WILLOW RIDGE WELLNESS & REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for elopement. <BR/>The facility failed to ensure Resident #1, who resided in the secure unit, was provided with adequate supervision to prevent elopement and as a result the resident sustained a laceration to his forehead after falling from his wheelchair and was sent to the hospital for treatment. <BR/>An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. <BR/>This failure could place residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Review of Resident #1's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included aphasia, non-Alzheimer's dementia, cerebrovascular accident, and hemiparesis. The MDS reflected the resident's cognition was severely impaired with a BIMS of 0, the resident sometimes understood others, and he sometimes was understood by others with clear speech. <BR/>Review of Resident #1's care plan initiated on 11/09/21 and revised on 03/31/23 revealed Resident #1 was at risk for self-harm and injury related to wandering and attempted elopement related to cognitive impairment and lack of safety awareness. The care plan goals for Resident #1 included wandering within the locked unit and maintaining his safety through the next review date.<BR/>Review of Resident #1's Wandering Risk Scale assessment dated [DATE] revealed he was a high risk to wander. <BR/>Review of Resident #1's Memory Care Unit Continued Stay Review dated 01/23/23 revealed the following:<BR/>Resident habitually wanders or would wander out of the building, and would not be able to find way back Resident continues to meet criteria for placement on the Memory Care Unit <BR/>Review of the facility's Provider Investigation Report dated 02/24/23 reflected the following:<BR/>Resident was last observed by staff member at approximately 2:30-2:40pm per staff interview and was returned to the facility at approximately 2:53pm. Resident was noted to be in his wheelchair sitting next to the exit door just prior to his exit. Nurse was at station charting and did not observe resident exit the facility. He was informed by an employee on her way home that resident was outside the facility in the far end of the parking lot at the entrance of the neighboring property. Employee brought the resident back to the facility and informed the charge nurse <BR/> .He was noted to have a laceration approximately 2cm and was treated at [the hospital ER] with dissolvable stitches <BR/>Review of Resident #1's progress notes dated 02/18/23 documented by LVN A revealed the following:<BR/>Resident went out of the building, found by a staff member and brought back to the unit with lacerations to the left side of the head. This nurse cleaned the lacerations with wound cleanser, stopped the bleeding and applied dry dressing Called 911 an sent resident to [hospital] Resident returned to unit from the ER at 10:11 pm. Stitches and derma bond put on lacerations <BR/>Observation on 04/20/23 at 10:45 AM of the secure unit revealed it consisted of one long hall with a dining room/activity room and a nurses' station coming off the hall. The unit had a main entrance, and exit door to the back of the facility, and a third exit to the patio, that also had an exit door to the outside of the facility. All three doors were equipped with a keypad which required a code to exit. <BR/>Observation and interview on 04/20/23 at 10:51 AM revealed Resident #1 was in the hallway sitting in a wheelchair at the end of the secure unit hall about 10 feet from the back exit door. The resident was primarily Spanish speaking and was asked if he had left the facility. He said he left about one to three months prior, but he was found and brought back to the facility by a woman after he fell from his wheelchair and was bleeding from his face. Resident #1 said he had put in the code to the door that led into the patio and entered the code again to the outside gate. Resident #1 wheeled himself on the sidewalk and did not notice there was loose gravel and fell over on the floor in his wheelchair. Resident #1 further stated there was a man that was going to give him a ride over there to pay traffic tickets to renew his driver's license so he could get back to work. The resident said after his fall he was taken to the hospital. Further observations of the secure unit revealed many of the resident were ambulatory or were able to self-propel in their wheelchairs. There were some residents that were wandering in the dining room, but none were observed to be exit-seeking or pushing on any of the doors. <BR/>Review of Resident #1's hospital records dated 02/18/23 reflected the following:<BR/>Reason for visit: Fall<BR/>Diagnosis: facial laceration<BR/>Further review of Resident #1's hospital records revealed there were no other details about of the extent of his lacerations or treatments. <BR/>Interview on 04/20/23 at 2:13 PM with the PTA revealed she was leaving the facility (02/18/23) after work around 2:30 PM and was driving down the road in front of the facility when she saw a man who appeared to be standing from his wheelchair at the bottom of one of the facility's entrances, near an adjacent business. The resident looked familiar, so she turned around and realized it was Resident #1 who was already sitting in his wheelchair bleeding from his face from a big face gash. The PTA asked Resident #1 what happened but because he was not able to speak English well, he just kept pointing to the corner of the street. She then pushed the resident back to the facility, and the staff told her they did not know how the resident got out of the secure unit, but they were going to call 911 and have him sent out for treatment. <BR/>Interview on 04/20/23 at 1:27 PM with LVN A revealed he was in the dining room with other residents in the secure unit when the PTA brought Resident #1 back, bleeding from his face. LVN A did not realize the resident had left the unit, and he did not know how the resident had gotten out. LVN A asked the resident about the incident, and Resident #1 would only smile. He said they thought Resident #1 had exited through the back exit door because at that time of the elopement, the back door was being used as an exit only door due to COVID-19 precautions. LVN A also thought someone might have gone out the back door and not verified the door had securely closed when the resident exited the facility. Prior to the COVID-19 outbreak, the back door was never used by staff per LVN A. He said after Resident #1's elopement, all the codes to the unit's doors were changed, there was a door alarm installed on the back exit door, and all residents were to be monitored more closely if they were by an exit door. <BR/>Interview on 04/20/23 at 3:28 PM with CNA C revealed she was working the day Resident #1 eloped from the secure unit. She said she was caring for another resident but remembered seeing Resident #1 not long before he was brought back by the PTA. She said normally Resident #1 sat by the back exit door or the dining room. CNA C said she saw LVN trying to clean Resident #1 face because he was bleeding before he was sent to the hospital. The CNA was not aware how the resident got out of the unit, but she was told Resident #1 had left out the back exit door. She said the back door was being used as COVID-19 exit only door during one of their outbreaks. CNA C further stated all the codes had been changed to the exit doors, an alarm was installed on the back exit door, they were educated to monitor the residents more closely, especially Resident #1. <BR/>Interview on 04/20/23 at 1:27 PM with LVN B revealed Resident #1 had a history of going to the exit doors; however, once the resident realized a door would not open, the resident would leave the door alone. LVN B stated Resident #1 had never eloped in the past that he was aware of. LVN B further stated after Resident #1 eloped, all codes to the doors were changed, an alarm was added to the back exit door and all residents were to be monitored more closely, especially Resident #1. <BR/>Interview on 04/20/23 at 2:50 PM with the ADON revealed she was told Resident #1 had eloped from the secure unit and fallen off a step outside and sustained a laceration. She was unaware of the resident having an elopement history but to prevent further incidents, all codes to the doors were changed, and alarm was installed on the back exit door to sound any time it was opened, and increased resident checks and activities to keep them busy.<BR/>Interview on 04/20/23 at 1:01 PM with the Administrator revealed once she was told about Resident #1's elopement, she went and spoke with the resident as she was Spanish speaking also. The resident told the Administrator he had gotten out of the unit by pushing on the door but did not elaborate after that. The Administrator said the back exit door had a 15 second release lock and they thought he held the handle until the lock released, allowing him to exit the facility. She also said staff told her Resident #1 often sat by the back exit door, so they assumed that was where he had gotten out of. After the elopement, all the codes to the unit doors were changed, an alarm to the back exit door was added to sound anytime it was opened, and all staff were in-serviced to closely monitor the residents especially Resident #1. <BR/>Review of the facility's policy titled Wandering and Elopements revised March 2019 reflected the following:<BR/>The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environments for residents.<BR/>An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. <BR/>The facility took the following actions to correct the non-compliance prior to the investigation:<BR/>Review of in-service records dated 02/18/23 through 02/23/23 revealed all nursing staff were educated on missing persons, wandering, elopement, abuse/neglect, and resident rights. Those in-services consisted of ensuring doors are closed and locked, new alarm on back door, and closely monitoring the residents especially residents with increased wandering. All staff working the secure unit were given the new codes to the exit doors. <BR/>Interviews were conducted with six CNAs, four LVNs, one PTA, and an ADON on 04/21/23 from 9:00 AM to 4:00 PM from various shifts. The staff were able to identify and monitor wandering/exit seeking residents, new codes to the exit doors, and made aware of the new back door alarm to sound when opened. <BR/>Observation on 04/20/23 at 9:30 AM revealed the back exit door had an alarm installed to sound if and when it was opened, and new door codes were verified to make sure they were not the same ones at that time of the elopement on 02/18/23. <BR/>Interview on 04/21/23 at 10:00 AM with Resident #1 revealed he did not recall the codes to the doors because the number he gave did not match the current codes to any of the doors. <BR/>The records revealed a plan of action had been initiated to include supervision prior to entry on 04/18/23. Review of the following reflected the facility was in compliance on 02/23/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviewsm the facility failed to maintain medical records on each resident that are accurate for 1 of 5 residents (Resident #1) reviewed for resident records. <BR/>CNA A failed to accurately document in Resident #1's EHR on 06/06/25 when she documented her care using CNA B's log-in credentials.<BR/>This failure could lead to incorrect documentation of resident care. <BR/>Findings included:<BR/>Record review of Resident #1's undated admission Record reflected the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's, dementia, and high blood pressure. <BR/>Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 3 indicating he had severe cognitive impairment. His Functional Status assessment indicated he was dependent on staff for all of his ADLs. <BR/>Record review of Resident #1's care plan, dated 05/30/25, reflected he had an ADL self-care deficit, and impaired cognition being non-verbal. <BR/>Record review of Resident #1's Tasks in her EHR reflected on 06/06/25 CNA B had documented all of the resident's cares as being completed.<BR/>In an interview on 06/08/25 at 2:20 PM, CNA B stated she had not worked with Resident #1 on 06/06/25 because she had been assigned to another unit. She stated CNA A had been assigned to work with Resident #1 on that date. <BR/>In a phone interview on 06/08/25 at 2:47 PM, CNA A stated she had provided Resident #1 with care on 06/06/25. She stated she had documented under CNA B's log-in credentials. She stated her log-in kicked her out all the time, so she used CNA B's log-in. She stated CNA-B was logged into the EHR when she tried to log-in, so she just used CNA B's log-in. She stated she had told people about the issue but nothing had been done. She stated she knew she was not supposed to use someone else's log-in. <BR/>In a follow up interview on 06/08/25 at 3:06 PM, CNA B stated she must not have signed off the computer at the end of her shift, which was how CNA A was able to chart under her name. She stated she knew not to share her log-in credentials with anyone. She stated the DON was responsible for re-setting credentials when needed. <BR/>In an interview on 06/09/25 at 3:08 PM, CNA C stated it was not allowed to use someone else's log-in to chart and it was also not allowed to share your log-in with anyone else. <BR/>In an interview on 06/09/25 at 3:10 PM, RN D stated it was not allowed to use someone else's log-in to chart, or to share your log-in with anyone else. She stated the risk to the resident was another discipline, such as a CNA, charting as a nurse or incorrect information being documented. <BR/>In an interview on 06/09/25 at 3:13 PM, RN E stated they were not allowed to document using someone else's log-in. She stated there was a risk of incorrect documentation being done and difficulty identifying who had documented something. <BR/>In an interview on 06/09/25 at 3:18 PM, RN F stated staff were not allowed to share log-ins or document using someone else's log-in. She stated the risk was someone documenting as a nurse when they were not. <BR/>In an interview on 06/09/25 at 3:20 PM, the ADON stated it was absolutely not allowed to share log-ins or document as someone other than oneself. She stated it would be considered false documentation and there were multiple risks with that. <BR/>In an interview on 06/09/25 at 3:35 PM, the DON stated it was not allowed to share log-ins with anyone else. She stated if a staff member had an issue with their log-in, she could reset it in a few minutes. She stated anyone documenting using another person's log-in was creating a false document. <BR/>In an interview on 06/09/25 at 3:30 PM, the Administrator stated she did not have a policy addressing not using other staff member's log-in credentials. She stated it was common sense not to do that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents were free from abuse for one of five residents (Resident #2) reviewed for abuse, neglect, and exploitation. <BR/>The facility failed to ensure Resident #2 was free from staff to resident abuse when CMA A slapped a glass of water out of Resident #2's hand on 4-23-2025, causing her to cry experiencing psychosocial harm. <BR/>This noncompliance was identified as a PNC. The noncompliance began on 4-23-2024 and ended on 4-30-2025. <BR/>This failure could place residents at risk for decreased quality of life, decreased self-esteem, and mental anguish. <BR/>Findings Included:<BR/>Record review of Resident #2's Face Sheet dated 5-8-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of Dementia with other behavioral disturbance (a decline in mental ability severe enough to interfere with daily life) and secondary diagnoses of Parkinsonism (a broad term encompassing various conditions that share similar movement symptoms with Parkinson's disease, such as slowness, stiffness, and tremors), Epilepsy without Epilepticus (a neurological disorder characterized by recurrent, unprovoked seizures), and Bipolar Disorder (a mental health condition characterized by extreme mood swings, including periods of intense elation or irritability (mania or hypomania) and periods of deep sadness or hopelessness). <BR/>Record review of Resident #2's Comprehensive MDS assessment dated [DATE], indicated Resident #2 had a BIMS Score of 13 which indicated she was cognitively intact. Behavioral Symptoms reflected: Physical and Verbal behavioral symptoms directed toward others 0 meaning behavior not exhibited. <BR/>Record review of Resident #2's Care Plan dated 2-10-2025 revealed Resident #2 was identified as PASRR (Preadmission screening and resident review) positive for having an intellectual disability and epilepsy and was care planned for using anti-anxiety medications. <BR/>Record review on 5-8-2025 at 10:00 AM, of the facility's Provider Investigation Report (PIR) #1005912 dated 4-30-2025, revealed CMA A was witnessed slapping a glass of water out of Resident #2's hand on 4-23-2025. The facility's self-report failed to name a time of the incident. The PIR stated FNP G sent an email of the incident to the Administrator on 4-23-2025 at 6:06 PM. The email stated FNP G was sitting across from the DON's Office, in a conference room, on 4-23-2025 at approximately 5:00 PM, when she heard Resident #2 speaking with CMA A. FNP G stated in the email the conversation between Resident #2 and CNA A started to get louder when FNP G heard Resident #2 call CMA A a bitch. CMA A responded to Resident #2 saying who are you speaking to. Resident #2 responded back to CMA A I'm speaking to myself. CMA A then responded back to Resident #2 saying You better be glad you are talking to yourself, or I will pour the cold water you are holding, on your head. FNP G stated right after that statement she heard a slapping sound and Resident #2 started crying. FNP G went to see what occurred and CMA A was picking the water cup up off the floor. CMA A then proceeded to get in Resident #2's face telling her to apologize. Resident #2 continued to cry and ask for staff to call the cops. Resident #2 then said she would throw herself on the floor. FNP G then stated staff then escorted Resident #2 to her room away from the situation. FNP G stated she asked RN E, who witnessed the incident, what occurred, and RN E said CMA A slapped the water out of Resident #2's hand. The facility's PIR stated the Administrator interviewed CMA A on 4-23-2025 at 5:30 PM and revealed CMA A said that Resident #2 had called her a bitch. CMA A then said she told Resident #2 you better not be talking to me and apologize. CMA A then said Resident #2 did not apologize to her, so I slapped the glass of water on her. She shouldn't have called me a bitch. The PIR further indicated the Administrator interviewed Resident #2 and asked Resident #2 what happened today with CMA A. Resident #2 stated I called her a bitch, and she poured the glass of water on me. It went on my shirt and on my face. I told her I was sorry. The PIR indicated the allegation of CMA A abusing Resident #2 was confirmed and CMA A was terminated. The PIR revealed abuse and neglect in-services were completed for staff on 4-30-2025 and safe surveys were completed with cognitive residents showing no additional findings of abuse. <BR/>On 5-8-2025 at 10:45 AM, record review of CMA A's background check was performed on CMA A showing a clear status. <BR/>On 5-11-2025 at 10:19 PM, an email was sent to FNP G asking FNP G to call me to speak with me about the event on 4-23-2025 between CNA A and Resident #2. No email or phone called was received from FNP G. <BR/>In an interview with CMA B on 5-8-2025 at 11:55 AM, it was conveyed that CMA B trained CMA A to be a medication aide. CMA B stated CMA A never exhibited aggressive behavior toward residents when she was training her but was a good aide. CMA B said she was told what CMA A did when she came back from vacation. CMA B said the facility did in-services on abuse and neglect covering different types of abuse (physical, verbal, punching, and mental) and neglect. Staff are supposed to redirect residents who are cussing, calling people names, or getting agitated. <BR/>In an interview and observation on 5-8-2025 at 12:00 PM, revealed Resident #2 was sitting in a wheelchair holding a cup and drinking its contents. Resident #2 was not able to recall the event with CMA A that occurred on 4-23-2025 except she said CMA A called her a bitch. Resident #2 got confused when asked further questions about the event with CMA A. <BR/>On 4-23-2025 at 3:45 PM, a phone call was made to CMA A and a voice message was left asking CMA A to return the call. A return call was never received. <BR/>In an interview with RN E on 5-8-2025 at 4:45 PM, revealed RN E witnessed the incident between Resident #2 and CMA A on 4-23-2025. RN E said Resident #2 was trying to use the land line phone at the nurse's station located in the Suites section of the facility when Resident #2 called CMA A a bitch. RN E said Resident #2 was holding a glass of water in her hand at the time when CMA A slapped the glass of water out of Resident #2's hand causing the water to go all over Resident #2 and on the floor. RN E said Resident #2 began to cry after CMA A slapped the glass of water out of her hand. RN E said she then told CMA A to leave the area and CMA A did. RN E then said Resident #2 was assessed showing no physical injuries but was emotionally upset. RN E said the facility in-serviced staff on abuse and neglect on 4-23-2025 after this incident occurred. RN E said staff are never to use physical aggression and retaliate against residents because of what they say or do. <BR/>In an interview with the DON on 5-8-2025 at 7:41 PM, it was conveyed that she expects facility staff to redirect residents when they are calling them names and not to react physically by slapping items out of resident's hands. The DON said the nurses are responsible to monitor the behaviors of the CNA/CMAs. The DON stated the risk to a resident, who got a glass of water slapped out of their hand, was that it could have caused emotional trauma, and they could have gotten physically hurt. <BR/>In an interview with the Administrator on 5-8-2025 at 7:55 PM, it was revealed she was in the building when the incident occurred between Resident #2 and CMA A. The Administrator said she interviewed CMA A immediately after the incident occurred. The Administrator said CMA A admitted to slapping the glass of water out of Resident #2's hand, and then she suspended and escorted CMA A off the facility property right after the interview. The Administrator said the nurses on duty are responsible for monitoring the behavior and interactions of the CNAs/CMAs on duty. The Administrator said the nursing staff ultimately answers to the DON. The Administrator said the potential risk to residents who get treated the way CMA A treated Resident #2 on 4-23-2025 was that it could depress residents and they could be scared. The Administrator's expectation was for staff to remain professional and not slap water out of a resident's hand when they are called names. <BR/>Record review of the facility's abuse policy titled Identifying Types of Abuse dated 2001 revised on September 2022 stated:<BR/>As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents .<BR/>1. Abuse of any kind against residents is strictly prohibited .<BR/>4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. <BR/>a. Abuse includes .mental, and psychosocial well-being .<BR/>b. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .<BR/>c. Abuse includes verbal abuse .and mental abuse .<BR/>Mental and Verbal Abuse<BR/>1. Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for elopement. <BR/>The facility failed to ensure Resident #1, who resided in the secure unit, was provided with adequate supervision to prevent elopement and as a result the resident sustained a laceration to his forehead after falling from his wheelchair and was sent to the hospital for treatment. <BR/>An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. <BR/>This failure could place residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Review of Resident #1's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included aphasia, non-Alzheimer's dementia, cerebrovascular accident, and hemiparesis. The MDS reflected the resident's cognition was severely impaired with a BIMS of 0, the resident sometimes understood others, and he sometimes was understood by others with clear speech. <BR/>Review of Resident #1's care plan initiated on 11/09/21 and revised on 03/31/23 revealed Resident #1 was at risk for self-harm and injury related to wandering and attempted elopement related to cognitive impairment and lack of safety awareness. The care plan goals for Resident #1 included wandering within the locked unit and maintaining his safety through the next review date.<BR/>Review of Resident #1's Wandering Risk Scale assessment dated [DATE] revealed he was a high risk to wander. <BR/>Review of Resident #1's Memory Care Unit Continued Stay Review dated 01/23/23 revealed the following:<BR/>Resident habitually wanders or would wander out of the building, and would not be able to find way back Resident continues to meet criteria for placement on the Memory Care Unit <BR/>Review of the facility's Provider Investigation Report dated 02/24/23 reflected the following:<BR/>Resident was last observed by staff member at approximately 2:30-2:40pm per staff interview and was returned to the facility at approximately 2:53pm. Resident was noted to be in his wheelchair sitting next to the exit door just prior to his exit. Nurse was at station charting and did not observe resident exit the facility. He was informed by an employee on her way home that resident was outside the facility in the far end of the parking lot at the entrance of the neighboring property. Employee brought the resident back to the facility and informed the charge nurse <BR/> .He was noted to have a laceration approximately 2cm and was treated at [the hospital ER] with dissolvable stitches <BR/>Review of Resident #1's progress notes dated 02/18/23 documented by LVN A revealed the following:<BR/>Resident went out of the building, found by a staff member and brought back to the unit with lacerations to the left side of the head. This nurse cleaned the lacerations with wound cleanser, stopped the bleeding and applied dry dressing Called 911 an sent resident to [hospital] Resident returned to unit from the ER at 10:11 pm. Stitches and derma bond put on lacerations <BR/>Observation on 04/20/23 at 10:45 AM of the secure unit revealed it consisted of one long hall with a dining room/activity room and a nurses' station coming off the hall. The unit had a main entrance, and exit door to the back of the facility, and a third exit to the patio, that also had an exit door to the outside of the facility. All three doors were equipped with a keypad which required a code to exit. <BR/>Observation and interview on 04/20/23 at 10:51 AM revealed Resident #1 was in the hallway sitting in a wheelchair at the end of the secure unit hall about 10 feet from the back exit door. The resident was primarily Spanish speaking and was asked if he had left the facility. He said he left about one to three months prior, but he was found and brought back to the facility by a woman after he fell from his wheelchair and was bleeding from his face. Resident #1 said he had put in the code to the door that led into the patio and entered the code again to the outside gate. Resident #1 wheeled himself on the sidewalk and did not notice there was loose gravel and fell over on the floor in his wheelchair. Resident #1 further stated there was a man that was going to give him a ride over there to pay traffic tickets to renew his driver's license so he could get back to work. The resident said after his fall he was taken to the hospital. Further observations of the secure unit revealed many of the resident were ambulatory or were able to self-propel in their wheelchairs. There were some residents that were wandering in the dining room, but none were observed to be exit-seeking or pushing on any of the doors. <BR/>Review of Resident #1's hospital records dated 02/18/23 reflected the following:<BR/>Reason for visit: Fall<BR/>Diagnosis: facial laceration<BR/>Further review of Resident #1's hospital records revealed there were no other details about of the extent of his lacerations or treatments. <BR/>Interview on 04/20/23 at 2:13 PM with the PTA revealed she was leaving the facility (02/18/23) after work around 2:30 PM and was driving down the road in front of the facility when she saw a man who appeared to be standing from his wheelchair at the bottom of one of the facility's entrances, near an adjacent business. The resident looked familiar, so she turned around and realized it was Resident #1 who was already sitting in his wheelchair bleeding from his face from a big face gash. The PTA asked Resident #1 what happened but because he was not able to speak English well, he just kept pointing to the corner of the street. She then pushed the resident back to the facility, and the staff told her they did not know how the resident got out of the secure unit, but they were going to call 911 and have him sent out for treatment. <BR/>Interview on 04/20/23 at 1:27 PM with LVN A revealed he was in the dining room with other residents in the secure unit when the PTA brought Resident #1 back, bleeding from his face. LVN A did not realize the resident had left the unit, and he did not know how the resident had gotten out. LVN A asked the resident about the incident, and Resident #1 would only smile. He said they thought Resident #1 had exited through the back exit door because at that time of the elopement, the back door was being used as an exit only door due to COVID-19 precautions. LVN A also thought someone might have gone out the back door and not verified the door had securely closed when the resident exited the facility. Prior to the COVID-19 outbreak, the back door was never used by staff per LVN A. He said after Resident #1's elopement, all the codes to the unit's doors were changed, there was a door alarm installed on the back exit door, and all residents were to be monitored more closely if they were by an exit door. <BR/>Interview on 04/20/23 at 3:28 PM with CNA C revealed she was working the day Resident #1 eloped from the secure unit. She said she was caring for another resident but remembered seeing Resident #1 not long before he was brought back by the PTA. She said normally Resident #1 sat by the back exit door or the dining room. CNA C said she saw LVN trying to clean Resident #1 face because he was bleeding before he was sent to the hospital. The CNA was not aware how the resident got out of the unit, but she was told Resident #1 had left out the back exit door. She said the back door was being used as COVID-19 exit only door during one of their outbreaks. CNA C further stated all the codes had been changed to the exit doors, an alarm was installed on the back exit door, they were educated to monitor the residents more closely, especially Resident #1. <BR/>Interview on 04/20/23 at 1:27 PM with LVN B revealed Resident #1 had a history of going to the exit doors; however, once the resident realized a door would not open, the resident would leave the door alone. LVN B stated Resident #1 had never eloped in the past that he was aware of. LVN B further stated after Resident #1 eloped, all codes to the doors were changed, an alarm was added to the back exit door and all residents were to be monitored more closely, especially Resident #1. <BR/>Interview on 04/20/23 at 2:50 PM with the ADON revealed she was told Resident #1 had eloped from the secure unit and fallen off a step outside and sustained a laceration. She was unaware of the resident having an elopement history but to prevent further incidents, all codes to the doors were changed, and alarm was installed on the back exit door to sound any time it was opened, and increased resident checks and activities to keep them busy.<BR/>Interview on 04/20/23 at 1:01 PM with the Administrator revealed once she was told about Resident #1's elopement, she went and spoke with the resident as she was Spanish speaking also. The resident told the Administrator he had gotten out of the unit by pushing on the door but did not elaborate after that. The Administrator said the back exit door had a 15 second release lock and they thought he held the handle until the lock released, allowing him to exit the facility. She also said staff told her Resident #1 often sat by the back exit door, so they assumed that was where he had gotten out of. After the elopement, all the codes to the unit doors were changed, an alarm to the back exit door was added to sound anytime it was opened, and all staff were in-serviced to closely monitor the residents especially Resident #1. <BR/>Review of the facility's policy titled Wandering and Elopements revised March 2019 reflected the following:<BR/>The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environments for residents.<BR/>An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. <BR/>The facility took the following actions to correct the non-compliance prior to the investigation:<BR/>Review of in-service records dated 02/18/23 through 02/23/23 revealed all nursing staff were educated on missing persons, wandering, elopement, abuse/neglect, and resident rights. Those in-services consisted of ensuring doors are closed and locked, new alarm on back door, and closely monitoring the residents especially residents with increased wandering. All staff working the secure unit were given the new codes to the exit doors. <BR/>Interviews were conducted with six CNAs, four LVNs, one PTA, and an ADON on 04/21/23 from 9:00 AM to 4:00 PM from various shifts. The staff were able to identify and monitor wandering/exit seeking residents, new codes to the exit doors, and made aware of the new back door alarm to sound when opened. <BR/>Observation on 04/20/23 at 9:30 AM revealed the back exit door had an alarm installed to sound if and when it was opened, and new door codes were verified to make sure they were not the same ones at that time of the elopement on 02/18/23. <BR/>Interview on 04/21/23 at 10:00 AM with Resident #1 revealed he did not recall the codes to the doors because the number he gave did not match the current codes to any of the doors. <BR/>The records revealed a plan of action had been initiated to include supervision prior to entry on 04/18/23. Review of the following reflected the facility was in compliance on 02/23/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents were free from abuse for one of five residents (Resident #2) reviewed for abuse, neglect, and exploitation. <BR/>The facility failed to ensure Resident #2 was free from staff to resident abuse when CMA A slapped a glass of water out of Resident #2's hand on 4-23-2025, causing her to cry experiencing psychosocial harm. <BR/>This noncompliance was identified as a PNC. The noncompliance began on 4-23-2024 and ended on 4-30-2025. <BR/>This failure could place residents at risk for decreased quality of life, decreased self-esteem, and mental anguish. <BR/>Findings Included:<BR/>Record review of Resident #2's Face Sheet dated 5-8-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of Dementia with other behavioral disturbance (a decline in mental ability severe enough to interfere with daily life) and secondary diagnoses of Parkinsonism (a broad term encompassing various conditions that share similar movement symptoms with Parkinson's disease, such as slowness, stiffness, and tremors), Epilepsy without Epilepticus (a neurological disorder characterized by recurrent, unprovoked seizures), and Bipolar Disorder (a mental health condition characterized by extreme mood swings, including periods of intense elation or irritability (mania or hypomania) and periods of deep sadness or hopelessness). <BR/>Record review of Resident #2's Comprehensive MDS assessment dated [DATE], indicated Resident #2 had a BIMS Score of 13 which indicated she was cognitively intact. Behavioral Symptoms reflected: Physical and Verbal behavioral symptoms directed toward others 0 meaning behavior not exhibited. <BR/>Record review of Resident #2's Care Plan dated 2-10-2025 revealed Resident #2 was identified as PASRR (Preadmission screening and resident review) positive for having an intellectual disability and epilepsy and was care planned for using anti-anxiety medications. <BR/>Record review on 5-8-2025 at 10:00 AM, of the facility's Provider Investigation Report (PIR) #1005912 dated 4-30-2025, revealed CMA A was witnessed slapping a glass of water out of Resident #2's hand on 4-23-2025. The facility's self-report failed to name a time of the incident. The PIR stated FNP G sent an email of the incident to the Administrator on 4-23-2025 at 6:06 PM. The email stated FNP G was sitting across from the DON's Office, in a conference room, on 4-23-2025 at approximately 5:00 PM, when she heard Resident #2 speaking with CMA A. FNP G stated in the email the conversation between Resident #2 and CNA A started to get louder when FNP G heard Resident #2 call CMA A a bitch. CMA A responded to Resident #2 saying who are you speaking to. Resident #2 responded back to CMA A I'm speaking to myself. CMA A then responded back to Resident #2 saying You better be glad you are talking to yourself, or I will pour the cold water you are holding, on your head. FNP G stated right after that statement she heard a slapping sound and Resident #2 started crying. FNP G went to see what occurred and CMA A was picking the water cup up off the floor. CMA A then proceeded to get in Resident #2's face telling her to apologize. Resident #2 continued to cry and ask for staff to call the cops. Resident #2 then said she would throw herself on the floor. FNP G then stated staff then escorted Resident #2 to her room away from the situation. FNP G stated she asked RN E, who witnessed the incident, what occurred, and RN E said CMA A slapped the water out of Resident #2's hand. The facility's PIR stated the Administrator interviewed CMA A on 4-23-2025 at 5:30 PM and revealed CMA A said that Resident #2 had called her a bitch. CMA A then said she told Resident #2 you better not be talking to me and apologize. CMA A then said Resident #2 did not apologize to her, so I slapped the glass of water on her. She shouldn't have called me a bitch. The PIR further indicated the Administrator interviewed Resident #2 and asked Resident #2 what happened today with CMA A. Resident #2 stated I called her a bitch, and she poured the glass of water on me. It went on my shirt and on my face. I told her I was sorry. The PIR indicated the allegation of CMA A abusing Resident #2 was confirmed and CMA A was terminated. The PIR revealed abuse and neglect in-services were completed for staff on 4-30-2025 and safe surveys were completed with cognitive residents showing no additional findings of abuse. <BR/>On 5-8-2025 at 10:45 AM, record review of CMA A's background check was performed on CMA A showing a clear status. <BR/>On 5-11-2025 at 10:19 PM, an email was sent to FNP G asking FNP G to call me to speak with me about the event on 4-23-2025 between CNA A and Resident #2. No email or phone called was received from FNP G. <BR/>In an interview with CMA B on 5-8-2025 at 11:55 AM, it was conveyed that CMA B trained CMA A to be a medication aide. CMA B stated CMA A never exhibited aggressive behavior toward residents when she was training her but was a good aide. CMA B said she was told what CMA A did when she came back from vacation. CMA B said the facility did in-services on abuse and neglect covering different types of abuse (physical, verbal, punching, and mental) and neglect. Staff are supposed to redirect residents who are cussing, calling people names, or getting agitated. <BR/>In an interview and observation on 5-8-2025 at 12:00 PM, revealed Resident #2 was sitting in a wheelchair holding a cup and drinking its contents. Resident #2 was not able to recall the event with CMA A that occurred on 4-23-2025 except she said CMA A called her a bitch. Resident #2 got confused when asked further questions about the event with CMA A. <BR/>On 4-23-2025 at 3:45 PM, a phone call was made to CMA A and a voice message was left asking CMA A to return the call. A return call was never received. <BR/>In an interview with RN E on 5-8-2025 at 4:45 PM, revealed RN E witnessed the incident between Resident #2 and CMA A on 4-23-2025. RN E said Resident #2 was trying to use the land line phone at the nurse's station located in the Suites section of the facility when Resident #2 called CMA A a bitch. RN E said Resident #2 was holding a glass of water in her hand at the time when CMA A slapped the glass of water out of Resident #2's hand causing the water to go all over Resident #2 and on the floor. RN E said Resident #2 began to cry after CMA A slapped the glass of water out of her hand. RN E said she then told CMA A to leave the area and CMA A did. RN E then said Resident #2 was assessed showing no physical injuries but was emotionally upset. RN E said the facility in-serviced staff on abuse and neglect on 4-23-2025 after this incident occurred. RN E said staff are never to use physical aggression and retaliate against residents because of what they say or do. <BR/>In an interview with the DON on 5-8-2025 at 7:41 PM, it was conveyed that she expects facility staff to redirect residents when they are calling them names and not to react physically by slapping items out of resident's hands. The DON said the nurses are responsible to monitor the behaviors of the CNA/CMAs. The DON stated the risk to a resident, who got a glass of water slapped out of their hand, was that it could have caused emotional trauma, and they could have gotten physically hurt. <BR/>In an interview with the Administrator on 5-8-2025 at 7:55 PM, it was revealed she was in the building when the incident occurred between Resident #2 and CMA A. The Administrator said she interviewed CMA A immediately after the incident occurred. The Administrator said CMA A admitted to slapping the glass of water out of Resident #2's hand, and then she suspended and escorted CMA A off the facility property right after the interview. The Administrator said the nurses on duty are responsible for monitoring the behavior and interactions of the CNAs/CMAs on duty. The Administrator said the nursing staff ultimately answers to the DON. The Administrator said the potential risk to residents who get treated the way CMA A treated Resident #2 on 4-23-2025 was that it could depress residents and they could be scared. The Administrator's expectation was for staff to remain professional and not slap water out of a resident's hand when they are called names. <BR/>Record review of the facility's abuse policy titled Identifying Types of Abuse dated 2001 revised on September 2022 stated:<BR/>As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents .<BR/>1. Abuse of any kind against residents is strictly prohibited .<BR/>4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. <BR/>a. Abuse includes .mental, and psychosocial well-being .<BR/>b. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .<BR/>c. Abuse includes verbal abuse .and mental abuse .<BR/>Mental and Verbal Abuse<BR/>1. Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to be free from Misappropriation of Resident Property for 1 of 5 residents (Resident #1), reviewed for drug diversion. <BR/>The facility failed to prevent the misappropriation of over 150 tablets of Norco (hydrocodone and acetaminophen an opioid which is a Schedule II controlled Substance), and 1 bottle of morphine (30 mL), by allowing the ADON (AP) to remove the medication from the nurses' cart, without authorization, for personal gain and never recovering the medication. Resident #1 experienced pain for two-three days at a level of 7-8, after his toe amputation, when his pain would have been relieved with Norco. <BR/>This noncompliance was identified as a PNC. The noncompliance began on 4-14-2024 and ended on 4-28-2025. <BR/>This failure could place residents at risk of misappropriation if medication resulting in unrelieved pain and substandard quality of life. <BR/>Findings Included:<BR/>Record review of Resident #1's Face Sheet dated 5-8-2024 revealed a 63-yer-old male who admitted to the facility on [DATE] with a primary diagnosis of Unspecified Dementia without behavioral disturbance (when someone experiences memory loss, thinking difficulties, and changes in social abilities that significantly impact their daily life, but the specific cause of the dementia is not determined), and secondary diagnoses of Type 2 Diabetes Mellitus (a chronic metabolic disorder characterized by elevated blood glucose levels due to the body's inability to effectively use insulin, or insulin resistance, and insufficient insulin production by the pancreas), End Stage Renal Disease (a severe condition where the kidneys have lost the ability to filter waste and excess fluid from the blood), Pain in Unspecified Joint (pain experienced in a joint, without a specific joint being identified), and Acquired Absence of Right Leg Below Knee (loss of the right leg distal to the knee joint, typically due to surgical amputation or a similar medical intervention).<BR/>Record review of Resident # 1's Quarterly MDS assessment dated [DATE], revealed a BIMS Score of 15 indicating Resident #1 was cognitively intact. The Pain Assessment Section of the MDS conveyed Resident #1 experienced pain at a level 5 occasionally. <BR/>Record review of Resident #1's Care Plan dated 1-9-2024 indicated Resident #1 had chronic pain related to Neuropathy (damage or dysfunction of the peripheral nervous system) of his below the knee amputation. Resident #1's Care Plan stated anticipate the resident's need for pain relief and respond immediately to any complaint of pain and evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. <BR/>Record review of Resident #1's electronic physician orders with a start date of 7-4-2024 and no end date, revealed an active order for Norco 10-325 MG to give 1 tablet by mouth every 6 hours as needed for pain. <BR/>Record review of Resident #1's Physician Orders dated 5-8-2025 revealed Tylenol with Codeine #3 30-300 MG and Acetaminophen 325 MG 2 tablets was ordered with a start date of 4-24-2025 at 6:30 AM. <BR/>Record review of Resident #1's MAR dated 5-8-2025 indicated Resident #1 was routinely given Tylenol with Codeine #3 30-300 MG and Acetaminophen 325 MG 2 tablets totaling 650 MG, when he returned from the hospital, from 4-18-2025 until 4-28-2025. The MAR indicated the Norco Drug was restored on 4-28-2025. Resident #1's MAR indicated his pain levels were at a zero for 4-19-2025 & 4-20-2025, a 7 on 4-21-2025, no entry for 4-22-2025, 5 on 4-23-2025, a 5 on 4-24-2025, a 8 on 4-25-2025, a 5 on 4-26-2025, a 0 on 4-27-2025, and a level 7 on 4-28-2025 when Norco was restored. <BR/>Record review of the facility's PIR (Provider Investigation Report) dated 4-29-2025 revealed it was discovered Resident #1 was missing 4 cards of Norco medication and another resident (not named) was missing 2 cards of Norco on 4-22-2025. LVN H said on 4-10-2025 ADON (AP) came to the Nursing cart and told her she was doing a Narcotics audit and was pulling out any Narcotics that were 90 days, not being used, or that were discontinued. LVN H said the ADON (AP) took some Narcotic cards but was not sure of everything she took. LVN H said she did not think anything wrong at the time because the ADON (AP) was part of the management team. On 4-18-2025, a Friday night, when Resident #1 came back from the hospital, after having a toe amputated, LVN H noticed Resident #1 did not have any Norco medication on the nurses' cart. LVN H then texted the DON to ask what the procedure was for pulling Narcotic cards from the nurse cart. The DON was busy at an event that night, so LVN H said she would talk with her about the procedure on Monday 4-21-2025. On Monday 4-21-2025 LVN H followed up with the DON. The DON explained to LVN H the procedure for pulling Narcotics off the nurses' cart was for the medication to be discontinued or not used for 90 days. On Tuesday morning 4-22-2025, LVN H asked the ADON (AP) about Resident #1's Norco cards and the ADON (AP) said the Norco cards for Resident #1 were destroyed because she was told Resident #1 was not coming back to the facility. LVN H then went to the DON on 4-22-2025 and asked if Resident #1's Norco Medication had been discontinued. The DON said no it had not been discontinued. LVN H then told the DON the ADON (AP) had pulled Resident #1's Norco cards and he does not have any left. The DON told LVN H no drugs had been destroyed for the facility this month. It was determined that the ADON (AP) mishandled or misplaced over 4 Norco Medication Cards that were never recovered and the ADON (AP) was terminated. The PIR indicated that on 4-24-2025 at 8:02 AM a drug test was performed on ADON (AP) showing negative results.<BR/>The PIR indicated on 4-22-2025 the facility conducted in-services with all nursing staff concerning Narcotics. The facility changed its policy to reflect that moving forward only the DON may remove Narcotic cards whether empty or full. Under no circumstances will anyone, other than the DON, be allowed to remove any Narcotic medications from any cart. <BR/>The PIR also indicated, in a voluntary statement dated 4-22-2025, by the Administrator given to the [Local Police Department], that one bottle of morphine (30 mL) for Resident #1 was missing. <BR/>On 5-8-2025 at 10:45 AM a record review of ADON (AP)'s background check was performed with negative results. <BR/>In an interview on 5-8-2025 at 11:15 AM, Resident #1 said he returned from the hospital in mid-April because he had his big toe amputated and needed pain medication. Resident #1 said he had a prescription for Norco, on file with the facility, before he went into the hospital. Resident #1 said he returned from the hospital, in about 10 days, and asked a nurse for his pain medication and the nurse told him he did not have any left because the ADON (AP) pulled them off the medication cart. Resident #1 stated he was provided Tylenol #3 with codeine, but they did not relieve his pain like the Norco. Resident #1 said his pain level was at a 7 or 8 for about 2-3 days then it subsided. Resident #1 said it was about a week until he started receiving Norco again. <BR/>In an interview with CMA B on 5-8-2025 at 11:55 AM, it was learned that she was told that the ADON (AP) had illegally taken Norco pills from the medication cart and was fired. CMA B said she was in-serviced on abuse, neglect, and misappropriation to include resident Narcotics. CMA B said the new policy stated that only the DON will remove any narcotics from the med carts even if the cards are empty. CMA B said the Narcotics are kept double locked inside the medication carts. <BR/>On 5-8-2025 at 2:45 PM, an attempted interview was made with the ADON (AP); however, the phone immediately went to a recording stating the phone cannot receive messages. <BR/>In an interview with RN E on 5-8-2025 at 4:45 PM, it was revealed that RN E worked the 2:00 PM-10PM shift. RN E said on 4-14-2025 ADON (AP) approached her, while she was working the medication cart, and told her Resident #1 was hospitalized more than 72 hours and staff are not supposed to keep Norco medication on the Med Cart when this occurs. RN E said she did not question if this was correct as ADON (AP) was part of the management team. RN E said she found out later it was not the protocol, of the facility, to not keep Norco in the medication cart if a resident was hospitalized over 72 hours. RN E said on 4-14-2025 ADON (AP) took 4 Norco cards over 100 pills from the nurse's cart that evening. RN E said she was in-serviced later, after the facility determined that Norco was missing, that the facility implemented a new policy that only the DON can remove any narcotic cards from the medication carts. RN E said the Narcotics will stay double locked in the medication carts unless the DON removes them. <BR/>In an interview with RN F on 5-8-2025 at 6:42 PM, it was stated the ADON (AP) came to her one evening, in the month of April 2025, and told her she cannot keep Norco over 3 months in the nurse's cart. RN F said the ADON (AP) told her it was a new policy of the facility to remove the Norco. RN F said the ADON (AP) took cards of Norco from the nurse cart she was using but she did not know how many cards of Norco she took. RN F said she was in-serviced a few weeks ago regarding removing Narcotics from the carts. The facility now has a new policy when a Narcotic medication card is empty, they contact the DON and the DON will sign for it along with another nurse. RN F said only the DON can take the Narcotics from the carts. <BR/>In an interview with CMA C on 5-8-2025 at 7:23 PM, it was revealed that she was in-serviced on narcotic medications a few weeks ago. CMA C said now only the DON can discard empty Narcotic cards. CMA C said only the DON can sign for full narcotic cards so only one person is responsible for disseminating and destroying them. CMA C said the Narcotics are kept in a lockbox within the medication carts. CMA C said this new policy keeps better control of these substances, so they don't come up missing. CMA C said the risk to residents not having their Norco was it could allow their pain levels to not be controlled. <BR/>In an interview with the DON on 5-8-2025 at 7:41 PM, it was revealed that before Norco medication became missing last month, when the narcotic cards were empty, the nurses would discard the cards themselves. If there were still pills left in the cards, for discarded Narcotics, they would bring the leftover pills to her, count the pills with her, and put them in a locked box attached to the wall in her office. The DON said now the policy for removing narcotic cards was only the DON can remove the cards. If there are any medications left in the cards, the policy was still to have 2 people verify it but only the DON removes them. The DON said she is responsible for the safe keeping and monitoring of Narcotics at the facility. The DON said her expectations were for all nurses and CMAs to follow the new procedures. The DON said the risk to the residents having medications missing was that they may not get the medication they need, be in pain, and could have withdrawal side effects. <BR/>In an interview with the Administrator on 5-8-2025 at 7:55 PM it was conveyed, that prior to the Norco missing at the facility, the DON was responsible for monitoring the disposal and the security of Narcotics at the facility. The Administrator said now the DON is the only one who can remove the Narcotics from the medication carts for disposal. The Administrator believed this would prevent Narcotics from missing at the facility. The Administrator said the risk to residents by having narcotic medication missing was there would be delayed pain treatment. <BR/>Record review of the facility's Proper Storage of Controlled Medications dated 4-25-2025 stated:<BR/>The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) .<BR/>The charge nurse on duty maintains the keys to controlled substance containers. The [DON] maintains a set of back-up keys for all medication storage areas .<BR/>The Director of Nursing (DON) identifies staff members who are authorized to handle controlled substances .<BR/>Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed .The director of nursing services maintains and disseminates to appropriate individuals a list of staff who have access to medication storage areas and controlled substance containers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status and/or a need to alter treatment significantly for 1 of 2 residents (Resident #2) reviewed for resident rights. <BR/>The facility failed to notify Resident #2's representative and/or family, on 5-3-2025, as appropriate of a significant change in Resident #2's mental status. <BR/>This failure could prevent their representative's authority from being notified or exercised preventing them from receiving competent choices.<BR/>Findings included:<BR/>Record review of Resident #2's Face Sheet dated 2-28-2025 revealed an [AGE] year-old female with an initial admittance date of 5-14-2019. Resident #2's primary diagnosis was dementia without psychotic disturbance (cognitive decline characteristic of the condition, but does not exhibit symptoms of psychosis, such as hallucinations or delusions) with secondary diagnoses in part of diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), auditory hallucinations (hearing sounds or voices that are not present in the real world), cerebral infarction (stroke where blood flow to the brain is interrupted, leading to the death of brain cells), and schizoaffective disorder (a mental health disorder causing hallucinations, delusions, disorganized thinking and speech) having an onset date of 5-3-2023. <BR/>Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating being cognitively intact. <BR/>Record Review of Resident #2's Care Plan dated 2-17-2022 revealed Resident #2 was care planned to use psychotropic medications on 2-17-2022 for hallucinations and explosive disorders. <BR/>Record review of Resident #2's Psychotropic Drug Regimen Review dated 12-31-2024 revealed Prozac, Risperdal, and Trileptal were ordered on 2-15-2023.<BR/>Record review of a Medical Power of Attorney/Living Will dated 5-5-2014, revealed Family Member A had a medical power of attorney for Resident #2. <BR/>In an interview on 2-28-2025 at 11:00 AM it was revealed Family Member A was Resident #2's Medical Power of Attorney. Family Member A stated she was never informed or consulted that Resident #2 had been diagnosed with any type of Schizophrenia and was not told she was put on the drug Risperidone. Family Member A said the last 1.5 years of Resident #2's life, dementia was so bad she could not turn off her phone nor be competent enough to sign for new drug treatments. <BR/>Record review of Resident #2's Psychiatric Care Notes dated 4-26-2023 indicated Resident #2 was assessed with having Bipolar Disorder. <BR/>Record review of Resident #2's Psychiatric Care Notes dated 5-2-2023 indicated Resident #2 was assessed with having Bipolar Disorder with episode manic severe with psychotic features.<BR/>Record review of Resident #2's Psychiatric Care Notes dated 5-3-2023 indicated Resident #2 was assessed with having Bipolar Disorder, Schizoaffective Disorder, and Dementia. 5-3-2023 Psychiatric Care Notes failed to indicate the facility notified Resident #2's representative(s) and/or family when there was a significant change in the resident's physical, mental, or psychosocial status. <BR/>Record review of Resident #2's Progress Notes in 5-2023 failed to indicate Resident #2's representative(s) and/or family about the diagnosis of Schizoaffective Disorder. <BR/>Record Review of Resident #2's Consent for Antipsychotic Medication Treatment HHS Form 3713 dated 6-1-2023, revealed Resident #2 signed the form for the treatment of Schizoaffective Disorder, Auditory Hallucinations, and to take the drug Risperidone. The form failed to state notification to Resident #2's representative(s) and/or family of this change in the treatment or diagnosis of Resident #2 <BR/>Record review of Resident #2's Progress Notes dated 6-7-2023 indicated that Resident #2 had a Medical Power of Attorney and Living Will on file with the facility. <BR/>Record review of Resident #2's Progress Notes dated 6-15-2025 titled Care Conference failed to include notice to Family Member A or any POA for Resident #2<BR/>Record review of Resident #2's Doctor's Orders revealed Resident #2 was put on hospice care on 2-13-2025.<BR/>Record review of Resident #2's Nursing Home and Swing Bed Tracking MDS dated [DATE] revealed Resident #2 died at the facility on 2-16-2025. <BR/>In an interview with the DON on 2-28-2025 at 6:40 PM, it was revealed that the DON expected the facility to notify a resident's representative or family whenever there was a change in a diagnoses or treatment. The DON stated she remembered Resident #2 had a lot of behavior problems. The DON stated the facility took over the current building in 2021 and it seemed at though the family of Resident #2 stopped signing forms for Resident #2 at that point in time. The DON stated the facility had the resident sign for consent for changes in diagnoses and treatment because she was her own responsible party. The DON said the potential harm that can come to a resident for not notifying her representatives or family could be the resident might decline where she may not be competent to sign for medications for herself. <BR/>Record review of the facility's Resident Rights Policy dated 2001 and revised in 2016 stated: Policy Interpretation and Implementation<BR/>1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/>c. be free from abuse, neglect, misappropriation of property, and exploitation .<BR/>f. communication with and access to people and services, both inside and outside the facility;<BR/>g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .<BR/>k. appoint a legal representative of his or her choice, in accordance with state law .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have physician orders for the resident's immediate care at the time a resident was admitted for 1 of 1 (Resident #1) resident reviewed for physician orders. <BR/>The facility failed to obtain physician orders for immediate care when Resident #1 admitted to the facility on [DATE] with a pressure wound to receive orders for treatment.<BR/>This failure could place residents at risk for delayed treatment causing a decline in health by not receiving treatment until two weeks later. <BR/>Findings included:<BR/>Review of Resident #1's Face Sheet dated 02/05/25 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses in part included hypertension (elevated blood pressure), neurogenic bladder (lack of bladder control due to brain, spinal cord, or never problem), quadriplegia (paralysis affecting all limbs and body from the neck down), diabetes (disease affecting the body's use of sugar), obesity (complex disease involving having too much body fat), and ulcer of the right buttocks, stage II (shallow, open wound that has broken through the top layer of skin and part of the layer below).<BR/>Record review of Resident #1's Care Plan Report dated 1-29-2025 and revised on 2-17-2025 revealed actual impairment to skin integrity pressure injury to the sacrum r/t immobility, disease process. <BR/>Record review of Resident #1's Hospital Records dated 1-29-2025 at 10:33 AM revealed an admission date of 8-26-2024 and a discharge date of 1-29-2025. The record indicated Resident #1 had a stage 2 pressure injury to his right buttock upon discharge. <BR/>Record review of Resident #1's Nurse Note dated 1-29-2025 at 5:21 PM revealed a skin assessment was performed indicating bilateral buttocks redness observed. <BR/>Record review of Resident #1's Nurse Notes dated from 1-29-2025 to 2-10-2025 failed to indicate the facility notified a physician about the pressure wound on Resident #1. <BR/>Record review of Resident #1's Weekly Skin Observation Tool dated 2-7-2025 indicated Resident #1 had a pressure ulcer on his sacrum area. <BR/>In an interview on 2-25-2025 at 3:50 PM, RN B (ADON) stated she conducted the Weekly Skin Observation Tool dated 2-7-2025 on Resident #1 but did not document that she contacted the doctor about seeing the wound on Resident #1's sacrum. RN B did not remember if she contacted a doctor about seeing the pressure wound. However, RN B was sure she told Physician A about Resident #1's pressure wound, when he came to the facility on 2-10-2025. RN B stated not notifying the doctor timely could allow the wound to get worse. RN B stated she did not see Resident #1's wound until 2-7-2025. <BR/>In an interview on 02/28/25 at 2:26 PM, Physician A reported that Resident #1's wound prognosis had changed from when he assessed him on 02/10/25 (fair prognosis) to the 02/17/25 (poor prognosis). Physician A stated the first time he was aware of Resident #1's wounds were on 2-10-2025. Physician A stated a delay in treatment could be a contributing factor in the decline of health concerning Resident #1's pressure wounds. <BR/>In an interview on 2-28-2025 at 6:40 PM it was disclosed that the DON expected the admitting nurse to call the doctor immediately when it was discovered that a new resident entered the facility with a wound to get orders from the doctor. The DON said it was the Admitting Nurse's responsibility to contact the doctor immediately. The DON stated the risk to the resident by not notifying the doctor of a wound in a timely manner was the wound could get worse. <BR/>Record review of the facility's policy dated 2001 (Revised April 2018) and titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol reflected, The nursing team member and practitioner will assess and document and individual's significant risk factors for developing pressure ulcers; and shall describe and document/report the following .a. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue . The policy also stated that, the team member and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions and the physician will order pertinent wound treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #1) reviewed for wound care services.<BR/>The facility failed to enter the wound care physician's orders given on 2-10-2025 until 2-13-2025, did not put the physician's orders that were given on 2-17-2025 until 2-20-2025, according to the TAR. Treatment for the wound did not start until the dates the orders entered, according to the TAR. <BR/>The facility failed to obtain orders for wound care when Resident #1 admitted to the facility on [DATE], from the hospital, with a stage II pressure injury to his buttocks. Wound care orders were not obtained until 2-10-2025 and not entered into the EHR System until 2-13-2025. Wound care orders were changed on 2-17-2025 and not entered into the EHR System until 2-20-2025. According to the TAR, treatment for Resident #1's wound did not start until the dates the orders were entered into the EHR System. Between 2-10-2025 and 2-17-2025, Resident #1's prognosis had changed from fair prognosis to poor prognosis. The wound was noted as a stage II pressure injury on 2-10-2025 and progressed to an unstageable pressure injury on 2-17-2025. <BR/>Findings included: <BR/>Review of Resident #1's Face Sheet dated 02/05/25 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses in part included hypertension (elevated blood pressure), neurogenic bladder (lack of bladder control due to brain, spinal cord, or never problem), quadriplegia (paralysis affecting all limbs and body from the neck down), diabetes (disease affecting the body's use of sugar), obesity (complex disease involving having too much body fat), and ulcer of the right buttocks, stage II (shallow, open wound that has broken through the top layer of skin and part of the layer below).<BR/>Record review of Resident #1's Care Plan Report dated 1-29-2025 and revised on 2-17-2025 revealed actual impairment to skin integrity pressure injury to the sacrum r/t immobility, disease process upon admission. <BR/>Record review of Resident #1's Hospital Records dated 1-29-2025 at 10:33 AM revealed an admission date of 8-26-2024 and a discharge date of 1-29-2025. The record indicated Resident #1 had a stage 2 pressure injury to his right buttock upon discharge. <BR/>Record review of Resident #1's Nurse Note dated 1-29-2025 at 5:21 PM revealed a skin assessment was performed indicating bilateral buttocks redness observed upon admission into the facility. <BR/>Record review of Resident #1's Weekly Skin Observation Tool dated 2-7-2025 indicated Resident #1 had a pressure ulcer on his sacrum area. <BR/>In a review of Resident #1's wound care notes on 2-25-2025, dated 2/10/25, Physician A noted that Resident #1's coccyx wound was a Stage II wound with fair prognosis and that resident was receiving a dressing including calcium alginate. Review of Resident #'1s TAR reflected that the resident did not begin receiving this treatment until 2/13/25.<BR/>In a review of Resident #1's wound care notes on 2-25-2025, dated 02/17/25, Physician A noted that Resident #1's coccyx wound had increased in size, was unstageable, and the wound dressing would now include applying a generous amount of honey to the calcium alginate. Physician A's prognosis was poor. Review of Resident #1s TAR reflected that the resident did not begin receiving this treatment until 2/21/25.<BR/>In an interview on 2-25-2025 at 3:50 PM, RN B (ADON) stated she conducted the Weekly Skin Observation Tool dated 2-7-2025 on Resident #1. RN B said she noted seeing a pressure injury on Resident #1's sacrum but did not indicate what stage it was on the form. RN B said the facility had a standing order when a pressure wound is first observed, nurses can use a barrier cream on the wound area and did so on Resident #1. RN B stated however, the facility does not document using barrier cream. <BR/>RN B stated the wound care doctor saw and assessed Resident #1's pressure injury on his sacrum on 2-10-2025. RN B said the facility's wound care nurse resigned, at the beginning of February, and the ADON's were making rounds with Physician A when he came to the facility. RN B said she believed Resident #1's pressure wound was worsening due to other disease processes, he was not able to move on his own, and did not like to be repositioned at times. RN B stated Resident #1 was receiving wound care treatment once a day. RN B stated the last time she saw Resident #1's pressure wound, to his sacrum, was on 2-10-2025 and it looked yellowish with redness. <BR/>In an observation on 02/28/25 at 11:15 AM, RN B provided wound care treatment to Resident #1. She was noted using appropriate PPE, infection control practices, wound care techniques, and following physician orders. The coccyx wound based appeared moist, the wound crossed the gluteal cleft (both right and left buttocks) and was unstageable (the presence of eschar [a piece of dead tissue, usually appearing as a dry, crusty, and often dark-colored scab] was noted). The resident tolerated well.<BR/>In an interview on 02/28/25 at 2:24 PM, RN B reported that she would put in PCC, the wound care orders when she was the one who did the rounds with Physician A. RN B reported that Physician A would tell her the changes he was making during the rounds, and then email the orders to her later the same day. RN B reported the nurse who attended the wound care rounds with Physician A, would then put the orders into PCC that day or the following morning if they had already left the facility for the day. RN B reported that when Physician A came to the facility on 2/10/25, the orders were not put in because she had been running late with everything and had left the facility without putting them in. RN B reported she had expected that the facility wound care nurse would enter them the next morning. However, RN B reported that the Wound Care Nurse had not put the orders into PCC on the next day, as she typically did, and quit working at the facility that day (02/11/25). RN B stated she put the wound care orders from 02/10/25 in the EHR on 02/12/25 when she realized they were not put in. RN B reported that on 02/17/25 she did wound care rounds with Physician A and received his orders on 02/18/25. RN B stated she should have placed these orders in the EHR on 02/18/25 and thought she did. RN B reported she was not sure why those orders were not placed in the EHR until 02/20/25. RN B reported that not having new wound care orders put in place could put the resident at risk for delayed wound healing.<BR/>In an interview on 02/28/25 at 3:30 PM, the DON reported that she expected staff would enter and implement wound care orders when they were received by the physician, and that a delay could result in a delay in a wound healing.<BR/>In an interview on 02/28/25 at 2:26 PM, Physician A reported that Resident #1's wound prognosis had changed from when he assessed him on 02/10/25 (fair prognosis) to the 02/17/25 (poor prognosis). Physician A reported that Resident #1's wound had changed from a Stage II to an unstageable wound during that time and that he considered an unstageable wound to be more severe than a wound that is a Stage II. Physician A reported that in the case of Resident #1, when he saw him on 02/17/25 the wound was unstageable due to eschar (a layer of dead, dried tissue that forms over a wound or burn) that limited assessment. Physician A stated this decline may have been related to the resident's size (obesity) and his near complete dependence in care. Physician A reported that when he made rounds with a nurse each week, he told them what he ordered, what he was changing, and later that day gave them written orders. Physician A stated his expectation was that the order would be entered into PCC right away so that any new wound care orders would begin the next day. Physician A reported he had no knowledge of any orders being entered days after he had written them. Physician A stated it was not ideal if it took several days for an order to be entered and implemented. Physician A reported that while he couldn't say for sure what caused Resident #1's wound deterioration, he stated this delay could be one of the contributing factors.<BR/>In an interview on 2-28-2025 at 6:40 PM, the DON stated when a resident admitted into the facility with a wound, the process was the admitting nurse would do an assessment, fill out the assessment form in detail, notify the wound care nurse, DON, and the wound care doctor. After that, the facility would get an order from the doctor. The DON stated when the admitting nurse sees a wound on a new resident her expectation was for the doctor to be contacted immediately and get orders from the doctor. The DON said the admitting nurse was responsible to see that this happened. The DON stated her expectation was that nurses make notes and put in the Resident's Care Plan when they have wounds. <BR/>Record review of the facility's policy dated 2001 (Revised April 2018) and titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol reflected, The nursing team member and practitioner will assess and document and individual's significant risk factors for developing pressure ulcers; and shall describe and document/report the following .a. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue . The policy also stated that, the team member and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions and the physician will order pertinent wound treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable well-being for one resident (Resident #54) of seven residents reviewed for care plans. The facility failed to complete care plans addressing Resident #54's behavior of picking and scratching at wounds on her arm, or her skin condition. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs.Findings included: Review of Resident #54's face sheet, dated 07/22/25, reflected she was an [AGE] year-old female, admitted on [DATE], with diagnoses which atopic neurodermatitis (a type of eczema which causes intense itching, leading to thick, leathery patches of skin), stroke affecting her left side, and anxiety disorder. Review of Resident #54's admission MDS assessment, dated 06/17/25, reflected she was usually able to understand others, and was usually able to be understood. She had a BIMS score of 13, indicating intact cognition. The document reflected no concerns regarding her mood, mental status, or behavior. Resident #54 used a wheelchair, and had one-sided impairment. While Resident #54 was noted to be at risk for skin breakdown, no skin issues were noted in the document. Review of Resident #54's Medication Administration Records and Treatment Administration Record from her admission on [DATE] through 06/22/25 reflected no orders having to do with the care of the resident's skin problem on her arms, or her behavior of picking and scratching. Review of Resident #54's order summary, dated 07/24/25, reflected an order for Triple Antibiotic External Ointment (Neomycin- Bacitracin-Polymyxin) Apply to Left outer elbow topically two times a day for Skin tear, started on 07/23/25. Review of Resident #54's care plans reflected the following:- The resident has an ADL self-care performance deficit r/t Date Initiated: 06/04/2025 The resident will maintain current level of function in [sic] through the review date. Date Initiated: 06/04/2025 Revision on: 07/22/2025 Target Date: 09/18/2025 BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 06/04/2025 (.) PERSONAL HYGIENE: The resident requires (SPECIFY assistance) by (X) staff with personal hygiene and oral care. Date Initiated: 06/04/2025- The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t Date Initiated: 06/04/2025- The resident will maintain or develop clean and intact skin by the review date. Date Initiated: 06/04/2025 Revision on: 07/22/2025 Target Date: 09/18/2025 Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Date Initiated: 06/04/2025 Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 06/04/2025 Pad bed rails, wheelchair arms or any other source of potential injury if possible. Date Initiated: 06/04/2025 An interview and observation on 07/22/25 at 10:51 AM with Resident #54 revealed her to be alert, and sitting in her wheelchair in her room. Resident #54 had two round scabbed areas, surrounded by flaky skin (approximately the size of a dime, including the flaky areas), and a vaguely rectangular spot of open skin approximately a centimeter and a half wide, and three centimeters long, appearing like the skin had been scraped off. When asked about the sores on her arm, the resident started to scratch and pick at one of the round areas, and explained she was a picker and that she fell at home, before she came to the facility, and scraped a bunch of skin off. She said it never healed all the way, because she constantly scratched and picked at them. Resident #54 said they would get better, then get bad again, because she could not leave them alone. She said the facility had wrapped her arm, to help her remember to leave the wounds alone, but it itched so she took it off. She did not remember if they had tried anything else. She said she was not upset by the sores, and she had always been a picker. An interview on 07/23/25 at 2:59 PM with RN A revealed she thought Resident #54 had problems with her skin on her arm when she was admitted . She said it would heal, then she would pick and scratch at it, and it would open up again. She said they wrapped her arm sometimes to discourage her from picking it, but she took the wrap off. An interview on 07/23/25 at 3:18 PM with CNA B revealed he was not sure how long Resident #54 had the problem with her skin on her arm, but he remembered that it was an on-going issue with her, and it got better, then it got worse again. An interview and observation on 07/24/25 at 10:14 AM with Resident #54 revealed the open wound on her arm appeared to be missing more skin than on previous observation, and she was actively scratching her arm when the surveyor entered the room. Her arm, in the area of the wound, had developed some redness (a possible sign of infection.) She was wearing a fabric sling on her left arm. She said she thought it was to keep her from scratching, but she did not like it, because it hurt her neck, and gave her a headache. She said the nurse said it looked like the open sore might be getting infected, so she called the doctor about it. An interview on 07/24/25 at 10:16 AM with the DON revealed she knew they had been addressing Resident #54's arm, and she thought they tried a sleeve before, but the resident did not like it because she felt like it was squeezing the top of her arm, and took it off, just like she took off the wraps. She felt the resident also simply did not like being unable to pick at her sore. She said they had called the Nurse Practitioner about the issue and would continue to try different things. She said the resident was able to communicate well with them, and she thought they would be able to find something that worked. An interview on 07/25/25 at 10:20 AM with ADON C revealed she was the person who had been working with Resident #54 about her arm. She said the sling was not to keep her from scratching, but because she could not hold that arm up, and she would let it hang outside her power wheelchair, and run into doorways and walls with it, re-opening the wound on her arm. They hoped the sling would help her keep her arm pulled up. She did say the resident complained about it putting pressure on her neck, so she moved the strap to the edge of her shoulder, and asked if they could try it there, so it would not push on her neck. The ADON said she noticed that morning that it looked like it might be getting infected, so she called the Nurse Practitioner. An interview on 07/24/25 at 1:42 PM with MDS revealed she wrote the care plans under the direction of the DON, since she was an LVN. She said she updated them upon completion of the MDS assessments, but the acute care plans were mostly done by the DON or ADON, and if something came up between the MDS assessments, they usually took care of those care plans. She said the behavior of picking at skin and causing open wounds should be care planned. MDS said the point of the care plans was for everyone to be on the same page about resident care. An interview on 07/24/25 at 1:55 PM with ADON C revealed the ADON role was new to her, and she had only been doing it for about six weeks, so she was still learning the job duties. She said she had not, at the time of the interview, been informed that writing care plans was one of her duties, and she had not reviewed them. She said the reason individualized care plans were important was to make sure the residents were getting care that was specialized for them. An interview on 07/24/25 at 2:02 PM with the DON revealed Resident #54 had not had the problem with her skin the entire time, but she did have a behavior of scratching and picking, and that should have been care-planned. She was not aware that Resident #54's care plan was not individualized. She said MDS was overall responsible for making sure care plans were accurate and updated, and was the one who reviewed them before the DON signed them. She said she signed them for completion, but not accuracy. An interview on 07/25/25 at 2:51 PM with the Administrator revealed the IDT was responsible for keeping the care plans updated and individualized. She said the risk of them not being kept up to date and not being individualized was that the residents might not get the services they needed. Review of the facility policy Care Plans, Comprehensive Person-Centered, revised December 2016, reflected Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: l. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. (.) 7. The care planning process will: (.) b. Include an assessment of the resident's strengths and needs; (.) 8. The comprehensive, person-centered care plan will:a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident 's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (.) g. Incorporate identified problem areas; (.) h. Incorporate risk factors associated with identified problems; 1. Build on the resident's strengths; J. Reflect the resident's expressed wishes regarding care and treatment goals; k. Reflect treatment goals, timetables and objectives in measurable outcomes; I. Identify the professional services that arc responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; (.) o. Reflect currently recognized standards of practice for problem areas and conditions. (.) 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. (.) 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. (.) 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (.). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for elopement. <BR/>The facility failed to ensure Resident #1, who resided in the secure unit, was provided with adequate supervision to prevent elopement and as a result the resident sustained a laceration to his forehead after falling from his wheelchair and was sent to the hospital for treatment. <BR/>An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. <BR/>This failure could place residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Review of Resident #1's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included aphasia, non-Alzheimer's dementia, cerebrovascular accident, and hemiparesis. The MDS reflected the resident's cognition was severely impaired with a BIMS of 0, the resident sometimes understood others, and he sometimes was understood by others with clear speech. <BR/>Review of Resident #1's care plan initiated on 11/09/21 and revised on 03/31/23 revealed Resident #1 was at risk for self-harm and injury related to wandering and attempted elopement related to cognitive impairment and lack of safety awareness. The care plan goals for Resident #1 included wandering within the locked unit and maintaining his safety through the next review date.<BR/>Review of Resident #1's Wandering Risk Scale assessment dated [DATE] revealed he was a high risk to wander. <BR/>Review of Resident #1's Memory Care Unit Continued Stay Review dated 01/23/23 revealed the following:<BR/>Resident habitually wanders or would wander out of the building, and would not be able to find way back Resident continues to meet criteria for placement on the Memory Care Unit <BR/>Review of the facility's Provider Investigation Report dated 02/24/23 reflected the following:<BR/>Resident was last observed by staff member at approximately 2:30-2:40pm per staff interview and was returned to the facility at approximately 2:53pm. Resident was noted to be in his wheelchair sitting next to the exit door just prior to his exit. Nurse was at station charting and did not observe resident exit the facility. He was informed by an employee on her way home that resident was outside the facility in the far end of the parking lot at the entrance of the neighboring property. Employee brought the resident back to the facility and informed the charge nurse <BR/> .He was noted to have a laceration approximately 2cm and was treated at [the hospital ER] with dissolvable stitches <BR/>Review of Resident #1's progress notes dated 02/18/23 documented by LVN A revealed the following:<BR/>Resident went out of the building, found by a staff member and brought back to the unit with lacerations to the left side of the head. This nurse cleaned the lacerations with wound cleanser, stopped the bleeding and applied dry dressing Called 911 an sent resident to [hospital] Resident returned to unit from the ER at 10:11 pm. Stitches and derma bond put on lacerations <BR/>Observation on 04/20/23 at 10:45 AM of the secure unit revealed it consisted of one long hall with a dining room/activity room and a nurses' station coming off the hall. The unit had a main entrance, and exit door to the back of the facility, and a third exit to the patio, that also had an exit door to the outside of the facility. All three doors were equipped with a keypad which required a code to exit. <BR/>Observation and interview on 04/20/23 at 10:51 AM revealed Resident #1 was in the hallway sitting in a wheelchair at the end of the secure unit hall about 10 feet from the back exit door. The resident was primarily Spanish speaking and was asked if he had left the facility. He said he left about one to three months prior, but he was found and brought back to the facility by a woman after he fell from his wheelchair and was bleeding from his face. Resident #1 said he had put in the code to the door that led into the patio and entered the code again to the outside gate. Resident #1 wheeled himself on the sidewalk and did not notice there was loose gravel and fell over on the floor in his wheelchair. Resident #1 further stated there was a man that was going to give him a ride over there to pay traffic tickets to renew his driver's license so he could get back to work. The resident said after his fall he was taken to the hospital. Further observations of the secure unit revealed many of the resident were ambulatory or were able to self-propel in their wheelchairs. There were some residents that were wandering in the dining room, but none were observed to be exit-seeking or pushing on any of the doors. <BR/>Review of Resident #1's hospital records dated 02/18/23 reflected the following:<BR/>Reason for visit: Fall<BR/>Diagnosis: facial laceration<BR/>Further review of Resident #1's hospital records revealed there were no other details about of the extent of his lacerations or treatments. <BR/>Interview on 04/20/23 at 2:13 PM with the PTA revealed she was leaving the facility (02/18/23) after work around 2:30 PM and was driving down the road in front of the facility when she saw a man who appeared to be standing from his wheelchair at the bottom of one of the facility's entrances, near an adjacent business. The resident looked familiar, so she turned around and realized it was Resident #1 who was already sitting in his wheelchair bleeding from his face from a big face gash. The PTA asked Resident #1 what happened but because he was not able to speak English well, he just kept pointing to the corner of the street. She then pushed the resident back to the facility, and the staff told her they did not know how the resident got out of the secure unit, but they were going to call 911 and have him sent out for treatment. <BR/>Interview on 04/20/23 at 1:27 PM with LVN A revealed he was in the dining room with other residents in the secure unit when the PTA brought Resident #1 back, bleeding from his face. LVN A did not realize the resident had left the unit, and he did not know how the resident had gotten out. LVN A asked the resident about the incident, and Resident #1 would only smile. He said they thought Resident #1 had exited through the back exit door because at that time of the elopement, the back door was being used as an exit only door due to COVID-19 precautions. LVN A also thought someone might have gone out the back door and not verified the door had securely closed when the resident exited the facility. Prior to the COVID-19 outbreak, the back door was never used by staff per LVN A. He said after Resident #1's elopement, all the codes to the unit's doors were changed, there was a door alarm installed on the back exit door, and all residents were to be monitored more closely if they were by an exit door. <BR/>Interview on 04/20/23 at 3:28 PM with CNA C revealed she was working the day Resident #1 eloped from the secure unit. She said she was caring for another resident but remembered seeing Resident #1 not long before he was brought back by the PTA. She said normally Resident #1 sat by the back exit door or the dining room. CNA C said she saw LVN trying to clean Resident #1 face because he was bleeding before he was sent to the hospital. The CNA was not aware how the resident got out of the unit, but she was told Resident #1 had left out the back exit door. She said the back door was being used as COVID-19 exit only door during one of their outbreaks. CNA C further stated all the codes had been changed to the exit doors, an alarm was installed on the back exit door, they were educated to monitor the residents more closely, especially Resident #1. <BR/>Interview on 04/20/23 at 1:27 PM with LVN B revealed Resident #1 had a history of going to the exit doors; however, once the resident realized a door would not open, the resident would leave the door alone. LVN B stated Resident #1 had never eloped in the past that he was aware of. LVN B further stated after Resident #1 eloped, all codes to the doors were changed, an alarm was added to the back exit door and all residents were to be monitored more closely, especially Resident #1. <BR/>Interview on 04/20/23 at 2:50 PM with the ADON revealed she was told Resident #1 had eloped from the secure unit and fallen off a step outside and sustained a laceration. She was unaware of the resident having an elopement history but to prevent further incidents, all codes to the doors were changed, and alarm was installed on the back exit door to sound any time it was opened, and increased resident checks and activities to keep them busy.<BR/>Interview on 04/20/23 at 1:01 PM with the Administrator revealed once she was told about Resident #1's elopement, she went and spoke with the resident as she was Spanish speaking also. The resident told the Administrator he had gotten out of the unit by pushing on the door but did not elaborate after that. The Administrator said the back exit door had a 15 second release lock and they thought he held the handle until the lock released, allowing him to exit the facility. She also said staff told her Resident #1 often sat by the back exit door, so they assumed that was where he had gotten out of. After the elopement, all the codes to the unit doors were changed, an alarm to the back exit door was added to sound anytime it was opened, and all staff were in-serviced to closely monitor the residents especially Resident #1. <BR/>Review of the facility's policy titled Wandering and Elopements revised March 2019 reflected the following:<BR/>The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environments for residents.<BR/>An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. <BR/>The facility took the following actions to correct the non-compliance prior to the investigation:<BR/>Review of in-service records dated 02/18/23 through 02/23/23 revealed all nursing staff were educated on missing persons, wandering, elopement, abuse/neglect, and resident rights. Those in-services consisted of ensuring doors are closed and locked, new alarm on back door, and closely monitoring the residents especially residents with increased wandering. All staff working the secure unit were given the new codes to the exit doors. <BR/>Interviews were conducted with six CNAs, four LVNs, one PTA, and an ADON on 04/21/23 from 9:00 AM to 4:00 PM from various shifts. The staff were able to identify and monitor wandering/exit seeking residents, new codes to the exit doors, and made aware of the new back door alarm to sound when opened. <BR/>Observation on 04/20/23 at 9:30 AM revealed the back exit door had an alarm installed to sound if and when it was opened, and new door codes were verified to make sure they were not the same ones at that time of the elopement on 02/18/23. <BR/>Interview on 04/21/23 at 10:00 AM with Resident #1 revealed he did not recall the codes to the doors because the number he gave did not match the current codes to any of the doors. <BR/>The records revealed a plan of action had been initiated to include supervision prior to entry on 04/18/23. Review of the following reflected the facility was in compliance on 02/23/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status and/or a need to alter treatment significantly for 1 of 2 residents (Resident #2) reviewed for resident rights. <BR/>The facility failed to notify Resident #2's representative and/or family, on 5-3-2025, as appropriate of a significant change in Resident #2's mental status. <BR/>This failure could prevent their representative's authority from being notified or exercised preventing them from receiving competent choices.<BR/>Findings included:<BR/>Record review of Resident #2's Face Sheet dated 2-28-2025 revealed an [AGE] year-old female with an initial admittance date of 5-14-2019. Resident #2's primary diagnosis was dementia without psychotic disturbance (cognitive decline characteristic of the condition, but does not exhibit symptoms of psychosis, such as hallucinations or delusions) with secondary diagnoses in part of diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), auditory hallucinations (hearing sounds or voices that are not present in the real world), cerebral infarction (stroke where blood flow to the brain is interrupted, leading to the death of brain cells), and schizoaffective disorder (a mental health disorder causing hallucinations, delusions, disorganized thinking and speech) having an onset date of 5-3-2023. <BR/>Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating being cognitively intact. <BR/>Record Review of Resident #2's Care Plan dated 2-17-2022 revealed Resident #2 was care planned to use psychotropic medications on 2-17-2022 for hallucinations and explosive disorders. <BR/>Record review of Resident #2's Psychotropic Drug Regimen Review dated 12-31-2024 revealed Prozac, Risperdal, and Trileptal were ordered on 2-15-2023.<BR/>Record review of a Medical Power of Attorney/Living Will dated 5-5-2014, revealed Family Member A had a medical power of attorney for Resident #2. <BR/>In an interview on 2-28-2025 at 11:00 AM it was revealed Family Member A was Resident #2's Medical Power of Attorney. Family Member A stated she was never informed or consulted that Resident #2 had been diagnosed with any type of Schizophrenia and was not told she was put on the drug Risperidone. Family Member A said the last 1.5 years of Resident #2's life, dementia was so bad she could not turn off her phone nor be competent enough to sign for new drug treatments. <BR/>Record review of Resident #2's Psychiatric Care Notes dated 4-26-2023 indicated Resident #2 was assessed with having Bipolar Disorder. <BR/>Record review of Resident #2's Psychiatric Care Notes dated 5-2-2023 indicated Resident #2 was assessed with having Bipolar Disorder with episode manic severe with psychotic features.<BR/>Record review of Resident #2's Psychiatric Care Notes dated 5-3-2023 indicated Resident #2 was assessed with having Bipolar Disorder, Schizoaffective Disorder, and Dementia. 5-3-2023 Psychiatric Care Notes failed to indicate the facility notified Resident #2's representative(s) and/or family when there was a significant change in the resident's physical, mental, or psychosocial status. <BR/>Record review of Resident #2's Progress Notes in 5-2023 failed to indicate Resident #2's representative(s) and/or family about the diagnosis of Schizoaffective Disorder. <BR/>Record Review of Resident #2's Consent for Antipsychotic Medication Treatment HHS Form 3713 dated 6-1-2023, revealed Resident #2 signed the form for the treatment of Schizoaffective Disorder, Auditory Hallucinations, and to take the drug Risperidone. The form failed to state notification to Resident #2's representative(s) and/or family of this change in the treatment or diagnosis of Resident #2 <BR/>Record review of Resident #2's Progress Notes dated 6-7-2023 indicated that Resident #2 had a Medical Power of Attorney and Living Will on file with the facility. <BR/>Record review of Resident #2's Progress Notes dated 6-15-2025 titled Care Conference failed to include notice to Family Member A or any POA for Resident #2<BR/>Record review of Resident #2's Doctor's Orders revealed Resident #2 was put on hospice care on 2-13-2025.<BR/>Record review of Resident #2's Nursing Home and Swing Bed Tracking MDS dated [DATE] revealed Resident #2 died at the facility on 2-16-2025. <BR/>In an interview with the DON on 2-28-2025 at 6:40 PM, it was revealed that the DON expected the facility to notify a resident's representative or family whenever there was a change in a diagnoses or treatment. The DON stated she remembered Resident #2 had a lot of behavior problems. The DON stated the facility took over the current building in 2021 and it seemed at though the family of Resident #2 stopped signing forms for Resident #2 at that point in time. The DON stated the facility had the resident sign for consent for changes in diagnoses and treatment because she was her own responsible party. The DON said the potential harm that can come to a resident for not notifying her representatives or family could be the resident might decline where she may not be competent to sign for medications for herself. <BR/>Record review of the facility's Resident Rights Policy dated 2001 and revised in 2016 stated: Policy Interpretation and Implementation<BR/>1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/>c. be free from abuse, neglect, misappropriation of property, and exploitation .<BR/>f. communication with and access to people and services, both inside and outside the facility;<BR/>g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .<BR/>k. appoint a legal representative of his or her choice, in accordance with state law .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #1) reviewed for wound care services.<BR/>The facility failed to enter the wound care physician's orders given on 2-10-2025 until 2-13-2025, did not put the physician's orders that were given on 2-17-2025 until 2-20-2025, according to the TAR. Treatment for the wound did not start until the dates the orders entered, according to the TAR. <BR/>The facility failed to obtain orders for wound care when Resident #1 admitted to the facility on [DATE], from the hospital, with a stage II pressure injury to his buttocks. Wound care orders were not obtained until 2-10-2025 and not entered into the EHR System until 2-13-2025. Wound care orders were changed on 2-17-2025 and not entered into the EHR System until 2-20-2025. According to the TAR, treatment for Resident #1's wound did not start until the dates the orders were entered into the EHR System. Between 2-10-2025 and 2-17-2025, Resident #1's prognosis had changed from fair prognosis to poor prognosis. The wound was noted as a stage II pressure injury on 2-10-2025 and progressed to an unstageable pressure injury on 2-17-2025. <BR/>Findings included: <BR/>Review of Resident #1's Face Sheet dated 02/05/25 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses in part included hypertension (elevated blood pressure), neurogenic bladder (lack of bladder control due to brain, spinal cord, or never problem), quadriplegia (paralysis affecting all limbs and body from the neck down), diabetes (disease affecting the body's use of sugar), obesity (complex disease involving having too much body fat), and ulcer of the right buttocks, stage II (shallow, open wound that has broken through the top layer of skin and part of the layer below).<BR/>Record review of Resident #1's Care Plan Report dated 1-29-2025 and revised on 2-17-2025 revealed actual impairment to skin integrity pressure injury to the sacrum r/t immobility, disease process upon admission. <BR/>Record review of Resident #1's Hospital Records dated 1-29-2025 at 10:33 AM revealed an admission date of 8-26-2024 and a discharge date of 1-29-2025. The record indicated Resident #1 had a stage 2 pressure injury to his right buttock upon discharge. <BR/>Record review of Resident #1's Nurse Note dated 1-29-2025 at 5:21 PM revealed a skin assessment was performed indicating bilateral buttocks redness observed upon admission into the facility. <BR/>Record review of Resident #1's Weekly Skin Observation Tool dated 2-7-2025 indicated Resident #1 had a pressure ulcer on his sacrum area. <BR/>In a review of Resident #1's wound care notes on 2-25-2025, dated 2/10/25, Physician A noted that Resident #1's coccyx wound was a Stage II wound with fair prognosis and that resident was receiving a dressing including calcium alginate. Review of Resident #'1s TAR reflected that the resident did not begin receiving this treatment until 2/13/25.<BR/>In a review of Resident #1's wound care notes on 2-25-2025, dated 02/17/25, Physician A noted that Resident #1's coccyx wound had increased in size, was unstageable, and the wound dressing would now include applying a generous amount of honey to the calcium alginate. Physician A's prognosis was poor. Review of Resident #1s TAR reflected that the resident did not begin receiving this treatment until 2/21/25.<BR/>In an interview on 2-25-2025 at 3:50 PM, RN B (ADON) stated she conducted the Weekly Skin Observation Tool dated 2-7-2025 on Resident #1. RN B said she noted seeing a pressure injury on Resident #1's sacrum but did not indicate what stage it was on the form. RN B said the facility had a standing order when a pressure wound is first observed, nurses can use a barrier cream on the wound area and did so on Resident #1. RN B stated however, the facility does not document using barrier cream. <BR/>RN B stated the wound care doctor saw and assessed Resident #1's pressure injury on his sacrum on 2-10-2025. RN B said the facility's wound care nurse resigned, at the beginning of February, and the ADON's were making rounds with Physician A when he came to the facility. RN B said she believed Resident #1's pressure wound was worsening due to other disease processes, he was not able to move on his own, and did not like to be repositioned at times. RN B stated Resident #1 was receiving wound care treatment once a day. RN B stated the last time she saw Resident #1's pressure wound, to his sacrum, was on 2-10-2025 and it looked yellowish with redness. <BR/>In an observation on 02/28/25 at 11:15 AM, RN B provided wound care treatment to Resident #1. She was noted using appropriate PPE, infection control practices, wound care techniques, and following physician orders. The coccyx wound based appeared moist, the wound crossed the gluteal cleft (both right and left buttocks) and was unstageable (the presence of eschar [a piece of dead tissue, usually appearing as a dry, crusty, and often dark-colored scab] was noted). The resident tolerated well.<BR/>In an interview on 02/28/25 at 2:24 PM, RN B reported that she would put in PCC, the wound care orders when she was the one who did the rounds with Physician A. RN B reported that Physician A would tell her the changes he was making during the rounds, and then email the orders to her later the same day. RN B reported the nurse who attended the wound care rounds with Physician A, would then put the orders into PCC that day or the following morning if they had already left the facility for the day. RN B reported that when Physician A came to the facility on 2/10/25, the orders were not put in because she had been running late with everything and had left the facility without putting them in. RN B reported she had expected that the facility wound care nurse would enter them the next morning. However, RN B reported that the Wound Care Nurse had not put the orders into PCC on the next day, as she typically did, and quit working at the facility that day (02/11/25). RN B stated she put the wound care orders from 02/10/25 in the EHR on 02/12/25 when she realized they were not put in. RN B reported that on 02/17/25 she did wound care rounds with Physician A and received his orders on 02/18/25. RN B stated she should have placed these orders in the EHR on 02/18/25 and thought she did. RN B reported she was not sure why those orders were not placed in the EHR until 02/20/25. RN B reported that not having new wound care orders put in place could put the resident at risk for delayed wound healing.<BR/>In an interview on 02/28/25 at 3:30 PM, the DON reported that she expected staff would enter and implement wound care orders when they were received by the physician, and that a delay could result in a delay in a wound healing.<BR/>In an interview on 02/28/25 at 2:26 PM, Physician A reported that Resident #1's wound prognosis had changed from when he assessed him on 02/10/25 (fair prognosis) to the 02/17/25 (poor prognosis). Physician A reported that Resident #1's wound had changed from a Stage II to an unstageable wound during that time and that he considered an unstageable wound to be more severe than a wound that is a Stage II. Physician A reported that in the case of Resident #1, when he saw him on 02/17/25 the wound was unstageable due to eschar (a layer of dead, dried tissue that forms over a wound or burn) that limited assessment. Physician A stated this decline may have been related to the resident's size (obesity) and his near complete dependence in care. Physician A reported that when he made rounds with a nurse each week, he told them what he ordered, what he was changing, and later that day gave them written orders. Physician A stated his expectation was that the order would be entered into PCC right away so that any new wound care orders would begin the next day. Physician A reported he had no knowledge of any orders being entered days after he had written them. Physician A stated it was not ideal if it took several days for an order to be entered and implemented. Physician A reported that while he couldn't say for sure what caused Resident #1's wound deterioration, he stated this delay could be one of the contributing factors.<BR/>In an interview on 2-28-2025 at 6:40 PM, the DON stated when a resident admitted into the facility with a wound, the process was the admitting nurse would do an assessment, fill out the assessment form in detail, notify the wound care nurse, DON, and the wound care doctor. After that, the facility would get an order from the doctor. The DON stated when the admitting nurse sees a wound on a new resident her expectation was for the doctor to be contacted immediately and get orders from the doctor. The DON said the admitting nurse was responsible to see that this happened. The DON stated her expectation was that nurses make notes and put in the Resident's Care Plan when they have wounds. <BR/>Record review of the facility's policy dated 2001 (Revised April 2018) and titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol reflected, The nursing team member and practitioner will assess and document and individual's significant risk factors for developing pressure ulcers; and shall describe and document/report the following .a. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue . The policy also stated that, the team member and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions and the physician will order pertinent wound treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #1, #12, and #47) of nineteen residents reviewed for call lights. <BR/>The facility failed to ensure Residents #1, #12, and #47 had cords attached to their call lights so that they could pull the call light switch to activate it when they needed assistance.<BR/>This failure could place the residents at risk of falling, injury, and feelings of low self-worth due to not being able to call for help. <BR/>Findings included:<BR/>A Review of Resident #1's face sheet, dated 06/13/24, reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included syndrome of inappropriate antidiuretic hormone secretion a condition in which high levels of hormones cause the body to retain water, glaucoma in both eyes is an eye disease that causes vision loss, seizures, high blood pressure, cataract in both eyes and paranoid schizophrenia is a disease in which the mind does not agree with reality. Resident #1 was a full code, code status. <BR/>Review of Resident #1 care plan on 06/12/24 reflected Resident #1 had communication impaired r/t dementia. The goal was for Resident #1 to make basic need known by signs and gestures. The intervention included to anticipate his needs and meet them and to ensure/provide a safe environment. Call light in reach. Resident #1 was also care planned for falls r/t walking and balance and poly medications. Goal was Resident #1 would be free of falls. Interventions were be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Care plan initiated 08/22/22, revision 01/29/24.<BR/>B. Review of Resident #12's face sheet, dated 06/13/24, reflected a [AGE] year-old male that admitted to the facility on [DATE]. His diagnoses included cerebral infarction (stroke), muscle weakness, seizures (epilepsy), reflux, paranoid schizophrenia is a disease in which the mind does not agree with reality, high blood pressure (HTN) and heart disease without chest pain.<BR/>Resident #12 had a code status of Full Code. <BR/>Review of Resident #12 quarterly MDS dated [DATE], reflected a BIMS sore of three indicating severe cognitive impairment.<BR/>Review of Resident #12 care plan on 06/12/24, reflected Resident #12 was a High risk for falls related to medications, high blood pressure, confusion, and Alzheimer. Goals included Resident #12 would be free from falls and he would be free of minor injury. The Intervention was Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Care plan initiated on 03/29/22, revision on 02/28/24 with a target date 03/09/24. <BR/>C. Review of Resident #47's face sheet, dated 06/13/24, reflected a [AGE] year-old male that admitted to the facility on [DATE]. His diagnoses included dementia a condition of cognitive decline, high blood pressure, uncontrolled blood sugars (diabetes mellitus), eye problem due to diabetes, left arm fracture, and age related macular degenerative in both eye is an eye disease that causes vision loss in both eyes. Resident R47 was his own responsible party and had a code status of Full Code.<BR/>Review of Resident #47 quarterly MDS dated [DATE], reflected a BIMS sore of three indicating severe cognitive impairment.<BR/>Review of Resident #47 care plan on 06/12/24, reflected Resident #47 had ADL self-care performance deficit r/t weakness and impaired cognition. The goal was to maintain current level of function in through the review date. Interventions included encourage the resident to use bell to call for assistance. Care plan initiated 09/21/22 and target date 06/11/24. Resident #47 had fall care plan r/t impaired mobility and impaired cognition. Goal was not to sustain significant injury through the review date. Interventions were Be sure the resident's call light is within reach and encourage the resident to use it or assistance as needed. The resident needs prompt response to all requests for<BR/>assistance. Resident #47 also care planned for musculoskeletal impaired r/t left shoulder fracture. The goal was to remain free of complications related to left shoulder fracture (blood clot, contracture, immobility). Interventions included Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Care plan initiated 09/21/22, revision 06/26/23, target date 06/11/24.<BR/>Observation on 06/11/24 at 10:29 AM revealed Resident #1, #12 and #47's rooms had no call lights in the room. A brown switch box approximately five by three inches that looked like a light switch observed between bed A and bed B. The switch box was approximately five feet high from the floor. The call light switch box was placed in between bed A and bed B with an on and off button on it. There was no string attached to the switch call box to activate the call light.<BR/>In an interview with CNA H on 06/11/24 at 10:37 AM, she demonstrated how the call lights were activated she pulling a yellow string made of yarn that was tied to a hook on the switch box to activate the call light she then reset the call light to turn it off. She stated that call light system worked and a light outside room would light up when activated. CNA H stated that most of the residents did not need the call light. She stated that most of the residents did things by themselves. She stated that they went to the bathroom by themselves and dressed themselves. CNA H did not state the risk to residents not having call lights in their rooms because she said they did not use it. She stated that she made rounds very frequently.<BR/>In an interview with LVN G on 06/11/24 at 12:52 PM, he stated that call lights system had were reported to management and he was informed by the maintenance department that it was a hazard for the residents on the unit to have call lights cords because residents could tie it around themselves or chock on it on the call light cords. He stated that he believed a resident went around and removed the yellow strings attached to the call light switch boxes in the rooms. He said that he had not seen any residents use their call lights however he believed that any resident had a right to a call light. He stated the risk to the resident not having a call light was that in a moment of clarity a resident may use a call light to get help if needed.<BR/>In an interview with maintenance supervisor on 06/13/24 at 11:15 AM, he stated that he was aware of the missing strings from the call lights. He stated that the ADM had placed a work order on 06/11/24 and he had completed it. He stated that some residents went around the unit and removed the yellow strings tied to the call light switch box. He said that the call system was old and had a switch to activate and not a normal pug in with a cord call light. He stated that he had never seen a resident on that unit use a call light. He stated that a string longer than twelve feet was a hazard, and he used the facility policy when he replaced the missing strings. He did not state the risk to the residents not having call lights. He stated, the gentlemen do not use the call lights.<BR/>In an interview with ADM on 06/13/24 at 05:26 PM, she stated it was the responsibility of all staff to report to maintenance anything broken. She stated that the maintenance team was always in servicing staff on the electronic work order submission by using an external link on point care click a system used by all nursing staff. She stated that she expected to report anything broken. She stated the risk to the resident was not getting care when they needed it. She stated that residents may have periods of clarity and could operate the call light if they needed help. She also stated that it was part of regulation for residents to have call lights.<BR/>Record review of facility QAPIP reflected . call light in reach of resident (check function) .bathroom call lights function .<BR/>Record review of the facility's policy dated 12/2016, titled, Resident Rights, reflected, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. Respect and Dignity: . The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for elopement. <BR/>The facility failed to ensure Resident #1, who resided in the secure unit, was provided with adequate supervision to prevent elopement and as a result the resident sustained a laceration to his forehead after falling from his wheelchair and was sent to the hospital for treatment. <BR/>An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. <BR/>This failure could place residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Review of Resident #1's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included aphasia, non-Alzheimer's dementia, cerebrovascular accident, and hemiparesis. The MDS reflected the resident's cognition was severely impaired with a BIMS of 0, the resident sometimes understood others, and he sometimes was understood by others with clear speech. <BR/>Review of Resident #1's care plan initiated on 11/09/21 and revised on 03/31/23 revealed Resident #1 was at risk for self-harm and injury related to wandering and attempted elopement related to cognitive impairment and lack of safety awareness. The care plan goals for Resident #1 included wandering within the locked unit and maintaining his safety through the next review date.<BR/>Review of Resident #1's Wandering Risk Scale assessment dated [DATE] revealed he was a high risk to wander. <BR/>Review of Resident #1's Memory Care Unit Continued Stay Review dated 01/23/23 revealed the following:<BR/>Resident habitually wanders or would wander out of the building, and would not be able to find way back Resident continues to meet criteria for placement on the Memory Care Unit <BR/>Review of the facility's Provider Investigation Report dated 02/24/23 reflected the following:<BR/>Resident was last observed by staff member at approximately 2:30-2:40pm per staff interview and was returned to the facility at approximately 2:53pm. Resident was noted to be in his wheelchair sitting next to the exit door just prior to his exit. Nurse was at station charting and did not observe resident exit the facility. He was informed by an employee on her way home that resident was outside the facility in the far end of the parking lot at the entrance of the neighboring property. Employee brought the resident back to the facility and informed the charge nurse <BR/> .He was noted to have a laceration approximately 2cm and was treated at [the hospital ER] with dissolvable stitches <BR/>Review of Resident #1's progress notes dated 02/18/23 documented by LVN A revealed the following:<BR/>Resident went out of the building, found by a staff member and brought back to the unit with lacerations to the left side of the head. This nurse cleaned the lacerations with wound cleanser, stopped the bleeding and applied dry dressing Called 911 an sent resident to [hospital] Resident returned to unit from the ER at 10:11 pm. Stitches and derma bond put on lacerations <BR/>Observation on 04/20/23 at 10:45 AM of the secure unit revealed it consisted of one long hall with a dining room/activity room and a nurses' station coming off the hall. The unit had a main entrance, and exit door to the back of the facility, and a third exit to the patio, that also had an exit door to the outside of the facility. All three doors were equipped with a keypad which required a code to exit. <BR/>Observation and interview on 04/20/23 at 10:51 AM revealed Resident #1 was in the hallway sitting in a wheelchair at the end of the secure unit hall about 10 feet from the back exit door. The resident was primarily Spanish speaking and was asked if he had left the facility. He said he left about one to three months prior, but he was found and brought back to the facility by a woman after he fell from his wheelchair and was bleeding from his face. Resident #1 said he had put in the code to the door that led into the patio and entered the code again to the outside gate. Resident #1 wheeled himself on the sidewalk and did not notice there was loose gravel and fell over on the floor in his wheelchair. Resident #1 further stated there was a man that was going to give him a ride over there to pay traffic tickets to renew his driver's license so he could get back to work. The resident said after his fall he was taken to the hospital. Further observations of the secure unit revealed many of the resident were ambulatory or were able to self-propel in their wheelchairs. There were some residents that were wandering in the dining room, but none were observed to be exit-seeking or pushing on any of the doors. <BR/>Review of Resident #1's hospital records dated 02/18/23 reflected the following:<BR/>Reason for visit: Fall<BR/>Diagnosis: facial laceration<BR/>Further review of Resident #1's hospital records revealed there were no other details about of the extent of his lacerations or treatments. <BR/>Interview on 04/20/23 at 2:13 PM with the PTA revealed she was leaving the facility (02/18/23) after work around 2:30 PM and was driving down the road in front of the facility when she saw a man who appeared to be standing from his wheelchair at the bottom of one of the facility's entrances, near an adjacent business. The resident looked familiar, so she turned around and realized it was Resident #1 who was already sitting in his wheelchair bleeding from his face from a big face gash. The PTA asked Resident #1 what happened but because he was not able to speak English well, he just kept pointing to the corner of the street. She then pushed the resident back to the facility, and the staff told her they did not know how the resident got out of the secure unit, but they were going to call 911 and have him sent out for treatment. <BR/>Interview on 04/20/23 at 1:27 PM with LVN A revealed he was in the dining room with other residents in the secure unit when the PTA brought Resident #1 back, bleeding from his face. LVN A did not realize the resident had left the unit, and he did not know how the resident had gotten out. LVN A asked the resident about the incident, and Resident #1 would only smile. He said they thought Resident #1 had exited through the back exit door because at that time of the elopement, the back door was being used as an exit only door due to COVID-19 precautions. LVN A also thought someone might have gone out the back door and not verified the door had securely closed when the resident exited the facility. Prior to the COVID-19 outbreak, the back door was never used by staff per LVN A. He said after Resident #1's elopement, all the codes to the unit's doors were changed, there was a door alarm installed on the back exit door, and all residents were to be monitored more closely if they were by an exit door. <BR/>Interview on 04/20/23 at 3:28 PM with CNA C revealed she was working the day Resident #1 eloped from the secure unit. She said she was caring for another resident but remembered seeing Resident #1 not long before he was brought back by the PTA. She said normally Resident #1 sat by the back exit door or the dining room. CNA C said she saw LVN trying to clean Resident #1 face because he was bleeding before he was sent to the hospital. The CNA was not aware how the resident got out of the unit, but she was told Resident #1 had left out the back exit door. She said the back door was being used as COVID-19 exit only door during one of their outbreaks. CNA C further stated all the codes had been changed to the exit doors, an alarm was installed on the back exit door, they were educated to monitor the residents more closely, especially Resident #1. <BR/>Interview on 04/20/23 at 1:27 PM with LVN B revealed Resident #1 had a history of going to the exit doors; however, once the resident realized a door would not open, the resident would leave the door alone. LVN B stated Resident #1 had never eloped in the past that he was aware of. LVN B further stated after Resident #1 eloped, all codes to the doors were changed, an alarm was added to the back exit door and all residents were to be monitored more closely, especially Resident #1. <BR/>Interview on 04/20/23 at 2:50 PM with the ADON revealed she was told Resident #1 had eloped from the secure unit and fallen off a step outside and sustained a laceration. She was unaware of the resident having an elopement history but to prevent further incidents, all codes to the doors were changed, and alarm was installed on the back exit door to sound any time it was opened, and increased resident checks and activities to keep them busy.<BR/>Interview on 04/20/23 at 1:01 PM with the Administrator revealed once she was told about Resident #1's elopement, she went and spoke with the resident as she was Spanish speaking also. The resident told the Administrator he had gotten out of the unit by pushing on the door but did not elaborate after that. The Administrator said the back exit door had a 15 second release lock and they thought he held the handle until the lock released, allowing him to exit the facility. She also said staff told her Resident #1 often sat by the back exit door, so they assumed that was where he had gotten out of. After the elopement, all the codes to the unit doors were changed, an alarm to the back exit door was added to sound anytime it was opened, and all staff were in-serviced to closely monitor the residents especially Resident #1. <BR/>Review of the facility's policy titled Wandering and Elopements revised March 2019 reflected the following:<BR/>The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environments for residents.<BR/>An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. <BR/>The facility took the following actions to correct the non-compliance prior to the investigation:<BR/>Review of in-service records dated 02/18/23 through 02/23/23 revealed all nursing staff were educated on missing persons, wandering, elopement, abuse/neglect, and resident rights. Those in-services consisted of ensuring doors are closed and locked, new alarm on back door, and closely monitoring the residents especially residents with increased wandering. All staff working the secure unit were given the new codes to the exit doors. <BR/>Interviews were conducted with six CNAs, four LVNs, one PTA, and an ADON on 04/21/23 from 9:00 AM to 4:00 PM from various shifts. The staff were able to identify and monitor wandering/exit seeking residents, new codes to the exit doors, and made aware of the new back door alarm to sound when opened. <BR/>Observation on 04/20/23 at 9:30 AM revealed the back exit door had an alarm installed to sound if and when it was opened, and new door codes were verified to make sure they were not the same ones at that time of the elopement on 02/18/23. <BR/>Interview on 04/21/23 at 10:00 AM with Resident #1 revealed he did not recall the codes to the doors because the number he gave did not match the current codes to any of the doors. <BR/>The records revealed a plan of action had been initiated to include supervision prior to entry on 04/18/23. Review of the following reflected the facility was in compliance on 02/23/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for one (Suites Medication Room) of two medication rooms reviewed for storage and biologicals.<BR/>The facility failed to store food brought in by family or visitors with labels of resident's names, expiration date, and stored in a way that was separated and distinguishable from residents, facilities, and staff's foods in the Suites Medication Room refrigerator on 06/12/24. <BR/>This failure could affect residents by placing them at risk for food-borne illness.<BR/>Finding included:<BR/>Observation and interview with ADON on 06/12/24 at 03:06 PM, revealed Suites Medication Room had a tall white refrigerator with 3 shelves. Temperature reading 40 degrees Fahrenheit. No medications in the refrigerator. On the top shelf- were a box of thickened water, a 2-liter coke bottle in a shopping bag, a brown box opened at top, a gallon pitcher with red drink undated with a loose fitted plastic wrap, half a sandwich undated in an open sandwich bag, an ensure bottle and unidentified yellow/orange container open to one side in the back of refrigerator. On the second shelf- were a white empty grocery bag, a half bag of mixed shredded cheese, a Mrs. Freshley's honey bun (name of product) that was undated and a box of cinnamon Chex. On the last shelf- was an open twenty can Coca-Cola box with resident name on it, a large pizza box and 2 smaller pizza boxes stacked together from pizza [NAME] dated 06/07/24. A grey bag tied at top of unknown contents with no date or name. On the very bottom of refrigerator was a slightly open drawer, yellow and brown sticky substance on bottom of refrigerator and inside door shelves. ADON said that she was unsure of the food in the refrigerator belonged to the staff or residents. She said the pizzas and the 2-liter drink belonged to a resident that liked to order uber eats (an outside food delivery service). She said the nursing staff were responsible for cleaning out the refrigerator and making sure food was up to date and labelled with resident's name as applicable. She said only nursing staff had access to medication rooms refrigerators. She said the risk to the residents was eating something that could make them sick because it had expired.<BR/>In an interview with DON on 06/12/24 at 03:13PM, she stated that she was unaware of the status of the refrigerator in Suites Medication Room. She said that she would get it cleaned and start an in service with the nursing staff about labeling and dating the items in the fridge. She said the risk to the residents was eating something contaminated that could make them ill. <BR/>In an interview with the ADM on 06/13/24 at 05:266 PM, she stated that she expected all nursing staff to follow facility policy and make sure that all foods labelled with resident's name and dated. She said she expected all staff to monitor that the food was safe for human consumption. She said the risk to resident was not knowing if food was safe to eat.<BR/>Review of facility policy titled Food safety for Residents revised 12/2016 reflected . 2. Cover, label with name, date stored and the date it must be used or discard. We recommend a use by date of 3 days after the food was prepared or purchased .plastic containers with tight fitting lids are recommended .<BR/>Review of facility policy titled Cleaning & Sanitation of Refrigerators & Freezers on Units revised 12/2016 reflected . Only residents' food will be stored in the pantry refrigerators. All food will be labeled, dated, and covered. Refrigerators<BR/>Will be checked each day for any food or supplement over 72 hours old and any outdated food will be discarded .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status and/or a need to alter treatment significantly for 1 of 2 residents (Resident #2) reviewed for resident rights. <BR/>The facility failed to notify Resident #2's representative and/or family, on 5-3-2025, as appropriate of a significant change in Resident #2's mental status. <BR/>This failure could prevent their representative's authority from being notified or exercised preventing them from receiving competent choices.<BR/>Findings included:<BR/>Record review of Resident #2's Face Sheet dated 2-28-2025 revealed an [AGE] year-old female with an initial admittance date of 5-14-2019. Resident #2's primary diagnosis was dementia without psychotic disturbance (cognitive decline characteristic of the condition, but does not exhibit symptoms of psychosis, such as hallucinations or delusions) with secondary diagnoses in part of diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), auditory hallucinations (hearing sounds or voices that are not present in the real world), cerebral infarction (stroke where blood flow to the brain is interrupted, leading to the death of brain cells), and schizoaffective disorder (a mental health disorder causing hallucinations, delusions, disorganized thinking and speech) having an onset date of 5-3-2023. <BR/>Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating being cognitively intact. <BR/>Record Review of Resident #2's Care Plan dated 2-17-2022 revealed Resident #2 was care planned to use psychotropic medications on 2-17-2022 for hallucinations and explosive disorders. <BR/>Record review of Resident #2's Psychotropic Drug Regimen Review dated 12-31-2024 revealed Prozac, Risperdal, and Trileptal were ordered on 2-15-2023.<BR/>Record review of a Medical Power of Attorney/Living Will dated 5-5-2014, revealed Family Member A had a medical power of attorney for Resident #2. <BR/>In an interview on 2-28-2025 at 11:00 AM it was revealed Family Member A was Resident #2's Medical Power of Attorney. Family Member A stated she was never informed or consulted that Resident #2 had been diagnosed with any type of Schizophrenia and was not told she was put on the drug Risperidone. Family Member A said the last 1.5 years of Resident #2's life, dementia was so bad she could not turn off her phone nor be competent enough to sign for new drug treatments. <BR/>Record review of Resident #2's Psychiatric Care Notes dated 4-26-2023 indicated Resident #2 was assessed with having Bipolar Disorder. <BR/>Record review of Resident #2's Psychiatric Care Notes dated 5-2-2023 indicated Resident #2 was assessed with having Bipolar Disorder with episode manic severe with psychotic features.<BR/>Record review of Resident #2's Psychiatric Care Notes dated 5-3-2023 indicated Resident #2 was assessed with having Bipolar Disorder, Schizoaffective Disorder, and Dementia. 5-3-2023 Psychiatric Care Notes failed to indicate the facility notified Resident #2's representative(s) and/or family when there was a significant change in the resident's physical, mental, or psychosocial status. <BR/>Record review of Resident #2's Progress Notes in 5-2023 failed to indicate Resident #2's representative(s) and/or family about the diagnosis of Schizoaffective Disorder. <BR/>Record Review of Resident #2's Consent for Antipsychotic Medication Treatment HHS Form 3713 dated 6-1-2023, revealed Resident #2 signed the form for the treatment of Schizoaffective Disorder, Auditory Hallucinations, and to take the drug Risperidone. The form failed to state notification to Resident #2's representative(s) and/or family of this change in the treatment or diagnosis of Resident #2 <BR/>Record review of Resident #2's Progress Notes dated 6-7-2023 indicated that Resident #2 had a Medical Power of Attorney and Living Will on file with the facility. <BR/>Record review of Resident #2's Progress Notes dated 6-15-2025 titled Care Conference failed to include notice to Family Member A or any POA for Resident #2<BR/>Record review of Resident #2's Doctor's Orders revealed Resident #2 was put on hospice care on 2-13-2025.<BR/>Record review of Resident #2's Nursing Home and Swing Bed Tracking MDS dated [DATE] revealed Resident #2 died at the facility on 2-16-2025. <BR/>In an interview with the DON on 2-28-2025 at 6:40 PM, it was revealed that the DON expected the facility to notify a resident's representative or family whenever there was a change in a diagnoses or treatment. The DON stated she remembered Resident #2 had a lot of behavior problems. The DON stated the facility took over the current building in 2021 and it seemed at though the family of Resident #2 stopped signing forms for Resident #2 at that point in time. The DON stated the facility had the resident sign for consent for changes in diagnoses and treatment because she was her own responsible party. The DON said the potential harm that can come to a resident for not notifying her representatives or family could be the resident might decline where she may not be competent to sign for medications for herself. <BR/>Record review of the facility's Resident Rights Policy dated 2001 and revised in 2016 stated: Policy Interpretation and Implementation<BR/>1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/>c. be free from abuse, neglect, misappropriation of property, and exploitation .<BR/>f. communication with and access to people and services, both inside and outside the facility;<BR/>g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .<BR/>k. appoint a legal representative of his or her choice, in accordance with state law .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents were free from abuse for one of five residents (Resident #2) reviewed for abuse, neglect, and exploitation. <BR/>The facility failed to ensure Resident #2 was free from staff to resident abuse when CMA A slapped a glass of water out of Resident #2's hand on 4-23-2025, causing her to cry experiencing psychosocial harm. <BR/>This noncompliance was identified as a PNC. The noncompliance began on 4-23-2024 and ended on 4-30-2025. <BR/>This failure could place residents at risk for decreased quality of life, decreased self-esteem, and mental anguish. <BR/>Findings Included:<BR/>Record review of Resident #2's Face Sheet dated 5-8-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of Dementia with other behavioral disturbance (a decline in mental ability severe enough to interfere with daily life) and secondary diagnoses of Parkinsonism (a broad term encompassing various conditions that share similar movement symptoms with Parkinson's disease, such as slowness, stiffness, and tremors), Epilepsy without Epilepticus (a neurological disorder characterized by recurrent, unprovoked seizures), and Bipolar Disorder (a mental health condition characterized by extreme mood swings, including periods of intense elation or irritability (mania or hypomania) and periods of deep sadness or hopelessness). <BR/>Record review of Resident #2's Comprehensive MDS assessment dated [DATE], indicated Resident #2 had a BIMS Score of 13 which indicated she was cognitively intact. Behavioral Symptoms reflected: Physical and Verbal behavioral symptoms directed toward others 0 meaning behavior not exhibited. <BR/>Record review of Resident #2's Care Plan dated 2-10-2025 revealed Resident #2 was identified as PASRR (Preadmission screening and resident review) positive for having an intellectual disability and epilepsy and was care planned for using anti-anxiety medications. <BR/>Record review on 5-8-2025 at 10:00 AM, of the facility's Provider Investigation Report (PIR) #1005912 dated 4-30-2025, revealed CMA A was witnessed slapping a glass of water out of Resident #2's hand on 4-23-2025. The facility's self-report failed to name a time of the incident. The PIR stated FNP G sent an email of the incident to the Administrator on 4-23-2025 at 6:06 PM. The email stated FNP G was sitting across from the DON's Office, in a conference room, on 4-23-2025 at approximately 5:00 PM, when she heard Resident #2 speaking with CMA A. FNP G stated in the email the conversation between Resident #2 and CNA A started to get louder when FNP G heard Resident #2 call CMA A a bitch. CMA A responded to Resident #2 saying who are you speaking to. Resident #2 responded back to CMA A I'm speaking to myself. CMA A then responded back to Resident #2 saying You better be glad you are talking to yourself, or I will pour the cold water you are holding, on your head. FNP G stated right after that statement she heard a slapping sound and Resident #2 started crying. FNP G went to see what occurred and CMA A was picking the water cup up off the floor. CMA A then proceeded to get in Resident #2's face telling her to apologize. Resident #2 continued to cry and ask for staff to call the cops. Resident #2 then said she would throw herself on the floor. FNP G then stated staff then escorted Resident #2 to her room away from the situation. FNP G stated she asked RN E, who witnessed the incident, what occurred, and RN E said CMA A slapped the water out of Resident #2's hand. The facility's PIR stated the Administrator interviewed CMA A on 4-23-2025 at 5:30 PM and revealed CMA A said that Resident #2 had called her a bitch. CMA A then said she told Resident #2 you better not be talking to me and apologize. CMA A then said Resident #2 did not apologize to her, so I slapped the glass of water on her. She shouldn't have called me a bitch. The PIR further indicated the Administrator interviewed Resident #2 and asked Resident #2 what happened today with CMA A. Resident #2 stated I called her a bitch, and she poured the glass of water on me. It went on my shirt and on my face. I told her I was sorry. The PIR indicated the allegation of CMA A abusing Resident #2 was confirmed and CMA A was terminated. The PIR revealed abuse and neglect in-services were completed for staff on 4-30-2025 and safe surveys were completed with cognitive residents showing no additional findings of abuse. <BR/>On 5-8-2025 at 10:45 AM, record review of CMA A's background check was performed on CMA A showing a clear status. <BR/>On 5-11-2025 at 10:19 PM, an email was sent to FNP G asking FNP G to call me to speak with me about the event on 4-23-2025 between CNA A and Resident #2. No email or phone called was received from FNP G. <BR/>In an interview with CMA B on 5-8-2025 at 11:55 AM, it was conveyed that CMA B trained CMA A to be a medication aide. CMA B stated CMA A never exhibited aggressive behavior toward residents when she was training her but was a good aide. CMA B said she was told what CMA A did when she came back from vacation. CMA B said the facility did in-services on abuse and neglect covering different types of abuse (physical, verbal, punching, and mental) and neglect. Staff are supposed to redirect residents who are cussing, calling people names, or getting agitated. <BR/>In an interview and observation on 5-8-2025 at 12:00 PM, revealed Resident #2 was sitting in a wheelchair holding a cup and drinking its contents. Resident #2 was not able to recall the event with CMA A that occurred on 4-23-2025 except she said CMA A called her a bitch. Resident #2 got confused when asked further questions about the event with CMA A. <BR/>On 4-23-2025 at 3:45 PM, a phone call was made to CMA A and a voice message was left asking CMA A to return the call. A return call was never received. <BR/>In an interview with RN E on 5-8-2025 at 4:45 PM, revealed RN E witnessed the incident between Resident #2 and CMA A on 4-23-2025. RN E said Resident #2 was trying to use the land line phone at the nurse's station located in the Suites section of the facility when Resident #2 called CMA A a bitch. RN E said Resident #2 was holding a glass of water in her hand at the time when CMA A slapped the glass of water out of Resident #2's hand causing the water to go all over Resident #2 and on the floor. RN E said Resident #2 began to cry after CMA A slapped the glass of water out of her hand. RN E said she then told CMA A to leave the area and CMA A did. RN E then said Resident #2 was assessed showing no physical injuries but was emotionally upset. RN E said the facility in-serviced staff on abuse and neglect on 4-23-2025 after this incident occurred. RN E said staff are never to use physical aggression and retaliate against residents because of what they say or do. <BR/>In an interview with the DON on 5-8-2025 at 7:41 PM, it was conveyed that she expects facility staff to redirect residents when they are calling them names and not to react physically by slapping items out of resident's hands. The DON said the nurses are responsible to monitor the behaviors of the CNA/CMAs. The DON stated the risk to a resident, who got a glass of water slapped out of their hand, was that it could have caused emotional trauma, and they could have gotten physically hurt. <BR/>In an interview with the Administrator on 5-8-2025 at 7:55 PM, it was revealed she was in the building when the incident occurred between Resident #2 and CMA A. The Administrator said she interviewed CMA A immediately after the incident occurred. The Administrator said CMA A admitted to slapping the glass of water out of Resident #2's hand, and then she suspended and escorted CMA A off the facility property right after the interview. The Administrator said the nurses on duty are responsible for monitoring the behavior and interactions of the CNAs/CMAs on duty. The Administrator said the nursing staff ultimately answers to the DON. The Administrator said the potential risk to residents who get treated the way CMA A treated Resident #2 on 4-23-2025 was that it could depress residents and they could be scared. The Administrator's expectation was for staff to remain professional and not slap water out of a resident's hand when they are called names. <BR/>Record review of the facility's abuse policy titled Identifying Types of Abuse dated 2001 revised on September 2022 stated:<BR/>As part of the abuse prevention strategy, volunteers, employees, and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents .<BR/>1. Abuse of any kind against residents is strictly prohibited .<BR/>4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. <BR/>a. Abuse includes .mental, and psychosocial well-being .<BR/>b. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .<BR/>c. Abuse includes verbal abuse .and mental abuse .<BR/>Mental and Verbal Abuse<BR/>1. Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent the neglect of residents for one resident (Resident #1) of nine residents reviewed for neglect. <BR/>-The facility failed to implement the facility's written policies and procedures to prohibit and prevent neglect of Resident #1 by not providing him goods and services (insulin), without additional intervention by notifying the physician, and as a result the resident fell and sustained critical injuries. <BR/>An Immediate Jeopardy was identified on 10/13/23. While the Immediate Jeopardy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal.<BR/>This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition. <BR/>Findings included:<BR/>Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, reflected in part the following:<BR/>Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. And physical and chemical restraint not required to treat the resident's symptoms. <BR/>Policy Interpretation and Implementation:<BR/>The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:<BR/>1. Protects residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:<BR/>a. facility staff<BR/> .<BR/>5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems.<BR/>Record review of Resident #1's face sheet, dated 10/12/23, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. admitted on [DATE] and readmitted on [DATE] with diagnosed that included: Alzheimer's disease (decline in memory, thinking, and behavior), Parkinson's disease (disorder of the central nervous system), type I diabetes (insulin-dependent), anxiety disorder, cardiac pacemaker, and history of traumatic brain injury. <BR/>Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and sometimes understood others. The MDS reflected the resident required supervision and/or extensive assistance with all activities of daily living. Further review reflect Resident #1 exhibited physical, verbal, and other behavioral symptoms towards others. <BR/>Review of Resident #1's care plan, initiated on 07/11/23, reflected he had delirium and confusion related to inattention, disorganized thinking, traumatic brain injury, Alzheimer's disease, and Parkinson's disease. Interventions included direct communication with the resident, consulting with the family and interdisciplinary team to establish baseline, monitoring resident's safety, monitor/record/report new onset signs and symptoms of delirium, and provide medications to relieve agitation. Further review revealed Resident #1 was diagnosed with diabetes mellitus with interventions that included administering diabetic medication as ordered and monitoring/documenting for side effects and effectiveness, checking blood sugar as ordered, and monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia. <BR/>In an interview on 10/12/23 at 8:45 AM the DON stated Resident #1 was currently admitted to a local hospital after having an unwitnessed fall at the facility that resulted in a laceration above his left eyebrow. The DON stated Resident #1 had just returned to the facility on [DATE] after spending three days at a psychiatric hospital. She stated Resident #1 did not exhibit any behaviors upon returning to the facility, likely due to having medications in his system from the psychiatric hospital. The DON stated the resident was later found to have pulled his mattress to the floor and was sleeping there. She stated the resident would not allow staff to assist him back to bed and because he was well, they left him there. The DON stated at approximately 12:00 AM, Resident #1 was found still lying on the floor but with blood on his head, finger, and there was blood on the windowsill. She stated the incident was reported to her at approximately 5:00 AM; however, the MD had already been notified and Resident #1 was sent out to the local hospital at approximately 1:00 AM. <BR/>Observation on 10/12/23 at 9:55 AM of Resident #1, at the local hospital, revealed he was unresponsive to verbal cues and had his eyes closed. Resident #1's body was making jerking motions and the entire left side of face, including the eye, was swollen and bruised. <BR/>In an interview on 10/12/23 at 10:25 AM, NP A revealed she was the attending NP at the local hospital making rounds for the physician assigned to Resident #1. NP A stated the resident was admitted to the SCU after being found on the floor at a nursing facility from a fall with a head injury. NP A stated Resident #1 had injuries that included left side facial fractures, sinus cavity fracture, hemorrhage in the white part of his left eyeball, bleed in ventricle and subdural (brain bleed), chronic T9 fracture (mid-back), type II cervical spine fracture (neck fracture), and multiple rib fractures on left side. NP A stated Resident #1 also arrived at the hospital vomiting and severely hyperglycemic, which was also concerning. NP A stated hyperglycemia could cause disorientation and dizziness, especially at levels Resident #1 was when he arrived. She stated Resident #1 was considered stable but due to age and comorbidities his prognosis was poor. NP A stated it would be difficult for Resident #1 to recover from his injuries and his family had decided to change his code status to DNR. NP A stated Resident #1's injuries were consistent with a fall and hitting a hard surface. <BR/>Record review of EMS report, dated 10/11/23, revealed in part the following:<BR/>Date/Time symptom onset: not recorded:<BR/>Medstar was dispatched to a [AGE] year-old male for a fall in a locked down dementia unit. Staff indicate patient came back today from [local hospital]. Staff indicate he had checked patient and come back within the hour and found him down. Staff indicate patient's normal GCS 13 combative. There is feces and urine on the ground around patient. Patient has laceration above left eye and swelling around left eye and left side of face above mouth towards ear to above eyebrow. Vitals and status assessed. BGL reads high. Patient is GCS 12 at this time. Attempted to place cervical collar. EMS request DNR .facility unable to produce copy of DNR. Patient was lifted from ground double provider full assist lift to the stretcher, secured and taken to ambulance .<BR/>Patient Care Timeline:<BR/>10/11/23 at 12:21 AM-Unit notified by dispatch<BR/>10/11/23 at 12:21 AM-PSAP call<BR/>10/11/23 at 12:21 AM-Dispatch notified<BR/>10/11/23 at 12:21 AM-Unit en route<BR/>10/11/23 at 12:29 AM-Unit arrived on scene<BR/>10/11/23 at 12: 37 AM-Med device<BR/>10/11/23 at 12:37 AM- Arrived at patient .<BR/>Review of Resident #1's medical records, dated 10/11/23, from the local hospital revealed in part the following:<BR/>Patient male 72 presenting to ED today for evaluation of fall. Patient has a history of dementia baseline GCS of 13/ EMS reports likely head strike and blood on nearby windowsill. Patient has obvious ecchymosis and swelling to the left eye. No other obvious trauma. Patient nonverbal keeping eyes closed, responsive to pain. Unable to follow commands or answer questions. Covered in vomitus on arrival . <BR/>-Vital taken on 10/11/23 at 1:32 AM revealed Resident #1 was tachycardic (rapid heartbeat) with blood pressure systolic in high 90s.<BR/>-Labs collected in 10/11/23 at 1:49 AM revealed glucose level was high at 586 mg/dL.<BR/>-Imaging results completed on 10/11/23 at 6:16 AM revealed the following injuries: subdural hematoma (pooled blood in brain), acute intraventricular hemorrhage in third ventricle (brain bleed), type II closed odontoid fracture (neck fracture), closed fracture of multiple left ribs, compression fracture of T9 (mid spine fracture) that could be chronic, acute fracture through left orbital roof (bone under eye), acute fracture of the left zygomatic arch (bone on side of head/eye), and acute fracture of the anterior and posterior walls of left maxillary sinus (sinus/nasal cavity).<BR/>Review of Resident #1's progress notes dated at 10/11/23 revealed the following entries:<BR/>10/10/23 4:15 PM by RN E:<BR/>Resident returned with no new orders from Hospital, no changes noted, Hospital to fax paperwork over to facility d/t their printers were down. This nurse provided fax number and e-fax number. Left message for Nurse Practitioner. Assessed skin as resident would allow with no new skin changes or concerns noted at this time.<BR/>10/10/23 8:13 PM by RN E:<BR/>Called and left message for physician that resident returned to facility with no new orders or changes.<BR/>10/10/23 8:25 PM by RN E:<BR/>Called and left message for RP that resident had returned to facility and to return call if any concerns or questions. Staff will continue to monitor.<BR/>10/11/23 2:25 AM by LVN C:<BR/>At the unset of this shift around 10pm, it was noted that resident was lying on his mattress on the floor. The outgoing team said he pulled the mattress to the floor by himself and efforts to take back to bed failed. We tried and failed, and he was allowed to have his way. This nurse checked back on him around 11:30pm and was OK on the mattress. However, at 12midnight that this nurse went back, it was noted that the lower part of his body on the floor but also noted that he was bleeding at the left eyebrow and laceration was noted on the left eyebrow. Also noted was a small blood noted by the window. It was assumed that he was trying to get up. 911 was called and was taken to ER . He even forced paramedics to remove his neck bracelet. [RP] notified. On-call [MD] notified, and DON notified.<BR/>Record review of Resident #1's orders, dated October 2023, revealed in part the following:<BR/>-Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML. Inject 20 units subcutaneously twice daily (7AM and bedtime) for type II diabetes. Start date: 7/30/23; End date: indefinite.<BR/>-HumaLOG KwikPen 100 unit/ML Solution pen-injector. Inject per sliding scale 0-12 units subcutaneously before meals and at bedtime. Start date: 7/20/23; End date: indefinite.<BR/>Record review of Resident #1's MAR for October 2023 revealed the following:<BR/>-Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 7:00 AM was initialed and coded as not given due to resident being hospitalized .<BR/>- Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ML on 10/10/23 at 8:00 PM was not initialed or coded, indicating it was not administered.<BR/>- HumaLOG KwikPen 100 unit/ML Solution pen was last administered to Resident #1 on 10/10/23 at 4:30 PM by RN E. The resident's BGL was 330 and he required 8 units of insulin. <BR/>- HumaLOG KwikPen 100 unit/ML Solution pen on 10/10/23 at 8:00 PM was not initialed or coded, indicating blood glucose level was not checked and insulin was not administered.<BR/>-Resident #1 historically had high blood glucose levels and required administration of HumaLOG sliding scale insulin, ranging from 2-12 units. From 10/01/23-10/10/10/23, Resident#1's BGL was checked 27 times and was under 150 mg/dL 8 times where he did not require a dose of the HumaLOG. <BR/>In an interview on 10/12/23 at 12:03 PM, LVN C stated he had worked at the facility for 4 years and currently worked overnight, 10:00 PM-6:00 AM. LVN C stated he worked overnight on 10/10/23-10/11/23. He stated it was routine for him to do rounds as soon as he entered the unit as he made his way down to the nurses' station to receive report. LVN C stated when he entered Resident #1's room he noticed him sleeping on his mattress on the floor and this was unusual. LVN C stated he received report from RN E who revealed that Resident #1 had returned to the facility from the psychiatric hospital earlier that day. LVN C stated RN E did not report any behaviors or issues with Resident #1 other then her finding him sleeping on the floor and refusing to get up. He stated RN E reported the resident was fine and was left sleeping on the floor. LVN C stated RN E basically told him Good luck. LVN C stated RN E did not report any discrepancies regarding Resident #1's BGLs or insulin administration and this was not something that was done during his shift. LVN C stated something told him to check on Resident #1 more frequently because it was unusual for him to sleep on the floor. He stated he rounded on Resident #1 at 11:30 PM and he was still asleep on the floor but fine. LVN C stated he checked on Resident #1 again at 12:00 AM and he was still asleep on the floor, but he was repositioned with his lower body on the bare floor and his head on the mattress. LVN C stated he also observed blood on Resident #1's face, shirt, and hand that was coming from a laceration on the left eyebrow. He stated he looked around the room to see if the resident had moved around and he saw blood on the corner of the windowsill. LVN C stated he assumed Resident #1 had fallen and hit his head, so he did not move him. He stated Resident #1 was not responsive but was making a snoring sound like he was sleeping. LVN C stated Resident #1's room was at the end of the hall, furthest away from the nurses' station. LVN C stated he and CNA D were sitting at the nurses' station watching the monitors and had not heard any noises or seen any movement in the hallway. LVN C stated 911 was immediately called and it took EMS approximately 15 minutes to arrive. LVN C stated Resident #1 was more alert by the time EMS arrived and he had become combative. LVN C stated he would not allow EMS to place a c-collar on him. He stated EMS was able to get Resident #1 safely onto the stretcher and transported him to the hospital. <BR/>In an interview on 10/12/23 at 12:03 PM, CNA D stated she had worked at the facility for 6 months, and currently worked overnight, 10:00 PM-6:00 AM. CNA D stated she worked overnight on 10/10/23-10/11/23. She stated she received report that Resident #1 had returned to the facility from the psychiatric hospital. CNA D stated the only report about a behavior was that Resident #1 had pulled his mattress to the floor and was sleeping on it. She stated the outgoing staff were unable to get him back in bed. CNA D stated LVN C had been doing rounds on Resident #1 about every 30 mins and around 12:00 AM he was found bleeding on the floor. CNA D stated LVN C called her down to the room and she saw blood on Resident #1's face and a gash above his eyebrow. She could not recall which eyebrow it was. CNA D stated there was also blood on the floor by the closet and on the window. She stated it appeared that Resident #1 had fallen and was smearing blood as he tried to get up. She stated LVN C had called 911 and gone to another hall to get help while she remained with Resident #1. She stated Resident #1 was becoming more alert and making moaning sounds. She stated he was fully alert and grabbing at them by the time EMS arrived. CNA D stated she could normally hear commotion and noises coming from down the hallway but that night they did not hear anything. She could not recall if Resident#1's room door was closed that night, but she stated it was usually cracked open. She stated Resident #1's room was one of the furthest ones from the nurses' station. CNA D stated she worked well with LVN C and stated she had never seen him upset or aggressive towards any residents. She denied having concerns for abuse of Resident #1 by any staff or other residents. She stated Resident #1's injuries had to be from an unwitnessed fall. <BR/>In an interview on 10/12/23 at 2:32 PM, RN E stated she worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. She stated Resident #1 returned to the facility from the psychiatric hospital at approximately 4:00 PM. She stated Resident #1 exhibited his usual combative behaviors when he arrived and the transport company who brought him back to the facility also reported that he had been aggressive during the ride. RN E stated she was able to check Resident #1's BGL at 4:30 PM and administer his insulin as ordered. She stated Resident #1 was scheduled to receive his routine insulin and have BGL checked for sliding scale insulin at 8:00 PM; however, she was unable to check his BGL or administer any insulin because Resident #1 was being combative and refusing. RN E stated she left him alone to complete BGL checks for other residents then went back to attempt to check Resident #1's BGL, but he was still combative and screaming No. She stated Resident #1's BGLs usually ran high, and she could keep him calm enough to take his insulin, but she could not that time. RN E stated she thought she had documented Resident #1's behaviors and refusal of insulin as she had been trained to do; however, it was not documented. She stated she did not notify the MD or DON about the missed insulin but knew that she should have. She could not state why she did not notify them. RN E stated she informed LVN C of Resident #1's behaviors and that he had refused to take his insulin. <BR/>In an interview on 10/12/23 at 5:00 PM, CNA F stated he worked the 2:00 PM-10:00PM shift and worked on 10/10/23 with Resident #1. He stated Resident #1 had returned to the facility from the psychiatric hospital on [DATE] during his shift. He could not recall what time Resident #1 returned. CNA F stated Resident #1 was unusually calm and sleepy when he returned to the facility. He stated Resident #1 went straight to sleep and slept through most of his shift. He stated Resident #1 woke up once around 8:00 PM. CNA F stated Resident #1 was soiled and needed to be cleaned up. He stated Resident #1 was not resistive and allowed him to clean him up. CNA F stated he also gave Resident #1 his dinner at that time because he had slept through regular dinnertime. CNA F stated Resident #1 was normally restless, agitated, and aggressive so staff would let him sleep as long as he wanted and not bother him unless necessary. CNA F stated Resident #1 would be woken up for medication and if he was aggressive towards the nurse, they would call the CNAs to assist. CNA F stated RN E often called him to help keep Resident #1 calm when he became combative with her, but she did not call for his help on 10/10/23. He stated he was unaware that Resident #1 had become combative with her and refused his medication. CNA F also stated he was not aware that Resident #1 had pulled his mattress to the floor. He stated he did his last rounds at approximately 9:00 PM and did not see Resident #1 on the floor. He stated he would have placed him back in bed if he had found him on the floor. CNA F stated he was working with CNA G, and RN E had not told either of them that she had found Resident #1 on the floor either. <BR/>Record review of in-service, dated 10/12/23, conducted by the DON revealed RN E received one-on-one training in topics that included the following: medication administration and documentation. The in-service stated Anytime a nurse failed to administer routine medication or treatment, must document reasons why and notify physician. Must also be notified on 24 report for follow-up. Also notify DON of omission and reasons.<BR/>In an interview on 10/13/23 at 9:21 AM, NP B stated she worked under the facility's MD overseeing care for the residents. She stated RN E was good at keeping her informed about all residents, including Resident #1. NP B stated RN E had informed her on 10/10/23 that Resident #1 returned to the facility from the psychiatric hospital. NP B did not have any documentation and could not recall RN E reporting any behaviors or refusal of medications from Resident #1 on 10/10/23. She stated her expectation was for staff to notify her or the MD of any discrepancies with medication administration. NP B stated dizziness or delirium were typically signs of hypoglycemia but could also be a symptom of severe hyperglycemia. When informed that Resident #1's BGL was 586 mg/dL, NP B stated that level could have caused dizziness and disorientation and led to Resident #1 falling. <BR/>In an interview on 10/13/23 at 12:40 PM, the DON stated nurses had been trained and in-serviced on documenting and notifying her and the MD of refusal of medications. She stated RN E should have initialed and coded Resident #1's MAR to indicate he refused his insulin and BGL check on 10/10/23 at 8:00 PM. The DON stated RN E should have also notified her and the MD of Resident #1's behaviors and refusal of insulin, then documented everything in the progress notes. The DON stated hyperglycemia could have caused Resident #1 to become dizzy and fall; however, the fall itself could have caused the hyperglycemia and there was no way to know which came first. She stated Resident #1 had a history of falls and wandering and could have fallen while trying to get up from floor, where he had been sleeping. She stated Resident #1 had also been drowsy after returning to the facility from the psychiatric hospital, which could have contributed to the fall. She stated there were many variables and no way to state the cause. <BR/>In an interview on 10/13/23 at 2:58 PM, the Administrator stated it was her expectation for the nurses to notify the MD and DON of resident behaviors and refusal of medications, and to document appropriately in the MAR and progress notes. The Administrator stated RN E was written up previously for not notifying the DON that a resident had a fall; therefore, would be terminated. <BR/>In an interview on 10/13/23 at 5:15 PM, CNA G stated she had worked at the facility for 37 years and currently worked 2:00 PM-10:00 PM on rotating days. She stated she worked on 10/10/23 with Resident #1. CNA G stated Resident #1 had returned to the facility from a psychiatric hospital. She stated although the transport company reported Resident #1 was aggressive during the ride, he was calm when he made it on the unit and allowed her to change his clothing. She stated Resident #1 was asleep most of her shift and only woke up once for incontinent care and to eat dinner at approximately 8:00 PM. CNA G stated RN E told her Resident #1 had refused his insulin. She stated RN E did not stated that Resident #1 was being combative, just that he refused his medication. CNA G stated her coworker, CNA F, was caring for Resident #1 but she assisted as needed. She stated she was not informed by RN E of CNA F that Resident #1 was sleeping on the floor. <BR/>Review of the facility's policy titled Insulin Administration, revised September 2014, reflected in part the following:<BR/>Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes.<BR/> .<BR/>Documentation:<BR/> .<BR/>5. How well the resident tolerated the procedure.<BR/>Reporting:<BR/>1. Notify your supervisor if the resident refuses the insulin injection.<BR/> .<BR/>Review of the facility's policy titled Change in a Resident's Condition or Status, revised February 2021, reflected in part the following:<BR/>Policy Statement: Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).<BR/>Policy Interpretation and Implementation:<BR/>1. The nurse will notify the resident's attending physician or physician on-call when there has been a (an):<BR/> .<BR/>d. significant change in the resident's physical, emotional/mental condition;<BR/> .<BR/>e. refusal of treatment or medications two (2) or more consecutive times;<BR/> .<BR/>An Immediate Jeopardy was identified on 10/13/23. The Administrator and the DON were notified of the Immediate Jeopardy on 10/13/23 at 1:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Plan of Removal was accepted on 10/14/23 at 10:02 AM and reflected the following:<BR/>Summary of Details which lead to outcomes. <BR/>On 10/13/23, a surveyor provided an IJ Template notification that the Survey Agency has determined that conditions at the center constitute immediate jeopardy to resident health. <BR/>The notification of the alleged immediate jeopardy states as follows:<BR/>F600 Neglect - The facility failed to ensure a resident was free from neglect by failing to provide services to a resident with Diabetes who required insulin which led to physical harm. The failure resulted in the resident falling and sustaining a serious injury. <BR/>The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with Diabetes who required insulin, the led to actual physical harm. The facility's failure to provide services to a resident with diabetes who required insulin resulted in the resident falling and sustaining a serious injury. <BR/>Identify residents who could be affected:<BR/>Resident [Resident #1] was resistant to care on admission on [DATE]. Resident missed one finger stick blood sugar test and one dose of insulin due to resistance to care on 10/10/23. MD was contacted on 10/14/23 to inquire about what next steps we should have taken to intervene with a resident who is resistant to care. MD stated she would have told staff to recheck the blood sugar the next morning if the resident remained combative. <BR/>All Residents receiving insulin have the potential to be affected. The number of residents at the facility receiving insulin on 10/13/23 is 13.<BR/>An audit was initiated on 10/13/23 of all residents receiving insulin were receiving it appropriately. The audit was completed on the same day. <BR/>In-Service Conducted <BR/>Nurse that was involved in resident's [Resident #1] care and who failed to document the resident's resistance to finger stick and insulin administration was previously counseled for failure to document. Subsequently, on 10/13/12, termination of employment was issued for the same failure to document properly. <BR/>All staff will receive re-education on Abuse, Mistreatment, and Neglect. Specifically, what constitutes potential neglect. <BR/>Any staff who are on Leave of Absence or are PRN who have not been able to be contacted will not be allowed to work until such in-services have been completed. <BR/>An in-service template will be developed for all agency nurses to review and sign off prior to working their shifts.<BR/>The DON and ADON will be provided with the same In-service education by the Regional Clinical Director on 10/13/23. <BR/>Implementation Date of Changes <BR/>In-servicing was initiated on 10/13/23 and will be completed by 10/14/23. <BR/>Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. <BR/>Involvement of Medical Director <BR/>The Medical Director, was notified about the Immediate Jeopardy on 10/13/23. <BR/>Involvement of QAPI <BR/>QAPI will review and approve Plan of Removal on 10/13/23.<BR/>Who is responsible for the implementation of process? <BR/>Administrator and DON (Director of Nursing). <BR/>Monitoring record review of Residents #2, #3, #4, #5, and #6's MARs from October 2023 revealed no missed doses or discrepancies with insulin administration. <BR/>Monitoring interviews were conducted on 10/14/23 starting at 10:06 AM and continued through 12:09 PM with the following staff from various shifts: DON, ADON, CNA H, CNA I, RN J, CNA K, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q, LVN R, CNA S, CNA T, CNA U. All nurses were able to provide competency regarding in-services over Diabetic Clinical Protocol, documentation in clinical record, notification to physician, use of SBAR/INTERACT Tool to assess a significant change of condition and identifying and gathering relevant and pertinent information. All staff were able to provide competency regarding neglect. <BR/>Monitoring observations and interviews on 10/14/23 from 12:14 PM- 12:38 PM with Residents #2, #3, #4, #5, #6, and #7 revealed no concerns for neglect or signs of hypo/hyperglycemia. Residents #2, #3, and #4 stated they received their insulin as ordered and had not experienced any symptoms such as fatigue, dizziness, sweating, excessive thirst/hunger, or confusion. Residents #6 and #7 were unable to be interviewed due to cognition. <BR/>The Administrator and the DON were notified on 10/13/23 at 1:46 PM, the Immediate Jeopardy and Immediate Threat was removed. While the immediacy was removed on 10/14/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #38) of 17 residents reviewed for labs and diagnostics. <BR/>The facility failed to retrieve results of an x-ray order of Resident #38's right arm in a timely manner after he was noted to be grimacing in pain and unable to move his right arm, which resulted in delayed treatment of a fractured clavicle for approximately 24 hours. <BR/>An Immediate Jeopardy was identified on 05/11/23. While the Immediate Jeopardy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal.<BR/>These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. <BR/>Findings included:<BR/>Review of Resident #38's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, encephalopathy, cognitive communication deficit, and muscle weakness. Resident #38 had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and usually understood others. <BR/>Review of Resident #38's care plan initiated on 09/21/22 reflected he was at risk for falls related to impaired mobility and impaired cognition. Approaches included anticipating and meeting the resident's needs. The care plan further reflected the resident was at risk for pain related to general discomforts and right should fracture. <BR/>Review of Resident #38's progress notes dated at 05/08/23 revealed the following entries:<BR/>05/08/23 7:53 AM <BR/>This nurse was called to resident room by CNA, on arrival, resident noted having facial expression of pain but resident unable to identify or point where the pain is, resident is usually able to stand on his own and assist with dressing, but his morning resident is unable to do it, resident expressed pain with movement Tylenol 325mg 2 tablets given for generalized pain <BR/>05/08/23 8:12 AM<BR/>Post pain assessment: Resident is expressing pain when he moves his right arm, bruising noted <BR/>05/08/23 9:38 AM<BR/>Spoke to [NP], new order given stat xray to right shoulder and right scapulars. CBC, BMP and A1C to be done tomorrow morning. Xray order call in to [mobile xray] stat. pending to be done. <BR/>05/08/23 1:06 PM<BR/> .I observed resident sitting up in W/C in obvious distress asked resident to move his arms he was unable to lift his R[ight] arm without using his L arm and grimaces with movement <BR/>05/08/23 1:20 PM<BR/>Call made to [mobile xray] to check for xray tech, this nurse was informed that xray tech is in route to come do stat x-rays as ordered. <BR/>05/08/23 6:40 PM<BR/>Xray tech arrived and completed xray to R shoulder R hip. Will wait for results<BR/>05/09/23 5:56 AM<BR/>Nurse aide notified charge nurse about 0550am that resident was having trouble moving his right arm while trying to change the resident. charge nurse did an assessment and observed resident could not lift up his arm, resident was able to squeeze nurses hand, resident was able to push and pull against nurses' hand with right foot resident could follow directions, asked if he fell resident stated no fall, resident was observed sleeping through the night in his bed, notified the next shift nurse. as at this time the next shift nurse was receiving report. <BR/>05/09/23 8:00 AM<BR/>When I arrived at 6:00AM this morning, I checked xray results. Xray results show, the comminuted humeral head fracture is visualized, likely acute fracture with displacement. [NP] notified; new order given to send resident to ER. [Nursing supervisor] notified, resident [family] called and notified. Medstar non-emergency transported resident sent to [hospital] ER for evaluation and treatment <BR/>05/09/23 12:04 PM <BR/>Resident returned from [hospital], Right shoulder fracture is non operative and is needed to be in a sling <BR/>Review of Resident #38's mobile xray results dated 05/08/23 and sent to the facility via fax at 8:06 PM reflected the following:<BR/>Right Shoulder X-Ray .<BR/>Impression:<BR/>The bones are osteoporotic. The comminuted humeral head fracture is visualized, likely acute fracture with displacement .<BR/>Review of Resident #38's hospital records dated 05/09/23 reflected the following:<BR/> .Diagnosis<BR/>Closed fracture of proximal end or right humerus, unspecified fracture morphology, initial encounter <BR/>Review of Resident #38's MAR/TAR for May 2023 revealed he was given two Acetaminophen Tablet 325 mg at 7:24 AM on 05/08/23, and the resident's pain level was documented as an 8 (pain scale of 1 to 10). There was no other documentation of pain medications given to Resident #38 until the following morning, 05/09/23 at 7:49 AM. <BR/>Observation on 05/10/23 at 12:14 PM of Resident #38 revealed he was sitting in a wheelchair at the dining room table of the secure unit with a black sling to his right arm/shoulder. The resident was asked why he was wearing a sling but he stated he did not know why and denied being pain. <BR/>Interview on 05/11/23 at 1:00 PM with CNA A revealed on Monday morning, 05/08/23, around 7:00 AM, she noticed Resident #38 was not up yet so she went to his room, and he was lying in bed. CNA A said that was not usual for the resident as he was always up ambulating or making his own bed. She tried sitting Resident #38 up and he began grunting like he was in pain so the CNA went and told LVN B. Because of Resident #38's dementia, he was not able to let them know where he was hurting. During the assessment, Resident #38 grunted and grimaced when his shoulder was touched so he was assisted to a wheelchair to attempt to make him more comfortable but throughout the day the resident was guarding his right arm and was having a hard time trying to eat on his own but refused assistance. CNA A further stated as long as the resident was lying down, he appeared to be more comfortable. <BR/>Interview on 05/10/23 at 12:31 PM with LVN B revealed CNA A was getting Resident #38 up on Monday morning, 05/08/23, and he was told the resident appeared to be in pain. LVN B assessed the resident and while the resident was trying to move his arm, he began to complain of pain and grimaced. LVN B stated he notified the Regional RN called in an order for an xray per physician orders. LVN B said he shift ended at 2:00 PM and the mobile xray company still had not arrived for Resident #38's xrays. LVN B let the Regional RN know and she called the mobile xray company back to get an ETA. LVN B further stated he returned to work the following morning, 05/09/23, and asked the night nurse, RN C, what the results of Resident #38's xrays were and she was not aware there were pending xrays for the resident so LVN B printed the results from the computer system and called the doctor for orders and he was told to send Resident #38 to the ER for evaluation and treatment. <BR/>Interview on 05/11/23 at 9:34 AM with CNA F revealed she worked with the resident #38 the morning and afternoon of 05/08/23 and the resident was guarding his arm while he was up in the wheelchair and would grimace when the resident's right shoulder was touched. She said Resident #38 was having to his left hand to eat because he was not able to use his right and he would not let staff assist him with feeding. <BR/>Interview on 05/10/23 at 3:57 PM with RN C she worked the Resident #38 the night Monday night through Tuesday morning, 05/08/23-05/09/23, 10:00 PM to 6:00 AM shift. RN C said she was doing round around 5:50 AM Tuesday morning, 05/09/23, and noticed his right arm was hurting, when the staff were trying to get him up in the morning. Resident #38 was not able to explain what happened but he continued to grimace like he was in pain. When she took report from LVN C the day prior, 05/08/23, at change of shift, RN D said LVN C mentioned Resident #38 was scheduled for an x-ray and blood work in the morning, 05/09/23 but there were no other details given to her. RN C was not aware the x-ray had already been done, and they were waiting on the results nor had LVN D told her about it during their shift change. On 05/09/23 when LVN B asked RN C for results of Resident #38's x-ray taken the day prior, and RN C told LVN B she was not aware of any pending results. It was at that time when LVN B went on to the computer and pulled up the x-ray results and at that time taught her how to use the computer system. RN C further stated she had been employed at the facility since 03/02/23, and she had not been trained to look up lab/x-ray results on the computer system. <BR/>Interview on 05/10/23 at 2:20 PM with LVN D revealed she worked for an agency, and she worked with Resident #38 on Monday, 05/08/23. She said the mobile x-ray company had arrived around 6:30 PM that evening to do Resident #38's x-ray, but she was not able to look in the computer system for the results because no one had taught her how. LVN D said she the only phone number she had was for management was the current DON, but she could not be reached because the DON was out of the country, so she had gone to ask LVN E, another agency nurse that was working at that time. She also said LVN E told her she did not know how to use the computer system to obtain x-ray results either so she gave report to RN C about the pending x-ray results at 10:00 PM during shift change and had also written it in the nursing 24 hour report.<BR/>Review of the 24-hour report dated 05/08/23 reflected the following:<BR/> .[Resident #38]<BR/>REMARKS(DAY) - pain R shoulder/scapular R hip/pelvis. Pending to be done BMP, CBC, and A1C tomorrow.<BR/>REMARKS(EVENING) - Results pending <BR/>Interview on 05/11/23 at 12:15 PM with LVN E revealed she was working the evening of 05/08/23 on another unit and she saw the mobile xray company arrive and she directed them to the men's secure unit. Later that same evening around 8:30 PM or 9:00 PM LVN D, went to her unit to look at schedule and LVN E asked LVN D about the xray results. LVN D asked LVN E if the xray results arrived via fax and LVN E told LVN D they usually did but she(LVN D) could check on the computer. LVN E also said she offered to help LVN D check the computer system and LVN E told her she would back to the unit and check herself. <BR/>Further interview on 05/10/23 at 3:57 with RN C revealed there was nothing written in the 24 hour report for Resident #38 by LVN D, for the evening shift when she worked on 05/08/23. RN C said when she returned to work the night of 05/09/23, all of a sudden there was an entry on the 24 hour report for the evening shift of 05/08/23 that read results pending. RN C remained adamant there had not been an entry for the evening shift on 05/08/23 on the 24 hour report and someone must have written it in after her shift ended on 05/09/23 at 6:00 AM. <BR/>Further interview on 05/11/23 at 9:25 AM with LVN B revealed when he arrived at work at 6:00 AM on 05/09/23, he asked RN C for the results of Resident #38's xrays. RN C told LVN B she was not aware there were pending xray results for the resident and RN C let him know she did not know how check the computer system for the results. At that time LVN B showed RN C how to check for xray results on the computer system and LVN B realized Resident #38's xrays had been put into the system the evening prior, 05/08/23, around 8:00 PM. LVN B called the physician with the xray results and LVN B was told to send the resident to the ER for evaluation and treatment. <BR/>Interview on 05/11/23 at 8:45 AM with the mobile xray company revealed Resident #38's xray results had been sent via fax to the facility and also emailed to four different staff members at 6:56 PM. Review of the four emails revealed three of them belonged to prior management staff that no longer worked at the facility and one email belonged to the ADON who was on vacation at the time it was sent. <BR/>Interview on 05/10/23 at 4:34 PM with the ADON revealed she had been on vacation and first day back to work was on Tuesday, 05/09/23, and she was told about Resident #38's xray results but the resident had already been sent out to the hospital. The ADON said she was not aware RN C did not know how to pull xray results on the computer system and she should have been taught by the charge nurse that she did orientation with, but did not recall who that was.<BR/>Interview on 05/11/23 at 9:49 AM with the Regional RN revealed the morning of 05/08/23, LVN B told her Resident #38 was grimacing when the staff were trying to get him up for the day. At that time they called the doctor for xray orders and the resident had already been medicated for pain by LVN B. The Regional RN stated when she assessed Resident #38, he was sitting in the wheelchair and she asked him if he was hurting he told her no but when the resident tried to lift his arm he began to grimace. The Regional RN said by 2:00 PM, on 05/08/23, the mobile xray company had not yet arrived so she called the supervisor of the company who told her the xrays had not been put in STAT on their end, therefore they had not been there within the four hours. The Regional RN told the xray company they needed the original xray order STAT and the company eventually showed up later that evening. The Regional RN was not made aware the staff had not been able to access Resident #38's xray results until the following morning, 05/09/23, when LVN B arrived to his shift and followed up on the results. There was a fax for Resident #38's xray results found on the fax machine the following day, 05/09/23, but the resident had already been sent to the hospital. The Regional RN stated the evening nurse, LVN D should have check the computer system during her shift to see if the xray results had been posted. She said LVN D should have known how to access the results on the computer and if she did not remember, there should have been some instructions posted at the nurse's station. The Regional Nurse stated she did not contact the physician or send Resident #38 out to the hospital because at the time of her assessment, the resident was not in any distress or grimacing and denied being pain, therefore she did not believe it was an urgent matter. <BR/>Observation on 05/12/23 at 11:56 AM revealed Resident #38 was in his room in bed watching TV. He right arm remained in a black sling and when he was asked if his arm was hurting, the resident tried to raise it and began to grimace and grunt and replied yes. <BR/>Observation on 05/10/23at 2:37 PM revealed there were no instructions at the nurse's station of the men's secure unit, informing staff how to retrieve xrays from the online portal. <BR/>Review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol revised on November 2018 reflected the following:<BR/> .1. When test results are reported to the facility, a nurse will first review the results.<BR/>a. <BR/>If team member who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure of reporting and documenting the results and their implications, another nurse in the facility(supervisor, charge nurse, etc.) should follow or coordinate the procedure <BR/>Identifying Situations that Warrant Immediate Notification <BR/>1. <BR/>Nursing team will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results:<BR/>Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison <BR/>An Immediate Jeopardy was identified on 05/11/23. The Administrator, Regional RN, and the Regional Director were notified of the Immediate Jeopardy on 05/11/23 at 2:38 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/12/23 at 12:00 PM and reflected the following:<BR/>The facility failed to provide timely treatment and hospitalization for Resident #38 after x-rays revealed the resident had sustained a right shoulder fracture on 05/08/23. <BR/>Identify residents who could be affected<BR/>All Residents have the potential to be affected. The Facility census on 5/11/23 was 68.<BR/>An audit was initiated on 5/11/23 and will be completed on 5/11/23 to ensure there are no further x-rays that were not completed or reported. <BR/>DON/Designee initiated and completed a round on all current residents on 5/11/23 to determine if there are any changes in residents' condition. No SCOC were identified. All findings were reported to Physician and orders obtained and carried out as required.<BR/>In-Service conducted<BR/>RDCS completed in-service with DON/ADON on all education to be provided and the POR.<BR/>All facility licensed nurses and agency nurses who were working received education on timely follow up of all radiology orders, education on how to log in and check for radiology results and timely notification of Physicians. In-servicing will be completed by DON/Designee.<BR/>An in-service template will be developed for all agency nurses to review and sign off on prior to working their shifts and will be verified by off going nurse. DON/Designee will monitor daily for compliance.<BR/>Implementation<BR/>DON/Designee will review all change of condition documentation during daily clinical meeting for appropriate follow up and notification corrective measures.<BR/>All patients have orders on the MAR to assess for pain every shift. Dementia patients have the PAIN/AD used for assessment of pain and will receive pain medication on identification of pain. DON/Designee will monitor during daily clinical meeting.<BR/>All PRN pain medications given flow to the 24 hour report and will be reviewed at change of shift with oncoming nurse DON/Designee will monitor during morning clinical meeting.<BR/>DON/Admin will monitor corrective measures daily during Morning Meeting and Afternoon Stand Down Meeting.<BR/>RDCS/RDO are monitoring implementation of <BR/>Implementation Date of Changes<BR/>In-servicing was initiated on 5/11/23 and will be completed by 5/11/23<BR/>Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee.<BR/>Involvement of Medical Director<BR/>The [Medical Director], was notified about the immediate Jeopardy on 5/11/23. <BR/>Involvement of QA<BR/>QAPI will review and approve Plan of Removal on 5/11/23<BR/>Who is responsible for implementation of process?<BR/>Administrator and DON (Director of Nursing).<BR/>Monitoring of the facility's implementation of the Plan of Removal revealed the following<BR/>Review of the in-services dated 05/11/23 revealed facility charge nurses from various shifts were in-serviced xray/laboratory portal access, documentation, and communication with the on-coming nurse. <BR/>Observation on 05/12/23 from 3:11 PM to 3:20 PM of the facility's three nurse's station revealed each computer has the xray portal icon was easily visible on the desktop and there were instructions posted at the nurse's station. <BR/>Interviews were conducted on 05/12/23 starting at 12:37 PM and continued through 3:34 PM with nine staff members from various shifts regarding in-services which included process for accessing radiology portal, documenting orders and pending orders, and reviewing documentation with the on-coming nurse, and STAT xray/laboratory follow-up. The staff interviewed from various shifts were as follows: ADON, LVN B, RN C, LVN E, LVN I, LVN J, RN K, LVN L, LVN M, and LVN N. <BR/>The Administrator was notified on 05/12/23 at 4:00 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviewsm the facility failed to maintain medical records on each resident that are accurate for 1 of 5 residents (Resident #1) reviewed for resident records. <BR/>CNA A failed to accurately document in Resident #1's EHR on 06/06/25 when she documented her care using CNA B's log-in credentials.<BR/>This failure could lead to incorrect documentation of resident care. <BR/>Findings included:<BR/>Record review of Resident #1's undated admission Record reflected the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's, dementia, and high blood pressure. <BR/>Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 3 indicating he had severe cognitive impairment. His Functional Status assessment indicated he was dependent on staff for all of his ADLs. <BR/>Record review of Resident #1's care plan, dated 05/30/25, reflected he had an ADL self-care deficit, and impaired cognition being non-verbal. <BR/>Record review of Resident #1's Tasks in her EHR reflected on 06/06/25 CNA B had documented all of the resident's cares as being completed.<BR/>In an interview on 06/08/25 at 2:20 PM, CNA B stated she had not worked with Resident #1 on 06/06/25 because she had been assigned to another unit. She stated CNA A had been assigned to work with Resident #1 on that date. <BR/>In a phone interview on 06/08/25 at 2:47 PM, CNA A stated she had provided Resident #1 with care on 06/06/25. She stated she had documented under CNA B's log-in credentials. She stated her log-in kicked her out all the time, so she used CNA B's log-in. She stated CNA-B was logged into the EHR when she tried to log-in, so she just used CNA B's log-in. She stated she had told people about the issue but nothing had been done. She stated she knew she was not supposed to use someone else's log-in. <BR/>In a follow up interview on 06/08/25 at 3:06 PM, CNA B stated she must not have signed off the computer at the end of her shift, which was how CNA A was able to chart under her name. She stated she knew not to share her log-in credentials with anyone. She stated the DON was responsible for re-setting credentials when needed. <BR/>In an interview on 06/09/25 at 3:08 PM, CNA C stated it was not allowed to use someone else's log-in to chart and it was also not allowed to share your log-in with anyone else. <BR/>In an interview on 06/09/25 at 3:10 PM, RN D stated it was not allowed to use someone else's log-in to chart, or to share your log-in with anyone else. She stated the risk to the resident was another discipline, such as a CNA, charting as a nurse or incorrect information being documented. <BR/>In an interview on 06/09/25 at 3:13 PM, RN E stated they were not allowed to document using someone else's log-in. She stated there was a risk of incorrect documentation being done and difficulty identifying who had documented something. <BR/>In an interview on 06/09/25 at 3:18 PM, RN F stated staff were not allowed to share log-ins or document using someone else's log-in. She stated the risk was someone documenting as a nurse when they were not. <BR/>In an interview on 06/09/25 at 3:20 PM, the ADON stated it was absolutely not allowed to share log-ins or document as someone other than oneself. She stated it would be considered false documentation and there were multiple risks with that. <BR/>In an interview on 06/09/25 at 3:35 PM, the DON stated it was not allowed to share log-ins with anyone else. She stated if a staff member had an issue with their log-in, she could reset it in a few minutes. She stated anyone documenting using another person's log-in was creating a false document. <BR/>In an interview on 06/09/25 at 3:30 PM, the Administrator stated she did not have a policy addressing not using other staff member's log-in credentials. She stated it was common sense not to do that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 2 residents (Resident #1) reviewed for grievances. <BR/>The facility did not ensure a grievance was resolved promptly when Resident #1's blanket was reported missing on 05/11/23.<BR/>These failures could place residents at risk for grievances not being addressed or resolved promptly leading to residents lost properties not being replaced .<BR/>Findings included:<BR/>Review of Resident #1's admission MDS dated [DATE] revealed the resident was [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, asthma and essential hypertension. The MDS further reflected the resident was cognitively Moderate impaired with a BIMS score of 10 out of 15.<BR/>Record review of the facility's grievances did not reveal a grievance for Resident #1's missing blue blanket being resolved. Resident #1's grievance report dated 05/11/23 completed by the Social Worker on 05/14/23 reflected the following:<BR/> .blanket still missing; look everywhere for blanket, blanket has not been found <BR/>Interview with Resident #1's family member on 06/27/23 at 9:15 AM revealed the resident's blue baby blanket went missing a month ago. The family member for Resident #1 stated she reported the missing blanket to Social Worker through an email and a grievance was filled out, but the family member was not given a resolution. The family member stated she had been trying to address the lost blanket even during care plan meetings, and she felt her grievance was not addressed timely.<BR/>Interview on 06/27/23 at 11:21 AM with the Social Worker revealed she was made aware Resident #1's blanket being missing on 05/11/23 by Resident #1's family member, and she completed the grievance report on 05/14/23. She stated they searched the residents' rooms and laundry, but the blanket had not been found . The Social Worker revealed she had not communicated the findings to Resident #1's family member because they were still looking for the blanket. The Social Worker stated it was her responsibility to follow-up with the person making tje grievance and update them on the findings. The Social Worker stated the Administrator asked her to reach out to Resident #1's family member to inquire about where she had bought the blanket. The Social Worker reported she had yet to write an email so that they could resolve the grievance.<BR/>Interview with the Administrator on 06/27/23 at 12:38 PM revealed Resident #1's family member reported a lost blanket, and they had been looking for it but had not found it. When an item was reported missing, she stated they would write a grievance and begin a search for the item. She stated grievances were addressed by the Social Worker. The Administrator stated residents signed admission paperwork which reflected the facility was not responsible for missing or stolen items, and they only tried to collect their wrongs when they replaced a lost item. The Administrator stated the facility's admission policy stated clearly that items retained in resident possession shall be entirely the responsibility and liability of the resident/responsible party. The Administrator stated she could not find the inventory list for Resident #1. She stated she discussed with the Social Worker talking with Resident #1's family to try and resolve the issue of the lost blanket by getting information about where it was bought. <BR/>Interview on 06/27/23 at 3:44 PM with the Laundry Manager revealed she was made aware Resident #1's blanket was missing by the Social Worker. She stated she mobilized her staff to look for the blanket in all resident rooms and the laundry, but the blanked was not found. The Laundry Manager revealed she communicated the findings with Social Worker.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for elopement. <BR/>The facility failed to ensure Resident #1, who resided in the secure unit, was provided with adequate supervision to prevent elopement and as a result the resident sustained a laceration to his forehead after falling from his wheelchair and was sent to the hospital for treatment. <BR/>An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. <BR/>This failure could place residents at risk of harm and/or serious injury.<BR/>Findings included:<BR/>Review of Resident #1's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included aphasia, non-Alzheimer's dementia, cerebrovascular accident, and hemiparesis. The MDS reflected the resident's cognition was severely impaired with a BIMS of 0, the resident sometimes understood others, and he sometimes was understood by others with clear speech. <BR/>Review of Resident #1's care plan initiated on 11/09/21 and revised on 03/31/23 revealed Resident #1 was at risk for self-harm and injury related to wandering and attempted elopement related to cognitive impairment and lack of safety awareness. The care plan goals for Resident #1 included wandering within the locked unit and maintaining his safety through the next review date.<BR/>Review of Resident #1's Wandering Risk Scale assessment dated [DATE] revealed he was a high risk to wander. <BR/>Review of Resident #1's Memory Care Unit Continued Stay Review dated 01/23/23 revealed the following:<BR/>Resident habitually wanders or would wander out of the building, and would not be able to find way back Resident continues to meet criteria for placement on the Memory Care Unit <BR/>Review of the facility's Provider Investigation Report dated 02/24/23 reflected the following:<BR/>Resident was last observed by staff member at approximately 2:30-2:40pm per staff interview and was returned to the facility at approximately 2:53pm. Resident was noted to be in his wheelchair sitting next to the exit door just prior to his exit. Nurse was at station charting and did not observe resident exit the facility. He was informed by an employee on her way home that resident was outside the facility in the far end of the parking lot at the entrance of the neighboring property. Employee brought the resident back to the facility and informed the charge nurse <BR/> .He was noted to have a laceration approximately 2cm and was treated at [the hospital ER] with dissolvable stitches <BR/>Review of Resident #1's progress notes dated 02/18/23 documented by LVN A revealed the following:<BR/>Resident went out of the building, found by a staff member and brought back to the unit with lacerations to the left side of the head. This nurse cleaned the lacerations with wound cleanser, stopped the bleeding and applied dry dressing Called 911 an sent resident to [hospital] Resident returned to unit from the ER at 10:11 pm. Stitches and derma bond put on lacerations <BR/>Observation on 04/20/23 at 10:45 AM of the secure unit revealed it consisted of one long hall with a dining room/activity room and a nurses' station coming off the hall. The unit had a main entrance, and exit door to the back of the facility, and a third exit to the patio, that also had an exit door to the outside of the facility. All three doors were equipped with a keypad which required a code to exit. <BR/>Observation and interview on 04/20/23 at 10:51 AM revealed Resident #1 was in the hallway sitting in a wheelchair at the end of the secure unit hall about 10 feet from the back exit door. The resident was primarily Spanish speaking and was asked if he had left the facility. He said he left about one to three months prior, but he was found and brought back to the facility by a woman after he fell from his wheelchair and was bleeding from his face. Resident #1 said he had put in the code to the door that led into the patio and entered the code again to the outside gate. Resident #1 wheeled himself on the sidewalk and did not notice there was loose gravel and fell over on the floor in his wheelchair. Resident #1 further stated there was a man that was going to give him a ride over there to pay traffic tickets to renew his driver's license so he could get back to work. The resident said after his fall he was taken to the hospital. Further observations of the secure unit revealed many of the resident were ambulatory or were able to self-propel in their wheelchairs. There were some residents that were wandering in the dining room, but none were observed to be exit-seeking or pushing on any of the doors. <BR/>Review of Resident #1's hospital records dated 02/18/23 reflected the following:<BR/>Reason for visit: Fall<BR/>Diagnosis: facial laceration<BR/>Further review of Resident #1's hospital records revealed there were no other details about of the extent of his lacerations or treatments. <BR/>Interview on 04/20/23 at 2:13 PM with the PTA revealed she was leaving the facility (02/18/23) after work around 2:30 PM and was driving down the road in front of the facility when she saw a man who appeared to be standing from his wheelchair at the bottom of one of the facility's entrances, near an adjacent business. The resident looked familiar, so she turned around and realized it was Resident #1 who was already sitting in his wheelchair bleeding from his face from a big face gash. The PTA asked Resident #1 what happened but because he was not able to speak English well, he just kept pointing to the corner of the street. She then pushed the resident back to the facility, and the staff told her they did not know how the resident got out of the secure unit, but they were going to call 911 and have him sent out for treatment. <BR/>Interview on 04/20/23 at 1:27 PM with LVN A revealed he was in the dining room with other residents in the secure unit when the PTA brought Resident #1 back, bleeding from his face. LVN A did not realize the resident had left the unit, and he did not know how the resident had gotten out. LVN A asked the resident about the incident, and Resident #1 would only smile. He said they thought Resident #1 had exited through the back exit door because at that time of the elopement, the back door was being used as an exit only door due to COVID-19 precautions. LVN A also thought someone might have gone out the back door and not verified the door had securely closed when the resident exited the facility. Prior to the COVID-19 outbreak, the back door was never used by staff per LVN A. He said after Resident #1's elopement, all the codes to the unit's doors were changed, there was a door alarm installed on the back exit door, and all residents were to be monitored more closely if they were by an exit door. <BR/>Interview on 04/20/23 at 3:28 PM with CNA C revealed she was working the day Resident #1 eloped from the secure unit. She said she was caring for another resident but remembered seeing Resident #1 not long before he was brought back by the PTA. She said normally Resident #1 sat by the back exit door or the dining room. CNA C said she saw LVN trying to clean Resident #1 face because he was bleeding before he was sent to the hospital. The CNA was not aware how the resident got out of the unit, but she was told Resident #1 had left out the back exit door. She said the back door was being used as COVID-19 exit only door during one of their outbreaks. CNA C further stated all the codes had been changed to the exit doors, an alarm was installed on the back exit door, they were educated to monitor the residents more closely, especially Resident #1. <BR/>Interview on 04/20/23 at 1:27 PM with LVN B revealed Resident #1 had a history of going to the exit doors; however, once the resident realized a door would not open, the resident would leave the door alone. LVN B stated Resident #1 had never eloped in the past that he was aware of. LVN B further stated after Resident #1 eloped, all codes to the doors were changed, an alarm was added to the back exit door and all residents were to be monitored more closely, especially Resident #1. <BR/>Interview on 04/20/23 at 2:50 PM with the ADON revealed she was told Resident #1 had eloped from the secure unit and fallen off a step outside and sustained a laceration. She was unaware of the resident having an elopement history but to prevent further incidents, all codes to the doors were changed, and alarm was installed on the back exit door to sound any time it was opened, and increased resident checks and activities to keep them busy.<BR/>Interview on 04/20/23 at 1:01 PM with the Administrator revealed once she was told about Resident #1's elopement, she went and spoke with the resident as she was Spanish speaking also. The resident told the Administrator he had gotten out of the unit by pushing on the door but did not elaborate after that. The Administrator said the back exit door had a 15 second release lock and they thought he held the handle until the lock released, allowing him to exit the facility. She also said staff told her Resident #1 often sat by the back exit door, so they assumed that was where he had gotten out of. After the elopement, all the codes to the unit doors were changed, an alarm to the back exit door was added to sound anytime it was opened, and all staff were in-serviced to closely monitor the residents especially Resident #1. <BR/>Review of the facility's policy titled Wandering and Elopements revised March 2019 reflected the following:<BR/>The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environments for residents.<BR/>An Immediate Jeopardy (IJ) was identified to have existed from 02/18/23 through 02/23/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. <BR/>The facility took the following actions to correct the non-compliance prior to the investigation:<BR/>Review of in-service records dated 02/18/23 through 02/23/23 revealed all nursing staff were educated on missing persons, wandering, elopement, abuse/neglect, and resident rights. Those in-services consisted of ensuring doors are closed and locked, new alarm on back door, and closely monitoring the residents especially residents with increased wandering. All staff working the secure unit were given the new codes to the exit doors. <BR/>Interviews were conducted with six CNAs, four LVNs, one PTA, and an ADON on 04/21/23 from 9:00 AM to 4:00 PM from various shifts. The staff were able to identify and monitor wandering/exit seeking residents, new codes to the exit doors, and made aware of the new back door alarm to sound when opened. <BR/>Observation on 04/20/23 at 9:30 AM revealed the back exit door had an alarm installed to sound if and when it was opened, and new door codes were verified to make sure they were not the same ones at that time of the elopement on 02/18/23. <BR/>Interview on 04/21/23 at 10:00 AM with Resident #1 revealed he did not recall the codes to the doors because the number he gave did not match the current codes to any of the doors. <BR/>The records revealed a plan of action had been initiated to include supervision prior to entry on 04/18/23. Review of the following reflected the facility was in compliance on 02/23/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability, or services of a lesser intensity for 1 of 3 residents (Resident #1) for residents reviewed for specialized rehabilitative services. <BR/>The facility failed to ensure Resident #1 received a physical therapy evaluation and physical therapy services after a fall. <BR/>This failure could place residents at risk of having a decline in activities for daily living. <BR/>Findings include:<BR/>Record review of Resident #1's Face Sheet, dated 1/3/2024, reflected a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had relevant diagnosis which included unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Right Bundle Branch-Block, Cerebral infarction (stroke), and Pain in Right Knee. <BR/>Record Review of Resident #1's Progress Notes, dated 12/12/2023, revealed a BIMS Score of 5 out of 15 which indicated severe cognitive impairment. <BR/>Record Review of Resident #1's Care Plan dated 5/6/2023 and revised on 8/2/2023 revealed the Resident had an ADL Self-Care Performance Deficit Right Impaired Gait/Balance. The Resident's Care Plan also revealed she was a High Risk for falls with a history of falls and unsteady balance. <BR/>Record review of Resident #1's Nursing Notes, dated 12/7/2023, at 12:40PM, revealed the Resident was found on the floor by a CNA with one sock on one foot without shoes. When the Resident was asked by the CNA what happened, the Resident responded, I wanted to go into the wheelchair. The nursing notes revealed the resident was assessed by a nurse but not referred to the therapy department for assessment or treatment. The assessment reflected Resident #1 was able to move all extremities well, was alert and oriented to self, and surroundings per her baseline. Resident #1 was assisted to lay back down in bed.<BR/>In an interview with Resident #1's Family Member, on 1/3/2024, at 10:20AM, revealed that Resident #1 had a history of strokes and falls. The Family Member stated when Resident #1 had a fall or medical need, the facility didn't refer Resident #1 to a hospital for help, the family had to refer Resident #1. The Family Member stated that the facility did not inform the family when Resident #1 falls. The family learned about Resident #1 falling from Resident #1. <BR/>In an interview with Resident #1 on 1/3/2024, at 11:55 AM, revealed she hurt her left knee when she had her last fall. Resident #1 revealed she could not remember the date of the fall but had more challenges in using her left knee since the fall. Resident #1 was observed in her bedroom sitting in a wheelchair. Resident #1 stated she uses a cane and walker to ambulate. Resident #1's bed appeared to be at normal height with no fall mat. <BR/>In an interview with PTA A, on 1/3/2024, at 1:40 PM, revealed she worked at the facility for 7 months. PTA A stated Resident #1 was not currently receiving any physical therapy. PTA A revealed she was not aware that Resident #1 had fallen on 12/07/2023. PTA A stated that the facility therapist was notified by the Department Heads regarding who would get assessed by the therapist and who received therapy. PTA A revealed the Department Heads meet Monday thru Friday in the morning hours. PTA A stated the facility's Regular Director of Rehabilitation was out on family leave. PTA A revealed that a Virtual Temporary Director of Rehabilitation took her place. PTA A stated that the VTDR virtually attended the morning meetings to determine which residents were assessed by the therapy department and which residents received therapy. PTA A stated 98% of the time, when a resident fell, they were referred to the therapy department to be assessed for therapy. <BR/>In an interview with the VTDR, on 1/3/2024, at 2:10PM, revealed she took over duties as Director of Rehabilitation Services, at the facility, since 11/22/2023. The VTDR stated she was notified through the PCC (Point Care Click) System for referrals. The VTDR stated that the DON was responsible for referring residents to the therapy department. The VTDR stated anyone at the facility could enter the information into the PCC System, for a resident to get referred to the therapy department. The VTDR stated if a resident fell, they should be referred to the therapy department to be assessed. The VTDR revealed it was an industry standard that a Nursing Facility referred a resident to the therapy department when they had a fall. The VTDR stated if a resident fell at the facility, and she did not know about it, someone did not contact her about it, and they should have. The VTDR stated now that she was aware that Resident #1 had a fall on 12/07/2023, she will have Resident #1 assessed by the therapy department. <BR/>In an interview with the DON, on 1/3/2024, at 3:45 PM, it was revealed the facility's process for responding to finding a resident on the floor was to have the charge nurse do an assessment - then notify the physician. Then the facility notifies the family. The facility then completes an incident report. The DON stated in nursing homes, the risk for falls was always high. The DON stated if someone was found on the floor, they should be referred to physical therapy or OT Therapy depending on the resident needs. <BR/>In an interview with the DON on 1/3/2024, at 4:00 PM, the DON revealed Resident #1 was not referred to therapy because Resident #1 had a UTI. The DON then stated she didn't always refer a resident to therapy when they fell. <BR/>Record Review of Resident #1's Nursing Notes dated ,12/20/2023, indicated Resident #1 completed her antibiotics for the UTI. <BR/>In an interview with PTA A, on 1/3/2024, at 4:20PM, revealed that Resident #1 was discharged from physical therapy on 12/6/2023. PTA A revealed the physical therapy notes form Resident #1's therapy which ended on 12/6/2023. <BR/>Record Review of Resident #1's Progress Note, dated 7/2/2023, at 10:29PM, revealed Resident #1 had an arthroplasty in her right knee with a prosthesis in anatomic alignment. <BR/>Record Review of the physical therapy notes, revealed the diagnosis of Resident #1, was for UTI, muscle weakness, and unspecified abnormalities of gait and mobility. <BR/>Record Review of the Facility's, undated, Managing Fall and Fall Risk Policy, reflected-<BR/>An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught hm/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents, who were unable to carry out activities of daily living, received the necessary services for three (Residents #15, #48, and # 52) of eighteen residents reviewed for maintenance of grooming and personal hygiene. <BR/>The facility failed to maintain the fingernails, toenails, and hair of Residents #15, #48, and #52.<BR/>This failure placed residents at risk of injury, decreased self esteem, and risk of infection.<BR/>Findings included:<BR/>Review of Resident #15's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, muscle weakness, contractures, and muscle wasting. <BR/>Review of Resident #15's quarterly MDS, dated [DATE], revealed a BIMS score of 15 indicating he was cognitively intact. His Functional Status revealed he was totally dependent on staff for all of his ADLs. <BR/>Review of Resident #15's care plan, dated 01/17/23, revealed he had an ADL self-care deficit related to muscoskeletal impairment and contractures, and limited physical mobility related to contractures and paraplegia. <BR/>Review of Resident #48's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included stroke, respiratory failure requiring a tracheostomy, and Alzheimer's disease. <BR/>Review of Resident #48's admission MDS, dated [DATE], revealed a BIMS score not calculable due to her medical conditions. Her Functional Status revealed she was totally dependent on staff for all of her ADLs. <BR/>Review of Resident #48's care plan, dated 02/22/23, revealed she had an ADL self-care deficit related to impaired mobility, and impaired cognitive function related to Alzheimer's disease.<BR/>Review of Resident #52's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, inability to speak and swallow, and persistent vegetative state.<BR/>Review of Resident #52's quarterly MDS, dated [DATE], revealed a BIMS score not calculable due to her medical conditions. Her Functional Status revealed she was totally dependent on staff for all of her ADLs. <BR/>Review of Resident #52's care plan, dated 07/20/22, revealed she had an ADL self-care deficit related to limited range of motion, altered musculoskeletal status related to hand contractures, and altered neurological status related to traumatic brain injury.<BR/>Observation and interview on 05/09/23 beginning at 10:44 AM revealed Resident #15's toenails on both feet were overgrown, both feet had scratches to the tops of them. Resident #15 stated he did not recall the last time he had seen a Podiatrist, and he scratched himself with his toenails when his feet rubbed together.<BR/>Observation on 05/09/23 at 10:46 AM revealed Resident #52's hair was greasy with white flakes throughout. Her toenails were overgrown. <BR/>Observation on 05/09/23 at 10:55 AM revealed Resident #48's toenails were overgrown.<BR/>Observation on 05/10/23 at 12:20 PM revealed Resident #15's toenails remained untrimmed. <BR/>Observation on 05/10/23 at 12:18 PM revealed Resident #52's hair remained unwashed, and her toenails remained untrimmed. <BR/>Observation on 05/10/23 at 1:05 PM revealed Resident #48's toenails remained unchanged from previous observations. <BR/>Observation on 05/11/23 at 9:20 AM revealed Resident #48's hair appeared to have been recently washed, but her toenails remain unchanged from previous observations. <BR/>Observation on 05/11/23 at 9:28 AM revealed Resident #52's hair remained unwashed and her toenails remained unchanged from previous observations. <BR/>Observation and interview on 05/11/23 at 9:30 AM revealed Resident #15's face was unshaven, and he stated he did not recall his last bath. His toenails remained overgrown. <BR/>Interview on 05/11/23 at 9:32 AM with CNA G revealed the bathing schedule for Resident #15 was Monday, Wednesday, and Friday. She did not know when Resident #15 had been bathed last. She stated she had not had time to bathe him on 05/10/23. CNA G stated Resident #52's bathing schedule was Tuesday, Thursday, and Saturday, and she would get a bath on the 2:00 PM-10:00 PM shift. <BR/>Interview on 05/11/23 at 9:38 AM with CNA H revealed all bathing and showering activities were documented on the computer under the Tasks tab, under ADLs. She stated they are required to document all of their tasks by the end of their shifts. <BR/>Interview on 05/11//23 at 9:42 AM with LVN I revealed resident fingernails were trimmed by the nurses and toenails were trimmed by the Podiatrist. He stated both fingernails and toenails status should be documented during the nurse's weekly skin assessment, which was usually done on Sundays. He did not know why the residents with long nails had not been reported to the nurse or the Social Worker. <BR/>Interview on 05/11/23 at 9:50 AM with the Social Worker revealed the Podiatrist came to the facility every 60 days and saw all the residents. The residents did not have to be placed on a list to be seen. The Podiatrist was next scheduled to visit on 05/16/23. The Social Worker stated the Podiatrist may not see each resident on a visit but would see them on the next visit if not seen on this one. <BR/>Review of podiatry notes provided by the Social Worker revealed the Podiatrist's first visit for 2023 was on 04/13/23. Residents #15, #48, and #52 had not seen the Podiatrist in 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #38) of 17 residents reviewed for labs and diagnostics. <BR/>The facility failed to retrieve results of an x-ray order of Resident #38's right arm in a timely manner after he was noted to be grimacing in pain and unable to move his right arm, which resulted in delayed treatment of a fractured clavicle for approximately 24 hours. <BR/>An Immediate Jeopardy was identified on 05/11/23. While the Immediate Jeopardy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal.<BR/>These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. <BR/>Findings included:<BR/>Review of Resident #38's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, encephalopathy, cognitive communication deficit, and muscle weakness. Resident #38 had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and usually understood others. <BR/>Review of Resident #38's care plan initiated on 09/21/22 reflected he was at risk for falls related to impaired mobility and impaired cognition. Approaches included anticipating and meeting the resident's needs. The care plan further reflected the resident was at risk for pain related to general discomforts and right should fracture. <BR/>Review of Resident #38's progress notes dated at 05/08/23 revealed the following entries:<BR/>05/08/23 7:53 AM <BR/>This nurse was called to resident room by CNA, on arrival, resident noted having facial expression of pain but resident unable to identify or point where the pain is, resident is usually able to stand on his own and assist with dressing, but his morning resident is unable to do it, resident expressed pain with movement Tylenol 325mg 2 tablets given for generalized pain <BR/>05/08/23 8:12 AM<BR/>Post pain assessment: Resident is expressing pain when he moves his right arm, bruising noted <BR/>05/08/23 9:38 AM<BR/>Spoke to [NP], new order given stat xray to right shoulder and right scapulars. CBC, BMP and A1C to be done tomorrow morning. Xray order call in to [mobile xray] stat. pending to be done. <BR/>05/08/23 1:06 PM<BR/> .I observed resident sitting up in W/C in obvious distress asked resident to move his arms he was unable to lift his R[ight] arm without using his L arm and grimaces with movement <BR/>05/08/23 1:20 PM<BR/>Call made to [mobile xray] to check for xray tech, this nurse was informed that xray tech is in route to come do stat x-rays as ordered. <BR/>05/08/23 6:40 PM<BR/>Xray tech arrived and completed xray to R shoulder R hip. Will wait for results<BR/>05/09/23 5:56 AM<BR/>Nurse aide notified charge nurse about 0550am that resident was having trouble moving his right arm while trying to change the resident. charge nurse did an assessment and observed resident could not lift up his arm, resident was able to squeeze nurses hand, resident was able to push and pull against nurses' hand with right foot resident could follow directions, asked if he fell resident stated no fall, resident was observed sleeping through the night in his bed, notified the next shift nurse. as at this time the next shift nurse was receiving report. <BR/>05/09/23 8:00 AM<BR/>When I arrived at 6:00AM this morning, I checked xray results. Xray results show, the comminuted humeral head fracture is visualized, likely acute fracture with displacement. [NP] notified; new order given to send resident to ER. [Nursing supervisor] notified, resident [family] called and notified. Medstar non-emergency transported resident sent to [hospital] ER for evaluation and treatment <BR/>05/09/23 12:04 PM <BR/>Resident returned from [hospital], Right shoulder fracture is non operative and is needed to be in a sling <BR/>Review of Resident #38's mobile xray results dated 05/08/23 and sent to the facility via fax at 8:06 PM reflected the following:<BR/>Right Shoulder X-Ray .<BR/>Impression:<BR/>The bones are osteoporotic. The comminuted humeral head fracture is visualized, likely acute fracture with displacement .<BR/>Review of Resident #38's hospital records dated 05/09/23 reflected the following:<BR/> .Diagnosis<BR/>Closed fracture of proximal end or right humerus, unspecified fracture morphology, initial encounter <BR/>Review of Resident #38's MAR/TAR for May 2023 revealed he was given two Acetaminophen Tablet 325 mg at 7:24 AM on 05/08/23, and the resident's pain level was documented as an 8 (pain scale of 1 to 10). There was no other documentation of pain medications given to Resident #38 until the following morning, 05/09/23 at 7:49 AM. <BR/>Observation on 05/10/23 at 12:14 PM of Resident #38 revealed he was sitting in a wheelchair at the dining room table of the secure unit with a black sling to his right arm/shoulder. The resident was asked why he was wearing a sling but he stated he did not know why and denied being pain. <BR/>Interview on 05/11/23 at 1:00 PM with CNA A revealed on Monday morning, 05/08/23, around 7:00 AM, she noticed Resident #38 was not up yet so she went to his room, and he was lying in bed. CNA A said that was not usual for the resident as he was always up ambulating or making his own bed. She tried sitting Resident #38 up and he began grunting like he was in pain so the CNA went and told LVN B. Because of Resident #38's dementia, he was not able to let them know where he was hurting. During the assessment, Resident #38 grunted and grimaced when his shoulder was touched so he was assisted to a wheelchair to attempt to make him more comfortable but throughout the day the resident was guarding his right arm and was having a hard time trying to eat on his own but refused assistance. CNA A further stated as long as the resident was lying down, he appeared to be more comfortable. <BR/>Interview on 05/10/23 at 12:31 PM with LVN B revealed CNA A was getting Resident #38 up on Monday morning, 05/08/23, and he was told the resident appeared to be in pain. LVN B assessed the resident and while the resident was trying to move his arm, he began to complain of pain and grimaced. LVN B stated he notified the Regional RN called in an order for an xray per physician orders. LVN B said he shift ended at 2:00 PM and the mobile xray company still had not arrived for Resident #38's xrays. LVN B let the Regional RN know and she called the mobile xray company back to get an ETA. LVN B further stated he returned to work the following morning, 05/09/23, and asked the night nurse, RN C, what the results of Resident #38's xrays were and she was not aware there were pending xrays for the resident so LVN B printed the results from the computer system and called the doctor for orders and he was told to send Resident #38 to the ER for evaluation and treatment. <BR/>Interview on 05/11/23 at 9:34 AM with CNA F revealed she worked with the resident #38 the morning and afternoon of 05/08/23 and the resident was guarding his arm while he was up in the wheelchair and would grimace when the resident's right shoulder was touched. She said Resident #38 was having to his left hand to eat because he was not able to use his right and he would not let staff assist him with feeding. <BR/>Interview on 05/10/23 at 3:57 PM with RN C she worked the Resident #38 the night Monday night through Tuesday morning, 05/08/23-05/09/23, 10:00 PM to 6:00 AM shift. RN C said she was doing round around 5:50 AM Tuesday morning, 05/09/23, and noticed his right arm was hurting, when the staff were trying to get him up in the morning. Resident #38 was not able to explain what happened but he continued to grimace like he was in pain. When she took report from LVN C the day prior, 05/08/23, at change of shift, RN D said LVN C mentioned Resident #38 was scheduled for an x-ray and blood work in the morning, 05/09/23 but there were no other details given to her. RN C was not aware the x-ray had already been done, and they were waiting on the results nor had LVN D told her about it during their shift change. On 05/09/23 when LVN B asked RN C for results of Resident #38's x-ray taken the day prior, and RN C told LVN B she was not aware of any pending results. It was at that time when LVN B went on to the computer and pulled up the x-ray results and at that time taught her how to use the computer system. RN C further stated she had been employed at the facility since 03/02/23, and she had not been trained to look up lab/x-ray results on the computer system. <BR/>Interview on 05/10/23 at 2:20 PM with LVN D revealed she worked for an agency, and she worked with Resident #38 on Monday, 05/08/23. She said the mobile x-ray company had arrived around 6:30 PM that evening to do Resident #38's x-ray, but she was not able to look in the computer system for the results because no one had taught her how. LVN D said she the only phone number she had was for management was the current DON, but she could not be reached because the DON was out of the country, so she had gone to ask LVN E, another agency nurse that was working at that time. She also said LVN E told her she did not know how to use the computer system to obtain x-ray results either so she gave report to RN C about the pending x-ray results at 10:00 PM during shift change and had also written it in the nursing 24 hour report.<BR/>Review of the 24-hour report dated 05/08/23 reflected the following:<BR/> .[Resident #38]<BR/>REMARKS(DAY) - pain R shoulder/scapular R hip/pelvis. Pending to be done BMP, CBC, and A1C tomorrow.<BR/>REMARKS(EVENING) - Results pending <BR/>Interview on 05/11/23 at 12:15 PM with LVN E revealed she was working the evening of 05/08/23 on another unit and she saw the mobile xray company arrive and she directed them to the men's secure unit. Later that same evening around 8:30 PM or 9:00 PM LVN D, went to her unit to look at schedule and LVN E asked LVN D about the xray results. LVN D asked LVN E if the xray results arrived via fax and LVN E told LVN D they usually did but she(LVN D) could check on the computer. LVN E also said she offered to help LVN D check the computer system and LVN E told her she would back to the unit and check herself. <BR/>Further interview on 05/10/23 at 3:57 with RN C revealed there was nothing written in the 24 hour report for Resident #38 by LVN D, for the evening shift when she worked on 05/08/23. RN C said when she returned to work the night of 05/09/23, all of a sudden there was an entry on the 24 hour report for the evening shift of 05/08/23 that read results pending. RN C remained adamant there had not been an entry for the evening shift on 05/08/23 on the 24 hour report and someone must have written it in after her shift ended on 05/09/23 at 6:00 AM. <BR/>Further interview on 05/11/23 at 9:25 AM with LVN B revealed when he arrived at work at 6:00 AM on 05/09/23, he asked RN C for the results of Resident #38's xrays. RN C told LVN B she was not aware there were pending xray results for the resident and RN C let him know she did not know how check the computer system for the results. At that time LVN B showed RN C how to check for xray results on the computer system and LVN B realized Resident #38's xrays had been put into the system the evening prior, 05/08/23, around 8:00 PM. LVN B called the physician with the xray results and LVN B was told to send the resident to the ER for evaluation and treatment. <BR/>Interview on 05/11/23 at 8:45 AM with the mobile xray company revealed Resident #38's xray results had been sent via fax to the facility and also emailed to four different staff members at 6:56 PM. Review of the four emails revealed three of them belonged to prior management staff that no longer worked at the facility and one email belonged to the ADON who was on vacation at the time it was sent. <BR/>Interview on 05/10/23 at 4:34 PM with the ADON revealed she had been on vacation and first day back to work was on Tuesday, 05/09/23, and she was told about Resident #38's xray results but the resident had already been sent out to the hospital. The ADON said she was not aware RN C did not know how to pull xray results on the computer system and she should have been taught by the charge nurse that she did orientation with, but did not recall who that was.<BR/>Interview on 05/11/23 at 9:49 AM with the Regional RN revealed the morning of 05/08/23, LVN B told her Resident #38 was grimacing when the staff were trying to get him up for the day. At that time they called the doctor for xray orders and the resident had already been medicated for pain by LVN B. The Regional RN stated when she assessed Resident #38, he was sitting in the wheelchair and she asked him if he was hurting he told her no but when the resident tried to lift his arm he began to grimace. The Regional RN said by 2:00 PM, on 05/08/23, the mobile xray company had not yet arrived so she called the supervisor of the company who told her the xrays had not been put in STAT on their end, therefore they had not been there within the four hours. The Regional RN told the xray company they needed the original xray order STAT and the company eventually showed up later that evening. The Regional RN was not made aware the staff had not been able to access Resident #38's xray results until the following morning, 05/09/23, when LVN B arrived to his shift and followed up on the results. There was a fax for Resident #38's xray results found on the fax machine the following day, 05/09/23, but the resident had already been sent to the hospital. The Regional RN stated the evening nurse, LVN D should have check the computer system during her shift to see if the xray results had been posted. She said LVN D should have known how to access the results on the computer and if she did not remember, there should have been some instructions posted at the nurse's station. The Regional Nurse stated she did not contact the physician or send Resident #38 out to the hospital because at the time of her assessment, the resident was not in any distress or grimacing and denied being pain, therefore she did not believe it was an urgent matter. <BR/>Observation on 05/12/23 at 11:56 AM revealed Resident #38 was in his room in bed watching TV. He right arm remained in a black sling and when he was asked if his arm was hurting, the resident tried to raise it and began to grimace and grunt and replied yes. <BR/>Observation on 05/10/23at 2:37 PM revealed there were no instructions at the nurse's station of the men's secure unit, informing staff how to retrieve xrays from the online portal. <BR/>Review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol revised on November 2018 reflected the following:<BR/> .1. When test results are reported to the facility, a nurse will first review the results.<BR/>a. <BR/>If team member who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure of reporting and documenting the results and their implications, another nurse in the facility(supervisor, charge nurse, etc.) should follow or coordinate the procedure <BR/>Identifying Situations that Warrant Immediate Notification <BR/>1. <BR/>Nursing team will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results:<BR/>Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison <BR/>An Immediate Jeopardy was identified on 05/11/23. The Administrator, Regional RN, and the Regional Director were notified of the Immediate Jeopardy on 05/11/23 at 2:38 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/12/23 at 12:00 PM and reflected the following:<BR/>The facility failed to provide timely treatment and hospitalization for Resident #38 after x-rays revealed the resident had sustained a right shoulder fracture on 05/08/23. <BR/>Identify residents who could be affected<BR/>All Residents have the potential to be affected. The Facility census on 5/11/23 was 68.<BR/>An audit was initiated on 5/11/23 and will be completed on 5/11/23 to ensure there are no further x-rays that were not completed or reported. <BR/>DON/Designee initiated and completed a round on all current residents on 5/11/23 to determine if there are any changes in residents' condition. No SCOC were identified. All findings were reported to Physician and orders obtained and carried out as required.<BR/>In-Service conducted<BR/>RDCS completed in-service with DON/ADON on all education to be provided and the POR.<BR/>All facility licensed nurses and agency nurses who were working received education on timely follow up of all radiology orders, education on how to log in and check for radiology results and timely notification of Physicians. In-servicing will be completed by DON/Designee.<BR/>An in-service template will be developed for all agency nurses to review and sign off on prior to working their shifts and will be verified by off going nurse. DON/Designee will monitor daily for compliance.<BR/>Implementation<BR/>DON/Designee will review all change of condition documentation during daily clinical meeting for appropriate follow up and notification corrective measures.<BR/>All patients have orders on the MAR to assess for pain every shift. Dementia patients have the PAIN/AD used for assessment of pain and will receive pain medication on identification of pain. DON/Designee will monitor during daily clinical meeting.<BR/>All PRN pain medications given flow to the 24 hour report and will be reviewed at change of shift with oncoming nurse DON/Designee will monitor during morning clinical meeting.<BR/>DON/Admin will monitor corrective measures daily during Morning Meeting and Afternoon Stand Down Meeting.<BR/>RDCS/RDO are monitoring implementation of <BR/>Implementation Date of Changes<BR/>In-servicing was initiated on 5/11/23 and will be completed by 5/11/23<BR/>Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee.<BR/>Involvement of Medical Director<BR/>The [Medical Director], was notified about the immediate Jeopardy on 5/11/23. <BR/>Involvement of QA<BR/>QAPI will review and approve Plan of Removal on 5/11/23<BR/>Who is responsible for implementation of process?<BR/>Administrator and DON (Director of Nursing).<BR/>Monitoring of the facility's implementation of the Plan of Removal revealed the following<BR/>Review of the in-services dated 05/11/23 revealed facility charge nurses from various shifts were in-serviced xray/laboratory portal access, documentation, and communication with the on-coming nurse. <BR/>Observation on 05/12/23 from 3:11 PM to 3:20 PM of the facility's three nurse's station revealed each computer has the xray portal icon was easily visible on the desktop and there were instructions posted at the nurse's station. <BR/>Interviews were conducted on 05/12/23 starting at 12:37 PM and continued through 3:34 PM with nine staff members from various shifts regarding in-services which included process for accessing radiology portal, documenting orders and pending orders, and reviewing documentation with the on-coming nurse, and STAT xray/laboratory follow-up. The staff interviewed from various shifts were as follows: ADON, LVN B, RN C, LVN E, LVN I, LVN J, RN K, LVN L, LVN M, and LVN N. <BR/>The Administrator was notified on 05/12/23 at 4:00 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promptly notify the ordering physician of results that fell outside of clinical reference ranges in accordance with facility policies and procedures for one (Resident #38) of four residents reviewed diagnostic services. <BR/>The facility failed to retrieve results of an x-ray order of Resident #38's right arm in a timely manner after he was noted to be grimacing in pain and unable to move his right arm, which resulted in delayed treatment of a fractured clavicle for approximately 24 hours. <BR/>An Immediate Jeopardy was identified on 05/11/23. While the Immediate Jeopardy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal.<BR/>These failures could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition. <BR/>Findings included:<BR/>Review of Resident #38's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, encephalopathy, cognitive communication deficit, and muscle weakness. Resident #38 had severe cognitive impairment with a BIMS score of 1. The MDS reflected the resident was usually understood by other and usually understood others. <BR/>Review of Resident #38's care plan initiated on 09/21/22 reflected he was at risk for falls related to impaired mobility and impaired cognition. Approaches included anticipating and meeting the resident's needs. The care plan further reflected the resident was at risk for pain related to general discomforts and right should fracture. <BR/>Review of Resident #38's progress notes dated at 05/08/23 revealed the following entries:<BR/>05/08/23 7:53 AM <BR/>This nurse was called to resident room by CNA, on arrival, resident noted having facial expression of pain but resident unable to identify or point where the pain is, resident is usually able to stand on his own and assist with dressing, but his morning resident is unable to do it, resident expressed pain with movement Tylenol 325mg 2 tablets given for generalized pain <BR/>05/08/23 8:12 AM<BR/>Post pain assessment: Resident is expressing pain when he moves his right arm, bruising noted <BR/>05/08/23 9:38 AM<BR/>Spoke to [NP], new order given stat xray to right shoulder and right scapulars. CBC, BMP and A1C to be done tomorrow morning. Xray order call in to [mobile xray] stat. pending to be done. <BR/>05/08/23 1:06 PM<BR/> .I observed resident sitting up in W/C in obvious distress asked resident to move his arms he was unable to lift his R[ight] arm without using his L arm and grimaces with movement <BR/>05/08/23 1:20 PM<BR/>Call made to [mobile xray] to check for xray tech, this nurse was informed that xray tech is in route to come do stat x-rays as ordered. <BR/>05/08/23 6:40 PM<BR/>Xray tech arrived and completed xray to R shoulder R hip. Will wait for results<BR/>05/09/23 5:56 AM<BR/>Nurse aide notified charge nurse about 0550am that resident was having trouble moving his right arm while trying to change the resident. charge nurse did an assessment and observed resident could not lift up his arm, resident was able to squeeze nurses hand, resident was able to push and pull against nurses' hand with right foot resident could follow directions, asked if he fell resident stated no fall, resident was observed sleeping through the night in his bed, notified the next shift nurse. as at this time the next shift nurse was receiving report. <BR/>05/09/23 8:00 AM<BR/>When I arrived at 6:00AM this morning, I checked xray results. Xray results show, the comminuted humeral head fracture is visualized, likely acute fracture with displacement. [NP] notified; new order given to send resident to ER. [Nursing supervisor] notified, resident [family] called and notified. Medstar non-emergency transported resident sent to [hospital] ER for evaluation and treatment <BR/>05/09/23 12:04 PM <BR/>Resident returned from [hospital], Right shoulder fracture is non operative and is needed to be in a sling <BR/>Review of Resident #38's mobile xray results dated 05/08/23 and sent to the facility via fax at 8:06 PM reflected the following:<BR/>Right Shoulder X-Ray .<BR/>Impression:<BR/>The bones are osteoporotic. The comminuted humeral head fracture is visualized, likely acute fracture with displacement .<BR/>Review of Resident #38's hospital records dated 05/09/23 reflected the following:<BR/> .Diagnosis<BR/>Closed fracture of proximal end or right humerus, unspecified fracture morphology, initial encounter <BR/>Review of Resident #38's MAR/TAR for May 2023 revealed he was given two Acetaminophen Tablet 325 mg at 7:24 AM on 05/08/23, and the resident's pain level was documented as an 8 (pain scale of 1 to 10). There was no other documentation of pain medications given to Resident #38 until the following morning, 05/09/23 at 7:49 AM. <BR/>Observation on 05/10/23 at 12:14 PM of Resident #38 revealed he was sitting in a wheelchair at the dining room table of the secure unit with a black sling to his right arm/shoulder. The resident was asked why he was wearing a sling but he stated he did not know why and denied being pain. <BR/>Interview on 05/11/23 at 1:00 PM with CNA A revealed on Monday morning, 05/08/23, around 7:00 AM, she noticed Resident #38 was not up yet so she went to his room, and he was lying in bed. CNA A said that was not usual for the resident as he was always up ambulating or making his own bed. She tried sitting Resident #38 up and he began grunting like he was in pain so the CNA went and told LVN B. Because of Resident #38's dementia, he was not able to let them know where he was hurting. During the assessment, Resident #38 grunted and grimaced when his shoulder was touched so he was assisted to a wheelchair to attempt to make him more comfortable but throughout the day the resident was guarding his right arm and was having a hard time trying to eat on his own but refused assistance. CNA A further stated as long as the resident was lying down, he appeared to be more comfortable. <BR/>Interview on 05/10/23 at 12:31 PM with LVN B revealed CNA A was getting Resident #38 up on Monday morning, 05/08/23, and he was told the resident appeared to be in pain. LVN B assessed the resident and while the resident was trying to move his arm, he began to complain of pain and grimaced. LVN B stated he notified the Regional RN called in an order for an xray per physician orders. LVN B said he shift ended at 2:00 PM and the mobile xray company still had not arrived for Resident #38's xrays. LVN B let the Regional RN know and she called the mobile xray company back to get an ETA. LVN B further stated he returned to work the following morning, 05/09/23, and asked the night nurse, RN C, what the results of Resident #38's xrays were and she was not aware there were pending xrays for the resident so LVN B printed the results from the computer system and called the doctor for orders and he was told to send Resident #38 to the ER for evaluation and treatment. <BR/>Interview on 05/11/23 at 9:34 AM with CNA F revealed she worked with the resident #38 the morning and afternoon of 05/08/23 and the resident was guarding his arm while he was up in the wheelchair and would grimace when the resident's right shoulder was touched. She said Resident #38 was having to his left hand to eat because he was not able to use his right and he would not let staff assist him with feeding. <BR/>Interview on 05/10/23 at 3:57 PM with RN C she worked the Resident #38 the night Monday night through Tuesday morning, 05/08/23-05/09/23, 10:00 PM to 6:00 AM shift. RN C said she was doing round around 5:50 AM Tuesday morning, 05/09/23, and noticed his right arm was hurting, when the staff were trying to get him up in the morning. Resident #38 was not able to explain what happened but he continued to grimace like he was in pain. When she took report from LVN C the day prior, 05/08/23, at change of shift, RN D said LVN C mentioned Resident #38 was scheduled for an x-ray and blood work in the morning, 05/09/23 but there were no other details given to her. RN C was not aware the x-ray had already been done, and they were waiting on the results nor had LVN D told her about it during their shift change. On 05/09/23 when LVN B asked RN C for results of Resident #38's x-ray taken the day prior, and RN C told LVN B she was not aware of any pending results. It was at that time when LVN B went on to the computer and pulled up the x-ray results and at that time taught her how to use the computer system. RN C further stated she had been employed at the facility since 03/02/23, and she had not been trained to look up lab/x-ray results on the computer system. <BR/>Interview on 05/10/23 at 2:20 PM with LVN D revealed she worked for an agency, and she worked with Resident #38 on Monday, 05/08/23. She said the mobile x-ray company had arrived around 6:30 PM that evening to do Resident #38's x-ray, but she was not able to look in the computer system for the results because no one had taught her how. LVN D said she the only phone number she had was for management was the current DON, but she could not be reached because the DON was out of the country, so she had gone to ask LVN E, another agency nurse that was working at that time. She also said LVN E told her she did not know how to use the computer system to obtain x-ray results either so she gave report to RN C about the pending x-ray results at 10:00 PM during shift change and had also written it in the nursing 24 hour report.<BR/>Review of the 24-hour report dated 05/08/23 reflected the following:<BR/> .[Resident #38]<BR/>REMARKS(DAY) - pain R shoulder/scapular R hip/pelvis. Pending to be done BMP, CBC, and A1C tomorrow.<BR/>REMARKS(EVENING) - Results pending <BR/>Interview on 05/11/23 at 12:15 PM with LVN E revealed she was working the evening of 05/08/23 on another unit and she saw the mobile xray company arrive and she directed them to the men's secure unit. Later that same evening around 8:30 PM or 9:00 PM LVN D, went to her unit to look at schedule and LVN E asked LVN D about the xray results. LVN D asked LVN E if the xray results arrived via fax and LVN E told LVN D they usually did but she(LVN D) could check on the computer. LVN E also said she offered to help LVN D check the computer system and LVN E told her she would back to the unit and check herself. <BR/>Further interview on 05/10/23 at 3:57 with RN C revealed there was nothing written in the 24 hour report for Resident #38 by LVN D, for the evening shift when she worked on 05/08/23. RN C said when she returned to work the night of 05/09/23, all of a sudden there was an entry on the 24 hour report for the evening shift of 05/08/23 that read results pending. RN C remained adamant there had not been an entry for the evening shift on 05/08/23 on the 24 hour report and someone must have written it in after her shift ended on 05/09/23 at 6:00 AM. <BR/>Further interview on 05/11/23 at 9:25 AM with LVN B revealed when he arrived at work at 6:00 AM on 05/09/23, he asked RN C for the results of Resident #38's xrays. RN C told LVN B she was not aware there were pending xray results for the resident and RN C let him know she did not know how check the computer system for the results. At that time LVN B showed RN C how to check for xray results on the computer system and LVN B realized Resident #38's xrays had been put into the system the evening prior, 05/08/23, around 8:00 PM. LVN B called the physician with the xray results and LVN B was told to send the resident to the ER for evaluation and treatment. <BR/>Interview on 05/11/23 at 8:45 AM with the mobile xray company revealed Resident #38's xray results had been sent via fax to the facility and also emailed to four different staff members at 6:56 PM. Review of the four emails revealed three of them belonged to prior management staff that no longer worked at the facility and one email belonged to the ADON who was on vacation at the time it was sent. <BR/>Interview on 05/10/23 at 4:34 PM with the ADON revealed she had been on vacation and first day back to work was on Tuesday, 05/09/23, and she was told about Resident #38's xray results but the resident had already been sent out to the hospital. The ADON said she was not aware RN C did not know how to pull xray results on the computer system and she should have been taught by the charge nurse that she did orientation with, but did not recall who that was.<BR/>Interview on 05/11/23 at 9:49 AM with the Regional RN revealed the morning of 05/08/23, LVN B told her Resident #38 was grimacing when the staff were trying to get him up for the day. At that time they called the doctor for xray orders and the resident had already been medicated for pain by LVN B. The Regional RN stated when she assessed Resident #38, he was sitting in the wheelchair and she asked him if he was hurting he told her no but when the resident tried to lift his arm he began to grimace. The Regional RN said by 2:00 PM, on 05/08/23, the mobile xray company had not yet arrived so she called the supervisor of the company who told her the xrays had not been put in STAT on their end, therefore they had not been there within the four hours. The Regional RN told the xray company they needed the original xray order STAT and the company eventually showed up later that evening. The Regional RN was not made aware the staff had not been able to access Resident #38's xray results until the following morning, 05/09/23, when LVN B arrived to his shift and followed up on the results. There was a fax for Resident #38's xray results found on the fax machine the following day, 05/09/23, but the resident had already been sent to the hospital. The Regional RN stated the evening nurse, LVN D should have check the computer system during her shift to see if the xray results had been posted. She said LVN D should have known how to access the results on the computer and if she did not remember, there should have been some instructions posted at the nurse's station. The Regional Nurse stated she did not contact the physician or send Resident #38 out to the hospital because at the time of her assessment, the resident was not in any distress or grimacing and denied being pain, therefore she did not believe it was an urgent matter. <BR/>Observation on 05/12/23 at 11:56 AM revealed Resident #38 was in his room in bed watching TV. He right arm remained in a black sling and when he was asked if his arm was hurting, the resident tried to raise it and began to grimace and grunt and replied yes. <BR/>Observation on 05/10/23at 2:37 PM revealed there were no instructions at the nurse's station of the men's secure unit, informing staff how to retrieve xrays from the online portal. <BR/>Review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol revised on November 2018 reflected the following:<BR/> .1. When test results are reported to the facility, a nurse will first review the results.<BR/>a. <BR/>If team member who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure of reporting and documenting the results and their implications, another nurse in the facility(supervisor, charge nurse, etc.) should follow or coordinate the procedure <BR/>Identifying Situations that Warrant Immediate Notification <BR/>1. <BR/>Nursing team will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results:<BR/>Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison <BR/>An Immediate Jeopardy was identified on 05/11/23. The Administrator, Regional RN, and the Regional Director were notified of the Immediate Jeopardy on 05/11/23 at 2:38 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/12/23 at 12:00 PM and reflected the following:<BR/>The facility failed to provide timely treatment and hospitalization for Resident #38 after x-rays revealed the resident had sustained a right shoulder fracture on 05/08/23. <BR/>Identify residents who could be affected<BR/>All Residents have the potential to be affected. The Facility census on 5/11/23 was 68.<BR/>An audit was initiated on 5/11/23 and will be completed on 5/11/23 to ensure there are no further x-rays that were not completed or reported. <BR/>DON/Designee initiated and completed a round on all current residents on 5/11/23 to determine if there are any changes in residents' condition. No SCOC were identified. All findings were reported to Physician and orders obtained and carried out as required.<BR/>In-Service conducted<BR/>RDCS completed in-service with DON/ADON on all education to be provided and the POR.<BR/>All facility licensed nurses and agency nurses who were working received education on timely follow up of all radiology orders, education on how to log in and check for radiology results and timely notification of Physicians. In-servicing will be completed by DON/Designee.<BR/>An in-service template will be developed for all agency nurses to review and sign off on prior to working their shifts and will be verified by off going nurse. DON/Designee will monitor daily for compliance.<BR/>Implementation<BR/>DON/Designee will review all change of condition documentation during daily clinical meeting for appropriate follow up and notification corrective measures.<BR/>All patients have orders on the MAR to assess for pain every shift. Dementia patients have the PAIN/AD used for assessment of pain and will receive pain medication on identification of pain. DON/Designee will monitor during daily clinical meeting.<BR/>All PRN pain medications given flow to the 24 hour report and will be reviewed at change of shift with oncoming nurse DON/Designee will monitor during morning clinical meeting.<BR/>DON/Admin will monitor corrective measures daily during Morning Meeting and Afternoon Stand Down Meeting.<BR/>RDCS/RDO are monitoring implementation of <BR/>Implementation Date of Changes<BR/>In-servicing was initiated on 5/11/23 and will be completed by 5/11/23<BR/>Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee.<BR/>Involvement of Medical Director<BR/>The [Medical Director], was notified about the immediate Jeopardy on 5/11/23. <BR/>Involvement of QA<BR/>QAPI will review and approve Plan of Removal on 5/11/23<BR/>Who is responsible for implementation of process?<BR/>Administrator and DON (Director of Nursing).<BR/>Monitoring of the facility's implementation of the Plan of Removal revealed the following<BR/>Review of the in-services dated 05/11/23 revealed facility charge nurses from various shifts were in-serviced xray/laboratory portal access, documentation, and communication with the on-coming nurse. <BR/>Observation on 05/12/23 from 3:11 PM to 3:20 PM of the facility's three nurse's station revealed each computer has the xray portal icon was easily visible on the desktop and there were instructions posted at the nurse's station. <BR/>Interviews were conducted on 05/12/23 starting at 12:37 PM and continued through 3:34 PM with nine staff members from various shifts regarding in-services which included process for accessing radiology portal, documenting orders and pending orders, and reviewing documentation with the on-coming nurse, and STAT xray/laboratory follow-up. The staff interviewed from various shifts were as follows: ADON, LVN B, RN C, LVN E, LVN I, LVN J, RN K, LVN L, LVN M, and LVN N. <BR/>The Administrator was notified on 05/12/23 at 4:00 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 05/12/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observations, interviews and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. <BR/>The facility failed on 06/11/2024 to ensure items found in the walk-in refrigerator, were labeled with the use by date.<BR/>These failures could place resident at risk for food-borne illness and food contamination. <BR/>Findings included:<BR/>Observation on 06/11/2024 at 9:11 am revealed in the facilities only walk-in refrigerator the following items not labeled or dated:<BR/>- <BR/>Large Ziplock bag containing cheese.<BR/>- <BR/>Large Ziplock back containing a sandwich, chips, packaged crackers, personal packet of mayonnaise.<BR/>- <BR/>Large Ziplock bag containing cooked bacon. <BR/>Observation on 06/11/2024 at 9:11 am revealed in the facilities only walk-in refrigerator the following items in open packaging:<BR/>- <BR/>Box of lunch meat on the shelf uncovered. <BR/>- <BR/>Box of 24 count eggs with 18 eggs remaining in the open box. <BR/>Interview on 06/12/2024 at 2:20 PM with admission Director; revealed he has been helping in the kitchen during preparation time because the dietary manager quit about three weeks ago. He stated he assist with ordering food and food preparation. He has a position within the facility that limited his time in the kitchen. He stated that he did remind dietary staff to maintain safe store practices. <BR/>Interview on 06/13/2024 at 3:06 PM with DON; she stated that food should be closed and sealed. The risk to the residents was cross contamination. <BR/>Interview on 06/13/2024 at 05:22 PM with Administrator; she stated food should be labeled for us to know that the food was not expired and safe for human consumption. <BR/>Review of the policy titled Food Storage, dated 2018 reflected; d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. <BR/>

Based on observations and interviews the facility failed to ensure medications on two of six carts and one medication room reviewed for medication storage were not expired in accordance with currently accepted professional principles, and in accordance with State and Federal laws<BR/>The facility failed to ensure medications stocked on the Nurse's and Medication Aide carts for the Suites unit, Nurse medication cart and the Medication room for the Terrace unit were not expired.<BR/>These failures placed the residents at risk of receiving medications that might not have their full effectiveness, or may have become toxic. <BR/>Findings included:<BR/>Observation on 05/10/23 at 10:10 AM the Medication Aide cart for the Suites unit revealed one bottle of Oyster shell with Calcium had expired in April of 2023, and one bottle of Zinc had expired in March of 2023. <BR/>Interview on 05/11/23 at 10:10 AM MA-O stated she was responsible for stocking the medications on her cart and checking for expired medications. She stated none of the residents received the expired medications, so that is why she didn't notice the medications had expired. <BR/>Observation on 05/10/23 at 10:23 AM the medication room for the Terrace unit revealed two bottles of Oyster shell with Calcium were stocked on the shelf that had expired in April 2023. <BR/>Observation on 05/10/23 at 10:25 AM the Nurse medication cart for the Terrace unit had one bottle of Oyster Shell with Calcium that had expired in April 2023. <BR/>Interview on 05/10/23 at 10:28 AM LVN-B stated the nurses stock the medication carts from the medication room. He stated somebody from Central Supply re-stocked the medication room. He stated the risk of giving expired medications could be an allergic reaction or a non-therapeutic dosage. <BR/>Interview on 05/11//23 at 12:29 PM the ADON stated she expected the nurses to check their carts weekly for expired medications and replace them as needed. She stated the risk of giving an expired medication was that it would not have the therapeutic effects intended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability, or services of a lesser intensity for 1 of 3 residents (Resident #1) for residents reviewed for specialized rehabilitative services. <BR/>The facility failed to ensure Resident #1 received a physical therapy evaluation and physical therapy services after a fall. <BR/>This failure could place residents at risk of having a decline in activities for daily living. <BR/>Findings include:<BR/>Record review of Resident #1's Face Sheet, dated 1/3/2024, reflected a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had relevant diagnosis which included unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Right Bundle Branch-Block, Cerebral infarction (stroke), and Pain in Right Knee. <BR/>Record Review of Resident #1's Progress Notes, dated 12/12/2023, revealed a BIMS Score of 5 out of 15 which indicated severe cognitive impairment. <BR/>Record Review of Resident #1's Care Plan dated 5/6/2023 and revised on 8/2/2023 revealed the Resident had an ADL Self-Care Performance Deficit Right Impaired Gait/Balance. The Resident's Care Plan also revealed she was a High Risk for falls with a history of falls and unsteady balance. <BR/>Record review of Resident #1's Nursing Notes, dated 12/7/2023, at 12:40PM, revealed the Resident was found on the floor by a CNA with one sock on one foot without shoes. When the Resident was asked by the CNA what happened, the Resident responded, I wanted to go into the wheelchair. The nursing notes revealed the resident was assessed by a nurse but not referred to the therapy department for assessment or treatment. The assessment reflected Resident #1 was able to move all extremities well, was alert and oriented to self, and surroundings per her baseline. Resident #1 was assisted to lay back down in bed.<BR/>In an interview with Resident #1's Family Member, on 1/3/2024, at 10:20AM, revealed that Resident #1 had a history of strokes and falls. The Family Member stated when Resident #1 had a fall or medical need, the facility didn't refer Resident #1 to a hospital for help, the family had to refer Resident #1. The Family Member stated that the facility did not inform the family when Resident #1 falls. The family learned about Resident #1 falling from Resident #1. <BR/>In an interview with Resident #1 on 1/3/2024, at 11:55 AM, revealed she hurt her left knee when she had her last fall. Resident #1 revealed she could not remember the date of the fall but had more challenges in using her left knee since the fall. Resident #1 was observed in her bedroom sitting in a wheelchair. Resident #1 stated she uses a cane and walker to ambulate. Resident #1's bed appeared to be at normal height with no fall mat. <BR/>In an interview with PTA A, on 1/3/2024, at 1:40 PM, revealed she worked at the facility for 7 months. PTA A stated Resident #1 was not currently receiving any physical therapy. PTA A revealed she was not aware that Resident #1 had fallen on 12/07/2023. PTA A stated that the facility therapist was notified by the Department Heads regarding who would get assessed by the therapist and who received therapy. PTA A revealed the Department Heads meet Monday thru Friday in the morning hours. PTA A stated the facility's Regular Director of Rehabilitation was out on family leave. PTA A revealed that a Virtual Temporary Director of Rehabilitation took her place. PTA A stated that the VTDR virtually attended the morning meetings to determine which residents were assessed by the therapy department and which residents received therapy. PTA A stated 98% of the time, when a resident fell, they were referred to the therapy department to be assessed for therapy. <BR/>In an interview with the VTDR, on 1/3/2024, at 2:10PM, revealed she took over duties as Director of Rehabilitation Services, at the facility, since 11/22/2023. The VTDR stated she was notified through the PCC (Point Care Click) System for referrals. The VTDR stated that the DON was responsible for referring residents to the therapy department. The VTDR stated anyone at the facility could enter the information into the PCC System, for a resident to get referred to the therapy department. The VTDR stated if a resident fell, they should be referred to the therapy department to be assessed. The VTDR revealed it was an industry standard that a Nursing Facility referred a resident to the therapy department when they had a fall. The VTDR stated if a resident fell at the facility, and she did not know about it, someone did not contact her about it, and they should have. The VTDR stated now that she was aware that Resident #1 had a fall on 12/07/2023, she will have Resident #1 assessed by the therapy department. <BR/>In an interview with the DON, on 1/3/2024, at 3:45 PM, it was revealed the facility's process for responding to finding a resident on the floor was to have the charge nurse do an assessment - then notify the physician. Then the facility notifies the family. The facility then completes an incident report. The DON stated in nursing homes, the risk for falls was always high. The DON stated if someone was found on the floor, they should be referred to physical therapy or OT Therapy depending on the resident needs. <BR/>In an interview with the DON on 1/3/2024, at 4:00 PM, the DON revealed Resident #1 was not referred to therapy because Resident #1 had a UTI. The DON then stated she didn't always refer a resident to therapy when they fell. <BR/>Record Review of Resident #1's Nursing Notes dated ,12/20/2023, indicated Resident #1 completed her antibiotics for the UTI. <BR/>In an interview with PTA A, on 1/3/2024, at 4:20PM, revealed that Resident #1 was discharged from physical therapy on 12/6/2023. PTA A revealed the physical therapy notes form Resident #1's therapy which ended on 12/6/2023. <BR/>Record Review of Resident #1's Progress Note, dated 7/2/2023, at 10:29PM, revealed Resident #1 had an arthroplasty in her right knee with a prosthesis in anatomic alignment. <BR/>Record Review of the physical therapy notes, revealed the diagnosis of Resident #1, was for UTI, muscle weakness, and unspecified abnormalities of gait and mobility. <BR/>Record Review of the Facility's, undated, Managing Fall and Fall Risk Policy, reflected-<BR/>An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught hm/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 3 (Residents #1, #2, and #3) of 15 resident reviewed for tracheostomy care. <BR/>The facility failed to ensure Residents #1, #2, and #3 had an emergency tracheostomy kit at the bedside.<BR/>This failure placed the resident at risk of delayed life saving interventions.<BR/>Findings included:<BR/>Review of Resident #1's EHR revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included respiratory failure requiring tracheostomy and ventilator support (inability to breathe requiring a hole in her neck to help her breathe via a machine) , emphysema, and diabetes. <BR/>Review of Resident #1's quarterly MDS assessment, dated 10/18/22, revealed a BIMS score of 15 indicating the resident was cognitively intact. The resident's functional status indicated he was totally dependent upon staff for his ADLs. <BR/>Review of Resident #1's care plan, dated 08/31/22, revealed he was at risk for respiratory impairment related to respiratory failure and requires a ventilator to support his breathing. <BR/>Review of Resident #2's EHR revealed the resident was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included emphysema, acute respiratory failure, and stroke. <BR/>Review of Resident #2's admission MDS assessment, dated 01/07/23, revealed a BIMS score not calculable related to her diagnoses. Her functional status indicated she was totally dependent on staff for all care. <BR/>Review of Resident #2' care plan, dated 12/07/22, revealed she was at risk for respiratory impairment related to respiratory failure and is completely dependent on the ventilator for her breathing.<BR/>Review of Resident #3's EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, morbid obesity, diabetes, and high blood pressure. <BR/>Review of Resident #3's admission MDS, dated [DATE], revealed a BIMS score not calculable related to her diagnoses. Her functional status indicated she is totally dependent upon staff for all of her ADLs. <BR/>Review of Resident #3's care plan, dated 12/26/22, revealed she was at risk for respiratory impairment related to respiratory failure and is totally reliant on the ventilator to assist her breathing. <BR/>Observation on 01/24/23 at 9:45 AM revealed Resident #1 had no emergency trach kit at his bedside. <BR/>Observation on 01/24/23 at 9:47 AM revealed Resident #2 had no emergency trach kit at her bedside.<BR/>Observation on 01/24/23 at 9:50 AM revealed Resident #3 had no emergency trach kit at her bedside. <BR/>Interview on 01/24/23 at 10:00 AM, RRT D stated it was a standard of care to have an emergency trach kit at the bedside of any resident who had a tracheostomy. The emergency kit contained everything needed to re-establish the resident's airway in the event their trach became dislodged or plugged. RRT D stated there were emergency supplies located in her office at the end of he hall if needed. RRT D was unaware the three residents had no kits, but the other 12 residents had emergency trach kits at their bedside. She admitted there was a failure because it was their practice to keep the kits at the bedside, and she did not know what had happened to the kits over the weekend. The nurses and respiraotory therapists were responsible for keeping them stocked. RRT D stated the respiratory office was not locked, and the facility had a respiratory therapist on staff around the clock. RRT D stated the nurses were also trained on trach care, which included changing out trach tubes using the emergency kits. <BR/>Observation on 01/24/23 at 10:20 AM, RRT D had replaced emergency trach kits for Residents #1, #2, and #3.<BR/>The facility did not have a policy about emergency trach kits specifically per the Respiratory Therapist

Based on observation and interview the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three nurse medication carts of five carts reviewed for infection control.<BR/>The facility failed to monitor the sharps containers for three medication carts to prevent them from being overfilled. <BR/>This failure placed residents at risk of exposure to bloodborne pathogens present on used sharps. <BR/>Findings included:<BR/>Observation on 01/24/23 at 10:23 AM revealed the sharps container (used to dispose of used syringes) for the nurse medication cart for the Terrace Unit was overfilled. The control flap was stuck in the open position with the inability to deposit any more sharps.<BR/>Interview on 01/24/23 at 10:25 AM, LVN A stated the nurses were responsible for changing out sharps containers when they were full. LVN A stated the overfilling the containers posed a risk for anyone, who might stick their hand near the opening, of being exposed to a used sharps. <BR/>Observation on 01/24/23 at 10:48 AM revealed the sharps container for the nurse medication cart for Pulmonary Unit was passed the fill line. <BR/>Interview on 01/24/23 at 10:50 AM LVN B stated nurses were responsible for changing out the sharps box when it hit the fill line to prevent exposure to the sharps it contained. <BR/>Observation on 01/24/23 at 10:54 AM the sharps container for the nurse medication cart for Suites Unit was overfilled with three syringes poking out the top of the box, needles facing downward. <BR/>Interview on 01/24/23 at 10:55 AM LVN C stated the nurses were responsible for monitoring the sharps boxes. He stated he did not know how the box got so full that syringes were sticking out the top of it. LVN C stated the exposed syringes could stick someone if they were not paying attention when trying to put another sharp into the box. <BR/>Interview on 01/24/23 at 1:24 PM, the DON stated the nurses were primarily responsible for monitoring their sharps boxes and changing them out when needed, but anyone walking by should check them as well and change them out. <BR/>The facility had no policy addressing sharps containers specifically per the DON.<BR/>Review of OSHA standards on sharps, as described on their website osha.gov, reflected the following:<BR/> .1910.1030(c)(1)(i) Each employer having employees with occupational exposure to bloodborne pathogens shall establish an Exposure Control Plan designed to eliminate or minimize employee exposure.<BR/> .1910.1030(d)(2)(viii) Immediately, or as soon as possible after use, contaminated sharps shall be placed in appropriate containers. These containers shall be:<BR/> . Puncture resistant<BR/> . Labeled or color-coded<BR/> . Leakproof<BR/> .1910.1030(d)(4)(iii)(A)(2) During use containers for sharps shall be:<BR/> . Easily accessible to personnel<BR/> . Maintained upright throughout use<BR/> . Replaced routinely and not be allowed to overfill<BR/> . Containers should be closed immediately to prevent spillage or protrusions of contents during handling, storage, transport, or shipping <BR/>

Based on observations and interviews the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet for one Hall (Terrace Unit) of 5 Halls reviewed for call lights.<BR/>The facility failed to ensure residents, who resided on the Terrace Unit, had call lights available to them.<BR/>This failure placed the residents at risk of falling, further injury, and unnecessary pain from not being able to call for help. <BR/>Findings included:<BR/>Observation on 01/24/23 at 10:25 AM of the Terrace Unit revealed it housed 17 male residents with memory issues. Observation of the rooms on the Terrace Unit revealed call light units were on the walls, but there were no pull cords available for the residents to use. Three residents were in their rooms with the doors closed.<BR/>Observation on 01/24/23 at 10:28 AM, the majority of the residents were in the common area and around the nurses' station. LVN A was assisting residents. <BR/>Interview on 01/24/23 at 10:30 AM, LVN A stated there was no reason the residents would not have call light cords, unless it had been determined to be a hazard at some point in the past. He was not aware of any resident being harmed by a call light pull cord. He stated most of the residents stayed in the common area during the day. A few residents stayed in their rooms and they yelled out for help as needed. He was not able to answer when asked about the residents with closed doors and if they could be heard if they called for help. <BR/>Interview on 01/24/23 at 10:34 AM, the DON stated she did not have a reason the residents could not have call light pull cords. She stated some might be missing because the residents pulled them off. She stated it might be a safety issue to have them, but she would have to check. <BR/>Attempts on 01/24/23 at 10:40 AM to interview the residents on the Terrace Unit were unsuccessful due to the residents having severe cognitive impairment. <BR/>Interview on 01/24/23 at 1:45 PM, the DON stated she made phone calls and discovered the Terrace Unit, under previous ownership, had once been a mental health unit. The call light pull cords had been removed after a resident tried to hang himself with one. She stated none of the current residents were at risk of suicide. The DON stated it put the residents at risk of not being able to call for help if needed. The DON stated the pull cords had been missing since the CHOW in 2019. <BR/>The facility did not have a policy on call lights specifically per the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 residents (Resident #13) reviewed for care plans. <BR/>The facility failed to ensure Resident #13's care plan was revised to reflect the prescribed diet of regular texture, regular consistency, and double protein portions. <BR/>These failures could place residents at risk of current needs not being met. <BR/>The findings included:<BR/>Review of Resident #13's Face Sheet, accessed on 6/12/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included Unspecified Dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), Parkinsonism, unspecified (term used to describe a collection of movement symptoms associated with several conditions-including Parkinson's disease which is a disorder of the central nervous system that affects movement), Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), End Stage Renal Disease (terminal illness that occurs when the kidneys can no longer function properly and support the body's needs), Dependence on Renal Dialysis (complex and evolving process that involves the use of renal dialysis (renal replacement therapy) to sustain life when the kidneys are no longer able to function properly), Anxiety Disorder (mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and age-related Nuclear Cataract, Left eye (major cause of blindness that occurs when the proteins in the eye's lens break down and clump together, causing cloudy spots in the center of the lens). <BR/>Review of Resident #13's Nutritional Risk Assessment, dated 2/26/24, indicated the RD recommended adding double protein portions with meals and nepro/novosource supplement once/day. <BR/>Review of Resident #13's Nutritional Risk Assessment, dated 4/19/24, indicated the resident does not like puree/NTL diet .Recommend prostat supplement once/day to provide addition 100kcal , (kilocalorie)15g protein. Continue large protein portions at meals.<BR/>Review of Resident #13's Nutritional Risk Assessment, dated 5/28/24, indicated the resident reported difficulty chewing but refused diet change, hated puree diet in the past. Dislikes tea, wants juice .Recommend Nepro/Novosource supplement BID (twice a day), double protein portions, and d/c [discontinue] prostat supplement. Recommend apple juice, lowest in K+.<BR/>Review of Resident #13's Progress Notes, dated 4/25/24 at 11:55 AM, indicated care plan meeting today. Staff present were the LMSW, MDS, AD, ADON, and therapy. The resident was present for the meeting; his family was present via phone.<BR/>Review of Resident #13's MDS, dated [DATE], did not indicate a BIMS score. <BR/>Review of Resident #13's MAR, accessed on 6/12/24, indicated he was on a Renal diet, regular texture, regular consistency, double protein portions.<BR/>Review of Resident #13's Care Plan, initiated on 2/16/24, indicated he had a Nutritional Status problem. The care plan stated the resident had a potential for nutritional problems r/t dislikes of mechanically altered diet/fluids, risk for aspiration r/t non-compliance with diet d/t spouse/family bringing regular diet foods for consumption while at dialysis. The care plan indicated his diet was: Pureed, Renal, Nectar Thick Liquids. Related interventions, revised on 4/19/24, included explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Further interventions, initiated on 2/16/24, stated RD (Registered Dietitian) to evaluate and make diet change recommendations PRN.<BR/>Observation on 6/12/24 8:10 AM revealed Resident #13 was sitting on the side of his bed in his room. Food tray was on his bedside table. Food on his plate consisted of scrambled eggs, bacon, and toast. CNA A entered the resident's room with coffee and assisted the resident with adding sugar and powdered creamer to his coffee and eating his food.<BR/>During an interview on 6/13/24 at 10:45 AM with the RD , she stated she has been employed with the facility for one month. She stated she was not yet familiar with all the residents and was currently screening priority residents which will then be seen monthly. She stated any concerns or changes to residents' diets were typically discussed during monthly meetings. She stated Resident #13's current diet was Renal, regular texture, regular consistency, and double protein. She stated that when she ordered a change of diet for a resident, she would email the team (administrator, DON, ADON, dietary manager) to update them on the change. She stated if a diet order changed from a pureed to regular diet was not updated and followed, it would not affect the nutritional status but would affect the resident's preferences. She stated she did not update care plans; nurses update resident care plans.<BR/>During an interview on 6/13/24 at 10:55 AM with the MDS nurse, she stated changes to care plans were the responsibility of herself and nursing. She stated she bases her changes to the care plan on the MDS or change of condition. MDS nurse stated changes to care plans were discussed in morning meetings after an order is given, or they wait on MDS. She stated Resident #13 was on a regular diet. She stated his care plan reflected a pureed diet with NTLs (National Dysphagia Diet Level 1). She stated if the resident was given a pureed diet, it would not affect the resident because nutritional value was the same. She stated if a care plan differed from actual orders, there would be conflicting information which could affect the residents' preferences and likes/dislikes. She stated that ultimately the resident would not be affected because the meal ticket was based on the orders and that is what is used to guide the food the resident was served. She stated anyone in nursing has the responsibility to change the care plan including the person who put the order in and nurses on the floor. She stated we care meetings were conducted weekly to discuss the residents' body systems (skin, weight, etc.) and any concerns. She stated IDT meetings were conducted quarterly to discuss the residents' plan of care, any concerns with the plan of care, and any concerns the resident may have. The MDS nurse stated she was updating the care plan during the interview to reflect orders for a regular consistency diet for Resident #13.<BR/>During an interview on 6/13/24 at 1:19 PM with the DON, she stated care plans were changed and updated when an order was given. She stated if care plans were not updated immediately, they were updated quarterly during care plan meetings with the residents and their families. She stated anyone can update care plans when new orders were given. She stated Resident #13 was currently on a renal, regular consistency diet. She stated that he refused pureed food. She stated if the care plan was not updated from pureed to a regular diet, it would not harm the resident, but it would not reflect his preferences . <BR/>During an interview on 6/13/24 at 5:26 PM with the Administrator, she stated care plans were updated when new orders were received. She stated nurses were responsible for updating care plans. She stated care plan meetings were conducted quarterly. <BR/>Review of the Facility's Care Plans, Comprehensive Person-Centered policy, revised March 2022, revealed the policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It further revealed the policy interpretations and implementation with the following relevant information: <BR/>1. <BR/>The comprehensive, person-centered care plan:<BR/>a. <BR/>Includes measurable objectives and timeframes;<BR/>b. <BR/>Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .<BR/>c. <BR/>Includes the resident's stated goals upon admission and desired outcomes;<BR/>d. <BR/>Builds on the resident's strengths; and <BR/>e. <BR/>Reflects currently recognized standards of practice for problem areas and conditions.<BR/>2. <BR/>Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.<BR/>3. <BR/>The interdisciplinary team reviews and updates the care plan:<BR/>a. <BR/>When there has been a significant change in the resident's condition;<BR/>b. <BR/>When the desired outcome is not met;<BR/>c. <BR/>When the resident had been readmitted to the facility from a hospital stay; and <BR/>d. <BR/>At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observations and interviews the facility failed to ensure medications on two of six carts and one medication room reviewed for medication storage were not expired in accordance with currently accepted professional principles, and in accordance with State and Federal laws<BR/>The facility failed to ensure medications stocked on the Nurse's and Medication Aide carts for the Suites unit, Nurse medication cart and the Medication room for the Terrace unit were not expired.<BR/>These failures placed the residents at risk of receiving medications that might not have their full effectiveness, or may have become toxic. <BR/>Findings included:<BR/>Observation on 05/10/23 at 10:10 AM the Medication Aide cart for the Suites unit revealed one bottle of Oyster shell with Calcium had expired in April of 2023, and one bottle of Zinc had expired in March of 2023. <BR/>Interview on 05/11/23 at 10:10 AM MA-O stated she was responsible for stocking the medications on her cart and checking for expired medications. She stated none of the residents received the expired medications, so that is why she didn't notice the medications had expired. <BR/>Observation on 05/10/23 at 10:23 AM the medication room for the Terrace unit revealed two bottles of Oyster shell with Calcium were stocked on the shelf that had expired in April 2023. <BR/>Observation on 05/10/23 at 10:25 AM the Nurse medication cart for the Terrace unit had one bottle of Oyster Shell with Calcium that had expired in April 2023. <BR/>Interview on 05/10/23 at 10:28 AM LVN-B stated the nurses stock the medication carts from the medication room. He stated somebody from Central Supply re-stocked the medication room. He stated the risk of giving expired medications could be an allergic reaction or a non-therapeutic dosage. <BR/>Interview on 05/11//23 at 12:29 PM the ADON stated she expected the nurses to check their carts weekly for expired medications and replace them as needed. She stated the risk of giving an expired medication was that it would not have the therapeutic effects intended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #67) of three residents reviewed for resident rights and dignity. <BR/>Facility failed to ensure Resident #67 had a privacy cover for his indwelling catheter while he was in therapy room at 09:58 AM and while he sat by the entrance area into the facility at 3:00 PM on 06/12/24. <BR/>This failure could place resident at risk for a loss of dignity, decreased self- worth, and decreased self-esteem. <BR/>Finding included<BR/>Review of Resident #67's face sheet, dated 06/13/24, reflected a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included paralysis that affects limbs and body from the neck down (Quadriplegia), a bedsore on scrum (pressure ulcer), uncontrolled blood sugars (diabetes mellitus), major depression, anxiety, post-traumatic stress, spinal cord disorder (cervical stenosis) and below the right knee amputee (Right BKA).<BR/>Review of Resident #67's order summary, dated 06/13/24, reflected urinary catheter 16 FR, with 10 cc for pressure injury (aka pressure ulcer/bed sore). Monitor urinary output each shift. Start date 03/27/24.<BR/>Review of Resident #67's quarterly MDS dated [DATE], reflected BIMS summary score of 15, indicating cognitively intact. Resident #67 could understand others and others could understand him.<BR/>Review of Resident #67's care plan on 06/13/24 reveled Resident #67 had ADL's self -care performance deficit related to quadriplegia, cervical stenosis, and Right BKA. The goal was to anticipate and meet needs, dignity would be maintained, he would be kept clean, dry and odor free. Resident #67's interventions included: Ensure boot was applied to left foot as ordered, bathing/showering check nail length and trim on bath days as necessary, dressing- assist resident to choose simple comfortable clothing that enhanced resident's ability to dress himself. Initiated 7/12/23 with target date 5/21/24.<BR/>Observation and interview with Resident #67 on 06/12/24 at 09:58 AM, revealed Resident #67 in physical therapy room in his wheelchair, his catheter bag exposed without a privacy cover. Urine was clear yellow and 200-300 cc of urine could be seen walking by physical therapy room window. Resident #67 stated that he had not even noticed his catheter bag. He did not state how it made him feel. Resident #67 observed again at 3:00 pm and 3:15 pm seated in his wheelchair by the front entrance area watching TV . Catheter bag exposed without a privacy cover. Urine was half full in catheter bag. DON alerted by surveyor at 03:13 PM. <BR/>In an interview with LVN D on 06/12/24 at 03:14 PM, she stated that she had Resident #67 assigned to her on her shift. She said that Resident #67 had a privacy cover earlier in her shift. LVN D did not state the risk to the resident for not having a privacy cover on his catheter bag with urine in it.<BR/>In an interview with DON on 06/12/24 at 03:13PM, she stated, after looking at Resident #67's urine catheter bag, that the catheter bag should be covered with a dark privacy cover. She said the privacy cover promotes dignity and not having one risked dignity issues for Resident #67. <BR/>In an interview with the ADM on 06/13/24 at 05:266 PM, she stated that she expected all nursing staff to promote privacy and dignity for all residents. She said that all catheter bags should have a privacy cover or in a dark privacy bag used in the facility. She said the risk to resident was their privacy and dignity. <BR/>Record Review of the facility's policy titled Resident Rights, revision 12/2016, reflected, . To ensure that care and services provided by the facility promote and/or enhance privacy, dignity, and overall quality of life .A. dignified existence .H. To be supported by the facility in exercising his or her rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #67) of three residents reviewed for resident rights and dignity. <BR/>Facility failed to ensure Resident #67 had a privacy cover for his indwelling catheter while he was in therapy room at 09:58 AM and while he sat by the entrance area into the facility at 3:00 PM on 06/12/24. <BR/>This failure could place resident at risk for a loss of dignity, decreased self- worth, and decreased self-esteem. <BR/>Finding included<BR/>Review of Resident #67's face sheet, dated 06/13/24, reflected a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included paralysis that affects limbs and body from the neck down (Quadriplegia), a bedsore on scrum (pressure ulcer), uncontrolled blood sugars (diabetes mellitus), major depression, anxiety, post-traumatic stress, spinal cord disorder (cervical stenosis) and below the right knee amputee (Right BKA).<BR/>Review of Resident #67's order summary, dated 06/13/24, reflected urinary catheter 16 FR, with 10 cc for pressure injury (aka pressure ulcer/bed sore). Monitor urinary output each shift. Start date 03/27/24.<BR/>Review of Resident #67's quarterly MDS dated [DATE], reflected BIMS summary score of 15, indicating cognitively intact. Resident #67 could understand others and others could understand him.<BR/>Review of Resident #67's care plan on 06/13/24 reveled Resident #67 had ADL's self -care performance deficit related to quadriplegia, cervical stenosis, and Right BKA. The goal was to anticipate and meet needs, dignity would be maintained, he would be kept clean, dry and odor free. Resident #67's interventions included: Ensure boot was applied to left foot as ordered, bathing/showering check nail length and trim on bath days as necessary, dressing- assist resident to choose simple comfortable clothing that enhanced resident's ability to dress himself. Initiated 7/12/23 with target date 5/21/24.<BR/>Observation and interview with Resident #67 on 06/12/24 at 09:58 AM, revealed Resident #67 in physical therapy room in his wheelchair, his catheter bag exposed without a privacy cover. Urine was clear yellow and 200-300 cc of urine could be seen walking by physical therapy room window. Resident #67 stated that he had not even noticed his catheter bag. He did not state how it made him feel. Resident #67 observed again at 3:00 pm and 3:15 pm seated in his wheelchair by the front entrance area watching TV . Catheter bag exposed without a privacy cover. Urine was half full in catheter bag. DON alerted by surveyor at 03:13 PM. <BR/>In an interview with LVN D on 06/12/24 at 03:14 PM, she stated that she had Resident #67 assigned to her on her shift. She said that Resident #67 had a privacy cover earlier in her shift. LVN D did not state the risk to the resident for not having a privacy cover on his catheter bag with urine in it.<BR/>In an interview with DON on 06/12/24 at 03:13PM, she stated, after looking at Resident #67's urine catheter bag, that the catheter bag should be covered with a dark privacy cover. She said the privacy cover promotes dignity and not having one risked dignity issues for Resident #67. <BR/>In an interview with the ADM on 06/13/24 at 05:266 PM, she stated that she expected all nursing staff to promote privacy and dignity for all residents. She said that all catheter bags should have a privacy cover or in a dark privacy bag used in the facility. She said the risk to resident was their privacy and dignity. <BR/>Record Review of the facility's policy titled Resident Rights, revision 12/2016, reflected, . To ensure that care and services provided by the facility promote and/or enhance privacy, dignity, and overall quality of life .A. dignified existence .H. To be supported by the facility in exercising his or her rights

Based on observations, interviews, and record review, the facility failed to provide a clean and homelike environment for three of five residential halls (Hall 200, Hall 300, and Hall 400) reviewed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure six air duct registers were free of small black spots, rust, paint chipping and securely fit into ceiling tiles. These failures could place residents at risk for decline in health and decreased quality of life due to living in unclean and non-homelike environment.Findings included: Observation on 07/22/2025 at 10:26AM in Hall 200 revealed: S One ceiling air duct register covered with small black spots. S One ceiling air duct register, with rust and peeled paint chips. Observation on 07/24/2025 at 11:59AM in Hall 300 revealed: S Two ceiling air duct registers covered with small black spots and rust S One ceiling air duct register covered with small black spots Observation on 07/24/2025 at 12:07PM in Hall 400 revealed: S One ceiling air duct register with small black spots in a white ceiling tile with small black spots lining the air duct register. The ceiling air duct register did not securely fit in the ceiling tile. An interview on 07/24/2025 at 01:11PM with the maintenance manager revealed housekeeping was responsible for cleaning the air ducts and maintenance replaces air duct registers. The maintenance manager explained he will talk with staff about maintenance requests, but staff must put in a work order. This surveyor showed the maintenance manager an image of the condition of one air duct register located in Hall 200; he stated that housekeeping would clean the air duct register, but maintenance would replace the air duct register based on its dirty appearance. The maintenance manager stated the substance on the air duct was not black mold, but it may be mold or dirt. The maintenance manager discussed that to resolve the problem with the air duct registers, he would replace them. An interview on 07/24/2025 at 01:45PM with the housekeeping manager revealed housekeeping staff was responsible for maintaining cleanliness of the air duct registers and maintenance replaces air duct registers. The housekeeping manager stated housekeeping staff cleaned resident rooms every day. She expected the air duct registers to be checked daily; if housekeepers see an issue, they inform her or nurses so a maintenance work order can be placed. The housekeeping manager stated housekeeping staff will check all air duct registers and make a list of the ones that need replaced. During an interview on 07/24/2025 at 02:03PM with the DON revealed room rounds are done to check the condition each room. The DON stated that she had not checked air duct registers. This surveyor showed the DON an image of the condition of one air duct register located in Hall 200, and she stated she will now check the air duct registers closely. She stated she would report the condition of the air duct register to housekeeping to have it cleaned. The DON stated clean air duct registers are important because resident rooms should be homelike, and so that the residents stay healthy and don't have issues because of a dirty air duct register. Record review of the facility policy Homelike Environment revised February 2021 reflected: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation. The community team members and management maximize, to the extent possible, the characteristics of the community that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment.

Based on observation and interview the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three nurse medication carts of five carts reviewed for infection control.<BR/>The facility failed to monitor the sharps containers for three medication carts to prevent them from being overfilled. <BR/>This failure placed residents at risk of exposure to bloodborne pathogens present on used sharps. <BR/>Findings included:<BR/>Observation on 01/24/23 at 10:23 AM revealed the sharps container (used to dispose of used syringes) for the nurse medication cart for the Terrace Unit was overfilled. The control flap was stuck in the open position with the inability to deposit any more sharps.<BR/>Interview on 01/24/23 at 10:25 AM, LVN A stated the nurses were responsible for changing out sharps containers when they were full. LVN A stated the overfilling the containers posed a risk for anyone, who might stick their hand near the opening, of being exposed to a used sharps. <BR/>Observation on 01/24/23 at 10:48 AM revealed the sharps container for the nurse medication cart for Pulmonary Unit was passed the fill line. <BR/>Interview on 01/24/23 at 10:50 AM LVN B stated nurses were responsible for changing out the sharps box when it hit the fill line to prevent exposure to the sharps it contained. <BR/>Observation on 01/24/23 at 10:54 AM the sharps container for the nurse medication cart for Suites Unit was overfilled with three syringes poking out the top of the box, needles facing downward. <BR/>Interview on 01/24/23 at 10:55 AM LVN C stated the nurses were responsible for monitoring the sharps boxes. He stated he did not know how the box got so full that syringes were sticking out the top of it. LVN C stated the exposed syringes could stick someone if they were not paying attention when trying to put another sharp into the box. <BR/>Interview on 01/24/23 at 1:24 PM, the DON stated the nurses were primarily responsible for monitoring their sharps boxes and changing them out when needed, but anyone walking by should check them as well and change them out. <BR/>The facility had no policy addressing sharps containers specifically per the DON.<BR/>Review of OSHA standards on sharps, as described on their website osha.gov, reflected the following:<BR/> .1910.1030(c)(1)(i) Each employer having employees with occupational exposure to bloodborne pathogens shall establish an Exposure Control Plan designed to eliminate or minimize employee exposure.<BR/> .1910.1030(d)(2)(viii) Immediately, or as soon as possible after use, contaminated sharps shall be placed in appropriate containers. These containers shall be:<BR/> . Puncture resistant<BR/> . Labeled or color-coded<BR/> . Leakproof<BR/> .1910.1030(d)(4)(iii)(A)(2) During use containers for sharps shall be:<BR/> . Easily accessible to personnel<BR/> . Maintained upright throughout use<BR/> . Replaced routinely and not be allowed to overfill<BR/> . Containers should be closed immediately to prevent spillage or protrusions of contents during handling, storage, transport, or shipping <BR/>

Based on observations, interviews and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. <BR/>The facility failed on 06/11/2024 to ensure items found in the walk-in refrigerator, were labeled with the use by date.<BR/>These failures could place resident at risk for food-borne illness and food contamination. <BR/>Findings included:<BR/>Observation on 06/11/2024 at 9:11 am revealed in the facilities only walk-in refrigerator the following items not labeled or dated:<BR/>- <BR/>Large Ziplock bag containing cheese.<BR/>- <BR/>Large Ziplock back containing a sandwich, chips, packaged crackers, personal packet of mayonnaise.<BR/>- <BR/>Large Ziplock bag containing cooked bacon. <BR/>Observation on 06/11/2024 at 9:11 am revealed in the facilities only walk-in refrigerator the following items in open packaging:<BR/>- <BR/>Box of lunch meat on the shelf uncovered. <BR/>- <BR/>Box of 24 count eggs with 18 eggs remaining in the open box. <BR/>Interview on 06/12/2024 at 2:20 PM with admission Director; revealed he has been helping in the kitchen during preparation time because the dietary manager quit about three weeks ago. He stated he assist with ordering food and food preparation. He has a position within the facility that limited his time in the kitchen. He stated that he did remind dietary staff to maintain safe store practices. <BR/>Interview on 06/13/2024 at 3:06 PM with DON; she stated that food should be closed and sealed. The risk to the residents was cross contamination. <BR/>Interview on 06/13/2024 at 05:22 PM with Administrator; she stated food should be labeled for us to know that the food was not expired and safe for human consumption. <BR/>Review of the policy titled Food Storage, dated 2018 reflected; d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. <BR/>

Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate accountability of controlled drugs for one (Suites Hall medication cart) of two medication carts reviewed for narcotic count documentation.<BR/>The facility did not obtain nursing staff signatures for the Controlled Drugs-Count Record for the Suites Hall medication cart for 01/02/23 on the 3:00 PM - 11:00 PM shift. <BR/>This failure could place residents receiving medications at risk for inadequate supply of medication, ineffective therapeutic outcomes, and drug diversion. <BR/>Findings included:<BR/>Review of The Controlled Drugs-Count Record for the Suites Hall medication cart dated January 2024 indicated the log was missing nursing staff signatures as follows:<BR/> 01/02/24 - 3:00 PM - 11:00 PM shift. There were no on-coming nurse and off-going nurse signatures.<BR/>Interview and record review on 01/10/24 at 11:52 AM with LVN A revealed she was working the 3:00 PM - 11:00 PM shift on 01/02/24. LVN A revealed the Suites Hall medication cart Controlled Drugs-Count Record was missing required signatures on 01/02/24 for the on-coming nurse and off-going nurse for the 3:00 PM - 11:00 PM shift. LVN A said she counted the controlled medications on 01/02/23 as required but did not sign the record as required. LVN A stated she did not know why she did not sign the record. <BR/>Interview on 01/10/24 at 2:23 PM with the ADM revealed the nursing staff are expected to count narcotics and sign the Controlled Drugs-Count Record upon starting their shifts and as they complete their shift to ensure there were no discrepancies. The ADM stated the risk of not signing the Controlled Drugs-Count Record could result in inconsistencies in documentation. <BR/>Interview with the DON was not available on 01/10/24, the DON was not scheduled to be working. <BR/>Facility policy titled Controlled Substances revised November 2022 indicated the following . 3 .individual sign the designed controlled substance record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement an admissions policy that did not request or require residents to waive potential facility liability for loss of personal property.<BR/>The facility failed to ensure the admission policy did not have a Resident Personal Property Waiver reflecting all articles retained by the resident shall be the responsibility of the resident. <BR/>This failure could result in harm to residents' well-being by fearing that their personal property is not protected from theft or loss.<BR/>Findings included:<BR/>Review of Resident #1's quarterly MDS dated [DATE] revealed the resident was [AGE] year-old female admitted to the facility on [DATE]. Resident #1 diagnoses included Alzheimer's disease (degenerative brain disorder), asthma (lung disorder), and essential hypertension (high blood pressure).The MDS further reflected Resident #1 was cognition was moderately impaired with a BIMS score of 10 out of 15.<BR/>Review of Resident #1's grievance report dated 05/11/23 completed by the Social Worker on 05/14/23 reflected the following: .blanket still missing; look everywhere for blanket, blanket has not been found <BR/>Interview with Resident #1's family member on 06/27/23 at 9:15 AM revealed the resident's blue baby blanket went missing a month ago. The family member stated she reported the resident's missing blanket to the Social Worker through an email and a grievance was filled out, but the family member was not given a resolution. The family member stated the facility needed to replace the blanket.<BR/>Interview with Resident #1 on 06/27/23 at 10:42 AM revealed she had a missing blue blanket, but she did not know how it got lost. Resident #1 stated the facility staff had been looking for the blanket, and it had not been found.<BR/>Interview on 06/27/23 at 11:21 AM with the Social Worker revealed she was made aware Resident #1's blanket was missing on 05/11/23 by Resident #1's family member. She stated they searched the resident's room and laundry, but the blanket had not been found. She revealed she had not communicated the findings with Resident #1's family member. The Social Worker stated she was asked by the Administrator to write an email to the family member of Resident #1 to inquire about where she had bought the blanket. She stated she had yet to write the email to Resident #1's family member.<BR/>Interview with the Administrator on 06/27/23 at 12:38 PM revealed Resident #1's family member reported a lost blanket, and they had been looking for it but had not found it. When an item was reported missing, the Social Worker completed a grievance report, and they searched for the item. The Administrator stated the residents signed admission paperwork which reflected the facility was not responsible for missing or stolen items, and they only tried to collect their wrongs when they replaced a lost item. The Administrator stated the facility admission policy reflected clearly that items retained in a resident's possession shall be entirely the responsibility and liability of the resident/responsible party.<BR/>Review of the facility's undated admission policy reflected the following: .6. Personal Belongings: All articles retained by Resident shall be entirely the responsibility and liability of Resident/Responsible party.

Based on observation, interview, and record review, the facility failed to maintain and effective pest control program to ensure the facility was free of pests for kitchen area.<BR/>The facility failed to ensure an effective pest control program was implemented to prevent the presence of gnats and files in the kitchen area.<BR/>This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.<BR/>Findings included: <BR/>Observation on 06/11/2024 at 9:10 am revealed 4-5 gnats fly from the trash can located next to the handwashing sink in the kitchen area. Observation of 4-5 flies around the stove, three compartment sink and juice dispenser. Observation of the kitchen backdoor used for taking out the trash and receiving delivers was partially open.<BR/>Observation on 06/12/2024 11:27 am revealed 4-5 flies around the steam table. Staff members were observed waving their arms at flies to prevent them from landing on food. Fly was observed landing on meal tray. <BR/>Interview with Dietary Aide on 06/12/2024 at 1:15 pm revealed there were several flies because during delivery the backdoor was left opened and this allows the files to come into the building. He stated that pest control will come and treat the kitchen area when there were a lot of flies and gnats. He stated that the gnats were usually around the dish machines and drains. The risk to the residents was they can lay eggs that become maggots and the residents can get sick. <BR/>Interview with the Admissions Director on 06/12/2024 at 2:20 pm revealed there is an issue with files in the kitchen area. He stated that the flies enter the building when food is delivered through the backdoor because it is held open during the delivery. He stated that it was not sanitary to have files around food when it was being prepared or served. <BR/>Interview with Maintenance director on 06/13/2024 at 4:23 PM revealed he stated that he was not aware of the flies and gnats until 06/13/2024. He stated that when he was told of the issue, he would contact pest control and they would come out and treat the affected areas. He stated the files were coming in through the backdoor and the gnats were coming through the drains because staff was not mopping the floors. <BR/>Record review of pest control services dated 06/12/2024 at 5:00 pm reflected facility requested additional pest service. Pest control on site for emergency service regarding flies. Upon arrival administrator requested full facility fly wipe down to treat for flies. Few flies were observed in hallways (2-3), then made it to the kitchen where the highest concentrations of flies and some gnats. Once all food items were put away and aerosol fly bait was applied to strategic corners of the kitchen to reduce fly and gnat's pressure. <BR/>Review of Pest Control policy reflected a request for facility policy was not received prior to exit

Based on observation and interview the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three nurse medication carts of five carts reviewed for infection control.<BR/>The facility failed to monitor the sharps containers for three medication carts to prevent them from being overfilled. <BR/>This failure placed residents at risk of exposure to bloodborne pathogens present on used sharps. <BR/>Findings included:<BR/>Observation on 01/24/23 at 10:23 AM revealed the sharps container (used to dispose of used syringes) for the nurse medication cart for the Terrace Unit was overfilled. The control flap was stuck in the open position with the inability to deposit any more sharps.<BR/>Interview on 01/24/23 at 10:25 AM, LVN A stated the nurses were responsible for changing out sharps containers when they were full. LVN A stated the overfilling the containers posed a risk for anyone, who might stick their hand near the opening, of being exposed to a used sharps. <BR/>Observation on 01/24/23 at 10:48 AM revealed the sharps container for the nurse medication cart for Pulmonary Unit was passed the fill line. <BR/>Interview on 01/24/23 at 10:50 AM LVN B stated nurses were responsible for changing out the sharps box when it hit the fill line to prevent exposure to the sharps it contained. <BR/>Observation on 01/24/23 at 10:54 AM the sharps container for the nurse medication cart for Suites Unit was overfilled with three syringes poking out the top of the box, needles facing downward. <BR/>Interview on 01/24/23 at 10:55 AM LVN C stated the nurses were responsible for monitoring the sharps boxes. He stated he did not know how the box got so full that syringes were sticking out the top of it. LVN C stated the exposed syringes could stick someone if they were not paying attention when trying to put another sharp into the box. <BR/>Interview on 01/24/23 at 1:24 PM, the DON stated the nurses were primarily responsible for monitoring their sharps boxes and changing them out when needed, but anyone walking by should check them as well and change them out. <BR/>The facility had no policy addressing sharps containers specifically per the DON.<BR/>Review of OSHA standards on sharps, as described on their website osha.gov, reflected the following:<BR/> .1910.1030(c)(1)(i) Each employer having employees with occupational exposure to bloodborne pathogens shall establish an Exposure Control Plan designed to eliminate or minimize employee exposure.<BR/> .1910.1030(d)(2)(viii) Immediately, or as soon as possible after use, contaminated sharps shall be placed in appropriate containers. These containers shall be:<BR/> . Puncture resistant<BR/> . Labeled or color-coded<BR/> . Leakproof<BR/> .1910.1030(d)(4)(iii)(A)(2) During use containers for sharps shall be:<BR/> . Easily accessible to personnel<BR/> . Maintained upright throughout use<BR/> . Replaced routinely and not be allowed to overfill<BR/> . Containers should be closed immediately to prevent spillage or protrusions of contents during handling, storage, transport, or shipping <BR/>