**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of four residents reviewed for supervision. The facility failed to provide adequate supervision to prevent Resident #1, who had severe cognitive impairment from eloping from the facility on 03/21/25. The resident was found at an intersection, across the street from the facility. The resident did not sustain any injuries and was found by a pedestrian. The noncompliance was identified as PNC IJ. The noncompliance began on 03/21/25 and ended on 03/21/25. The facility corrected the noncompliance before the investigation began. This failure could place residents at risk for injury and/or death. Findings included: Review of Resident #1's Face Sheet, dated 03/21/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Senile Degeneration of Brain (encompasses a range of neurological disorders characterized by a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities), Cerebral Infarction (also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain), Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Anxiety Disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Cognitive Communication Deficit (a communication difficulty caused by a cognitive impairment). Review of Resident #1's MDS (Minimum Data Set) assessment, dated 01/06/25, revealed the resident was sometimes understood by others and sometimes understood others, had a BIMS (Brief Interview for Mental Status) was 04, which indicates severe cognitive impairment, had impairment of his lower extremities and used a wheelchair to ambulate independently, able to ambulate without support from staff. Review of the Elopement Risk Observation assessment dated [DATE], identified Resident #1 as having exit-seeking behaviors, as it indicated t he had attempted to leave the healthcare facility. Review of Resident #1's Care Plan, last Care Conference dated 08/29/24, revealed the resident had cognitive loss/Dementia as evidenced by long term memory recall, inability to understand commands/communication, poor decision-making; Related to diagnoses of Dementia and Cerebrovascular Accident, also known as a stroke. Goal: Resident #1 will understand helpful reminders, will have needs met by staff as identified or anticipated, will have minimal negative emotional distress related to cognitive issues. As evidenced by documentation in the medical record. Approach: Continue to assess periodically for changes in cognition, encourage decision-making when able, reinforce use of memory cues. Review of Resident #'1's Care Plan, revised 03/21/25, revealed the resident will not have negative events related to wandering, will remine safely in the facility as evidence by documentation in the medical record. Approach: find placement for secured unit Approach: assist with 1:1 supervision at all times Approach: Attempt to identify patterns to time of increased wandering (shift change, evening, after family visits, when hungry or near mealtimes .- not if no patterns identified.) Approach: Resident will be assessed by activities and potential intervention are identified as: activities of interest include: (add preferences) The interventions will be noted on the POC. Approach: Resident will be identified to staff through the facility alert system as an elopement risk. Approach: Resident's physical needs will be met; hunger, thirst, toileting Review of Resident #1's Care Plan, last reviewed/revised on 03/25/25, revealed the Category of Behavioral Symptoms: Problem - Resident #1 wanders through out the facility, is a risk for 1. Elopement . Related to diagnosis of Dementia. Goal(s): Resident will not have negative events related wo wandering, will remain safely in the facility as evidence by documentation in the medical record. Approach(es): Resident eloped on 03/21/25. Resident receiving one and one monitoring. Social Worker working with Responsible Party to locate secure unit. Attempt to identify patters to time of increased wandering (shift change, evening, after family visits, when hungry or near mealtimes .not if no patters identified.) Resident will be assessed by activities and potential intervention are identified as: activities of interest include: The interventions will be noted on the Plan of Corrections. Resident will be identified to staff through the facility alert system as an elopement risk. Resident's physical needs will be met; hunger, thirst, toileting. Review of Resident #1's admission Elopement Risk Observation Assessment, dated 04/30/24, revealed the resident was cognitively impaired with poor decision-making skills, confused, independent with aide (wheelchair) in mobility, and had a known history of wandering, placing him at significant risk for getting to potentially dangerous places (stairs, outside of facility). Review of Resident #1's Progress Notes, dated 03/21/25 at 3:24 PM, revealed the resident propelled himself out of the front entrance door and was noted outside the building. The resident was noted at the intersection from which the resident was assisted back to facility by responding staff. No acute s/s of distress noted. Call placed to the Responsible Party to notify. The Responsible Party stated, Resident #1 use to be in the military and is super-fast and quiet. I know he's a pain in the butt. The Responsible Party apologized and thanked this writer for notifying her. The resident is currently with the assigned charge nurse head to toe assessment, skin assessment, hydration and Activities of Daily Living care implemented. Resident is currently in line of sight, one on one supervision of 1 staff. No signs/symptoms of distress noted. Call placed to physician; no new orders received. Date & Time Template Progress Notes 4/17/25, 3:18 PM Observation of the intersection on 04/16/25 at 9:00 AM, revealed the intersection began at the corner of the parking lot's west entrance. The intersection consists of three, eastbound lanes with the outermost lane for moving straight ahead or turning right onto another street. The innermost lane being a left turning lane, which leads into the facility's parking lot's west entrance. The intersection also consists of three westbound lanes with the innermost lane being a left turning lane and the outermost lane for moving straight ahead or turning right, into the facility's parking lot's west entrance. There was a median separating the two directions of traffic and there were traffic lights for both directions of traffic. The resident would have had to exit from the parking lot's west entrance, heading southbound, cross the street, stop at the median to avoid eastbound traffic, and then cross the eastbound lanes to reach the corner where the pedestrian stopped him and kept him, until the Administrator arrived. There were businesses on the block which the pedestrian stopped the resident and across the street, west of the businesses, was a gated senior living community. The resident had to cross six lanes to get to the other side of the street. The speed limit for the lanes going east and west bound was 40 miles per hour. An interview with the Receptionist on 04/16/25 at 10:11 AM, revealed the day of Resident #1's elopement, the front area was busy with a group of residents playing a card game and staff were passing through and talking. She stated she saw Resident #1 in the lobby area; however, he was not near the entrance door at the time. She stated when the vendor came in with another resident, they stopped at the counter, and she was talking to the vendor and the resident. She stated she did not notice that Resident #1 had reached the door and exited. She stated she contacted the vendor and told them that they had to make sure the door was closed behind them, whenever they entered and exited the facility, and they stated they understood. She stated she was instructed to contact the vendor, by the Administrator. She stated that day, the orange notice was placed on the door, telling visitors and vendors to make sure the door was closed when they enter and/or exit the facility. An interview with the Director of Nursing (DON) on 04/16/25 at 5:19 PM, revealed Resident #1 was an exit-seeker, he was already in the Elopement Risk Binder prior to the incident. She stated she did not know the last time he attempted or if he had ever been successful at eloping, prior to this date. She stated he had not attempted to elope since she had been at the facility, prior to the day of the incident. She stated the Elopement Risk Binder with residents' pictures are at the reception desk, and both nurses' stations. She stated the books are reviewed when new staff start and if there was an elopement attempt on the 24-hour Report, the binders are updated, and it was discussed during their shift changes and morning meetings. She stated they had not had an elopement, since she was at the facility. She stated they had Elopement Drills monthly and as needed. She stated they monitored Elopement Risk residents for change in condition, whether they declined, or their behavior increased, she stated any change in the resident, was discussed and they would update the binder and their care plans. She stated when this incident happened, they educated the staff, and the vendor was contacted to ensure they understood to make sure the door closed behind them. An observation on 04/16/18 at 6:28 PM, revealed the facility front door, which lead to the lobby, had a bright orange sign placed at eye-level, which instructed visitors and vendors to make sure all doors were closed behind them when they entered and exited the facility, to ensure residents were not able to leave the building unassisted. Interview with the Administrator on 04/17/25 at 9:25 AM, revealed Resident #1 had eloped from the facility through the front entrance. She stated the facility received a call from a pedestrian who found the resident on the corner of the intersection, across the street from the facility. The Administrator stated she was notified and immediately told other administrative staff. She stated she exited the building and saw Resident #1 across the street. She stated she went to the resident and asked him where he was going and he replied, I was trying to get away. She stated she assessed him and did not observe any signs of injury or distress. She told him he had to go back home and that she would take him. She stated the resident agreed. She stated by then, other staff had arrived, and they all escorted the resident back to the facility. She stated resident was assessed by a nurse and no injuries or signs of distress were noted. She stated the resident was placed on 1:1 monitoring, and the monitoring continued until he was discharged . She stated the resident's physician and Responsible Party was notified. She stated they reviewed video footage to determine how the resident exited the facility, and they saw that he stopped the door from closing, after a vendor entered the facility with another resident. She stated the vendor stopped at the reception desk and as was talking to the receptionist, the resident exited without being seen. She stated a Care Conference was set up and during the Care Conference, they discussed the resident requiring a secured unit being a more suitable placement for the resident and the Responsible Party agreed. She stated the Social Worker, assisted the Responsible Party with finding a facility with a secured unit. She stated the resident was discharged to the new facility on 03/26/25. She stated on the day of the elopement, all staff were in-serviced on Elopements, and she instructed the DON to post signs telling visitors and vendors to ensure the door closes completely, behind them. Review of the facility's Elopement Policy, dated 11/01/17, revealed Policy: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident. Procedures: 1. Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead Purple. 2. The DON/designee completes a missing resident profile. 3. The DON or designee organizes and institutes an immediate and thorough search of the center and surrounding grounds. The search should include but is not limited to a search of the area outside the nearest exit to the patient/resident's room or the exit where he/she was last seen, and the entire unit where the patient/resident resides or was last seen, the remainder of the facility (all rooms, closets - including storage facilities - and bathroom) and grounds, extending beyond the fence line. 4. The entire search process of the facility and grounds, from the time the patient/resident is missing, will be completed within (30) thirty minutes. 5. If the search fails to locate the missing patient/resident within (30) thirty minutes from the time the patient/resident is found missing, the Administrator or designee contacts the appropriate community agencies (Police, Local Health Department) and Administration, the patient/resident's legal representative and attending physician. Staff will provide the Police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex, and clothing if known. 6. The search is continued. Two staff members search the surrounding streets by car for a (2) two-mile radius around the facility. 7. When the patient/resident is located, the Charge Nurse completes a head-to-toe assessment. The Social Services designee assesses the patient/resident for emotional distress. The Charge Nurse reports any findings to the DON or designee. The DON or designee notifies the Administrator/designee and notifies the appropriate community agencies, attending physician, and patient/resident's legal representative .11. Facilities Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences. The Administrator and DON were notified on 04/17/25 at 4:10 PM, that a Past Non-Compliance IJ situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an IJ situation on 03/21/25. The facility implemented the following interventions: Interventions initiated prior to surveyor entry on 03/25/25: * Daily inspection log of all exits beginning 03/21/25 * Elopement drills with all staff on 03/21/25 * Updated Care plan for Resident #1 on 03/21/25 * 100 % audit all residents for elopement risk. 03/21/25 * The facility conducted appropriate in-service trainings, on 03/21/25, in regard to: Elopement Risk What to do if resident is missing Abuse, Neglect, and Exploitation * Resident #1 was discharged from the facility to another facility, accompanied by a C.N.A. via transport in wheelchair. The resident departed in stable condition with all remaining belongings and medication. Copy of face sheet and Continuity of Care Documents were sent with the resident on 03/26/25. There had been no previous and no new incidents for any additional residents as of 03/21/25. Interviews: 04/16/25 at 5:41 PM with C.N.A. A, revealed Elopement In-services on checking doors to make sure they are closed. Check on the residents. They had to always try to keep residents who moved around all the time, in an area where everyone could see them and know where they were. If an alarm went off, they would check the doors to see if they could see who went out or was trying to go out. They were then supposed to go outside and look around the parking lot and the sidewalk out front, to see if they could see a resident. If no residents were found, they were supposed to come back in and locate all of their assigned residents. They would check the Elopement Binder to make sure those residents were in the building. They would report to the nurse that all of their people were in the building. She stated if a resident eloped, they would call Code Purple over the speakers. She stated they would round on their residents every 15 to 30 minutes because they had to constantly be working and making sure the residents were ok and to see if they needed something. She stated if she saw a resident going toward an Exit door, she would run and get them and redirect them. If its someone who was combative, she would call for help and then try to redirect them. She stated they were told to not give the door code to visitors and vendors. She stated they were also told to tell visitors and vendors to make sure the door closed behind them. She stated the back door was only used for staff and vendors who were bringing in supplies. She stated everyone else had to use the front door to enter and exit the building. She stated they never used the side doors that had a sign saying This is not an Exit. She stated they were for emergencies only. She stated when they were doing 1:1 monitoring, they would have to stay with that resident at all times. She stated if they need to go to the restroom, they have to get someone to sit with the resident until they get back. She stated even if the resident is asleep, they have to stay in the room with them, in case they get up. She stated 1:1 monitoring would last as long as they were told to do it. She stated she was not assigned to be on 1:1 monitoring for Resident #1. She stated she worked with Resident #1 and she never saw him trying to get out of the building. She stated if she witnessed any type of abuse, she would report it to the nurse and to the Administrator. She stated if it was resident-to-resident abuse, she would separate them and call for help, then report it. 04/16/25 at 5:38 PM with ADON R, revealed the last time they had an Elopement in-service was when they had an elopement in March. She stated they talked about what to do when an elopement occurs. She stated they were to check the doors to see if they can see who was at the door or went out of the door. She stated if they did not see anyone, they were supposed to go outside and search the parking lot and up and down the street. She stated if they did not see anyone, they were to come back in the building and search for the residents who were in the Elopement Binder, then make sure the rest of the residents were in the building. She stated once everyone had been accounted for, the aides were to report to the CNAs who would report to the ADONs The ADONs reported to the DON and Administrator. She stated the code word for an elopement was Purple. She stated in the in-service, they were told to tell visitors and vendors to make sure they physically close the door behind them, going and coming. She stated if they saw a resident attempting to exit, they would gently redirect them away from the door and would take them to where they could engage in an activity or where they could be seen by other staff. Such as at the nurses' stations. 04/16/25 at 6:12 PM with ADON S, revealed she stated they had elopement skills drills every three months. She stated if an elopement happened, they would call a code purple and everyone had to search for the missing resident. She stated some staff would ensure that all of their residents were accounted for, while also looking for the missing resident. She stated other staff would search closets, empty rooms, storage rooms, and outside. She stated once the missing resident was found, they would assess the resident and a report would be written. She stated they had to notify the physician, family, Administrator, and DON. She stated staff were to remind vendors and visitors to make sure the doors closed behind them, when they entered and exited the facility. 04/17/25 at 7:15 AM called RN E, no answer, and not able to leave a voice message. 04/17/25 at 7:25 AM called C.N.A. P, no answer, and not able to leave a voice message. 04/17/25 at 7:30 AM called LPN H, no answer, and not able to leave a voice message. 04/17/25 at 10:31 AM with LVN J, revealed in-services were done quarterly and whenever there was an elopement incident. She stated if there was an elopement, the person who noticed a resident was missing, they were to call Code Purple. She stated some of them looked for the missing resident, while the others were going room-to-room counting everyone else to make sure everyone else was accounted for. She stated they looked throughout the building and outside. She stated there were signs on the doors for the visitors or vendors know to make sure the doors close behind them before walking off. She stated this was important so residents could not get out. She stated they walked around and made sure they knew where the residents were, who were an elopement risk. She stated even residents who were not at their baseline of behaviors, she watched them more diligently to make sure they did not slip out of the building or attempt to. 04/17/25 at 11:09 AM with C.N.A. W, revealed they had an in-service no Elopement about a week ago. She stated she was not sure how often they had Elopement Drills, but they had them frequently. She stated they went around saying Code Purple, so staff had to drop everything and start looking. She stated she rounded on her residents every 30 minutes, for the bed-bound residents. She stated for residents who were an elopement risk, she looked for them frequently. She stated most of the time, they gave them a coloring book or some activity to keep them busy at the nurses' station, so they could see them at all times. She stated in the in-services, they were told to tell visitors and vendors to make sure the doors closed behind them and to make sure they did not let residents out the door, like did not hold the door open for them. 04/17/25 at 11:50 AM with LVN U, revealed the last time they had an in-service on Elopement was maybe a couple of weeks ago. She stated they had Elopement Drills quarterly, and when an elopement occurred. She stated if someone eloped, they would call a Code Purple and everyone would be hands on, looking for the missing resident. She stated staff were to round on the residents every two hours or more often if needed. She stated for residents who were elopement risk, they had to know where they were at all times. She stated they kept them busy with activities and they took them to the bathroom regularly. She stated they had Elopement books at the nurses' stations and the front desk. She stated they were to remind visitors and vendors to be mindful of residents around them and make sure the doors closed behind them, so the residents did not get out of the building. 04/17/25 at 1:44 PM called LPN K, left a voice message. 04/17/25 at 1:47 PM called RN M, left a voice message. 04/17/25 at 2:49 PM with LVN K, revealed they recently had an elopement, and they had an in-service a few weeks ago. She stated she was not sure how often Elopement Drills occurred through the week, but she knew they had them. She stated they had not had one during the weekends. She stated the code word for an elopement was Purple. She stated they were to immediately alert the staff of the Code Purple, then start searching for the resident, and they did a head count of all residents. Then once everyone was accounted for or if they still could not find the resident, they were to let the DON and Administrator know. 04/17/25 at 9:00 PM with RN K, revealed they had an in-service on Elopement about two weeks. She stated the vendors and visitors had to look at the door to make sure the door was closed so residents could not get out. She stated if there was an Elopement, they would call Code Purple, and everyone knew to start searching for the missing resident. She stated they counted to make sure everyone was there. She stated they had to report it to the DON and Administrator. She stated they had an Elopement binder at each nurses' station and at the front desk. She stated they did not have Elopement Drills on the night shift, but they had been educated on what to do. 04/17/25 at 9:11 PM with C.N.A. C, revealed the last in-service on Elopement was last month. She stated they had the in-service because a resident had eloped. She stated if they had an elopement, the staff were to make sure all staff were aware and then they all would look all over the building to make sure they saw all of the residents, while others looked outside to try to find the missing resident, if they did not find them inside. She stated once all of the residents were located, they would tell the nurse. She stated if they could not find a resident, they would call 9-1-1. She stated she was not sure what the code word was for elopement, but she knew that it was in the Elopement books which were located at both nurses' stations and at the front desk. 04/17/25 at 9:22 PM with LPN L, revealed the last in-service on Elopement was a few weeks ago. She stated they were told to tell vendors and visitors to make sure the doors closed behind them, so the residents could not get out. She stated they had Elopement binders at the front desk and at the nurses' stations. She stated if someone was missing, they would call code purple and the aides check to see if all of their people were in the building, while the nurses looked, and other staff looked outside in the parking lot and the back of the building and up and down the street. She stated once the missing resident was found, a report would be written, and the DON and Administrator would be notified. She stated they had an elopement a few weeks ago and that was why they had the in-service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to notify the physician of an accident that resulted in an injury and required the physician intervention for 1 (Residents #25) of 1 resident reviewed for notification of changes. The Director of Therapy failed to notify Resident #25's physician when the resident injured her left leg on 04/02/24 while being transported in her wheelchair without footrests. Resident #25 sustained a fracture which was not discovered until 04/06/24 when the NP was notified and ordered an x-ray. This failure placed the resident at risk of not receiving immediate medical attention and at risk of further damage to her leg. The noncompliance was identified as past noncompliance (PNC) The IJ began on 04/02/24 and ended on 04/08/24. The facility had corrected the noncompliance before the state's investigation began. Findings included: Record review of Resident #25's face sheet, dated 07/23/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included diabetes (high blood sugar) and hemiplegia. Record review of Resident #25's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and for ADL care it stated, for transfers, toileting, and bathing, the resident required moderate assistance. Record review of Resident #25's progress notes from 04/02/24 thru 04/05/24, revealed no indication of the resident complaining of pain. Pain assessments were completed, and all documentation indicated Resident Denies of Pain or Discomfort for This Shift. Record review of Resident #25's progress notes on 04/06/24 indicated that the resident had complained of pain in her left leg to LPN M, who completed a pain assessment, and notified the Nurse Practitioner who ordered an x-ray be completed of Resident #25's left leg. Further review of Resident #25's progress notes entered by LPN M dated 04/06/24 at 6:53 PM, revealed Xray diagnostic company called and reported that x-ray is positive for Left knee FX, NP notified and gave order to send out to ER, Daughter family member, Resident notified, ADON, DON and Administrator notified. PRN pain medication administered. In an interview on 07/23/24 at 01:57 PM, Resident #25 stated the Director of Therapy had caused her to break her leg. She stated the on 04/02/24 the DOT was pushing her back to her room from the dining room. She stated that on her way back to her room, her sneakers had gripped the floor, and it caused her left leg to get caught under her wheelchair. She stated the accident caused her to break her knee. She stated that she had to lay in bed for 8 weeks until she was able to sit in her wheelchair and begin moving again. She stated the facility had terminated the DOT for injuring her. She stated she was in pain when the accident occurred, and she had complained about her leg hurting her unto the weekend nurse on 04/06/24. She contacted the physician, and the physician advised the nurse to send the resident out for an x-ray, which was when she was advised that she had fractured her leg. She stated she had no concerns with staff and felt safe at the facility. In an interview on 07/24/24 at 11:31 AM, the Physical Therapist stated she had been at the facility for over 2 years. She stated she was familiar with Resident #25, but she was not at the facility when the incident occurred on 04/02/24. She stated she heard the resident was being wheeled by the Occupational Therapist Assistant, who was also the DOT, from the dining room and for some reason the DOT failed to install the footrest for the resident. She stated she heard that the resident's leg had gotten caught under the wheelchair and she injured her leg. She stated the DOT did not report the incident until the resident had complained about the injury. She stated because of this, she was terminated. The PT stated staff was in-serviced on reporting any injuries or changes in condition on 04/08/24. She stated the risk of not notifying the resident's physician could result in the resident going untreated for a severe injury. In an interview on 07/25/24 at 09:45 AM, the Regional Director of Operations, stated she had been the director since January 2024 and the Area Director prior to her new role. She stated the resident had complained of pain throughout the weekend (04/06/24 and 04/07/24), they found out about the resident being injured, and it was not reported. They stated they immediately placed the Director of Therapy on leave and removed her from all resident responsibility. She stated the team was in-serviced on transporting residents in wheelchairs, using the footrest, and reporting incidents. She stated the resident had increased pain over the weekend and it was discussed during the morning meeting on 04/08/24. The DOT did not report the incident that occurred on 04/02/24 until the morning meeting on 04/08/24. The Administrator immediately suspended her, and ultimately terminated her employment. She stated the risk of the Director of Therapy not reporting the incident until 04/08/24 could have resulted in the resident experiencing a severe injury and having pain. In an interview on 07/25/24 at 09:53 AM, RN K stated she had been at the facility for almost two years. She stated that she managed the 100-Hall, and she was familiar with Resident #25. She stated the resident only complained about her normal pain and she was not aware of any new pain the resident was having. She stated the resident did not like getting out of bed, only for special events, and the resident council meetings. She stated she was made aware of the resident's injury when she returned to work on 04/08/24. She acknowledged completing an in-service on reporting changes in condition and notifying the physician. She stated the risk of not reporting the pain the resident had could result in serious injury like a broken bone. In an interview on 07/25/24 at 10:05 AM, the ADON stated she was familiar with the incident regarding Resident #25. She stated she heard the DOT was taking the resident back to her room and she had failed to put the footrests on the resident's wheelchair and the resident injured her leg. She stated she had not heard the resident complaining of pain until 04/06/24, and the weekend nurse contacted the physician, who referred her to the hospital for x-rays. She stated she had heard a couple of days later of what happened after speaking with the resident. She stated the CNA was supposed to notify the nurse of any pain a resident was having so that the nurse can follow up with the resident to assess what was wrong. She stated she nor the nursing staff received any reports of the resident having any new pains. She stated the resident rarely got out of her bed and she had not gotten out of bed that week (04/03/24 to 04/05/24). She stated the risk of not reporting the incident could result in the resident experiencing a severe injury and having pain untreated. In an interview on 07/25/24 at 10:25 AM, the Administrator stated that he knew of the incidents that occurred with Resident #25, and he stated it should have been reported sooner, which was why he had suspended and later terminated the DOT for being neglectful. He stated he had met with all staff and had in-serviced them on reporting injuries, fall protocols, and proper wheelchair transport and positioning on 04/08/24. He stated that he decided to terminate the DOT because of her not reporting the incident and her being neglectful in not using the resident footrest. He stated he had made several attempts to contact the DOT to interview her, but she had not returned his call. He stated the risk for not using the footrest and not reporting the incident once the incident had occurred was not good for the resident because she had a serious injury that went unnoticed for several days. In an interview on 07/25/24 at 03:10 PM, the Nurse Practitioner stated he was advised of the incident that occurred with the resident on 04/06/24. He stated when he was advised that the resident was complaining of pain in her leg, he immediately had her sent out for x-rays. He stated he was made aware that there was an incident involving a wheelchair and she had twisted her left leg. He stated the resident sustained a fracture below her knee, but it did not result in her needing a cast on her leg but instead a leg immobilizer. He stated the resident rarely left her bed and could have had pain when readjusting herself in bed. Attempts were made to contact the DOT for an interview on 07/24/24 at 12:00 PM, on 07/25/23 at 11:00 AM, and on 08/06/24. Each time the phone went directly to voicemail. Record review of the facility policy referencing PHYSICIAN AND OTHER COMMUNICATION/CHANGE IN CONDITION dated 05/05/23, To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. The facility took the following actions to correct the noncompliance prior to the investigation: The facility re-educated the staff on Policy and procedure for Wheelchair transport and positioning, Patient Safety and Incident Reporting; and Fall Protocol. The facility conducted an AD Hoc Quality Assurance Meeting and terminated the previous Director of Therapy prior to the beginning of the HHSC investigation on 07/22/24. The Staff confirmed when interviewed they were adequately trained to report immediately to the Administrator, if they heard or suspected abuse, neglect or exploitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents for 1 (Residents #25) of 1 resident reviewed for accidents and hazards. On 04/02/24, Director of Therapy failed to utilize Resident #25's footrest when transporting her which resulted in a fracture to her left leg. This failure placed the resident at risk of further injury due to improper use of equipment. The noncompliance was identified as past noncompliance (PNC) The IJ began on 04/02/24 and ended on 04/08/24. The facility had corrected the noncompliance before the state's investigation began. Findings included: Record review of Resident #25's face sheet, dated 07/23/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included diabetes (high blood sugar) and hemiplegia. Record review of Resident #25's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and for ADL care it stated, for transfers, toileting, and bathing, the resident required moderate assistance. Record review of Resident #25's progress notes from 04/02/24 thru 04/05/24, revealed no indication of the resident complaining of pain. Pain assessments were completed, and all documentation indicated Resident Denies of Pain or Discomfort for This Shift. Record review of Resident #25's progress notes on 04/06/24 indicated that the resident had complained of pain in her left leg to LPN M, who completed a pain assessment, and notified the Nurse Practitioner who ordered an x-ray be completed of Resident #25's left leg. Further review of Resident #25's progress notes entered by LPN M dated 04/06/24 at 6:53 PM, revealed Xray diagnostic company called and reported that x-ray is positive for Left knee FX, NP notified and gave order to send out to ER, Daughter family member, Resident notified, ADON, DON and Administrator notified. PRN pain medication administered. In an interview on 07/23/24 at 01:57 PM, Resident #25 stated the Director of Therapy had caused her to break her leg. She stated the on 04/02/24 the DOT was pushing her back to her room from the dining room. She stated that on her way back to her room, her sneakers had gripped the floor, and it caused her left leg to get caught under her wheelchair. She stated the accident caused her to break her knee. She stated that she had to lay in bed for 8 weeks until she was able to sit in her wheelchair and begin moving again. She stated the facility had terminated the DOT for injuring her. She stated she was in pain when the accident occurred, and she had complained about her leg hurting her unto the weekend nurse on 04/06/24. She contacted the physician, and the physician advised the nurse to send the resident out for an x-ray, which was when she was advised that she had fractured her leg. She stated she had no concerns with staff and felt safe at the facility. In an interview on 07/24/24 at 11:31 AM, the Physical Therapist stated she had been at the facility for over 2 years. She stated she was familiar with Resident #25, but she was not at the facility when the incident occurred on 04/02/24. She stated she heard the resident was being wheeled by the Occupational Therapist Assistant, who was also the DOT, from the dining room and for some reason the DOT failed to install the footrest for the resident. She stated she heard that the resident's leg had gotten caught under the wheelchair and she injured her leg. She stated the DOT did not report the incident until the resident had complained about the injury. She stated because of this, she was terminated. The PT stated staff was in-serviced on reporting any injuries or changes in condition on 04/08/24. She stated the risk of not notifying the resident's physician could result in the resident going untreated for a severe injury. In an interview on 07/25/24 at 09:45 AM, the Regional Director of Operations, stated she had been the director since January 2024 and the Area Director prior to her new role. She stated the resident had complained of pain throughout the weekend (04/06/24 and 04/07/24), they found out about the resident being injured, and it was not reported. They stated they immediately placed the Director of Therapy on leave and removed her from all resident responsibility. She stated the team was in-serviced on transporting residents in wheelchairs, using the footrest, and reporting incidents. She stated the resident had increased pain over the weekend and it was discussed during the morning meeting on 04/08/24. The DOT did not report the incident that occurred on 04/02/24 until the morning meeting on 04/08/24. The Administrator immediately suspended her, and ultimately terminated her employment. She stated the risk of the Director of Therapy not reporting the incident until 04/08/24 could have resulted in the resident experiencing a severe injury and having pain. In an interview on 07/25/24 at 09:53 AM, RN K stated she had been at the facility for almost two years. She stated that she managed the 100-Hall, and she was familiar with Resident #25. She stated the resident only complained about her normal pain and she was not aware of any new pain the resident was having. She stated the resident did not like getting out of bed, only for special events, and the resident council meetings. She stated she was made aware of the resident's injury when she returned to work on 04/08/24. She acknowledged completing an in-service on reporting changes in condition and notifying the physician. She stated the risk of not reporting the pain the resident had could result in serious injury like a broken bone. In an interview on 07/25/24 at 10:05 AM, the ADON stated she was familiar with the incident regarding Resident #25. She stated she heard the DOT was taking the resident back to her room and she had failed to put the footrests on the resident's wheelchair and the resident injured her leg. She stated she had not heard the resident complaining of pain until 04/06/24, and the weekend nurse contacted the physician, who referred her to the hospital for x-rays. She stated she had heard a couple of days later of what happened after speaking with the resident. She stated the CNA was supposed to notify the nurse of any pain a resident was having so that the nurse can follow up with the resident to assess what was wrong. She stated she nor the nursing staff received any reports of the resident having any new pains. She stated the resident rarely got out of her bed and she had not gotten out of bed that week (04/03/24 to 04/05/24). She stated the risk of not reporting the incident could result in the resident experiencing a severe injury and having pain untreated. In an interview on 07/25/24 at 10:25 AM, the Administrator stated that he knew of the incidents that occurred with Resident #25, and he stated it should have been reported sooner, which was why he had suspended and later terminated the DOT for being neglectful. He stated he had met with all staff and had in-serviced them on reporting injuries, fall protocols, and proper wheelchair transport and positioning on 04/08/24. He stated that he decided to terminate the DOT because of her not reporting the incident and her being neglectful in not using the resident footrest. He stated he had made several attempts to contact the DOT to interview her, but she had not returned his call. He stated the risk for not using the footrest and not reporting the incident once the incident had occurred was not good for the resident because she had a serious injury that went unnoticed for several days. In an interview on 07/25/24 at 03:10 PM, the Nurse Practitioner stated he was advised of the incident that occurred with the resident on 04/06/24. He stated when he was advised that the resident was complaining of pain in her leg, he immediately had her sent out for x-rays. He stated he was made aware that there was an incident involving a wheelchair and she had twisted her left leg. He stated the resident sustained a fracture below her knee, but it did not result in her needing a cast on her leg but instead a leg immobilizer. He stated the resident rarely left her bed and could have had pain when readjusting herself in bed. Attempts were made to contact the DOT for an interview on 07/24/24 at 12:00 PM, on 07/25/23 at 11:00 AM, and on 08/06/24. Each time the phone went straight to voicemail. The noncompliance was identified as past noncompliance (PNC) The IJ began on 04/02/24 and ended on 04/08/24. The facility had corrected the noncompliance before the state's investigation began: The facility re-educated the staff on Policy and procedure for Wheelchair transport and positioning, Patient Safety and Incident Reporting; and Fall Protocol. The facility conducted an AD Hoc Quality Assurance Meeting and terminated the previous Director of Therapy prior to the beginning of the HHSC investigation on 07/22/24. The Staff confirmed when interviewed they were adequately trained to report immediately to the Administrator, if they heard or suspected abuse, neglect or exploitation.