Every finding on record at Arbor Lake Nursing & Rehabilitation, LLC

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Residents #1) reviewed for comprehensive care plans in that: Resident #1's care plan did not address he was a smoker/vaper (A vape (short for vaporizer) is a battery-operated electronic device that heats a liquid to create an aerosol (mist or vapor) that is inhaled into the lungs. It simulates cigarette smoking but does not burn tobacco. Vaping refers to the act of using this device). The failure poses real risks to resident and others like fire hazards, chemical exposure and lack of supervision and care for all residents. Findings included:Record review of Resident #1's MDS dated [DATE] reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses of depression (mood disorder), primary progressive multiple sclerosis (a chronic, autoimmune disease of the central nervous system), and mild cognitive impairment (noticeable problems with memory, language, or judgment). Resident #1 had a moderately impaired cognition with a BIMS score of 11. Record review of Resident #1's physician orders dated 07/03/2026 reflected an order for: Ativan Oral Tablet 1 MG (1 tablet every 8 hours as needed for agitation for 14days., Quetiapine Fumarate Oral Tablet 200 MG Give 1 tablet bedtime for (mood disorder) .Monitor for potential for side effects and.Admit to [hospices] Dx: Primary Progressive Multiple Sclerosis Contact MD for further information. No directions specified for order. Record review of Resident #1's Safe Smoking Evaluation dated 04/14/2026 reflected that he was approved for smoking and vaping at the facility under the supervision. During an observation and interview with Resident #1 on 07/08/2026 at 1:40 PM in his room, he was observed lying in bed on his back. Resident #1 stated that he used a vape device that contains liquid tobacco, and the staff kept the device locked at the nursing station. Record review of Resident #1's care plan dated 05/27/2026 did not reflect his use of tobacco/vape or care interventions addressing his smoking. During an interview on 07/08/2026 at 3:03 PM, the MDSC stated that Resident #1 used a vape during scheduled smoking times with other residents. She said she was responsible for creating individualized care plans that addressed each resident's specific needs, preferences, and daily care routines. She said she also conducted routine audits on her own to check for accuracy. The MDSC stated that care plans were reviewed during morning meetings with other staff members. The meetings helped them track a resident's progress, make changes, and plan new medical treatments. The MDSC noted that Resident #1 vaped during scheduled smoking times with other residents. She admitted it was an oversight on her part, when she failed to document Resident #1's smoking goal in his care plan. She stated that it was important to include smoking on the care plan so staff could properly supervise the resident while they used a nicotine product. The MDSC stated that without the smoking goal in the care plan, the resident might hide the vape in their room and use it too much, other residents could access and use it resulting in illness or hospitalization. The MDSC stated that reviewing care plans for accuracy was responsibility of the DON. During an interview on 07/08/2026 at 3:29 PM with the DON, he stated that it was the MDSC staff's responsibility to develop, revise, and correct care plans during the facilities IDT (refers to a coordinated group of professionals) meetings with department leadership to review goals, interventions, assure the plan was individualized and reflected the resident's needs for obtaining his highest functionality, while in care. DON stated it was his responsibility to monitor and assess the care plan after MDSC and IDT completed the plan and ensure clinical staff that provide direct care implement the plans as directed. The DON said failing to identify Resident#1's goal for smoking and interventions could result in lack of supervision during smoking, ongoing documentation, safety measures during smoking, and a failure of the residents rights. The DON stated that it is their expectation for the MDSC to create a comprehensive, individualized care plan addressing all specific care and task requirements. During an interview on 07/08/2026 at 3:29 PM with the Administrator, he said it was DON's responsibility to monitor care plans completed by the MDSC. The Administrator noted that excluding the goal posed no risk to Resident #1. Administrator stated that care plans were reviewed in IDT meetings when there have been changes with behaviors, care, treatments, and preferences. The Administrator stated that all staff are trained in smoking protocols, supervision, and safety. The Administrator maintained that failing to document Resident #1's smoking on the care plan did not create a risk for the resident. The Administrator stated that care plans have since been updated to include the missing goals. Record review of the facility's Smoking by Residents, Purpose Nursing Manual - Nursing Administration policy reflected: To respect resident choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers. allowed to smoke in these areas. Residents who cannot smoke safely will be accompanied by Facility Staff while smoking This policy applies to the use of both cigarettes and e-cigarettes. Procedure Smokers shall be identified at the time of admission. Residents will be provided with a copy of this policy during the admission process.A Licensed Nurse will complete a Safe Smoking Assessment for residents who wish to smoke. The assessment will be completed in (EMR). All smokers shall be assessed related to smoking safety at the time of admission and then at least quarterly as outlined by OBRA assessment timeframes.If necessary, a referral to PT/OT to assess for the necessary eye-hand coordination and cognitive skills for safe smoking may be required. The IDT shall create a Smoking Care Plan for the resident. See Smoking Care Plan.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 kitchen to keep it free of flies. The facility failed to ensure the kitchen was free of flies on 05/19/26. This failure could affect residents who eat from the kitchen placing them at risk for the potential spread of infection and decreased quality of life.Findings included: Observation on 05/19/26 at 10:45 AM of the facility's kitchen revealed there were 7 flies, 5 of the flies were on a cord of the food processor that was plugged into the outlet, 1 fly was on the outlet, and another fly was observed on the leg of the prep table while 3 staff members prepared lunch. Review of the Pest Control for March, April, and May 2025, reflected they made routine visits and flies had not been a targeted pest.Interview on 05/19/26 at 10:54 AM with Dietary Aide A revealed the flies came into the kitchen through the back door when they opened the door to take the trash out. Dietary Aide A said the number of flies in the kitchen depended on the weather outside, but she said lately the flies had been bad. She stated she thought someone had sprayed something in the kitchen for the flies, but she did not remember whom.Interview on 05/19/26 at 12:56 PM with the Dishwasher revealed this was the time of the year when they would begin to see flies in the facility. The Dishwasher said she could not recall how long she had seen them in the kitchen.Interview on 05/19/26 at 12:58 PM with the Dietitian revealed she was at the facility every Tuesday. She stated she had not noticed any flies the days she had been there, but she did recall seeing one fly today, 05/19/26. The Dietitian said no one had mentioned to her they were having problems with flies in the kitchen. She stated there should not be flies in the kitchen because flies carried bacteria with the potential of the flies coming into contact with food. Interview on 05/19/26 at 1:22 PM with the Interim Dietary Manager revealed he had been overseeing the kitchen at the facility for the past two months. The Interim Dietary Manager said today, 05/19/26, was the only day he had noticed flying in the kitchen since he had been going to the facility. The Interim Dietary Manager said the facility had pest control and they treated the facility, including the kitchen at least once a month. He further stated there should not be any flies in the kitchen because of the risk of bacteria spreading to the food.Interview on 05/19/26 at 3:23 PM with the Administrator revealed he never had issues with flies in the kitchen since he began working at the facility. The Administrator said he had just been made aware today, 05/19/26, by the dietary staff that there were flies in the kitchen. The Administrator further stated they had already called pest control to treat for flies. He stated there should not be any flies in the kitchen due to infection control. Review of the facility's policy titled Pest Control revised August 2020 reflected the following: PurposeTo ensure the Facility is free if insects, rodents, and other pests that could compromise the health, safety, and comfort of resident, Facility Staff, and visitors

Based on observations, interviews and record reviews, the facility failed to act as a fiduciary of the residents' funds and hold, safeguard, manage and account for the personal funds of the resident deposited with the facility for nine (Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9) of nine residents reviewed for resident trust accounts. The facility did not monitor resident trust fund account balances to ensure funds did not exceed Medicaid resource limits. The facility allowed Residents #1, # 2, #3, #4, #5, #6, #7, #8 and #9 trust funds to remain over $3,000, which placed them at risk of losing their Medicaid eligibility. This deficient practice could affect all residents with a resident trust account by placing their Medicaid eligibility at risk and becoming ineligible for nursing facility care, financial hardship, and possible involuntary discharge for nonpayment. Findings included:1. Record review of Resident #1's Face Sheet dated 09/08/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1's diagnoses included senile degeneration of brain (a progressive decline in cognitive function that occurs with aging), major depression disorder (persistent sadness), dementia (progressive cognitive impairments in memory, thinking, and reasoning that interfere with daily life) and reduced mobility. Resident #1 was listed as his own responsible party with a family member being an emergency contact. Record review of Resident #1's significant change MDS assessment dated [DATE] reflected he had no hearing, speech or vision issues, and his BIMS score was a 15, which indicated no cognitive impairment. Review of Resident #1's Trust Fund Statement dated 09/08/25 reflected his current balance was $9,717.03. On 08/15/25, Resident #1 received a payment from Social Security for $9,113. Aside from his monthly care costs paid to the facility ($1,398) and $50 allowance withdrawals, no other debits were made from his trust fund account to assist in spending down his excess finances. 2. Record review of Resident #2's Face Sheet dated 09/08/25 reflected he was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's diagnoses included aphasia (difficulty expressing wants and needs), reduced mobility, deafness, dysphagia (difficulty swallowing) and dementia. Resident #2 did not have a medical or durable power of attorney listed nor any emergency contacts. Resident #2 was listed as his own responsible party. Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected his hearing was highly impaired, he had unclear speech, was rarely understood by others, and he had moderately impaired vision. Resident #2 had short/long term memory impairment and moderately impaired cognitive skills for daily decision making.Record review of Resident #2's Trust Fund Statement dated 09/08/25 reflected his current balance was $7,383.40. His account had been over $7,000 for the past three months and there was no evidence the facility completed a spend down for him. Debits from Resident #2's account for the past three months included monthly care cost payment to the facility for $774 and $50 of allowance debits total. 3. Record review of Resident #3's Face Sheet dated 09/08/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #3's diagnoses included right eye blindness, multiple sclerosis (a chronic autoimmune disease that affects the central nervous system), cognitive communication deficit and dysphagia. Resident #3 did not have a medical or durable power of attorney listed and had a family member listed as an emergency contact. Resident #3 was listed as her own responsible party. Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected no hearing or speech issues and was sometimes able to make herself understood. Her BIMS score was a 06, which indicated severe cognitive impairment. Record review of Resident #3's Trust Fund Statement dated 09/08/25 reflected her current balance was $5,536.98. On 08/01/25 her balance was $7,348.84, on 07/01/25 it was $5,366.84 and on 06/02/25 it was $3,976.82. There was no evidence the facility completed a spend down for her over the past quarter. Debits from Resident #3's account for the past three months included monthly care cost payment to the facility for $504.56 and two advanced cash payments of $75 and $60. There were no other debits from her trust fund account to assist in spending down her excess finances. 4. Record review of Resident #4's Face Sheet dated 09/08/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1's active diagnoses included COPD (a long-term lung disease), abnormalities of gait and mobility and cirrhosis of liver (scar tissue on liver that interferes with functioning). Resident #4 did not have a MPOA/DPOA or any emergency contacts listed. Resident #4 was listed as his own responsible party. Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #4's Trust Fund Statement dated 09/08/25 reflected his current balance was $4,270.20. Resident #4's balance remained over $4,000 since 06/02/25 and was increasing each month. There were no care costs paid to the facility. The only debits from her account for the past three months were resident cash advances totaling $270. There was no evidence the facility completed a spend down for her over the past quarter for her excess funds. An interview with Resident #4 on 09/08/25 at 2:05 PM revealed he was aware that he was over-resourced and at risk for being ineligible for Medicaid. He stated that he did not know what he was supposed to spend his money on. He said most of the money came from a large back pay from Social Security. Resident #4 continued to state that he did not know what kinds of things he should buy or needed since he was living in a nursing facility. 5. Record review of Resident #5's Face Sheet dated 09/08/25 reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #5's active diagnoses included metabolic encephalopathy (altered brain function), dementia, repeated falls, hemiplegia (complete paralysis on one side) and hemiparesis (muscle weakness on one side of the body), dysphagia and psychotic disorder with delusions (distorted perceptions, thoughts and behaviors). Resident #5 had a family member listed as her responsible party/emergency contact, but no MPOA/DPOA was listed. Review of Resident #5's 06/16/25 quarterly MDS assessment reflected she had a BIMS score of 04, which indicated severe cognitive impairment. Record review of Resident #5's Trust Fund Statement dated 09/08/25 reflected her current balance was $3,590.57 and had remained over $3,000 for the past three months and was increasing each month. There were no withdrawals or debits to assist her to spend down her excess funds for the past quarter. She received monthly payments from the state comptroller and Social Security totaling $75 a month as her income.6. Record review of Resident #6's Face Sheet dated 09/08/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #6's active diagnoses vascular dementia (problems with memory, thinking and behavior). Resident #6 had a family member listed as her legal guardian. Record review of Resident #6's quarterly MDS assessment dated [DATE] reflected she had unclear speech and was sometimes understood by others. Resident #6 had a BIMS score of 00, which indicated severe cognitive impairment. Record review of Resident #6's Trust Fund Statement dated 09/08/25 reflected her current balance was $3,208.80 and was increasing over the past quarter: 06/02/25=$2,979.56, 07/01/25=$3,055.98. There were no withdrawals or debits to assist her to spend down her excess funds for the past quarter. She received monthly payments from the state comptroller and Social Security totaling $75 a month as her income. An observation of Resident #6's room on 09/08/25 at 1:34 PM revealed she was not in her room. Her room smelled strong of urine and had an older electric recliner, one artificial plant and a mini fridge on the floor in the corner. She did not have any bedding other than what the facility provided. There were no pictures on the wall, no artwork and no decorations and minimal to no personal affects. 7. Record review of Resident #7's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 02, which indicated severe cognitive impairment. Record review of Resident #7's Trust Fund Statement dated 09/08/25 reflected his current balance was $3,129.61 and had been increasing over the past quarter: 06/02/25=$2,832.33, 07/01/25=$2,905.75. His care cost payments to the facility were $1,306 monthly. He had $15 of allowance withdrawals over the past three months, partly to include payment for a haircut. There were no other withdrawals or debits to assist him to spend down his excess funds for the past quarter.An observation of Resident #7's room on 09/08/25 at 1:52 PM revealed he was not present. His television was cracked across the whole screen, was not functionable and did not work per his roommate. There were no decorations, personal items, nothing to make the room look homelike. His dresser drawers did not have anything in them except a pack of markers and a page that was colored. He had no shoes in his closet. 8. Record review of Resident #8's Face Sheet dated 09/08/25 reflected he was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #8's active diagnoses included Alzheimer's disease, reduced mobility, lack of coordination and cognitive communication deficit. Resident #8 had a family member listed as his financial and emergency contact. Record review of Resident #8's quarterly MDS assessment dated [DATE] reflected a BIMS score of 08, which indicated moderate cognitive impairment. An observation of Resident #8's room on 09/08/25 at 1:40 PM revealed he was not in his room. His side of the room had no visible decorations, was not home-like and had no personal belongings except for a small alarm clock and a water bottle. He had no television to watch on his side of the room. Record review of Resident #8's Trust Fund Statement dated 09/08/25 reflected his current balance was $3,276.41. He paid no care costs to the facility and there were multiple cash allowance withdrawals totaling $475 over the past quarter and an income from Social Security and State Comptroller for $75 each month. There were no other withdrawals or debits to assist him to spend down his excess funds this past quarter. 9. Record review of Resident #9's Face Sheet dated 09/08/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. His active diagnoses included alcohol-induced persisting dementia, mood disorder and dysphagia. Resident #9 had a family member listed as his MPOA/DPOA/Emergency Contact. Record review of Resident #9's annual MDS assessment dated [DATE] reflected moderate difficulty hearing and use of a hearing aid, sometimes was understood and had a BIMS score of 03, which indicated severe cognitive impairment. Record review of Resident #9's Trust Fund Statement dated 09/08/25 reflected his current balance was $3,116.46. His monthly balance stayed over $3,000 for the past three months: 06/02/25=$3,096.47, 07/01/25=$3,068.47, and 08/01/25=$3,092.33, . Even though he had multiple debits from his trust fund for tobacco products and allowance, there were no other withdrawals or debits to assist him to spend down his excess funds this past quarter. An observation of Resident #9's room on 09/08/25 at 1:55 PM revealed he was not in his room. His room was observed to have blank walls, no decor, no pictures, nothing to make it look homelike. He had no shoes in his closet. He had no observed personal affects other than 14 articles of clothing and a mini radio. 10. Record review the most recent Resident Fund Balance Notifications dated two months ago on 07/03/25, reflected Residents #1, #2, #3, #4, #7, #8 and #9 were notified of their balances being within $200 or exceeding what was allowed under the Medical Assistance. The notification letter stated, Please contact your Social Worker within the next 7 days to discuss ways to assure continuance of Medicaid benefits. There was no evidence the RPs or MPOA/DPOA were notified as the only signatures on the forms were of the residents' signature scribbles and facility's representative. Residents #5 and #6 did not have any documentation provided to show they were notified of the trust funds being over-resourced.11. An interview with the AD on 09/08/25 at 11:20 AM revealed she was not involved in any resident trust funds or the spend down process. She stated only once in the past three years she had spent resident's funds in that way. The AD stated if a resident wanted to make some purchases, she encouraged them to come out in the community to the local stores she took residents to and make purchases themselves, instead of having her buy them for the resident. She stated the only exception was that she would periodically purchase cigarettes for residents with their trust fund money. An interview with the BOM on 09/08/25 at 11:30 AM revealed she had been out on leave for the past six weeks and the admissions coordinator had been covering for her while out. She stated a resident's excess funds could be spent down by reimbursing a DPOA/RP if they purchased items for a resident and brought in the receipts. The BOM stated the activity director did not usually help with spending down a resident's excess funds unless it was under special circumstances and then they would have to get consent, sign the money out, and return with receipts. The BOM said being over-resourced meant having any funds in the residents' accounts over $2,000. She stated she knew Residents #1, # 2, #3, #4, #5, #6, #7, #8 and #9 were over-resourced and it was something she was working on. The BOM stated when a resident was over-resourced, she could talk to the family or the resident to assist in making purchasing decisions such as burial plans if needed. She also stated if there was no family involvement or the resident was not alert/oriented, she would then talk to the staff to see what items the resident may be needing that the facility could purchase on their behalf. She stated she had two magazines that were specific vendor approved items that could be purchased for the long-term care population, and she made purchases from it in the past when she needed to spend down resident funds. A follow up interview with the BOM on 09/08/25 at 2:20 PM revealed when a residents' trust fund balance was approaching being within $200 of the limit of $2,000, she could use the facility's online accounting system to track it and see who all was within that range. Then the system would generate a letter called a Resident Fund Balance Notification that would be mailed to the RP or given to the resident if they had no RP. Then the resident or RP had to return the notification letter signed. She stated the SW was listed as the only contact person on that letter, but he was not a part of buying any items for residents or part of the spend down process. The BOM stated, That is just me. I can help them. She said there were a lot of residents in the facility who did not request any allowance withdraws from their trust fund accounts, so their balance was increasing. The BOM stated Resident #1 just received a large back payment from Social Security a month prior while the BOM was out on leave. She said Resident #2 got money out as cash, and the facility did purchase him a television and clothes in the past. For Resident #3, she stated she needed to contact her family and see if they wanted to purchase a burial plot. She stated Resident #4, knows it is in there, but he spends what he wants to spend. The BOM stated Resident #5's family member usually brought receipts for purchases and would get reimbursed and the family was interested in a custom wheelchair. The BOM stated she left that issue with the previous social worker, but there had been a new one hired while she was on leave so she did not know if anything had been done about it. With Resident #6, the BOM stated she talked to the family member who lived out of state and had reimbursed the RP for online purchases, but the purchase amounts were not enough to bring the balance under $2,000. The BOM stated Resident #8's balance had been going down and he got money out as cash. For Resident #9, she stated she could purchase him some clothes and he had family that was not involved. The BOM stated that she could not release any more than $75 cash to an A/O resident monthly, so if they needed to spend down, then she would have to write them a check to cash, which came with its own issues if they had no identification or a way to cash the money. She stated that usually she would have the resident just take out $75 cash each month until they spend down. She stated, They get upset about it, but I can't just give them cash if over-resourced. She stated online purchases by the facility from a resident's trust fund was not allowed with the exception being two company-approved catalogs she had to purchase from online. The BOM stated Medicaid usually gave nursing facilities a six-month grace period after a large back pay was given to a resident to spend it down. She stated Medicaid renewals were annually, so the main goal would be to make sure the residents' balances were under $2,000 sixty days before the renewal date. An interview with the SW on 09/08/25 at 11:55 AM revealed he did not handle anything related to resident trust funds or the spend down process. He was unaware of the notification letter that was being sent to RPs that stated he was the contact for any spend down process related to Medicaid eligibility. The SW stated he was new to his position at the facility but would be happy to help with the spend down process if needed. He said he knew if a resident had over $2,000 in their account, they could lose their Medicaid coverage.An interview with the ADM on 09/08/25 at 2:30 PM revealed he was one week new to the facility and he was not aware of the nine residents who were over-resourced related to trust fund management. He stated the residents could lose their Medicaid eligibility if they had over $2,000 in their account. The ADM said he wanted to make sure going forward, that he sat down with the BOM each week to review trust fund accounts to see how they could spend down residents who had excessive funds. An interview with C-RN A on 09/08/25 at 2:32 PM revealed the BOM was responsible to help with the spend down process and there were certain things they were allowed to purchase. She stated the AD was great for shopping trips in the community and would let the family members know and get involved when a resident's funds needed to be spent down. C-RN A stated she knew there had been a couple of residents who received a large back pay of money from Social Security and knew the nine residents were at risk for losing their eligibility if they over $2,000. C-RN A stated she would speak with the Corporate BOM over trust funds to see what could be done. 12. Review of the facility's, Resident Trust Fund (not dated) reflected, To establish uniform guidelines in the protection of personal funds managed by our facilities on behalf of its residents and to maintain a complete and accurate accounting for patient monies.The Administrator is responsible for ensuring the establishment and accurate maintenance of the Resident Trust Fund and the related Resident trust Fund Petty Cash Account.

Based on observation, interview, and record review, the facility failed to ensure that a resident who displays or was diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #33) reviewed for dementia services. The facility failed to ensure Resident #33 was provided with treatment and services to address his wandering behaviors related to his diagnosis of dementia which resulted in the resident entering Resident #21's room and being pushed by Resident #1. Upon being pushed, Resident #33's face/head bumped Resident #21's dresser, and Resident #33 sustained abrasions on his nose and right knee. This failure puts residents with dementia at increased risk of not having their dementia-related needs met. Findings included: Record review of Resident #33's Quarterly MDS, dated [DATE], reflected Resident #33 was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), non-Alzheimer's dementia (encompasses a variety of progressive neurological disorders that cause cognitive decline, but are distinct from Alzheimer's disease), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). The MDS reflected resident had severe cognitive impairment with a BIMS score of 3, and he was independent with transfers and mobility. The MDS further reflected Resident #33 did not have any behaviors.Record review of Resident #33's Care Plan Report, dated 07/24/25, reflected: Focus: Resident #33. wandered into another resident's room and was pushed causing him to fall back, abrasion to bridge of nose and right knee on 06/24/25 .Goal: Resident #33 will be free of falls through the review date.Interventions: When resident is wandering redirect as needed to prevent as much as possible him infringing on the rights of others. Further review of Resident #33's Care Plan Reports reflected there were no documented care plans specifically addressing the resident's wandering behavior nor were there person-centered interventions care planned to address the resident's wandering behaviors. Record review of Resident #33's Progress Notes by LVN A, dated 06/24/25 at 8:30 PM, reflected, Resident was found in [Resident #21's room] sitting on the floor holding on his face, nose skin abrasion noted, swelling and pain = 5/10, PRN Tylenol 100mg was given, ice was applied to nose for swelling and was helpful abrasion noted on right knee, [Resident #21] was standing in front of him and denied any confrontation but later [Resident #21] claimed that Resident #33 fell down while being chased out [Resident #21's room], assessment done, neuros done and are in range, facial series called in as ordered by Doctor. Record review of Resident #33's facial series results, dated 06/25/25 at 1:50 AM, reflected, Findings: The visual skull and facial bones demonstrate no acute fracture. No joint dislocation. Unremarkable soft tissues. The nasal bone is not visualized due to overpenetration. Conclusion: 1. No obvious or acutely displaced fracture. 2. A CT is recommended for better sensitivity if symptoms persist or worsen. Record review of Resident #33's psychiatric assessment, dated 06/30/25, reflected, CN reports an incident between the resident and another male resident. CN reported the resident was hit on the face by another male resident. Pt is seen sitting in bed with his wife. Pt could not explain to the provider what happened but reported another resident hit him on the face. Some minor bruised noted on patient's face. Pt denies any pain or reoccurring thought trauma.The provider encouraged the nurse to ensure residents are separated from each other to prevent any reoccurrence of altercations. Record review of Resident #21's Quarterly MDS, dated [DATE], reflected Resident #21 was a [AGE] year-old male who was originally admitted on [DATE] and re-admitted on [DATE]. The resident's diagnoses included: cerebral infarction (a condition where blood flow to the brain is blocked, causing brain tissue damage due to lack of oxygen and nutrients), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and antisocial personality disorder (a mental health disorder characterized by disorganized for other people). The MDS reflected the resident was cognitively intact, had no behaviors, had upper extremity impairment on one side, and he was independent with transfers and mobility.Record review of Resident #21's Care Plan Report, initiated on 03/01/23 and revised 01/04/24, reflected Resident #21 had impaired cognitive function/dementia or impaired thought processes. Record review of Resident #21's Care Plan Report, initiated on 08/02/23, reflected Resident #21 was an elopement risk related to his elopement risk evaluation score being high at 15.Record review of Resident #21's Care Plan Report, initiated on 11/12/23, reflected Resident #21 was a high risk for elopement, and he was admitted to the secure unit due to his diagnosis of schizoaffective disorder and having an elopement risk score of 15. Observation on 07/23/25 at 2:25 PM revealed Resident #33 wandering down Resident #21's hall in the secured unit. Staff re-directed after Resident #33 began to speak loudly to Resident #21. Resident #33 was redirected to his hall and then to his room. Interview on 07/23/25 at 2:19 PM with LVN A revealed Resident #33 often wandered after dinner. LVN A stated on 06/24/25 after dinner, she heard screaming and found Resident #33 sitting on the floor crying with this hand on his face with Resident #21 standing in the middle of the room laughing. She stated that Resident #21 said Resident #33 attempted to wake him and then Resident #21 shoved Resident #33 causing him to bump into the dresser and fall. LVN A said that she had sat down at the nurses' station and did not see Resident #33 wander into Resident #21's room. LVN A stated that she watched the mirrors on the hall to attempt to watch the residents that wander on the unit. LVN A said she was unsure where the aide was at the time of the incident. LVN A stated that dementia residents had to be watched to ensure that they did not wander into other residents' areas. LVN A stated that she reported the incident to the Administrator and the DON when the incident occurred. The LVN could not recall the last in-service on dementia related care that the facility provided. Interview on 07/23/25 at 6:03 PM with CNA B revealed Resident #33 went into residents' rooms in the secured unit. CNA B stated that he responded that evening to Resident #33 yelling in Resident #21' room. CNA B stated that he did not see Resident #33 go into Resident #21's room that evening. CNA B said that Resident #21 usually was not physically aggressive toward residents, but that he was usually verbally aggressive toward other residents only. CNA B revealed that he attempted to keep the two residents apart in the sitting area during his shifts. CNA B said that he understood that Resident #33 had dementia and did not understand whose room he was in that night. CNA B stated that he would notify his nurse if he observed an incident between residents on the secured unit because residents could be hurt if they got into an altercation. CNA B also said that he had recently been in-serviced on resident-to-resident abuse and handling residents with behaviors. Interview on 07/24/25 at 8:34 AM with the ADON revealed she had been employed at the facility about a month. The ADON stated her first day at the facility was the day after the incident. The ADON explained that she only knew the facility policy and was not aware of any details about the altercation between Resident #33 and Resident #21. The ADON said if dementia residents were seen wandering, they should be redirected to their room. The ADON revealed that staff attempt to keep all the residents seated around the nurses' station so that they can be watched for behaviors and wandering. The ADON stated that the staff keep the residents in line of site to prevent incidents. Interview on 07/24/25 at 3:22 PM with the DON revealed that she had been employed at the facility for two approximately two weeks. The DON stated that she was not aware of the altercation between Resident #33 and Resident #21. The DON said that increased supervision should have occurred since the altercation. The DON said it is the staff's responsibility on the secured unit to monitor all residents that wonder. The DON also stated that residents who wander could go into other residents' rooms and get into their belonging which could lead to conflicts between residents. Interview on 07/24/25 at 3:51 PM with the facility Psychiatric Provider revealed he had previously asked the staff to keep eyes on Resident #33 and to redirect the resident if he was seen wandering. The facility Psychiatric Provider also stated that he has seen the staff redirect residents when they were in the tv room. The facility Psychiatric Provider revealed that he has directed the staff in the unit to not allow confused residents to wander into other resident's room because an incident could occur. The facility Psychiatric Provider stated that all staff in the secured unit are responsible for watching the residents who wander. Record review of the facility's current, undated Secure Care Training policy reflected: . Residents are in the secure environment because they are exit seeking and are unable to make safe decisions or feel more secure in a more structured environment. In order to provide a safe environment, the staff should practice the following: o On coming shift will make rounds with the off going shift to ensure all residents are accounted for and safe.o The staff will make a safety round before going on a lunch break and will ensure that there is sufficient staff in the secure area to provide a safe environment while they are on break. o Upon returning to the secure area, staff will make a walking round to ensure all residents are accounted for and safe.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 1 of 6 residents (Resident #33) reviewed for abuse. The facility failed to ensure residents were free resident-to-resident abuse when Resident #33 entered Resident #21's room, and Resident #21 pushed Resident #33 down. Resident #33 sustained abrasions on his nose and right knee. The failure placed residents at risk for abuse. Findings included:Record review of Resident #33's Quarterly MDS, dated [DATE], reflected Resident #33 was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), non-Alzheimer's dementia (encompasses a variety of progressive neurological disorders that cause cognitive decline, but are distinct from Alzheimer's disease), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). The MDS reflected resident had severe cognitive impairment with a BIMS score of 3, and he was independent with transfers and mobility. The MDS further reflected Resident #33 did not have any behaviors.Record review of Resident #33's Care Plan, dated 07/24/25, reflected: Focus: Resident #33. wandered into another resident's room and was pushed causing him to fall back, abrasion to bridge of nose and right knee on 06/24/25 . Goal: Resident #33 will be free of falls through the review date. Interventions: When resident is wandering redirect as needed to prevent as much as possible him infringing on the rights of others.Further review of Resident #33's Care Plans reflected there were no documented care plans specifically addressing the resident's wandering behavior nor were there person-centered interventions care planned to address the resident's wandering behaviors. Record review of Resident #33's Progress Notes by LVN A, dated 06/24/25 at 8:30 PM, reflected, Resident was found in [Resident #21's room] sitting on the floor holding on his face, nose skin abrasion noted, swelling and pain = 5/10, PRN Tylenol 100mg was given, ice was applied to nose for swelling and was helpful abrasion noted on right knee, [Resident #21] was standing in front of him and denied any confrontation but later [Resident #21] claimed that Resident #33 fell down while being chased out [Resident #21's room], assessment done, neuros done and are in range, facial series called in as ordered by Doctor. Record review of Resident #33's facial series results, dated 06/25/25 at 1:50 AM, reflected, Findings: The visual skull and facial bones demonstrate no acute fracture. No joint dislocation. Unremarkable soft tissues. The nasal bone is not visualized due to overpenetration. Conclusion: 1. No obvious or acutely displaced fracture. 2. A CT is recommended for better sensitivity if symptoms persist or worsen. Record review of Resident #33's psychiatric assessment, dated 06/30/25, reflected, CN reports an incident between the resident and another male resident. CN reported the resident was hit on the face by another male resident. Pt is seen sitting in bed with his wife. Pt could not explain to the provider what happened but reported another resident hit him on the face. Some minor bruised noted on patient's face. Pt denies any pain or reoccurring thought trauma.The provider encouraged the nurse to ensure residents are separated from each other to prevent any reoccurrence of altercations. Record review of Resident #21's Quarterly MDS, dated [DATE], reflected Resident #21 was a [AGE] year-old male who was originally admitted on [DATE] and re-admitted on [DATE]. The resident's diagnoses included: cerebral infarction (a condition where blood flow to the brain is blocked, causing brain tissue damage due to lack of oxygen and nutrients), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and antisocial personality disorder (a mental health disorder characterized by disorganized for other people). The MDS reflected the resident was cognitively intact, had no behaviors, had upper extremity impairment on one side, and he was independent with transfers and mobility.Record review of Resident #21's Care Plan Report, initiated on 03/01/23 and revised 01/04/24, reflected Resident #21 had impaired cognitive function/dementia or impaired thought processes. Record review of Resident #21's Care Plan Report, initiated on 08/02/23, reflected Resident #21 was an elopement risk related to his elopement risk evaluation score being high at 15.Record review of Resident #21's Care Plan Report, initiated on 11/12/23, reflected Resident #21 was a high risk for elopement, and he was admitted to the secure unit due to his diagnosis of schizoaffective disorder and having an elopement risk score of 15. Observation on 07/23/25 at 2:25 PM revealed Resident #33 wandering down Resident #21's hall in the secured unit. Staff re-directed after Resident #33 began to speak loudly to Resident #21. Resident #33 was redirected to his hall and then to his room. Interview on 07/23/25 at 2:19 PM with LVN A revealed Resident #33 often wandered after dinner. LVN A stated on 06/24/25 after dinner, she heard screaming and found Resident #33 sitting on the floor crying with this hand on his face with Resident #21 standing in the middle of the room laughing. She stated that Resident #21 said Resident #33 attempted to wake him and then Resident #21 shoved Resident #33 causing him to bump into the dresser and fall. LVN A said that she had sat down at the nurses' station and did not see Resident #33 wander into Resident #21's room. LVN A stated that she watched the mirrors on the hall to attempt to watch the residents that wander on the unit. LVN A said she was unsure where the aide was at the time of the incident. LVN A stated that dementia residents had to be watched to ensure that they did not wander into other residents' areas. LVN A stated that she reported the incident to the Administrator and the DON when the incident occurred. The LVN could not recall the last in-service on dementia related care that the facility provided. Interview on 07/23/25 at 6:03 PM with CNA B revealed Resident #33 went into residents' rooms in the secured unit. CNA B stated that he responded that evening to Resident #33 yelling in Resident #21' room. CNA B stated that he did not see Resident #33 go into Resident #21's room that evening. CNA B said that Resident #21 usually was not physically aggressive toward residents, but that he was usually verbally aggressive toward other residents only. CNA B revealed that he attempted to keep the two residents apart in the sitting area during his shifts. CNA B said that he understood that Resident #33 had dementia and did not understand whose room he was in that night. CNA B stated that he would notify his nurse if he observed an incident between residents on the secured unit because residents could be hurt if they got into an altercation. CNA B also said that he had recently been in-serviced on resident-to-resident abuse and handling residents with behaviors. Interview on 07/24/25 at 8:34 AM with the ADON revealed she had been employed at the facility about a month. The ADON stated her first day at the facility was the day after the incident. The ADON explained that she only knew the facility policy and was not aware of any details about the altercation between Resident #33 and Resident #21. The ADON said if dementia residents were seen wandering, they should be redirected to their room. The ADON revealed that staff attempt to keep all the residents seated around the nurses' station so that they can be watched for behaviors and wandering. The ADON stated that the staff keep the residents in line of site to prevent incidents. Interview on 07/24/25 at 3:22 PM with the DON revealed that she had been employed at the facility for two approximately two weeks. The DON stated that she was not aware of the altercation between Resident #33 and Resident #21. The DON said that increased supervision should have occurred since the altercation. The DON said it is the staff's responsibility on the secured unit to monitor all residents that wonder. The DON also stated that residents who wander could go into other residents' rooms and get into their belonging which could lead to conflicts between residents. Interview on 07/24/25 at 3:51 PM with the facility Psychiatric Provider revealed he had previously asked the staff to keep eyes on Resident #33 and to redirect the resident if he was seen wandering. The facility Psychiatric Provider also stated that he has seen the staff redirect residents when they were in the tv room. The facility Psychiatric Provider revealed that he has directed the staff in the unit to not allow confused residents to wander into other resident's room because an incident could occur. The facility Psychiatric Provider stated that all staff in the secured unit are responsible for watching the residents who wander. Record review of the facility's current, undated Secure Care Training policy reflected: . Residents are in the secure environment because they are exit seeking and are unable to make safe decisions or feel more secure in a more structured environment. In order to provide a safe environment, the staff should practice the following: o On coming shift will make rounds with the off going shift to ensure all residents are accounted for and safe.o The staff will make a safety round before going on a lunch break and will ensure that there is sufficient staff in the secure area to provide a safe environment while they are on break. o Upon returning to the secure area, staff will make a walking round to ensure all residents are accounted for and safe.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Resident #19 and Resident #59) reviewed for ADL care.The facility failed to provide Resident #19 and Resident #59 assistance with grooming and nail care. Resident #19 and Resident #59's nails were observed to be about half inch long with black debris under nails on both hands. Both resident's appearance was disheveled with their clothing and uncleaned hair. This failure could place the residents at risk for decreased feelings of self-worth and infection. 1.Record review of Resident #19's face sheet, dated 07/25/25, revealed Resident #19 was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted [DATE] and current admission date of 01/14/25.Record review of Resident #19's Quarterly MDS assessment, dated 04/14/25, revealed Resident #19 had cognition intact with a BIMS score of 9 (indicating cognitive impairment). Resident #19 required substantial/maximal assistance with shower/bathe self, and personal hygiene. Active diagnosis included Stroke, Dementia (memory loss), Heart Disease, anxiety disorder (uncontrollable feelings of fear), bipolar disorder (mood swings of emotional highs and lows), psychotic disorder (thought process leading to loss of touch with reality), Schizophrenia (having hallucinations and delusions) and lack of coordination and other abnormalities of gait and mobility. Review of Resident #19's care plan, undated, revealed Resident #19 had Self Care Deficit related to age and disease processes. Goal: Resident #19 will maintain current level of function in (.toilet use and personal hygiene). Interventions included Resident #19 required minimal to moderate assist of one staff member for bathing, transfer and had to reach areas and supervision for other areas. Resident #19 required set up and minimal assist and supervision of one staff member for personal hygiene/oral care. Observation on 07/22/2025 at 11:14 AM of Resident #19 in his room revealed he was sitting on the side of his bed. His hair was greasy and disheveled. His nails were at least half inch long with black debris underneath and around the nail bed. Resident #19 stated he was unsure of the last time staff assisted with showers, hair shampooing, or his nails cleaned. 2. Record review of Resident #59's face sheet, dated 07/25/25, revealed Resident #59 was an [AGE] year-old male originally admitted to the facility on [DATE].Record review of Resident #59's Quarterly MDS assessment, dated 05/14/25, revealed Resident #59 had cognition intact with a BIMS score of 99 (indicating Resident was not able to complete assessment). Resident #59 required partial/moderate assistance with shower/bathe self, and personal hygiene. Active diagnosis included Traumatic Brain Injury (external force that disrupts normal brain function), Dementia (memory loss), High Blood Pressure, anxiety disorder (uncontrollable feelings of fear), depression (persistent feeling of sadness) and lack of coordination and other abnormalities of gait and mobility.Review of Resident #59's care plan, undated, revealed Resident #59 had Self Care Deficit related to Dementia. Goal: Resident #59 will maintain current level of function in (.toilet use and personal hygiene). Interventions included Resident #59 required extensive assist of one staff member for bathing, and personal hygiene/oral care.Observation on 07/22/2025 at 11:57 AM with Resident #59 revealed Resident #59 had long nails at least half inch and longer on some with black debris underneath his nails. Resident #59 had on socks with holes in the toe area. Resident #59's hair was not combed and his clothing with colored stains. Interview on 07/23/25 at 2:02 PM with CNA F revealed Resident #19 was scheduled for showers on 2:00 PM - 10:00 PM shift on Monday, Wednesday, and Fridays. According to CNA F it was hard to say if he had a shower last night because he will mess with his hair, it does not look like he recently had a shower but would have one today on 07/23/25. Interview on 07/24/25 at 11:18 AM with CNA F revealed nail care, shaving and hair grooming should be completed on resident shower days. CNA F stated it did not appear that Resident #19 or Resident #59 completed a shower or any grooming on 07/23/25 . Shower sheet for Resident #19 revealed showers were done 7/22/25, 07/21/25, 07/17/25, 07/15/25, 07/14/25, 07/11/25, 07/10/25, sheet for Resident #59 revealed showers were completed on 07/22/25, 07/21/25, 07/20/25, 07/19/25, 07/18/25, 07/17/25. CNA F stated it was the responsibility of the aides to complete nail care and grooming for residents, not doing so placed residents at risk of infections, and becoming ill. Interview on 07/24/25 at 3:26 PM with LVN G revealed some residents were showered on Monday, Wednesday, and Fridays depending on which bed letter they had, (A, B or C beds). LVN G stated both Resident #19 and Resident #59 needed assistance with nail care and grooming and it should be completed on their shower days by the CNAs (Monday, Wednesday, and Fridays). LVN G stated if there was an issue with completing nail care or grooming, the CNA was responsible for notifying the nurse, so that further attempts could be made. LVN G stated not completing nail care with cleaning and cutting nails or grooming placed residents at risks of infections. Interview on 07/24/25 at 3:25 PM with the DON revealed CNAs were responsible for all grooming which included nails to be cleaned and cut, shampooing and combing hair, shaving, skin care, and clean clothing needed to be done on residents' shower days. The DON stated nurses were responsible for following up with resident observations to ensure residents were properly groomed. The DON stated not completing total body care and grooming with residents placed them at risk of infections. Review of the facility's undated Grooming Care of the Fingernails and Toenails policy reflected: Nail care is given to clean and keep the nails trimmed. Fingernails are trimmed by Certified Nursing Assistants except for residents with the following conditions: Diabetes or circulatory impairment of the hands. Ingrown infected, or painful nails. Nails that are too hard, thick, or difficult to cut easily. Review of the facility's undated Resident Rights-Quality of Life policy revealed the facility must ensure all residents are treated with the level of dignity they are entitled to while residing at the facility. Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, and individuality.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #76 and #96) of 3 residents reviewed for infection control during medication administration.The facility failed to ensure MA E disinfected the blood pressure cuff in between blood pressure checks for Resident #98 and Resident #76. RN D failed to wear a gown while providing care for Resident #96, who was on enhanced barrier precautions for Gastronomy tube. These failures could place residents at-risk of cross contamination which could result in infections or illness.Findings included:1.Review of Resident #76's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #76 had diagnoses which included hypertension (high blood pressure) and heart failure (a serious condition but not the same as a heart attack, where blood flow to the heart is suddenly blocked). He had a BIMS score of 09 which indicated his cognition was moderately impaired. Observation on 07/23/25 at 07:29 AM revealed MA E did not disinfect the blood pressure cuff after she checked the blood pressure for Resident #98. She went directly from Resident #98's room to Resident #76's room and checked Resident #76's blood pressure without disinfecting the blood pressure cuff. Interview with MA E on 07/23/25 at 07:40 AM revealed she did not disinfect the blood pressure cuff between Residents #98 and #76. She stated she knew she should disinfect between 2 residents. She stated she had been told here in the facility she should disinfect between resident, and she forgot. She stated she was supposed to disinfect between residents to prevent cross contamination, but she had developed a habit of disinfecting after 2 residents. She stated she had done trainings on infection control two months ago. 2. Record review of Resident #96's Quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE] and readmission on [DATE]. The resident had severe cognitive impairment with a BIMS score of 00, and his diagnoses included gastronomy status (presence of a gastrostomy tube, an artificial opening into the stomach used for feeding) and dysphagia (swallowing difficulties), and the MDS reflected he had a feeding tube for nutrition. Record review of Resident #96's care plan dated 06/01/25 reflected: Focus: [Resident #96] has infection of the G tube site. Goal: [Resident #96] will be free from complications related to infection through the review date. Interventions: Maintain universal precautions when providing resident care. Observation on 07/23/25 08:20AM revealed RN D prepared all the medications, and she entered to Resident #96's room. RN D washed her hands, put on gloves, and performed blood pressure check. She removed her gloves, washed her hands, and put on new gloves. She administered Resident #96's medications through his gastronomy tube without wearing a gown. The gloves were the only PPE that RN D wore while administering medication through gastronomy tube. Resident #96 was observed to have a gastronomy tube with a dressing dated 07/23/25. Interview on 07/23/25 at 08:41 AM with RN D revealed she knew she was supposed to wear gloves and a gown when caring for residents on enhanced barrier precautions, but she forgot to wear a gown before entering the room. She stated she had done in-services on infection control, but she could not recall the date. Interview on 07/24/25 at 01:00 PM with the ADON revealed, her expectation was for staff to disinfect blood pressure cuffs between each Resident. She stated she noticed MA E did not disinfect the blood pressure cuff after she left Resident #98 room and she used the same cuff on Resident #76. She also stated she expected for all residents on EBP, for staff to wear a gown and gloves when having direct contact with the resident. The ADON stated the EBP were in place to protect the resident from exposure to infectious agents and disinfecting blood pressure cuff between residents was to prevent cross contamination. She stated the facility had done training on enhanced barrier precautions, and disinfection of equipment, but she was not sure whether the staff were in attendance since some were new to the facility. Interview with the DON on 07/24/25 at 03:32PM revealed, her expectation was for staff to disinfect blood pressure cuffs between each resident due to risk of cross contamination. She stated when it came to contact, staff should use gown and gloves on residents who are on enhanced barrier precautions. She stated the facility had done in-services on infection control and enhanced barrier precautions. She stated the facility's management was supposed to be doing spot check on staff for equipment disinfection and the use of enhanced barrier precautions, but she had not done one since she was new to the facility. Record review of the facility's training records for EBP, dated 05/13/25, reflected RN D, was in attendance. Record review of the facility's training records for equipment cleaning, dated 04/13/25, reflected MA E and RN D, were in attendance. Record review of the facility's Enhanced Barrier Precautions policy, dated April 2024, reflected:Enhanced Barrier Precautions is an infection control intervention to reduce transmission of multi-drug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities.B. For resident whom EBP are indicated EBP should be used when performing the following high contact resident care activities should be used for any is indicated for residents with any of the following:vii. Device care or use: Central line, urinary catheter, feeding tube tracheostomy/ventilator. Review of the facility's policy for Cleaning & Disinfection of Environmental surface and Equipment, dated June 2020, reflected, The following categories are used to distinguish the level of sterilization/disinfection necessary for items used in the Resident environment. c. Noncritical items are those that come in contact with intact skin but not mucous membranes.ii. non-critical equipment items include bed pans, blood pressure cuffs, crutches, computers including those that are used for mobile charting, monitoring equipment.

Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for 2 of 17 residents (Residents #3 and Resident #13) reviewed for environment. 1.The facility failed to maintain a comfortable or private homelike environment for Residents #3 and #13. These failures placed residents at risk of decreased feelings of self-worth, increased harm and an impersonalized homelike environment. Findings included:1. Observation on 07/22/2025 at 11:37 AM revealed Resident #3 had broken blinds. The blinds were missing the end pieces of approximately 4 blinds leaving an area of approximately 6 inches by 10 inches without blinds. Observation on 07/23/2025 at 9:20 AM revealed Resident #3 had broken blinds. The blinds were still missing the end pieces of approximately 4 blinds leaving an area of approximately 6 inches by 10 inches without blinds. Observation and interview on 07/23/2025 at 1:49 PM with CNA C revealed that she had not noticed the broken blinds, and that neither resident had complained to her about the broken blinds. CNA C stated that she had reported the blinds. CNA C said that she should have reported it to the Maintenance Director and her nurse. CNA C also revealed that it was all the staff's responsibility to report maintenance issues. CNA C said that blinds were important because it helped the residents maintain their dignity as well as providing privacy in their home. Observation and interview on 07/23/2025 at 2:03 PM with Resident #3 revealed that he had noticed the broken blinds. Resident #3 stated that the broken blinds were ugly, and he wanted them replaced. Observation and interview on 07/23/2025 at 2:10 PM with RN D revealed that she had not reported the broken blinds in Resident #3's room. RN D stated that it was her responsibility to report broken blinds to the maintenance supervisor. RN D revealed that it was important because broken blinds could injure a resident. RN D stated that if the Maintenance Director did not respond to her work order, she would report it to the ADON. Observation and interview on 07/23/2025 at 1:55 PM with the Maintenance Director revealed that it was his responsibility to ensure residents' blinds were in proper working order. The Maintenance Director stated that staff could put a maintenance request in the maintenance logbook or through the app on his phone. The Maintenance Director said that proper working blinds are important because they are a dignity issue. The Maintenance Director stated he would be purchasing new blinds for the residents' room. Interview on 07/25/2025 at 10:32 AM with the Administrator revealed that the facility uses a phone app for the maintenance requests. The Administrator stated that it was everyone's responsibility to report maintenance issues when they saw them. The Administrator stated that he had instructed the Maintenance Director, the previous day, to purchase blinds and replace the broken blinds in residents' rooms. The Administrator revealed the broken blinds were a privacy issue for residents. 2. Record Review of Resident #13's Quarterly MDS assessment, dated 06/05/25 reflected Resident #13 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #13's MDS also reflected diagnoses of non-Alzheimer's dementia (a range of neurodegenerative and other disorders that cause cognitive decline, distinct from Alzheimer's disease), anxiety disorder, and depression. Resident #13's MDS also reflected a BIMS score of 4 (meaning severe cognitive impairment). Resident #13's MDS also reflected Resident #13 required assistance and supervision for ADLs. Record review of Resident #13's Care Plan dated 02/20/25 revealed Resident #13 was dependent on staff for activities, cognitive stimulation, social interaction. Goal included Resident #13 will maintain involvement in cognitive stimulation, social activities as desired. Interventions included Assure that the activities Resident #13 was attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), compatible with individual needs and abilities and age appropriate. Resident #13 had adjustment issues to admission. Goal included to maintain the ability to seek social contact and stimulation. Interventions included encourage ongoing family involvement. Invite Resident #13's family to attend special events, activities, and meals. Encourage Resident #13 to participate in conversation with staff, other residents daily. Introduce Resident #13 to residents with similar background, interests, and encourage/facilitate interaction. Observation and interview on 07/22/25 at 11:53 AM with Resident #13 revealed he was in the small television room with other residents watching television. Resident #13 stated that he was doing ok, he liked to watch television, and that he felt safe to live in the facility. Resident #13 then got up and walked into another resident's room and shut the door.Interview on 07/22/25 at 1:16 PM with Resident #13's Responsible Party revealed that Resident #13 enjoyed watching television. The Responsible Party stated the family brought a television to the facility 5 months ago for Resident #13's room, however it was currently sitting behind the nursing station. The Responsible Party stated, Maintenance would not let me hang it up, but they have not either, they don't do anything that you ask. Observation on 07/22/25 at 1:30 PM revealed Resident #13 did not have a television in his room. Interview on 07/24/2025 11:23 AM with CNA F revealed she noted a television behind the nursing station. However, it had been there for so long, she did not recall who it belonged to or why it was back there. CNA F stated Resident #13 did wander but was easily redirected to the television room or with a snack. CNA F stated when there was a maintenance issue, she reported to the nurse, and the nurse would report to the maintenance department. CNA F reported that there was no risk to Resident #13 for not having his television in his room because there was a television in the living area. Observation and interview on 07/24/2025 11:33 AM with LVN G revealed she was aware of the television behind the nurse station. Observed a box pulled out from nursing station. LVN G indicated the box was the television. LVN G stated the box had been back there so long, she had forgotten it was there. LVN G stated the family brought in the television several months ago and asked the Maintenance Department to hang the television in Resident #13's room. LVN G stated she reminded the Maintenance Director several times and his response would be I got it, I will be back to do it, or No Problem but it was never done. LVN G stated the facility now had a new Maintenance Director, and she could not recall if she had requested with the new Maintenance Director to have the television hung. LVN G stated she was responsible for requesting for the television to be hung in Resident #13's room. LVN G stated she had not reported to anyone other than the previous the Maintenance Director. LVN G stated not having the television hung for Resident #13 placed him at risk of not being comfortable in his room, wandering, and his personal property being lost or stolen. Interview on 07/24/25 at 3:28 PM with the DON revealed if there was something the Maintenance Department needed to handle the nurse or aide should report that need to the Maintenance Department. The DON stated she had only worked in the facility for two weeks, and was not completely sure how the requests were done or tracked. The DON stated if a request was made to hang up a television, she would expect it to be hung within a reasonable amount of time, by the Maintenance Department. The DON stated not hanging up the television within a reasonable amount of time, or at all, placed Resident #13 at risk for lack of activity or entertainment in the comfort of his own room. Interview on 07/24/25 at 3:55 PM with the Maintenance Director revealed he was new on staff to the facility (2 months). The Maintenance Director stated the facility used a phone app to enter maintenance requests or they would verbally inform him of any maintenance concerns. The Maintenance Director stated he was not able to review any past requests, and when he was hired, he just started working on current request. The Maintenance Director stated he had not been informed about Resident #13's television, and hanging a television was an easy task and he could complete that quickly. The Maintenance Director stated not being able to use a television that had been brought in for Resident #13, five months ago, could place Resident #13 at risk of feeling not heard or respected, this could be upsetting for Resident #13. Interview on 07/25/2025 10:25 AM with the Administrator revealed he had only been in the facility for a week, however, he had been working with the Maintenance Director to complete some tasks. The Administrator stated the staff on the floor were responsible for reporting to the Maintenance Department when there was a need. The Administrator stated no one had reported to him that a television needed to be hung, and he was not able to review any past maintenance request. The Administrator stated his expectations were for the Maintenance Director to fulfill all maintenance requests in a timely manner. The Administrator stated not fulfilling maintenance requests, like hanging a television in a resident's room, could place residents at risk of not having a safe homelike environment.Record review of the facility's Resident Rooms and Environment policy, dated 08/2020, reflected: Purpose: To provide residents with a safe, clean, comfortable and homelike environment. Policy: The facility provides resident with safe, clean, comfortable, and homelike environment. Facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensure that residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. To this end, the facility encourages residents to use their personal belongings to the extent possible.

The facility failed to provide a 30-day written notice of discharge as well as discharge planning for 1 of 14 residents reviewed for discharge planning. * The failure to provide a 30-day written discharge notice and discharge planning could result in residents experiencing psychosocial harm due to inappropriate discharges and placed residents at risk of being discharged without alternate placement and not having access to available advocacy services, discharge/transfer options, and denying them their rights in the appeal process. Findings included: Record review of Resident #1's face sheet dated 5/24/25, indicated a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a diagnosis of type 2 Diabetes (when the body can't use insulin properly, causing sugar to build up in the blood), cognitive communication deficit (trouble thinking, understanding, or expressing themselves due to problems with the brain), and atherosclerotic heart disease (when the arteries that supply blood to the heart become narrowed or blocked by a buildup of plaque). Record review of Resident #1's annual Minimum Data Set assessment dated [DATE], indicated a discharge assessment of return not anticipated. The type of discharge indicated on the report specified as unplanned with a discharge date of 4/16/25. The discharge status indicated to home/community. The behavioral section indicated no physical or verbal behavioral symptoms directed to others. The behavioral section indicated no other behavioral symptoms not directed toward others. Record review of Resident #1's Electronic Medical Record on 05/24/25 did not reveal a 30-day discharge notice. Record review of Resident #1's Electronic Medical Record did not reveal discharge planning. Record review of Resident #1's Recapitulation of Stay Resident Discharge summary dated [DATE] indicated resident was discharged on 4/16/25. The discharge summary revealed Resident was in the skilled nursing facility for long term care and was discharged to home with family. Record review of Resident #1's Care plan dated 5/24/25 reflected a documented status of being a sex offender. Interventions included notifying physician/family/police/probation officer of any known inappropriate behavior and psych services as needed. Further interventions revealed the following for sexually inappropriate behaviors: evaluate the resident's ability to understand behavior and the consequences of that behavior, explain to the resident the acceptable expressions of sexuality based on the cognitive evaluation, listen/talk to the resident - see if they will tell you why they do the behavior, Psychiatric Services consult as needed, reinforce with staff that clear, firm limits are healthy and required when resident makes inappropriate gestures or statements, and report incidents of target behavior to charge nurse. Record review of Resident #1's Transfer/Discharge Report dated 5/24/25 did not indicate a reason for discharge. Record review of Incidents by Incident Type log with a date range of 02/23/2025 - 05/23/2025, dated 05/23/2025 revealed no incidents that involved Resident #1. Interview with Administrator on 5/24/25 at 12 p.m. revealed she discharged Resident #1 because he was a registered sex offender and was getting too friendly in the dining room. The Administrator reported the friendliness was not directed toward any certain resident. She reported she never received any reports by other residents regarding Resident #1 being inappropriate toward other residents. When asked to explain what too friendly meant, the Administrator stated Resident #1 would say he wanted a girlfriend and he wanted to sit by females in the dining room. The Administrator stated Resident #1 was not given a 30-day notice. The Administrator stated she discharged planned the day prior with the social worker and family member over the phone. An attempt to interview the Social Worker was made on 5/24/25 at 10:23 a.m. and was unsuccessful. Interview with Director of Nursing on 5/24/25 at 11:40 a.m. revealed Resident #1 was discharged due to making comments about wanting a girlfriend and because of his history of being a sex offender. When asked if there was discharge planning completed, the Director of Nursing stated the discharge was discussed with the social worker a couple of days prior to the discharge date between the Administrator and Social Worker. She spoke to the family member the day he was discharged and shared their concerns about Resident #1 and that another facility had accepted Resident #1. The Director of Nursing stated the family member told her that facility was too far and agreed to take him home. The Director of Nursing stated a 30-day notice was not provided to Resident #1 or his family member. Interview with Resident #1's family member on 5/24/25 at 10:34 a.m. revealed he was called on 4/16/25 by the facility and was told to come pick up Resident #1 or the cops would be called to remove him. The family member stated he was told the reason for discharge was inappropriate behavior but was not told what the behavior was. The family member stated that was the only time he spoke to anyone at the facility. The family member stated the facility offered another facility, but it was too far. He stated he brought Resident #1 home and then Resident #1 went to another facility. Interview with Weekend Supervisor on 5/24/25 at 11:29 a.m. revealed she was not aware of why Resident #1 was discharged . She reported that she completed Resident #1's Recapitulation of Stay. She stated you need to know why the resident went home when completing the form; she stated she documented that why the resident was discharged on the form. The Weekend Supervisor stated she never saw Resident #1 being inappropriate toward other residents. Interview with RN A on 5/24/25 at 10:39 a.m. revealed she did not know why Resident #1 was discharged . She reported she never had concerns about his behavior. She stated Resident #1 usually stayed to himself in his room. Interview with RN B on 5/24/25 at 11:18 a.m. revealed she did not know why Resident #1 was discharged . She reported she was not aware of any inappropriate behaviors by Resident #1. Interview with CNA A on 5/24/25 at 10:54 a.m. revealed she did not know why Resident #1 was discharged . She stated Resident #1 stayed mostly in his room and never saw him act inappropriately toward other residents. CNA A stated Resident #1 would sit at a table with all men at lunch. Interview with CNA B on 5/24/25 at 11:08 a.m. revealed she did not know why Resident #1 was discharged . She reported she never saw him being too friendly with other residents. She stated Resident #1 barely spoke. She stated she never saw him hanging out with other residents. Interview with Dietary Aide A on 5/24/25 at 10:59 a.m. revealed Resident #1 was a nice man and never saw him doing anything wrong to other residents. Interview with Dietary Aide B on 5/24/25 at 11:02 a.m. revealed he never saw Resident #1 being inappropriate toward other residents. Interview with Human Resources on 5/24/25 at 10:24 a.m. revealed she was familiar with Resident #1 and was not aware of any incidents of him being inappropriate toward other residents. She reported she was not aware of the reason for his discharge. Interview with 14 Residents selected for sample on 5/24/25 between 8:15 a.m. and 9:23 a.m. revealed no concerns for safety or inappropriate behaviors from other residents. Record review of the facility transfer and discharge policy on 5/24/25 was dated and revised on 6/2020. The policy stated To ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing provider. The Facility may transfer or discharge a resident for the following reasons. A. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, B. The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility, C. The safety of individual in the facility is endangered by the resident's presence, D. The health of individuals in the facility would otherwise be endangered by the resident's presence, E. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid, or F. The facility ceases to operate. IV. Facility staff will provide the resident with reasonable advance notice of the transfer or discharge before it occurs. Unless exigent circumstances exist, the notice should be provided 30 days prior to the proposed date of transfer/discharge. Situations that may prevent 30 days' notice include: A. The resident poses a threat to the health or safety of other individuals at the facility, B. The resident's health improves sufficiently to allow for more immediate transfer/discharge, C. The resident is experiencing urgent medical needs, or D. The resident has not resided in the facility for 30 days. III. Prior to transfer/discharge, Social Services Staff or designee will provide the resident or responsible party with reasonable notice that the resident is going to be transferred or discharged .

43791 Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was free from accidents/hazards on 03/16/25 when she was shocked after plugging in her phone charger to the wall socket, that resulted in burns to her fingers and hand. An IJ was identified on 04/14/25. The IJ template was provided to the facility on [DATE] at 4:03 PM. While the IJ was removed on 04/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could expose residents to risk of injury or death from electrical shock. Findings included: Record review of Resident #1's Admission Record, dated 04/14/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #1's Admission MDS Assessment, dated 03/04/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her active diagnoses included cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke, seizure disorder or epilepsy (a chronic brain condition characterized by recurrent seizures caused by abnormal electrical activity in the brain), anxiety disorder (a group of mental health conditions characterized by fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities once enjoyed). Record review of Resident #1's progress notes reflected: -On 03/16/25 at 3:50 AM, LVN A wrote: Resident reported to have had an electrical malfunction of her bed connection cable that plugs the bed to wall socket.Resident [sic] said she felt some spackling sounds from the cables as she placed her hand to plug the bed into the wall.This [sic] nurse and a cna in the facility noted that the socket plug on her bed was loose without any electrical power on bed to wall socket.Resident [sic] denied pain or discomfort at this time.Head [sic] to toe assessment on resident noted no skin tear or bruising at this time.vS [sic] 118/72,82,20,97.7.o2 sat 86% on room air.Resident [sic] prefered [sic] not to go for any evaluation at the hospital at this time.[Physician Z] [sic] call placed.Resident [sic] transferred to a different room on a different bed.Facility [sic] administrator and DON notified.Will [sic] continue to monitor. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 3:45 AM reflected Resident #1's index finger with a black charred mark on the side of it. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 3:33 AM reflected a bed frame against the wall, behind it was a plug on the wall that had a black cord plugged in to it and a metal cover was loose and hanging on the cord; there was a charred/burned mark to the top left of the cover and on the wall as well. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 8:18 AM reflected Resident #1's hand; her thumb and finger were in view and had white blisters on them. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 8:40 AM reflected a bed frame against the wall, behind it was a plug on the wall that was exposed and did not have a plate covering it; the top portion of the top plug was black and charred as well as the wall right above the top plug on the left side. Record review of the incident/accident log from 01/14/25 to 04/14/25 revealed no incidents had occurred related to a resident being burned or shocked during this timeframe. There was also not an incident report for Resident #1 on 03/16/25 listed. Record review of a Work Order , created 03/16/25 at 11:05 AM reflected the following: Plug in [Resident #1's room number] behind bed not working .Notes: Replaced plugs and breaker .Priority: Critical Category: Electrical .Comments: Resident removed plate cover when plugging phone in to receptacle it popped the breaker I have replaced the plug but still no power coming to any of the outlets or next room over. [sic]. Record review of an invoice from the Electrician, dated 03/17/25, reflected the following description: .Trouble Shoot Loss of Power To Three Resident Rooms. Found Severed Hot Wire At Outlet Box. Found Defective Circuit Breaker in Panel. Repaired Wire At Outlet Box. Replaced Defective Circuit Breaker With Spare Circuit Breaker Not Being Used. Replaced 20A Duplex Receptacles and Plates . Interview on the phone on 04/09/25 at 1:40 PM with LVN A revealed he was called to Resident #1's room because she had no power to her bed. LVN A said he checked the plug to see if the bed was plugged in and he noted part of it was burnt. LVN A said he asked Resident #1 if she had touched th e plug, and she told him she had. LVN A said he then checked Resident #1 for any injury. LVN A said Resident #1 did not have any injuries, had no complaints of pain, and she had declined to go to the hospital. Interview on the phone on 04/11/25 at 4:54 PM with Resident #1 revealed around 3:33 AM on 03/16/25, she was trying to get her charger into the plug on the wall when she was shocked. Resident #1 said she took pictures immediately after it happened. Resident #1 said she was scared and thought she was going to catch on fire, and it was painful when she was shocked. Resident #1 said she had a burn on her thumb and finger that blistered up and was white. Resident #1 said she showed the SW and the nurse who came to her room that night her hand. Resident #1 said the SW saw the black mark and blisters on her finger and thumb. Resident #1 said the nurse who came to her room was mostly concerned about getting her to a different room so that she would be safe. Resident #1 said she was very anxious and when the nurse asked her if she wanted to go to the hospital she said no, she wanted to stay there at the facility. Resident #1 said she tried to show her hand to the nurse, but he just wanted to take her out of the room. Resident #1 said she asked for an incident report and was told there was not one completed. Resident #1 said she did talk to the Administrator about replacing her phone charger. Resident #1 said when the shocks came out of the plug she screamed, and CNA F came to the room and tried to turn the lights on but they did not work so she left to get the nurse. Resident #1 said she immediately took pictures right after it happened of her fingers that showed they were black. Resident #1 said later that day she took pictures of her thumb and finger that showed the white blisters. Observations on 04/14/25 at 9:00 AM made on the 100 hallway of resident rooms, specifically looking at their plugs and sockets in their rooms revealed there were not any concerns noted. Record review of Resident #7's Admission Record, dated 04/14/25, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #7's Annual MDS Assessment, dated 01/13/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Interview on 04/14/25 at 9:51 AM with Resident #7 revealed she was in the dining room sitting at a table waiting to play dominoes. Resident #7 wanted to stay where she was to talk and explained that she was friends with Resident #1 while she was at the facility. Resident #7 said she knew about Resident #1's burns because she told her about it. Resident #7 said Resident #1 told her she was plugging in her phone charger, and it electrocuted her. Resident #7 said Resident #1 told her that there were sparks that came out of the plug and burned her hand. Resident #7 said she saw Resident #1's hand where there were blisters on the inside and outside of her hands, like on the top and bottom of it. Resident #7 said Resident #1's finger and thumb area looked raw, red, and pink which was strange because the resident had a darker skin complexion. Resident #7 said she also saw dots on her hand and thumb areas and one big dot on her thumb on Resident #1's hand. Resident #7 said Resident #1 told her she was also in a lot of pain. Resident #7 said she did not know she was supposed to talk to anyone about what happened but knew that Resident #1 had told staff but they did not want to do anything about it. Record review of Resident #6's Admission Record, dated 04/14/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #6's Quarterly MDS Assessment, dated 03/23/25, 03/23/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Interview on 04/14/25 at 1:38 PM with Resident #6 she said she was roommates with Resident #1 before she left the facility. Resident #6 said one Sunday a few weeks ago at about 4:00 AM, she heard a big bang out in the hallway. Resident #6 said she had a TV in front of her and one to the side of her and both were still working but the light behind her had turned off. Resident #6 said the previous Maintenance Director was called that night to come and fix the issue. Resident #6 said she was partially blind so could not see anything in the room even if she wanted to if there were sparks or anything like that. Record review of Resident #2's Admission Record, dated 04/14/25, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #2's Annual MDS Assessment, dated 01/13/25, reflected he had a BIMS score of 14, indicating no cognitive impairment. Interview on 04/14/25 at 1:44 PM with Resident #2 he said he had plugs in his room that failed all the time because they were worn out. Resident #2 said he also saw a lot of sparks sometimes if a plug was loaded too much, for instance if he plugged in his refrigerator and TV to the same plug. Resident #2 said he saw the burns to Resident #1's hands and took pictures of her hand for her to have. Resident #2 said Resident #7 also saw the injuries to Resident #1's hands. Resident #2 said he saw a charred mark on the top of Resident #1's hand that was black. Resident #2 said he was not sure if Resident #1 had blisters or not but she told him that she plugged her phone charger in to the wall and got electrocuted. Attempted interview on the phone on 04/14/25 at 10:15 AM with CNA F was unsuccessful as there was no answer or call back prior to exit. Interview on 04/14/25 at 10:51 AM with the SW revealed he spoke with Resident #1 one day and she told him that there was a malfunction to the outlet on her wall. The SW said Resident #1 told him either her laptop or charger got messed up and she was shocked by the plug. The SW said Resident #1 showed her hand to him and said look what happened but he did not see anything. Interview on 04/14/25 at 11:00 AM with the Maintenance Director revealed he had only been in the building for three days now. The Maintenance Director said he was not aware of any issues with any electrical outlets in any of the rooms. Interview on 04/14/25 at 11:14 AM with the RN Supervisor revealed she heard about what happened to Resident #1. The RN Supervisor said she talked to Resident #1 who told her that when she plugged something into her wall the plug sparked or something like that. The RN Supervisor said the previous Maintenance Director had been called to come to the building to fix the issue. The RN Supervisor said she looked at Resident #1's hands and did not see anything but was not sure what day this was. The RN Supervisor said this happened a few weeks ago but could not give a specific date. Interview on 04/14/25 at 11:33 AM with the DON revealed she was told on Monday morning (03/17/25) that there was an electrical issue in Resident #1's room and her bed was not working because of it. The DON said Resident #1 was moved to a different room where the bed did work in the meantime. The DON said Resident #1 was allegedly sparked by the electricity in the plug but was not injured. The DON said the nurse on duty (LVN A) completed a head-to-toe assessment on Resident #1 which had no findings. The DON said that plugs spark sometimes if a person pulls a plug out or jerks a plug out sometimes it will spark. Interview on the phone on 04/14/25 at 11:55 AM with the Electrician revealed it was not impossible that a person could have been shocked by the plug in the facility. The Electrician said typically in nursing facilities, the outlet receptacles were really worn out and need to be replaced because overtime they get worn out so when a resident goes to plug something in to it, it's loose and not making a good connection. The Electrician said if the plug was loose and not making good contact, it's going to heat up and get hot. The Electrician said if someone were being careless when plugging something in and did not keep their fingers back and their fingers touched the prongs, they could get shocked in that circumstance. The Electrician said this could happen because there was a load being drawn to that plug from something else, meaning there was a current already there at the plug site. The Electrician said if the receptacle was worn out and the current was also there then the electricity would arch and if someone's fingers were too close to the metal prongs on the plug it could cause a spark or shock to that person. The Electrician compared it to unplugging a turned-on appliance, there will be a spark once it's trying to be removed from the plug in the wall. Interview on 04/14/25 at 12:28 PM with the Administrator revealed the previous Maintenance Director called her the day the incident happened with Resident #1 although she could not remember what day that was. The Administrator said the previous Maintenance Director told her that the plug was not working, and he was going to the facility, so she sent him the Electrician's number. The Administrator said Resident #1 was moved to a different room and nothing else was reported to her by the staff or the resident. The Administrator said she did not know that any sparks occurred, she found that information out last week when an HHSC surveyor asked her about that. The Administrator said LVN A told them there was only an electrical malfunction and that Resident #1 heard something coming from the plug and there was no power to the outlet. The Administrator said she never knew Resident #1 had alleged she was electrocuted or sparked, and the resident did not tell anyone about what happened to her hand. The Administrator said she also knew that Resident #1's phone charger stopped working and she wanted a new one but she discharged before the facility could replace it. The Administrator said the facility did not provide any in-services to the staff after the incident occurred because it was simply a maintenance issue. The Administrator said the facility was not monitoring the plugs in resident's rooms because there was not a reason to do so. The Administrator said the Maintenance Director just started a few days ago and was brand new so he did not know anything about Resident #1 or the incident. The Administrator said her expectation was that all residents were kept safe and free from any accident or hazard in the facility. Interview on 04/14/25 at 1:21 PM with the previous Maintenance Director revealed he was in Resident #1's room on Friday (03/14/25) fixing her overbed lightbulbs and he saw that her plug cover behind her bed was fine and did not have any burn marks or anything on it. The previous Maintenance Director said he got a call on either the Saturday or Sunday afterwards from staff saying that there was a loss of power to a few of the rooms. The previous Maintenance Director said he took the plugs out and tested the wires but found no electricity, so he put it all back together and called the Electrician. The previous Maintenance Director said the Electrician came out on Monday (03/17/25) and replaced the plugs in the room and fixed the circuit breaker in the breaker box. The previous Maintenance Director said when he arrived to the facility on Sunday (03/16/25), he saw the plug cover on the floor and he was not sure how it got there. The previous Maintenance Director said from what he assumed, the plug was messed with in between Friday and Sunday or somehow the plug cover was taken off. The previous Maintenance Director said if the cover was taken off and exposed the inside of the plugs a little buzz or spark could happen. The previous Maintenance Director said he did not talk to Resident #1 or her nurse to see if the resident was affected. The previous Maintenance Director said before everything could be fixed, Resident #1 was moved to a different room. Interview on 04/14/25 at 2:00 PM with the Administrator revealed the facility has not had any other electrical issues in the building since 03/01/25, except for what happened on 03/16/25. Interview on 04/14/25 at 3:20 PM with the Administrator revealed the facility did not have a policy that addressed incidents or accidents specifically. An IJ was identified on 04/14/25. The IJ template was provided to the the Administrator on 04/14/25 at 4:03 PM. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 04/15/25 at 7:30 AM and reflected the following: Date: 04/14/2025 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes. F689 On 4/14/2025 during a P1re- survey [sic] at [Facility Name] at [Facility Address], HHSC surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility allegedly failed to ensure Resident #1 was free from accidents/ hazards. The notification of the alleged immediate jeopardy states as follows: The facility failed to keep all residents safe from accidents/hazards when resident # 1 [sic] was allegedly shocked after plugging in her phone charger to the wall outlet on 3/16/25 in her room. Resident #1 sustained a burn mark and blister from the incident. Identify residents who could be affected. All residents have the potential to be affected. Identify responsible staff/ what action taken. All Staff in serviced on the event of any electrical issue or any other hazard, they will immediately place the issue in the maintenance log and follow with phone call to administrator. With completion date of 4/14/25. All outlets in resident rooms checked by maintenance director to ensure that they are in working order and do not present a hazard. Completion date of 4/14/25. All staff in-service [sic] on prevention of accidents, incidents and hazards. Completion date of 4/14/2025. In-Service conducted. All Staff in serviced on the event of any electrical issue or any other hazard, they will immediately place the issue in the maintenance log and follow with phone call to administrator. With completion date of 4/14/25. All staff in-service [sic] on prevention of accidents, incidents and hazards. Completion date of 4/14/2025. Implementation of Changes All Staff in serviced on the event of any electrical issue or any other hazard, they will immediately place the issue in the maintenance log and follow with phone call to administrator. With completion date of 4/14/25. All outlets in resident rooms checked by maintenance director to ensure that they are in working order and do not present a hazard. Completion date of 4/14/25. All staff in-service [sic] on prevention of accidents, incidents and hazards. Completion date of 4/14/2025. 6 resident rooms per week x 4 weeks will be randomly audited to ensure electrical outlets are in working order. The changes were started by the Administrator. The changes were implemented effective on 4/142025 [sic] and training was completed on 4/142025. [sic] Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on completing maintenance log to report any electrical issues or any other hazard with follow up call to administrator. Prevention of accident and incidents and hazards. [sic] Monitoring The Administrator/Designee will be responsible for monitoring the implementation and effectiveness of in-service on 4/14/25. The Administrator/Regional director of Operations [sic]/Maintenance director/designee will check 6 rooms weekly to ensure outlets are in working order weekly x4 weeks, then monthly thereafter and report any adverse finding during QAPI. The Administrator/Maintenance director/designee will check maintenance log daily to check for any new risk/ electoral issues and report any adverse findings during QAPI. [sic] Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 4/14/2025 and conducted an Ad HOC QAPI regarding ensuring all resident room outlets were checked to ensure working and not a hazard and all staff educated on accident/incident/hazard prevention, and all staff educated on reporting any electrical issues or other hazards. The Medical Director was notified about the immediate Jeopardy on 4/14/2025, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 4/14/2025. Who is responsible for the implementation of the process? The Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 4/14/2025. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 4/14/2025. Monitoring of the facility's Plan of Removal included the following: Interviews with the following staff from 04/15/25 at 9:00 AM to 3:01 PM, both in person and by phone, who worked all shifts and days of the week revealed they had been in-serviced to immediately report any electrical issues to the Administrator by phone, log the information into the Maintenance Logbook, and knew to report any accident/hazard/incident to the Administrator immediately: RN G, CNA H, CNA I, the Maintenance Director, LVN C, the ADON, RN J, CNA B, CNA D, CNA K, CNA L, the Dish Washer, LVN M, the Dietary Aide, the COTA, CNA N, LVN O, CNA P, MA Q, MA R, LVN S, CNA T, CNA U, CNA V, CNA W, CNA X, LVN Y, CNA BB, CNA CC, LVN AA, CNA DD, MA EE, the DON, and the Administrator. Record review of an in-service sign in sheet, dated 04/14/25, revealed 62 total staff had been in-serviced regarding Hazard/Electrical Issues. Record review of an in-service sign-in sheet, dated 04/14/25, revealed 63 total staff had been in-serviced regarding Prevention of Accidents and Incidents and Hazards. Record review of an in-service sign-in sheet, dated 04/14/25, revealed the ADON and DON had been in-serviced regarding Accident and Incident Follow-up and care x72 hrs. Record review of an AD Hoc Quality Assurance and Performance Improvement Plan was held on 04/14/25. Record review of a census sheet, dated 04/14/25, reflected the Maintenance Director's initials next to each room acknowledging that he had checked each room's electrical plugs to ensure they were working and there were no hazards to the residents. An IJ was identified on 04/14/25. The IJ template was provided to the facility on [DATE] at 4:03 PM. While the IJ was removed on 04/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on interviews, and record reviews the facility failed to ensure that an alleged violation involving neglect, or injuries of unknown source were reported immediately for 1 of 3 residents (Resident #1) reviewed for accidents. LVN A failed to immediately report an incident to the Administrator i nvolving Resident #1 on 03/16/25 when she alleged she was shocked after plugging in her phone charger to the wall. Resident #1 sustained a charred mark to her finger and blisters to her finger and thumb from the incident. This failure could have caused residents to suffer cardiac issues. Findings included: Record review of Resident #1's Admission Record, dated 04/14/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #1's Admission MDS Assessment, dated 03/04/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her active diagnoses included cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke, seizure disorder or epilepsy (a chronic brain condition characterized by recurrent seizures caused by abnormal electrical activity in the brain), anxiety disorder (a group of mental health conditions characterized by fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities once enjoyed). Record review of Resident #1's progress notes reflected: - On 03/16/25 at 3:50 AM, LVN A wrote: Resident reported to have had an electrical malfunction of her bed connection cable that plugs the bed to wall socket.Resident [sic] said she felt some spackling sounds from the cables as she placed her hand to plug the bed into the wall.This [sic] nurse and a cna in the facility noted that the socket plug on her bed was loose without any electrical power on bed to wall socket.Resident [sic] denied pain or discomfort at this time.Head [sic] to toe assessment on resident noted no skin tear or bruising at this time.vS [sic] 118/72,82,20,97.7.o2 sat 86% on room air.Resident [sic] prefered [sic] not to go for any evaluation at the hospital at this time.[Physician Z] [sic] call placed.Resident [sic] transferred to a different room on a different bed.Facility [sic] administrator and DON notified .Will [sic] continue to monitor. Interview on the phone on 04/11/25 at 4:54 PM with Resident #1 revealed around 3:33 AM on 03/16/25, she was trying to get her charger into the plug on the wall when she was shocked. Resident #1 said she took pictures immediately after it happened. Resident #1 said she was scared and thought she was going to catch on fire, and it was painful when she was shocked. Resident #1 said she had a burn on her thumb and finger that blistered up and was white. Resident #1 said she showed the SW and the nurse who came to her room that night her hand. Resident #1 said the SW saw the black mark and blisters on her finger and thumb. Resident #1 said the nurse who came to her room was mostly concerned about getting her to a different room so that she would be safe. Resident #1 said she was very anxious and when the nurse asked her if she wanted to go to the hospital she said no, she wanted to stay there at the facility. Resident #1 said she tried to show her hand to the nurse, but he just wanted to take her out of the room. Resident #1 said she asked for an incident report and was told there was not one completed. Resident #1 said she did talk to the Administrator about replacing her phone charger. Resident #1 said when the shocks came out of the plug she screamed, and CNA F came to the room and tried to turn the lights on but they did not work so she left to get the nurse. Resident #1 said she immediately took pictures right after it happened of her fingers that showed they were black. Resident #1 said later that day she took pictures of her thumb and finger that showed the white blisters. Interview on the phone on 04/09/25 at 1:40 PM with LVN A revealed he was called to Resident #1's room because she had no power to her bed. LVN A said he checked the plug to see if the bed was plugged in and he noted part of it was burnt. LVN A said he asked Resident #1 if she had touched the plug, and she told him she had. LVN A said he then checked Resident #1 for any injury. LVN A said Resident #1 did not have any injuries, had no complaints of pain, and she had declined to go to the hospital. Follow-up interview on the phone on 04/14/25 at 10:08 AM with LVN A revealed he only reported the electrical issue to the Administrator on 03/16/25. LVN A said since Resident #1 had no injuries, there was nothing else to report to the Administrator at that time. Interview on 04/14/25 at 1:21 PM with the previous Maintenance Director revealed he was in Resident #1's room on Friday (03/14/25) fixing her overbed lightbulbs and he saw that her plug cover behind her bed was fine and did not have any burn marks or anything on it. The previous Maintenance Director said he got a call on either the Saturday or Sunday afterwards from staff saying that there was a loss of power to a few of the rooms. The previous Maintenance Director said he took the plugs out and tested the wires but found no electricity, so he put it all back together and called the Electrician. The previous Maintenance Director said the Electrician came out on Monday (03/17/25) and replaced the plugs in the room and fixed the circuit breaker in the breaker box. The previous Maintenance Director said when he arrived to the facility on Sunday (03/16/25), he saw the plug cover on the floor and he was not sure how it got there. The previous Maintenance Director said from what he assumed, the plug was messed with in between Friday and Sunday or somehow the plug cover was taken off. The previous Maintenance Director said if the cover was taken off and exposed the inside of the plugs a little buzz or spark could happen. The previous Maintenance Director said he did not talk to Resident #1 or her nurse to see if the resident was affected. The previous Maintenance Director said before everything could be fixed, Resident #1 was moved to a different room. Interview on 04/14/25 at 12:28 PM with the Administrator revealed the previous Maintenance Director called her the day the incident happened with Resident #1 although she could not remember what day that was. The Administrator said the previous Maintenance Director told her that the plug was not working, and he was going to the facility, so she sent him the Electrician's number. The Administrator said Resident #1 was moved to a different room and nothing else was reported to her by the staff or the resident. The Administrator said she did not know that any sparks occurred, she found that information out last week when an HHSC surveyor asked her about that. The Administrator said LVN A told them there was only an electrical malfunction and that Resident #1 heard something coming from the plug and there was no power to the outlet. The Administrator said she never knew Resident #1 had alleged she was electrocuted or sparked, and the resident did not tell anyone about what happened to her hand. The Administrator said she would have to look at the Provider Letter first to determine if a resident coming in contact with an electrical current was considered reportable or not. The Administrator said even if a resident sustained burns/marks/blisters she was still unsure if that was a reportable incident or not. The Administrator said all injuries to a resident should be reported to her. The Administrator said she would be responsible for reporting and if Resident #1 had said she was shocked or electrocuted by a plug in the facility, that should have been reported to her. The Administrator said all staff have been trained on what and when to report things to her. The Administrator said she expected all staff to follow their abuse/neglect policy. The Administrator said the purpose of reporting any allegation of abuse/neglect was to ensure a resident's safety and keep them safe from harm. The Administrator said any staff who had knowledge of an allegation of abuse/neglect should report it. The Administrator said she monitored the building 24/7 to ensure all instances or allegations of abuse/neglect were reported to her. The Administrator did not want to answer how a resident could be affected by an allegation not being reported to her immediately. Record review of the facility's policy revised 10/24/22, and titled Abuse Prevention and Prohibition Program reflected: IX. Reporting/Response .A. Facility Staff are Mandatory Reporters .B. Administrator, or his/her designee, as Abuse Coordinator .ii. Facility Staff will report known or suspected instances of abuse to the Administrator or his/her designee .D. The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property, or other incidents that qualify as a crime .

Based on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 received treatment after she sustained blisters to her fingers on 03/16/25 after coming into contact with an electrical outlet in her room that sparked and caused scorching on the outlet and surrounding wall area. The failure placed residents at risk of delay treatment. Findings included: Record review of Resident #1's Admission Record, dated 04/14/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #1's Admission MDS Assessment, dated 03/04/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her active diagnoses included cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke, seizure disorder or epilepsy (a chronic brain condition characterized by recurrent seizures caused by abnormal electrical activity in the brain), anxiety disorder (a group of mental health conditions characterized by fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities once enjoyed). Record review of Resident #1's progress notes reflected: - On 03/16/25 at 3:50 AM, LVN A wrote: Resident reported to have had an electrical malfunction of her bed connection cable that plugs the bed to wall socket.Resident [sic] said she felt some spackling sounds from the cables as she placed her hand to plug the bed into the wall.This [sic] nurse and a cna in the facility noted that the socket plug on her bed was loose without any electrical power on bed to wall socket.Resident [sic] denied pain or discomfort at this time.Head [sic] to toe assessment on resident noted no skin tear or bruising at this time.vS [sic] 118/72,82,20,97.7.o2 sat 86% on room air.Resident [sic] prefered [sic] not to go for any evaluation at the hospital at this time.[Physician Z] [sic] call placed.Resident [sic] transferred to a different room on a different bed.Facility [sic] administrator and DON notified.Will [sic] continue to monitor. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 3:45 AM reflected Resident #1's index finger with a black charred mark on the side of it. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 3:33 AM reflected a bed frame against the wall, behind it was a plug on the wall that had a black cord plugged in to it and a metal cover was loose and hanging on the cord; there was a charred/burned mark to the top left of the cover and on the wall as well. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 8:18 AM reflected Resident #1's hand; her thumb and finger were in view and had white blisters on them. Record review of a picture provided by Resident #1, dated 03/16/25, and timed 8:40 AM reflected a bed frame against the wall, behind it was a plug on the wall that was exposed and did not have a plate covering it; the top portion of the top plug was black and charred as well as the wall right above the top plug on the left side. Record review of the incident/accident log from 01/14/25 to 04/14/25 revealed no incidents had occurred related to a resident being burned or shocked during this timeframe. There was also not an incident report for Resident #1 on 03/16/25 listed. Interview on the phone on 04/09/25 at 1:40 PM with LVN A revealed he was called to Resident #1's room because she had no power to her bed. LVN A said he checked the plug to see if the bed was plugged in and he noted part of it was burnt. LVN A said he asked Resident #1 if she had touched the plug, and she told him she had. LVN A said he then checked Resident #1 for any injury. LVN A said Resident #1 did not have any injuries, had no complaints of pain, and she had declined to go to the hospital. Interview on the phone on 04/11/25 at 4:54 PM with Resident #1 revealed around 3:33 AM on 03/16/25, she was trying to get her charger into the plug on the wall when she was shocked. Resident #1 said she took pictures immediately after it happened. Resident #1 said she was scared and thought she was going to catch on fire and it was painful when she was shocked. Resident #1 said she had a burn on her thumb and finger that blistered up and was white and now her hand was numb. Resident #1 said she showed the SW and the nurse who came to her room that night her hand. Resident #1 said the SW saw the black mark and blisters on her finger and thumb. Resident #1 said the nurse who came to her room was mostly concerned about getting her to a different room so that she would be safe. Resident #1 said she was very anxious and when the nurse asked her if she wanted to go to the hospital she said not, she wanted to stay there at the facility. Resident #1 said she tried to show her hand to the nurse, but he just wanted to take her out of the room. Resident #1 said she asked for an incident report and was told there was not one completed. Resident #1 said she did talk to the Administrator about replacing her phone charger. Resident #1 said when the shocks came out of the plug she screamed, and CNA F came to the room and tried to turn the lights on but they did not work so she left to get the nurse. Resident #1 said she immediately took pictures right after it happened of her fingers that showed they were black. Resident #1 said later that day she took pictures of her thumb and finger that showed the white blisters. Observations on 04/14/25 at 9:00 AM made on the 100 hallway of resident rooms, specifically looking at their plugs and sockets in their rooms revealed there were not any concerns noted. Record review of Resident #7's Admission Record, dated 04/14/25, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #7's Annual MDS Assessment, dated 01/13/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Interview on 04/14/25 at 9:51 AM with Resident #7 revealed she was in the dining room sitting at a table waiting to play dominoes. Resident #7 wanted to stay where she was to talk and explained that she was friends with Resident #1 while she was at the facility. Resident #7 said she knew about Resident #1's burns because she told her about it. Resident #7 said Resident #1 told her she was plugging in her phone charger, and it electrocuted her. Resident #7 said Resident #1 told her that there were sparks that came out of the plug and burned her hand. Resident #7 said she saw Resident #1's hand where there were blisters on the inside and outside of her hands, like on the top and bottom of it. Resident #7 said Resident #1's finger and thumb area looked raw, red, and pink which was strange because the resident had a darker skin complexion. Resident #7 said she also saw dots on her hand and thumb areas and one big dot on her thumb on Resident #1's hand. Resident #7 said Resident #1 told her she was also in a lot of pain. Resident #7 said she did not know she was supposed to talk to anyone about what happened but knew that Resident #1 had told staff, but they did not want to do anything about it. Record review of Resident #6's Admission Record, dated 04/14/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #6's Quarterly MDS Assessment, dated 03/23/25, 03/23/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Interview on 04/14/25 at 1:38 PM with Resident #6 revealed she was in her bed scrolling on her phone. Resident #6 said she was roommates with Resident #1 before she left the facility. Resident #6 said one Sunday a few weeks ago at about 4:00 AM, she heard a big bang out in the hallway. Resident #6 said she had a TV in front of her and one to the side of her and both were still working but the light behind her had turned off. Resident #6 said the previous Maintenance Director was called that night to come and fix the issue. Resident #6 said she was partially blind so could not see anything in the room even if she wanted to if there were sparks or anything like that. Record review of Resident #2's Admission Record, dated 04/14/25, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #2's Annual MDS Assessment, dated 01/13/25, reflected he had a BIMS score of 14, indicating no cognitive impairment. Interview on 04/14/25 at 1:44 PM with Resident #2 revealed he was in his room laying in his bed. Resident #2 said he had plugs in his room that failed all the time because they were worn out. Resident #2 said he also saw a lot of sparks sometimes if a plug was loaded too much, for instance if he plugged in his refrigerator and TV to the same plug. Resident #2 said he saw the burns to Resident #1's hands and took pictures of her hand for her to have. Resident #2 said Resident #7 also saw the injuries to Resident #1's hands. Resident #2 said he saw a charred mark on the top of Resident #1's hand that was black. Resident #2 said he was not sure if Resident #1 had blisters or not but she told him that she plugged her phone charger in to the wall and got electrocuted. Attempted interview on the phone on 04/14/25 at 10:15 AM with CNA F was unsuccessful as there was no answer or call back prior to exit. Interview on 04/14/25 at 10:51 AM with the SW revealed he spoke with Resident #1 one day and she told him that there was a malfunction to the outlet on her wall. The SW said Resident #1 told him either her laptop or charger got messed up and she was shocked by the plug. The SW said Resident #1 showed her hand to him and said look what happened but he did not see anything and was not sure what date this was. Interview on 04/14/25 at 11:14 AM with the RN Supervisor revealed she heard about what happened to Resident #1. The RN Supervisor said she talked to Resident #1 who told her that when she plugged something in to her wall the plug sparked or something like that. The RN Supervisor said the previous Maintenance Director had been called to come to the building to fix the issue. The RN Supervisor said she looked at Resident #1's hands and did not see anything but was not sure what day this was. Interview on 04/14/25 at 11:28 AM with the ADON revealed she heard that Resident #1 had something going on and she checked with the nurse to make sure a full body assessment was done . The ADON said Resident #1 did not have any injuries that she was told about so there was no follow-up required. Interview on 04/14/25 at 11:33 AM with the DON revealed she was told on Monday morning (03/17/25) that there was an electrical issue in Resident #1's room and her bed was not working because of it. The DON said Resident #1 was moved to a different room where the bed did work in the meantime. The DON said Resident #1 was allegedly sparked by the electricity in the plug but was not injured. The DON said the nurse on duty (LVN A) completed a head-to-toe assessment on Resident #1 which had no findings. The DON said that plugs spark sometimes if a person pulls a plug out or jerks a plug out sometimes it will spark. The DON said she did not follow-up on Resident #1 to see if there was a delayed injury after the nurse did the initial assessment. The DON said if Resident #1 had been shocked or burned it would have shown an injury immediately, not hours later. The DON said if LVN A did an appropriate assessment on Resident #1 immediately after it happened and saw nothing then there was no need to follow-up. The DON said if an incident occurs that results in an injury, the nursing staff usually follow-up for at least three days. The DON said even with the allegation that sparks came from the plug/outlet that was not enough for nursing staff to follow-up for delayed injury after the initial assessment. Interview on the phone on 04/14/25 at 11:55 AM with the Electrician revealed it was not impossible that a person could have been shocked by the plug in the facility. The Electrician said typically in nursing facilities, the outlet receptacles are really worn out and need to be replaced because overtime they get worn out so when a resident goes to plug something into it, it's loose and not making a good connection. The Electrician said if the plug is loose and not making good contact, it's going to heat up and get hot. The Electrician said if someone were being careless when plugging something in and did not keep their fingers back and their fingers touched the prongs, they could get shocked in that circumstance. The Electrician said this could happen because there is a load being drawn to that plug from something else, meaning there is a current already there at the plug site. The Electrician said if the receptacle was worn out and the current was also there then the electricity would arch and if someone's fingers were too close to the metal prongs on the plug it could cause a spark or shock to that person. The Electrician compared it to unplugging a turned-on appliance, there will be a spark once it's trying to be removed from the plug in the wall. Interview on 04/14/25 at 12:28 PM with the Administrator revealed the previous Maintenance Director called her the day the incident happened with Resident #1 although she could not remember what day that was. The Administrator said the previous Maintenance Director told her that the plug was not working, and he was going to the facility so she sent him the Electrician's number. The Administrator said Resident #1 was moved to a different room and nothing else was reported to her by the staff or the resident. The Administrator said she did not know that any sparks occurred, she found that information out last week when an HHSC surveyor asked her about that. The Administrator said LVN A told them there was only an electrical malfunction and that Resident #1 heard something coming from the plug and there was no power to the outlet. The Administrator said she never knew Resident #1 had alleged she was electrocuted or sparked, and the resident did not tell anyone about what happened to her hand. The Administrator said, when staff completed a head-to-toe assessment on Resident #1 and saw nothing on her, what are they to do at that point?. The Administrator said, if the nurse who completed the assessment reported there were no injuries, and that there were no injuries to her hands, the outlet was fixed, then there was no need for a follow-up and no reason to do anything else. Interview on 04/14/25 at 1:21 PM with the previous Maintenance Director revealed he was in Resident #1's room on Friday (03/14/25) fixing her overbed lightbulbs and he saw that her plug cover behind her bed was fine and did not have any burn marks or anything on it. The previous Maintenance Director said he got a call on either the Saturday or Sunday afterwards from staff saying that there was a loss of power to a few of the rooms. The previous Maintenance Director said he took the plugs out and tested the wires but found no electricity, so he put it all back together and called the Electrician. The previous Maintenance Director said the Electrician came out on Monday (03/17/25) and replaced the plugs in the room and fixed the circuit breaker in the breaker box. The previous Maintenance Director said when he arrived to the facility on Sunday (03/16/25), he saw the plug cover on the floor and he was not sure how it got there. The previous Maintenance Director said from what he assumed, the plug was messed with in between Friday and Sunday or somehow the plug cover was taken off. The previous Maintenance Director said if the cover was taken off and exposed the inside of the plugs a little buzz or spark could happen. The previous Maintenance Director said he did not talk to Resident #1 or her nurse to see if the resident was affected. The previous Maintenance Director said before everything could be fixed, Resident #1 was moved to a different room.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 8 residents (Resident #1) reviewed for pest control. The facility failed to prevent pests from entering the facility. On 05/28/25, Resident #1 was found in bed with ants (breed/type unknown) on his body, and he had been bitten multiple times on his torso, arms, and legs. This failure placed residents at risk of physical harm from ant or other pest bites. Findings included: Record review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility 04/09/25. His diagnoses included stroke, hemiplegia (paralysis of one side of the body), anoxic brain damage (when the brain is deprived of oxygen, leading to damage brain cells) and bell's palsy (a condition that causes temporary weakness or paralysis of the muscles on one side of the face). Resident #1 had a BIMS of 0 indicating his cognition was severely impaired. The MDS further reflected the resident required substantial/maximal assistance (helper does more than half of the effort) for all ADLs. Record review of Resident #1's care plan revised on 05/19/25 reflected the resident had an ADLs self-care performance deficit related to confusion, limited mobility, and anoxic brain damage. Interventions included the resident would require assistance with ADLs. Record review of Resident #1's progress notes dated 05/28/25 at 6:23 AM documented by RN A reflected the following: Summoned by the nurse aide that there's ants in the resident bed, arrived at the resident room noted ants on the bed and on resident's gown, resident denies being in pain at this time. Moved the resident to his recliner, head to toe assessment noted, no ant bites noted at this time, denies being in pain, no sign of discomfort noted, bath given and transferred temporarily to [Room], Management and RP notified, closely monitoring for any changes. Further progress notes reflected the following: - 05/28/25 at 8:18 AM - Resident noted to have ant bites to left shoulder and upper back, [Doctor] notified with order received to hydrocortisone cream each shift. - 05/29/25 - Redness remains on shoulder and upper back, denies any pain or itching, No signs or symptoms of infection noted . - 05/30/25 - Resident's area of possible bites from ants are fading, redness less, denies any itching at this time. Record review of Resident #1's physician orders for May 2025 reflected Hydrocortisone External Cream 2.5% was orders and instructed to apply to left shoulder topically every shift for ant bites for 7 days. Record review of the pest control log for the following dates reflected: - 05/28/25 - inspected and treated room [ROOM NUMBER] and 309 for ants - 06/02/25 - replaced and treated facility for roaches and ants on the exterior - 06/09/25 - treated for ants inside and out. Attempts to contact RN A, CNA D, and CNA E, who worked at the time of the incident, on 06/10/25 were unsuccessful. Observation and interview on 06/10/25 at 1:01 PM revealed Resident #1 was in bed awake. The resident denied pain and was unable to answer if he had been bitten by any ants. Resident #1's skin was observed with CNA F, and there were no signs of ant bites on the residents' shoulders and/or upper back. Observation on 06/10/25 from 12:56 PM through 1:27 PM of Resident #1's room and six other rooms on that hall revealed there was no evidence of ants in the rooms of the hallway. Interview on 06/10/25 at 2:12 PM, LVN B revealed she worked with Resident #1 on the 2:00 PM-10:00 PM shift the day of the incident (05/28/25). She stated she observed a few ants bites on the resident's shoulder only, and they were gone within a couple of days after that. LVN B said that during those two days, they were treating the ant bites with cream. Interview on 06/10/25 at 2:20 PM, LVN C revealed she worked with Resident #1 on the morning shift, a few hours after the incident (05/28/25) with the ant bite. She stated she had only noted a small rash on the resident's upper shoulder. LVN C said the resident was not complaining of any discomfort and once they started to treat the ant bites with cream, the ant bites quickly faded. Interview on 06/10/25 at 2:58 PM, the ADON revealed she was aware a resident had been bitten by ants, but she was not aware if had been Resident #1; therefore, she did not know the details of the incident. Interview on 06/10/25 at 3:22 PM, the DON revealed she had been told there were ants in Resident #1's room but was not told he had been bitten. The DON said the resident was moved to another room, bathed, and pest control had been called to treat the room/facility. Record review of the facility's Pest Control policy, revised on August 2020, reflected the following: Purpose To ensure the Facility if free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, Facility Staff, and visitors. Policy The Facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 8 residents (Resident #1) reviewed for pest control. The facility failed to prevent pests from entering the facility. On 05/28/25, Resident #1 was found in bed with ants (breed/type unknown) on his body, and he had been bitten multiple times on his torso, arms, and legs. This failure placed residents at risk of physical harm from ant or other pest bites. Findings included: Record review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility 04/09/25. His diagnoses included stroke, hemiplegia (paralysis of one side of the body), anoxic brain damage (when the brain is deprived of oxygen, leading to damage brain cells) and bell's palsy (a condition that causes temporary weakness or paralysis of the muscles on one side of the face). Resident #1 had a BIMS of 0 indicating his cognition was severely impaired. The MDS further reflected the resident required substantial/maximal assistance (helper does more than half of the effort) for all ADLs. Record review of Resident #1's care plan revised on 05/19/25 reflected the resident had an ADLs self-care performance deficit related to confusion, limited mobility, and anoxic brain damage. Interventions included the resident would require assistance with ADLs. Record review of Resident #1's progress notes dated 05/28/25 at 6:23 AM documented by RN A reflected the following: Summoned by the nurse aide that there's ants in the resident bed, arrived at the resident room noted ants on the bed and on resident's gown, resident denies being in pain at this time. Moved the resident to his recliner, head to toe assessment noted, no ant bites noted at this time, denies being in pain, no sign of discomfort noted, bath given and transferred temporarily to [Room], Management and RP notified, closely monitoring for any changes. Further progress notes reflected the following: - 05/28/25 at 8:18 AM - Resident noted to have ant bites to left shoulder and upper back, [Doctor] notified with order received to hydrocortisone cream each shift. - 05/29/25 - Redness remains on shoulder and upper back, denies any pain or itching, No signs or symptoms of infection noted . - 05/30/25 - Resident's area of possible bites from ants are fading, redness less, denies any itching at this time. Record review of Resident #1's physician orders for May 2025 reflected Hydrocortisone External Cream 2.5% was orders and instructed to apply to left shoulder topically every shift for ant bites for 7 days. Record review of the pest control log for the following dates reflected: - 05/28/25 - inspected and treated room [ROOM NUMBER] and 309 for ants - 06/02/25 - replaced and treated facility for roaches and ants on the exterior - 06/09/25 - treated for ants inside and out. Attempts to contact RN A, CNA D, and CNA E, who worked at the time of the incident, on 06/10/25 were unsuccessful. Observation and interview on 06/10/25 at 1:01 PM revealed Resident #1 was in bed awake. The resident denied pain and was unable to answer if he had been bitten by any ants. Resident #1's skin was observed with CNA F, and there were no signs of ant bites on the residents' shoulders and/or upper back. Observation on 06/10/25 from 12:56 PM through 1:27 PM of Resident #1's room and six other rooms on that hall revealed there was no evidence of ants in the rooms of the hallway. Interview on 06/10/25 at 2:12 PM, LVN B revealed she worked with Resident #1 on the 2:00 PM-10:00 PM shift the day of the incident (05/28/25). She stated she observed a few ants bites on the resident's shoulder only, and they were gone within a couple of days after that. LVN B said that during those two days, they were treating the ant bites with cream. Interview on 06/10/25 at 2:20 PM, LVN C revealed she worked with Resident #1 on the morning shift, a few hours after the incident (05/28/25) with the ant bite. She stated she had only noted a small rash on the resident's upper shoulder. LVN C said the resident was not complaining of any discomfort and once they started to treat the ant bites with cream, the ant bites quickly faded. Interview on 06/10/25 at 2:58 PM, the ADON revealed she was aware a resident had been bitten by ants, but she was not aware if had been Resident #1; therefore, she did not know the details of the incident. Interview on 06/10/25 at 3:22 PM, the DON revealed she had been told there were ants in Resident #1's room but was not told he had been bitten. The DON said the resident was moved to another room, bathed, and pest control had been called to treat the room/facility. Record review of the facility's Pest Control policy, revised on August 2020, reflected the following: Purpose To ensure the Facility if free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, Facility Staff, and visitors. Policy The Facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests

Based on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for one (Residents #1) of three residents reviewed for parenenteral fluids. The facility failed to ensure Resident #1 received routine PICC line dressing changes per physician orders. This failure placed the residents at risk for infections. Findings included: Review of Resident #1's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included hypertension, diabetes, encounter for other orthopedic aftercare, and infection reaction due to sepsis (a serious condition in which the body responds improperly to infection) to joint prosthetic. The MDS further reflected Resident #1's cognition was intact, and he was on IV medications. Review of Resident #1's care plan created on 07/21/24 reflected Resident #1 used a PICC line (a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) for administration of IV antibiotic. Interventions included to change PICC line dressing every Wednesday 6:00 AM-2:00 PM and as needed. Review of Resident #1's August 2024 monthly physician orders reflected: Change PICC line dressing every Wednesday on the 6-2 (6:00 AM-2:00 PM) shift and PRN. Review of Resident #1's MAR/TAR for August 2024 reflected the PICC line dressing should have been changed on Wednesday 08/14/24 and it was blank, indicating the dressing change had not marked as done. Observation and interview on 08/15/24 at 8:54 AM revealed Resident #1 was in bed watching television, and he was connected to an IV pump with medication infusing. The resident's PICC line was on his left arm and the dressing was coming off and was soiled and it was dated 08/06/24. Resident #1 stated the dressing had been coming off for 2 to 3 days now and he had told the nurses, but did not give any names, but the dressing had not been changed. The PICC site was intact and there was no redness, swelling, or any other signs of infection. Interview on 08/15/24 at 1:20 PM with RN A revealed she had changed Resident #1's PICC line dressing today, 08/15/24 , because she noted it was coming off, but she had not checked the order on when it needed to be changed. RN A further stated she had attempted to change the dressing the day prior, 08/14/24, but the resident had told her he was not ready. RN A also said risks of not changing the PICC line dressing as ordered increased the risk of infection. Interview on 08/15/24 at 2:01 PM with the ADON revealed PICC line dressings should be changed every 7 days, and that the facility they were set to be changed every Wednesday. The ADON further stated it was important to change PICC line dressing as ordered to ensure the site remained clean and to prevent infection. Interview on 08/15/24 at 2:14 PM with the DON revealed PICC line dressings were to be changed every 7 days and as needed and at the facility, most PICC line dressings were to be changed every Wednesday. The DON said Resident #1 would pick at his dressing at times stating it was itching, causing it to lift, so the resident's needed to be changed more frequently at times. The DON also stated risks of not changing the PICC line dressings as ordered to prevent bacteria from entering the site and getting infected. Review of the facility's undated policy titled Central Venous Catheter reflected the following: .Obtain physicians order for dressing change

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 8 residents reviewed for infection control. The facility failed to investigate and report to the County Health Department when Resident #2 was diagnosed with shigella. This failure placed residents at risk for infections. Findings included: Review of Resident #2's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility [DATE]. His diagnoses included cancer, cerebrovascular accident (stoke), and seizure disorder and Resident #1's cognition was moderately impaired. The MDS further reflected the resident used a wheelchair for mobility. Review of Resident #2's progress notes dated [DATE] reflected the following: Received order and sent resident out to Hospital via EMS for medical evaluation and treatment of altered mental status, diarrhea, nausea and abdominal pain. Review of Resident #2's hospital records dated [DATE] reflected the following: .Assessment/Plan: Sepsis (a serious condition in which the body responds improperly to an infection) Patient found to have ESBL bacteremia with shigella (intestinal infection caused by a family if bacteria and the main sign is diarrhea, which often is bloody. Shigella can also be passed infected food or by drinking or swimming in unsafe water) Further review of Resident #2's hospital records dated [DATE] documented by the infectious disease doctor reflected the following: .Impression ESBL bacteremia with shigella - atypical; gastroenteritis .Plan: (shigella - intestinal infection caused by a family if bacteria and the main sign is diarrhea, which often is bloody. Shigella can also be passed infected food or by drinking or swimming in unsafe water) 1. Continue meropenem (antibiotic) ordered 10 day total 2. Organism may need to be reported to the [County] Observation and interview on [DATE] at 8:44 AM with Resident #2 revealed he was in bed watching television. The resident said he had been to the hospital not long ago, but did not specify the date, because he was running a fever and had diarrhea. While he was at the hospital he was told he had an infection in his stomach from something he ate and the infection that then gone into his blood stream. Resident #2 further stated the hospital staff said the infection could have been caused by eating eggs that were not fully cooked. Resident #2 said he ate all of his meals at the facility and would eat scrambled eggs in the morning for breakfast. Interview on [DATE] at 9:51 AM with the [NAME] revealed all of the eggs they served were pasteurized. and the scrambled eggs were delivered frozen in a bag. The bag of eggs were then put in boiling water until they formed a hard scramble, and then they were served. The [NAME] also said they were not allowed to make over easy eggs and if a resident ordered a fried egg, they had to ensure the yolk was fully cooked. The [NAME] further stated they had not had any concerns or reports of residents becoming sick after eating the meals. Observation on [DATE] at 11:20 AM of the facility's kitchen revealed all refrigerated dairy products were dated, and there were no expired items stored. Observation of the scrambled eggs revealed they were in single large bags, and there were no concerns regarding expiration dates. Interview on [DATE] at 11:27 AM with the Dietary Manager revealed all the eggs they served to the residents were pasteurized and if residents ordered a fried egg, they were not allowed to serve them over easy and made sure the yolk was fully cooked. She said the scrambled eggs came in a bag and they were precooked and had a fridge life of two years as long as they remained frozen. The Dietary Manager further stated they did not have any concerns or incidents of resident becoming sick after eating breakfast or any of the meals. Review of the facility's infection control log for July and [DATE] reflected there were no concerns of an gastrointestinal infection outbreak. Interview on [DATE] at 12:46 PM with the Physician revealed he had not been made aware Resident #2 had been diagnosed with shigella and had he known he would have placed the resident on contact isolation precautions. The Physician said he would have expected the facility staff to look into the origin of the infection and follow-up with other residents to see if they were also affected. Interview on [DATE] at 2:01 PM with the ADON revealed she had been told Resident #2 had been treated for Ecoli in the urine when he returned from the hospital so he had been put in isolation. The ADON said the DON was responsible for reading hospital records prior to residents admitting from the hospital or the hospital usually called in and gave report to the charge nurses. The ADON further stated she was not aware Resident #2 had been diagnosed with shigella but since the resident had been put in isolation, they would not have done anything different. Interview on [DATE] at 2:14 PM with the DON revealed there was a facility liaison group, but she did not know who they were, that reviewed resident hospital records before they were admitted to the facility. The DON said she then would get an email letting her know the resident had been approved to admit and Resident #2 had been approved and knew he required isolation. The DON further stated she was not aware Resident #2 had been diagnosed with shigella and was told he had ecoli and believed it was in the urine. She said if they would have been aware the resident had shigella, they would have continued the same precautions and kept the resident on contact isolation. Interview on [DATE] at 2:35 PM with the Administrator revealed when Resident #2 returned from the hospital, the resident said he wanted to warn her that the health department had been notified he had gotten an infection for eating eggs that had not been cooked all they way. The Administrator said at that time she spoke to the dietary staff and she was told all of their eggs were pasteurized and served fully cooked. She also said there were no other resident who were experiencing the same symptoms so there was no outbreak. The Administrator further stated she was not aware Resident #2 had been diagnosed with shigella and said they would not have done anything different because the resident had already been placed on isolation precautions when he returned. Interview on [DATE] at 2:53 PM with RN B revealed she had readmitted Resident #2 from hospital and she did not recall who told her the resident has been diagnosed with ESBL in his bowels; therefore, he was immediately put in isolation. RN B further stated she did not read the resident's admitting paperwork; therefore, she was not aware Resident #2 had been diagnosed with shigella. Interview on [DATE] at 2:53 PM with the County Epidemiologist revealed shigella was a disease that should be reported to the County Health Department by the nursing facilities because it was easily spread from person-to-person. The County Epidemiologist said an infected resident would require contract isolation precautions during the remainder of the antibiotic regimen. Review of the facility's policy titled Infection Prevention and Control Program revised [DATE] reflected the following: Purpose The ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease an infection in accordance with Federal and State requirements. Policy .1. Identifies, investigates, controls, and prevents infections in the Facility

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for one of three residents (Resident #1) reviewed for wound records. The facility failed to accurately document Residents #1's wound care. This failure could place residents at risk of missed wound care and infection. Findings included: Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident#1 was a [AGE] year-old male who was admitted to the facility on [DATE] and a re-admission on 10/17/23. Resident #1 had diagnoses which included paraplegia (paralysis of the legs and lower body). He had a BIMS score of 15, which indicated he was cognitively intact. In the section Skin Conditions reflected he was at risk of developing pressure ulcer injuries. Record review of Resident #1's, undated, care plan reflected multiple Non-Pressure and Pressure/ Injuries r/t Immobility, he is often not compliant with treatment. Does not want staff to provide treatment. Interventions: Administer Treatments as Ordered and Monitor for Effectiveness. Resident refuses treatment at times, doesn't like the ordered treatment -nurse will work with him to reach an acceptable treatment, she will educate him on the risks and hazards of non-compliance with treatment. Record review of Resident #1's physician orders reflected an order written on 06/11/24 for Cleansing Site with normal saline. Mix Nystatin Powder with zinc Oxide Ointment 2) apply to affected areas 2X's daily, as needed after each incontinent episode one time a day for (Promotion of Wound Healing) related to paraplegia. Record review of the Resident#1's June 2024 MAR reflected the nurses were documenting wound care was being provided. There were no days omitted. Observation of LVN A on 06/25/24 at 10:00 AM performing a skin assessment on Resident #1 revealed he had wounds on his right and left ischium. The wound was clean with no signs of infection noted. Interview on 06/25/24 at 11:00 AM, Resident #1 stated he was supposed to get wound care every day, but he did not. He stated he was aware the nurses were supposed to apply cream on his ischium, and they documented it was done when it was not. He stated he learned there was documentation in his record showing he had gotten wound care, and he knew there were days he would not get wound care. Interview on 06/25/24 at 1:42 PM with LVN B revealed she worked Monday through Friday morning shift. She said she had been providing wound care to Resident #1 but not every day. She stated some days the Wound Care Nurse would perform the resident's wound care, and she documented that the wound care was provided to Resident #1 even when she had not witnessed the wound care being done. She stated she would document that it was done even on the days she had not done the wound care, so her records would not show red reporting care was late or not done. LVN B stated she was aware she was not supposed to falsify records. She stated failure to follow the doctor's orders could lead to the resident developing an infection. She stated she had completed an in-service regarding documentation and wound care. Interview on 06/25/24 at 2:31 PM with RN C revealed she worked the Monday evening shift. She stated she knew Resident #1 had orders for wound care in the evening, but Resident #1 would not allow her to apply the cream when he got to bed. She stated she would assume the Wound Care Nurse performed wound care and instead of documenting the resident refused she was documenting that the wound care had been done. She stated she had no reason for doing that. She stated she knew she was supposed to notify management of his refusal, but she did not. She stated failure to follow physician orders could lead to wound infection and affect wound healing. RN C stated she was aware failure to administer, treat and document as administered was falsifying the records. She stated she had not done training on documentation. Interview on 06/25/24 at 3:24 PM with LVN A, who was the Wound Care Nurse, revealed she was responsible for all wounds in the facility. She stated she was in school now, so she went to the facility early to perform some wound care. She stated she would let the nurses know, which residents she had not provided wound care. She stated wound care for Resident #1 was on the nurses' MAR because of his timing. She stated Resident #1 sometimes refused care in the morning. She said she was not aware the nurses were documenting they provided care on the MAR when they had not. She revealed she was also not documenting on the nurses' MAR when she provided care. She revealed she did not have any reason why she was not documenting on the nurses' MAR or notifying them when she provided care. She stated failure to follow orders could lead to infection and affect wound healing. Interview on 06/25/24 at 5:05 PM with the DON revealed her expectation was for the nurse to document on the MAR only the care given. If Resident #1 refused care, they were supposed to document the refusal in the progress notes. The DON stated they care planned Resident #1's refusal of care and not being compliant with treatment. She stated she interviewed her nurses and LVN B told her she did not like seeing red on her computer that was why she signed off. The DON stated LVN C was written up due to not following the physician orders in another incident on 05/07/24. The DON stated the risk of documenting care as given when it was not could lead to infection and not following the physician orders the nurses were falsifying the administration records. Record review of the facility training records reflected they had done in-services on the documentation of medication administration on 05/09/24. Record review of the facility's current, undated Medication Administration policy reflected the following: .XVI. The Licensed Nurse will chart the drug; time administered and initial his/her name with each medication administration. Record review of the facility's Documentation - Nursing policy, revised June 2020, reflected the following: To provide documentation of resident status and care given by nursing staff. Nursing documentation will be concise, clear, pertinent, accurate and evidence based . Nursing staff will not falsify or improperly correct nursing documentation. .H. Medication administration records and treatment administration records are completed with each medication or treatment completed. J. Treatments completed and documented as per physician's order.

Based on interview, and record review, the facility failed to provide and document sufficient preparation to ensure safe and orderly discharge from the facility for one resident (Resident #1) of five residents reviewed for discharge. The facility failed to ensure Resident #1's home health and wound care services were confirmed and in place prior to discharge. These failures could place residents at risk of being discharged without preparation, causing a disruption in their care and place the residents at risk for their needs not being met. Findings included: Review of Resident #1's Face Sheet, dated 06/03/2024, revealed a [AGE] year-old male originally admitted on [DATE], readmitted on [DATE], and discharged on [DATE] with diagnoses that included: osteomyelitis of vertebra (the most common form of vertebral infection), sacral and sacrococcygeal region, Brown-Sequard syndrome (is a rare neurological condition characterized by a lesion in the spinal cord which results in weakness or paralysis on one side of the body and a loss of sensation on the opposite side), sepsis (a serious condition in which the body responds improperly to an infection), muscle weakness, lack of coordination, unsteadiness on feet, type two diabetes mellitus without complications, neuromuscular dysfunction of the bladder. Review of Resident #1's Care Plan, dated 05/31/2024, revealed Resident #1 has Sacral Stage 4 with slough and/or eschar present on admission, Resident #1 has a suprapubic catheter placed, Resident #1 has bowel incontinence immobility and paralysis Review of Resident #1's discharge MDS assessment, dated 05/30/2024, revealed resident #1's BIMS was noted as 15, which indicates the resident's cognition was intact. Resident #1 functional status documented on discharge MDS is not completed. During an interview on 06/02/2024 at 10:50 a.m. with SW revealed Resident #1's discharge was resident initiated and planned. Resident #1 was to the home on 05/30/2024 and would transfer from home to another rehabilitation facility on 06/01/2024. SW stated once residents decide to discharge will ask resident and/or family if they require home health services and what equipment is at home, if residents require additional items for home will place referral. In this case resident refused home health, so no order or referral was provided for Resident #1 due to family member refusal of home health services. Social worker could not provide documentation of refusal. During an interview on 06/02/2024 at 1:08 p.m. with Resident #1's family member revealed that Resident #1 was discharged home on 5/30/2024. Resident #1's family member expressed concern on providing care for resident due to not able to be present all day. Resident #1s family member stated that the facility did not provide proper education was not shown how to perform wound care. Additionally, resident's #1 family member stated the facility did not provide and instructions on wound care. She stated that the facility did provide wound care supplies. During an interview on 06/02/2024 at 1:37 p.m. with LVN B revealed that Resident #1 had a stage four pressure wound on sacrum and was incontinent of the bowels. This required Resident #1 to be changed prior to treating the wound to prevent infection. Due to incontinence issues Resident #1 required frequent wound care during each shift. LVN B felt it was not safe to transfer home without home health care as Resident #1 required constant care and assistance times two to transfer from bed to chair. Wound care training was provided once to family when they came to visit at that time resident had wound vac (an alternative method of wound management, which uses the negative pressure to prepare the wound for spontaneous healing or by lesser reconstructive options) on. No other training was provided to family of Resident #1. During an interview on 06/02/2024 at 1:57 p.m. with the Wound Physician via phone revealed that Resident #1 wanted to return home but told Resident #1 if he transferred home someone would need to be at home 24 hours to assist with his wound care dressing changes. The Wound Physician suggested to Resident #1 home health would be best option for Resident #1 to discharge home. During an interview on 06/02/2024 at 3:48 p.m. with ADON revealed Resident #1 was ready to go home, but needed more care so agreed to go to another rehabilitation facility . Resident #1 and family were encouraged to remain at the facility, but family refused to pay the private pay for days that would not be covered. Resident #1 was educated, instructions for care were provided and wound care supplies provided prior to discharge. Additionally, the facility provided the resident his remaining medications. ADON was unable to provide discharge instructions or medications resident was sent home with. During an interview on 06/03/2024 at 2:00 p.m. with LVN E revealed Resident #1 had a stage four wound, muscle weakness in legs and was unsteady so would need transfer assistance from bed to chair. LVN E stated she felt it would be safe for resident to transfer home if he had home health as resident was incontinent of the stools, so whoever was caring for his wound would need to first clean him prior to any dressing changes. LVN E said if this did not occur it could lead to infection. During an interview on 06/03/2024 at 3:00 p.m. with Regional Nurse revealed Resident #1 was alert and oriented to person, place, time and situations , he was a Medicare patient with days were running out and decided to discharge with family support. Family did not want to pay the private pay days. Resident #1's family member was trained by treatment nurse and given supplies to care for resident until his transfer to another rehabilitation facility.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for 5 of 15 residents (confidential residents) reviewed for safe, clean, comfortable, and homelike environment. The facility failed to maintain resident's wheelchairs in a sanitary and safe operating condition according to 5 residents who attended the confidential group interview. These failures could affect residents and place them at risk for not having a safe and sanitary homelike environment. Findings included: During the confidential resident group interview and observation, 5 of the 10 residents revealed their wheelchairs were not being cleaned. Seven residents were sitting in their wheelchairs. The wheelchairs had dust build-up on the wheel spokes, footrest, breaks, and frame. The residents stated they had not seen anyone clean the wheelchair. The residents stated they did not like the wheelchairs being dirty. Interview on 05/09/24 at 1:06 PM with LVN B revealed residents' wheelchairs were cleaned during the 10:00 PM-6:00 AM shift. She stated she had noticed residents' wheelchairs were dirty. She stated when she noticed a wheelchair dirty, she would clean it. She stated she had not cleaned any wheelchairs lately. She stated she was not sure what system was in place. However, the nurses should notify the 10:00 PM-6:00 AM shift regarding which wheelchairs needed to be cleaned. She stated the potential risk of wheelchair being dirty could lead to infections. Interview on 05/09/24 at 1:24 PM with CNA E revealed resident's wheelchairs were cleaned during the 10:00 PM-6:00 AM shift. She stated she had noticed residents' wheelchairs were dirty. She stated she would notify the nurses on the hall. She stated night shift were responsible for cleaning the wheelchairs, but they don't. She stated she had not had any residents complain about the wheelchairs, but she had noticed them being dirty. She stated the risk of not cleaning the wheelchairs could lead to infections. Interview on 05/09/24 at 3:17 PM with the ADON revealed night shift staff were responsible for cleaning the wheelchairs. She stated she and central supply staff were supposed to ensure wheelchairs were being cleaned. She stated she had noticed night shift staff had been lacking on cleaning wheelchairs. She stated she had noticed some wheelchairs being dirty. She stated the dirt on the wheelchairs posed an infection control and sanitation concern. Interview on 05/09/24 at 3:26 PM with the DON revealed wheelchairs were cleaned by the 10:00 PM-6:00 AM staff. She stated it was the responsibility of the ADON to ensure that wheelchairs were being cleaned. She stated on occasions she had noticed residents' wheelchairs were dirty, and she would ask her staff to cleaned them. She stated the potential risk would be dignity issues. Interview on 05/09/24 at 4:04 PM with the Administrator revealed the 10:00 PM-6:00 AM shift were responsible for cleaning residents' wheelchairs. She stated nursing management was responsible for ensuring wheelchairs were being cleaned. She stated her expectation was for residents' wheelchairs to be cleaned. She stated the potential risk of wheelchairs being dirty would be a dignity concern. Review of facility Resident Rights policy, revised dated August 2020, reflected the following: To promote and protect the rights of all residents at the Facility. All residents have 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. The Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on observation, interview, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 1 of 1 resident (Resident #31) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #31 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care. Findings included: Record review of Resident #31's face sheet dated 05/09/24 revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included end stage renal failure (when kidneys suddenly become unable to filter waste products from blood), chronic kidney disease (longstanding disease of the kidneys), Type 2 diabetes (increased blood sugar), and essential hypertension (increased blood pressure). Record review of Resident #31's quarterly MDS assessment dated [DATE], revealed Resident #31 had a BIMS score of 12, reflecting the resident's cognition was mildly impaired. The MDS section O, related to special treatments, procedures, and programs, reflected Resident #31 received dialysis. Record review of Resident #31's care plan, revised date 01/24/24, revealed Focus: Resident #31 has Stage 3 Renal Failure relating to Kidneys. Goals: will have no signs/symptoms of complications relating to fluid deficit through the review date. Interventions included assist resident with ADL'S and ambulation as needed. Fluids as ordered. Restrict or give as ordered. Give medications as ordered by physician. Record review of Resident 31's physician's order, dated 04/11/24, reflected Hemodialysis treatments to be performed via AV shunt, . as indicated on the following days of the week: T-TH-S. Record review of Resident #31's dialysis communication forms on facility's EHR from 04/11/24-05/09/24 reflected either no pre-dialysis weight or post dialysis weight. There were no dialysis communication forms with completed vitals, pre-dialysis weights, and post-dialysis weights for the time reviewed. Observation and interview on 05/09/24 at 10:12 AM revealed Resident #31 sitting in his wheelchair. Resident #31 stated he was doing well. Resident denied any pain. Resident #31 stated he was a dialysis patient, and his dialysis days were Tuesdays, Thursdays, and Saturdays. Interview on 05/09/24 at 10:31 AM with RN A revealed dialysis residents were supposed to obtain pre and post dialysis weights and vitals on the communication form when they arrive to the dialysis center and before they leave the dialysis center. RN A stated the importance of viewing pre and post dialysis weights was to ensure the dialysis was working. RN A revealed if the dialysis does not pull enough water off the resident, then edema and shortness of breath can occur along with pain and confusion. RN A stated the responsibility of ensuring that pre- and post-dialysis weights were completed on the communication form and returned with the resident along with pre and post dialysis vitals is the receiving nurse. Interview on 05/09/24 at 10:50 AM with the ADON revealed the dialysis center was supposed to send back the completed pre and post dialysis weights and vitals on the communication form. The ADON also stated it was the responsibility of the charge nurse to receive the before and after weights of dialysis and vitals from the dialysis center. The ADON revealed that she recently in-serviced the nursing staff on 04/02/24 because her nursing staff were not obtaining pre and post vitals and weights from the dialysis center when residents returned. The ADON stated that pre and post dialysis weights were important because weight change can signal a change in condition. For example, large water retention can signal a decline in health and the resident would need to be seen by the doctor or be sent out to the emergency room . Interview on 05/09/24 at 4:03 PM with the DON about the missing information on the dialysis communication forms revealed that the protocol for dialysis patients was that the dialysis center was supposed to weigh the resident before and after dialysis to prevent using two different scales and therefore being a variance in weights. The DON was not aware of the missing information. The DON also stated that the receiving nurse should check to make sure that weights were completed on the communication sheet and returned with the resident upon return from dialysis. She also revealed the ADON audits charts and calls dialysis centers to follow up and obtain weights as needed. The DON revealed that the risk of not obtaining pre and post dialysis weights was that the facility does not know the amount of water pulled from the resident during dialysis. This can lead the resident to weakness, syncope, and other health condition without the facility having accurate information. Record Review of the facility's current Dialysis Care policy, dated June 2020, reflected the following: .The dialysis provider will communicate in writing to the facility: a. The resident's current vital signs. b. Pre and post dialysis weight. c. Any problems encountered while the resident was at the dialysis provider. iii. Nursing Staff will keep the Attending Physician, the resident and the resident's family informed of any change in .

Based on observation, interview and record review, the facility failed to ensure each resident had the right to be free from neglect for one (Resident #2) of five residents reviewed for neglect. The facility failed to consistently monitor Resident #2's bowel function in February 2017. The resident was transferred to the hospital on [DATE] and passed away on 03/06/17 as a result [MEDICAL CONDITION] due to large bowel instruction. The resident had a history of [REDACTED]. An Immediate Jeopardy (IJ) was identified on 04/25/17. While the IJ was removed on 04/26/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. This failure could affect the facility's 32 residents who were incontinent of bowel and placed them at risk for not being assessed properly which could lead to a decline in their health status, the need for hospitalization , and/or death. Findings included: Review of Resident #2's Minimum Data Set assessment, dated 12/02/16, revealed he was [AGE] years old and was admitted to the facility on [DATE]. The resident was cognitively intact and his [DIAGNOSES REDACTED]. Review of Resident #2's comprehensive plan of care, dated 12/15/16, revealed . Resident has a History of Constipation and is at Risk for Impactions and Bowel Obstructions . Will have a B.M. (bowel movement) at least every three days and will have no s/s (signs or symptoms) of impaction or bowel instruction over next 90 days . Monitor B.M.s for amount and consistency . If no B.M. after three days - perform a bowel assessment, report abnormal findings to M.D. (medical doctor) . Review of Resident #2's ADL Flow Record, dated February 2017, revealed bowel functions were to be documented during the night, day and evening shifts. Only 34 of 69 shifts documented the resident's bowel function. There was no documentation for the remaining shifts. Nine shifts were documented from 02/16/17 to 02/23/17 and all documented shifts had zero episodes of bowel function. Review of Resident #2's undated Weight Flow Sheet revealed the following weights: 163 pounds on 01/04/17; 160 pounds on 01/11/17; 152 pounds on 01/25/17; 148 pounds on 02/01/17; 147 pounds on 02/08/17; 147 pounds on 02/15/17; and 140 pounds on 02/22/17. Review of Resident #2's Resident Transfer Form, dated 02/24/17 and completed by LVN O, revealed . Blood noted in cath (catheter) U/A (urinalysis) specimen - poor intake PO (by mouth) - 19 lb (pound) wt (weight) loss (times one) month . Review of Resident #2's physician telephone orders revealed there was an order to send the resident to the hospital for evaluation on 02/24/17. Review of Resident #2's nurse's notes, dated 02/24/17 (note: no time listed) and authored by LVN O, revealed . Con't (Continue) to have poor to 0 P.O (by mouth) intake (sic) Only drinks sodas (and) eats candy - U/A (urinalysis) collected (with) blood noted in specimen (sic) Resident noted to be thin (and) frail, has had 19 lb (pound) wt. (weight) loss in (one) month. Order recd (received) to send to ER (emergency room ) for eval (evaluation) Review of Resident #2's hospital CAT (computerized axial tomography) scan, dated 02/24/17, revealed, . Impression: A severe amount of stool is present within the rectum, right colon, and [MEDICATION NAME] colon. The stool within the rectum is concerning for fecal impaction. There is associated mild small bowel dilation with air, which could be related to ileus (inability of the intestine (bowel) to contract normally and move waste out of the body) Review of Resident #2's hospital record, dated 02/25/17, revealed . Patient seen and examined. Per RN (Registered Nurse), despite exhaustive efforts at free water enema and fecal disimpaction, minimal stool expelled. RN . was unable to feel bowel contractions during impaction Concern that patient is too malnourished and frail for more invasive procedures for fecal disimpaction was addressed with family who agreed. Family understands that patient may develope (sic) further complications such as toxic megacolon and or (sic) bowel perforation. Family has requested a representative from palliative care/hospice come evaluate patient and answer questions Abdomen: distended, minimal bowel sounds, tender to palpation . Review of Resident #2's Medical Abstract of Death Certificate, dated 03/09/17, revealed .date of death . March 6, 2017 . immediate cause (final disease or condition resulting in death) .[MEDICAL CONDITION] due to large bowel obstruction . Approximate interval onset to death . weeks . Interview on 04/25/17 at 11:21 AM with LVN O revealed she never knew Resident #2 had problems with his bowel function. She stated the CNAs informed her that the resident was having bowel movements. She stated the resident would fight (hit, kick, or spit) if he did not want care provided, which was 90 percent of the time. She stated the CNAs were supposed to notify the nurse if a resident did not have a bowel movement after two to three days. She stated there were no complaints of pain or stomach discomfort from the resident. She stated the resident regularly ate candy bars and soda. She stated the resident refused nutritional supplements. She stated the previous DON notified her that the resident had lost 19 pounds in one month. She stated she was unable to tell the resident had lost weight when she would see him lying in bed. She stated she noticed the resident's weight loss the day before he went to the hospital when she saw him up in a wheelchair. She stated she contacted the resident's family regarding his weight loss and candy/soda consumption. She stated the resident's skin checks were done on the 2:00 PM to 10:00 PM shift once a week and she did not recall a need to check the resident's skin on her shift from 02/20/17 to 02/24/17. She stated she had not been notified by the CNAs that the resident had any weight loss. She stated she was not monitoring the CNAs' ADL book and stated that she should have been. She stated the CNAs mentioned that the resident's bedding was soiled with stool the day he was sent out to the hospital. She stated there were no complaints from the resident or his family regarding not being able to have a bowel movement or weight loss. She stated there had been no foul odors from the resident. She stated she had not checked the resident's bowel sounds from 02/20/17 to 02/24/17. She stated she sent the resident to the hospital due to his sickly appearance and the recent notification of 19 pounds weight loss in one month. Interview on 04/25/17 at 11:48 AM with CNA P revealed she was assigned to Resident #2 on 02/24/17. She stated she notified LVN O that the resident had liquid stool in his brief. She stated the resident mentioned that he did not feel good, but was not more specific than that. She stated she did not recall complaints from the resident from 02/18/17 to 02/23/17. She stated she would go to the resident's room to assist the other CNAs assigned to him. She stated the resident was a two-person assist with care. She stated she believed the resident had one small ball of stool the same day he was sent to the hospital, which she notified LVN O of. She stated the resident's nurse was notified between 02/18/17 to 02/23/17 when stool would be on the wipe during incontinence care, but not in the resident's brief. She stated she did not recall the resident having a regular bowel movement from 02/18/17 to 02/24/17. She stated the nurse would check on the resident after a concern was brought to his/her attention. She stated she noticed the resident had lost weight and spoke with LVN O. Interview on 04/25/17 at 12:23 PM with CNA Q revealed she was assigned to Resident #2 off and on from 02/18/17 to 02/24/17. She stated she did not recall anything out of the ordinary regarding the resident's bowel function. She stated the resident had small (regular consistency) bowel movements the last few days of his stay at the facility on her shift off and on. She stated the resident would say that he was not feeling good. She stated she and CNA R reported to the nurse that the resident had soiled bedding. She stated she could not recall which nurse she reported the resident's bedding to, and was unsure if the bedding was soiled with urine or stool. She stated the resident was not his everyday self and she reported it to the nurse on duty. She stated the resident was not feeling well but there was nothing more specific. She stated the resident would eat meals, kept snacks, and his family brought meals for him as well. She stated one intervention such as taking the resident to the dining room for meals was in place in response to his weight loss. She stated the resident ate approximately 30 to 50 percent of his food. She stated the CNAs were documenting the residents' bowel movements in the ADL book during February 2017 and it was expected that the nurses reviewed the documentation. Interview on 04/25/17 at 12:42 PM with CNA R revealed she would see large blood stains every other week on Resident #2's bed approximately one month prior to his hospitalization . She stated the charge nurse and previous DON were notified of the blood stains and they both stated they would take care of it. CNA R stated there was an odor of urine/mildew/musk in the resident's room. She stated the stains on the resident's bed would still be wet and were coffee ground colored. She stated she recalled the resident had one small, black ball of stool, which she informed the nurse of, the last month of his stay at the facility. She stated she would place the resident on the toilet but he was unable to have a bowel movement. She stated the resident urinated regularly. She stated the resident was pleasant and did not complain about much. She stated there were no complaints from the resident regarding not being able to go to have a bowel movement. She stated there were no complaints of stomach pain or discomfort from the resident. She stated she noticed the resident stopped eating about two weeks prior to him going to the hospital. She stated she would take the resident to the dining room for meals but he would only eat about 25 percent of his food. She stated the CNAs were in charge of documenting bowel movements in the ADL book during February 2017. Interview on 04/25/17 at 10:03 AM with the current DON revealed the nurses began documenting the residents' bowel movements on 04/07/17 in the TAR. She stated the CNAs had previously documented the residents' bowel movements in the ADL book. Interview on 04/25/17 at 2:10 PM with the previous DON revealed Resident #2 was care planned and observed regarding his weight loss. She stated the resident ate junk food and picked at his meals. She stated the resident never wanted to get out of bed and ate candy often. She stated the resident was on her radar due to his appetite decline during the last three to four months of his day at the facility. She stated the resident's doctor was contacted regarding his weight loss. She stated the resident was encouraged to get up for meals but he refused. She stated the staff encouraged the resident to eat meals and believed he was also on a nutritional supplement. She stated she checked up on the resident after he was sent to the hospital on [DATE]. She stated the hospital mentioned that there was a possible blockage with the resident. She stated she then checked the ADL books and discovered the documentation was horrible. She stated she asked CNA Q who said the resident had two good bowel movements the last week of his stay at the facility. She stated she believed another CNA, whose name she could not recall, on the 2:00 PM to 10:00 PM shift also stated the resident had one good bowel movement on their shift the last week of his stay. The previous DON stated the nurses were expected to monitor the ADL book and the CNAs should have reported to the nurse when there was no bowel movement with a resident. She stated she in-serviced the staff (CNAs and nurses) which was ongoing regarding the ADL book documentation. She stated she concentrated on the 2:00 PM to 10:00 PM shift because that was where the documentation lacked the most. She stated she discussed with the staff the importance of documenting a resident's ADLs. She stated it was the nurses' duty to check the ADL book at the end of their shifts. Interview on 04/25/17 at 11:00 AM with LVN/ADON B (note: LVN/ADON B was an ADON on 04/25/17) revealed she was a charge nurse for Resident #2 during February 2017. She stated the resident would usually eat at dinner, but not very much at breakfast or lunch. She stated she was in communication with NP N regarding the resident who refused to get out of bed or take showers. She stated the staff would give the resident bed baths. She stated the resident regularly ate chocolate and drank sodas. She stated she tried to provide nutritional supplements to the resident but he refused. She stated she was unaware of any problems with the resident regarding constipation. She stated the CNAs were supposed to notify the nurse if a resident did not have a bowel movement after three days. She stated there was a gradual decline with the resident. She stated there had been no problems with the resident's vital signs. She stated there were no complaints from the resident regarding stomach pain or other stomach concerns. She stated no concerns had been brought to her attention regarding the resident not being able to have a bowel movement or not having one. She stated the resident was able to answer questions, but his voice was raspy and he denied having a sore throat. Interview on 04/25/17 at 1:30 PM with CNA C revealed she worked with Resident #2 off and on. She stated the resident requested snacks such as soda and chips frequently. She stated the resident did not eat a lot of the meals served. She stated the resident's appetite had slowed. She stated the resident would say that he had a bowel movement, but when checked he was clean. She stated the resident was alert and oriented but his speech became very soft and she was hardly able to hear him. She stated she would let the resident know that he had not had a bowel movement and the resident would be surprised. She stated the resident had a little ball of stool a couple of times during a two week span. She stated she did not recall the resident having regular bowel movements the last two weeks of his stay at the facility. She stated the resident occasionally asked for milk of magnesia (a couple of times a month during her shift). She stated she notified the medication aide of the resident's request, but she did not follow-up with the medication aide. She stated she did not notify the nurse of the resident's request for milk of magnesia. She stated she would have documented that the resident had small balls of stool and would only notify the nurse if the resident did not have any bowel movements in two days. Interview on 04/25/17 at 4:28 PM with CNA S revealed she worked with Resident #2 during the last week of his stay at the facility. She stated the nurses asked her to notify them if the resident urinated because he had not been urinating. She stated the resident was not speaking that much during that time (low voice volume). She stated she could not remember if the resident had a bowel movement during her shifts. She stated she did not recall complaints of stomach pain or discomfort by the resident. She stated the resident would ask staff to get sodas for him. She stated the resident was acting normal days before he went to the hospital. She stated the resident was eating food but could not recall the percentage and ate snacks. She stated she was unaware the resident had any weight loss. Interview on 04/26/17 at 1:07 PM with CNA T revealed she observed what appeared to be dried stool on Resident #2's bed approximately one to two days before he was sent to the hospital. She stated she heard later on that it may have been blood that was on the resident's bed. She stated the resident regularly asked to go to the bathroom. She stated she was not assigned to the resident but would assist with his care. She stated the resident made no complaints to her regarding not being able to have a bowel movement. She stated the resident's appetite declined over several weeks. Interview on 04/26/17 at 3:56 PM with LVN Y revealed she worked with Resident #2 during the overnight shift and there were no complaints of abdominal pain or discomfort from January 2017 to February 2017. On 04/25/17 at 1:59 PM the current DON was asked when resident bowel sounds would be documented and/or abdominal assessments performed. The current DON stated resident vital signs were taken as needed and when incidents such as falls, order changes, and changes in condition occurred. The current DON stated she contacted the facility's lab and there was no KUB (Kidney, Ureter, Bladder) ordered for Resident #2 from December 2016 to February 2017. Interview on 04/25/17 at 10:23 AM with the current DON revealed she discovered the ADL book was not being filled out consistently by the CNAs, which prompted a change where the nurses were now documenting the residents' bowel movements. Interview on 04/25/17 at 3:43 PM with ADON J revealed she had not been assigned to Resident #2. She stated she was not sure where the in-service related to the ADL book documentation was and would contact the previous DON to see where she had placed it. Interview on 04/25/17 at 4:10 PM with the ADM revealed she called the previous DON who said an in-service on ADL book documentation was done in either late February 2017 or early March 2017. The ADM stated she looked through the in-service book and could not find anything related to the ADL book documentation. Interview on 04/25/17 at 4:47 PM with LVN/ADON I (note: LVN/ADON I was a charge nurse on 04/25/17) revealed he was aware of Resident #2's weight loss. He stated he was not aware of any problem regarding the resident's bowel function and stated he should have known because it was his job to know. He stated as an ADON, he should have monitored the resident's documentation. He stated the charge nurses were supposed to monitor the residents' documentation in the ADL flow record and then report concerns to him. He stated he would have intervened immediately (KUB, laxatives, et cetera) if he had known of the concern. He stated the concern should have been caught and hated that it was missed. He stated he did not recall any specific in-service related to Resident #2. He stated a number of in-services were done regularly. He stated he did not know about the concern related to possible blockage/impaction with the resident until 04/06/17 after an investigation was started. He stated he looked over the resident's ADL flow record and noticed it was not documented consistently. He stated he had already decided to change his work schedule prior to the concern with Resident #2 and now worked on the weekends and during the week as needed as a charge nurse. Interview on 04/26/17 at 11:34 AM with LVN O revealed she did not recall any previous incidents regarding impaction for Resident #2. Interview on 04/26/17 at 11:40 AM with LVN/ADON B revealed she did not recall any previous incidents regarding impaction for Resident #2. A joint interview was conducted on 04/26/17 at 11:53 AM with the ADM, DON, and Director of Operations. The DON and ADM stated they felt the CNAs failed to alert the charge nurses that Resident #2 was not having any bowel movements and the nurses failed to monitor the ADL book documentation. Interview on 04/26/17 at 12:30 PM with LVN/ADON I revealed he was not aware of any other incidents regarding impaction with Resident #2. He stated he was an ADON at the facility from June 2016 to April 2017. Interview on 04/26/17 at 5:49 PM with the previous DON revealed Resident #2's reported obstruction was not verified. She stated she conducted an in-service regarding the ADL book documentation and checked the ADL book documentation for all of the residents. She stated no assessments were done on any of the residents related to possible problems with bowel function at that time. Interview on 04/26/17 at 6:12 PM with Physician U revealed he did not recall any staff informing him of any concerns related to Resident #2's bowel function. He stated the facility had to be more diligent regarding the residents' toileting. On 04/25/17 at 4:15 PM, the ADM and DON were informed an IJ had been identified. At that time, the facility was requested to provide a plan of removal. The facility's Plan of Removal, dated 04/26/17, was accepted on 04/26/17 at 3:23 PM and reflected the following: . Responsibility for documentation of Bowel Movements has been transferred from the nurse aides to the licensed nurses as of 4/26/17 starting at 6:00am (sic) All Nurses will be in-serviced by (DON)/Designee on the following: Bowel Management Program (See attached) and will be required to show competence by successfully passing a post-test (sic) Performing a head-to-toe assessments on residents with significant change in conditions (sic) Relaying information to oncoming shift regarding significant change in condition (including bowel movements) of all residents (sic) Facility abuse and neglect policies with a special emphasis on neglect (start 4/26/17 at 2:00pm and end at 6:00pm for all current staff with the remainder being in-serviced prior to accepting a floor assignment as monitored by (DON)) (sic) In-services began at 6:00pm for all nurses currently working (sic) 75% of all nurses completed in-servicing by 10:00am on Wednesday April 26th, 2017. All remaining off-duty nurses will be in-serviced by 5:00pm on 4/26/17 or prior to accepting an assignment on their next scheduled day. (DON) will monitor that no nurse accepts a floor assignment prior to receiving the required in-servicing (sic) All newly hired nurses will receive the above education upon hire and be required to show competence where a post-test is administered related to the facility Bowel Management Program (sic) All Certified Nurses Assistants and Certified Medication Aides will be in-serviced by (DON)/Designee on the following (sic) Bowel Management Program (See attached) (sic) Be retrained in properly documenting a bowel movement (sic) Appropriately communicating significant changes (including bowel movements) to the charge nurse (sic) In-services began at 6:00pm for all nurses currently working (sic) 75% of all CNAs and (Medication Aides) completed in-servicing by 10:00am on Wednesday April 26th, 2017 (sic) Facility abuse and neglect policies with a special emphasis on neglect (start 4/26/17 at 2:00pm and end at 6:00pm for all current staff with the remainder being in-serviced prior to accepting a floor assignment as monitored by (DON)) (sic) All remaining off-duty CNAs and (Medication Aides) will be in-serviced by 5:00pm on 4/26/17 or prior to accepting an assignment on their next scheduled day. (DON) will monitor that no nurse accepts a floor assignment prior to receiving the required in-servicing (sic) All newly hired Certified Nurses Aides and (Medication Aides) will receive the above education upon hire (sic) The facility Medical Director (Physician U) was notified of the IJ on 4/25/17 around 5:00pm. The Medical Director will receive monitoring results at the facility QAPI (Quality Assurance Performance Improvement) meetings and any recommendations will be implemented where appropriate and relevant (sic) The facility is having a QAPI meeting on 4/26/17 at 12:00pm to discuss the IJ and corresponding Plan of Removal (sic) To prevent reoccurrence (DON), (ADM), (ADON J) and (LVN/ADON B) will monitor for effectiveness of this Plan of Removal on the Monitoring Sheet. Frequency of monitoring will be: 1x/day for 30 Days; then 3x/week for the 30 days; and 1x/week thereafter. To verify the facility implemented their Plan of Removal the following interviews were obtained and the following records were reviewed. Review of the bowel assessment records completed on 04/26/17 for all 81 current residents at the facility did not reveal concerns. Interviews conducted on 04/26/17 from 12:30 PM to 5:28 PM with LVN/ADON I, CNA T, CNA V, CNA Q, LVN O, LVN W, RN G, CNA X, LVN Y, LVN Z, LVN D, CNA M, and LVN BB (who represented all shifts at the facility) regarding monitoring bowel function, identifying bowel obstructions, and assessing resident abdominal concerns revealed no concerns. Review of the facility's training records, dated 04/25/16 and 04/26/16, revealed CNAs and Medication Aides were in-serviced on monitoring and reporting bowel function and changes in resident condition. The LVNs and RNs were in-serviced on monitoring and documenting bowel function, when to conduct an assessment, physician notification, the protocol for significant changes in resident condition, and signs and symptoms of bowel obstruction. On 04/26/17 at 6:45 PM, the Administrator and DON were informed the IJ was removed. While the IJ was removed on 04/26/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. Review of the facility's undated Reportable and Non-Reportable Events Manual revealed . The residents of this facility have the right to be free from abuse, neglect and exploitation Neglect . The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness Review of a list provided by the facility, dated 05/08/17, revealed 32 residents were incontinent of bowel on 04/05/17.

Based on observation, interview and record review, the facility failed to implement written policies and procedures, which prohibit neglect for one (Resident #2) of five residents reviewed for neglect. The facility failed to consistently monitor Resident #2's bowel function in February 2017. The resident was transferred to the hospital on [DATE] and passed away on 03/06/17 as a result [MEDICAL CONDITION] due to large bowel instruction. The resident had a history of [REDACTED]. An Immediate Jeopardy (IJ) was identified on 04/25/17. While the IJ was removed on 04/26/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. This failure could affect the facility's 32 residents who were incontinent of bowel and placed them at risk for not being assessed properly which could lead to a decline in their health status, the need for hospitalization , and/or death. Findings included: Review of the facility's undated Reportable and Non-Reportable Events Manual revealed . The residents of this facility have the right to be free from abuse, neglect and exploitation Neglect . The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness Review of Resident #2's Minimum Data Set assessment, dated 12/02/16, revealed he was [AGE] years old and was admitted to the facility on [DATE]. The resident was cognitively intact and his [DIAGNOSES REDACTED]. Review of Resident #2's comprehensive plan of care, dated 12/15/16, revealed . Resident has a History of Constipation and is at Risk for Impactions and Bowel Obstructions . Will have a B.M. (bowel movement) at least every three days and will have no s/s (signs or symptoms) of impaction or bowel instruction over next 90 days . Monitor B.M.s for amount and consistency . If no B.M. after three days - perform a bowel assessment, report abnormal findings to M.D. (medical doctor) . Review of Resident #2's ADL Flow Record, dated February 2017, revealed bowel functions were to be documented during the night, day and evening shifts. Only 34 of 69 shifts documented the resident's bowel function. There was no documentation for the remaining shifts. Nine shifts were documented from 02/16/17 to 02/23/17 and all documented shifts had zero episodes of bowel function. Review of Resident #2's undated Weight Flow Sheet revealed the following weights: 163 pounds on 01/04/17; 160 pounds on 01/11/17; 152 pounds on 01/25/17; 148 pounds on 02/01/17; 147 pounds on 02/08/17; 147 pounds on 02/15/17; and 140 pounds on 02/22/17. Review of Resident #2's Resident Transfer Form, dated 02/24/17 and completed by LVN O, revealed . Blood noted in cath (catheter) U/A (urinalysis) specimen - poor intake PO (by mouth) - 19 lb (pound) wt (weight) loss (times one) month . Review of Resident #2's physician telephone orders revealed there was an order to send the resident to the hospital for evaluation on 02/24/17. Review of Resident #2's nurse's notes, dated 02/24/17 (note: no time listed) and authored by LVN O, revealed . Con't (Continue) to have poor to 0 P.O (by mouth) intake (sic) Only drinks sodas (and) eats candy - U/A (urinalysis) collected (with) blood noted in specimen (sic) Resident noted to be thin (and) frail, has had 19 lb (pound) wt. (weight) loss in (one) month. Order recd (received) to send to ER (emergency room ) for eval (evaluation) Review of Resident #2's hospital CAT (computerized axial tomography) scan, dated 02/24/17, revealed, . Impression: A severe amount of stool is present within the rectum, right colon, and [MEDICATION NAME] colon. The stool within the rectum is concerning for fecal impaction. There is associated mild small bowel dilation with air, which could be related to ileus (inability of the intestine (bowel) to contract normally and move waste out of the body) Review of Resident #2's hospital record, dated 02/25/17, revealed . Patient seen and examined. Per RN (Registered Nurse), despite exhaustive efforts at free water enema and fecal disimpaction, minimal stool expelled. RN . was unable to feel bowel contractions during impaction Concern that patient is too malnourished and frail for more invasive procedures for fecal disimpaction was addressed with family who agreed. Family understands that patient may develope (sic) further complications such as toxic megacolon and or (sic) bowel perforation. Family has requested a representative from palliative care/hospice come evaluate patient and answer questions Abdomen: distended, minimal bowel sounds, tender to palpation . Review of Resident #2's Medical Abstract of Death Certificate, dated 03/09/17, revealed .date of death . March 6, 2017 . immediate cause (final disease or condition resulting in death) .[MEDICAL CONDITION] due to large bowel obstruction . Approximate interval onset to death . weeks . Interview on 04/25/17 at 11:21 AM with LVN O revealed she never knew Resident #2 had problems with his bowel function. She stated the CNAs informed her that the resident was having bowel movements. She stated the resident would fight (hit, kick, or spit) if he did not want care provided, which was 90 percent of the time. She stated the CNAs were supposed to notify the nurse if a resident did not have a bowel movement after two to three days. She stated there were no complaints of pain or stomach discomfort from the resident. She stated the resident regularly ate candy bars and soda. She stated the resident refused nutritional supplements. She stated the previous DON notified her that the resident had lost 19 pounds in one month. She stated she was unable to tell the resident had lost weight when she would see him lying in bed. She stated she noticed the resident's weight loss the day before he went to the hospital when she saw him up in a wheelchair. She stated she contacted the resident's family regarding his weight loss and candy/soda consumption. She stated the resident's skin checks were done on the 2:00 PM to 10:00 PM shift once a week and she did not recall a need to check the resident's skin on her shift from 02/20/17 to 02/24/17. She stated she had not been notified by the CNAs that the resident had any weight loss. She stated she was not monitoring the CNAs' ADL book and stated that she should have been. She stated the CNAs mentioned that the resident's bedding was soiled with stool the day he was sent out to the hospital. She stated there were no complaints from the resident or his family regarding not being able to have a bowel movement or weight loss. She stated there had been no foul odors from the resident. She stated she had not checked the resident's bowel sounds from 02/20/17 to 02/24/17. She stated she sent the resident to the hospital due to his sickly appearance and the recent notification of 19 pounds weight loss in one month. Interview on 04/25/17 at 11:48 AM with CNA P revealed she was assigned to Resident #2 on 02/24/17. She stated she notified LVN O that the resident had liquid stool in his brief. She stated the resident mentioned that he did not feel good, but was not more specific than that. She stated she did not recall complaints from the resident from 02/18/17 to 02/23/17. She stated she would go to the resident's room to assist the other CNAs assigned to him. She stated the resident was a two-person assist with care. She stated she believed the resident had one small ball of stool the same day he was sent to the hospital, which she notified LVN O of. She stated the resident's nurse was notified between 02/18/17 to 02/23/17 when stool would be on the wipe during incontinence care, but not in the resident's brief. She stated she did not recall the resident having a regular bowel movement from 02/18/17 to 02/24/17. She stated the nurse would check on the resident after a concern was brought to his/her attention. She stated she noticed the resident had lost weight and spoke with LVN O. Interview on 04/25/17 at 12:23 PM with CNA Q revealed she was assigned to Resident #2 off and on from 02/18/17 to 02/24/17. She stated she did not recall anything out of the ordinary regarding the resident's bowel function. She stated the resident had small (regular consistency) bowel movements the last few days of his stay at the facility on her shift off and on. She stated the resident would say that he was not feeling good. She stated she and CNA R reported to the nurse that the resident had soiled bedding. She stated she could not recall which nurse she reported the resident's bedding to, and was unsure if the bedding was soiled with urine or stool. She stated the resident was not his everyday self and she reported it to the nurse on duty. She stated the resident was not feeling well but there was nothing more specific. She stated the resident would eat meals, kept snacks, and his family brought meals for him as well. She stated one intervention such as taking the resident to the dining room for meals was in place in response to his weight loss. She stated the resident ate approximately 30 to 50 percent of his food. She stated the CNAs were documenting the residents' bowel movements in the ADL book during February 2017 and it was expected that the nurses reviewed the documentation. Interview on 04/25/17 at 12:42 PM with CNA R revealed she would see large blood stains every other week on Resident #2's bed approximately one month prior to his hospitalization . She stated the charge nurse and previous DON were notified of the blood stains and they both stated they would take care of it. CNA R stated there was an odor of urine/mildew/musk in the resident's room. She stated the stains on the resident's bed would still be wet and were coffee ground colored. She stated she recalled the resident had one small, black ball of stool, which she informed the nurse of, the last month of his stay at the facility. She stated she would place the resident on the toilet but he was unable to have a bowel movement. She stated the resident urinated regularly. She stated the resident was pleasant and did not complain about much. She stated there were no complaints from the resident regarding not being able to go to have a bowel movement. She stated there were no complaints of stomach pain or discomfort from the resident. She stated she noticed the resident stopped eating about two weeks prior to him going to the hospital. She stated she would take the resident to the dining room for meals but he would only eat about 25 percent of his food. She stated the CNAs were in charge of documenting bowel movements in the ADL book during February 2017. Interview on 04/25/17 at 10:03 AM with the current DON revealed the nurses began documenting the residents' bowel movements on 04/07/17 in the TAR. She stated the CNAs had previously documented the residents' bowel movements in the ADL book. Interview on 04/25/17 at 2:10 PM with the previous DON revealed Resident #2 was care planned and observed regarding his weight loss. She stated the resident ate junk food and picked at his meals. She stated the resident never wanted to get out of bed and ate candy often. She stated the resident was on her radar due to his appetite decline during the last three to four months of his day at the facility. She stated the resident's doctor was contacted regarding his weight loss. She stated the resident was encouraged to get up for meals but he refused. She stated the staff encouraged the resident to eat meals and believed he was also on a nutritional supplement. She stated she checked up on the resident after he was sent to the hospital on [DATE]. She stated the hospital mentioned that there was a possible blockage with the resident. She stated she then checked the ADL books and discovered the documentation was horrible. She stated she asked CNA Q who said the resident had two good bowel movements the last week of his stay at the facility. She stated she believed another CNA, whose name she could not recall, on the 2:00 PM to 10:00 PM shift also stated the resident had one good bowel movement on their shift the last week of his stay. The previous DON stated the nurses were expected to monitor the ADL book and the CNAs should have reported to the nurse when there was no bowel movement with a resident. She stated she in-serviced the staff (CNAs and nurses) which was ongoing regarding the ADL book documentation. She stated she concentrated on the 2:00 PM to 10:00 PM shift because that was where the documentation lacked the most. She stated she discussed with the staff the importance of documenting a resident's ADLs. She stated it was the nurses' duty to check the ADL book at the end of their shifts. Interview on 04/25/17 at 11:00 AM with LVN/ADON B (note: LVN/ADON B was an ADON on 04/25/17) revealed she was a charge nurse for Resident #2 during February 2017. She stated the resident would usually eat at dinner, but not very much at breakfast or lunch. She stated she was in communication with NP N regarding the resident who refused to get out of bed or take showers. She stated the staff would give the resident bed baths. She stated the resident regularly ate chocolate and drank sodas. She stated she tried to provide nutritional supplements to the resident but he refused. She stated she was unaware of any problems with the resident regarding constipation. She stated the CNAs were supposed to notify the nurse if a resident did not have a bowel movement after three days. She stated there was a gradual decline with the resident. She stated there had been no problems with the resident's vital signs. She stated there were no complaints from the resident regarding stomach pain or other stomach concerns. She stated no concerns had been brought to her attention regarding the resident not being able to have a bowel movement or not having one. She stated the resident was able to answer questions, but his voice was raspy and he denied having a sore throat. Interview on 04/25/17 at 1:30 PM with CNA C revealed she worked with Resident #2 off and on. She stated the resident requested snacks such as soda and chips frequently. She stated the resident did not eat a lot of the meals served. She stated the resident's appetite had slowed. She stated the resident would say that he had a bowel movement, but when checked he was clean. She stated the resident was alert and oriented but his speech became very soft and she was hardly able to hear him. She stated she would let the resident know that he had not had a bowel movement and the resident would be surprised. She stated the resident had a little ball of stool a couple of times during a two week span. She stated she did not recall the resident having regular bowel movements the last two weeks of his stay at the facility. She stated the resident occasionally asked for milk of magnesia (a couple of times a month during her shift). She stated she notified the medication aide of the resident's request, but she did not follow-up with the medication aide. She stated she did not notify the nurse of the resident's request for milk of magnesia. She stated she would have documented that the resident had small balls of stool and would only notify the nurse if the resident did not have any bowel movements in two days. Interview on 04/25/17 at 4:28 PM with CNA S revealed she worked with Resident #2 during the last week of his stay at the facility. She stated the nurses asked her to notify them if the resident urinated because he had not been urinating. She stated the resident was not speaking that much during that time (low voice volume). She stated she could not remember if the resident had a bowel movement during her shifts. She stated she did not recall complaints of stomach pain or discomfort by the resident. She stated the resident would ask staff to get sodas for him. She stated the resident was acting normal days before he went to the hospital. She stated the resident was eating food but could not recall the percentage and ate snacks. She stated she was unaware the resident had any weight loss. Interview on 04/26/17 at 1:07 PM with CNA T revealed she observed what appeared to be dried stool on Resident #2's bed approximately one to two days before he was sent to the hospital. She stated she heard later on that it may have been blood that was on the resident's bed. She stated the resident regularly asked to go to the bathroom. She stated she was not assigned to the resident but would assist with his care. She stated the resident made no complaints to her regarding not being able to have a bowel movement. She stated the resident's appetite declined over several weeks. Interview on 04/26/17 at 3:56 PM with LVN Y revealed she worked with Resident #2 during the overnight shift and there were no complaints of abdominal pain or discomfort from January 2017 to February 2017. On 04/25/17 at 1:59 PM the current DON was asked when resident bowel sounds would be documented and/or abdominal assessments performed. The current DON stated resident vital signs were taken as needed and when incidents such as falls, order changes, and changes in condition occurred. The current DON stated she contacted the facility's lab and there was no KUB (Kidney, Ureter, Bladder) ordered for Resident #2 from December 2016 to February 2017. Interview on 04/25/17 at 10:23 AM with the current DON revealed she discovered the ADL book was not being filled out consistently by the CNAs, which prompted a change where the nurses were now documenting the residents' bowel movements. Interview on 04/25/17 at 3:43 PM with ADON J revealed she had not been assigned to Resident #2. She stated she was not sure where the in-service related to the ADL book documentation was and would contact the previous DON to see where she had placed it. Interview on 04/25/17 at 4:10 PM with the ADM revealed she called the previous DON who said an in-service on ADL book documentation was done in either late February 2017 or early March 2017. The ADM stated she looked through the in-service book and could not find anything related to the ADL book documentation. Interview on 04/25/17 at 4:47 PM with LVN/ADON I (note: LVN/ADON I was a charge nurse on 04/25/17) revealed he was aware of Resident #2's weight loss. He stated he was not aware of any problem regarding the resident's bowel function and stated he should have known because it was his job to know. He stated as an ADON, he should have monitored the resident's documentation. He stated the charge nurses were supposed to monitor the residents' documentation in the ADL flow record and then report concerns to him. He stated he would have intervened immediately (KUB, laxatives, et cetera) if he had known of the concern. He stated the concern should have been caught and hated that it was missed. He stated he did not recall any specific in-service related to Resident #2. He stated a number of in-services were done regularly. He stated he did not know about the concern related to possible blockage/impaction with the resident until 04/06/17 after an investigation was started. He stated he looked over the resident's ADL flow record and noticed it was not documented consistently. He stated he had already decided to change his work schedule prior to the concern with Resident #2 and now worked on the weekends and during the week as needed as a charge nurse. Interview on 04/26/17 at 11:34 AM with LVN O revealed she did not recall any previous incidents regarding impaction for Resident #2. Interview on 04/26/17 at 11:40 AM with LVN/ADON B revealed she did not recall any previous incidents regarding impaction for Resident #2. A joint interview was conducted on 04/26/17 at 11:53 AM with the ADM, DON, and Director of Operations. The DON and ADM stated they felt the CNAs failed to alert the charge nurses that Resident #2 was not having any bowel movements and the nurses failed to monitor the ADL book documentation. Interview on 04/26/17 at 12:30 PM with LVN/ADON I revealed he was not aware of any other incidents regarding impaction with Resident #2. He stated he was an ADON at the facility from June 2016 to April 2017. Interview on 04/26/17 at 5:49 PM with the previous DON revealed Resident #2's reported obstruction was not verified. She stated she conducted an in-service regarding the ADL book documentation and checked the ADL book documentation for all of the residents. She stated no assessments were done on any of the residents related to possible problems with bowel function at that time. Interview on 04/26/17 at 6:12 PM with Physician U revealed he did not recall any staff informing him of any concerns related to Resident #2's bowel function. He stated the facility had to be more diligent regarding the residents' toileting. On 04/25/17 at 4:15 PM, the ADM and DON were informed an IJ had been identified. At that time, the facility was requested to provide a plan of removal. The facility's Plan of Removal, dated 04/26/17, was accepted on 04/26/17 at 3:23 PM and reflected the following: . Responsibility for documentation of Bowel Movements has been transferred from the nurse aides to the licensed nurses as of 4/26/17 starting at 6:00am (sic) All Nurses will be in-serviced by (DON)/Designee on the following: Bowel Management Program (See attached) and will be required to show competence by successfully passing a post-test (sic) Performing a head-to-toe assessments on residents with significant change in conditions (sic) Relaying information to oncoming shift regarding significant change in condition (including bowel movements) of all residents (sic) Facility abuse and neglect policies with a special emphasis on neglect (start 4/26/17 at 2:00pm and end at 6:00pm for all current staff with the remainder being in-serviced prior to accepting a floor assignment as monitored by (DON)) (sic) In-services began at 6:00pm for all nurses currently working (sic) 75% of all nurses completed in-servicing by 10:00am on Wednesday April 26th, 2017. All remaining off-duty nurses will be in-serviced by 5:00pm on 4/26/17 or prior to accepting an assignment on their next scheduled day. (DON) will monitor that no nurse accepts a floor assignment prior to receiving the required in-servicing (sic) All newly hired nurses will receive the above education upon hire and be required to show competence where a post-test is administered related to the facility Bowel Management Program (sic) All Certified Nurses Assistants and Certified Medication Aides will be in-serviced by (DON)/Designee on the following (sic) Bowel Management Program (See attached) (sic) Be retrained in properly documenting a bowel movement (sic) Appropriately communicating significant changes (including bowel movements) to the charge nurse (sic) In-services began at 6:00pm for all nurses currently working (sic) 75% of all CNAs and (Medication Aides) completed in-servicing by 10:00am on Wednesday April 26th, 2017 (sic) Facility abuse and neglect policies with a special emphasis on neglect (start 4/26/17 at 2:00pm and end at 6:00pm for all current staff with the remainder being in-serviced prior to accepting a floor assignment as monitored by (DON)) (sic) All remaining off-duty CNAs and (Medication Aides) will be in-serviced by 5:00pm on 4/26/17 or prior to accepting an assignment on their next scheduled day. (DON) will monitor that no nurse accepts a floor assignment prior to receiving the required in-servicing (sic) All newly hired Certified Nurses Aides and (Medication Aides) will receive the above education upon hire (sic) The facility Medical Director (Physician U) was notified of the IJ on 4/25/17 around 5:00pm. The Medical Director will receive monitoring results at the facility QAPI (Quality Assurance Performance Improvement) meetings and any recommendations will be implemented where appropriate and relevant (sic) The facility is having a QAPI meeting on 4/26/17 at 12:00pm to discuss the IJ and corresponding Plan of Removal (sic) To prevent reoccurrence (DON), (ADM), (ADON J) and (LVN/ADON B) will monitor for effectiveness of this Plan of Removal on the Monitoring Sheet. Frequency of monitoring will be: 1x/day for 30 Days; then 3x/week for the 30 days; and 1x/week thereafter. To verify the facility implemented their Plan of Removal the following interviews were obtained and the following records were reviewed. Review of the bowel assessment records completed on 04/26/17 for all 81 current residents at the facility did not reveal concerns. Interviews conducted on 04/26/17 from 12:30 PM to 5:28 PM with LVN/ADON I, CNA T, CNA V, CNA Q, LVN O, LVN W, RN G, CNA X, LVN Y, LVN Z, LVN D, CNA M, and LVN BB (who represented all shifts at the facility) regarding monitoring bowel function, identifying bowel obstructions, and assessing resident abdominal concerns revealed no concerns. Review of the facility's training records, dated 04/25/16 and 04/26/16, revealed CNAs and Medication Aides were in-serviced on monitoring and reporting bowel function and changes in resident condition. The LVNs and RNs were in-serviced on monitoring and documenting bowel function, when to conduct an assessment, physician notification, the protocol for significant changes in resident condition, and signs and symptoms of bowel obstruction. On 04/26/17 at 6:45 PM, the Administrator and DON were informed the IJ was removed. While the IJ was removed on 04/26/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. Review of a list provided by the facility, dated 05/08/17, revealed 32 residents were incontinent of bowel on 04/05/17.

Based on observation, interview and record review, the facility failed to, based on the comprehensive assessment, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #2) of five residents reviewed for quality of care. The facility failed to consistently monitor Resident #2's bowel function in February 2017. The resident was transferred to the hospital on [DATE] and passed away on 03/06/17 as a result [MEDICAL CONDITION] due to large bowel instruction. The resident had a history of [REDACTED]. An Immediate Jeopardy (IJ) was identified on 04/25/17. While the IJ was removed on 04/26/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. This failure could affect the facility's 32 residents who were incontinent of bowel and placed them at risk for not being assessed properly which could lead to a decline in their health status, the need for hospitalization , and/or death. Findings included: Review of Resident #2's Minimum Data Set assessment, dated 12/02/16, revealed he was [AGE] years old and was admitted to the facility on [DATE]. The resident was cognitively intact and his [DIAGNOSES REDACTED]. Review of Resident #2's comprehensive plan of care, dated 12/15/16, revealed . Resident has a History of Constipation and is at Risk for Impactions and Bowel Obstructions . Will have a B.M. (bowel movement) at least every three days and will have no s/s (signs or symptoms) of impaction or bowel instruction over next 90 days . Monitor B.M.s for amount and consistency . If no B.M. after three days - perform a bowel assessment, report abnormal findings to M.D. (medical doctor) . Review of Resident #2's ADL Flow Record, dated February 2017, revealed bowel functions were to be documented during the night, day and evening shifts. Only 34 of 69 shifts documented the resident's bowel function. There was no documentation for the remaining shifts. Nine shifts were documented from 02/16/17 to 02/23/17 and all documented shifts had zero episodes of bowel function. Review of Resident #2's undated Weight Flow Sheet revealed the following weights: 163 pounds on 01/04/17; 160 pounds on 01/11/17; 152 pounds on 01/25/17; 148 pounds on 02/01/17; 147 pounds on 02/08/17; 147 pounds on 02/15/17; and 140 pounds on 02/22/17. Review of Resident #2's Resident Transfer Form, dated 02/24/17 and completed by LVN O, revealed . Blood noted in cath (catheter) U/A (urinalysis) specimen - poor intake PO (by mouth) - 19 lb (pound) wt (weight) loss (times one) month . Review of Resident #2's physician telephone orders revealed there was an order to send the resident to the hospital for evaluation on 02/24/17. Review of Resident #2's nurse's notes, dated 02/24/17 (note: no time listed) and authored by LVN O, revealed . Con't (Continue) to have poor to 0 P.O (by mouth) intake (sic) Only drinks sodas (and) eats candy - U/A (urinalysis) collected (with) blood noted in specimen (sic) Resident noted to be thin (and) frail, has had 19 lb (pound) wt. (weight) loss in (one) month. Order recd (received) to send to ER (emergency room ) for eval (evaluation) Review of Resident #2's hospital CAT (computerized axial tomography) scan, dated 02/24/17, revealed, . Impression: A severe amount of stool is present within the rectum, right colon, and [MEDICATION NAME] colon. The stool within the rectum is concerning for fecal impaction. There is associated mild small bowel dilation with air, which could be related to ileus (inability of the intestine (bowel) to contract normally and move waste out of the body) Review of Resident #2's hospital record, dated 02/25/17, revealed . Patient seen and examined. Per RN (Registered Nurse), despite exhaustive efforts at free water enema and fecal disimpaction, minimal stool expelled. RN . was unable to feel bowel contractions during impaction Concern that patient is too malnourished and frail for more invasive procedures for fecal disimpaction was addressed with family who agreed. Family understands that patient may develope (sic) further complications such as toxic megacolon and or (sic) bowel perforation. Family has requested a representative from palliative care/hospice come evaluate patient and answer questions Abdomen: distended, minimal bowel sounds, tender to palpation . Review of Resident #2's Medical Abstract of Death Certificate, dated 03/09/17, revealed .date of death . March 6, 2017 . immediate cause (final disease or condition resulting in death) .[MEDICAL CONDITION] due to large bowel obstruction . Approximate interval onset to death . weeks . Interview on 04/25/17 at 11:21 AM with LVN O revealed she never knew Resident #2 had problems with his bowel function. She stated the CNAs informed her that the resident was having bowel movements. She stated the resident would fight (hit, kick, or spit) if he did not want care provided, which was 90 percent of the time. She stated the CNAs were supposed to notify the nurse if a resident did not have a bowel movement after two to three days. She stated there were no complaints of pain or stomach discomfort from the resident. She stated the resident regularly ate candy bars and soda. She stated the resident refused nutritional supplements. She stated the previous DON notified her that the resident had lost 19 pounds in one month. She stated she was unable to tell the resident had lost weight when she would see him lying in bed. She stated she noticed the resident's weight loss the day before he went to the hospital when she saw him up in a wheelchair. She stated she contacted the resident's family regarding his weight loss and candy/soda consumption. She stated the resident's skin checks were done on the 2:00 PM to 10:00 PM shift once a week and she did not recall a need to check the resident's skin on her shift from 02/20/17 to 02/24/17. She stated she had not been notified by the CNAs that the resident had any weight loss. She stated she was not monitoring the CNAs' ADL book and stated that she should have been. She stated the CNAs mentioned that the resident's bedding was soiled with stool the day he was sent out to the hospital. She stated there were no complaints from the resident or his family regarding not being able to have a bowel movement or weight loss. She stated there had been no foul odors from the resident. She stated she had not checked the resident's bowel sounds from 02/20/17 to 02/24/17. She stated she sent the resident to the hospital due to his sickly appearance and the recent notification of 19 pounds weight loss in one month. Interview on 04/25/17 at 11:48 AM with CNA P revealed she was assigned to Resident #2 on 02/24/17. She stated she notified LVN O that the resident had liquid stool in his brief. She stated the resident mentioned that he did not feel good, but was not more specific than that. She stated she did not recall complaints from the resident from 02/18/17 to 02/23/17. She stated she would go to the resident's room to assist the other CNAs assigned to him. She stated the resident was a two-person assist with care. She stated she believed the resident had one small ball of stool the same day he was sent to the hospital, which she notified LVN O of. She stated the resident's nurse was notified between 02/18/17 to 02/23/17 when stool would be on the wipe during incontinence care, but not in the resident's brief. She stated she did not recall the resident having a regular bowel movement from 02/18/17 to 02/24/17. She stated the nurse would check on the resident after a concern was brought to his/her attention. She stated she noticed the resident had lost weight and spoke with LVN O. Interview on 04/25/17 at 12:23 PM with CNA Q revealed she was assigned to Resident #2 off and on from 02/18/17 to 02/24/17. She stated she did not recall anything out of the ordinary regarding the resident's bowel function. She stated the resident had small (regular consistency) bowel movements the last few days of his stay at the facility on her shift off and on. She stated the resident would say that he was not feeling good. She stated she and CNA R reported to the nurse that the resident had soiled bedding. She stated she could not recall which nurse she reported the resident's bedding to, and was unsure if the bedding was soiled with urine or stool. She stated the resident was not his everyday self and she reported it to the nurse on duty. She stated the resident was not feeling well but there was nothing more specific. She stated the resident would eat meals, kept snacks, and his family brought meals for him as well. She stated one intervention such as taking the resident to the dining room for meals was in place in response to his weight loss. She stated the resident ate approximately 30 to 50 percent of his food. She stated the CNAs were documenting the residents' bowel movements in the ADL book during February 2017 and it was expected that the nurses reviewed the documentation. Interview on 04/25/17 at 12:42 PM with CNA R revealed she would see large blood stains every other week on Resident #2's bed approximately one month prior to his hospitalization . She stated the charge nurse and previous DON were notified of the blood stains and they both stated they would take care of it. CNA R stated there was an odor of urine/mildew/musk in the resident's room. She stated the stains on the resident's bed would still be wet and were coffee ground colored. She stated she recalled the resident had one small, black ball of stool, which she informed the nurse of, the last month of his stay at the facility. She stated she would place the resident on the toilet but he was unable to have a bowel movement. She stated the resident urinated regularly. She stated the resident was pleasant and did not complain about much. She stated there were no complaints from the resident regarding not being able to go to have a bowel movement. She stated there were no complaints of stomach pain or discomfort from the resident. She stated she noticed the resident stopped eating about two weeks prior to him going to the hospital. She stated she would take the resident to the dining room for meals but he would only eat about 25 percent of his food. She stated the CNAs were in charge of documenting bowel movements in the ADL book during February 2017. Interview on 04/25/17 at 10:03 AM with the current DON revealed the nurses began documenting the residents' bowel movements on 04/07/17 in the TAR. She stated the CNAs had previously documented the residents' bowel movements in the ADL book. Interview on 04/25/17 at 2:10 PM with the previous DON revealed Resident #2 was care planned and observed regarding his weight loss. She stated the resident ate junk food and picked at his meals. She stated the resident never wanted to get out of bed and ate candy often. She stated the resident was on her radar due to his appetite decline during the last three to four months of his day at the facility. She stated the resident's doctor was contacted regarding his weight loss. She stated the resident was encouraged to get up for meals but he refused. She stated the staff encouraged the resident to eat meals and believed he was also on a nutritional supplement. She stated she checked up on the resident after he was sent to the hospital on [DATE]. She stated the hospital mentioned that there was a possible blockage with the resident. She stated she then checked the ADL books and discovered the documentation was horrible. She stated she asked CNA Q who said the resident had two good bowel movements the last week of his stay at the facility. She stated she believed another CNA, whose name she could not recall, on the 2:00 PM to 10:00 PM shift also stated the resident had one good bowel movement on their shift the last week of his stay. The previous DON stated the nurses were expected to monitor the ADL book and the CNAs should have reported to the nurse when there was no bowel movement with a resident. She stated she in-serviced the staff (CNAs and nurses) which was ongoing regarding the ADL book documentation. She stated she concentrated on the 2:00 PM to 10:00 PM shift because that was where the documentation lacked the most. She stated she discussed with the staff the importance of documenting a resident's ADLs. She stated it was the nurses' duty to check the ADL book at the end of their shifts. Interview on 04/25/17 at 11:00 AM with LVN/ADON B (note: LVN/ADON B was an ADON on 04/25/17) revealed she was a charge nurse for Resident #2 during February 2017. She stated the resident would usually eat at dinner, but not very much at breakfast or lunch. She stated she was in communication with NP N regarding the resident who refused to get out of bed or take showers. She stated the staff would give the resident bed baths. She stated the resident regularly ate chocolate and drank sodas. She stated she tried to provide nutritional supplements to the resident but he refused. She stated she was unaware of any problems with the resident regarding constipation. She stated the CNAs were supposed to notify the nurse if a resident did not have a bowel movement after three days. She stated there was a gradual decline with the resident. She stated there had been no problems with the resident's vital signs. She stated there were no complaints from the resident regarding stomach pain or other stomach concerns. She stated no concerns had been brought to her attention regarding the resident not being able to have a bowel movement or not having one. She stated the resident was able to answer questions, but his voice was raspy and he denied having a sore throat. Interview on 04/25/17 at 1:30 PM with CNA C revealed she worked with Resident #2 off and on. She stated the resident requested snacks such as soda and chips frequently. She stated the resident did not eat a lot of the meals served. She stated the resident's appetite had slowed. She stated the resident would say that he had a bowel movement, but when checked he was clean. She stated the resident was alert and oriented but his speech became very soft and she was hardly able to hear him. She stated she would let the resident know that he had not had a bowel movement and the resident would be surprised. She stated the resident had a little ball of stool a couple of times during a two week span. She stated she did not recall the resident having regular bowel movements the last two weeks of his stay at the facility. She stated the resident occasionally asked for milk of magnesia (a couple of times a month during her shift). She stated she notified the medication aide of the resident's request, but she did not follow-up with the medication aide. She stated she did not notify the nurse of the resident's request for milk of magnesia. She stated she would have documented that the resident had small balls of stool and would only notify the nurse if the resident did not have any bowel movements in two days. Interview on 04/25/17 at 4:28 PM with CNA S revealed she worked with Resident #2 during the last week of his stay at the facility. She stated the nurses asked her to notify them if the resident urinated because he had not been urinating. She stated the resident was not speaking that much during that time (low voice volume). She stated she could not remember if the resident had a bowel movement during her shifts. She stated she did not recall complaints of stomach pain or discomfort by the resident. She stated the resident would ask staff to get sodas for him. She stated the resident was acting normal days before he went to the hospital. She stated the resident was eating food but could not recall the percentage and ate snacks. She stated she was unaware the resident had any weight loss. Interview on 04/26/17 at 1:07 PM with CNA T revealed she observed what appeared to be dried stool on Resident #2's bed approximately one to two days before he was sent to the hospital. She stated she heard later on that it may have been blood that was on the resident's bed. She stated the resident regularly asked to go to the bathroom. She stated she was not assigned to the resident but would assist with his care. She stated the resident made no complaints to her regarding not being able to have a bowel movement. She stated the resident's appetite declined over several weeks. Interview on 04/26/17 at 3:56 PM with LVN Y revealed she worked with Resident #2 during the overnight shift and there were no complaints of abdominal pain or discomfort from January 2017 to February 2017. On 04/25/17 at 1:59 PM the current DON was asked when resident bowel sounds would be documented and/or abdominal assessments performed. The current DON stated resident vital signs were taken as needed and when incidents such as falls, order changes, and changes in condition occurred. The current DON stated she contacted the facility's lab and there was no KUB (Kidney, Ureter, Bladder) ordered for Resident #2 from December 2016 to February 2017. Interview on 04/25/17 at 10:23 AM with the current DON revealed she discovered the ADL book was not being filled out consistently by the CNAs, which prompted a change where the nurses were now documenting the residents' bowel movements. Interview on 04/25/17 at 3:43 PM with ADON J revealed she had not been assigned to Resident #2. She stated she was not sure where the in-service related to the ADL book documentation was and would contact the previous DON to see where she had placed it. Interview on 04/25/17 at 4:10 PM with the ADM revealed she called the previous DON who said an in-service on ADL book documentation was done in either late February 2017 or early March 2017. The ADM stated she looked through the in-service book and could not find anything related to the ADL book documentation. Interview on 04/25/17 at 4:47 PM with LVN/ADON I (note: LVN/ADON I was a charge nurse on 04/25/17) revealed he was aware of Resident #2's weight loss. He stated he was not aware of any problem regarding the resident's bowel function and stated he should have known because it was his job to know. He stated as an ADON, he should have monitored the resident's documentation. He stated the charge nurses were supposed to monitor the residents' documentation in the ADL flow record and then report concerns to him. He stated he would have intervened immediately (KUB, laxatives, et cetera) if he had known of the concern. He stated the concern should have been caught and hated that it was missed. He stated he did not recall any specific in-service related to Resident #2. He stated a number of in-services were done regularly. He stated he did not know about the concern related to possible blockage/impaction with the resident until 04/06/17 after an investigation was started. He stated he looked over the resident's ADL flow record and noticed it was not documented consistently. He stated he had already decided to change his work schedule prior to the concern with Resident #2 and now worked on the weekends and during the week as needed as a charge nurse. Interview on 04/26/17 at 11:34 AM with LVN O revealed she did not recall any previous incidents regarding impaction for Resident #2. Interview on 04/26/17 at 11:40 AM with LVN/ADON B revealed she did not recall any previous incidents regarding impaction for Resident #2. A joint interview was conducted on 04/26/17 at 11:53 AM with the ADM, DON, and Director of Operations. The DON and ADM stated they felt the CNAs failed to alert the charge nurses that Resident #2 was not having any bowel movements and the nurses failed to monitor the ADL book documentation. Interview on 04/26/17 at 12:30 PM with LVN/ADON I revealed he was not aware of any other incidents regarding impaction with Resident #2. He stated he was an ADON at the facility from June 2016 to April 2017. Interview on 04/26/17 at 5:49 PM with the previous DON revealed Resident #2's reported obstruction was not verified. She stated she conducted an in-service regarding the ADL book documentation and checked the ADL book documentation for all of the residents. She stated no assessments were done on any of the residents related to possible problems with bowel function at that time. Interview on 04/26/17 at 6:12 PM with Physician U revealed he did not recall any staff informing him of any concerns related to Resident #2's bowel function. He stated the facility had to be more diligent regarding the residents' toileting. On 04/25/17 at 4:15 PM, the ADM and DON were informed an IJ had been identified. At that time, the facility was requested to provide a plan of removal. The facility's Plan of Removal, dated 04/26/17, was accepted on 04/26/17 at 3:23 PM and reflected the following: . Responsibility for documentation of Bowel Movements has been transferred from the nurse aides to the licensed nurses as of 4/26/17 starting at 6:00am (sic) All Nurses will be in-serviced by (DON)/Designee on the following: Bowel Management Program (See attached) and will be required to show competence by successfully passing a post-test (sic) Performing a head-to-toe assessments on residents with significant change in conditions (sic) Relaying information to oncoming shift regarding significant change in condition (including bowel movements) of all residents (sic) Facility abuse and neglect policies with a special emphasis on neglect (start 4/26/17 at 2:00pm and end at 6:00pm for all current staff with the remainder being in-serviced prior to accepting a floor assignment as monitored by (DON)) (sic) In-services began at 6:00pm for all nurses currently working (sic) 75% of all nurses completed in-servicing by 10:00am on Wednesday April 26th, 2017. All remaining off-duty nurses will be in-serviced by 5:00pm on 4/26/17 or prior to accepting an assignment on their next scheduled day. (DON) will monitor that no nurse accepts a floor assignment prior to receiving the required in-servicing (sic) All newly hired nurses will receive the above education upon hire and be required to show competence where a post-test is administered related to the facility Bowel Management Program (sic) All Certified Nurses Assistants and Certified Medication Aides will be in-serviced by (DON)/Designee on the following (sic) Bowel Management Program (See attached) (sic) Be retrained in properly documenting a bowel movement (sic) Appropriately communicating significant changes (including bowel movements) to the charge nurse (sic) In-services began at 6:00pm for all nurses currently working (sic) 75% of all CNAs and (Medication Aides) completed in-servicing by 10:00am on Wednesday April 26th, 2017 (sic) Facility abuse and neglect policies with a special emphasis on neglect (start 4/26/17 at 2:00pm and end at 6:00pm for all current staff with the remainder being in-serviced prior to accepting a floor assignment as monitored by (DON)) (sic) All remaining off-duty CNAs and (Medication Aides) will be in-serviced by 5:00pm on 4/26/17 or prior to accepting an assignment on their next scheduled day. (DON) will monitor that no nurse accepts a floor assignment prior to receiving the required in-servicing (sic) All newly hired Certified Nurses Aides and (Medication Aides) will receive the above education upon hire (sic) The facility Medical Director (Physician U) was notified of the IJ on 4/25/17 around 5:00pm. The Medical Director will receive monitoring results at the facility QAPI (Quality Assurance Performance Improvement) meetings and any recommendations will be implemented where appropriate and relevant (sic) The facility is having a QAPI meeting on 4/26/17 at 12:00pm to discuss the IJ and corresponding Plan of Removal (sic) To prevent reoccurrence (DON), (ADM), (ADON J) and (LVN/ADON B) will monitor for effectiveness of this Plan of Removal on the Monitoring Sheet. Frequency of monitoring will be: 1x/day for 30 Days; then 3x/week for the 30 days; and 1x/week thereafter. To verify the facility implemented their Plan of Removal the following interviews were obtained and the following records were reviewed. Review of the bowel assessment records completed on 04/26/17 for all 81 current residents at the facility did not reveal concerns. Interviews conducted on 04/26/17 from 12:30 PM to 5:28 PM with LVN/ADON I, CNA T, CNA V, CNA Q, LVN O, LVN W, RN G, CNA X, LVN Y, LVN Z, LVN D, CNA M, and LVN BB (who represented all shifts at the facility) regarding monitoring bowel function, identifying bowel obstructions, and assessing resident abdominal concerns revealed no concerns. Review of the facility's training records, dated 04/25/16 and 04/26/16, revealed CNAs and Medication Aides were in-serviced on monitoring and reporting bowel function and changes in resident condition. The LVNs and RNs were in-serviced on monitoring and documenting bowel function, when to conduct an assessment, physician notification, the protocol for significant changes in resident condition, and signs and symptoms of bowel obstruction. On 04/26/17 at 6:45 PM, the Administrator and DON were informed the IJ was removed. While the IJ was removed on 04/26/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. Review of a list provided by the facility, dated 05/08/17, revealed 32 residents were incontinent of bowel on 04/05/17.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents for one (Resident #1) of six residents reviewed who required staff assistance with transfers. CNA A failed to transfer Resident #1, who was care planned for transfers via a mechanical lift, with assistance on 03/27/17, which resulted in the resident being injured and sustaining a right midclavicular shaft fracture. This failure could affect the facility's 23 residents, who required staff assistance for transfers and placed them at risk for falling, lacerations, fractures and the need for hospitalization . Findings included: Review of Resident #1's MDS assessment, dated 03/31/17, revealed he was [AGE] years old and was admitted to the facility on [DATE]. The resident's cognitive skills for daily decision making were severely impaired. The resident was totally dependent on two or more people for transfers. The resident's [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive plan of care, dated 03/17/17, revealed ADL (Activities of Daily Living): Self Performance deficit due to dx (diagnoses) of Resident has cognitive as well as physical deficits. Resident requires total care from staff are all bathing, grooming, personal hygiene, bed mobility, locomotion on and off unit, transfers, toileting, dressing, and eating Use Hoyer lift for all transferrs (sic) . Review of the facility's Provider Investigation Report, dated 03/30/17 and regarding Resident #1, revealed, . Description of the Allegation One of the straps on the sling for the mechanical lift broke during transfer. Resident fell as a result of sling breaking. Description of Injury Fracture to right clavicle . Review of Resident #1's x-ray report, dated 03/27/17, revealed, .Findings: Bowing proximal shaft of humerus possibly congenital. Midclavicular shaft fracture noted. Impression: Midclavicular shaft fracture as noted above . Review of an Incident/Accident Report for Resident #1, dated 03/27/17, revealed, .(CNA A) was lifting resident from geri-chair (geriatric chair) to bed (and) one strap on the Hoyer pad broken - resident fell about 2 ft (feet) . Review of Resident #1's TAR, dated April 2017, revealed, . Charge nurse to be present during all hoyer lift transfers. Charge nurse to initial treatment sheet that this is being done. Every day and evening shift for fracture of right clavicle -start date- 04/06/2017, and, . Resident to have hoyer lift transferrs (sic) on 6/2 (6:00 AM to 2:00 PM) and 2/10 (2:00 PM to 10:00 PM) shift only. Charge nurse must be present for each transfer. Every day and evening shift for fractured right clavicle -start date- 04/06/2017 . Interview on 04/05/17 at 5:22 PM with CNA A revealed he transferred Resident #1 via the mechanical lift without assistance. CNA A stated it was normally difficult to find other staff to help assist him but he had not asked for assistance at the time of the incident. CNA A stated he transferred the resident via the mechanical lift without assistance on a regular basis. CNA A was unable to give the number of times he had transferred the resident via the mechanical lift without assistance. CNA A stated the resident was in his geriatric chair and he was transferring the resident to his bed when the strap near the resident's right shoulder broke and the resident slid about two feet to the floor hitting his right shoulder. CNA A stated he called for RN G who responded and assessed the resident. CNA A stated he, along with RN G and another CNA got the resident up from the floor and onto his bed. CNA A stated there was no pain noted with the resident during that time. CNA A stated he believed the resident was unable to express pain appropriately. CNA A stated he did not believe the outcome of the incident would have been different if another person had been there during the transfer except that another person may have been able to help break the resident's fall. CNA A stated the mechanical lift sling straps were intact and no fraying was observed prior to the resident's transfer. Interview on 04/05/17 at 4:25 PM with the DON revealed Resident #1 had an intellectual disability and was not interviewable. The DON stated CNA A was terminated due to the incident. She stated Resident #1 sustained a right clavicle fracture after falling during a mechanical lift transfer. Observation on 04/05/17 at 4:28 PM revealed Resident #1 was in his room, lying in bed, awake. The resident was not interviewable. There were no signs of pain noted with the resident. The resident was observed moving both of his arms. The resident was transferred via mechanical lift by CNA E and CNA S and no concerns were revealed during the transfer. Interview on 04/05/17 at 4:42 PM with the DON revealed CNA A transferred Resident #1 with the mechanical lift without assistance. The DON stated one of four sling straps had torn off causing the resident to fall. She stated the other mechanical lift slings in the facility were inspected for damage. At that time, Resident #1's previous sling used during the incident was observed and one of four straps was torn off. Interview on 04/05/17 at 7:07 PM with RN G revealed CNA A informed her that Resident #1 had fallen. RN G stated she went to the resident's room and found him on the floor facing the ceiling. RN G stated she, along with CNA A and another CNA, got the resident up and placed him in his bed. RN G stated there were no signs of pain with the resident. RN G stated the resident would slap himself if he was in pain, which he did not do. RN G stated she assessed the resident and the doctor was called. RN G stated the resident's x-ray was positive for a fracture and the resident was sent to the hospital. RN G stated she had no idea CNA A was transferring the resident via the mechanical lift without assistance. RN G stated CNA A would have been assisted, but no help was requested. RN G stated she always saw CNA A with another staff member when the resident was being transferred. Interviews on 04/05/17 from 4:48 PM to 6:09 PM with LVN/ADON B (note: LVN/ADON B was a charge nurse on 04/05/17), CNA C, LVN D, CNA E, CNA F, and CNA H revealed they knew two staff members were needed to operate the mechanical lift properly. Review of the facility's in-service records, dated 09/27/16, revealed use of gait belt and proper transfers was discussed with CNAs, including CNA A. Review of the facility's in-service records, dated 03/28/17, revealed abuse and neglect was discussed. Review of the facility's in-service records, dated 03/28/17, revealed training on proper use of gait belt with return demonstration. Review of the facility's in-service records, dated 03/28/17, revealed how to use a Hoyer lift, always having two people while using the lift, checking the slings for any signs of wear and tear, and reporting concerns was discussed. Review of the facility's in-service records, dated 04/05/17, revealed all Hoyer lift transfers had to be done in the presence of two staff and the charge nurse on the 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM shifts. Hoyer lift transfers could not be done on the 10:00 PM to 6:00 AM shift unless there was an emergency and two staff and a charge nurse still had to be present with no exceptions was discussed. Interview on 04/05/17 at 5:55 PM with the ADM revealed the facility implemented a mechanical lift return demonstration training with the nursing staff as well as a check-off for central supply to inspect the mechanical lifts and slings on a weekly basis after the incident with Resident #1. Review of the facility's Hoyer Lift Check List, dated April 2017, revealed two hoyers were inspected during the first week of April 2017 and no concerns were noted. Interview on 04/05/17 at 6:03 PM with Resident #3 revealed there were always two staff members present during her mechanical lift transfers. Observation on 04/05/17 at 6:07 PM did not reveal concerns regarding Resident #3's mechanical lift sling. Interview on 04/05/17 at 6:20 PM with the DON revealed all mechanical lift slings had been replaced and all staff had been in-serviced regarding the proper use of the mechanical lift with return demonstrations. Interview on 04/05/17 at 6:25 PM with the DON revealed she had not observed any mechanical lift transfers since the incident with Resident #1 when the facility conducted an in-service with return demonstrations. Interview on 04/05/17 at 6:29 PM with LVN/ADON I (note: LVN/ADON I was an ADON on 04/05/17) and ADON J revealed they had not observed any mechanical lift transfers since the incident with Resident #1 when the facility conducted an in-service with return demonstrations. Interview on 04/05/17 at 7:31 PM with the ADM and DON revealed there was no current plan in place to monitor the residents' mechanical lift transfers. The ADM and DON both stated their main concern was that the mechanical lift sling had malfunctioned. The DON stated she could set up a plan to monitor Resident #1's mechanical lift transfers. Observations on 04/05/17 from 12:39 PM to 1:22 PM of mechanical lift and gait belt transfers for Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7 did not reveal concerns. Interviews on 04/05/17 from 1:34 PM to 1:54 PM with Resident #8, Resident #9, Resident #10, and Resident #11 did not reveal concerns regarding staff assistance. Review of the facility's undated policy and procedure on Mechanical or Hydraulic Lift revealed, .The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. It requires two or three staff members to safely operate and accomplish the transfer . Review of a list provided by the facility, dated 05/08/17, revealed 13 residents required the assistance of one person for gait belt transfers, six residents required the assistance of two people for gait belt transfers, and four residents received hoyer lift transfers on 04/05/17.

Based on observation, interview and record review, the facility failed to ensure residents were free from of any significant medication errors for one (Resident #1) of 13 residents reviewed for medications. The facility failed to obtain Resident #1's physician-ordered levetiracetam (anticonvulsant) resulting in five missed doses over the course of three days. Resident #1 had a [MEDICAL CONDITION] on 10/17/16 and was transported to the hospital while still seizing. She was admitted to the hospital. An Immediate Jeopardy (IJ) was identified on 10/31/16. While the IJ was removed on 11/01/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. This failure placed the facility's 13 residents who received anticonvulsants at risk for [MEDICAL CONDITION] and worsening of their medical conditions. Findings included: Review of Resident #1's Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had severe cognitive impairment. Resident #1's [DIAGNOSES REDACTED]. The MDS reflected the resident received hospice care while she was a resident. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Comprehensive Plan of Care, dated 09/01/16, revealed . Potential for [MEDICAL CONDITION] activity, injury related to [MEDICAL CONDITION] disorder Administer medications as ordered and monitor for effectiveness, side effects Review of Resident #1's Medications Flowsheet, dated 10/01/16 - 10/31/16, revealed levetiracetam 1000 mg tablet was not administered to the resident at 8:00 a.m. on 10/15/16, 10/16/16 and 10/17/16 or at 4:00 p.m. on 10/15/16 and 10/16/16. Review of Resident #1's Nurse's Notes revealed . 10/17/16 1645 (4:45 p.m.) Resident up in w/c (wheelchair) in dining room; Began to have [MEDICAL CONDITION]; Returned to room et (and) assisted to bed; Continues to have [MEDICAL CONDITION] . (LVN C) . 1700 (5:00 p.m.) . [MEDICAL CONDITION] continues; 911 called at this time . (LVN C) . 1720 (5:20 p.m.) . ambulance here; [MEDICAL CONDITION] continues . (LVN C) . 1730 (5:30 p.m.) Transported to (Hospital) via . ambulance at this time . (LVN C) . Review of Resident #1's Physician's Telephone Order, dated 10/17/16, revealed . Send to (Hospital) ER (emergency room ) for [MEDICAL CONDITION] . Review of the Resident Transfer Form for Resident #1, dated 10/17/16, revealed . [DIAGNOSES REDACTED]. [MEDICAL CONDITION] Activity . Reason for Transfer Possible [MEDICAL CONDITION] Activity . Review of the facility's 24 Hour Report/Change of Condition Report, dated 10/13/16 - 10/17/16, revealed there was no documentation regarding Resident #1's levetiracetam not being available for administration. The report, dated 10/17/16, reflected the resident was transferred to the hospital for a [MEDICAL CONDITION]. Interview on 10/31/16 at 10:04 a.m. with Resident #1 revealed she had a [MEDICAL CONDITION] after she did not receive her anticonvulsant medication for three to four days. The resident stated there had been no problems receiving her medication before or after that incident. The resident stated she felt fine now. The resident was unable to provide specific information regarding the incident. Review of the Medication Error Report regarding Resident #1, dated 10/17/16, revealed . Date of error 10/15/16 (and) 10/16/16 Time of error Both doses missed Sat (Saturday), Sun (Sunday) and Mon (Monday) morg (morning) . Description of error (include name of medication, dose, route and time(s) administered) Weekend Medication Aide failed to medicate pt (patient). Outcome to resident Res (Resident) had [MEDICAL CONDITION] and was sent to ER (emergency room ) (sic) admitted to hosp (hospital) Measures taken to prevent the recurrence of similar error(s) Inservice started/ongoing on ordering medication Type of Error(s) . Missed 5 doses . Reason for Error(s) . (Medication Aide) - failed to notify nurse . Person making error (MA A and MA B) . Interview on 10/31/16 at 11:17 a.m. with MA B revealed she reordered Resident #1's levetiracetam on 10/12/16 (Wednesday) during her shift (6:00 a.m. to 2:00 p.m.). She stated the resident took levetiracetam twice a day and she last provided the medication in the morning on 10/14/16 (Friday). She stated the pharmacy did not delivery medications during her shift. She stated she notified the hospice agency and LVN G that the resident's levetiracetam was running low and that she had placed a reorder and they both stated they would get back with her. She stated Resident #1 was already at the hospital at the start of her shift (6:00 a.m. to 2:00 p.m.) on 10/17/16 (Monday). She stated she called the pharmacy on 10/17/16 and the resident's medication arrived after the resident was sent to the hospital. Interview on 10/31/16 at 1:04 p.m. with LVN G revealed she worked 6:00 a.m. to 2:00 p.m. with Resident #1 on 10/12/16 to 10/14/16 and 10/17/16. She stated she worked on 10/16/16 (Sunday) but did not work with Resident #1. She stated she was not notified that the resident's levetiracetam was running low or that it was unavailable. She stated there was nothing out of the ordinary with the resident during those shifts. She stated the resident asked for a medication for general pain towards the end of her shift on 10/17/16. She stated she was not aware of any other problems with medication availability. She stated she would call the pharmacy and send the medication reorder via fax if a medication was running low or unavailable. She stated she would notify the oncoming nurse regarding the reorder and follow-up the next day. Interview on 10/31/16 at 11:53 a.m. with MA A revealed he noticed Resident #1's levetiracetam was unavailable during his double shift (6:00 a.m. to 10:00 p.m.) on 10/15/16 (Saturday) and 10/16/16 (Sunday). He stated he informed a female nurse (LVN F) on 10/15/16 and they both faxed a reorder to the pharmacy. He stated he informed a male nurse (LVN E) on 10/16/16 about the resident's medication and he and the nurse searched the medication room but found nothing. He stated the nurses did not follow-up with him after the medication was not obtained. He stated he left a note regarding Resident #1's levetiracetam being unavailable. MA A stated he had just started working at the facility and did not know the names of the nurses he spoke with on 10/15/16 and 10/16/16. Interview on 10/31/16 at 1:57 p.m. with LVN E revealed he worked 6:00 a.m. to 6:00 p.m. on 10/15/16 and 10/16/16. He stated he was not aware that Resident #1's levetiracetam was unavailable. He stated MA A did not inform him that the resident's medication was not administered. He stated he would have tried to contact the DON and pharmacy to find out the best way to get the resident's medication if he had known it was unavailable. He stated there was nothing out of the ordinary with Resident #1 during those shifts. He stated Resident #1 did not make any unusual complaints during those shifts worked. Interview on 11/01/16 at 2:46 p.m. with LVN F revealed she worked 6:00 p.m. to 6:00 a.m. on 10/15/16 and 10/16/16. She stated she was not informed that Resident #1 ' s levetiracetam was unavailable during her shifts over the weekend. She stated she was not aware of any other problems with medication availability. Interview on 10/31/16 at 3:50 p.m. with the DON revealed her focus was to get the staff who worked Monday through Friday in-serviced following the incident with Resident #1 because that was when most medication orders were placed. The DON provided a list of staff that reflected five nurses and MAs who worked on the weekend and six nurses and MAs who worked as needed had not been in-serviced following the incident with Resident #1. Interview on 10/31/16 at 5:17 p.m. with MA D revealed she worked 2:00 p.m. to 10:00 p.m. on 10/12/16 to 10/14/16. She stated she placed a reorder for Resident #1's levetiracetam on 10/13/16 (Thursday). She stated she notified LVN C on 10/14/16 when the medication was not received. MA D stated she thought the morning MA had reordered the resident's medication on 10/12/16 as well. Interview on 10/31/16 at 2:09 p.m. with LVN C revealed she worked 2:00 p.m. to 10:00 p.m. on 10/12/16 to 10/14/16 and 10/17/16. She stated MA D informed her on 10/14/16 there were no more doses of levetiracetam for Resident #1. LVN C stated medications had to be ordered three days prior to the last dose. She stated she faxed the pharmacy which then called the facility. She stated the pharmacy said the resident's levetiracetam would be provided by the hospice agency. She stated she then called the hospice agency to obtain the resident's medication. She stated the resident's medication had not arrived when her shift ended. She stated medications provided by hospice were delivered at all times of the day and night. She stated she assumed the resident's medication would be sent since she had not been informed of any problems by the hospice agency. She stated she could not be sure of what she provided in report to the oncoming nurse. She stated the resident experienced a change in condition during the evening meal on 10/17/16. She stated she was informed the resident was acting strange. She stated MA I said the resident complained of a headache and was requesting a pain medication which was then given. She stated the Administrator informed her the resident was at the front of the building and needed assistance. She stated the resident was then given [MEDICATION NAME] per her request and the resident then went to the dining room. She stated the resident had a [MEDICAL CONDITION] while in the dining room. She stated the resident was then taken to her room, she was laid down, 911 was called and she was transferred to the hospital. Interview on 10/31/16 at 3:02 p.m. with MA I revealed she worked 2:00 p.m. to 10:00 p.m. on 10/17/16. She stated Resident #1 had a [MEDICAL CONDITION] around 4:30 p.m. to 5:00 p.m. during the evening meal on 10/17/16. She stated other staff members noticed the resident's face was twitching. She stated she went to check on the resident and the twitching occurred for a few seconds and then stopped. She stated the twitching then started again about 10 minutes later and she went to get LVN C. She stated two staff members were bringing the resident out of the dining room when she and LVN C returned. She stated the resident was taken to her room and 911 was called. MA I stated she had not gotten to the resident's routine medications prior to her [MEDICAL CONDITION]. She stated the resident had approached her and asked for a medication for pain before the evening meal. She stated the resident complained of a headache. She stated there was nothing out of the ordinary with the resident at that time. She stated the resident's [MEDICAL CONDITION] occurred about an hour later. She stated she had not been in-serviced regarding resident medications following the incident. She stated she next worked at the facility on 10/29/16 following her shift on 10/17/16. Interview on 10/31/16 at 3:57 p.m. with LVN J revealed she worked 10:00 p.m. to 6:00 a.m. on 10/12/16 to 10/14/16 with Resident #1. She stated she was never notified that Resident #1's levetiracetam was unavailable. She stated she found out about the incident on 10/17/16 during report from LVN C. She stated medications were normally reordered when a seven day supply remained. She stated the MAs were responsible for noting which medications needed to be reordered and the request was then signed off by the nurse. Review of Resident #1's hospital History and Physical, dated 10/18/16, revealed . Chief Complaint: [MEDICAL CONDITION]. History of Present Illness . Patient also has [MEDICAL CONDITION] disorder. She currently presented to the emergency room via EMS (Emergency Medical Services) due to prolonged [MEDICAL CONDITION], and EMS reported patient was seizing at about 4:45 p.m. on the day of admission and was still seizing at 5:15 p.m. on their arrival. The patient is not known to have any trauma such as tongue bite, head injury. The patient was given Versed (sedative used to treat [MEDICAL CONDITION]) 5 mg IV (intravenous) push and subsequently 2 mg IV push, and the patient stopped seizing after 2 doses of Versed, and the patient has not had any recurrence of [MEDICAL CONDITION] in the emergency room or throughout the day here subsequent to that. The patient is unable to provide any history and is somnolent Past Medical History: Significant for [MEDICAL CONDITION] [MEDICAL CONDITION] disorder, dementia, aneurysm, [MEDICAL CONDITION] disorder, [MEDICAL CONDITIONS], migraine headaches, hypertension Review of Resident #1's hospital Discharge Instructions, dated 10/21/16, revealed the resident was to continue to take one levetiracetam 1000 mg by mouth twice a day. An interview was conducted on 10/31/16 at 9:25 a.m. with the Administrator and DON. The Administrator stated MA B tried to reorder Resident #1's levetiracetam on 10/12/16 when she saw the resident's medication was running low but was unsuccessful. The Administrator stated the resident was on hospice services and the pharmacy did not send out the medication because there was confusion regarding whether the hospice agency was going to provide the medication. The DON stated Resident #1 took levetiracetam twice a day and had missed four doses over the weekend (10/15/16 and 10/16/16). The DON stated MA D gave the last dose of levetiracetam to the resident on 10/14/16 and notified LVN C who then placed a reorder to the pharmacy that same day. The DON stated LVN C thought the resident's medication would arrive later that night. The Administrator stated MA A was new to the facility and worked a double shift on 10/15/16 and 10/16/16. The Administrator stated MA A identified the resident's missed doses of levetiracetam and noted it on the Medication Administration Record. The Administrator stated she believed MA A also left a note on the medication cart regarding the resident's missed doses of levetiracetam but MA A had not reported the concern to the nurse. The Administrator stated weekend LVNs E and F said they were not notified of Resident #1's missed doses of levetiracetam. The DON stated MA B's employment was terminated because she failed to notify the nurse that Resident #1's levetiracetam was unavailable. The DON stated MA A came to the facility on [DATE], wrote a statement regarding the incident and was in-serviced regarding what to do when a medication was not available. The DON stated MA A did not call or show up for his next shift and she was unable to reach him over the telephone following 10/17/16. The DON stated she met with the facility's designated pharmacy and the residents' routine medications were now refilled automatically when the supply became low. The DON stated she obtained a list of all the medications being provided to the residents on hospice to determine what hospice supplied. The DON stated the MAs and nurses were in-serviced regarding what to do when a medication was not available. The DON stated Resident #1's doctor and family were notified. The DON stated full cart audits were completed to make sure resident medications were available. The DON stated some carts were missing over-the-counter medications and the supplies were replenished from the facility's supply. The DON stated the resident medications that were running low had already been reordered and no further missed doses of medications were identified. The DON stated the facility would have paid for Resident #1's levetiracetam if they had known the medication was unavailable. The DON stated she had spoken with the pharmacy within the past week regarding getting levetiracetam added to the facility's emergency kit. Interview on 10/31/16 at 10:30 a.m. with the Administrator revealed Resident #1 did not feel well in the afternoon on 10/17/16. She stated the resident complained of a headache but did not want to lie down. She stated the resident asked that a CNA stay with her. She stated a CNA took the resident to the dining room where she had a [MEDICAL CONDITION]. She stated the resident's missed levetiracetam doses were discovered when the facility began to investigate what could have led up to the resident's [MEDICAL CONDITION]. She stated the nurse had provided a medication to the resident following her complaint of a headache. She stated MA B did not notify anyone of the resident's missed dose of levetiracetam on 10/17/16. She stated the facility would have sent the resident to the hospital for emergency treatment to possibly prevent the [MEDICAL CONDITION] if they had been made aware the resident's medication was unavailable on 10/17/16. Interview on 10/31/16 at 10:37 a.m. with the DON revealed she was still in the process of completing in-services for the incident with Resident #1. She stated some of the staff who had not been in-serviced worked on a PRN (as needed) basis. Interview on 10/31/16 at 4:48 p.m. with the DON revealed no disciplinary action was taken against LVN C. The DON stated she believed LVN C thought the resident's levetiracetam was going to be sent by the hospice agency. The DON stated she did not ask LVN C if she had notified the oncoming nurse regarding the resident's reorder of levetiracetam. According to www.[MEDICATION NAME].com/includes/pdf/[MEDICATION NAME].pdf <http://www.[MEDICATION NAME].com/includes/pdf/[MEDICATION NAME].pdf> . Antiepileptic drugs, including [MEDICATION NAME] (levetiracetam), should be withdrawn gradually to minimize the potential of increased [MEDICAL CONDITION] frequency Levetiracetam plasma half-life in adults is 7 ± 1 hour and is unaffected by either dose or repeated administration Do not stop [MEDICATION NAME] without first talking to a healthcare provider. Stopping [MEDICATION NAME] suddenly can cause serious problems. Stopping a [MEDICAL CONDITION] medicine suddenly can cause [MEDICAL CONDITION] that will not stop ([DIAGNOSES REDACTED]) Review of the facility's in-service record for CNAs and MAs, dated 10/17/16, revealed . Notify nurse when meds (medications) running low, and or (sic) meds are not delivered by pharmacy (sic) Review of the facility's in-service record for nurses and MAs, dated 10/19/16, revealed . (MA) will be responsible for reordering medications in a timely manner. If medications do not come in you must notify your charge nurse and DON Medication carts will be audited to ensure medications are available. Audit is to include OTC (over the counter) meds (medications) as well Review of the facility's in-service record for nurses and MAs, dated 10/31/16, revealed . Med (Medication) Aides must reorder medication at least 7 days prior to last pill Charge nurse / (and) DON must be notified immediately if medication . is not available or medication is running low . Review of the facility ' s Daily Start Up forms, dated 10/18/16 and 10/28/16, revealed medication cart audits were completed. All resident medications were available and no concerns were noted. Review of the facility's Physician Medication Orders policy and procedure, dated April 2010, revealed . Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available On 10/31/16 at 5:20 p.m. the Administrator and DON were informed an IJ had been identified. At that time, the facility was requested to provide a plan of removal. The facility's Plan of Removal, dated 10/31/16, was accepted on 11/01/16 at 5:55 p.m. and reflected the following: . Corrective Action On 10/19/2016 (MA B) was terminated for failure to order medications timely and failure to inform Charge Nurse / (and) D.O.N. (Director of Nurses) that [MEDICAL CONDITION] medication was not ordered / delivered causing negative outcome for (Resident #1). On 10/19/16 D.O.N. and ADON's (Assistant Director of Nurses) performed a completed MAR (Medication Administration Record) to cart audit. No drugs were missing. Nursing Management started cart Audits every Friday and this was added as a part of the morning start up for Fridays. D.O.N. will randomly monitor weekly. The D.O.N. started in-servicing all nurses and medication aides on medication ordering and re-ordering. All med (medication) aides and nurses were not completely in-serviced at the time the surveyor entered the facility on 10/31/16. The D.O.N. or designee will train all employee that have not been trained before the start of their shift. 10/21/16 Automatic re-order was set-up with pharmacy. As of 10/31/16 in-servicing is on going (sic) with nurses and MA's (Medication Aides). The New information that was add (sic) to the in-service is as follows: Staff was informed that all medications are on Automatic Reorder (sic) This means that all medications will be sent to the facility without any information being sent to the pharmacy When you recieve (sic) DC (discontinue) or Changes in dosage you must communicate this to the pharmacy On New admissions all medication must be verified by Dr (Doctor) / PA and medication sheet faxed ASAP (as soon as possible) to pharmacy (sic) followed by a phone call. If the pharmacy tells you that the medication cannot be sent out for ANY reason (sic) Notify the DON or ADON's immediately. If you are the charge nurse and a medication is not delivered prior to the end of your shift, you MUST inform the oncoming nurse and write the information on the 24 hour report to ensure follow up is made on the medication. Nursing staff will not be allowed to work until they have been in-serviced regarding ordering and re-ordering of medications. As of 11/1/16 all nurses and medication aides have been re-inserviced with the new information except for 2 employees who will not be allowed to work until they have been re-inservice (sic) by the DON or ADON. 11/01/16 nurses & M.A's will recieve (sic) a pre and post test administered by the D.O.N. / ADON's regarding the ordering and re-ordering of medications. The nurses and MA's will not be able to work until they have passed the post test. All newly hired nurses and MA's will be in-serviced and given the pre & post test prior to working To verify the facility implemented their Plan of Removal the following observations and interviews were obtained and the following records were reviewed. Observation on 10/31/16 at 4:26 p.m. revealed the anticonvulsant medications for Residents #1 - #13 were available for administration. Review of the Medication Administration Records / Treatment Administration Records / Medications Flowsheets, dated 10/01/16 - 10/31/16 for Residents #2 - #13 did not reveal missed anticonvulsant medications. Review of the facility ' s in-service training, dated 11/01/16, revealed RNs, LVNs and MAs completed pre and posttests regarding when a medication should be reordered and steps to take if a medication has not been received in a timely manner or is missing, which included notifying the oncoming nurse and documenting on the 24 hour report to ensure follow-up. Review of a statement provided by the facility's designated pharmacy, dated 10/31/16, revealed resident medications were placed on auto refill beginning 10/21/16. Review of the Refills Due report from the facility's designated pharmacy, dated 10/31/16, revealed resident medications were listed along with the medication expiration dates. The report reflected how much of each medication would be delivered along with the listed date of delivery. An interview was conducted with the Administrator and DON on 11/01/16 at 9:16 a.m. The DON stated she did not believe there was a widespread problem at the facility regarding resident medications. The DON stated there had been no other incidents at the facility regarding a medication not being administered and there was no problem with medication availability. The DON and Administrator both stated staff would not be allowed to work until they completed the required training regarding the incident with Resident #1. The Administrator stated the required training would be completed for all staff on 11/01/16. The Administrator stated PRN staff who had not worked in a while would be taken off the schedule. The DON stated the staff would complete the required training at the facility or it would be done over the phone. The DON stated she, along with ADONs K and L, were training the staff. Interviews were conducted with MA Q, LVN G, LVN C, RN H, MA M, MA N, MA D, MA S, LVN R, LVN T, LVN F, LVN E and MA I on 11/01/16 from 12:29 p.m. through 4:48 p.m. The staff knew when to reorder medications, what to do when a medication supply was running low, and what to do when a medication was unavailable. The MAs knew they were to notify the charge nurse, DON or ADONs when a resident was down to a three-day supply of medication and the nurses knew to report to the ADON or DON when they had not received a medication from the pharmacy so the DON or ADON could call the pharmacy regarding delivery time. The nurses knew to communicate any medication concerns to the oncoming nurse and to document the concern in the 24 hour report. On 11/01/16 at 6:10 p.m., the Administrator was informed the IJ was removed. While the IJ was removed on 11/01/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. An undated list of residents, provided by the DON on 10/31/16, reflected 13 residents received anticonvulsants.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, administering and disposition of all drugs and biologicals to meet the needs of one (Resident #1) of 13 residents, reviewed for pharmacy services. The facility failed to obtain Resident #1's physician-ordered levetiracetam (anticonvulsant) resulting in five missed doses over the course of three days. Resident #1 had a seizure on 10/17/16 and was transported to the hospital while still seizing. She was admitted to the hospital. An Immediate Jeopardy (IJ) was identified on 10/31/16. While the IJ was removed on 11/01/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. This failure placed the facility's 13 residents who received anticonvulsants at risk for seizures and worsening of their medical conditions. Findings included: Review of Resident #1's Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had severe cognitive impairment. Resident #1's [DIAGNOSES REDACTED]. The MDS reflected the resident received hospice care while she was a resident. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Comprehensive Plan of Care, dated 09/01/16, revealed . Potential for seizure activity, injury related to seizure disorder Administer medications as ordered and monitor for effectiveness, side effects Review of Resident #1's Medications Flowsheet, dated 10/01/16 - 10/31/16, revealed levetiracetam 1000 mg tablet was not administered to the resident at 8:00 a.m. on 10/15/16, 10/16/16 and 10/17/16 or at 4:00 p.m. on 10/15/16 and 10/16/16. Review of Resident #1's Nurse's Notes revealed . 10/17/16 1645 (4:45 p.m.) Resident up in w/c (wheelchair) in dining room; Began to have seizure; Returned to room et (and) assisted to bed; Continues to have seizure . (LVN C) . 1700 (5:00 p.m.) . Seizure continues; 911 called at this time . (LVN C) . 1720 (5:20 p.m.) . ambulance here; Seizure continues . (LVN C) . 1730 (5:30 p.m.) Transported to (Hospital) via . ambulance at this time . (LVN C) . Review of Resident #1's Physician's Telephone Order, dated 10/17/16, revealed . Send to (Hospital) ER (emergency room ) for seizures . Review of the Resident Transfer Form for Resident #1, dated 10/17/16, revealed . [DIAGNOSES REDACTED]. Seizure Activity . Reason for Transfer Possible Seizure Activity . Review of the facility's 24 Hour Report/Change of Condition Report, dated 10/13/16 - 10/17/16, revealed there was no documentation regarding Resident #1's levetiracetam not being available for administration. The report, dated 10/17/16, reflected the resident was transferred to the hospital for a seizure. Interview on 10/31/16 at 10:04 a.m. with Resident #1 revealed she had a seizure after she did not receive her anticonvulsant medication for three to four days. The resident stated there had been no problems receiving her medication before or after that incident. The resident stated she felt fine now. The resident was unable to provide specific information regarding the incident. Review of the Medication Error Report regarding Resident #1, dated 10/17/16, revealed . Date of error 10/15/16 (and) 10/16/16 Time of error Both doses missed Sat (Saturday), Sun (Sunday) and Mon (Monday) morg (morning) . Description of error (include name of medication, dose, route and time(s) administered) Weekend Medication Aide failed to medicate pt (patient). Outcome to resident Res (Resident) had seizure and was sent to ER (emergency room ) (sic) admitted to hosp (hospital) Measures taken to prevent the recurrence of similar error(s) Inservice started/ongoing on ordering medication Type of Error(s) . Missed 5 doses . Reason for Error(s) . (Medication Aide) - failed to notify nurse . Person making error (MA A and MA B) . Interview on 10/31/16 at 11:17 a.m. with MA B revealed she reordered Resident #1's levetiracetam on 10/12/16 (Wednesday) during her shift (6:00 a.m. to 2:00 p.m.). She stated the resident took levetiracetam twice a day and she last provided the medication in the morning on 10/14/16 (Friday). She stated the pharmacy did not delivery medications during her shift. She stated she notified the hospice agency and LVN G that the resident's levetiracetam was running low and that she had placed a reorder and they both stated they would get back with her. She stated Resident #1 was already at the hospital at the start of her shift (6:00 a.m. to 2:00 p.m.) on 10/17/16 (Monday). She stated she called the pharmacy on 10/17/16 and the resident's medication arrived after the resident was sent to the hospital. Interview on 10/31/16 at 1:04 p.m. with LVN G revealed she worked 6:00 a.m. to 2:00 p.m. with Resident #1 on 10/12/16 to 10/14/16 and 10/17/16. She stated she worked on 10/16/16 (Sunday) but did not work with Resident #1. She stated she was not notified that the resident's levetiracetam was running low or that it was unavailable. She stated there was nothing out of the ordinary with the resident during those shifts. She stated the resident asked for a medication for general pain towards the end of her shift on 10/17/16. She stated she was not aware of any other problems with medication availability. She stated she would call the pharmacy and send the medication reorder via fax if a medication was running low or unavailable. She stated she would notify the oncoming nurse regarding the reorder and follow-up the next day. Interview on 10/31/16 at 11:53 a.m. with MA A revealed he noticed Resident #1's levetiracetam was unavailable during his double shift (6:00 a.m. to 10:00 p.m.) on 10/15/16 (Saturday) and 10/16/16 (Sunday). He stated he informed a female nurse (LVN F) on 10/15/16 and they both faxed a reorder to the pharmacy. He stated he informed a male nurse (LVN E) on 10/16/16 about the resident's medication and he and the nurse searched the medication room but found nothing. He stated the nurses did not follow-up with him after the medication was not obtained. He stated he left a note regarding Resident #1's levetiracetam being unavailable. MA A stated he had just started working at the facility and did not know the names of the nurses he spoke with on 10/15/16 and 10/16/16. Interview on 10/31/16 at 1:57 p.m. with LVN E revealed he worked 6:00 a.m. to 6:00 p.m. on 10/15/16 and 10/16/16. He stated he was not aware that Resident #1's levetiracetam was unavailable. He stated MA A did not inform him that the resident's medication was not administered. He stated he would have tried to contact the DON and pharmacy to find out the best way to get the resident's medication if he had known it was unavailable. He stated there was nothing out of the ordinary with Resident #1 during those shifts. He stated Resident #1 did not make any unusual complaints during those shifts worked. Interview on 11/01/16 at 2:46 p.m. with LVN F revealed she worked 6:00 p.m. to 6:00 a.m. on 10/15/16 and 10/16/16. She stated she was not informed that Resident #1 ' s levetiracetam was unavailable during her shifts over the weekend. She stated she was not aware of any other problems with medication availability. Interview on 10/31/16 at 3:50 p.m. with the DON revealed her focus was to get the staff who worked Monday through Friday in-serviced following the incident with Resident #1 because that was when most medication orders were placed. The DON provided a list of staff that reflected five nurses and MAs who worked on the weekend and six nurses and MAs who worked as needed had not been in-serviced following the incident with Resident #1. Interview on 10/31/16 at 5:17 p.m. with MA D revealed she worked 2:00 p.m. to 10:00 p.m. on 10/12/16 to 10/14/16. She stated she placed a reorder for Resident #1's levetiracetam on 10/13/16 (Thursday). She stated she notified LVN C on 10/14/16 when the medication was not received. MA D stated she thought the morning MA had reordered the resident's medication on 10/12/16 as well. Interview on 10/31/16 at 2:09 p.m. with LVN C revealed she worked 2:00 p.m. to 10:00 p.m. on 10/12/16 to 10/14/16 and 10/17/16. She stated MA D informed her on 10/14/16 there were no more doses of levetiracetam for Resident #1. LVN C stated medications had to be ordered three days prior to the last dose. She stated she faxed the pharmacy which then called the facility. She stated the pharmacy said the resident's levetiracetam would be provided by the hospice agency. She stated she then called the hospice agency to obtain the resident's medication. She stated the resident's medication had not arrived when her shift ended. She stated medications provided by hospice were delivered at all times of the day and night. She stated she assumed the resident's medication would be sent since she had not been informed of any problems by the hospice agency. She stated she could not be sure of what she provided in report to the oncoming nurse. She stated the resident experienced a change in condition during the evening meal on 10/17/16. She stated she was informed the resident was acting strange. She stated MA I said the resident complained of a headache and was requesting a pain medication which was then given. She stated the Administrator informed her the resident was at the front of the building and needed assistance. She stated the resident was then given morphine per her request and the resident then went to the dining room. She stated the resident had a seizure while in the dining room. She stated the resident was then taken to her room, she was laid down, 911 was called and she was transferred to the hospital. Interview on 10/31/16 at 3:02 p.m. with MA I revealed she worked 2:00 p.m. to 10:00 p.m. on 10/17/16. She stated Resident #1 had a seizure around 4:30 p.m. to 5:00 p.m. during the evening meal on 10/17/16. She stated other staff members noticed the resident's face was twitching. She stated she went to check on the resident and the twitching occurred for a few seconds and then stopped. She stated the twitching then started again about 10 minutes later and she went to get LVN C. She stated two staff members were bringing the resident out of the dining room when she and LVN C returned. She stated the resident was taken to her room and 911 was called. MA I stated she had not gotten to the resident's routine medications prior to her seizure. She stated the resident had approached her and asked for a medication for pain before the evening meal. She stated the resident complained of a headache. She stated there was nothing out of the ordinary with the resident at that time. She stated the resident's seizure occurred about an hour later. She stated she had not been in-serviced regarding resident medications following the incident. She stated she next worked at the facility on 10/29/16 following her shift on 10/17/16. Interview on 10/31/16 at 3:57 p.m. with LVN J revealed she worked 10:00 p.m. to 6:00 a.m. on 10/12/16 to 10/14/16 with Resident #1. She stated she was never notified that Resident #1's levetiracetam was unavailable. She stated she found out about the incident on 10/17/16 during report from LVN C. She stated medications were normally reordered when a seven day supply remained. She stated the MAs were responsible for noting which medications needed to be reordered and the request was then signed off by the nurse. Review of Resident #1's hospital History and Physical, dated 10/18/16, revealed . Chief Complaint: Seizure. History of Present Illness . Patient also has seizure disorder. She currently presented to the emergency room via EMS (Emergency Medical Services) due to prolonged seizure, and EMS reported patient was seizing at about 4:45 p.m. on the day of admission and was still seizing at 5:15 p.m. on their arrival. The patient is not known to have any trauma such as tongue bite, head injury. The patient was given Versed (sedative used to treat epilepsy) 5 mg IV (intravenous) push and subsequently 2 mg IV push, and the patient stopped seizing after 2 doses of Versed, and the patient has not had any recurrence of seizures in the emergency room or throughout the day here subsequent to that. The patient is unable to provide any history and is somnolent Past Medical History: Significant for COPD (chronic obstructive pulmonary disease), seizure disorder, dementia, aneurysm, bipolar disorder, congestive heart failure, osteoarthritis, migraine headaches, hypertension Review of Resident #1's hospital Discharge Instructions, dated 10/21/16, revealed the resident was to continue to take one levetiracetam 1000 mg by mouth twice a day. An interview was conducted on 10/31/16 at 9:25 a.m. with the Administrator and DON. The Administrator stated MA B tried to reorder Resident #1's levetiracetam on 10/12/16 when she saw the resident's medication was running low but was unsuccessful. The Administrator stated the resident was on hospice services and the pharmacy did not send out the medication because there was confusion regarding whether the hospice agency was going to provide the medication. The DON stated Resident #1 took levetiracetam twice a day and had missed four doses over the weekend (10/15/16 and 10/16/16). The DON stated MA D gave the last dose of levetiracetam to the resident on 10/14/16 and notified LVN C who then placed a reorder to the pharmacy that same day. The DON stated LVN C thought the resident's medication would arrive later that night. The Administrator stated MA A was new to the facility and worked a double shift on 10/15/16 and 10/16/16. The Administrator stated MA A identified the resident's missed doses of levetiracetam and noted it on the Medication Administration Record. The Administrator stated she believed MA A also left a note on the medication cart regarding the resident's missed doses of levetiracetam but MA A had not reported the concern to the nurse. The Administrator stated weekend LVNs E and F said they were not notified of Resident #1's missed doses of levetiracetam. The DON stated MA B's employment was terminated because she failed to notify the nurse that Resident #1's levetiracetam was unavailable. The DON stated MA A came to the facility on [DATE], wrote a statement regarding the incident and was in-serviced regarding what to do when a medication was not available. The DON stated MA A did not call or show up for his next shift and she was unable to reach him over the telephone following 10/17/16. The DON stated she met with the facility's designated pharmacy and the residents' routine medications were now refilled automatically when the supply became low. The DON stated she obtained a list of all the medications being provided to the residents on hospice to determine what hospice supplied. The DON stated the MAs and nurses were in-serviced regarding what to do when a medication was not available. The DON stated Resident #1's doctor and family were notified. The DON stated full cart audits were completed to make sure resident medications were available. The DON stated some carts were missing over-the-counter medications and the supplies were replenished from the facility's supply. The DON stated the resident medications that were running low had already been reordered and no further missed doses of medications were identified. The DON stated the facility would have paid for Resident #1's levetiracetam if they had known the medication was unavailable. The DON stated she had spoken with the pharmacy within the past week regarding getting levetiracetam added to the facility's emergency kit. Interview on 10/31/16 at 10:30 a.m. with the Administrator revealed Resident #1 did not feel well in the afternoon on 10/17/16. She stated the resident complained of a headache but did not want to lie down. She stated the resident asked that a CNA stay with her. She stated a CNA took the resident to the dining room where she had a seizure. She stated the resident's missed levetiracetam doses were discovered when the facility began to investigate what could have led up to the resident's seizure. She stated the nurse had provided a medication to the resident following her complaint of a headache. She stated MA B did not notify anyone of the resident's missed dose of levetiracetam on 10/17/16. She stated the facility would have sent the resident to the hospital for emergency treatment to possibly prevent the seizure if they had been made aware the resident's medication was unavailable on 10/17/16. Interview on 10/31/16 at 10:37 a.m. with the DON revealed she was still in the process of completing in-services for the incident with Resident #1. She stated some of the staff who had not been in-serviced worked on a PRN (as needed) basis. Interview on 10/31/16 at 4:48 p.m. with the DON revealed no disciplinary action was taken against LVN C. The DON stated she believed LVN C thought the resident's levetiracetam was going to be sent by the hospice agency. The DON stated she did not ask LVN C if she had notified the oncoming nurse regarding the resident's reorder of levetiracetam. According to www.keppraxr.com/includes/pdf/Keppra_Injection_PI.pdf <http://www.keppraxr.com/includes/pdf/Keppra_Injection_PI.pdf> . Antiepileptic drugs, including KEPPRA (levetiracetam), should be withdrawn gradually to minimize the potential of increased seizure frequency Levetiracetam plasma half-life in adults is 7 ± 1 hour and is unaffected by either dose or repeated administration Do not stop KEPPRA without first talking to a healthcare provider. Stopping KEPPRA suddenly can cause serious problems. Stopping a seizure medicine suddenly can cause seizures that will not stop ([DIAGNOSES REDACTED]) Review of the facility's in-service record for CNAs and MAs, dated 10/17/16, revealed . Notify nurse when meds (medications) running low, and or (sic) meds are not delivered by pharmacy (sic) Review of the facility's in-service record for nurses and MAs, dated 10/19/16, revealed . (MA) will be responsible for reordering medications in a timely manner. If medications do not come in you must notify your charge nurse and DON Medication carts will be audited to ensure medications are available. Audit is to include OTC (over the counter) meds (medications) as well Review of the facility's in-service record for nurses and MAs, dated 10/31/16, revealed . Med (Medication) Aides must reorder medication at least 7 days prior to last pill Charge nurse / (and) DON must be notified immediately if medication . is not available or medication is running low . Review of the facility ' s Daily Start Up forms, dated 10/18/16 and 10/28/16, revealed medication cart audits were completed. All resident medications were available and no concerns were noted. Review of the facility's Physician Medication Orders policy and procedure, dated April 2010, revealed . Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available On 10/31/16 at 5:20 p.m. the Administrator and DON were informed an IJ had been identified. At that time, the facility was requested to provide a plan of removal. The facility's Plan of Removal, dated 10/31/16, was accepted on 11/01/16 at 5:55 p.m. and reflected the following: . Corrective Action On 10/19/2016 (MA B) was terminated for failure to order medications timely and failure to inform Charge Nurse / (and) D.O.N. (Director of Nurses) that seizure medication was not ordered / delivered causing negative outcome for (Resident #1). On 10/19/16 D.O.N. and ADON's (Assistant Director of Nurses) performed a completed MAR (Medication Administration Record) to cart audit. No drugs were missing. Nursing Management started cart Audits every Friday and this was added as a part of the morning start up for Fridays. D.O.N. will randomly monitor weekly. The D.O.N. started in-servicing all nurses and medication aides on medication ordering and re-ordering. All med (medication) aides and nurses were not completely in-serviced at the time the surveyor entered the facility on 10/31/16. The D.O.N. or designee will train all employee that have not been trained before the start of their shift. 10/21/16 Automatic re-order was set-up with pharmacy. As of 10/31/16 in-servicing is on going (sic) with nurses and MA's (Medication Aides). The New information that was add (sic) to the in-service is as follows: Staff was informed that all medications are on Automatic Reorder (sic) This means that all medications will be sent to the facility without any information being sent to the pharmacy When you recieve (sic) DC (discontinue) or Changes in dosage you must communicate this to the pharmacy On New admissions all medication must be verified by Dr (Doctor) / PA and medication sheet faxed ASAP (as soon as possible) to pharmacy (sic) followed by a phone call. If the pharmacy tells you that the medication cannot be sent out for ANY reason (sic) Notify the DON or ADON's immediately. If you are the charge nurse and a medication is not delivered prior to the end of your shift, you MUST inform the oncoming nurse and write the information on the 24 hour report to ensure follow up is made on the medication. Nursing staff will not be allowed to work until they have been in-serviced regarding ordering and re-ordering of medications. As of 11/1/16 all nurses and medication aides have been re-inserviced with the new information except for 2 employees who will not be allowed to work until they have been re-inservice (sic) by the DON or ADON. 11/01/16 nurses & M.A's will recieve (sic) a pre and post test administered by the D.O.N. / ADON's regarding the ordering and re-ordering of medications. The nurses and MA's will not be able to work until they have passed the post test. All newly hired nurses and MA's will be in-serviced and given the pre & post test prior to working To verify the facility implemented their Plan of Removal the following observations and interviews were obtained and the following records were reviewed. Observation on 10/31/16 at 4:26 p.m. revealed the anticonvulsant medications for Residents #1 - #13 were available for administration. Review of the Medication Administration Records / Treatment Administration Records / Medications Flowsheets, dated 10/01/16 - 10/31/16 for Residents #2 - #13 did not reveal missed anticonvulsant medications. Review of the facility ' s in-service training, dated 11/01/16, revealed RNs, LVNs and MAs completed pre and posttests regarding when a medication should be reordered and steps to take if a medication has not been received in a timely manner or is missing, which included notifying the oncoming nurse and documenting on the 24 hour report to ensure follow-up. Review of a statement provided by the facility's designated pharmacy, dated 10/31/16, revealed resident medications were placed on auto refill beginning 10/21/16. Review of the Refills Due report from the facility's designated pharmacy, dated 10/31/16, revealed resident medications were listed along with the medication expiration dates. The report reflected how much of each medication would be delivered along with the listed date of delivery. An interview was conducted with the Administrator and DON on 11/01/16 at 9:16 a.m. The DON stated she did not believe there was a widespread problem at the facility regarding resident medications. The DON stated there had been no other incidents at the facility regarding a medication not being administered and there was no problem with medication availability. The DON and Administrator both stated staff would not be allowed to work until they completed the required training regarding the incident with Resident #1. The Administrator stated the required training would be completed for all staff on 11/01/16. The Administrator stated PRN staff who had not worked in a while would be taken off the schedule. The DON stated the staff would complete the required training at the facility or it would be done over the phone. The DON stated she, along with ADONs K and L, were training the staff. Interviews were conducted with MA Q, LVN G, LVN C, RN H, MA M, MA N, MA D, MA S, LVN R, LVN T, LVN F, LVN E and MA I on 11/01/16 from 12:29 p.m. through 4:48 p.m. The staff knew when to reorder medications, what to do when a medication supply was running low, and what to do when a medication was unavailable. The MAs knew they were to notify the charge nurse, DON or ADONs when a resident was down to a three-day supply of medication and the nurses knew to report to the ADON or DON when they had not received a medication from the pharmacy so the DON or ADON could call the pharmacy regarding delivery time. The nurses knew to communicate any medication concerns to the oncoming nurse and to document the concern in the 24 hour report. On 11/01/16 at 6:10 p.m., the Administrator was informed the IJ was removed. While the IJ was removed on 11/01/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. An undated list of residents, provided by the DON on 10/31/16, reflected 13 residents received anticonvulsants.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of 13 residents reviewed for quality of care. The facility failed to obtain Resident #1's physician-ordered levetiracetam (anticonvulsant) resulting in five missed doses over the course of three days. Resident #1 had a [MEDICAL CONDITION] on 10/17/16 and was transported to the hospital while still seizing. She was admitted to the hospital. An Immediate Jeopardy (IJ) was identified on 10/31/16. While the IJ was removed on 11/01/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. This failure placed the facility's 13 residents who received anticonvulsants at risk for [MEDICAL CONDITION] and worsening of their medical conditions. Findings included: Review of Resident #1's Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had severe cognitive impairment. Resident #1's [DIAGNOSES REDACTED]. The MDS reflected the resident received hospice care while she was a resident. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Comprehensive Plan of Care, dated 09/01/16, revealed . Potential for [MEDICAL CONDITION] activity, injury related to [MEDICAL CONDITION] disorder Administer medications as ordered and monitor for effectiveness, side effects Review of Resident #1's Medications Flowsheet, dated 10/01/16 - 10/31/16, revealed levetiracetam 1000 mg tablet was not administered to the resident at 8:00 a.m. on 10/15/16, 10/16/16 and 10/17/16 or at 4:00 p.m. on 10/15/16 and 10/16/16. Review of Resident #1's Nurse's Notes revealed . 10/17/16 1645 (4:45 p.m.) Resident up in w/c (wheelchair) in dining room; Began to have [MEDICAL CONDITION]; Returned to room et (and) assisted to bed; Continues to have [MEDICAL CONDITION] . (LVN C) . 1700 (5:00 p.m.) . [MEDICAL CONDITION] continues; 911 called at this time . (LVN C) . 1720 (5:20 p.m.) . ambulance here; [MEDICAL CONDITION] continues . (LVN C) . 1730 (5:30 p.m.) Transported to (Hospital) via . ambulance at this time . (LVN C) . Review of Resident #1's Physician's Telephone Order, dated 10/17/16, revealed . Send to (Hospital) ER (emergency room ) for [MEDICAL CONDITION] . Review of the Resident Transfer Form for Resident #1, dated 10/17/16, revealed . [DIAGNOSES REDACTED]. [MEDICAL CONDITION] Activity . Reason for Transfer Possible [MEDICAL CONDITION] Activity . Review of the facility's 24 Hour Report/Change of Condition Report, dated 10/13/16 - 10/17/16, revealed there was no documentation regarding Resident #1's levetiracetam not being available for administration. The report, dated 10/17/16, reflected the resident was transferred to the hospital for a [MEDICAL CONDITION]. Interview on 10/31/16 at 10:04 a.m. with Resident #1 revealed she had a [MEDICAL CONDITION] after she did not receive her anticonvulsant medication for three to four days. The resident stated there had been no problems receiving her medication before or after that incident. The resident stated she felt fine now. The resident was unable to provide specific information regarding the incident. Review of the Medication Error Report regarding Resident #1, dated 10/17/16, revealed . Date of error 10/15/16 (and) 10/16/16 Time of error Both doses missed Sat (Saturday), Sun (Sunday) and Mon (Monday) morg (morning) . Description of error (include name of medication, dose, route and time(s) administered) Weekend Medication Aide failed to medicate pt (patient). Outcome to resident Res (Resident) had [MEDICAL CONDITION] and was sent to ER (emergency room ) (sic) admitted to hosp (hospital) Measures taken to prevent the recurrence of similar error(s) Inservice started/ongoing on ordering medication Type of Error(s) . Missed 5 doses . Reason for Error(s) . (Medication Aide) - failed to notify nurse . Person making error (MA A and MA B) . Interview on 10/31/16 at 11:17 a.m. with MA B revealed she reordered Resident #1's levetiracetam on 10/12/16 (Wednesday) during her shift (6:00 a.m. to 2:00 p.m.). She stated the resident took levetiracetam twice a day and she last provided the medication in the morning on 10/14/16 (Friday). She stated the pharmacy did not delivery medications during her shift. She stated she notified the hospice agency and LVN G that the resident's levetiracetam was running low and that she had placed a reorder and they both stated they would get back with her. She stated Resident #1 was already at the hospital at the start of her shift (6:00 a.m. to 2:00 p.m.) on 10/17/16 (Monday). She stated she called the pharmacy on 10/17/16 and the resident's medication arrived after the resident was sent to the hospital. Interview on 10/31/16 at 1:04 p.m. with LVN G revealed she worked 6:00 a.m. to 2:00 p.m. with Resident #1 on 10/12/16 to 10/14/16 and 10/17/16. She stated she worked on 10/16/16 (Sunday) but did not work with Resident #1. She stated she was not notified that the resident's levetiracetam was running low or that it was unavailable. She stated there was nothing out of the ordinary with the resident during those shifts. She stated the resident asked for a medication for general pain towards the end of her shift on 10/17/16. She stated she was not aware of any other problems with medication availability. She stated she would call the pharmacy and send the medication reorder via fax if a medication was running low or unavailable. She stated she would notify the oncoming nurse regarding the reorder and follow-up the next day. Interview on 10/31/16 at 11:53 a.m. with MA A revealed he noticed Resident #1's levetiracetam was unavailable during his double shift (6:00 a.m. to 10:00 p.m.) on 10/15/16 (Saturday) and 10/16/16 (Sunday). He stated he informed a female nurse (LVN F) on 10/15/16 and they both faxed a reorder to the pharmacy. He stated he informed a male nurse (LVN E) on 10/16/16 about the resident's medication and he and the nurse searched the medication room but found nothing. He stated the nurses did not follow-up with him after the medication was not obtained. He stated he left a note regarding Resident #1's levetiracetam being unavailable. MA A stated he had just started working at the facility and did not know the names of the nurses he spoke with on 10/15/16 and 10/16/16. Interview on 10/31/16 at 1:57 p.m. with LVN E revealed he worked 6:00 a.m. to 6:00 p.m. on 10/15/16 and 10/16/16. He stated he was not aware that Resident #1's levetiracetam was unavailable. He stated MA A did not inform him that the resident's medication was not administered. He stated he would have tried to contact the DON and pharmacy to find out the best way to get the resident's medication if he had known it was unavailable. He stated there was nothing out of the ordinary with Resident #1 during those shifts. He stated Resident #1 did not make any unusual complaints during those shifts worked. Interview on 11/01/16 at 2:46 p.m. with LVN F revealed she worked 6:00 p.m. to 6:00 a.m. on 10/15/16 and 10/16/16. She stated she was not informed that Resident #1 ' s levetiracetam was unavailable during her shifts over the weekend. She stated she was not aware of any other problems with medication availability. Interview on 10/31/16 at 3:50 p.m. with the DON revealed her focus was to get the staff who worked Monday through Friday in-serviced following the incident with Resident #1 because that was when most medication orders were placed. The DON provided a list of staff that reflected five nurses and MAs who worked on the weekend and six nurses and MAs who worked as needed had not been in-serviced following the incident with Resident #1. Interview on 10/31/16 at 5:17 p.m. with MA D revealed she worked 2:00 p.m. to 10:00 p.m. on 10/12/16 to 10/14/16. She stated she placed a reorder for Resident #1's levetiracetam on 10/13/16 (Thursday). She stated she notified LVN C on 10/14/16 when the medication was not received. MA D stated she thought the morning MA had reordered the resident's medication on 10/12/16 as well. Interview on 10/31/16 at 2:09 p.m. with LVN C revealed she worked 2:00 p.m. to 10:00 p.m. on 10/12/16 to 10/14/16 and 10/17/16. She stated MA D informed her on 10/14/16 there were no more doses of levetiracetam for Resident #1. LVN C stated medications had to be ordered three days prior to the last dose. She stated she faxed the pharmacy which then called the facility. She stated the pharmacy said the resident's levetiracetam would be provided by the hospice agency. She stated she then called the hospice agency to obtain the resident's medication. She stated the resident's medication had not arrived when her shift ended. She stated medications provided by hospice were delivered at all times of the day and night. She stated she assumed the resident's medication would be sent since she had not been informed of any problems by the hospice agency. She stated she could not be sure of what she provided in report to the oncoming nurse. She stated the resident experienced a change in condition during the evening meal on 10/17/16. She stated she was informed the resident was acting strange. She stated MA I said the resident complained of a headache and was requesting a pain medication which was then given. She stated the Administrator informed her the resident was at the front of the building and needed assistance. She stated the resident was then given [MEDICATION NAME] per her request and the resident then went to the dining room. She stated the resident had a [MEDICAL CONDITION] while in the dining room. She stated the resident was then taken to her room, she was laid down, 911 was called and she was transferred to the hospital. Interview on 10/31/16 at 3:02 p.m. with MA I revealed she worked 2:00 p.m. to 10:00 p.m. on 10/17/16. She stated Resident #1 had a [MEDICAL CONDITION] around 4:30 p.m. to 5:00 p.m. during the evening meal on 10/17/16. She stated other staff members noticed the resident's face was twitching. She stated she went to check on the resident and the twitching occurred for a few seconds and then stopped. She stated the twitching then started again about 10 minutes later and she went to get LVN C. She stated two staff members were bringing the resident out of the dining room when she and LVN C returned. She stated the resident was taken to her room and 911 was called. MA I stated she had not gotten to the resident's routine medications prior to her [MEDICAL CONDITION]. She stated the resident had approached her and asked for a medication for pain before the evening meal. She stated the resident complained of a headache. She stated there was nothing out of the ordinary with the resident at that time. She stated the resident's [MEDICAL CONDITION] occurred about an hour later. She stated she had not been in-serviced regarding resident medications following the incident. She stated she next worked at the facility on 10/29/16 following her shift on 10/17/16. Interview on 10/31/16 at 3:57 p.m. with LVN J revealed she worked 10:00 p.m. to 6:00 a.m. on 10/12/16 to 10/14/16 with Resident #1. She stated she was never notified that Resident #1's levetiracetam was unavailable. She stated she found out about the incident on 10/17/16 during report from LVN C. She stated medications were normally reordered when a seven day supply remained. She stated the MAs were responsible for noting which medications needed to be reordered and the request was then signed off by the nurse. Review of Resident #1's hospital History and Physical, dated 10/18/16, revealed . Chief Complaint: [MEDICAL CONDITION]. History of Present Illness . Patient also has [MEDICAL CONDITION] disorder. She currently presented to the emergency room via EMS (Emergency Medical Services) due to prolonged [MEDICAL CONDITION], and EMS reported patient was seizing at about 4:45 p.m. on the day of admission and was still seizing at 5:15 p.m. on their arrival. The patient is not known to have any trauma such as tongue bite, head injury. The patient was given Versed (sedative used to treat [MEDICAL CONDITION]) 5 mg IV (intravenous) push and subsequently 2 mg IV push, and the patient stopped seizing after 2 doses of Versed, and the patient has not had any recurrence of [MEDICAL CONDITION] in the emergency room or throughout the day here subsequent to that. The patient is unable to provide any history and is somnolent Past Medical History: Significant for [MEDICAL CONDITION] [MEDICAL CONDITION] disorder, dementia, aneurysm, [MEDICAL CONDITION] disorder, [MEDICAL CONDITIONS], migraine headaches, hypertension Review of Resident #1's hospital Discharge Instructions, dated 10/21/16, revealed the resident was to continue to take one levetiracetam 1000 mg by mouth twice a day. An interview was conducted on 10/31/16 at 9:25 a.m. with the Administrator and DON. The Administrator stated MA B tried to reorder Resident #1's levetiracetam on 10/12/16 when she saw the resident's medication was running low but was unsuccessful. The Administrator stated the resident was on hospice services and the pharmacy did not send out the medication because there was confusion regarding whether the hospice agency was going to provide the medication. The DON stated Resident #1 took levetiracetam twice a day and had missed four doses over the weekend (10/15/16 and 10/16/16). The DON stated MA D gave the last dose of levetiracetam to the resident on 10/14/16 and notified LVN C who then placed a reorder to the pharmacy that same day. The DON stated LVN C thought the resident's medication would arrive later that night. The Administrator stated MA A was new to the facility and worked a double shift on 10/15/16 and 10/16/16. The Administrator stated MA A identified the resident's missed doses of levetiracetam and noted it on the Medication Administration Record. The Administrator stated she believed MA A also left a note on the medication cart regarding the resident's missed doses of levetiracetam but MA A had not reported the concern to the nurse. The Administrator stated weekend LVNs E and F said they were not notified of Resident #1's missed doses of levetiracetam. The DON stated MA B's employment was terminated because she failed to notify the nurse that Resident #1's levetiracetam was unavailable. The DON stated MA A came to the facility on [DATE], wrote a statement regarding the incident and was in-serviced regarding what to do when a medication was not available. The DON stated MA A did not call or show up for his next shift and she was unable to reach him over the telephone following 10/17/16. The DON stated she met with the facility's designated pharmacy and the residents' routine medications were now refilled automatically when the supply became low. The DON stated she obtained a list of all the medications being provided to the residents on hospice to determine what hospice supplied. The DON stated the MAs and nurses were in-serviced regarding what to do when a medication was not available. The DON stated Resident #1's doctor and family were notified. The DON stated full cart audits were completed to make sure resident medications were available. The DON stated some carts were missing over-the-counter medications and the supplies were replenished from the facility's supply. The DON stated the resident medications that were running low had already been reordered and no further missed doses of medications were identified. The DON stated the facility would have paid for Resident #1's levetiracetam if they had known the medication was unavailable. The DON stated she had spoken with the pharmacy within the past week regarding getting levetiracetam added to the facility's emergency kit. Interview on 10/31/16 at 10:30 a.m. with the Administrator revealed Resident #1 did not feel well in the afternoon on 10/17/16. She stated the resident complained of a headache but did not want to lie down. She stated the resident asked that a CNA stay with her. She stated a CNA took the resident to the dining room where she had a [MEDICAL CONDITION]. She stated the resident's missed levetiracetam doses were discovered when the facility began to investigate what could have led up to the resident's [MEDICAL CONDITION]. She stated the nurse had provided a medication to the resident following her complaint of a headache. She stated MA B did not notify anyone of the resident's missed dose of levetiracetam on 10/17/16. She stated the facility would have sent the resident to the hospital for emergency treatment to possibly prevent the [MEDICAL CONDITION] if they had been made aware the resident's medication was unavailable on 10/17/16. Interview on 10/31/16 at 10:37 a.m. with the DON revealed she was still in the process of completing in-services for the incident with Resident #1. She stated some of the staff who had not been in-serviced worked on a PRN (as needed) basis. Interview on 10/31/16 at 4:48 p.m. with the DON revealed no disciplinary action was taken against LVN C. The DON stated she believed LVN C thought the resident's levetiracetam was going to be sent by the hospice agency. The DON stated she did not ask LVN C if she had notified the oncoming nurse regarding the resident's reorder of levetiracetam. According to www.[MEDICATION NAME].com/includes/pdf/[MEDICATION NAME].pdf <http://www.[MEDICATION NAME].com/includes/pdf/[MEDICATION NAME].pdf> . Antiepileptic drugs, including [MEDICATION NAME] (levetiracetam), should be withdrawn gradually to minimize the potential of increased [MEDICAL CONDITION] frequency Levetiracetam plasma half-life in adults is 7 ± 1 hour and is unaffected by either dose or repeated administration Do not stop [MEDICATION NAME] without first talking to a healthcare provider. Stopping [MEDICATION NAME] suddenly can cause serious problems. Stopping a [MEDICAL CONDITION] medicine suddenly can cause [MEDICAL CONDITION] that will not stop ([DIAGNOSES REDACTED]) Review of the facility's in-service record for CNAs and MAs, dated 10/17/16, revealed . Notify nurse when meds (medications) running low, and or (sic) meds are not delivered by pharmacy (sic) Review of the facility's in-service record for nurses and MAs, dated 10/19/16, revealed . (MA) will be responsible for reordering medications in a timely manner. If medications do not come in you must notify your charge nurse and DON Medication carts will be audited to ensure medications are available. Audit is to include OTC (over the counter) meds (medications) as well Review of the facility's in-service record for nurses and MAs, dated 10/31/16, revealed . Med (Medication) Aides must reorder medication at least 7 days prior to last pill Charge nurse / (and) DON must be notified immediately if medication . is not available or medication is running low . Review of the facility ' s Daily Start Up forms, dated 10/18/16 and 10/28/16, revealed medication cart audits were completed. All resident medications were available and no concerns were noted. Review of the facility's Physician Medication Orders policy and procedure, dated April 2010, revealed . Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available On 10/31/16 at 5:20 p.m. the Administrator and DON were informed an IJ had been identified. At that time, the facility was requested to provide a plan of removal. The facility's Plan of Removal, dated 10/31/16, was accepted on 11/01/16 at 5:55 p.m. and reflected the following: . Corrective Action On 10/19/2016 (MA B) was terminated for failure to order medications timely and failure to inform Charge Nurse / (and) D.O.N. (Director of Nurses) that [MEDICAL CONDITION] medication was not ordered / delivered causing negative outcome for (Resident #1). On 10/19/16 D.O.N. and ADON's (Assistant Director of Nurses) performed a completed MAR (Medication Administration Record) to cart audit. No drugs were missing. Nursing Management started cart Audits every Friday and this was added as a part of the morning start up for Fridays. D.O.N. will randomly monitor weekly. The D.O.N. started in-servicing all nurses and medication aides on medication ordering and re-ordering. All med (medication) aides and nurses were not completely in-serviced at the time the surveyor entered the facility on 10/31/16. The D.O.N. or designee will train all employee that have not been trained before the start of their shift. 10/21/16 Automatic re-order was set-up with pharmacy. As of 10/31/16 in-servicing is on going (sic) with nurses and MA's (Medication Aides). The New information that was add (sic) to the in-service is as follows: Staff was informed that all medications are on Automatic Reorder (sic) This means that all medications will be sent to the facility without any information being sent to the pharmacy When you recieve (sic) DC (discontinue) or Changes in dosage you must communicate this to the pharmacy On New admissions all medication must be verified by Dr (Doctor) / PA and medication sheet faxed ASAP (as soon as possible) to pharmacy (sic) followed by a phone call. If the pharmacy tells you that the medication cannot be sent out for ANY reason (sic) Notify the DON or ADON's immediately. If you are the charge nurse and a medication is not delivered prior to the end of your shift, you MUST inform the oncoming nurse and write the information on the 24 hour report to ensure follow up is made on the medication. Nursing staff will not be allowed to work until they have been in-serviced regarding ordering and re-ordering of medications. As of 11/1/16 all nurses and medication aides have been re-inserviced with the new information except for 2 employees who will not be allowed to work until they have been re-inservice (sic) by the DON or ADON. 11/01/16 nurses & M.A's will recieve (sic) a pre and post test administered by the D.O.N. / ADON's regarding the ordering and re-ordering of medications. The nurses and MA's will not be able to work until they have passed the post test. All newly hired nurses and MA's will be in-serviced and given the pre & post test prior to working To verify the facility implemented their Plan of Removal the following observations and interviews were obtained and the following records were reviewed. Observation on 10/31/16 at 4:26 p.m. revealed the anticonvulsant medications for Residents #1 - #13 were available for administration. Review of the Medication Administration Records / Treatment Administration Records / Medications Flowsheets, dated 10/01/16 - 10/31/16 for Residents #2 - #13 did not reveal missed anticonvulsant medications. Review of the facility ' s in-service training, dated 11/01/16, revealed RNs, LVNs and MAs completed pre and posttests regarding when a medication should be reordered and steps to take if a medication has not been received in a timely manner or is missing, which included notifying the oncoming nurse and documenting on the 24 hour report to ensure follow-up. Review of a statement provided by the facility's designated pharmacy, dated 10/31/16, revealed resident medications were placed on auto refill beginning 10/21/16. Review of the Refills Due report from the facility's designated pharmacy, dated 10/31/16, revealed resident medications were listed along with the medication expiration dates. The report reflected how much of each medication would be delivered along with the listed date of delivery. An interview was conducted with the Administrator and DON on 11/01/16 at 9:16 a.m. The DON stated she did not believe there was a widespread problem at the facility regarding resident medications. The DON stated there had been no other incidents at the facility regarding a medication not being administered and there was no problem with medication availability. The DON and Administrator both stated staff would not be allowed to work until they completed the required training regarding the incident with Resident #1. The Administrator stated the required training would be completed for all staff on 11/01/16. The Administrator stated PRN staff who had not worked in a while would be taken off the schedule. The DON stated the staff would complete the required training at the facility or it would be done over the phone. The DON stated she, along with ADONs K and L, were training the staff. Interviews were conducted with MA Q, LVN G, LVN C, RN H, MA M, MA N, MA D, MA S, LVN R, LVN T, LVN F, LVN E and MA I on 11/01/16 from 12:29 p.m. through 4:48 p.m. The staff knew when to reorder medications, what to do when a medication supply was running low, and what to do when a medication was unavailable. The MAs knew they were to notify the charge nurse, DON or ADONs when a resident was down to a three-day supply of medication and the nurses knew to report to the ADON or DON when they had not received a medication from the pharmacy so the DON or ADON could call the pharmacy regarding delivery time. The nurses knew to communicate any medication concerns to the oncoming nurse and to document the concern in the 24 hour report. On 11/01/16 at 6:10 p.m., the Administrator was informed the IJ was removed. While the IJ was removed on 11/01/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. An undated list of residents, provided by the DON on 10/31/16, reflected 13 residents received anticonvulsants.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #1) of two residents reviewed for ADL decline did not diminish in his abilities to perform ADLs. Since 10/20/10 to the present, Resident #1 was neither asked nor provided the opportunity to get out of bed, take a shower, or sit up in a Geri-chair. The facility failed to follow therapist orders/physician orders and did not provide range of motion exercises to Resident #1 as ordered to prevent further or worsening contracture. Staff did not know how to provide range of motion exercises for Resident #1 and range of motion exercises were not included in the facility's ADL book for Resident #1. These failures resulted in Resident #1 experiencing a further decline in contractures of his body, became rigid and unable to bend at the waist and became bed bound with the inability to be transferred to a Geri chair or currently to a Hoyer lift. Resident #1 declined from needing extensive assistance from staff to requiring total assistance from the staff for all ADLs. These failures could affect the 23 residents with contractures, the 53 residents, who required the assistance of staff for bathing; 31 residents, who required the assistance of staff for dressing; 21 residents, who required the assistance of staff for transferring; six residents, who required the assistance of staff for toileting; and nine residents, who required the assistance of staff for eating at risk for decline and requiring the total assistance of staff with ADLs, resulting in a decreased qulaity of life and the development or furthering of depression and decreased socialization. Findings included: The MDS assessment dated [DATE] reflected Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 10/03/11 at 9:15 AM, the surveyor and LVN A conducted observation rounds. As the surveyor observed Resident #1, LVN A stated, "____ (Resident #1) is bed bound. He does not get up. He has a [DEVICE] with continuous feedings, unclear speech and uses a communication board. ____ (Resident #1) requires total care for all activities of daily living." LVN A then stated Resident #1 was alert and refused to get up. While the surveyor was in the room, Resident #1 attempted to communicate. The surveyor could not understand Resident #1 and promised the resident the surveyor would return to hear what he had to say. During the noon meal on 10/03/11 at 12:20 PM, the surveyor returned to Resident #1's room and communicated with the resident. The communication took a long time, because he had a communication problem. The surveyor was finally able to determine what the resident stated. Resident #1 stated, "I heard nurse. I want to get up. I want a shower. No one get me up." (Symbol for residents own words.) On 10/03/11 at 12:57 PM, a second interview was conducted with LVN A. LVN A repeated Resident #1 was bed bound. LVN A further stated the resident did not receive showers and only received bed baths. LVN A stated Resident #1 was provided total care. The LVN stated the resident did not have any skin problems, but both of his legs were severely contracted. The surveyor asked LVN A if he (LVN A) had ever asked Resident #1 to get up or to get a shower. LVN A said, "No. I never asked ____ (Resident #1) if he wanted to get up or to get a shower. I was told by the CNAs ____ (Resident #1) was a bed bath and refused to get up." On 10/04/11 at 10:47 AM, an interview was conducted with LVN B, ADON, concerning Resident #1. LVN B stated Resident #1 could not be transferred for a shower, because the Hoyer lift in the facility did not have the appropriate sling. LVN B stated Resident #1 was rigid, and the facility needed to purchase a sling, which was adjustable and could accommodate Resident #1's contractures. LVN B stated Resident #1 could bend some at the waist, but not enough to get up in the shower chair. LVN B stated he explained to Resident #1 why he could not be transferred for a shower. LVN B stated he (LVN B) had only observed Resident #1 up in the wheelchair twice since he had started working at the facility in August 2010. The surveyor asked LVN B if he (LVN B) had ever asked Resident #1 if he wanted to get up or if he wanted a shower. LVN B stated, "No. I was told ____ (Resident #1) refused to get up in the Geri chair, because it was painful." The surveyor asked LVN B if the physician was notified of the pain when Resident #1 was transferred to the Geri chair. LVN B reviewed Resident #1's nurses' notes and medical record to locate documentation. LVN B stated, "I could not find any documentation if the physician was notified of Resident #1's pain when the resident was transferred to sit up. I found one nurses note dated 03/07/10 where ____ (Resident #1) did not want to get up in the chair for church services." On 10/04/11 at 2:00 PM, a third interview was conducted with LVN A, Resident #1's nurse. LVN A stated this morning and yesterday he had asked Resident #1 if he wanted to get up, and Resident #1 said he wanted a shower. LVN A stated he called the physical therapist and told the physical therapist Resident #1 needed a Hoyer lift, which was adjustable with a sling so Resident #1 could transfer into the shower. LVN A opened the bathroom door and stated, "Yes. ____ (Resident #1) will be able to shower. The bathroom is large enough." LVN A then stated, "I worked in the facility since March 2011 and was told by the CNAs, ____ (Resident #1) would not allow anyone to get him up for a shower." Noted: This occurred after the surveyor asked Resident #1 if he wanted to get up for a shower and Resident #1 said yes. On 10/04/11 at 2:22 PM, the physical therapist was called to Resident #1's room. The physical therapist stated he was new in the facility, and he would evaluate Resident #1 for PT, OT, and ST on 10/05/11. The PT stated he would ask for a doctor's order. The PT Director stated he would start looking for a sling, which would fit the Hoyer lift. He further stated, because of Resident #1's contracted leg, the left leg flexed into the right leg, it was difficult to get the resident up without special equipment. On 10/05/11 at 9:00 AM, an interview was conducted with the DON concerning Resident #1 being transferred out of bed. The DON stated she was hired on 09/21/10 as the weekend RN and became the DON in November 2010. The DON stated she never saw Resident #1 up on the weekends when she was working weekends. The DON further stated Resident #1's left leg was contracted, and he extended his right leg. The DON stated the CNA told her Resident #1 had gotten up in the past, it caused the resident pain and they did not try to get him up anymore. The DON stated LVN I told her Resident #1 did not want to get up. The surveyor asked the DON if anyone had asked Resident #1 to get up in the last 10 months. The DON stated she did not know. She said she did not ask him to get up. An interview was conducted with LVN B at 9:10 AM on 10/05/11. LVN B stated he reviewed Resident #1's care plan, and he would have to look to see why the staff was not getting Resident #1 out of bed. The surveyor asked LVN B if any of the nurses took the initiative to ask Resident #1 about getting up for a shower or getting up in the Geri-chair. LVN B stated, "No." The surveyor asked if since October 2010, had any staff in the facility asked Resident #1 about getting up for a shower or getting up in the Geri chair. LVN B stated, "I do not know any staff, who attempted or asked Resident #1 to get out of bed." On 10/05/11 at 9:20 AM, an interview was conducted with LVN I. LVN I was asked if when she worked with Resident #1, hadshe ever tried to get him out of bed or had talked with the resident about getting out of bed or getting up in the Geri-chair. LVN I stated Resident #1 had gotten up in the wheelchair in 2010, it caused pain and then he had therapy. LVN I stated Resident #1 was up in the Geri-chair, because it caused less pain. LVN I further stated Resident #1 used to get up in the Hoyer lift and attended activities until he was transferred to the hospital for uncontrolled [MEDICAL CONDITION]. LVN I stated she had not seen Resident #1 out of bed since he returned to the facility from the hospital. Review of the MDS assessment dated [DATE] revealed: Functional Status A. Bed mobility: Extensive assistance one person physical assist B. Dressing: Extensive assistance with one person physical assist C. Eating: Extensive assistance with one person physical assist D. Toilet use: Extensive assistance with one person physical assist E. Personal Hygiene: Extensive assistance F. Mobility Devices: Wheelchair Review of the MDS assessment dated [DATE] revealed: Functional Status A. Bed mobility: Total dependence full staff performance every time B. Dressing: Total dependence full staff performance every time C. Eating: Total dependence full staff performance every time D. Toilet use: Total dependence full staff performance every time E. Personal Hygiene: Total dependence full staff performance every time F. Mobility Devices - zero. On 10/05/11 at 2:45 PM, the surveyor and LVN B reviewed Resident #1's plan of care, which was updated and continued on 11/24/10, 02/09/11, 04/27/11, and 07/20/11. It reflected the following: (1) Problem: potential for complications related to [MEDICAL CONDITION], as evidenced by decline in ADLs, abilities, cognitive impairment, communication impaired, dysphasia, behavior problems on visual disturbances. Approaches: 1) Gentle range of motion as tolerated with daily care. 2) Provide adaptive equipment as needed. Instruct and monitor use of adaptive equipment. 3) PT/OT, ST evaluation and treatment as ordered. (2) Problem: Mobility impaired related to contractures, right leg, left leg. The goal will increase active joint range of motion over the next 60 days. Approaches: 1) Active/passive range of motion (exercises). 2) Assist out of bed several times daily or as ordered. 3) Encourage and promote exercise with any degree of toleration to promote pain relief. Review of the physician's orders dated 10/04/10 revealed: Discharge patient to Restorative Nurse (RNT) Physician's orders dated 10/02/10: OT to evaluated and treat as indicated. On 10/04/10, physical therapy discharged Resident #1. Review of the physical therapy assessment dated [DATE] revealed "patient with poor rehabilitation potential, has been on PT treatment before with poor progress. The patient will be placed on RNT for range of motion exercise and positioning in bed to prevent further contractures." On 10/05/11 at 9:30 AM, an interview was conducted with CNA K. CNA K was asked if she provided assistance to get Resident #1 out of bed or to the shower, and whether she provided range of motion exercises to Resident #1. CNA K stated she provided total care to Resident #1, but she did not provide range of motion exercises. CNA K stated she did not know Resident #! was supposed to receive range of motion and she had not been trained in doing range of motion on residents. CNA K stated she was told the resident was bed bound and would not get out of bed, so she did not attempt to get him up. On 10/05/11 at 9:35 AM, an interview was conducted with CNA L concerning Resident #1 getting out of bed, up to the shower or whether she conducted his range of motion exercises. CNA L stated she provided total care. She said she massaged Resident #1's feet, and she did not get him out of bed. CNA L stated she had not seen Resident #1 out of bed since she had started working there, she did not know how to do range of motion exercises and did not know he was to receive range of motion exercises. On 10/05/11 at 9:52 AM, an interview was conducted with LVN A concerning care for Resident #1 and range of motion exercises. LVN A stated "someone else" prepared the daily schedules for the CNAs. LVN A stated he did not see range of motion exercises on the CNAs' assignments for Resident #1. LVN A reviewed the ADL book. No documentation was found for range of motion exercises provided by CNAs for Resident #1. An interview was conducted on 10/05/11 at 10:00 AM with CNA M concerning Resident #1 getting up for a shower and his range of motion exercises. CNA M stated she provided total care to Resident #1, but she did not ask him to get up for showers, because on the CNA sheet, it indicated bed bath. She stated she had given him a bed bath. She said for as long as she had worked at the facility, she had never gotten him up for a shower. CNA M stated she was never taught how to do range of motion exercises for Resident #1. CNA M stated she had tried to move Resident #1's limbs on her own, but no one had trained her on what to do. Review of the facility's ADL book dated 10/05/11 and review of the facility's ADL book for recent months revealed range of motion exercises were not included or indicated as something to be provided for Resident #1. Review of the facility's ADL flow record revealed no documentation of range of motion exercises for Resident #1. The physical therapist provided a report dated 10/06/11 to the surveyor in regard to Resident #1. The physical therapist told the surveyor he would work with the staff and train CNAs on range of motion to prevent further contractures. The report reflected: "Try level of function, bed bound with contractures. The patient is bed bound with contractures and currently not getting out of bed. PT consulted by nursing to assess safety transfer and range of motion assessment. The patient cannot sit secondary to contractures and unable to dissociate trunk from pelvis currently for sitting. The patient can moderately roll to the left side, but moderately roll to the right side. Only right arm follows gross motor skills. Pain: The patient moans when attempting to do range of motion, pain in his leg and left arm. Further review of the evaluation of PT, the patient is very limited by contractures. The patient is unable to actively have any control. PT sling was assessed and facility Hoyer lift was not appropriate and lack adjustments to safely get patient up based on contractures and postural extensions. PT performed gentle TROMB range of motion to legs and left arm and 15 to 20 repeats with 10 to 15-second hold. PT is limited by severe right hip internal rotation and flexion limiting left leg from flexion." Review of Resident #1's documentation and staff interviews, October 2010 Resident #1 was transferred to the wheelchair and Geri chair. The resident, after October 2010, was never transferred out of bed in the Geri chair or wheelchair. Therefore, ADL decline occurred and he received contractures that prevented him from getting into a wheelchair or Geri chair at this time. The facility ' s equipment for the Hoyer lift will not accommodate Resident #1. The resident had deteriorated in one year from being transferred into a wheelchair/ Geri chair and now he is rigid and unable to even bend or get into any chair according to the physical therapy report. There was no special equipment on hand to transfer Resident #1 up to the shower. Review of the facility's current Rehabilitative Nursing Care policy dated revised April 2007 revealed rehabilitative nursing care is provided for each resident admitted . "...4. Rehabilitative nursing care is performed daily for those residents who require such service. Such program includes, but is not limited to: a. Maintaining good body alignment and proper positioning; b. Encouraging and assisting bedfast residents to change positions at least every two (2) hours (day and night) to stimulate circulation and to prevent decubitus ulcers, contractures, and deformities; ...f. Assisting residents with their routine range of motion exercises...." Review of the facility's current Range of Motion Exercises policy dated: revised April 2007 revealed: Purpose: The purpose of this procedure is to exercise the resident's joints and muscles. 1) Verify that there is a physician's order for this procedure. If there is no order for treatment, contact the attending physician to obtain treatment orders. 2) Review the resident's care plan to assess for any special needs of the resident. Documentation: The following information should be recorded in the resident ' s medical record: 1) The date and time that the exercises were performed 2) The name and title of the individual who performed the procedure. 3) The type of ROM exercise given. 4) Whether the exercise was active or passive. 5) How long the exercise was conducted.... 6) Any problems or complaints made by the resident related to the procedure. 7) If the resident refused the treatment, the reason why and the intervention taken. The Form CMS-672, Resident Census and Conditions of Residents, dated 10/03/11 and signed by the DON reflected there were 23 residents with contractures, 14 of whom had contractures on admission; there were 53 residents, who required the assistance of staff for bathing, 31 residents required the assistance of staff for dressing, 21 residents required the assistance of staff for transferring, six residents required the assistance of staff for toileting and nine residents required the assistance of staff for eating.