected RN B was not in attendance, but LVN A was in attendance.<BR/>Record review of the facility's Enteral feeding safety precautions policy, dated MAY 2014 , reflected:<BR/> .1.Check the enteral nutrition label against the order before administration. Check the following information .<BR/>g. Rate of administration (ml/hour) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #98) reviewed for dialysis.<BR/>The facility failed to ensure dialysis communication forms for Resident #98 were completed with the resident's dialysis treatment information on the following dates: 05/02/25, 05/05/25, and 05/09/25.<BR/>This failure could place residents at risk of inadequate communication between the facility and dialysis center. <BR/>Findings included: <BR/>Record review of Resident #98's admission record, dated 05/14/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. <BR/>Record review of Resident #98's admission MDS Assessment, dated 04/28/25, reflected she had a BIMS score of 10, indicating moderate cognitive impairment. Her active diagnoses included renal insufficiency, renal failure, or end-stage renal disease, heart failure, and respiratory failure. Her MDS indicated she received dialysis services.<BR/>Record review of Resident #98's physician's orders, dated 05/14/25, reflected the following: <BR/>- <BR/>Dialysis- Post Tx Frequency in the evening every Mon, Wed, Fri Upon [sic] return, enter Dialysis Treatment Information received from Dialysis Center onto the Dialysis Communication Record. Complete the Post Dialysis Assessment Section. Check for any labs/ notes/ orders [sic] from the Dialysis Center with an active date of 04/29/25.<BR/>- <BR/>Dialysis- Pre Tx Frequency every day shift every Mon, Wed, Fri Complete Pre-Treatment section of Dialysis Communication Record. Print record and place in Dialysis Communication Folder prior to Transport. Ensure Food and/ or [sic] Meal goes with patient to each Dialysis treatment. with an active date of 04/29/25.<BR/>Record review of Resident #98's care plan, initiated 04/23/25, reflected the following: <BR/>Focus: The resident needs dialysis .<BR/>Record review of Resident #98's Dialysis Communication Forms, dated 05/02/25 and 05/05/25, reflected only the Pre-Dialysis Information was filled in; the Dialysis Information was left blank.<BR/>Record review of Resident #98's Dialysis Communication Form, dated 05/09/25, reflected the Pre-Dialysis Information was filled in, but the Dialysis Information had N/A written in each spot.<BR/>Observation and interview on 05/13/25 at 11:26 AM with Resident #98 revealed she was lying in bed and was sleepy. Resident #98 said she never has any issues when she went to dialysis.<BR/>Interview on 05/14/25 at 12:58 PM with LVN D revealed Resident #98 went to dialysis on Mondays, Wednesdays, and Fridays. LVN D said she worked the 6 AM to 2 PM shift so she sent Resident #98 to dialysis with a red binder. LVN D said the binder included her face sheet, orders, and dialysis communication form filled out for the pre-dialysis information. LVN D said Resident #98 did not come back on her shift from dialysis, so the 2 PM to 10 PM shift nurse on duty would be responsible for completing Resident #98's dialysis forms. <BR/>Interview on 05/15/25 at 2:48 PM with LVN E revealed Resident #98 went to dialysis in the mornings on Mondays, Wednesdays, and Fridays and came back during her shift around 5:30 PM/6 PM. LVN E said Resident #98 left to go to dialysis with a red binder that included her dialysis communication forms. LVN E said the morning nurse for Resident #98 filled out the pre dialysis information on the form and the dialysis center was supposed to fill out the rest of the form and return it with the resident. LVN E said the dialysis center has not been returning the forms filled out for Resident #98 and when that happened she would call the dialysis center to get the information. LVN E said sometimes she was able to get in touch with someone at the dialysis center for the information and sometimes it was more difficult. LVN E said she was responsible for making sure the post dialysis information was included on the forms and filled out since she was the nurse on duty at the time the resident was brought back to the facility from dialysis. <BR/>Interview on 05/15/25 at 3:01 PM with the DON revealed since Resident #98 came back to the facility from the dialysis center, the afternoon shift nurse would have been responsible for completing the dialysis communication form was filled out. The DON said the purpose of the form was to make sure the resident's vitals were okay and to communicate anything that required any follow-up. The DON said the ADON was responsible for making sure that the nurses were completing the dialysis communication forms for residents. The DON said she expected all staff to complete the dialysis communication form for residents and they had been trained to do that. The DON said if the dialysis communication form was not completed, the facility may not know how stable a resident was so they might send them to the hospital for something that the facility could have handled in house. <BR/>Interview on 05/15/25 at 3:30 PM with ADON F revealed she was the ADON in charge of Resident #98's hall. ADON F said she checked the dialysis communication forms for completion about once a week. ADON F said she was not aware that Resident #98's dialysis communication forms were not completed.<BR/>Record review of the facility's policy, dated August 2007, and untitled reflected the following: .7. The [Management Company's Name] will send a Dialysis Communication Record .to the dialysis center upon each dialysis visit. The [Management Company's Name] will complete the top section of the form, entitled 'Nursing Home Nurses' and provide to the Resident [sic] prior to exiting the center .8. The dialysis center should be encouraged to complete the middle section of the Dialysis Communication Record and return to the [Management Company's Name] .9. The [Management Company's Name] nurse will complete the Post Dialysis Assessment section of the Dialysis Communication Record and file the form in the dialysis binder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of three medication carts (500 hall) and 2 of 2(Residents #25 and #59 ) reviewed for pharmacy services.<BR/>The facility failed to ensure the 500 Hall nurses' medication cart contained accurate narcotic logs for Resident #25 and #59 on 05/14/25.<BR/>These failures could place residents at risk for medication error, and drug diversion.<BR/>Findings included:<BR/>1. Review of Resident# 25's Quarterly MDS Assessment, dated 12/29/24, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included Hip and Knee Replacement. The resident had moderately impaired cognition with a BIMS score of 10.<BR/>Review of Resident #25's physician's orders dated 2/27/25 reflected an order for the resident to receive one tablet of Acetaminophen-Codeine Tablet 300-30MG (pain medication) by mouth as needed every six hours.<BR/>2. Review of Resident# 59's Quarterly MDS assessment, dated 04/07/25, reflected the resident was [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included pain. The resident had intact cognitive with a BIMS score of 15.<BR/>Review of Resident #59's physician orders dated 04/13/24 reflected an order for the resident to received 1tablets of hydroco/apap tab 10-325mg by mouth every 6 hours for pain.<BR/>Observation and record review on 05/14/25 at 8:52 AM of 500 Hall nurses' medication cart and the Narcotic Administration Record, with LVN C, revealed the following:<BR/>Resident #25's Narcotic Administration Record for Acetaminophen-Codeine Tablet 300-30MG reflected a total of 51 pills remaining, while the blister pack count was 50 pills. It was last administered on 05/14/25 at 7:00AM.<BR/>Resident #59's Narcotic Administration Record sheet for hydrocodone-acetaminophen 10-325 mg was last signed off on 05/14/25 for one-tablet dose given at 7:00 AM, for a total of 82 pills remaining, while the blister pack count was 83 pills.<BR/>Interview with LVN C on 05/14/25 at 10:58 AM revealed she did not realize the narcotic count and narcotic log was not matching and she did not know she was missing 1 tablet.She checked on her MAR and she found out she had administered on 5/12/25 and she forgot to log of, and nobody had noted during shift change.LVN C stated she had administered medication to Resident#25 on 5/15/24 at 7:00AM and she did not compare the count and what was remaining,and she knew she was supposed to reconcile after administering . She stated failure to log after medication administration would cause drug diversion. She stated the Narcotic log should always match with the count.LVN C stated for Resident #59 hydrocodone-acetaminophen 10-325 mg by mouth every 6 hours for pain she stated she had signed off on 5/14/25 at 7:00AM and she got destructed and she forgot to administer to resident. She stated she knew she was supposed to sign-out on the narcotic count sheet after administration and on the Medication Administration Record, but she did not. She stated signing off when no medication was administered it could lead to medication error. She stated she had done an in-service on medication administration, but she could not recall when. <BR/>Interview on 05/15/25 at 10.35AM with Resident #59 revealed he get his pain pill every morning with other medications. He stated on 5/14/25 for some reasons LVN C came back at around 10:00AM and told him she had forgotten to administer the pain pill. He stated he does not ask for the pain pill but when nurses are administering the morning medications would ask whether he need pain pill and they would administer.<BR/>Interview on 05/15/25 at 10.35AM with Resident #25 revealed she get pain pill every morning before therapy and again at night before she sleeps.<BR/>Interview on 05/15/25 at 03:21 PM, the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log to prevent discrepancies and to have proof the medications were administered. She stated the oncoming should count with outgoing staffs each shift and report any discrepancies. She stated the Narcotic administration record should match the count . She stated when she was notified she went back to the medication administration record, and she found out that LVN C had administered medication on 5/12/25 which was not logged off on the narcotic administration record . The DON stated nobody follows behind the nurses ,the nurses are supposed to check on each other ensuring the counts are correct. She stated Failure to document could lead to discrepancy and adverse effects like pain not being controlled .She stated her expectation was nurses to be completing one task before going to another task . She stated she had done training on medication administration.<BR/>Review of the facility trainings reflected all as needed controlled substance must be documented on medication administration this is the only record of administration.The controlled substance reconciliation log if not a record of administration. Narcotics needs to be signed as you give them on 04/13/25 and LVN C was in attendance .<BR/>Review of the facility's current Management of Controlled Medication - policy, dated January 2024, reflected:<BR/>g. You must administer medication and sign the medication administration record and sign the medication administration record according to facility policy(either pop-sign-give)or (pop-give-sign),please ask and know your facility policy on this procedure prior to passing medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for one of three staff (LVN Q) which resulted in a 10% medication error rate after 30 opportunities with 3 errors for one of five residents (Residents #97) reviewed for medications.<BR/>LVN Q crushed all medications and mixed them all together into one cup of pudding without an order to do so for Resident #97, creating an error rate of 10%, (3 errors out of 30 opportunities).<BR/>This failure could place residents at risk of physical and chemical incompatibilities leading to an altered therapeutic response. <BR/>Findings included:<BR/> Record review of Resident #97's comprehensive MDS assessment, dated 04/21/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE].The assessment reflected the resident cognition was severely impaired with a BIMS score of 5.The resident had diagnoses which included pneumonia(infection that inflames the air sacs in one or both lungs) and chronic kidney disease(a condition where the kidneys are damaged and cannot filter blood as effectively as they should).<BR/>Record review of Resident #97's, May 2025, Physician Orders revealed the following order:<BR/>-Bismuth/Metronidazole/Tetracycline Capsule 140-125-125 MG(Bismuth Sub citrate Potassium-Metronidazole-Tetracycline).Give 3 capsules by mouth three times a day.<BR/>-Ascorbic Acid Tablet 500 MG. Give 1 tablet daily<BR/>-Renal-Vite Oral Tablet 0.8 MG(B-Complex w/ C & Folic Acid).Give 1 tablet daily.<BR/>Observation on 05/14/25 8:40 AM, revealed LVN Q crushed the following 2 medications for Resident #97 and opened three capsules put them together in one medication cup and mixed with pudding: <BR/>-Bismuth /metronidazole/tetracycline capsule 140-125-125,3 capsule three times, <BR/>-Renal vite 0.8 mgs b- complex v and folic acid 1 tablet daily <BR/>-Vit C 500mgs 1 tablet daily <BR/>She then administered all three medications embedded in pudding in one cup by mouth to Resident #97.<BR/>Interview with LVN Q on 05/14/25 8:43 AM revealed she did not have a physician's order to crush and mix medications for Resident #97. She stated she was not aware she was supposed to have an order to crush and mix and she stated she need to inquire from her ADON. She stated she had been crushing and mixing since the resident had been there in the facility. She went to ask and came back and stated she was supposed to have an order to crush and mix together the medication. She stated the risk of mixing was drug interaction she stated she had done training on medication administration.<BR/>Interview with ADON N on 05/14/25 12:59 PM revealed the facility staffs are supposed to have an order to crush and mix. ADON N stated the facility had a standing order for crushing medication but was not included on Resident #97 physician orders. to crush unless contraindicated. The DON stated he was not sure whether they should have orders to mix after crushing all the medications together. ADON N stated LVN Q was supposed to check orders before mixing into the cup and after crushing. He stated the risk of crushing and mixing was drug interaction. He stated facility had done in-service on medication administration.<BR/>Interview with DON on 05/15/25 3:35 PM revealed her expectation was nurses should have physician orders to crush and mix medication. The DON stated the facility had standing orders to crush ,but she realized they were not on Resident #97 medication administration record. She stated her expectation was nurses should put all medications in different cups because of contraindications and interactions and incase the resident denies taking one it would be easier to separate. The DON stated she had completed training on medication administration with staff.<BR/>Record review of the facility's current Administering Medication training dated 4/13/25 reflected the following:<BR/>i. Do not crush meds without appropriate may crush meds order on medication administration record, this requires a physician order after speech therapy evaluation and a care plan for administration of crushed medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24-hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (which included the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures for 1 of 3 residents (Resident #154) reviewed for abuse and neglect. <BR/>The facility failed to report to HHSC when Resident #154 was found to have eloped from the facility on 04/19/24.<BR/>This failure to report could place the residents at risk for neglect. <BR/>Findings included:<BR/>Review of Resident #154's Face Sheet, dated 05/13/25, reflected he was an [AGE] year-old male who admitted to the facility on [DATE] and discharged on 11/20/24.<BR/>Review of Resident #154's Quarterly MDS Assessment, dated 02/28/24, reflected he had a BIMS score of 04, indicating severe cognitive impairment. His MDS indicated he did not have any behaviors of wandering and that he utilized a wheelchair to ambulate. His active diagnoses included depression (feelings of severe despondency and dejection) and bipolar disorder (a mental health condition characterized by significant mood swings).<BR/>Review of Resident #154's Care Plan, dated 05/14/25, reflected the following: <BR/>Problems: [Resident #154] is at risk for wandering as evidenced by: Dementia/Alzheimer's .Interventions: Observe location each shift and prn .Report any attempts to exit the facility to IDT, family & MD as indicated and record in the clinical record .Place a wanderguard bracelet on [Resident #154] if attempt to leave out the facility [sic] .[Resident #154] requires a Wander Guard Bracelet [sic] and is at risk for injury from wandering in an un-safe enviornment [sic] .Interventions: Monitor for placement q shift, monitor for proper functioning q 24 hours .<BR/>Review of Resident #154's Elopement Risk Assessment, dated 11/01/24, reflected the following: 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK, A) Patient is cognitively impaired AND .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .Comments: Shows no signs of elopement.<BR/>Review of Resident #154's Elopement Risk Assessment, dated 06/27/24, reflected the following: 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .<BR/>Review of Resident #154's electronic health chart revealed there were not any other elopement risk assessments completed. <BR/>Review of Resident #154's Clinical Notes Report reflected the following: <BR/>- <BR/>pt left the facility and was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. She is getting me some coffee'. [sic] pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix written on 04/19/24 at 9:24 PM by RN G<BR/>- <BR/>At this time resident remains in bed, no s/s of pain and or discomfort noted. Resident noted to be resting on and off, but resident remains in bed and no attempts to get out of bed or facility noted at this time. All safety measures met. Written on 04/20/24 at 12:33 AM by LVN H<BR/>- <BR/>Resident was brought to nurses station by reception informed [sic] that resident pushed door open trying to go outside call [sic] placed to [the NP]. Notified of resident attempt to go out of front door [sic]. N/O may apply Wander guard for safety. Call to [Resident #154's Family Member] at [phone number] notified of attempt to go out of front door will be [sic] placing a wander guard to lower extremity. foe [sic] safety reason. stated'thank You' [sic] written by LVN I on 07/26/24 at 11:39 AM.<BR/>Review of an Accident/Incident Report, dated 04/19/24, reflected the following : <BR/>Person in charge- account of occurrence: pt left the facility was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. she is getting me some coffee'. pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix. Completed by RN G.<BR/>Review of the Texas Unified Licensure Information Portal revealed there was no incident report regarding Resident #154's elopement on 04/19/24 indicating the facility never reported it. <BR/>Interview on the phone on 05/12/25 at 10:53 AM with Resident #154's Family Member revealed Resident #154 left the facility in November 2024. Resident #154's Family Member said Resident #154 used a wander guard bracelet while at the facility which she said was not necessary because the resident as far as she knew never tried leaving or left the facility. <BR/>Interview on the phone on 05/13/25 at 2:06 PM with RN G revealed, she no longer worked at the facility and could not remember the incident from April 2024.<BR/>Interview on the phone on 05/13/25 at 2:24 PM with CNA J was unsuccessful as she did not answer. CNA J was working on 04/19/24 and was assigned to Resident #154. <BR/>Interview on 05/13/25 at 2:30 PM with RA K revealed she was not here when Resident #154 eloped from the facility on 04/19/24 but she heard he had left through the back door of the facility near where the dumpsters were at. RA K said Resident #154 had a wander guard placed on his leg after this incident happened. <BR/>Interview on 05/14/25 at 11:45 AM with LVN H revealed she could not recall anything about Resident #154's elopement on 04/19/24. <BR/>Interview on 05/14/25 at 3:15 PM with the DON revealed she was in training in April 2024 when Resident #154 eloped from the facility so she did not have any details about it. The DON said after reading the incident report, the elopement should have been reported to the state. <BR/>Interview on the phone on 05/15/25 at 9:20 AM with the Previous Administrator was unsuccessful as she did not answer.<BR/>Interview on the phone on 05/15/25 at 9:21 AM with the Previous DON was unsuccessful as he did not answer. <BR/>Interview on 05/15/25 at 10:10 AM with the Administrator revealed she was not yet employed by the facility on 04/19/24 when Resident #154 eloped from the facility. The Administrator said she was not informed about the elopement either when she arrived to the facility. The Administrator said since she was not at the facility on 04/19/24 she had no details about what happened. The Administrator said she expected staff to report when a resident eloped from the facility. The Administrator said she was not sure if this incident was reportable or not because she would have to review the criteria and guidelines to see if it met the requirements to be reported. The Administrator said currently she was the Abuse Coordinator for the facility and would help to determine if something was reportable or not. The Administrator said at the time of the incident, the Previous Administrator or their designee would have been responsible for reporting the incident involving Resident #154's elopement on 04/19/24. The Administrator said all staff had been trained to know the facility's abuse/neglect policy. The Administrator said if the facility failed to report they would be cited for that. The Administrator said she rounds frequently with staff to ensure they were reporting necessary things to her. <BR/>Review of an in-service roster, dated 11/01/24, and titled Staff in-services initiated the following: abuse prevention policy .Timely Reporting/Recognizing Abuse , Neglect [sic] and Misappropriation . reflected 108 staff's signatures. <BR/>Review of the facility's policy, dated January 2024, and titled Elopement Response Protocol reflected: .9. Notify the state regulatory department according to the guidelines for reportable incidents.<BR/>Review of the facility's policy, dated April 2019, and titled Abuse Protocol reflected: .7. The following definitions are provided to assist our Facility's [sic] staff members in recognizing incidents of Patient Abuse [sic]: i. Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof .l. Neglect is the facility, it's employees or service providers to provide goods and services to a Patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .10. The Abuse Prevention Coordinator will: a Immediately (within 2 hours) report to The Department of Aging and Disability Services (DADS) and other appropriate authorities incidents of Patient Abuse [sic] as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to The Department of Aging and Disability Services (DADS) and other appropriate authorities as required under applicable regulations and regulatory guidance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #154) reviewed for elopements.<BR/>The facility failed to ensure Resident #154 did not elope from the facility's back door on 04/19/24. Resident #154 was found on the street attempting to go to the gas station across the street from the facility that was located directly off a busy highway. Resident #154 had suffered a skin tear to his arm . <BR/>The noncompliance was identified as past noncompliance. The IJ began on 04/19/24 and ended on 11/01/24. The facility had corrected the noncompliance before the survey began. <BR/>This failure could placed residents at risk of serious injury or death.<BR/>Findings included:<BR/>Review of Resident #154's Face Sheet, dated 05/13/25, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 11/20/24.<BR/>Review of Resident #154's Quarterly MDS Assessment, dated 02/28/24, reflected he had a BIMS score of 04, indicating severe cognitive impairment. His MDS indicated he did not have any behaviors of wandering and that he utilized a wheelchair to ambulate. His active diagnoses included depression (feelings of severe despondency and dejection) and bipolar disorder (a mental health condition characterized by significant mood swings).<BR/>Review of Resident #154's Care Plan, dated 05/14/25, reflected the following: <BR/>Problems: [Resident #154] is at risk for wandering as evidenced by: Dementia/Alzheimer's .Interventions: Observe location each shift and prn .Report any attempts to exit the facility to IDT, family & MD as indicated and record in the clinical record .Place a wanderguard bracelet on [Resident #154] if attempt to leave out the facility [sic] .[Resident #154] requires a Wander Guard Bracelet [sic] and is at risk for injury from wandering in an un-safe enviornment [sic] .Interventions: Monitor for placement q shift, monitor for proper functioning q 24 hours .<BR/>Review of Resident #154's Elopement Risk Assessment, dated 11/01/24, reflected the following : 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK, A) Patient is cognitively impaired AND .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .Comments: Shows no signs of elopement.<BR/>Review of Resident #154's Elopement Risk Assessment, dated 06/27/24, reflected the following: 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .<BR/>Review of Resident #154's electronic health chart revealed there were not any other elopement risk assessments completed. <BR/>Review of Resident #154's Clinical Notes Report reflected the following: <BR/>- <BR/>pt left the facility and was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. She is getting me some coffee'. [sic] pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix written on 04/19/24 at 9:24 PM by RN G<BR/>- <BR/>At this time resident remains in bed, no s/s of pain and or discomfort noted. Resident noted to be resting on and off, but resident remains in bed and no attempts to get out of bed or facility noted at this time. All safety measures met. Written on 04/20/24 at 12:33 AM by LVN H<BR/>- <BR/>Resident was brought to nurses station by reception informed [sic] that resident pushed door open trying to go outside call [sic] placed to [the NP]. Notified of resident attempt to go out of front door [sic]. N/O may apply Wander guard for safety. Call to [Resident #154's Family Member] at [phone number] notified of attempt to go out of front door will be [sic] placing a wander guard to lower extremity. foe [sic] safety reason. stated'thank You' [sic] written by LVN I on 07/26/24 at 11:39 AM.<BR/>Review of an Accident/Incident Report, dated 04/19/24, reflected the following: <BR/>Person in charge- account of occurrence: pt left the facility was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. she is getting me some coffee'. pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix. Completed by RN G .<BR/>Interview on the phone on 05/12/25 at 10:53 AM with Resident #154's Family Member revealed Resident #154 left the facility in November 2024. Resident #154's Family Member said Resident #154 used a wanderguard bracelet while at the facility which she said was not necessary because the resident as far as she knew he never tried leaving or left the facility. <BR/>Interview on the phone on 05/13/25 at 2:06 PM with RN G revealed she no longer worked at the facility and could not remember the incident from April 2024.<BR/>Interview on the phone on 05/13/25 at 2:24 PM with CNA J was unsuccessful as she did not answer. CNA J was working on 04/19/24 and was assigned to Resident #154. <BR/>Interview on 05/13/25 at 2:30 PM with RA K revealed she was not here when Resident #154 eloped from the facility on 04/19/24 but she heard he had left through the back door of the facility near where the dumpsters were at. RA K said Resident #154 had a wander guard placed on his leg after this incident happened. RA K said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. RA K said she was in-serviced regarding elopements and wandering residents. RA K said she knew to immediately report to the nurse if she noticed a resident began to wander or make an attempt to elope from the facility. RA K said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. <BR/>Interview on 05/14/25 at 8:50 AM with LVN I revealed she cared for Resident #154 but had no idea about his elopement on 04/19/24. LVN I said she remembered Resident #154 had a wander guard bracelet because he had a tendency to wander around the facility. LVN I said if a resident began to have wandering or elopement behaviors it should be reported to her so that she may complete an elopement assessment on the resident. LVN I said she currently had residents who used a wander guard bracelet because they were at risk of wandering or eloping. LVN I said as the nurse she checks those identified resident's wander guard bracelets every shift for placement and functioning. LVN I said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. LVN I said she was in-serviced regarding elopements and wandering residents. LVN I said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. <BR/>Interview on 05/14/25 at 11:45 AM with LVN H revealed she could not recall anything about Resident #154's elopement on 04/19/24. LVN H said if a resident began to have wandering or elopement behaviors it should be reported to her so that she may complete an elopement assessment on the resident. LVN H said she did not currently have residents who used a wander guard bracelet because they were at risk of wandering or eloping. LVN H if she did care for a resident who used a wander guard bracelet, as the nurse she would check them every shift for placement and functioning. LVN H said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. LVN H said she was in-serviced regarding elopements and wandering residents. LVN H said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 1:07 PM with CNA L revealed he did not know about Resident #154 elopement from the facility on 04/19/24. CNA L said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. CNA L said he was in-serviced regarding elopements and wandering residents. CNA L said he knew to immediately report to the nurse if he noticed a resident began to wander or make an attempt to elope from the facility. CNA L said he knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 1:18 PM with CNA M revealed she had only been at the facility for four weeks. CNA M said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. CNA M said she was in-serviced regarding elopements and wandering residents. CNA M said she knew to immediately report to the nurse if she noticed a resident began to wander or make an attempt to elope from the facility. CNA M said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 3:15 PM with the DON revealed she was in training in April 2024 when Resident #154 eloped from the facility so she did not have any details about it. The DON said she recalled when they had to put a wander guard bracelet on Resident #154 because he would stand up and try to walk towards the doors and set the alarms off to the doors. The DON said with the wander guard bracelet, if Resident #154 got too close to the door the door alarm and the wander guard alarm would both go off and scare Resident #154 so he would back away from it after that. The DON said Resident #154 was easily redirectable but was exit seeking while he tried to find his family. The DON said Resident #154's family was not happy with him having the wander guard bracelet and did not believe the resident required one. The DON said when a resident eloped from the facility she expected staff to get them back inside right away and report to the Administrator and her about what happened. The DON said when the elopement code was activated she also expected her staff to do a sweep of the facility to ensure all residents were in house and safe. The DON said after the resident was safe the facility would investigate to see how they eloped from the facility and that would be corrected. The DON said staff should know to be supervising residents and watching them to make sure they did not leave and if they heard an alarm going off they should make sure they are responding to them. The DON said a number of things could happen to a resident if they eloped from the facility, depending on the weather it could be too cold or hot so they could die, or be hit by a car since there's a busy street behind the facility. The DON said staff were trained and in-serviced regarding resident elopements recently. The DON said when a resident was admitted and had elopement or wandering behaviors the facility would complete an elopement assessment on them and if a wander guard bracelet was necessary to keep them safe one would be placed. The DON said all staff knew to immediately report any new behaviors of a resident wandering or making elopement attempts.<BR/>Interview on the phone on 05/15/25 at 9:20 AM with the Previous Administrator was unsuccessful as she did not answer.<BR/>Interview on the phone on 05/15/25 at 9:21 AM with the Previous DON was unsuccessful as he did not answer. <BR/>Interview on 05/15/25 at 10:10 AM with the Administrator revealed she was not yet employed by the facility on 04/19/24 when Resident #154 eloped from the facility. The Administrator said she was not informed about the elopement either when she arrived to the facility. The Administrator said since she was not at the facility on 04/19/24 she had no details about what happened. The Administrator said Resident #154 had tendencies to wander and exit seek and his family was upset about him having to wear a wander guard bracelet. The Administrator said Resident #154 was always at the doors of the facility trying to leave. The Administrator said Resident #154 was always setting off the door alarms and the wander guard system alarms. The Administrator said Resident #154 was easily redirectable away from the doors, however. The Administrator said Resident #154 should not have been able to elope from the facility back in April 2024. The Administrator said she expected all staff to frequently monitor all residents who were at risk of eloping/wandering and to ensure they each were inside and safely in the facility. The Administrator said if a resident had been identified as being at risk of eloping/wandering a wander guard bracelet was placed on them. The Administrator said each resident's nurse would be responsible for checking the wander guard bracelet's placement and functioning each shift. The Administrator said the Maintenance Director checked each door every week to make sure that the wander guard system was working as well. The Administrator said the staff were provided with training on elopements because the facility had other residents elope back in November 2024. The Administrator said if a resident was able to elope from the facility they were at risk because it was not safe outside the facility. The Administrator said she expected staff to report when a resident eloped from the facility. <BR/>Interview and observation on 05/15/25 at 12:53 PM with the Maintenance Director revealed he was notified of Resident #154's elopement back in April 2024 but he could not recall any of the details. The Maintenance Director said if Resident #154 eloped from the back door of the facility near the dumpsters it would have been the door near the therapy gym at the end of the 400-hallway. Observation of the door at the end of the 400-hallway revealed it had a wander guard system alarm on it and the door was locked and required a code to turn the alarm off. Observation of the door being pushed open revealed an alarm went off and staff would have to enter the code in to the keypad to turn the alarm off. The door led out to a small parking lot that had the facility's dumpsters off to the left side and a gas station could be seen across the street. In front of the gas station was a busy highway as well. The Maintenance Director said he checks to make sure the wander guard system was working on each of the exterior doors once a week and documents that on his check off sheet. <BR/>The facility implemented the following interventions:<BR/>Review of an in-service roster, dated 11/01/24, and titled Staff in-services initiated the following: .elopement policy . reflected 108 staff's signatures. <BR/>Review of the facility's policy, dated January 2024, and titled Elopement Response Protocol reflected: 1. Conduct a thorough search of the Facility and its grounds .8. A complete head to toe nursing assessment must be completed upon return of the Patient [sic].<BR/>The Administrator was informed of the PNC IJ on 05/15/25 at 12:42 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for 1 of 5 residents (Resident #306) reviewed for laboratory services.<BR/>The facility failed to send Resident #306's weekly labs to the infectious disease doctor while the resident resided at the facility from 11/27/24 to 12/20/24. <BR/>This deficient practice placed the residents at high risk of not receiving treatment, and/or developing complications.<BR/>Findings included:<BR/>Review of Resident 306's MDS dated [DATE] reflected the resident was [AGE] year-old female admitted to the facility on [DATE] and discharged on 12/20/24. Her diagnoses included diabetes and anxiety disorder. Resident #306 had a BIMS of 6 indicating her cognition was severely impaired. The MDS also reflected the resident had a stage 4 pressure ulcer.<BR/>Review of Resident #306's care plan effective on 11/28/24 reflected the resident had pressure ulcers to her right heel, unstageable to right hip, and stage 4 to the left lateral ankle. Interventions included to obtain labs per physician orders. <BR/>Review of Resident #306's discharge hospital records dated 11/27/24 reflected the following:<BR/> Labs to be followed: weekly CRP (a blood test that measures the level of CRP, a protein produced by the liver in response to inflammation)/BMP (measures eight different substances in your blood and it provides important information about your body's fluid balance, your metabolism and how well your kidneys are working)/CBC (group of blood tests that measure the number and size of the different cells in your blood) faxed to the office of [Doctor] <BR/>Review of Resident #306's facility clinical record revealed labs were obtained on 12/02/24, 12/09/24, and on 12/16/24.<BR/>Interview on 05/15/25 at 12:13 PM with Resident #306's family revealed the resident was discharged from the facility on 12/20/24. The family said the infectious disease doctor had ordered for the resident to have weekly labs drawn and faxed over to his office and the doctor's clinic said they had never received any of the lab requested. <BR/>Interview on 05/15/25 at 11:47 AM with the Infectious Disease Doctor's clinic revealed they had called the facility on 12/02/24, 12/18/25 and on 12/31/24 to try and obtain Resident #306's labs copies. The clinic said that on 12/31/24 the facility finally sent one set of labs that were dated for 12/02/24. The Infectious Disease Clinic further stated the doctor would have wanted to keep up with the resident's infection treatment. <BR/>Interview on 05/15/25 at 2:42 with ADON N revealed he will send or fax labs when he was asked but he could not specifically recall if he had sent Resident #306's labs to the infectious disease clinic. <BR/>Interview on 05/15/25 at 2:55 PM with the DON revealed she thought she was sure she had asked ADON N to fax Resident #306's labs results to the infectious disease clinic. The DON further stated she did not know what else could have happened with the labs during that time. <BR/>Review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol revised on 09/2012 reflected the following:<BR/>Assessment and Recognition <BR/>1. The physician will identify and order diagnostic lab testing on diagnostic and monitoring needs. <BR/>2. The staff will process test requisitions and arrange for tests. <BR/>3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility <BR/>1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent <BR/>a. Facility staff should document information about when, how, and to whom the information was provided and the response

**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 rights set forth, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 (Resident #1) of 6 residents reviewed for care plans. <BR/>The facility failed to ensure Resident #1's ADL care plan was completed to reveal what level a assistance he needed for dressing, toileting, bed mobility and transfers. <BR/>This failure could place residents at risk of their needs not being met if staff did not know how to care for the residents properly, which could result in falls, pain, wounds and decreased psychosocial well-being and physical functioning.<BR/>Findings included:<BR/>Record review of Resident #1's admission MDS Assessment completed on 04/02/25, by MDS M revealed Resident #1 was an [AGE] year old male who admitted to [This Facility] on 03/25/25 with a BIMS score of 09 (Moderate Cognitive Impairment). He was dependent (2 person helpers did all assist) with toileting, showering/bathing, lower body dressing and putting on footwear. And partial to moderate assist with bed mobility and transfers. He was occasionally incontinent with bladder and always incontinent with bowel. His active diagnoses were medically complex conditions and he was diagnosed with atrial fibrillation, HTN, BPH, diabetes, hyperlipidemia, metabolic encephalopathy, acute pancreatis without infection, diverticulitis of small intestines without perforation or abscess. He had a history of falling within the past month. And based on Braden and clinical assessment he was at risk for pressure injuries and had 1 or more pressure injuries, <BR/>Record review of Resident #1's Comprehensive Care Plan dated 04/08/25 for bladder incontinence related to confusion and impaired mobility, 03/31/25 Pressure Ulcer and enhanced barrier precautions implemented related to pressure ulcer. And 04/06/25 risk for falls . <BR/>Record review of Resident #1's Incident Report dated 04/06/25 at 2:15 am revealed, Resident was found on the floor next to his bed by CNA. No apparent injuries. Resident Unable to give Description, Vital signs taken, complete body assessment completed and neuro-checks initiated. MD/NP Called received order for XRs of bilateral lower extremities and lumbar spine. No injuries noted at the time of incident, bedridden, oriented to person, pain aid 4 (moaning/groaning, facial grimacing, distressed), confused, incontinent, gait imbalance, impaired memory. Responsible party, DON and DR/NP notified.<BR/>Interview on 04/11/25 at 12:14 pm, MDS L stated Resident #1 used to visit a resident here, now he was a resident. She stated Resident #1 was maybe a 1 person assist for transfers and 2 person assist for his other ADL's she believed. She stated she needed to get her computer. After she returned she stated Resident #1's admission MDS Assessment showed he was substantial max assistance with ADL care and 1 to 2 staff with transfers. She stated Resident #1 should be care planned stated he was incontinent and not able to walk or weight bear. She stated Resident #1 had an ADL care plan and as she looked in the EMR she said she did not see one. She stated if Resident #1 required help he should have a care plan. She stated she was going to add the ADL care plan now and said it had not been added and she was not sure why. She stated multiple staff could add care plans and she captured the basic information and it was a team effort on doing the care plans. She stated she was ultimately responsible for ensuring the care plans were accurate and added the ADL Care plan (based on the MDS Assessment) and Plan of Care (based on the care plan the CNA's used) should have the same information. She stated the CNA's looked at the POC to know how to care for the residents. She stated they normally had two MDS Coordinators but not any longer. She stated it was just her now and there were a lot of residents she had to keep up with. She stated if the care plans were not accurate it could cause safety issues with the residents. She stated it would not allow them to care for the residents properly and to have interventions in place and proper care could be delayed. She stated she was off from work the other day and was not sure who filled in for her during that time. <BR/>Interview on 04/11/25 at 1:24 pm, Administrator she stated she was not aware of any issues with Resident #1's ADL care plan being missing. She stated she planned to talk to the MDS Coordinator and nurse management because they should be working together to update the care plans. She stated the therapy department evaluated the residents to ensure they were all on the same page. She stated the IDT were supposed to create the acute care plans and the nurse managers were responsible for ensuring they were done . She stated the care plans should be the same as the MDS Assessments. She stated the care plan should tell the staff what the residents needs were. She stated if the ADL care plans were not accurate, the staff could potentially not meet the resident's needs.<BR/>Interview on 04/11/25 at 2:39 pm, the DOR stated Resident #1 was getting skilled services for all three disciplines PT, OT, and ST since 03/26/25. She stated he was at baseline as far as his progress because he was not able to sustain his attention span. She stated they were working on his orientation today and time and motivating him to do therapy. She stated Resident #1's ADL was maximal assist for 2 person assist with toileting and bathing. She stated Resident #1 needed minimum assist for upper body dressing and moderate assist for lower body dressing and his mobility was inconsistent. She stated Resident #1 had good days and bad days with the same tasks depending on the level of his participation. She stated Resident #1 had a fall recently and was evaluated and to continue to educate fall risk on safety awareness. She stated there was no change with therapy level after he fell and was not able to weight bear or walk. She stated he was not able to toilet by himself due to his cognition and physical status.<BR/>Record review of the Facility's Care Plan policy revised September 2010 revealed, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy interpretation and implementation: 1. Our facility's Care Planning/Interdisciplinary team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. 3. Each resident's comprehensive care plan is designed to incorporate identified problem areas .assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care planning/Interdisciplinary Team is responsible for review and updating of care plans: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #154) reviewed for elopements.<BR/>The facility failed to ensure Resident #154 did not elope from the facility's back door on 04/19/24. Resident #154 was found on the street attempting to go to the gas station across the street from the facility that was located directly off a busy highway. Resident #154 had suffered a skin tear to his arm . <BR/>The noncompliance was identified as past noncompliance. The IJ began on 04/19/24 and ended on 11/01/24. The facility had corrected the noncompliance before the survey began. <BR/>This failure could placed residents at risk of serious injury or death.<BR/>Findings included:<BR/>Review of Resident #154's Face Sheet, dated 05/13/25, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 11/20/24.<BR/>Review of Resident #154's Quarterly MDS Assessment, dated 02/28/24, reflected he had a BIMS score of 04, indicating severe cognitive impairment. His MDS indicated he did not have any behaviors of wandering and that he utilized a wheelchair to ambulate. His active diagnoses included depression (feelings of severe despondency and dejection) and bipolar disorder (a mental health condition characterized by significant mood swings).<BR/>Review of Resident #154's Care Plan, dated 05/14/25, reflected the following: <BR/>Problems: [Resident #154] is at risk for wandering as evidenced by: Dementia/Alzheimer's .Interventions: Observe location each shift and prn .Report any attempts to exit the facility to IDT, family & MD as indicated and record in the clinical record .Place a wanderguard bracelet on [Resident #154] if attempt to leave out the facility [sic] .[Resident #154] requires a Wander Guard Bracelet [sic] and is at risk for injury from wandering in an un-safe enviornment [sic] .Interventions: Monitor for placement q shift, monitor for proper functioning q 24 hours .<BR/>Review of Resident #154's Elopement Risk Assessment, dated 11/01/24, reflected the following : 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK, A) Patient is cognitively impaired AND .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .Comments: Shows no signs of elopement.<BR/>Review of Resident #154's Elopement Risk Assessment, dated 06/27/24, reflected the following: 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .<BR/>Review of Resident #154's electronic health chart revealed there were not any other elopement risk assessments completed. <BR/>Review of Resident #154's Clinical Notes Report reflected the following: <BR/>- <BR/>pt left the facility and was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. She is getting me some coffee'. [sic] pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix written on 04/19/24 at 9:24 PM by RN G<BR/>- <BR/>At this time resident remains in bed, no s/s of pain and or discomfort noted. Resident noted to be resting on and off, but resident remains in bed and no attempts to get out of bed or facility noted at this time. All safety measures met. Written on 04/20/24 at 12:33 AM by LVN H<BR/>- <BR/>Resident was brought to nurses station by reception informed [sic] that resident pushed door open trying to go outside call [sic] placed to [the NP]. Notified of resident attempt to go out of front door [sic]. N/O may apply Wander guard for safety. Call to [Resident #154's Family Member] at [phone number] notified of attempt to go out of front door will be [sic] placing a wander guard to lower extremity. foe [sic] safety reason. stated'thank You' [sic] written by LVN I on 07/26/24 at 11:39 AM.<BR/>Review of an Accident/Incident Report, dated 04/19/24, reflected the following: <BR/>Person in charge- account of occurrence: pt left the facility was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. she is getting me some coffee'. pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix. Completed by RN G .<BR/>Interview on the phone on 05/12/25 at 10:53 AM with Resident #154's Family Member revealed Resident #154 left the facility in November 2024. Resident #154's Family Member said Resident #154 used a wanderguard bracelet while at the facility which she said was not necessary because the resident as far as she knew he never tried leaving or left the facility. <BR/>Interview on the phone on 05/13/25 at 2:06 PM with RN G revealed she no longer worked at the facility and could not remember the incident from April 2024.<BR/>Interview on the phone on 05/13/25 at 2:24 PM with CNA J was unsuccessful as she did not answer. CNA J was working on 04/19/24 and was assigned to Resident #154. <BR/>Interview on 05/13/25 at 2:30 PM with RA K revealed she was not here when Resident #154 eloped from the facility on 04/19/24 but she heard he had left through the back door of the facility near where the dumpsters were at. RA K said Resident #154 had a wander guard placed on his leg after this incident happened. RA K said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. RA K said she was in-serviced regarding elopements and wandering residents. RA K said she knew to immediately report to the nurse if she noticed a resident began to wander or make an attempt to elope from the facility. RA K said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. <BR/>Interview on 05/14/25 at 8:50 AM with LVN I revealed she cared for Resident #154 but had no idea about his elopement on 04/19/24. LVN I said she remembered Resident #154 had a wander guard bracelet because he had a tendency to wander around the facility. LVN I said if a resident began to have wandering or elopement behaviors it should be reported to her so that she may complete an elopement assessment on the resident. LVN I said she currently had residents who used a wander guard bracelet because they were at risk of wandering or eloping. LVN I said as the nurse she checks those identified resident's wander guard bracelets every shift for placement and functioning. LVN I said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. LVN I said she was in-serviced regarding elopements and wandering residents. LVN I said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. <BR/>Interview on 05/14/25 at 11:45 AM with LVN H revealed she could not recall anything about Resident #154's elopement on 04/19/24. LVN H said if a resident began to have wandering or elopement behaviors it should be reported to her so that she may complete an elopement assessment on the resident. LVN H said she did not currently have residents who used a wander guard bracelet because they were at risk of wandering or eloping. LVN H if she did care for a resident who used a wander guard bracelet, as the nurse she would check them every shift for placement and functioning. LVN H said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. LVN H said she was in-serviced regarding elopements and wandering residents. LVN H said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 1:07 PM with CNA L revealed he did not know about Resident #154 elopement from the facility on 04/19/24. CNA L said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. CNA L said he was in-serviced regarding elopements and wandering residents. CNA L said he knew to immediately report to the nurse if he noticed a resident began to wander or make an attempt to elope from the facility. CNA L said he knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 1:18 PM with CNA M revealed she had only been at the facility for four weeks. CNA M said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. CNA M said she was in-serviced regarding elopements and wandering residents. CNA M said she knew to immediately report to the nurse if she noticed a resident began to wander or make an attempt to elope from the facility. CNA M said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 3:15 PM with the DON revealed she was in training in April 2024 when Resident #154 eloped from the facility so she did not have any details about it. The DON said she recalled when they had to put a wander guard bracelet on Resident #154 because he would stand up and try to walk towards the doors and set the alarms off to the doors. The DON said with the wander guard bracelet, if Resident #154 got too close to the door the door alarm and the wander guard alarm would both go off and scare Resident #154 so he would back away from it after that. The DON said Resident #154 was easily redirectable but was exit seeking while he tried to find his family. The DON said Resident #154's family was not happy with him having the wander guard bracelet and did not believe the resident required one. The DON said when a resident eloped from the facility she expected staff to get them back inside right away and report to the Administrator and her about what happened. The DON said when the elopement code was activated she also expected her staff to do a sweep of the facility to ensure all residents were in house and safe. The DON said after the resident was safe the facility would investigate to see how they eloped from the facility and that would be corrected. The DON said staff should know to be supervising residents and watching them to make sure they did not leave and if they heard an alarm going off they should make sure they are responding to them. The DON said a number of things could happen to a resident if they eloped from the facility, depending on the weather it could be too cold or hot so they could die, or be hit by a car since there's a busy street behind the facility. The DON said staff were trained and in-serviced regarding resident elopements recently. The DON said when a resident was admitted and had elopement or wandering behaviors the facility would complete an elopement assessment on them and if a wander guard bracelet was necessary to keep them safe one would be placed. The DON said all staff knew to immediately report any new behaviors of a resident wandering or making elopement attempts.<BR/>Interview on the phone on 05/15/25 at 9:20 AM with the Previous Administrator was unsuccessful as she did not answer.<BR/>Interview on the phone on 05/15/25 at 9:21 AM with the Previous DON was unsuccessful as he did not answer. <BR/>Interview on 05/15/25 at 10:10 AM with the Administrator revealed she was not yet employed by the facility on 04/19/24 when Resident #154 eloped from the facility. The Administrator said she was not informed about the elopement either when she arrived to the facility. The Administrator said since she was not at the facility on 04/19/24 she had no details about what happened. The Administrator said Resident #154 had tendencies to wander and exit seek and his family was upset about him having to wear a wander guard bracelet. The Administrator said Resident #154 was always at the doors of the facility trying to leave. The Administrator said Resident #154 was always setting off the door alarms and the wander guard system alarms. The Administrator said Resident #154 was easily redirectable away from the doors, however. The Administrator said Resident #154 should not have been able to elope from the facility back in April 2024. The Administrator said she expected all staff to frequently monitor all residents who were at risk of eloping/wandering and to ensure they each were inside and safely in the facility. The Administrator said if a resident had been identified as being at risk of eloping/wandering a wander guard bracelet was placed on them. The Administrator said each resident's nurse would be responsible for checking the wander guard bracelet's placement and functioning each shift. The Administrator said the Maintenance Director checked each door every week to make sure that the wander guard system was working as well. The Administrator said the staff were provided with training on elopements because the facility had other residents elope back in November 2024. The Administrator said if a resident was able to elope from the facility they were at risk because it was not safe outside the facility. The Administrator said she expected staff to report when a resident eloped from the facility. <BR/>Interview and observation on 05/15/25 at 12:53 PM with the Maintenance Director revealed he was notified of Resident #154's elopement back in April 2024 but he could not recall any of the details. The Maintenance Director said if Resident #154 eloped from the back door of the facility near the dumpsters it would have been the door near the therapy gym at the end of the 400-hallway. Observation of the door at the end of the 400-hallway revealed it had a wander guard system alarm on it and the door was locked and required a code to turn the alarm off. Observation of the door being pushed open revealed an alarm went off and staff would have to enter the code in to the keypad to turn the alarm off. The door led out to a small parking lot that had the facility's dumpsters off to the left side and a gas station could be seen across the street. In front of the gas station was a busy highway as well. The Maintenance Director said he checks to make sure the wander guard system was working on each of the exterior doors once a week and documents that on his check off sheet. <BR/>The facility implemented the following interventions:<BR/>Review of an in-service roster, dated 11/01/24, and titled Staff in-services initiated the following: .elopement policy . reflected 108 staff's signatures. <BR/>Review of the facility's policy, dated January 2024, and titled Elopement Response Protocol reflected: 1. Conduct a thorough search of the Facility and its grounds .8. A complete head to toe nursing assessment must be completed upon return of the Patient [sic].<BR/>The Administrator was informed of the PNC IJ on 05/15/25 at 12:42 PM.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food safety in the facility's only kitchen. <BR/>1. The facility failed to ensure food items were properly sealed, dated, and stored in the pantry.<BR/>2. The facility failed to ensure food items were properly sealed and stored in the freezer.<BR/>3. Dietary Aide H failed to perform proper sanitization of thermometer while checking the temperature of food items. <BR/>These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness.<BR/>Findings included:<BR/>An observation on 03/07/23 at 9:44 AM revealed the following:<BR/>In the pantry:<BR/>-2 bags of tea were directly on the shelf without a label, name, date, and storage bag.<BR/>-3 dented cans of jalapenos on the same shelf as the non-dented cans. The dented cans with an unknown black liquid on top of the lid. <BR/>Interview with Nutrition Director on 03/07/23 at 10:32 AM with the Dietary Director, revealed she had worked at the facility since 02/09/23. The Nutrition Director stated the two unlabeled bags were tea bags and should have been thrown in the trash when kitchen staff notice the item was not labeled and stored properly. She stated the kitchen staff that opens the original package is responsible for storing, naming, and dating the food items. The Nutrition Director stated she knew about the three dented cans of jalapenos. She stated she did not know what the black liquid was on top of the lid. She stated the three dented cans of jalapenos have been there since she was hired almost a month ago. The Nutrition Director stated the supplier had refused to take the dented cans because of the unknown liquid on top of the cans. The Dietary Director stated she should have discarded the three dented cans with unknown black liquid and labeled a designated area for dented cans. She stated the kitchen staff had not been trained on properly storing food items since she has been employed with the facility and was unable to provide proof of the previous training. The Nutrition Director stated the risk of not properly storing food items could lead to contaminating the food and the residents could get a food-borne illnesses.<BR/>In the freezer, the following individual food items below were open to air:<BR/>- 1 box of burger patties,<BR/>- corn,<BR/>- veggie blend, <BR/>- turkey sausages,<BR/>- okra,<BR/>- green beans, and <BR/>- pizza crust.<BR/>Interview with Nutrition Director on 03/07/23 at 10:38 AM with the Dietary Director, revealed she had worked at the facility for about a month. The Nutrition Director stated she could see the burger patties, corn, veggie blend, turkey sausages, okra, green beans, and pizza crust open to air. She stated the food could get frost bite and should have been thrown in the trash. She stated the cooks were responsible for storing food items in a sealed storage bag after use. She stated the kitchen staff had not been trained on properly storing food items since she has been employed with the facility and was unable to provide proof of the previous training. The Nutrition Director stated the risk of not properly storing food items could lead to food contamination, and the residents could get a food borne illnesses.<BR/>Observation on 03/08/23 at 4:28 PM of Dietary Aide H, revealed she did not take sanitizing wipes out of the sealed package to clean the temperature probe. Dietary Aide H punctured the middle of the dirty sanitizing package with the temperature probe and used the same temperature probe to check the temperatures of the food. The food that had come in direct contact with the temperature probe was served to residents. <BR/>Interview on 03/08/23 at 5:00 PM with Dietary Aide H revealed she knew the sanitizing packaging was not clean and was stored above the sink with the spices. She stated the practice used to clean the temperature probe could introduce bacteria to the temperature probe and food. She stated the bacteria that was introduced to the food could make the residents sick. Dietary Aide H stated the correct practice to clean a temperature probe was to open the sanitizing package, take the sanitizing wipe out of the package, clean the temperature probe, allow the temperature probe to dry, and check the temperature of the food. She stated she had done training on infection control with the facility staff but was unable to recall the last training. <BR/>Interview with the Dietary Director on 03/09/23 at 3:44 PM revealed she had known the temperature probe had not been sanitized correctly while observing Dietary Aide H. She stated she did not stop Dietary Aide H from cleaning the temperature probe incorrectly. Dietary Director unable to provide a policy on sanitizing the temperature probe. She stated her expectation was for Dietary Aide H to open the sanitizing package, take the sanitizing wipes out of the package, and clean the temperature probe. She stated she has been there for a month and the staff members had their first training with her on 03/09/2023 at 2:00 PM. <BR/>A record review of the facility's policy entitled Food Storage revealed in part the following:<BR/>Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, an appetizing .All foods should be covered, labeled, and dated.<BR/>A record review on 03/09/23 at 4:00 PM of Federal Drug Administration Food Code, dated 2017 section 3-305.11 Food Storage reflected: (A) Except as specified in (B) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to maintain medical records on each resident that were complete for 1 (Resident #1) of 6 residents reviewed for Medical records. <BR/>MDS L or MDS M failed to add to Resident #1's EMR profile, of him having a sacral pressure ulcer he was diagnosed with on 03/31/25. <BR/>These failures could place residents at risk of not getting appropriate care if the resident's documentation were missing from their medical profile which could cause missed care and treatment resulting in a decline in health and psycho-social well-being. <BR/>Findings included: <BR/>Record review of Resident #1's admission MDS Assessment completed on 04/02/25, by MDS M revealed Resident #1 was an [AGE] year old male who admitted to [This Facility] on 03/25/25 with a BIMS score of 09 (Moderate Cognitive Impairment). He was dependent (2 person helpers did all assist) with toileting, showering/bathing, lower body dressing and putting on footwear. And partial to moderate assist with bed mobility and transfers. He was occasionally incontinent with bladder and always incontinent with bowel. His active diagnoses were medically complex conditions and he was diagnosed with atrial fibrillation, HTN, BPH, diabetes, hyperlipidemia, metabolic encephalopathy, acute pancreatis without infection, diverticulitis of small intestines without perforation or abscess. He had a history of falling within the past month. And based on Braden and clinical assessment he was at risk for pressure injuries and had 1 or more pressure injuries, <BR/>Record review of Resident #1's Care Plan dated 04/08/25 for bladder incontinence related to confusion and impaired mobility, 03/31/25 Pressure Ulcer and enhanced barrier precautions implemented related to pressure ulcer. And 04/06/25 risk for falls.<BR/>Interview on 04/11/25 at 12:14 pm, MDS L stated for the residents new diagnoses she was responsible for ensuring they were added to the residents EMR profile. She stated both ADON's and the DON could also add new diagnoses. She stated she was aware Resident #1 had a sacral wound and just found out while looking at his record he had a new left heel wound . She stated she would add his Sacral wound diagnoses to his EMR profile. She stated when resident's diagnoses were missing from their EMR profile it could cause safety issues and not allow them to care for them properly. She stated it could cause them to not have interventions in place and proper care could be delayed.<BR/>Interview on 04/11/25 at 1:24 pm, the Administrator stated she was not aware of any issues with adding the residents diagnoses to their medical records. She stated the MDS L was not at work last Friday and called out and added they did not have another person designated for adding diagnoses. She stated the resident's diagnoses were needed in the EMR profile to adequately reflect the residents condition. She stated the MDS Coordinator was responsible for adding any new diagnoses to the resident's file. She stated Resident#1 has had the sacral wound for a couple of weeks. <BR/>Record review of the facility's Medical records policy was requested and on 04/11/25 at 3:30 pm, the Regional Nurse Consultant said they did not have one. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to immediately inform his or her authority, the resident representative(s) when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention and when a need to transfer or discharge the resident from the facility for 1 (Resident #1) of 6 residents reviewed for Change in condition. <BR/>1.LVN D failed to notify FM 1 after Resident #1 had an unwitnessed fall and complained of back pain on 04/06/25 at 2:50 am. <BR/>2.RN E failed to notify FM about Resident #1's transfer to the hospital after he fell with abnormal x-rays of his back on 04/06/25 around 3:26 pm.<BR/>These failures could place residents with fall incidents or abnormal radiology reports at risk of a delay in prompt medical decisions, which could result in a decline in a resident's health and psycho-social well-being. <BR/>Findings included:<BR/>Record review of Resident #1's admission MDS Assessment completed on 04/02/25, by MDS M revealed Resident #1 was an [AGE] year old male who admitted to [This Facility] on 03/25/25 with a BIMS score of 09 (Moderate Cognitive Impairment). He was dependent (2 person helpers did all assist) with toileting, showering/bathing, lower body dressing and putting on footwear. And partial to moderate assist with bed mobility and transfers. He was occasionally incontinent with bladder and always incontinent with bowel. His active diagnoses were medically complex conditions and he was diagnosed with atrial fibrillation, HTN, BPH, diabetes, hyperlipidemia, metabolic encephalopathy, acute pancreatis without infection, diverticulitis of small intestines without perforation or abscess. He had a history of falling within the past month. And based on Braden and clinical assessment he was at risk for pressure injuries and had 1 or more pressure injuries, <BR/>Record review of Resident #1's Care Plan dated 04/08/25 for bladder incontinence related to confusion and impaired mobility, 03/31/25 Pressure Ulcer and enhanced barrier precautions implemented related to pressure ulcer. And 04/06/25 risk for falls. <BR/>Record review of Resident #1's Face Sheet dated 04/08/25 revealed only one FM listed [FM 1] as the Responsible party and Resident #1 was the alternate contact. (FM 2 was not listed). <BR/>Record review of Resident #1's Nurse Progress notes by LVN D dated 04/06/25 at 2:37 am revealed, Resident was found on the floor in his room next to his bed while CNA was making rounds. resident is unable to verbalize what happened. We were able to put resident back into the bed, when asked if he had injured himself, he pointed to his low back. neuro-checks were initiated and within normal limits, vital signs Temp 97.9-Blood Pressure-146/80-Respirations 16-Saturations 97% Room Air. Call To MD/NP received new orders for X-ray for lumbar spine and bilateral Lower Extremity. Family, DON/ADON informed. will continue to monitor condition.<BR/>Record review of Resident #1's Nurse Progress notes by LVN D dated 04/06/25 at 4:02 am revealed, XR (x-ray) requested for Lumbar Spine and Bilateral Hips.<BR/>Record review of Resident #1's Nurse Progress note by RN K dated 04/06/25 at 11:13 am revealed, Resident continues neuro checks due to recent fall. No pain or discomfort noted. Patient resting in bed. respirations even and unlabored. Medications given per orders.<BR/>Record review of Resident #1's Nurse Progress note by RN E dated 04/06/25 at 3:36 pm revealed, x-ray of spin and bilateral hip results received provider hotline called, reviewed results with NP H, order to send to ER for evaluation. Responsible party made aware.<BR/>Record review of Resident #1's Nurse Progress note by RN E dated 04/06/25 at 6:52 pm revealed, FM 2 was in the facility on day shift, made aware of resident's fall and pending x-ray by day shift staff, FM 2 exited the facility, FM 2 called the facility multiple times, left note with the receptionist for charge nurse to call him back to follow up on Resident #1's pending x-rays, this charge nurse called FM 2 back and FM 2 stated I came to visit Resident #1 a few hours ago, I was informed that Resident #1 fell and there were pending x-rays, are the results available yet? this charge nurse stated the x-ray results had been received and the NP was made aware of the results and the NP wanted to send the resident out for further evaluation, FM 2 said ok, he will come in and pick up a few things for Resident #1 such as his wallet and a few other items Resident #1 may want, FM later came into facility, this charge nurse informed FM that resident was transported to hospital for further evaluation pending x-ray results. <BR/>Record review of Resident #1's Nurse progress note by RN E dated 04/06/25 at 9:35 pm revealed, Resident returned from [The Hospital] with no new orders, np made aware FM made aware @ (at) phone # (number). <BR/>Record review of Resident #1's Change of condition completed by unknown staff dated 04/06/25 at 6:55 pm revealed, this change started 04/06/25 this afternoon. Resident's vitals were taken that were normal and he had an abnormal spine x-ray. The Resident Representative Notification was blank and there was not a signature on who completed this form. <BR/>Record review of Resident #1's Radiology Report dated 04/06/25 revealed, PROCEDURE: SPINE 1V SPECIFY LEVEL Status: Final, Reason for Study: M54.50 LOW BACK PAIN, UNSPECIFIED, SPINE 1V SPECIFY LEVEL: FINDINGS: Moderate L1 and mild L2-L3 vertebral body compression demonstrated. The age of the compression is indeterminate. Vertebral bodies show degenerative osteophytic spurring and narrowing of disc spaces. The bones appear diffusely demineralized. L5-S1 anterior fusion hardware present. No comparison study is available. CONCLUSION: Abnormal spine. Consider more sensitive imaging evaluation with CT/MRI as clinically directed.<BR/>Record review of Resident #1's Incident Report dated 04/06/25 at 2:15 am revealed, Resident was found on the floor next to his bed by CNA. No apparent injuries. Resident Unable to give Description, Vital signs taken, complete body assessment completed and neuro-checks initiated. MD/NP Called received order for XR ((X-rays) of bilateral lower extremities and lumbar spine. No injuries noted at the time of incident, bedridden, oriented to person, pain aid 4 (moaning/groaning, facial grimacing, distressed), confused, incontinent, gait imbalance, impaired memory. Responsible party, DON and DR/NP notified. <BR/>Record review of Resident #1's Hospital Record dated 04/06/25 4:26 pm revealed, He admitted for abdominal pain and fall. At 4:43 PM Resident #1 is an [AGE] year-old male with a PMHx of HTN, a-fib, acute ischemic Left middle cerebral artery stroke, pancreatitis, and diabetes mellites who presents to the Emergency Department via Emergency Medical Service from a nursing home status post a fall yesterday evening. Per nurse relaying EMS, nursing home staff noticed the patient had an Altered Mental Status after falling out of bed yesterday evening. Per patient, he has bad back pain, left lower quadrant abdomen tenderness, and has vomited an unknown number of times recently. History of present illness and review of system limited secondary to chronic aphasia. CT scan of abdomen and pelvis with no abnormal findings. Radiology report from nursing home conducted at 1:00 pm today shows L1-L3 compression, unknown if acute or chronic. No acute changes on hips/pelvis x-ray. Pt (patient) has extensive cardiac history and history of stroke. The Lumbar findings were seen on prior imaging studies. Patient escorted from Emergency Department via stretcher accompanied by Ambulance service. Patient being taken back to the [The Facility]. Intravenous line removed by this RN. Discharge papers and face sheet given to transport team. No belongings left in room on pt departure. This RN attempted to call nursing home to let them know pt (patient) is coming back, no one responded.<BR/>Interview on 04/09/25 at 1:48 pm, FM 1 stated he did not get a call about Resident #1 falling from the facility staff last Sunday 04/06/25. He stated FM 2 visited Resident #1 and was given the information about him falling and going to the hospital. He stated FM #2 called him around 4:30 pm telling him about Resident #1 falling and went to the hospital Sunday 04/06/25. He stated on 04/06/25 around 6:00 pm he went to the facility to get more information and they said they did not know where he was and finally the lady said Resident #1 was at the hospital. He stated they called him Sunday 04/06/25 at 10:30 pm saying Resident #1 had returned from the hospital and the nurse was not able to say what the hospital results were. He stated the nurse said he was okay and that it was abnormal but he was not sure what was abnormal. He stated he asked when did Resident #1 fall and was told by RN Weekend Supervisor F he fell last night. He stated some 15 &frac12; hours later they told FM 2 not on the face sheet about his fall and hospital transfer. He stated RN Weekend Supervisor F said Resident #1's fall was reported to her and they needed to resolve his concern about not being notified of Resident #1's fall and hospital transfer. He stated the weekend supervisor said she would call the DON and Administrator about this issue. He stated to this day he's not been explained as to how his father fell and what was abnormal. <BR/>Interview on 04/09/25 at 3:58 pm, CNA G stated on 04/06/25, she overheard Resident #1 had a fall on a previous shift and then he went to the hospital. She stated FM 1 was at this facility wanting to know about the fall and said no one had contacted him from this facility that he had gone to the hospital. She stated Resident #1 returned around 9:00 pm on 04/06/25. <BR/>Interview on 04/10/25 at 9:55 am, the DON stated on 04/06/25 this past weekend, She stated Resident #1 fell and x-rays showed he had a lumbar spine that looked abnormal. She stated he was sent to the hospital and returned from the hospital and they confirmed the lumbar spine was a preexisting diagnosis. She stated RN E reached out to FM 2 and not FM 1 who was the responsible party . She stated she was not sure how she got confused, because she should have called FM 1 on the face sheet. She stated FM 1 spoke to the weekend supervisor about the matter. She stated she had not spoken to the staff about ensuring they spoke to the right family member but planned to do. She stated they planned to talk to the staff this upcoming Friday about incident reporting, notifications, and call outs. She stated RN Weekend supervisor F talked to RN E to try to figure out why she did not do the communication correctly. She stated after reviewing with RN E the notification on face sheet, RN E said she thought she had the right person. She stated she had not had a chance to speak to RN E because the State Surveyor came to the facility. She stated she had been tied up and was not aware FM 1 had not been updated about Resident # 1's hospital visit. <BR/>Interview on 04/10/25 at 10:41 am, the Administrator stated she thought FM 1 had a concern on the weekend of 04/06/25 about FM 2 being notified instead of him . She stated FM 2 visited Resident #1 and was told by the nurse he fell and was waiting for the x-ray results. She stated Resident #1 went to the hospital and had no complaints about why Resident #1 was sent to hospital and result afterwards. She stated on 04/06/25 at 2:37 am, Resident #1 was found on floor, in his room and the resident was unable to say what happened. She stated according to the nurses notes, the nurse called the Dr/NP and family. She stated she had no complaints from FM 1 about not being aware of Resident #1 falling, abnormal x-ray and transfer to the hospital. She stated he was sent back the same day 04/06/25 and the facility had no issues with FM 1 about the details of Resident #1's hospital visit and fall that she was aware of. <BR/>Interview on 04/10/25 at 11:45 am, ADON A stated FM 1 said a few days ago Resident #1 went to the hospital and he was not informed. She stated FM 1 should have been informed because he was listed as the Responsible party. She stated she reviewed Resident #1's chart and FM 2 was not on it but FM 2 was in Resident #1's room visiting on 04/06/25. She stated she addressed this issue with RN E making sure they informed the right people on the face sheet because the RP needed to be notified for change of condition. She stated not being sure if FM 1 was notified of Resident #1 falling. She stated if the nurse called and left a message she should have called again then let upcoming nurse know to keep calling and go to next person on face sheet. She stated in Resident #1's case there was not a second contact person but RN E assumed FM 2 was the RP. She stated they planned to have a training with all staff to ensure no one was contacting the wrong person. She stated she was not aware of FM 1 complained about not being notified of the hospital visit findings. She stated the staff were supposed to call the RP to let them know the resident returned and outcome of hospital stay. <BR/>Interview on 04/11/25 at 10:59 am, Doctor J stated his NP H received the notice about Resident #1 fell and x-rays were ordered 04/06/25. She stated PA I was notified about the abnormal x-rays on 04/06/25 and sent the resident to the hospital. He stated Resident #1 fell out of bed and had bad back pain and had some vomiting. He stated he blood pressure and labs were fine and other vitals were fine and at the hospital he had a normal CT of his abdomen/pelvis. He stated Resident #1 had a diagnoses of diverticulitis and arthritis. He stated Resident #1's lumbar L1 and L2 were also negative and was sent back to this nursing facility the same day . <BR/>Interview on 04/11/25 at 12:42 pm, LVN D stated she worked the 300 and 400 halls and on 04/06/25 around 1:30 or 2:30 am, Resident #1 fell. She stated the CNA told her he was on the floor and after he was assessed he was assisted back into his bed. She stated Resident #1 said he had pain and pointed to his lower back then she called NP H and she ordered x-rays for his lumbar and bilateral hips. She stated she called FM 1 but he did not answer and got a voice mail and she left a message to call [This Facility]. She stated FM 1 did not call back and she did not try to call FM 1 back, then she left at 6:15 am. She stated she documented he fell and she initiated neuro checks because he had an unwitnessed fall. She stated Resident #1 was on his back on the floor, between the 2 beds, he was lying flat on the floor with his knees up. She stated she found out later he was taken to the hospital for irregular x-rays. <BR/>Interview on 04/11/24 at 1:24 pm, the Administrator stated they were trying to solve FM 1's complaints and they could not drop the ball again. She stated they had a meeting with FM 1 today 04/11/25 and FM 1 was giving them another opportunity to make things right for Resident #1. She stated not contacting the RP could potentially lead to the resident's needs not being met. She stated the DON was responsible for ensuring the change of condition process was done properly. She stated they were handling the issue with RN E and she was going to be written up and counseled, because she did not follow appropriate protocol. She stated FM 1 said when he came to the facility 04/06/25 to find out more information RN E was arguing with him that she had call him and he said no she did not call him. She stated RN E should have verified she spoke to the RP. She stated she was not aware LVN D did not call FM 1 after Resident #1 fell <BR/>Interview on 04/11/25 at 10:09 am, RN E stated last Sunday 04/06/25 LVN K told her Resident #1 fell and neuro checks were needed. She stated FM 2 had visited earlier that day 04/06/25 and he found out about the fall and pending x-ray. She stated Resident #1 was in a little bit pain of pain of his lower back she told him he's going to the hospital for abnormal x-rays and he said okay. She stated she called NP H and got the order to send Resident #1 to the hospital for an evaluation. She stated Resident #1 was sent to the hospital around 3:00 pm or 4:00 pm because he had an abnormal lumbar x-ray. She stated FM 2 contacted her but she had not had the opportunity to call anyone yet, then she returned FM 2's call to follow-up with the x-ray result and told him what was going on and the resident was going to the hospital. She stated later that evening FM 1 said he was the RP and she responded she was unaware of that. She stated she normally looked at the face sheet to see who the RP was but did not in this case. She stated FM 1 wanted a follow-up on Resident #1's fall and x-ray results and she told him that she did not know the residents well on the 400 hall. She stated she was told FM 1 was the only RP Resident #1 had and to only contact him. She stated the DON told her to look at the resident's face sheets before talking to anyone about the residents. She stated the RP was upset and she apologized for not looking at the face sheet and not contacting him first. She stated around 10:00 pm Resident #1 returned back to the facility with no new orders. <BR/>Record review of the Facility's Change in Condition policy undated revealed, CHANGE OF CONDITION Policy: To identify and evaluate a change in condition and notify the Physician and Responsible Party when indicated. A significant change in Resident's status is any sign or symptom that is Acute or sudden onset: - A marked change (i.e., more severe) in relation to usual signs and symptoms - New or worsening symptoms - Examples include but are not limited to the following: cardiovascular, respiratory, behavioral, fall with major injury, infection, dehydration, altered mental status, pressure injury and any other condition based on professional judgment. Procedure: When a change in condition occurs, the Licensed Nurse will: .3. Document date, time Physician, Responsible Party was notified of findings from the evaluation and any new orders obtained . 6. If the Physician chooses to send the Resident to the hospital for further evaluation and treatment, the charge nurse will initiate the transfer process. Evaluation findings will be documented on the communication tool used to transition the Resident to the next level of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #154) reviewed for elopements.<BR/>The facility failed to ensure Resident #154 did not elope from the facility's back door on 04/19/24. Resident #154 was found on the street attempting to go to the gas station across the street from the facility that was located directly off a busy highway. Resident #154 had suffered a skin tear to his arm . <BR/>The noncompliance was identified as past noncompliance. The IJ began on 04/19/24 and ended on 11/01/24. The facility had corrected the noncompliance before the survey began. <BR/>This failure could placed residents at risk of serious injury or death.<BR/>Findings included:<BR/>Review of Resident #154's Face Sheet, dated 05/13/25, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 11/20/24.<BR/>Review of Resident #154's Quarterly MDS Assessment, dated 02/28/24, reflected he had a BIMS score of 04, indicating severe cognitive impairment. His MDS indicated he did not have any behaviors of wandering and that he utilized a wheelchair to ambulate. His active diagnoses included depression (feelings of severe despondency and dejection) and bipolar disorder (a mental health condition characterized by significant mood swings).<BR/>Review of Resident #154's Care Plan, dated 05/14/25, reflected the following: <BR/>Problems: [Resident #154] is at risk for wandering as evidenced by: Dementia/Alzheimer's .Interventions: Observe location each shift and prn .Report any attempts to exit the facility to IDT, family & MD as indicated and record in the clinical record .Place a wanderguard bracelet on [Resident #154] if attempt to leave out the facility [sic] .[Resident #154] requires a Wander Guard Bracelet [sic] and is at risk for injury from wandering in an un-safe enviornment [sic] .Interventions: Monitor for placement q shift, monitor for proper functioning q 24 hours .<BR/>Review of Resident #154's Elopement Risk Assessment, dated 11/01/24, reflected the following : 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK, A) Patient is cognitively impaired AND .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .Comments: Shows no signs of elopement.<BR/>Review of Resident #154's Elopement Risk Assessment, dated 06/27/24, reflected the following: 1. NO RISK, B) Patient is unable to ambulate or mobilize wheelchairs .2. MODERATE RISK .3. IMMINENT RISK, ACTION: Implement Elopement Risk Care Plan .<BR/>Review of Resident #154's electronic health chart revealed there were not any other elopement risk assessments completed. <BR/>Review of Resident #154's Clinical Notes Report reflected the following: <BR/>- <BR/>pt left the facility and was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. She is getting me some coffee'. [sic] pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix written on 04/19/24 at 9:24 PM by RN G<BR/>- <BR/>At this time resident remains in bed, no s/s of pain and or discomfort noted. Resident noted to be resting on and off, but resident remains in bed and no attempts to get out of bed or facility noted at this time. All safety measures met. Written on 04/20/24 at 12:33 AM by LVN H<BR/>- <BR/>Resident was brought to nurses station by reception informed [sic] that resident pushed door open trying to go outside call [sic] placed to [the NP]. Notified of resident attempt to go out of front door [sic]. N/O may apply Wander guard for safety. Call to [Resident #154's Family Member] at [phone number] notified of attempt to go out of front door will be [sic] placing a wander guard to lower extremity. foe [sic] safety reason. stated'thank You' [sic] written by LVN I on 07/26/24 at 11:39 AM.<BR/>Review of an Accident/Incident Report, dated 04/19/24, reflected the following: <BR/>Person in charge- account of occurrence: pt left the facility was on the street on his own. A staff member brought the patient back in the facility and when asked why the patient went to the road, pt replied meeting my wife at the gas station. she is getting me some coffee'. pt was told by the RN that his wife is not in the gas station. pt had a skin tear on his left arm. the skin tear was cleansed, and bacterial ointment was applied and then it was covered with kerlix. Completed by RN G .<BR/>Interview on the phone on 05/12/25 at 10:53 AM with Resident #154's Family Member revealed Resident #154 left the facility in November 2024. Resident #154's Family Member said Resident #154 used a wanderguard bracelet while at the facility which she said was not necessary because the resident as far as she knew he never tried leaving or left the facility. <BR/>Interview on the phone on 05/13/25 at 2:06 PM with RN G revealed she no longer worked at the facility and could not remember the incident from April 2024.<BR/>Interview on the phone on 05/13/25 at 2:24 PM with CNA J was unsuccessful as she did not answer. CNA J was working on 04/19/24 and was assigned to Resident #154. <BR/>Interview on 05/13/25 at 2:30 PM with RA K revealed she was not here when Resident #154 eloped from the facility on 04/19/24 but she heard he had left through the back door of the facility near where the dumpsters were at. RA K said Resident #154 had a wander guard placed on his leg after this incident happened. RA K said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. RA K said she was in-serviced regarding elopements and wandering residents. RA K said she knew to immediately report to the nurse if she noticed a resident began to wander or make an attempt to elope from the facility. RA K said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. <BR/>Interview on 05/14/25 at 8:50 AM with LVN I revealed she cared for Resident #154 but had no idea about his elopement on 04/19/24. LVN I said she remembered Resident #154 had a wander guard bracelet because he had a tendency to wander around the facility. LVN I said if a resident began to have wandering or elopement behaviors it should be reported to her so that she may complete an elopement assessment on the resident. LVN I said she currently had residents who used a wander guard bracelet because they were at risk of wandering or eloping. LVN I said as the nurse she checks those identified resident's wander guard bracelets every shift for placement and functioning. LVN I said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. LVN I said she was in-serviced regarding elopements and wandering residents. LVN I said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident. <BR/>Interview on 05/14/25 at 11:45 AM with LVN H revealed she could not recall anything about Resident #154's elopement on 04/19/24. LVN H said if a resident began to have wandering or elopement behaviors it should be reported to her so that she may complete an elopement assessment on the resident. LVN H said she did not currently have residents who used a wander guard bracelet because they were at risk of wandering or eloping. LVN H if she did care for a resident who used a wander guard bracelet, as the nurse she would check them every shift for placement and functioning. LVN H said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. LVN H said she was in-serviced regarding elopements and wandering residents. LVN H said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 1:07 PM with CNA L revealed he did not know about Resident #154 elopement from the facility on 04/19/24. CNA L said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. CNA L said he was in-serviced regarding elopements and wandering residents. CNA L said he knew to immediately report to the nurse if he noticed a resident began to wander or make an attempt to elope from the facility. CNA L said he knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 1:18 PM with CNA M revealed she had only been at the facility for four weeks. CNA M said when a resident had a wander guard on, if they went near a door the alarm would sound off and staff would have to go to redirect them away from the door and reset the code to turn the alarm off. CNA M said she was in-serviced regarding elopements and wandering residents. CNA M said she knew to immediately report to the nurse if she noticed a resident began to wander or make an attempt to elope from the facility. CNA M said she knew the code for an elopement or missing resident was white and required a search of the facility and the grounds to try and find the resident.<BR/>Interview on 05/14/25 at 3:15 PM with the DON revealed she was in training in April 2024 when Resident #154 eloped from the facility so she did not have any details about it. The DON said she recalled when they had to put a wander guard bracelet on Resident #154 because he would stand up and try to walk towards the doors and set the alarms off to the doors. The DON said with the wander guard bracelet, if Resident #154 got too close to the door the door alarm and the wander guard alarm would both go off and scare Resident #154 so he would back away from it after that. The DON said Resident #154 was easily redirectable but was exit seeking while he tried to find his family. The DON said Resident #154's family was not happy with him having the wander guard bracelet and did not believe the resident required one. The DON said when a resident eloped from the facility she expected staff to get them back inside right away and report to the Administrator and her about what happened. The DON said when the elopement code was activated she also expected her staff to do a sweep of the facility to ensure all residents were in house and safe. The DON said after the resident was safe the facility would investigate to see how they eloped from the facility and that would be corrected. The DON said staff should know to be supervising residents and watching them to make sure they did not leave and if they heard an alarm going off they should make sure they are responding to them. The DON said a number of things could happen to a resident if they eloped from the facility, depending on the weather it could be too cold or hot so they could die, or be hit by a car since there's a busy street behind the facility. The DON said staff were trained and in-serviced regarding resident elopements recently. The DON said when a resident was admitted and had elopement or wandering behaviors the facility would complete an elopement assessment on them and if a wander guard bracelet was necessary to keep them safe one would be placed. The DON said all staff knew to immediately report any new behaviors of a resident wandering or making elopement attempts.<BR/>Interview on the phone on 05/15/25 at 9:20 AM with the Previous Administrator was unsuccessful as she did not answer.<BR/>Interview on the phone on 05/15/25 at 9:21 AM with the Previous DON was unsuccessful as he did not answer. <BR/>Interview on 05/15/25 at 10:10 AM with the Administrator revealed she was not yet employed by the facility on 04/19/24 when Resident #154 eloped from the facility. The Administrator said she was not informed about the elopement either when she arrived to the facility. The Administrator said since she was not at the facility on 04/19/24 she had no details about what happened. The Administrator said Resident #154 had tendencies to wander and exit seek and his family was upset about him having to wear a wander guard bracelet. The Administrator said Resident #154 was always at the doors of the facility trying to leave. The Administrator said Resident #154 was always setting off the door alarms and the wander guard system alarms. The Administrator said Resident #154 was easily redirectable away from the doors, however. The Administrator said Resident #154 should not have been able to elope from the facility back in April 2024. The Administrator said she expected all staff to frequently monitor all residents who were at risk of eloping/wandering and to ensure they each were inside and safely in the facility. The Administrator said if a resident had been identified as being at risk of eloping/wandering a wander guard bracelet was placed on them. The Administrator said each resident's nurse would be responsible for checking the wander guard bracelet's placement and functioning each shift. The Administrator said the Maintenance Director checked each door every week to make sure that the wander guard system was working as well. The Administrator said the staff were provided with training on elopements because the facility had other residents elope back in November 2024. The Administrator said if a resident was able to elope from the facility they were at risk because it was not safe outside the facility. The Administrator said she expected staff to report when a resident eloped from the facility. <BR/>Interview and observation on 05/15/25 at 12:53 PM with the Maintenance Director revealed he was notified of Resident #154's elopement back in April 2024 but he could not recall any of the details. The Maintenance Director said if Resident #154 eloped from the back door of the facility near the dumpsters it would have been the door near the therapy gym at the end of the 400-hallway. Observation of the door at the end of the 400-hallway revealed it had a wander guard system alarm on it and the door was locked and required a code to turn the alarm off. Observation of the door being pushed open revealed an alarm went off and staff would have to enter the code in to the keypad to turn the alarm off. The door led out to a small parking lot that had the facility's dumpsters off to the left side and a gas station could be seen across the street. In front of the gas station was a busy highway as well. The Maintenance Director said he checks to make sure the wander guard system was working on each of the exterior doors once a week and documents that on his check off sheet. <BR/>The facility implemented the following interventions:<BR/>Review of an in-service roster, dated 11/01/24, and titled Staff in-services initiated the following: .elopement policy . reflected 108 staff's signatures. <BR/>Review of the facility's policy, dated January 2024, and titled Elopement Response Protocol reflected: 1. Conduct a thorough search of the Facility and its grounds .8. A complete head to toe nursing assessment must be completed upon return of the Patient [sic].<BR/>The Administrator was informed of the PNC IJ on 05/15/25 at 12:42 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #98) reviewed for dialysis.<BR/>The facility failed to ensure dialysis communication forms for Resident #98 were completed with the resident's dialysis treatment information on the following dates: 05/02/25, 05/05/25, and 05/09/25.<BR/>This failure could place residents at risk of inadequate communication between the facility and dialysis center. <BR/>Findings included: <BR/>Record review of Resident #98's admission record, dated 05/14/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. <BR/>Record review of Resident #98's admission MDS Assessment, dated 04/28/25, reflected she had a BIMS score of 10, indicating moderate cognitive impairment. Her active diagnoses included renal insufficiency, renal failure, or end-stage renal disease, heart failure, and respiratory failure. Her MDS indicated she received dialysis services.<BR/>Record review of Resident #98's physician's orders, dated 05/14/25, reflected the following: <BR/>- <BR/>Dialysis- Post Tx Frequency in the evening every Mon, Wed, Fri Upon [sic] return, enter Dialysis Treatment Information received from Dialysis Center onto the Dialysis Communication Record. Complete the Post Dialysis Assessment Section. Check for any labs/ notes/ orders [sic] from the Dialysis Center with an active date of 04/29/25.<BR/>- <BR/>Dialysis- Pre Tx Frequency every day shift every Mon, Wed, Fri Complete Pre-Treatment section of Dialysis Communication Record. Print record and place in Dialysis Communication Folder prior to Transport. Ensure Food and/ or [sic] Meal goes with patient to each Dialysis treatment. with an active date of 04/29/25.<BR/>Record review of Resident #98's care plan, initiated 04/23/25, reflected the following: <BR/>Focus: The resident needs dialysis .<BR/>Record review of Resident #98's Dialysis Communication Forms, dated 05/02/25 and 05/05/25, reflected only the Pre-Dialysis Information was filled in; the Dialysis Information was left blank.<BR/>Record review of Resident #98's Dialysis Communication Form, dated 05/09/25, reflected the Pre-Dialysis Information was filled in, but the Dialysis Information had N/A written in each spot.<BR/>Observation and interview on 05/13/25 at 11:26 AM with Resident #98 revealed she was lying in bed and was sleepy. Resident #98 said she never has any issues when she went to dialysis.<BR/>Interview on 05/14/25 at 12:58 PM with LVN D revealed Resident #98 went to dialysis on Mondays, Wednesdays, and Fridays. LVN D said she worked the 6 AM to 2 PM shift so she sent Resident #98 to dialysis with a red binder. LVN D said the binder included her face sheet, orders, and dialysis communication form filled out for the pre-dialysis information. LVN D said Resident #98 did not come back on her shift from dialysis, so the 2 PM to 10 PM shift nurse on duty would be responsible for completing Resident #98's dialysis forms. <BR/>Interview on 05/15/25 at 2:48 PM with LVN E revealed Resident #98 went to dialysis in the mornings on Mondays, Wednesdays, and Fridays and came back during her shift around 5:30 PM/6 PM. LVN E said Resident #98 left to go to dialysis with a red binder that included her dialysis communication forms. LVN E said the morning nurse for Resident #98 filled out the pre dialysis information on the form and the dialysis center was supposed to fill out the rest of the form and return it with the resident. LVN E said the dialysis center has not been returning the forms filled out for Resident #98 and when that happened she would call the dialysis center to get the information. LVN E said sometimes she was able to get in touch with someone at the dialysis center for the information and sometimes it was more difficult. LVN E said she was responsible for making sure the post dialysis information was included on the forms and filled out since she was the nurse on duty at the time the resident was brought back to the facility from dialysis. <BR/>Interview on 05/15/25 at 3:01 PM with the DON revealed since Resident #98 came back to the facility from the dialysis center, the afternoon shift nurse would have been responsible for completing the dialysis communication form was filled out. The DON said the purpose of the form was to make sure the resident's vitals were okay and to communicate anything that required any follow-up. The DON said the ADON was responsible for making sure that the nurses were completing the dialysis communication forms for residents. The DON said she expected all staff to complete the dialysis communication form for residents and they had been trained to do that. The DON said if the dialysis communication form was not completed, the facility may not know how stable a resident was so they might send them to the hospital for something that the facility could have handled in house. <BR/>Interview on 05/15/25 at 3:30 PM with ADON F revealed she was the ADON in charge of Resident #98's hall. ADON F said she checked the dialysis communication forms for completion about once a week. ADON F said she was not aware that Resident #98's dialysis communication forms were not completed.<BR/>Record review of the facility's policy, dated August 2007, and untitled reflected the following: .7. The [Management Company's Name] will send a Dialysis Communication Record .to the dialysis center upon each dialysis visit. The [Management Company's Name] will complete the top section of the form, entitled 'Nursing Home Nurses' and provide to the Resident [sic] prior to exiting the center .8. The dialysis center should be encouraged to complete the middle section of the Dialysis Communication Record and return to the [Management Company's Name] .9. The [Management Company's Name] nurse will complete the Post Dialysis Assessment section of the Dialysis Communication Record and file the form in the dialysis binder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADL activity the necessary services to maintain good personal hygiene for 2 (Residents #1, #2) of 9 residents reviewed for ADL care. <BR/>The facility failed to ensure Resident #1 and #2 were provided timely incontinent care as needed. <BR/>These failures could place residents at risk of not receiving personal care services, having decreased quality of life, and skin breakdown.<BR/>Findings include:<BR/>Record review of Resident's #1s Face Sheet dated 3-13-2024, showed a [AGE] year-old female, with a BIMS (Brief Interview of Mental Status) score of 11, which shows moderate cognitive impairment, who was admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), type 2 diabetes mellitus with diabetic Neuropathy, gastro-esophageal reflux, cramps and spasms, Weakness, Hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), and urinary tract infection. <BR/>In an observation of Hall 200, on 3-13-2024, at 9:20 AM, most of the 200-hall smelled of urine. <BR/>In an observation/interview of Resident #1, on 3-13-2024, at 6:30 AM, Resident #1 was in bed with a strong smell of urine in the room. Resident #1 revealed she had not been changed, with a wet brief, since 4 AM. Resident #1 stated that when CNA-C works her hall, CNA-C will provide incontinent care for her non-verbal roommate, but not her. At 9:40 AM, Resident #1 pressed her call light to get incontinent care. <BR/>In an observation/interview on 3-13-2024, at 10:30 AM, Resident #1 still had not received incontinent care. Resident #1's room, still smelled of urine. Resident #1 stated that 10 minutes after she pressed the call light at 9:40 AM, a CNA came into her room, cut off the light, and left the room without providing incontinent care. <BR/>In an observation of Resident #1s room, on 3-13-2024, at 11:45 AM, revealed Resident #1 received incontinent care. <BR/>Record review of Resident #1s care plan, dated 7-24-2023, revealed resident is totally dependent on staff required a 2 person Hoyer lift to be moved out of bed and that incontinent care be provided every 2 hours. <BR/>Record review of Resident #1's MDS Screening, revealed Resident #1 needed substantial/maximal assistance with toilet transfers, required partial/moderate assistance (helper does less than half the effort helper lifts, holds, or supports trunk or limbs, but provides less than half the effort), and rated as being frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). <BR/>Record review of Resident #2's Face Sheet dated 3-13-2024, showed a [AGE] year-old female, with a BIMS (Brief Interview for Mental Status) (it is a quick snapshot of how well you are functioning cognitively at the moment) score of 15 (which shows no cognitive impairment), who was admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of Muscle wasting, rheumatoid arthritis, muscle weakness, type 2 diabetes mellites, Constipation, contracture of left hand, wheezing, intoxication delirium, vomiting without nausea, unspecified open-angle glaucoma, and indeterminate hypermetropia.<BR/>In an observation/interview of Resident #2, on 3-13-2024, at 11:20 AM, it was revealed Resident #2 had not had her brief changed since 6:00 AM. There was a strong smell of urine in Resident #2s room. Resident #2 stated many times when she has pressed the call light, an aide comes in the room, turns the light off, leaves the room without providing incontinent care - until about 30 minutes later. Resident #2 stated that the 200-hall has a high percentage need of incontinent care, and the facility needs 2 aides to work that hall to provide timely incontinent care. However, the facility only has one aide for the hall and sometimes they are used in other halls - not just hall 200. Resident #2 said her right hand is paralyzed and cannot pull up her own brief. Resident #2 stated CNA-C, is not a good aide to deal with as she was needing help to fix her brief as it was pinching her after CNA-C provided incontinent care. Resident #2 stated she asked CNA-C to re-adjust the brief and CNA-C told Resident #2 to adjust it herself. Resident #2 stated she asked CNA-C to leave her room. After that incident, when CNA-C is working, CNA-C will not provide incontinent care, pick up resident #2s food tray, and won't provide Resident #2 with water. Resident #2 revealed this makes Resident #2 feel neglected. Resident #2 stated she has developed a rash due to incontinent care not being provided timely. Resident #2 stated she has had to wait up to 10 hours before receiving incontinent care at this facility. Resident #2 stated this makes her feel neglected. Resident #2 pressed the call light at 11:35 AM. Incontinent care was observed to be provided at 11:55 AM. <BR/>Record review of Resident #2s care plan dated 6-15-2022, stated that Resident #2 needs assistance with ADL care to include incontinent care. Resident #2s care plan revealed the goal for Resident #2 is to maintain a sense of dignity by being clean, dry, odor free, and well-groomed. Resident #2s care plan stated for resident to be turned every 2 hours and use skin protocols with barrier cream. <BR/>Record review of Resident #2's MDS (Minimum Data Set) ratings, revealed that Resident #2 was Dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting hygiene. <BR/>In an interview with CNA-B, on 3-13-2024, at 12:31 PM, it was revealed that the facility is short staffed especially in the 200-hall. CNA-B stated the 200-hall needs 2 CNAs to keep up with the workload of providing care needed for residents. CNA-B revealed that she believes the urine that has been smelling in Resident #1s room, was probably from her roommate who is non-verbal. CNA-B stated Resident #1s roommate fights staff when staff try to provide incontinent care and it takes 2 people to provide incontinent care. CNA-B said she does not know if the night shift provides incontinent care to Resident #1s roommate because she can be so combative. CNA-B stated she does not believe the night shift are providing timely incontinent care. CNA-B stated she is the CNA who turned off Resident #1s call light at around 9:50 AM, and could not provide incontinent care at the time, because the Administrator pulled her out of the 200-hall to help with 100-hall to provide incontinent care. <BR/>In an interview with CNA-C, on 3-14-2024, at 11:10 AM, it was revealed CNA-C will not provide incontinent care to a resident if the resident is rude or speaks mean or is abusive to her. CNA-C stated she will switch out with another CNA to provide care for the resident(s) who are rude, mean, or abusive toward her. <BR/>In an interview with the Administrator, on 3-14-2024, at 2:45 PM, it was revealed that her call light response expectations were in a perfect world not to take over 10 minutes. The Administrator stated call light response becomes neglect by not being conducted. The Administrator stated, just make sure the residents are safe, if staff cannot meet their needs. The Administrator stated that it was the ADON and the DON's responsibility to ensure there was adequate staffing to meet the demands of call lights being used by residents. The Administrator stated if an aide cannot meet the needs, of a resident using a call light, just ensure staff are communicating with residents, at the time, and let them know you will be back later. The Administrator revealed it was everyone's responsibility to respond to call lights. The Administrator's expectations were for CNAs to make rounds for incontinent care every 2 hours. The Administrator stated that if a particular CNA isn't comfortable with providing care for certain residents, she wants to know about it. The Administrator stated if a CNA isn't comfortable with providing call light response to a resident, they will assign that particular room to another aide. <BR/>Review of an article from International Continence Society, file:///C:/Users/TCodd01/Downloads/Skin_Damage_from_Incontinence%20(1).pdf, undated, revealed, .Urine or feces can damage skin if not immediately removed and the affected area thoroughly cleaned and dried. Irritating substances in feces can cause inflammation of the skin .skin damage from prolonged exposure to urine or feces can occur fast - within just a few days .<BR/>Record Review of the facility's Call Light Policy, dated 6-14-2006, stated the purpose of the call light system is to provide prompt assistance to patients and ensure the system is working. <BR/>1. <BR/>Answer all call lights promptly, whether or not you are assigned to the patient.<BR/>2. <BR/>Answer all call lights in a prompt, calm, courteous manner. <BR/>3. <BR/>Never make the patient feel you are too busy to give assistance; offer further assistance before you leave the room .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure each resident had the right to a safe, clean, comfortable and homelike environment, which included but not limited to receiving treatment and supports for daily living for 4 of 20 Residents (Resident #3, #32, #12, #10 ) reviewed for environmental concerns. <BR/>1. The facility failed to clean the restroom in Resident #3 and Resident #32's room.<BR/>2. The facility failed to ensure Resident #12 and Resident #10 had a lever on the doorhandle.<BR/>These failures could place residents at risk by exposing them to an unsanitary and an unsafe environment. <BR/>Findings include:<BR/>Record review of Resident #3's face sheet, dated 04/12/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of anoxic brain damage and dementia. <BR/>Record review of Resident #3's Quarterly MDS, undated, revealed a BIMS score of 6, indicating sever cognitive impairment. Further review of the MDS revealed Resident #3 was always incontinent of bowel and bladder. <BR/>Observation on 04/09/2024 at 11:09 AM revealed a foul odor in room in Resident #3's room. Observation of the bathroom revealed a dried black substance which appeared to be fecal matter on the floor in front of the toilet bowl and on the toilet seat. Attempted interview with Resident #3 was unsuccessful and Resident #32 was not in the room. <BR/>Record review of Resident #12's face sheet, dated 04/12/2024, revealed an [AGE] year-old female who admitted on [DATE] with diagnosis of unspecified dementia. <BR/>Record review of Resident #12's Annual MDS, undated, revealed a BIMS of 14, indicating intact cognition. <BR/>Record review of Resident #10's face sheet, dated 04/12/2024, revealed [AGE] year-old female who admitted on [DATE] with a diagnosis of bipolar disorder. <BR/>Record review of Resident #10's Annual MDS, undated, revealed a BIMS score of 9, indicating moderate cognitive impairment. <BR/>Observation and interview on 04/09/2024 at 11:29 AM, in Resident #12 and #10's room, revealed the lever on the inside of the room door was missing. There was no knob or handle to turn and the door was hard to open from the inside when closed. Resident #12 stated they (Resident #12 and Resident #10) leave the door open and do not close it at night. Resident #12 stated the lever had been missing for a while, but it did not bother her. She stated no one came in the room but the nurse and she pulled the curtain for privacy. Resident #10 was not interviewable.<BR/>Interview on 04/12/2024 at 2:01 PM, the DON stated if there were feces on the ground that was not cleaned up the risk would be touching or stepping on it. The Administrator stated Resident #32 utilized the bathroom, and Resident #3 would not go to the bathroom. She stated housekeeping did rounds and rooms were cleaned daily. She stated the CNAs could disinfect and then housekeeping would follow up as well. When asked about 201's door handle, the Administrator stated one resident did not come out of the room and the door handle was fixed immediately upon notification. The Administrator stated she could not confirm how long the lever was missing. The Administrator stated the risk was not being able to open the door to leave in any state of emergency. The Administrator stated the residents in 201 had never mentioned any concerns wanting the door closed and Resident #12 always has the privacy curtain drawn.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles for two (100 and 200 halls Nurses Medication Carts) of the four medication carts and one medication room reviewed for labeling and storage.<BR/>1. The facility failed to ensure insulin vials were dated after they were opened. <BR/>2. The facility failed to ensure expired insulins and medications were removed from the cart and medication room.<BR/>The failure could place residents at risk of receiving medications that were ineffective due to not labeling with opening dates and removing the expired medications. <BR/>Findings included:<BR/>Observation on 03/08/23 at 7:40 AM of Hall 200 Medication Cart with LVN C revealed one Lantus insulin vial was opened, partially used, and not labeled with the open date.<BR/>Interview on 03/08/23 at 7:52 AM with LVN C, who was the Charge Nurse, revealed she knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed in the cart. She stated she knew she was supposed to check her cart to ensure insulins were labeled and dated, but she did not check that morning. She stated the risks of not putting the open date was that a nurse would not know when the insulins expired, and the insulins might not be effective leading to residents having high blood sugar readings. She stated she was trained on labeling and dating medications.<BR/>Observation on 03/08/23 at 8:18 AM of Hall 100 Medication Cart with RN B revealed 3 insulin vials, to include two Lantus, one Humalog and NovoLog flex pen, that were opened and partially used with no open date. There was also Novolin insulin vial and Novolog insulin vial was opened, partially used, with the open date of 02/06/23 and 02/07/23.<BR/>Interview on 03/08/23 at 08:22 AM with RN B, who was the Charge Nurse, revealed she knew short-acting insulin pens and vials were good for only 28 days. She stated she knew it was all nurses' responsibility to check the cart each shift for expired medication. She stated she was aware there were insulins with expired dates and others with no open date in her cart, but she forgot to discard them. She stated the risks of not checking the cart and removing expired medications was the insulin would not be effective, blood sugars would not be controlled, and the resident could get brain damage. She stated she had done training on medication labeling and storage and removal of expired medications.<BR/>Interview with the DON on 03/08/23 at 8:50 AM revealed it was her expectation that staff date the insulin pens/vials once they pulled them from the refrigerator. She stated if the staff were not putting the opening dates on the insulin pens and vials that required an open date it placed residents at risk of receiving expired medication, having reactions, and the medication being ineffective leading to high blood sugar levels. She stated her expectation was once a resident's order had been discontinued the staff should remove the medications/insulins from their carts. She stated it was the responsibility of all nurses to check their halls cart each shift. She stated it was the responsibility of the ADON to monitor the carts and the medication storage for the expired insulins/medications and labeling once a week, but she was new to that position. She stated she had done training with nurses on expired medications which included instructing them to remove the expired medications, placing expired medications in the destruction boxes, and labeling medications with an open date when they opened medications and insulins.<BR/>Interview with the ADON on 03/08/23 at 4:42 PM revealed it was her responsibility to monitor the carts for expired medications and auditing the carts to ensure the nurses were putting open dates when they opened medications. She stated she last checked the carts in February 2023, since she has been busy covering position for two ADONs. She stated she had done training with nurses on checking the carts for expired medications and labeling with open dates when they opened medications and insulins.<BR/>Observation on 03/09/23 at 8:49 AM of the Medication Room with ADON revealed 9 Heparin vials with expiry dates of 08/22 (August 2022).<BR/>Interview with the ADON on 03/09/23 at 8:58 AM revealed it was her responsibility to check and monitor the medication room for expired medications weekly and ensuring they are labeled. She stated she had checked the medication room [ROOM NUMBER]/08/23, and she thought she missed the expiry dates on those heparin vials. She stated they were supposed to be put in the destruction box. She stated the risk of keeping expired medication in medication room was that residents could be administered expired medication which could be ineffective.<BR/>Interview with the DON on 03/09/23 at 9:56 AM revealed it was the responsibility of the ADON to check the medication room weekly for labeling and expired medications. She stated failure to check could lead to nurses administering expired medications to residents that would be ineffective. <BR/>Review of the facility's Storage of Medicationpolicy, dated November 2020, reflected: <BR/> .4.insulin-date after opening.<BR/>Insulin vials and pens are good x28days after open<BR/>Levemir vial and pen is good for x42 days after open.<BR/>Medication room.<BR/>Log discontinued medications for destruction<BR/>Audit over the counter medications stores.<BR/>Review of the Lantus Prescribing Information from the manufacturer, revised December 2020, reflected in-use, opened Lantus can be kept for 28 days either refrigerated or at room temperature. The manufacturer's prescribing information reflected: .The LANTUS vials you are using should be thrown away after 28 days, even if it still has insulin left in it <BR/>Review of the Humalog Prescribing Information from the manufacturer, revised April 2020, reflected: .Do not use your Pen past the expiration date printed on the Label or for more than 28 days after you first start using the Pen Throw away the HUMALOG Pen you are using after 28 days, even if it still has insulin left in it.<BR/>Review of the Novolog Prescribing Information from the manufacturer, revised February 2023, reflected: <BR/> .PenFill cartridges in use:<BR/>&middot; <BR/> Store the PenFill cartridge you are currently using in the insulin delivery device at room <BR/>temperature below 86&deg;F (30&deg;C) for up to 28 days. Do not refrigerate.<BR/>&middot; <BR/> The NovoLog PenFill cartridge you are using should be thrown away after 28 days, even if <BR/>it still has insulin left in it

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food safety in the facility's only kitchen. <BR/>1. The facility failed to ensure food items were properly sealed, dated, and stored in the pantry.<BR/>2. The facility failed to ensure food items were properly sealed and stored in the freezer.<BR/>3. Dietary Aide H failed to perform proper sanitization of thermometer while checking the temperature of food items. <BR/>These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness.<BR/>Findings included:<BR/>An observation on 03/07/23 at 9:44 AM revealed the following:<BR/>In the pantry:<BR/>-2 bags of tea were directly on the shelf without a label, name, date, and storage bag.<BR/>-3 dented cans of jalapenos on the same shelf as the non-dented cans. The dented cans with an unknown black liquid on top of the lid. <BR/>Interview with Nutrition Director on 03/07/23 at 10:32 AM with the Dietary Director, revealed she had worked at the facility since 02/09/23. The Nutrition Director stated the two unlabeled bags were tea bags and should have been thrown in the trash when kitchen staff notice the item was not labeled and stored properly. She stated the kitchen staff that opens the original package is responsible for storing, naming, and dating the food items. The Nutrition Director stated she knew about the three dented cans of jalapenos. She stated she did not know what the black liquid was on top of the lid. She stated the three dented cans of jalapenos have been there since she was hired almost a month ago. The Nutrition Director stated the supplier had refused to take the dented cans because of the unknown liquid on top of the cans. The Dietary Director stated she should have discarded the three dented cans with unknown black liquid and labeled a designated area for dented cans. She stated the kitchen staff had not been trained on properly storing food items since she has been employed with the facility and was unable to provide proof of the previous training. The Nutrition Director stated the risk of not properly storing food items could lead to contaminating the food and the residents could get a food-borne illnesses.<BR/>In the freezer, the following individual food items below were open to air:<BR/>- 1 box of burger patties,<BR/>- corn,<BR/>- veggie blend, <BR/>- turkey sausages,<BR/>- okra,<BR/>- green beans, and <BR/>- pizza crust.<BR/>Interview with Nutrition Director on 03/07/23 at 10:38 AM with the Dietary Director, revealed she had worked at the facility for about a month. The Nutrition Director stated she could see the burger patties, corn, veggie blend, turkey sausages, okra, green beans, and pizza crust open to air. She stated the food could get frost bite and should have been thrown in the trash. She stated the cooks were responsible for storing food items in a sealed storage bag after use. She stated the kitchen staff had not been trained on properly storing food items since she has been employed with the facility and was unable to provide proof of the previous training. The Nutrition Director stated the risk of not properly storing food items could lead to food contamination, and the residents could get a food borne illnesses.<BR/>Observation on 03/08/23 at 4:28 PM of Dietary Aide H, revealed she did not take sanitizing wipes out of the sealed package to clean the temperature probe. Dietary Aide H punctured the middle of the dirty sanitizing package with the temperature probe and used the same temperature probe to check the temperatures of the food. The food that had come in direct contact with the temperature probe was served to residents. <BR/>Interview on 03/08/23 at 5:00 PM with Dietary Aide H revealed she knew the sanitizing packaging was not clean and was stored above the sink with the spices. She stated the practice used to clean the temperature probe could introduce bacteria to the temperature probe and food. She stated the bacteria that was introduced to the food could make the residents sick. Dietary Aide H stated the correct practice to clean a temperature probe was to open the sanitizing package, take the sanitizing wipe out of the package, clean the temperature probe, allow the temperature probe to dry, and check the temperature of the food. She stated she had done training on infection control with the facility staff but was unable to recall the last training. <BR/>Interview with the Dietary Director on 03/09/23 at 3:44 PM revealed she had known the temperature probe had not been sanitized correctly while observing Dietary Aide H. She stated she did not stop Dietary Aide H from cleaning the temperature probe incorrectly. Dietary Director unable to provide a policy on sanitizing the temperature probe. She stated her expectation was for Dietary Aide H to open the sanitizing package, take the sanitizing wipes out of the package, and clean the temperature probe. She stated she has been there for a month and the staff members had their first training with her on 03/09/2023 at 2:00 PM. <BR/>A record review of the facility's policy entitled Food Storage revealed in part the following:<BR/>Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, an appetizing .All foods should be covered, labeled, and dated.<BR/>A record review on 03/09/23 at 4:00 PM of Federal Drug Administration Food Code, dated 2017 section 3-305.11 Food Storage reflected: (A) Except as specified in (B) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 (500 hallway) of 6 hallways observed for physical environment. <BR/>The facility failed to keep the facility comfortable and free of lingering foul odors. <BR/>This failure placed all residents who reside in the facility at risk of diminished quality of life, discomfort, and psychosocial harm from being exposed to foul odors in areas of the facility inhabited and utilized by the residents.<BR/>Findings included:<BR/>An observation upon entry to the facility on [DATE] at 8:45 AM revealed a strong odor of urine and mildew. <BR/>An observation on 03/07/2023 at 11:05 AM revealed a strong odor of urine and mildew on the 500 hall, There were no obvious stains on the carpet; however, the mildew and urine smell was coming from the carpet. The odor was more persistent in room [ROOM NUMBER].<BR/>An observation on 03/08/23 at 10:00 AM revealed housekeeping cleaning the carpet down the middle of 500 hallway and in room [ROOM NUMBER]. <BR/>An observation on 03/09/23 at 9:00 AM revealed the odor of urine remained at the entrance of the facility and on the 500 hall. There was no longer an odor of mildew. <BR/>During an observation and interview on 03/07/23 at 11:25 AM with a resident, who resided in room [ROOM NUMBER]B, revealed the room was clean but had an odor of urine. The resident stated the smell was coming from down the hall this time; however, sometimes the smell would come from her bedside commode as the staff did not always empty it when needed. Observation of beside commode revealed it was emptied and did not have an odor at that time. The resident stated housekeeping cleaned her room daily but not thoroughly enough to eliminate the unpleasant odors. She stated the smell was sometimes unbearable and affected her breathing, making her feel that she needed to get some fresh air.<BR/>During an observation and interview on 03/07/23 at 11:28 AM with a resident, who resided in room [ROOM NUMBER]A, revealed the room was clean but had an odor of urine. The resident stated the room had smelled of urine consistently for months. She stated the smell was not present when she first moved to the facility. The resident stated she believed the smell was due to other residents down the hall being left in soiled briefs. She also stated that her roommate's bedside commode sometimes had urine left in it for long periods of time. She stated it was embarrassing because her family would complain about the smell when they visited. <BR/>In a confidential group interview on 03/08/23 at 1:30 PM, three of seven residents in attendance said the facility had a foul odor starting at the front entrance and they were unsure where it came from. The residents stated their personal rooms were clean and did not have an odor; however, they smelled the foul odor in common areas towards the front of the facility. They said housekeeping cleaned their rooms every day and cleaned the carpet at least once a week. <BR/>An interview on 03/09/23 at 2:30 PM with the Housekeeping Supervisor revealed the resident rooms were on a rotating schedule for deep cleanings, which included cleaning the carpet. He stated there were rooms that were focused on more due to resident behaviors, like room [ROOM NUMBER]. The Housekeeping Supervisor stated there was a resident in room [ROOM NUMBER] that poured urine on the floor so that room was on the schedule to be deep cleaned daily, including the carpet. He stated the room had an odor of urine but denied smelling mildew. When asked if there could be mildew under the carpet due to the constant cleaning of the floor, he stated it was possible but could not confirm it. The Housekeeping Supervisor denied that other parts of the facility smelled like urine and/or mildew. He stated it was his responsibility to ensure that all rooms were cleaned, disinfected and free from odors. <BR/>An interview on 03/09/23 at 4:00 PM with the Administrator revealed it was her expectation for the facility to be free of foul and unpleasant odors. She stated there was a resident in room [ROOM NUMBER] who exhibited a behavior of pouring urine out of his urinal onto the carpet; however, that room was one of the facility's focused rooms and the carpet was cleaned daily to prevent the room and hallway from smelling like urine. The Administrator stated the facility had a great floor technician who did well at keeping the carpet clean, The Administrator denied smelling any odors in the facility or receiving any complaints from residents or families. <BR/>Review of the facility's policy titled Homelike Environment, revised February 2021, revealed in part the following:<BR/>Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. <BR/>Policy Interpretation and Implementation:<BR/>1. <BR/>Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. <BR/>2. <BR/>The facility staff and management maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:<BR/>-clean, sanitary, and orderly environment. <BR/> .-pleasant, neutral scents<BR/>Review of the facility's policy titled Cleaning/Repairing Carpeting and Cloth Furnishings, revised December 2009, revealed in part the following:<BR/>Policy Statement: Carpeting and cloth furnishings shall be cleaned regularly and repaired promptly.<BR/>Policy Interpretation and Implementation:<BR/> .3. <BR/>Spills of blood or bodily fluids shall be cleaned promptly. Carpet tiles will be replaced if contaminated by blood or body fluids.

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 three (CNA A and CNA G) of four staff observed and four residents (Resident #73, Resident #61, Resident #43 and Resident #79) of 18 residents observed for infection control.<BR/>1. CNA A failed to perform hand hygiene and change gloves during incontinence care for Resident #43.<BR/>2. CNA G failed to wear proper PPE while performing incontinent care for Resident #73 and proceeded to provide incontinent care for Resident #61.<BR/>These failures placed all residents at risk of cross-contamination and infections leading to illness.<BR/>Findings included:<BR/>1. Observation on 03/08/23 at 11:30 AM revealed CNA A failed to perform hand hygiene before entering Resident #43's room and before donning the gloves to provide incontinence care for Resident #43. CNA A was observed positioning Resident #43 with help of RN B. Resident #43 was observed on two briefs. CNA A and RN B turned the resident to remove one brief and it was noticed the resident had bowel movement. CNA A was observed removing the soiled brief from Resident #43 and using the brief to wipe the bowel movement. The gloves got soiled with bowel movement. CNA A was observed leaving resident #43 area with the soiled brief. CNA A was observed opening the drawer for Resident#79 with soiled gloves and she removed a packet of wipes and place it on Resident #43 bed. CNA A was observed discarding the soiled brief and the soiled gloves. She failed to perform hand hygiene and she don new gloves. After providing the resident with incontinence care, CNA A removed gloves and she did not perform hand hygiene before touching the clean brief. They turned the resident and RN B cleansed Resident #43 on the right side. <BR/>Interview on 03/08/23 at 02:05 PM with CNA A, revealed she did not know who put two briefs on Resident #43. She did not want to respond to questions. She stated she changed her gloves.<BR/>Interview with RN B on 03/08/23 at 2:35 PM who was helping with the incontinence care revealed Resident #43 had two briefs. RN B revealed, when CNA A realized the resident had a bowel movement, she pulled the soiled brief and her hands got soiled with bowel movement. She stated her expectation was for CNA A to discard the soiled brief, change gloves and perform hand hygiene, but she went with soiled brief and with soiled gloves she opened Resident #79's drawer, and she removed a packet of wipes. RN B stated failure to change the gloves and perform hand hygiene would lead to infection and cross contamination. She stated CNA A was supposed to perform hand and change gloves when moving from dirty to clean and Resident #43 should wear one brief each time she gets incontinent care.<BR/>Interview with DON on 03/09/23 at 9:58 AM revealed her expectation was each resident should wear one brief at each time after incontinent care, and for staff to discard the soiled brief and doff the gloves and perform hand hygiene. She stated she expected the staff to have all the supplies ready before the procedure to prevent cross contamination and to change gloves between the procedure and wash hands. She stated she expected the staffs to start incontinent care form the front to the back and from the clean area to the dirty. She stated failure to follow the facility perineal care protocol can lead to cross contamination and infection. She stated she had done training on infection control, hand washing and peri care.<BR/>2. Observation on 03/09/23 at 4:22 AM, revealed CNA G was coming from behind Resident #73's privacy curtains while holding a clear bag with Resident #73's soiled brief and linen in gloved hands, but she was not wearing a gown. She was observed putting soiled briefs and linen in the designated areas in the restroom. CNA G performed hand hygiene, applied gloves, allowed her scrub top to touch the resident as she was assisted with incontinent care on Resident #61.<BR/>Interview on 03/09/23 at 4:28 AM, revealed CNA G stated she had done incontinent care on Resident #73 without wearing a gown. She stated she did not see the red precaution sign that was observed on Resident #73, and she did not know why Resident #73 was on contact precaution. She stated PPE such as gown and gloves was required before entering the room and taken off before leaving the room. CNA G stated wearing correct PPE will prevent residents from getting sick and stop the spread of infection to other residents. She stated her last training on infection control was last month. <BR/>Interview on 03/09/23 at 6:45 AM with the DON, revealed Resident #73 tested positive for CRE on 05/17/22. She stated CRE was a contagious infection that will remain in the body forever, because antibiotics cannot cure the infection. She stated the resident could test negative for CRE and still have CRE dormant in the body until the resident start showing signs and symptoms of CRE. The DON stated Resident #73 was on enhanced precautions, meaning Resident #73 could leave her room, congregate with other residents, be in a room by herself, or have a roommate with CRE. She stated enhanced precaution was treated the same as contact precaution. The DON stated staff was required to use a gown and gloves when providing incontinence care for Resident #73, because CRE was transmitted through urine and feces. The DON stated her expectation was for staff to wear proper PPE such as gloves and gown when providing incontinence care to Resident #73. She stated wearing proper PPE with Resident #73 would prevent the spread of CRE from one resident to another. She stated all staff members has had recent training on infection control. <BR/>Review of information retrieved from the CDC at https://www.cdc.gov/hai/organisms/cre/cre-facilities.html reflected the following regarding CRE:<BR/>Healthcare-Associated Infections<BR/>Healthcare Facilities: Information About CRE<BR/>Carbapenem-resistant Enterobacterales (CRE) are a serious threat to public health .<BR/>Healthcare Facilities Should:<BR/> .Ensure precautions are implemented for CRE colonized or infected patients<BR/> .Have and enforce a policy for using gown and gloves when caring for patients with CRE.<BR/>Have and enforce policies for healthcare personnel hand hygiene before and after contact with patient or their environment, and increase emphasis on hand hygiene on a unit caring for a patient or resident with CRE.<BR/>Healthcare personnel should follow standard hand hygiene practices, which include use of alcohol-based hand sanitizer or, if hands are visibly soiled, washing with soap and water <BR/>Review of the facility's current policy for Perineal Care Protocol, dated February 2022, reflected:<BR/> .1. Assemble supplies on bedside <BR/>. Wash hands apply gloves <BR/>. Assist patient to supine position and remove soiled brief. If needed clean soiled areas first by wiping off fecal material with wipes.<BR/>. Remove gloves, sanitize hands and apply new gloves.<BR/>. Using clean wipe wash, beginning from front toward rectum front to back.<BR/>. Wash/sanitize hands. Apply clean gloves.<BR/>. position/fasten clean brief under patient and adjust .<BR/>Review of the facility's Infection Control policy dated March 2019, reflected: Follow all manufacturer's directions for use of surface disinfectants and apply the product for the correct contact time.<BR/>Review of the facility's Infection Control policy, dated March 2019, reflected: <BR/> .Gloves for touching bloody fluids, excretions . Gowns during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids secretions and excretions is anticipated.<BR/>Review of the facility's Contact Precautions instructions, dated 03/09/20, reflected: Contact precautions everyone must clean hands .put on gloves before room entry .and put on gown before room entry .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles for two (100 and 200 halls Nurses Medication Carts) of the four medication carts and one medication room reviewed for labeling and storage.<BR/>1. The facility failed to ensure insulin vials were dated after they were opened. <BR/>2. The facility failed to ensure expired insulins and medications were removed from the cart and medication room.<BR/>The failure could place residents at risk of receiving medications that were ineffective due to not labeling with opening dates and removing the expired medications. <BR/>Findings included:<BR/>Observation on 03/08/23 at 7:40 AM of Hall 200 Medication Cart with LVN C revealed one Lantus insulin vial was opened, partially used, and not labeled with the open date.<BR/>Interview on 03/08/23 at 7:52 AM with LVN C, who was the Charge Nurse, revealed she knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed in the cart. She stated she knew she was supposed to check her cart to ensure insulins were labeled and dated, but she did not check that morning. She stated the risks of not putting the open date was that a nurse would not know when the insulins expired, and the insulins might not be effective leading to residents having high blood sugar readings. She stated she was trained on labeling and dating medications.<BR/>Observation on 03/08/23 at 8:18 AM of Hall 100 Medication Cart with RN B revealed 3 insulin vials, to include two Lantus, one Humalog and NovoLog flex pen, that were opened and partially used with no open date. There was also Novolin insulin vial and Novolog insulin vial was opened, partially used, with the open date of 02/06/23 and 02/07/23.<BR/>Interview on 03/08/23 at 08:22 AM with RN B, who was the Charge Nurse, revealed she knew short-acting insulin pens and vials were good for only 28 days. She stated she knew it was all nurses' responsibility to check the cart each shift for expired medication. She stated she was aware there were insulins with expired dates and others with no open date in her cart, but she forgot to discard them. She stated the risks of not checking the cart and removing expired medications was the insulin would not be effective, blood sugars would not be controlled, and the resident could get brain damage. She stated she had done training on medication labeling and storage and removal of expired medications.<BR/>Interview with the DON on 03/08/23 at 8:50 AM revealed it was her expectation that staff date the insulin pens/vials once they pulled them from the refrigerator. She stated if the staff were not putting the opening dates on the insulin pens and vials that required an open date it placed residents at risk of receiving expired medication, having reactions, and the medication being ineffective leading to high blood sugar levels. She stated her expectation was once a resident's order had been discontinued the staff should remove the medications/insulins from their carts. She stated it was the responsibility of all nurses to check their halls cart each shift. She stated it was the responsibility of the ADON to monitor the carts and the medication storage for the expired insulins/medications and labeling once a week, but she was new to that position. She stated she had done training with nurses on expired medications which included instructing them to remove the expired medications, placing expired medications in the destruction boxes, and labeling medications with an open date when they opened medications and insulins.<BR/>Interview with the ADON on 03/08/23 at 4:42 PM revealed it was her responsibility to monitor the carts for expired medications and auditing the carts to ensure the nurses were putting open dates when they opened medications. She stated she last checked the carts in February 2023, since she has been busy covering position for two ADONs. She stated she had done training with nurses on checking the carts for expired medications and labeling with open dates when they opened medications and insulins.<BR/>Observation on 03/09/23 at 8:49 AM of the Medication Room with ADON revealed 9 Heparin vials with expiry dates of 08/22 (August 2022).<BR/>Interview with the ADON on 03/09/23 at 8:58 AM revealed it was her responsibility to check and monitor the medication room for expired medications weekly and ensuring they are labeled. She stated she had checked the medication room [ROOM NUMBER]/08/23, and she thought she missed the expiry dates on those heparin vials. She stated they were supposed to be put in the destruction box. She stated the risk of keeping expired medication in medication room was that residents could be administered expired medication which could be ineffective.<BR/>Interview with the DON on 03/09/23 at 9:56 AM revealed it was the responsibility of the ADON to check the medication room weekly for labeling and expired medications. She stated failure to check could lead to nurses administering expired medications to residents that would be ineffective. <BR/>Review of the facility's Storage of Medicationpolicy, dated November 2020, reflected: <BR/> .4.insulin-date after opening.<BR/>Insulin vials and pens are good x28days after open<BR/>Levemir vial and pen is good for x42 days after open.<BR/>Medication room.<BR/>Log discontinued medications for destruction<BR/>Audit over the counter medications stores.<BR/>Review of the Lantus Prescribing Information from the manufacturer, revised December 2020, reflected in-use, opened Lantus can be kept for 28 days either refrigerated or at room temperature. The manufacturer's prescribing information reflected: .The LANTUS vials you are using should be thrown away after 28 days, even if it still has insulin left in it <BR/>Review of the Humalog Prescribing Information from the manufacturer, revised April 2020, reflected: .Do not use your Pen past the expiration date printed on the Label or for more than 28 days after you first start using the Pen Throw away the HUMALOG Pen you are using after 28 days, even if it still has insulin left in it.<BR/>Review of the Novolog Prescribing Information from the manufacturer, revised February 2023, reflected: <BR/> .PenFill cartridges in use:<BR/>&middot; <BR/> Store the PenFill cartridge you are currently using in the insulin delivery device at room <BR/>temperature below 86&deg;F (30&deg;C) for up to 28 days. Do not refrigerate.<BR/>&middot; <BR/> The NovoLog PenFill cartridge you are using should be thrown away after 28 days, even if <BR/>it still has insulin left in it

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #80) reviewed for regular ground diet needs.<BR/>The facility failed to provide Resident #80 with his regular ground foods (mechanically altered diet that was prescribed for individuals who have difficulty chewing or swallowing food) as designated on his meal ticket on 05/14/25. <BR/>This deficient practice could place residents at risk for poor food intake, weight loss, and not having their nutritional needs met.<BR/>The findings included:<BR/>Record review of Resident #80's face sheet dated 05/15/25 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. <BR/>Record review of Resident #80's quarterly MDS Assessment, dated 04/15/25, reflected the resident had an active diagnosis of protein-calorie malnutrition, essential hypertension, depression and bipolar disorder. Resident #80's BIMS score of 03 indicating severe cognitive impairment.<BR/>Record review of Resident #80's Care plan reflected Weight gain aeb 25lbs/90days. (13.2%)<BR/>Regular Ground diet. 5/12/25: Weight Gain of 19.80lbs/180days (10.1%). Goal: The resident will not develop complications from weight gain such as skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. Intervention: Resident encouraged to eat meals in the DR if tolerated.<BR/>Interview on 05/13/25 at 03:24 PM, Resident #80 stated he was doing well. Resident #80 stated the only concern he had was that his meals had been a liquid/pureed texture instead of his food being cut/chopped. Resident #80 stated he did not like being served pureed foods. He stated when he gets the liquid texture he does not want to eat it. <BR/>Observation on 05/14/25 at 12:20 PM, Resident #80 was provided with pureed consistency meal. Lunch meal consisted of pureed texture Salisbury steak, mashed potatoes and carrots. Resident #80's meal ticket indicated Regular Ground. Observed Central Supply feeding Resident #80's pureed lunch. <BR/>Observation and interview on 05/14/25 at 12:28 PM, RD reviewed Resident #80's meal ticket, observed resident lunch and revealed Resident #80's was provided with the wrong food texture. RD stated resident should be on regular ground and not pureed. Resident #80 was provided with the correct meal texture. <BR/>Interview on 05/14/25 at 12:38 PM with Director of Rehab revealed Resident #80 was on regular ground texture. <BR/>Interview on 05/14/25 at 12:42 PM with Central Supply staff revealed each resident should receive what was on the meal ticket. She stated she glanced at the meal ticket to verify the name but did not ensure the food texture was correct. She stated since the nurse had checked it prior to giving her the lunch tray, she assumed the food was correct. <BR/>Interview on 05/14/25 at 12:47 PM, Resident #80 stated it had been a while since he was provided with the correct food consistency. Resident #80 stated he had been provided with pureed food and he did not like that. <BR/>Interview on 05/14/25 at 1:40 PM, Dietary Manager revealed his expectations were for all staff to follow meal tickets. He stated platting starts with the [NAME] and ends with the nurse verifying the residents receiving the correct meal. Dietary Manager stated today (05/14/25) the DON was checking meal tickets, and it was her responsibility to verify residents received the correct meal tray. He stated Resident #80's lunch meal should had been corrected before it was serviced to him. Dietary Manager stated there was no potential risk to the resident; however, it was a downgrade of texture. <BR/>Interview on 05/14/25 at 1:48 PM, RD revealed her expectations were for all staff to follow exactly what was on the meal ticket. She stated they have a nurse who double checks the meal trays to ensure the trays are correct. RD stated today (05/14/25) the DON was checking the meal trays and meal tickets. She stated there was an error on Resident #80 lunch meal, he received pureed texture instead of regular ground. RD stated there was no potential risk of chocking since it was pureed; however, it was a downgrade of texture.<BR/>Interview on 05/15/25 at 2:57 PM, the DON stated she was responsible for verifying meal tickets. She stated she observed Resident #80's tray and she observed ground meat. She stated when reviewed the meal tickets she ensures the food being plated matches the meal ticket. <BR/>Record review of facility Therapeutic Diets policy, revised 10/2017, reflected the following: <BR/>1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will be determined whether the resident is prescribed a therapeutic diet.

**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 rights set forth, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 (Resident #1) of 6 residents reviewed for care plans. <BR/>The facility failed to ensure Resident #1's ADL care plan was completed to reveal what level a assistance he needed for dressing, toileting, bed mobility and transfers. <BR/>This failure could place residents at risk of their needs not being met if staff did not know how to care for the residents properly, which could result in falls, pain, wounds and decreased psychosocial well-being and physical functioning.<BR/>Findings included:<BR/>Record review of Resident #1's admission MDS Assessment completed on 04/02/25, by MDS M revealed Resident #1 was an [AGE] year old male who admitted to [This Facility] on 03/25/25 with a BIMS score of 09 (Moderate Cognitive Impairment). He was dependent (2 person helpers did all assist) with toileting, showering/bathing, lower body dressing and putting on footwear. And partial to moderate assist with bed mobility and transfers. He was occasionally incontinent with bladder and always incontinent with bowel. His active diagnoses were medically complex conditions and he was diagnosed with atrial fibrillation, HTN, BPH, diabetes, hyperlipidemia, metabolic encephalopathy, acute pancreatis without infection, diverticulitis of small intestines without perforation or abscess. He had a history of falling within the past month. And based on Braden and clinical assessment he was at risk for pressure injuries and had 1 or more pressure injuries, <BR/>Record review of Resident #1's Comprehensive Care Plan dated 04/08/25 for bladder incontinence related to confusion and impaired mobility, 03/31/25 Pressure Ulcer and enhanced barrier precautions implemented related to pressure ulcer. And 04/06/25 risk for falls . <BR/>Record review of Resident #1's Incident Report dated 04/06/25 at 2:15 am revealed, Resident was found on the floor next to his bed by CNA. No apparent injuries. Resident Unable to give Description, Vital signs taken, complete body assessment completed and neuro-checks initiated. MD/NP Called received order for XRs of bilateral lower extremities and lumbar spine. No injuries noted at the time of incident, bedridden, oriented to person, pain aid 4 (moaning/groaning, facial grimacing, distressed), confused, incontinent, gait imbalance, impaired memory. Responsible party, DON and DR/NP notified.<BR/>Interview on 04/11/25 at 12:14 pm, MDS L stated Resident #1 used to visit a resident here, now he was a resident. She stated Resident #1 was maybe a 1 person assist for transfers and 2 person assist for his other ADL's she believed. She stated she needed to get her computer. After she returned she stated Resident #1's admission MDS Assessment showed he was substantial max assistance with ADL care and 1 to 2 staff with transfers. She stated Resident #1 should be care planned stated he was incontinent and not able to walk or weight bear. She stated Resident #1 had an ADL care plan and as she looked in the EMR she said she did not see one. She stated if Resident #1 required help he should have a care plan. She stated she was going to add the ADL care plan now and said it had not been added and she was not sure why. She stated multiple staff could add care plans and she captured the basic information and it was a team effort on doing the care plans. She stated she was ultimately responsible for ensuring the care plans were accurate and added the ADL Care plan (based on the MDS Assessment) and Plan of Care (based on the care plan the CNA's used) should have the same information. She stated the CNA's looked at the POC to know how to care for the residents. She stated they normally had two MDS Coordinators but not any longer. She stated it was just her now and there were a lot of residents she had to keep up with. She stated if the care plans were not accurate it could cause safety issues with the residents. She stated it would not allow them to care for the residents properly and to have interventions in place and proper care could be delayed. She stated she was off from work the other day and was not sure who filled in for her during that time. <BR/>Interview on 04/11/25 at 1:24 pm, Administrator she stated she was not aware of any issues with Resident #1's ADL care plan being missing. She stated she planned to talk to the MDS Coordinator and nurse management because they should be working together to update the care plans. She stated the therapy department evaluated the residents to ensure they were all on the same page. She stated the IDT were supposed to create the acute care plans and the nurse managers were responsible for ensuring they were done . She stated the care plans should be the same as the MDS Assessments. She stated the care plan should tell the staff what the residents needs were. She stated if the ADL care plans were not accurate, the staff could potentially not meet the resident's needs.<BR/>Interview on 04/11/25 at 2:39 pm, the DOR stated Resident #1 was getting skilled services for all three disciplines PT, OT, and ST since 03/26/25. She stated he was at baseline as far as his progress because he was not able to sustain his attention span. She stated they were working on his orientation today and time and motivating him to do therapy. She stated Resident #1's ADL was maximal assist for 2 person assist with toileting and bathing. She stated Resident #1 needed minimum assist for upper body dressing and moderate assist for lower body dressing and his mobility was inconsistent. She stated Resident #1 had good days and bad days with the same tasks depending on the level of his participation. She stated Resident #1 had a fall recently and was evaluated and to continue to educate fall risk on safety awareness. She stated there was no change with therapy level after he fell and was not able to weight bear or walk. She stated he was not able to toilet by himself due to his cognition and physical status.<BR/>Record review of the Facility's Care Plan policy revised September 2010 revealed, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy interpretation and implementation: 1. Our facility's Care Planning/Interdisciplinary team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. 3. Each resident's comprehensive care plan is designed to incorporate identified problem areas .assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care planning/Interdisciplinary Team is responsible for review and updating of care plans: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met

**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 rights set forth, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 (Resident #1) of 6 residents reviewed for care plans. <BR/>The facility failed to ensure Resident #1's ADL care plan was completed to reveal what level a assistance he needed for dressing, toileting, bed mobility and transfers. <BR/>This failure could place residents at risk of their needs not being met if staff did not know how to care for the residents properly, which could result in falls, pain, wounds and decreased psychosocial well-being and physical functioning.<BR/>Findings included:<BR/>Record review of Resident #1's admission MDS Assessment completed on 04/02/25, by MDS M revealed Resident #1 was an [AGE] year old male who admitted to [This Facility] on 03/25/25 with a BIMS score of 09 (Moderate Cognitive Impairment). He was dependent (2 person helpers did all assist) with toileting, showering/bathing, lower body dressing and putting on footwear. And partial to moderate assist with bed mobility and transfers. He was occasionally incontinent with bladder and always incontinent with bowel. His active diagnoses were medically complex conditions and he was diagnosed with atrial fibrillation, HTN, BPH, diabetes, hyperlipidemia, metabolic encephalopathy, acute pancreatis without infection, diverticulitis of small intestines without perforation or abscess. He had a history of falling within the past month. And based on Braden and clinical assessment he was at risk for pressure injuries and had 1 or more pressure injuries, <BR/>Record review of Resident #1's Comprehensive Care Plan dated 04/08/25 for bladder incontinence related to confusion and impaired mobility, 03/31/25 Pressure Ulcer and enhanced barrier precautions implemented related to pressure ulcer. And 04/06/25 risk for falls . <BR/>Record review of Resident #1's Incident Report dated 04/06/25 at 2:15 am revealed, Resident was found on the floor next to his bed by CNA. No apparent injuries. Resident Unable to give Description, Vital signs taken, complete body assessment completed and neuro-checks initiated. MD/NP Called received order for XRs of bilateral lower extremities and lumbar spine. No injuries noted at the time of incident, bedridden, oriented to person, pain aid 4 (moaning/groaning, facial grimacing, distressed), confused, incontinent, gait imbalance, impaired memory. Responsible party, DON and DR/NP notified.<BR/>Interview on 04/11/25 at 12:14 pm, MDS L stated Resident #1 used to visit a resident here, now he was a resident. She stated Resident #1 was maybe a 1 person assist for transfers and 2 person assist for his other ADL's she believed. She stated she needed to get her computer. After she returned she stated Resident #1's admission MDS Assessment showed he was substantial max assistance with ADL care and 1 to 2 staff with transfers. She stated Resident #1 should be care planned stated he was incontinent and not able to walk or weight bear. She stated Resident #1 had an ADL care plan and as she looked in the EMR she said she did not see one. She stated if Resident #1 required help he should have a care plan. She stated she was going to add the ADL care plan now and said it had not been added and she was not sure why. She stated multiple staff could add care plans and she captured the basic information and it was a team effort on doing the care plans. She stated she was ultimately responsible for ensuring the care plans were accurate and added the ADL Care plan (based on the MDS Assessment) and Plan of Care (based on the care plan the CNA's used) should have the same information. She stated the CNA's looked at the POC to know how to care for the residents. She stated they normally had two MDS Coordinators but not any longer. She stated it was just her now and there were a lot of residents she had to keep up with. She stated if the care plans were not accurate it could cause safety issues with the residents. She stated it would not allow them to care for the residents properly and to have interventions in place and proper care could be delayed. She stated she was off from work the other day and was not sure who filled in for her during that time. <BR/>Interview on 04/11/25 at 1:24 pm, Administrator she stated she was not aware of any issues with Resident #1's ADL care plan being missing. She stated she planned to talk to the MDS Coordinator and nurse management because they should be working together to update the care plans. She stated the therapy department evaluated the residents to ensure they were all on the same page. She stated the IDT were supposed to create the acute care plans and the nurse managers were responsible for ensuring they were done . She stated the care plans should be the same as the MDS Assessments. She stated the care plan should tell the staff what the residents needs were. She stated if the ADL care plans were not accurate, the staff could potentially not meet the resident's needs.<BR/>Interview on 04/11/25 at 2:39 pm, the DOR stated Resident #1 was getting skilled services for all three disciplines PT, OT, and ST since 03/26/25. She stated he was at baseline as far as his progress because he was not able to sustain his attention span. She stated they were working on his orientation today and time and motivating him to do therapy. She stated Resident #1's ADL was maximal assist for 2 person assist with toileting and bathing. She stated Resident #1 needed minimum assist for upper body dressing and moderate assist for lower body dressing and his mobility was inconsistent. She stated Resident #1 had good days and bad days with the same tasks depending on the level of his participation. She stated Resident #1 had a fall recently and was evaluated and to continue to educate fall risk on safety awareness. She stated there was no change with therapy level after he fell and was not able to weight bear or walk. She stated he was not able to toilet by himself due to his cognition and physical status.<BR/>Record review of the Facility's Care Plan policy revised September 2010 revealed, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy interpretation and implementation: 1. Our facility's Care Planning/Interdisciplinary team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. 3. Each resident's comprehensive care plan is designed to incorporate identified problem areas .assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care planning/Interdisciplinary Team is responsible for review and updating of care plans: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met