Every finding on record at Arbor View Nursing & Rehabilitation

Based on observation, interview and record review the facility failed to ensure that residents with loss of bladder control received treatment or services to prevent urinary tract infections and to restore continence to the extent possible for three of three residents reviewed for incontinent care (Resident #45, Resident #86 and Resident #25).CNA E failed to clean the penis area with different areas of the wipe when she provided foley catheter care to Resident #45.CNA F failed to clean the foley catheter tubing of Resident #86 while providing Foley Catheter care.CNA E was observed to remove Resident #45's foley catheter bag from the floor and place it onto the bed prior to providing incontinence care.Resident #45 and Resident #25 were observed to have Foley Catheter bags lying on the floor next to the bed. These failures could place residents at risk for urinary tract infections due to the provision of improper incontinent care.The findings include:Resident #45Record review of Resident #45's face sheet, dated 09/04/2026, revealed a [AGE] year-old male with an admission date of 04/11/2026. Diagnoses included encephalopathy (disease affecting the functioning of the brain), personal history of transient ischemic attack (brief stroke-like attack that resolves in time), cerebral infarction (disruption of blood flow in the brain) and benign prostatic hyperplasia with low urinary tract symptoms (overgrowth of prostate cells in the male which can cause difficulties with urination) Record review of Resident #45's quarterly MDS dated [DATE], section C revealed resident had a BIMS score of 15 out of 15 which means that his cognitive status was fully intact. Section GG of the MDS revealed that Resident #45 required partial/moderate assistance for toileting hygiene. Section H revealed the resident had an indwelling catheter present and frequently had bowel incontinence.Record review of Resident #45's order summary report dated 09/04/2026 revealed a phone order dated 04/28/2026 that read as follows: Provide catheter care every shift to reduce the risk of infection. Every day and night shift for infection control.Record review of Resident #45's care plan report with initiation date of 04/11/2026 revealed the following: Focus: Mr.----has an indwelling Foley Catheter r/t urinary retention. Date initiated 06/04/2026. Revision on: 06/04/2026. with Goal: Mr.---will show no s/sx of urinary infection through review date. Date initiated: 06/04/2026. Revision on: 06/04/2026. Target Date: 10/26/2026. Interventions include: Provide catheter care every shift to reduce the risk of infection with initiated date of 08/02/2026.During an observation of foley catheter care for Resident #45 on 09/03/2026 at 10:53 a.m., CNA E was observed to pick up the foley bag from the floor and place it on the end of the bed. The catheter bag remained on top of the bed until Resident #45 was repositioned in the bed after care was provided. CNA E was also observed to wipe the head of Resident #45's penis and the Foley Catheter tubing several times using the same areas of the wipes. During an interview with CNA E on 09/03/2026 at 11:15 a.m., she stated that she had not used the same area of the wipe when wiping the penis head and foley tubing for Resident #45. She stated that she had quickly changed wipe areas each time as she was trained to do. CNA E did not respond to questions about the foley bag being on the floor or placed on the bed.Resident #25Record review of Resident #25's face sheet, dated 09/03/2026, revealed a [AGE] year-old male with an initial admission date of 01/29/2026 and readmission date of 07/31/2026. Diagnoses included cerebral ischemia (condition resulting in brain tissue damage due to a blockage of blood flow in the brain), pressure ulcer of sacral region, stage 4 (severe injury to skin and underlying tissue at the base of the spine), schizophrenia (chronic mental illness that causes disordered thought processes), generalized anxiety disorder (condition causing excessive worry), vascular dementia (change in thinking and memory due to a disruption in the blood flow in the brain).Record review of Resident #25's order summary report dated 09/03/2026 revealed the following verbal order, received on 08/20/2026: Urinary catheter 16 [NAME] with 10cc bulb for wound healing.Record review of Resident #25's comprehensive MDS dated [DATE], section B revealed resident had unclear speech and rarely/never understands others, therefore the BIMS interview was not conducted (cognitive status was not assessed). He was assessed to display fluctuating inattention, disorganized thinking and altered levels of consciousness. Section GG of the MDS revealed that Resident #25 was dependent on staff for all ADLs, including toileting hygiene. Section H revealed that the resident had an indwelling catheter.Record review of Resident #25's care plan report initiated on 02/13/2026 revealed the following: Focus: Mr. ---- has a 16 French 10 cc bulb indwelling catheter to assist with healing of stage IV sacrum (bottom of the spine) wound. Date initiated: 08/20/2026. Revision on: 08/20/2026. with a goal of: Mr. --- will show no signs/symptoms of Urinary infection through review date. Date initiated: 08/20/2026. Revision on: 08/20/2026. Target Date: 09/06/2026. During an observation on 09/02/2026 at 6:25 p.m., Resident #25 was observed to be lying on his back on his bed which was in low position. The Foley Catheter bag was attached to the bed hook on the left side of the bed and the catheter bag was lying on the floor mat.During an interview with CNA G on 09/02/2026 at 06:30 p.m., regarding Resident #25, she stated that she was trained that foley bags should not be on the floor, should be in a privacy bag, with tubing crossed over the leg and not under the patient. She stated that the resident should also have a leg strap present. She stated that by having the catheter bag on the floor fluid can push back into him and cause infection.During an interview with LVN H on 09/02/2026 at 6:36 p.m., he stated that Resident #25's Foley Catheter bag was on the floor so the residents bed needed to be raised up due to the possibility of infection.During an interview with the DON on 09/02/2026 at 6:40 p.m., she verified that Resident #25's foley catheter bag should not be on the floor to prevention infection. She then stated that the staff were presently working on getting the catheter bag removed from the floor.Resident #86Record review of Resident #86's face sheet, dated 09/04/2026, revealed an [AGE] year-old female with an admission date of 08/29/2026. Diagnoses included metabolic encephalopathy (chemical imbalance in the blood that causes issues in the brain), acute cystitis (rapid onset bladder infection) and Parkinson's disease (disorder of the nervous system that affects movement).Record review of Resident #86's MDS assessment dated [DATE] revealed that the assessment had not been completed except for Section A: Identification Information, as Resident #86 had just been admitted to the facility on [DATE].Record review of Resident #86's care plan report on 09/04/2026 showed an initiation date of 08/31/2026 stated the following: Focus: The resident has an indwelling Foley Catheter: urinary retention. Date Initiated: 08/31/2026. Revision on: 08/31/2026. Goal: The resident will be/remain free from catheter-related trauma through review date. Date Initiated: 08/31/2026. Target Date: 11/29/2026. Interventions include: Monitor for s/sx of discomfort on urination and frequency. Date Initiated: 08/31/2026.Record review of Resident #86's order summary report dated 09/04/2026 revealed a verbal order dated 08/31/2026 that states: Urinary catheter care every day and night shiftDuring an observation of incontinent and [NAME] catheter care for Resident #86 on 09/03/2026 at 12:35 p.m., CNA F did not wipe the foley catheter tubing while providing foley catheter care.During an interview with CNA F on 09/03/2026 at 12:45 p.m., she stated that it was important to wipe the foley tubing for Resident #86 to prevent infection because it can travel back up to the resident if the tubing is not cleaned. She stated that she was trained to clean 6 inches of the tubing but forgot to do so.During an interview with the ADON on 09/03/2026 at 12:58 p.m., she stated that by not cleaning the foley tubing, you could introduce infection. She said that staff are trained to hold the labia (outer folds of skin around the vagina in a female) and wipe about 6 inches down the tubing.Review of facility policy entitled Catheter Care with implementation date of 05/02/2025 revealed the following: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care. and ensure drainage bag is located below the level of the bladder to discourage backflow of urine. In addition, the policy states that for a female receiving foley catheter care: With a new moistened cloth, starting at the urinary meatus (external opening of the tube where urine goes out of the body) moving out, wipe the catheter making sure to hold the catheter in place so not to pull on the catheter. For the male, it states: Using circular motion, cleans the meatus with a clean cloth.with a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft (long, cylindrical part extending from the base to the head) of the penis.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen reviewed for cleanliness. The facility failed to have in clean order the following:The ice maker machineThe floor space behind the behind, under, and around the ice machineThe floor space around the food freezerThe surface of the beverage cart The facility failed to have their dietary staff wear gloves while wrapping utensils in paper napkins. The Food Service Manager was observed to not wear a hair restraint for the intermittent observations, from 9/2/2026 through 9/3/2026 at mealtimes, breakfast, lunch, and dinners, of the facility's kitchen. These failures could place residents at risk for unsanitary food preparation conditions.The findings included: During an observation on 9/2/2026 at 9:40 AM revealed the facility's kitchen ice machine with visible pink wavy lines approximately 2mm in width covering the air filters. The ice machine also had a white semi liquid drainage streak dripping from the ice machine vent, to the floor. The floor space directly behind the ice machine was visibly dirty with accumulated dust and debris which included a discarded plastic beverage mug. The space between the ice machine and the food preparation counter had an exposed sewer drainpipe which arose from the floor 2 inches. The pipe was covered in an unidentified black accumulation of growth. Further observation revealed the stand-up double door freezer had condensation droplets accumulating on the front of the freezer, in between the double doors. The condensation drained onto the floor and accumulated upon a black spotted area. Intermittent observations, from 9/2/2026 through 9/3/2026 at mealtimes, breakfast, lunch, and dinners, of the facility's kitchen wheeled beverage cart revealed the staff prepared coffee and juices which were stored in plastic multi-quart sized pitchers and insulated coffee dispensers top of the cart. The staff also stored coffee cups and condiments for coffee alongside the beverages atop of the cart. The beverage cart surface was observed to have constant semi-wet black stains which appeared to have thickness and textures. During an observation on 9/2/2026 at 1:15 PM revealed DA C was wrapping utensils in paper napkins with his bare hands. During an observation on 9/3/2026 at 1:15 PM revealed DA D was wrapping utensils in paper napkins with his bare hands. During an interview on 9/3/2026 at 3:00 PM the FSM stated his expectation was for Dietary staff to wear gloves while touching clean utensils. The FSM stated he would have the beverage cart deep cleaned, the ice machine and surrounding area deep cleaned, and the floor by the freezer cleaned of black residue. The FSM stated he had not worn a hair net because he was misinformed, he did not have to wear a hair restraint. The FSM stated the potential negative outcome to residents could be food borne illnesses. During an interview on 9/43/2026 at 3:10 PM the DON stated she had witnessed the ice machine and surrounding floor area and the beverage cart. The DON stated she was informed the FSM had a plan to clean the kitchen. The DON stated the condition of the dirty areas of the kitchen could potentially have a negative outcome for residents contracting food borne illnesses. A policy was requested and not received A record review of the United States of America's Food and Drug Administrations website titled 2022 Food Code accessed 9/4/2026:https://www.fda.gov/media/164194/download?attachmentrevealed, 2-402 Hair Restraints2-402.11 Effectiveness. FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. 4-6 Cleaning of Equipment and Utensils 4-601 Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. Chapter 4 - 20 FDA Food Code 2022 Chapter 4 Equipment, Utensils, and Linens(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations.(C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 4-602.13 Nonfood-Contact Surfaces.Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 4-904 Preventing Contamination4-904.11 Kitchenware and Tableware.SINGLE-SERVICE and SINGLE-USE ARTICLES and cleaned and SANITIZED UTENSILS shall be handled, displayed, and dispensed so that contamination of FOOD- and lip-contact surfaces is prevented.Knives, forks, and spoons that are not prewrapped shall be presented so that only the handles are touched by EMPLOYEES and by CONSUMERS if CONSUMER self service is provided. 6-5 Maintenance and Operation 6-501 Premises, Structures, Attachments, and Fixtures - Methods . 6-501.18 Cleaning of Plumbing Fixtures. PLUMBING FIXTURES such as HANDWASHING SINKS, toilets, and urinals shall be cleaned as often as necessary to keep them clean

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 to help prevent the development and transmission of communicable diseases and infections for two (Resident #89 and Resident #45) of three residents and two (CNA E and LVN B) of four staff observed for infection control practices in that:CNA E failed to remove her soiled gloves, perform hand hygiene and don clean gloves after handling the soiled towel that had been placed under Resident #45 during incontinence care.LVN B failed to remove her soiled gloves, perform hand hygiene and don clean gloves while providing wound care for Resident #89.These failures could place residents at risk for cross contamination and the spread of infection.The findings include:Record review of Resident #89's face sheet, dated 09/04/2026, revealed an [AGE] year-old male with an admission date of 09/01/2026. Diagnoses included atherosclerotic heart disease of native coronary artery (buildup of fat int the artery walls), anemia (low number of red blood cells) and chronic obstructive pulmonary disease (progressive lung disease).Record review of Resident #89's MDS review dated 09/01/2026 revealed that the MDS did not include assessments of Resident #89's BIMS, ADL status, or other pertinent information, due to this being a new admission to the facility.Record review of Resident #89's care plan report, initiated 09/02/2026 revealed the following: Focus: The resident is on enhanced barrier precautions (EBP) r/t wounds. Date initiated: 09/02/2026. Revision on: 09/02/2026. Interventions included Direct care staff to utilize gowns and gloves for all personal care. Date initiated: 09/02/2026.Record review of Resident #89's order summary report dated 09/04/2026 revealed a verbal order dated 09/03/2026 that read as follows: Clean wound on coccyx (tailbone) with normal saline or wound cleanser, pat dry, apply Medi honey to wound bed, cover with bordered gauze dressing until healed in the morning every Tues, Thu. for pressure ulcer and as needed for pressure ulcer as needed if loose or soiled.Observation of wound care on 09/03/2026 at 11:35 a.m., for Resident #89, LVN B was observed to pick up clean wound care supplies (Q-Tip applicator and bordered gauze dressing) after cleaning the coccyx wound and handling the soiled gauze. LVN B did not remove her soiled gloves, perform hand hygiene or change into new gloves after she discarded the soiled dressing into the trash. She then picked up the clean Q-Tip applicator with the soiled gloves to apply gel to the wound and then applied the clean dressing.During an interview with LVN B on 09/03/2026 at 11:41 a.m., she stated during Resident #89's wound care she was probably supposed to change gloves when she went from dirty to clean; before handling the clean wound supplies. She stated that by changing gloves, it would have helped to keep infection from spreading.Record review of Resident #45's face sheet, dated 09/04/2026, revealed a [AGE] year-old male with an admission date of 04/11/2026. Diagnoses included encephalopathy (disease affecting the functioning of the brain), altered mental status (sudden change in the way a person thinks, acts or reacts) and personal history of transient ischemic attack (brief stroke-like attack that resolves in time) and cerebral infarction (disruption of blood flow in the brain)Record review of Resident #45's order summary report dated 09/04/2026 revealed a phone order dated 04/28/2026 that read as follows: Provide catheter care every shift to reduce the risk of infection. Every day and night shift for infection control.Record review of Resident #45's quarterly MDS dated [DATE] section C revealed resident has a BIMS score of 15 out of 15 which means that his cognitive status is fully intact. Section GG of the MDS revealed that Resident #45 required partial/moderate assistance for toileting hygiene. Section H revealed that the resident had an indwelling catheter present and frequently had bowel incontinence.Record review of Resident #45's care plan report with initiation date of 04/11/2026 revealed the following: Focus: Mr.----has an indwelling foley catheter r/t urinary retention. Date initiated 06/04/2026. Revision on: 06/04/2026. with Goal: Mr.---will show no s/sx of urinary infection through review date. Date initiated: 06/04/2026. Revision on: 06/04/2026. Target [NAME]: 10/26/2026. Interventions include: Provide catheter care every shift to reduce the risk of infection with an initiated date of 08/02/2026.During observation of incontinent care for Resident #45 on 09/03/2026 at 10:53 a.m., CNA E was observed to remove a soiled towel that she had placed under Resident #45 just prior to handling the residents newly applied clean brief. CNA E did not remove her gloves, wash or sanitize her hands, or apply clean gloves prior to handling the clean newly applied brief. During an interview with CNA E on 09/03/2026 at 11:15 a.m., she stated she should have removed her gloves and changed to new gloves after handling the towel that was underneath the resident because it could potentially spread infection.During an interview with the DON on 09/03/2026 at 12:15 p.m., she stated it is an infection control issue going from dirty to clean. Staff should be washing hands before handling the clean for infection control. She stated she had already started inservices with the staff pertaining to this.Review of policy entitled Infection Prevention and Control Program with original date of 06.2021 and revision/review date of 4.2025 stated the following: 5. Reporting Mechanisms for Infection Control.3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection.b. Facility personnel will wash their hands after each direct resident contact for which hand washing is indicted by accepted professional practice.Review of policy entitled Hand Hygiene with implementation date of 04/11/2025 revealed the following: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Furthermore, the attached Hand Hygiene Table states that either soap and water or alcohol-based hand rub should be used Before and after handling clean or soiled dressings, linens, etc.

Based on observations and interviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facility kitchen reviewed for safe operating equipment. The facility failed maintain equipment in safe operating condition. The kitchen presented with a walk-in freezer and a walk-in refrigerator which were inoperable. This failure could place residents at risk for denying the benefits of essential equipment.The findings included: During an observation and interview on 9/4/2026 at 10:00 AM, the FSM demonstrated the facility's inoperable walk-in refrigerator and adjacent walk-in freezer. The FSM stated the equipment had been inoperable since September 2025. The FSM stated he and the Administrator had contracted with a local commercial appliance repair contractor to repair the walk-in refrigerator and walk-in freezer; however, the contractor had not yet fulfilled the contract. During an interview on 9/4/2026 at 2:00 PM, the Administrator stated he had contracted with a local commercial appliance repair contractor to repair the facility's walk-in freezer and walk-in refrigerator. The Administrator stated that the contractor was paid for the repair in April 2026 and was awaiting back-order repair part and had not yet completed the repairs. A record review of the United States of America's Food and Drug Administration's website titled 2022 Food Code accessed 9/4/2026:https://www.fda.gov/media/164194/download?attachmentrevealed, 4-5 Maintenance and Operation4-501 Equipment4-501.11 Good Repair and Proper Adjustment. EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. A record review of the facility's Physical Environment: Electrical Equipment policy dated 6/15/2025, revealed, The facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition.Policy Explanation and Compliance Guidelines:The Maintenance Director shall maintain schedules for routine inspection and maintenance of all mechanical, electrical, and patient care equipment.Frequency of inspection and maintenance shall be in accordance with the facility's Electrical Safety policy, current Life Safety Code requirements, and manufacturer recommendations.Equipment that is malfunctioning or exhibits safety hazards, such as frayed wires or plugs, shall be removed from use.Essential equipment shall be repaired or replaced as soon as practicable. Examples of essential equipment include, but are not limited to:Boiler room equipmentHVAC equipmentNursing unit/medication room refrigeratorsPatient care-related electrical equipmentKitchen refrigerator/freezerLaundry equipmentOnly trained individuals shall repair electrical equipment. The Maintenance Director is responsible for coordinating repairs, if outside sources are required.

Based on interviews and record reviews the facility failed to ensure that residents had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 3 of 9 residents (Residents #1, #21 and #63) reviewed for psychotropic medication informed consents. Record review of Resident #1's electronic medical record revealed no informed consents for her prescribed antipsychotic medications. Record review of Resident #21's electronic medical record revealed no informed consents for his prescribed antipsychotic medications. Record review of Resident #63's electronic medical record revealed invalid informed consents for her prescribed antipsychotic medications. These failures could deny residents their right to be informed of the benefits and risk of the medical treatment they received.The findings included:Resident #1A record review of Resident #1's admission record dated 9/3/2026 revealed an admission date of 1/5/2026 with a diagnosis of schizoaffective disorder (a long-term mental health condition defined by a combination of psychotic symptoms (delusions and hallucinations) and mood disorder symptoms (like depression or mood swings). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for LTC activities of daily life supports complicated by diseases which included COPD (chronic obstructive pulmonary disorder, a long-term lung condition that makes it hard to breathe by damaging the airways and air sacs), morbid obesity (a serious health condition with significant weight-related health problems), and Hypertension (high blood pressure). Resident #1 was assessed with a BIMS score of 7 out of 15, which indicated severe cognitive impairment. A record review of Resident #1's physicians' orders dated 9/3/2026 revealed that on 4/20/2026 the physician prescribed for Resident #1 to receive an injection of Risperidone (an antipsychotic prescription used to treat serious mental health conditions) 12.5mg every 14 days, for schizoaffective disorder. Further review revealed on 10/9/2024 the physician prescribed for Resident #1 to receive oral risperidone 4mg tablet twice a day for schizoaffective disorder. A record review of Resident #1's care plan dated 9/3/2026 revealed, (Resident #1) Uses psychotropic medications related to schizophrenia, bipolar disorder, August 18th, 2025, revision on May 21st, 2026, . administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. A record review of Resident #1's electronic medical record revealed no informed consents for Resident #1's antipsychotic medication regiments. Resident #21A record review of Resident #21's admission record dated 9/4/2026 revealed an admission date of 1/24/2024 with diagnoses which included schizophrenia (a serious mental health condition that affects how a person thinks, feels, and behaves, often causing them to lose touch with reality), major depressive disorder (a common and serious medical condition also known as clinical depression), and anxiety disorder (common mental health conditions involving persistent, excessive fear or worry that interferes with daily life). A record review of Resident #21's quarterly MDS assessment dated [DATE] revealed Resident #21 was a [AGE] year-old male admitted for LTC with supports of activities of daily life complicated by mental illness. Resident #21 was assessed with a BIMS score of 13 which indicated intact cognition. A record review of Resident #21's physicians orders dated 9/4/2026 revealed that:On 2/9/2026 the physician prescribed for Resident #21 to receive oral quetiapine 800mg at bedtime for schizophrenia.On 3/31/2026 the physician prescribed for Resident #21 to receive oral quetiapine daily for schizophrenia.On 2/15/2026 the physician prescribed for Resident #21 to receive oral risperidone 1mg twice a day for schizophrenia. A record review of Resident #21's care plan dated 9/4/2026 revealed, (Resident #21) has a potential for complications related to antipsychotic medication use. Diagnosis schizophrenia. Date initiated 7/25/2025 . administer drug as ordered by physician . A record review of Resident #1's electronic medical record revealed no informed consents for Resident #1's antipsychotic medication regiments. Resident #63Record review of Resident #63's face sheet, dated 09/01/2026, revealed an [AGE] year-old female with an admission date of 07/03/2026. Her diagnoses included multiple fractures of pelvis (breaks in the ring of bones that connects the legs to the body), mild protein-calorie malnutrition (lack of adequate nutrition for the body to work and heal properly), depression (mood disorder causing sadness), anxiety (condition in which a person has excessive worry) and unspecified dementia (difficulty with memory, thinking and/or making decisions). Under the Contacts section of the face sheet, it stated that Resident #63 was her own responsible party. She also had a case manager listed as a contact on her file.Record review of Resident #63's comprehensive MDS dated [DATE] section C revealed resident has a BIMS score of 02 out of 15, indicating that she has severe difficulties with thinking and memory. Section C also revealed that Resident #63 has fluctuating behaviors of inattention and disorganized thinking. Section D revealed the presence of symptoms of depression and Section E reported presence of delusions (person is totally convinced of a reality that is completely untrue), as well as verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others which occurred 1 to 3 days during the seven day lookback period for the assessment. Record review of Resident #63's order summary report, dated 09/01/2026 details the following orders: Buspirone 7.5mg: Give 1 tablet by mouth two times a day related to anxiety disorder (per verbal order given on 08/28/2026), Sertraline 25mg: Give 1 tablet by mouth one time a day related to depression and anxiety (entered by prescriber on 07/09/2026), and Trazadone 50mg: Give 1 tablet by mouth at bedtime for sleep (per verbal order given on 08/28/2026).Record review of Resident #63's Consent to Treatment, dated 07/03/2026 revealed that the resident had signed her own consent for admission to the facility.Record review of the document entitled, Psychoactive Consent for Resident #63 in regard to the order for the medication Sertraline dated 07/09/2026 with effective date of 09/02/2026 revealed that telephone/verbal consent was obtained from Resident #63's case manager who is listed on the consent as the person authorized by law to consent on behalf of the Resident. The area on the consent requesting a signature and date of Resident, Guardian or Legal Representative listed above was blank on the document.Record review of the document entitled, Psychoactive Consent TIDE for Resident #63 in regard to the order for the medication Trazadone dated 08/28/2026 with an effective date of 09/02/2026 revealed that telephone/verbal consent was obtained from Resident #63's case manager who is listed on the consent as the person authorized by law to consent on behalf of the Resident. The area on the consent requesting a signature and date of Resident, Guardian or Legal Representative listed above was blank on the document.Record review of the document entitled, Psychoactive Consent TIDE for Resident #63 in regard to the order for the medication Buspar dated 08/28/2026 with an effective date of 09/02/2026 revealed that telephone/verbal consent was obtained from Resident #63's case manager who is listed on the consent as the person authorized by law to consent on behalf of the Resident. The area on the consent requesting a signature and date of Resident, Guardian or Legal Representative listed above was blank on the document.During a telephone interview with Resident #63's APS case manager on 09/04/2026 at 2:50 p.m. it was revealed that the case manager does not have legal guardianship for the resident. She stated that she has no authority to provide consents of any kind for Resident #63.During an interview with the ADON on 09/04/2026 at 3:30 p.m., she stated that she thought Resident #63 was under APS with the case manager serving as a guardian who could provide consent for treatments. The ADON stated that the staff can attempt to reassess the residents' BIMS score or get a process in place for her to obtain a legal guardian.During an interview with the DON on 09/04/2026 at 4:00 p.m., she stated that Resident #63 came in as an APS case and the staff were working now to determine if a legal guardian was needed for the resident. After discussing that the APS case manager was not Resident #63's legal guardian and was unable to provide consent for psychoactive medications, the DON removed the case manager from the three consents on file in the EHR. She stated that the resident may now be able to provide consent on her own behalf. During an interview on 9/3/2026 at 2:00 PM the MDS nurse stated both Residents #1 and #21 had received prescribed antipsychotic medications without informed consents. The MDS nurse stated it was the responsibility of the IDT to ensure Residents had received informed consents prior to receiving their antipsychotic medications. During a joint interview on 9/3/2026 at 4:00 PM the DON and the ADON stated both Residents #1 and #21 had received prescribed antipsychotic medications without informed consents. The DON stated it was the responsibility of the IDT to ensure Residents had received informed consents prior to receiving their antipsychotic medications. The DON stated the potential negative outcome for residents who received antipsychotic medications without first receiving informed consents could be they would not have participated in their own medication regiment decisions and would not have had the benefit of knowing the benefits versus the risks associated with their prescribed medications. A record review of the facility's Resident Rights policy dated 6/10/2025 revealed, The facility will inform the resident both hourly and in writing, in a language that the resident understands, of his or her rights and all rules or regulations governing resident conduct and responsibilities during the stay in the facility. Planning and Implementing Care: . The right to be informed in advance, of the care to be furnished and the type of caregiver or professional that will furnish the care. The right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.A record review of the United States of Americas' National Library of Medicines' website: https://pmc.ncbi.nlm.nih.gov/articles/PMC12928841/Accessed 9/4/2026, titled Supporting the appropriate use of psychotropic medicines in aged and disability care revealed, . Quality statement 2: Informed consent for psychotropic medicines: If psychotropic medicines are being considered, the person - and their family, support people or nominated decision maker as appropriate - is informed about the reason, intended duration, and potential benefits and harms of treatment. If use of a psychotropic medicine is agreed, informed consent is documented before use.

Based on interviews and record reviews, the facility failed to ensure that residents who were discharged had a summary that included a recapitulation of the resident's stay for 1 of 4 residents (Resident #85) reviewed for discharges. The facility failed to complete a discharge summary for Resident #85 who was discharged on 6/5/26 without having developed and implemented a discharge summary with supporting documentation. This failure could put residents at risk for poor discharge healthcare management.The findings included: A record review of Resident #85's admission record dated 9/4/2026 revealed an admission date of 5/21/2026 with diagnosis which included schizoaffective disorder (a chronic mental health condition that combines symptoms of a psychotic illness like schizophrenia with a mood disorder like depression or bipolar disorder) and cerebral palsy (a group of permanent movement and posture disorders that appear in early childhood and affect a person's ability to control their muscles). A record review of Resident #85's planned discharge MDS assessment dated [DATE], revealed Resident #85 was a [AGE] year-old female admitted for LTC activities of daily life supports. Resident #85 was assessed with a BIMS score of 12 out of 15 which indicated a moderately impaired cognition. Further review revealed resident #85 was discharged to an unidentified skilled nursing facility. A record review of Resident #85's medical record for the period of 5/21/2026 through 6/5/2026 revealed no documentation regarding Resident #85's discharge on [DATE]. During a joint interview on 9/4/2026 at 1:00 PM, the DON and the ADON stated Resident #85 was discharged and transferred to another nursing home without having developed and implemented a discharge summary. The DON stated that the potential negative outcome for residents who were discharged without a discharge summary and supporting documentation could result in poor healthcare management. A record review of the facility's Discharge Summary policy dated 6/6/2025, revealed, It is the policy of this facility to ensure that a discharge summary is provided upon a residence discharge which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies. The discharge summary provides necessary information to continuing care providers pertaining to the course of treatment while the resident was in the facility and the residents plan for care after discharge. It must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another.

Based on record review and interview, the facility failed to obtain physician orders for the resident's immediate care at the time the resident was admitted for one of six residents (Resident #63) reviewed for admission orders in that:Resident #63 did not have orders on file for admission to the memory care (secure) unit at the facility upon her admission [DATE].This failure could place the residents at risk of not receiving necessary care that could result in worsening of conditions or declines in the resident's health.The findings include:Record review of Resident #63's's face sheet, dated 09/01/2026, revealed an [AGE] year-old female with an admission date of 07/03/2026. Diagnoses included multiple fractures of pelvis (breaks in the ring of bones that connects the legs to the body), mild protein-calorie malnutrition (lack of adequate nutrition for the body to work and heal properly), depression (mood disorder causing sadness), anxiety (condition in which a person has excessive worry) and unspecified dementia (difficulty with memory, thinking and/or making decisions).Record review of Resident #63's comprehensive MDS dated [DATE] section C revealed resident has a BIMS score of 02 out of 15, indicating that she had severe difficulties with thinking and memory. Section C also revealed that Resident #63 had fluctuating behaviors of inattention and disorganized thinking. Section D revealed the presence of symptoms of depression and Section E reported presence of delusions (person is totally convinced of a reality that is completely untrue), as well as verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others which occurred 1 to 3 days during the seven day lookback period for the assessment.Record review of Resident #63's order summary report, printed on 09/01/2026 revealed the following orders: Verbal order for Admit to for skilled care was received on 07/03/2026 and a verbal order dated 07/09/2026 which stated: Admit to secured unit for dx of dementia and wandering. Record review of Resident #63's Census List printed on 09/04/2026 shows that the resident was admitted on [DATE] to the same room that she currently resided in. During an interview with the ADON on 09/04/2026 at 3:30 p.m., she stated that Resident #63 had admitted to the memory care unit when she arrived to the facility on [DATE]. She also stated that there was not an order in place for her to be admitted to the memory care unit until 07/09/2026. She said that the staff did not have an order giving permission for Resident #63 to be admitted to the memory care unit upon her arrival on 07/03/2026. She stated that they could have done an elopement risk assessment when she admitted and let the MD know immediately that she needed to be in the secure unit and obtain the order. During an interview with the DON on 09/04/2026 at 4:00 p.m., she stated that Resident #63 was admitted to skilled on 07/03/2026 per her review of the Census List. She stated that the resident had remained admitted to the memory care unit and had not changed rooms during her stay. She verified that orders for the memory care unit were obtained on 07/09/2026. She stated that this could potentially affect the rights of the resident and affect her having the proper placement in the facility.

Based on observations, interviews, and record reviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 4 residents (Resident #21) reviewed for PASRR specialized services. The facility failed to coordinate specialized consulting services for Resident #21 after he was assessed by the Local Intellectual and Developmental Disability Authority (LIDDA) as needing specialized services for schizophrenia (a chronic mental disorder characterized by disturbances in thinking, perception, emotions, and behavior, often affecting daily functioning and social interactions). This failure could place residents at risk of not receiving specialized services as recommended.The findings included: A record review of Resident #21's admission record dated 9/4/2026 revealed an admission date of 1/24/2024 with diagnoses which included schizophrenia and major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). A record review of Resident #21's quarterly MDS assessment dated [DATE] revealed Resident #21 was a [AGE] year-old male admitted for LTC activities of daily life. A record review of Resident #21's care plan dated 9/4/2026 revealed, (Resident #21) has a positive PASRR evaluation related to mental illness diagnosis: he requires specialized services: skills training and development and routine case management, he receives services with (QMHP-CS) . initiated 6/4/2026 . Further review revealed no specific interventions regarding Resident #21's QMHP-CS's recommendations. Further review revealed Resident #21 had a history of paranoia with ideations that residents are taking his property. A record review of Resident #21's medical record for the period 8/1/2026 through 9/2/2026 revealed no documentation to verify Resident #21 was visited, assessed, and received services from QMHP-CS. A record review of an email correspondence between the facility's MDS nurse and Resident #21's QMHP dated 9/4/2026 revealed that Resident #21's QMHP-CS had not visited nor assessed Resident #21 since 4/20/2026, The email read: Good afternoon!In the event you aren't able to return the voicemail I just left, I'll respond here as well:I was under the impression that (Resident #21) was going to be removed from the facility due to behavioral acuity per social worker (SW). I'm assuming since you're reaching out to me that that was either not the case or simply didn't pan out as such. Either way, I'll be happy to get him rescheduled again. My apologies for the misunderstanding.Thank you,(QMHP-CS) During an observation and interview on 9/2/2026 at 9:00 AM Resident #21 was in his room seated at a small table. Resident #21 stated he received no visitors other than facility staff and had not received a visit from a mental health care provider. Resident #21 stated he felt safe in the facility and that staff treated him well. During an interview on 9/2/2026 at 9:10 AM MA A stated she was unaware if Resident #21 was seen by anyone from psych services and had not observed anyone visiting him, he stays in his room, most of the time. During an interview on 9/2/2026 at 9:40 AM LVN B stated she had not observed anyone visiting Resident #21 to provide PASRR services. During an interview on 9/3/2026 at 11:20 AM Resident #21's Representative stated Resident #21 had lived with schizophrenia since childhood but currently has developed coping strategies which he could use to make his own decisions and understand he needs to take his medications and to be compliant with care provided for his own wellbeing. Resident #21's Representative stated she was not aware if Resident #21 was receiving specialized services from a QMHP. Resident #21's Representative stated if Resident #21 was approved for QMHP services he should receive those services. During an interview on 9/3/2026 at 1:00 PM the MDS nurse stated she was unaware if Resident #21 was receiving services from a local QMHP and had not observed anyone visit Resident #21 for specialized services. The MDS Nurse stated Resident #21 was assessed by the LIDDA and approved for specialized services. The MDS Nurse stated she documented in Resident #21's care plan, that he was to receive services from a local QMHP provider but had not received any feedback nor documentation that a QMHP had assessed Resident #21. During a joint interview on 9/4/2026 at 2:10 PM the MDS nurse and Resident #21's QMHP-CP stated Resident #21 was PASRR positive and was assessed by the LIDDA and was approved to receive services from QMHP-CP beginning 4/20/2026. Resident #1's QMHP-CP stated he had not visited Resident #21 since being assigned and had not provided any services. During a joint interview on 9/4/2026 at 3:30 PM the DON and the ADON stated they were not aware that on 4/20/2026 Resident #21 was approved by the LIDDA to receive services and were not aware Resident #21's QMHP-CS had not visited Resident #21. The DON and the ADON stated the responsibility of ensuring residents receive care as approved by the LIDDA rested with the IDT and care plan meetings. The DON and the ADON stated that the potential negative outcome for residents approved for specialized services was that the residents may not benefit from the assessment and recommended services of a QMHP. A record review of the facility's policy titled Resident Assessment - Coordination with PASARR Program dated 6/30/2025, revealed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . 7. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care .

Based on record review and interview, the facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care of the residents for one (Resident #63) of six residents reviewed for baseline care plans for newly admitted residents in that: The facility did not initiate a baseline careplan for Resident #63 for six days after she was admitted on [DATE]. This failure could place residents at risk of not having their needs met and increases the risk for residents to experience adverse events, exacerbations or complications from medical conditions.The findings include:Record review of Resident #63's face sheet, dated 09/01/2026, revealed an [AGE] year-old female with an admission date of 07/03/2026. Diagnoses included multiple fractures of pelvis (breaks in the ring of bones that connects the legs to the body), mild protein-calorie malnutrition (lack of adequate nutrition for the body to work and heal properly), depression (mood disorder causing sadness), anxiety (condition in which a person has excessive worry) and unspecified dementia (difficulty with memory, thinking and/or making decisions).Record review of Resident #63's comprehensive MDS dated [DATE] section C revealed resident has a BIMS score of 02 out of 15, indicating that she had severe difficulties with thinking and memory. Section C also revealed that Resident #63 had fluctuating behaviors of inattention and disorganized thinking. Section D revealed the presence of symptoms of depression and Section E reported presence of delusions (person is totally convinced of a reality that is completely untrue), as well as verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others which occurred 1 to 3 days during the seven day lookback period for the assessment.Record review of Resident #63's baseline care plan report on 09/01/2026 showed an initiation date of 07/09/2026 for the care plan.During an interview with the ADON on 09/04/2026 at 3:30 p.m., she stated the baseline care plan initiation timeline is 48 hours. This baseline care plan tells the staff how to care for the resident properly; without this the resident may not receive the proper care.During an interview with the DON on 9/04/2026 at 4:00 p.m., she stated Resident #63 was admitted on [DATE] but noted that the baseline care plan was not in place by 07/05/2026 as it should have been. She stated the baseline care plan should have been done within 48 hours of admission. By not completing it within the 48-hour timeframe, the staff might not have known how to meet the residents needs or take care of her.Review of policy entitled Baseline Care Plan with implemented and reviewed/revised date of 6/30/2025 states the following: Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission.2. The admitting nurse, or supervising nurse on duty shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. In addition, the policy states, 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.

Based on interview and record review, the facility failed to use the services of a registered nurse of at least 8 consecutive hours a day, 7 days a week for 1 of 60 days reviewed for RN coverage (06/19/2026).The facility failed to ensure they had an RN charge nurse on duty on 06/19/2026.This failure could place the residents at risk of missed nursing assessments, interventions, care and treatment.Findings included:Record review of the June 2026 overall RN hours reflected less than 8 consecutive hours worked by an RN on 06/19/2026. Record reviews of timecard punches for 06/19/2026 reflected less than 8 hours worked by an RN. RN2 worked 5.75 hours on 06/19/2026 from 5:43 PM till 12:00 AM. During an interview on 09/03/2026 at 11:56 AM, the HR revealed that the RN only worked 5.75 hours and that HR was not aware that the 8 hours had to be consecutive or that the full 12-hour shift of RN 2 did not back cover the hours as it was one shift, 6:00 PM to 6:00 AM.During an interview on 09/04/2026 at 2:35 PM, the DON revealed that she was unaware that the RN coverage had to be 8 consecutive hours of coverage for the facility. The DON revealed that they had switched to RN coverage for 12-hour shifts before survey, but that day the RN scheduled to work 6:00 AM to 6:00 PM had called out. The DON revealed that since they had an RN scheduled for the evening they did not find coverage. Record review of the facility policy for Nursing Services and Sufficient Staff, dated 05/13/2025, revealed that the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Based on observations, interviews, and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete for 1 of 4 residents (Residents #1) reviewed for medical records. Resident #1 was assessed as a PASARR positive resident without a PASARR positive document in her medical record. Resident #1 was assessed by the LIDDA and was issued a PASARR Evaluation letter without the document uploaded into her medical record. These failures could place residents at risk for inaccurate medical records. The findings included: A record review of Resident #1's admission record dated 9/4/2026 revealed an admission date of 1/5/2026 with diagnoses which included schizoaffective disorder (a chronic mental health condition that combines symptoms of a psychotic illness like schizophrenia with a mood disorder like depression or bipolar disorder) and bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, activity levels, and the ability to focus). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for LTC activities of daily life. A record review of Resident #1's care plan dated 9/4/2026 revealed, (Resident #1) Has a history of schizoaffective disorder and bipolar disorder; placing them at risk for mood instability, hallucinations, delusions, impaired judgment, and difficulty with social . date initiated 9/4/2025 . A record review of Resident #1's medical record for the period 1/5/2026 through 9/2/2026 revealed no documentation to verify Resident #1 was assessed with a PASARR level 1 screening nor a PASARR evaluation. During an observation and interview on 9/2/2026 at 8:20 AM, Resident #1 was in her wheelchair awaiting the breakfast meal. Further observations revealed Resident #1 was unable to speak clearly and communicated with staff with attempted verbal vocalizations. During an interview on 9/3/2026 at 1:00 PM, the MDS nurse stated she was responsible for entering PASARR data into the Texas Medicaid and Healthcare Partnership portal (TMHP) via SIMPLE (a web-based application which helps Texas nursing facilities pre-fill and manage MDS documentation to reduce manual data entry required by TMHP). The MDS Nurse stated Resident #1 was PASARR positive and had a PASARR evaluation from the LIDDA. The MDS Nurse stated the evidence of Resident #1's PASARR 1 and PASARR evaluation resided in the TMHP. The MDS nurse stated a record review of Resident #1's medical record revealed no PASARR 1 document nor Resident #1's LIDDA PASARR evaluation assessment document. The MDS nurse stated she was unaware she was a member of the IDT responsible for coordinating the PASARR 1 and PASARR evaluation documents were uploaded into Resident #1's medical record. During a joint interview on 9/4/2026 at 3:50 PM, the DON and the ADON stated resident records were expected to be complete and accurate and readily accessible. The DON and the ADON stated Resident #1's PASARR 1 and PASARR evaluation documents were not reflected in her medical record. The DON stated the IDT was responsible for ensuring the documents were in the medical record, and several key members could have reviewed and ensured the documents were in the medical record. The DON stated the potential negative outcome could be residents would have inaccurate records. A record review of the facility's policy titled Resident Assessment - Coordination with PASRR Program dated 6/30/2025, revealed, This facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . Policy Explanation and Compliance Guidelines:1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening . 3. A record review of the facility's policy titled Maintenance of Electronic Clinical Records dated 5/16/2025, revealed, This facility will maintain electronic clinical records for each resident in accordance with acceptable standards of practice.Policy Explanation and Compliance Guidelines:A complete and accurate electronic clinical record will be maintained on each resident and kept accessible and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident while maintaining the confidentiality of the residents' information.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 2 residents (Resident #1 and #2) reviewed for care plans.1. The facility failed to ensure Resident #1's comprehensive care plan reflected that resident had a diagnosis of diabetes mellitus and was receiving insulin.2. The facility failed to ensure Resident #2's comprehensive care plan reflected that resident had a diagnosis of diabetes mellitus type 2 and was receiving insulin.These failures could place residents at risk for not having their needs met.The findings were:1. Record review of Resident #1's face sheet reflected a [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE]. Her diagnoses included: diabetes mellitus (a chronic condition where blood sugar levels are too high because the body does not make enough insulin, cannot use insulin properly, or both).Record review of Resident #1's quarterly MDS assessment dated [DATE], revealed a BIMS score of 10 out of 15, which indicated moderate cognitive impairment, Section I-Active Diagnoses, I2900 for Diabetes Mellitus, and Section N-Medications, N0350 Insulin, indicated insulin was administered 7 out of the last 7 days. Record review of Resident #1's care plan dated 07/29/2026, did not reflect a focus of diabetes mellitus as a diagnosis, the use of insulin medication, or interventions to manage diabetes. Record review of Resident #1's order summary report reflected an active order for Insulin Glargine Solution 100 UNIT/ML Inject 27 unit subcutaneously at bedtime for diabetes, with a start date of 11/07/2025.During an interview on 07/28/2026 at 1:50pm, Resident #1 revealed she received her insulin on time and had no concerns with her care at this time. 2. Record review of Resident #2's face sheet, dated 07/28/2026, reflected a [AGE] year-old male initially admitted on [DATE] and re-admitted [DATE]. His diagnoses included: type 2 diabetes mellitus (a chronic condition where the body resists insulin or does not make enough of it, causing high blood sugar).Record review of Resident #2's quarterly MDS assessment, dated 06/12/2026 revealed a BIMS score of 11 out of 15, which indicated moderate cognitive impairment, Section I-Active Diagnoses included I2900 for Diabetes Mellitus, and Section N-Medications, N0350 Insulin, indicated insulin was administered 7 out of the last 7 days.Record review of Resident #2's care plan dated 07/29/2026, did not reflect a focus of diabetes mellitus type 2 as a diagnosis, the use of insulin medication, or interventions to manage diabetes. During an interview on 07/28/2026 at 4:00pm, Resident #2 revealed he received his insulin on time and correctly and had no concerns about his care.During an interview on 07/29/2026 at 10:20am, LVN A revealed she was an MDS nurse and was responsible for comprehensive care plans. She stated that both Resident #1 and Resident #2 did not have a care plan for diabetes mellitus, the use of insulin, or interventions to manage diabetes, but should. LVN A stated she was currently in the process of auditing all care plans for accuracy and would add those care plans immediately. LVN A stated the importance of care plans was to provide information to the nurse regarding the physician's orders and interventions needed to properly care for the residents. During an interview on 07/29/2026 at 10:45am, the DON stated her expectation was that care plans reflect the needs of the residents so the nursing staff would know how to provide care for the residents and Resident #1 and Resident #2 should have a care plan for their diagnosis of diabetes. The DON stated the interdisciplinary team developed and reviewed care plans and the MDS nurse was currently conducting an audit of care plans. Record review of the facility's policy Comprehensive Care Plans, last revised 6/30/2025, reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the residents comprehensive assessment and meet professional standards of quality.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 2 of 4 showers (200 hall and 300 hall showers); and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 Residents (Resident #1) reviewed for accidents/hazards. The facility failed to secure razors in the 200 and 300 halls. The facility failed to ensure Resident #1 had a fall mat in place, as indicated by physician's order and care planning. These failures could lead to injury and decreased quality of life. and could result in residents' self-harm. Findings included: 1.Observation on 7/12/2026 at 4:09 PM in the 300-hall shower room, revealed the shower door was open, and found 39 razors, some in a box of razor containers and some in a cabinet. The cabinet did have a lock attached to the doors, but it was not locked. Interview on 7/12/2026 at 4:11 PM with MA F, CNA G and RN H who were outside the 300-hall shower room, near the nurse's station, came into the 300-hall shower room. CNA G, MA F, and RN H stated that the 300-hall shower door was open and had 39 razors that were unsecured. MA F, CAN F, and RN H stated residents could self-harm or other residents with unsecure razors. The staff stated they were not sure why the shower room door was open. Observation on 7/1/2026 at 4:28 PM with LVN I, in the 200-hall shower room, door was shut and was unlocked. Inside the Shower room had 22 razors left unsecure. In an interview on 7/1/2026 at 4:29 PM LVN I revealed the 200-shower room door was unlocked, and 22 razors were left unsecure in a razor box. LVN, I stated residents could harm themselves. LVN I stated she was not sure why the shower door was unlocked. In an interview on 7/3/2026 at 11:39 AM with ADON B she stated she was not aware the 200 and 300 shower rooms had unsecure razors. ADON B stated that with unsecure razors resident could cause harm to themselves, and the razors needed to be in a secure area with staff present, if residents need to use razors. Interview on 7/3/2026 at 2:28 PM with ADM stated that unsecure razors cause harm and residents could cut themselves. ADM had no comment. Record review of policy, Safe and home like environment dated 6/10/2025. Policy: In accordance with residents' rights, the facility will provide a safe, clean and comfortable and home like environment, allowing the residents to use his or her personal belongings to the extent possible. This includes ensuring that the residents can receive care and services safely and that the physical layout of the facility maximizes residence independence and does not pose a safety risk. Record review of Resident #1's admission Record dated 7/2/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included repeated falls. 2. Record review of Resident #1's annual MDS dated [DATE] reflected a BIMS score of 06, which indicated severely impaired cognitive status. Section J1900 of the MDS indicated Resident #1 had experienced 1 fall since admission or Prior injury without injury, one fall with injury, and no falls with major injury. Record review of Resident #1's Order Summer Report dated 7/2/2026 reflected the following physician's order dated 7/23/2025: May use fall mat at bedside while in bed Record review of Resident #1's Care Planning Report undated/ printed 7/2/2026, reflected Resident #1 was at risk for falls. Interventions included the following: .Continue to monitor Resident frequently throughout night for safety and redirect as needed for safe practices. Ensure fall mat is in place. Date initiated 11/04/2025 . .The resident uses FALL MAT [sic] at bedside. Ensure the device is in place as needed. Date initiated 7/23/2025 . In an observation on 7/2/2026 at 11:35 AM, Resident #1 was observed in bed, asleep. No fall mat was observed on the floor next to the bed or near the bed. In an interview on 7/2/2026 at 11:37 AM, CNA C said Resident #1 was not supposed to have a fall mat. She said she knew which residents require fall mats because the mats will be in the room already. She was unsure how to access a resident's care plan to review care planned interventions. In an interview on 7/2/2026 at 11:50, RN D and LVN E both said Resident #1 was at high risk for falls but did not require a fall mat. They said any resident who requires a fall mat will have a task scheduled for confirmation during the shift, but Resident #1 did not have the task assigned. They said they will occasionally review care plans for residents if they are unsure about care for a resident. In an interview with ADON A on 7/3/2026 at 11:53, she said Resident #1 required a fall mat, and it should have been a scheduled task for nursing staff to ensure implementation, but she had entered the order incorrectly last year. She said the potential harm of Resident #1 not having a floor mat in place was injury. In an interview with the ADM on 7/3/2026 at 2:02 PM, he said falls and interventions were reviewed during daily clinical meetings at the facility. He said the clinical team will document new interventions on a whiteboard and follow-up to ensure the interventions have been implemented, and this task was primarily overseen by the DON. He said the DON was out on leave, and he was unable to reach her by telephone for interview. Record review of the facility policy titled Fall Prevention Program dated 5/29/2025 reflected the following: .6.High Risk Protocols:i.Indicate fall risk on care plan.b.Implement interventions from Low/Moderate Risk Protocols.c.Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status .

Based on interview and record review, the facility failed to ensure that all alleged violations of injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 4 residents (Resident #2) reviewed for neglect. The facility failed to ensure rib fractures from an unknown origin sustained by Resident #2 on or around 5/31/2026 were reported to the SSA. This failure could lead to lack of oversight and abuse, neglect, or exploitation of residents. Findings included: Record review of Resident #2's admission Record dated 7/2/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included MULTIPLE FRACTURES OF RIBS, RIGHT SIDE, SUBSEQUENT ENCOUNTER FORFRACTURE WITH ROUTINE HEALING [sic] with an onset date recorded as 6/03/2026. Record review of Resident #2's annual MDS dated [DATE] reflected a BIMS score of 05, which indicated severely impaired cognition. Section J1800 of the MDS reflected Resident #2 had not had any falls in the assessment period. Record review of Resident #2's Care Plan Report undated/ printed 7/2/2026 reflected the following:[Resident #2] has rib fractures of the 8th, 9th, and 10th ribs r/t osteoporosis and hitting his right side on headboard [sic]. Date Initiated: 6/03/2026 Record review of Resident #2's progress notes reflected a change in condition note dated 5/31/2026 at 9:58 AM that reflected Resident #2 was being sent to the hospital for evaluation of abdominal pain to the right side. Record review of the facility incident log dated 7/1/2026 did not reveal an incident related to Resident #2 on or around 5/31/2026. Record review of Resident #2's hospital paperwork dated 6/2/2026 reflected an admission history documented on 5/31/2026 that read as follows: . [Resident #2] is awake and conversant but not able to provide much insight into his current or past medical history so that is obtained from chart review and discussion with [family member] on the phone. When asked why patient came the hospital he is not able to provide an answer when asked if he had fallen he said maybe per discussion with [family member] he spoke with his facility and they sent him to be evaluated due to right sided chest versus abdominal pain and he was told they wanted to send him in to have his gallbladder evaluated. He was noted to have right rib fractures 8-10 CT of the chest as well as had abdominal pelvic CT that showed normal gallbladder as well as a reducible right inguinal hernia . Record review of Resident #2's progress notes revealed documentation dated 6/2/2026 at 5:11 PM which reflected the following:Spoke with [Resident #2] upon coming back to the facility. Discussed what happened with him regarding how he received his fractures he then said he hit his left side on his headboard and was experiencing abdominal pain. I asked if he was in pain and he said yes. Asked Nurse to administer pain medication . Resident #2 was unable to participate in an interview attempted on 7/2/2026 at 11:40 AM due to cognitive decline. In an interview with Resident #2's family member on 7/02/2026 at 2:50 PM, he said he was unsure if he had been contacted by the facility at the time Resident #2 was hospitalized on [DATE]. He said the hospital staff told him Resident #2 had fallen and caused rib fractures. He said he had not received any additional contact from the facility regarding the rib fractures, and he had no concerns about the care provided by the facility for Resident #2. The DON was unavailable for interview during the survey due to leave. In an interview on 7/02/2026 at 11:50 AM, RN D and LVN E said they were not working on the day Resident #2 was transferred to the hospital for pain. They said he had significant memory issues and would not be able to accurately recount recent events, including falls. In an interview with ADON B on 7/03/2026 at 12:20 PM, she said Resident #2 had severe memory issues and could not recall recent events accurately. She said he sustained the rib fractures after he hurt himself on the headboard of his bed. She was unsure how the facility had determined this was the cause of the injury, and she said she was not involved in an investigation of the incident. She said the DON was in the memory care unit after Resident #2 returned and had interviewed staff. She was unsure of the results of these interviews. In an interview with the ADM on 7/3/2026 at 2:02 PM, he said he recalled the rib fractures sustained by Resident #2, but any investigation was led by the DON. He was unsure why the DON had not reported the injury to the SSA or initiated a formal investigation into the incident. He said if a resident has a fracture, he typically was notified, but he was not notified of the rib fractures on Resident #2. He said he felt the injury should have been reported and investigated. Record review of the facility policy titled Abuse, Neglect and Exploitation dated 6/30/2025, reflected the following: .VII. Reporting/ResponseA.The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a.Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .

Based on interview and record review, the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, the have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 4 residents (Resident #2) reviewed for neglect. The facility failed to have evidence of an investigation regarding rib fractures from unknown origin sustained by Resident #2 on or around May 31, 2026. This failure could lead to lack of oversight and abuse/neglect of residents. Findings included: Record review of Resident #2's admission Record dated 7/2/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included MULTIPLE FRACTURES OF RIBS, RIGHT SIDE, SUBSEQUENT ENCOUNTER FORFRACTURE WITH ROUTINE HEALING [sic] with an onset date recorded as 6/03/2026. Record review of Resident #2's annual MDS dated [DATE] reflected a BIMS score of 05, which indicated severely impaired cognition. Section J1800 of the MDS reflected Resident #2 had not had any falls in the assessment period. Record review of Resident #2's Care Plan Report undated/ printed 7/2/2026 reflected the following:[Resident #2] has rib fractures of the 8th, 9th, and 10th ribs r/t osteoporosis and hitting his right side on headboard [sic]. Date Initiated: 6/03/2026 Record review of Resident #2's progress notes reflected a change in condition note dated 5/31/2026 at 9:58 AM that reflected Resident #2 was being sent to the hospital for evaluation of abdominal pain to the right side. An additional progress note dated 6/2/2026 at 5:11 PM reflected the following:Spoke with [Resident #2] upon coming back to the facility. Discussed what happened with him regarding how he received his fractures he then said he hit his left side on his headboard and was experiencing abdominal pain. I asked if he was in pain and he said yes. Asked Nurse to administer pain medication . Record review of Resident #2's hospital paperwork dated 6/2/2026 reflected an admission history documented on 5/31/2026 that read as follows: . [Resident #2] is awake and conversant but not able to provide much insight into his current or past medical history so that is obtained from chart review and discussion with [family member] on the phone. When asked why patient came the hospital he is not able to provide an answer when asked if he had fallen he said maybe per discussion with [family member] he spoke with his facility and they sent him to be evaluated due to right sided chest versus abdominal pain and he was told they wanted to send him in to have his gallbladder evaluated. He was noted to have right rib fractures 8-10 CT of the chest as well as had abdominal pelvic CT that showed normal gallbladder as well as a reducible right inguinal hernia . Record review of the facility incident log dated 7/1/2026 did reveal an incident related to Resident #2 on or around 5/31/2026. Resident #2 was unable to participate in an interview attempted on 7/2/2026 at 11:40 AM due to cognitive decline. In an interview with Resident #2's family member on 7/02/2026 at 2:50 PM, he said he was unsure if he had been contacted by the facility at the time Resident #2 was hospitalized on [DATE]. He said the hospital staff told him Resident #2 had fallen and caused rib fractures. He said he had not received any additional contact from the facility regarding the rib fractures, and he had no concerns about the care provided by the facility for Resident #2. The DON was unavailable for interview during the survey due to leave. In an interview with the ADON B on 7/03/2026 at 12:20 PM, she said Resident #2 had severe memory issues and could not recall recent events accurately. She said he sustained the rib fractures after he hurt himself on the headboard of his bed. She was unsure how the facility had determined this was the cause of the injury, and she said she was not involved in an investigation of the incident. She said the DON was in the memory care unit after Resident #2 returned and had interviewed staff. She was unsure of the results of these interviews. In an interview with the ADM on 7/3/2026 at 2:02 PM, he said he recalled the rib fractures sustained by Resident #2, but any investigation was led by the DON. He was unsure why the DON had not reported the injury to the SSA or initiated a formal investigation into the incident. He said if a resident has a fracture, he typically is notified, but he was not notified of the rib fractures on Resident #2. He said he felt the injury should have been reported and investigated. Record review of the facility policy titled Abuse, Neglect and Exploitation dated 6/30/2025 reflected the following: .V. Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .

Based on observations, interviews and record reviews, the facility failed to ensure other Environmental Conditions. The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 4 (300 hall shower room) shower rooms in that:The facility failed to ensure the 300-hall shower did not have black substance/mold on the tile walls of the shower. This could cause harm to residents and could cause respiratory illnesses. The Findings: In an Observation on 7/1/2026 at 4:09 pm, the 300-shower room had black substance on the tile walls of the shower. In an observation and interview on 7/1/2026 at 4:11 PM with MA F, CNA G and RN H who were outside the 300-hall shower room, near the nurse's station. came into the 300-hall shower room. CNA G, MA F, and RN H stated that the 300-hall shower had black substances on the tile walls of the shower. CNA G stated she had not notified the nurse or the maintenance of the mold on the tile. RN H stated the mold could harm residents in the shower room. In an Interview on 7/2/2026 at 2:28 PM with Maintenance Supervisor stated he did see the black substance on the 300-hall shower room. The Maintenance Supervisor stated he will get the housekeeping to clean with better tools and train staff on cleaning shower rooms. In an interview on 7/3/2026 at 10:15 AM, HSK J stated she was not sure about the black substance, but he cleans the resident's showers, including the walls. In an interview on 7/3/2026 at 2:28 PM, ADM stated that the black substance in the 300-hall shower room could lead to respiratory problems for residents. In an interview on 7/3/2026 at 2:36PM HSK K stated he cleaned the 300-hall shower room, and he did not see the black substance on the shower walls. HSK K stated he cleaned the resident shower rooms on the 300 hall, including walls, took out trash, sweeps and mops the floors. The interview with HSK K stated that all resident showers were to be cleaned. Record review of policy, Safe and home like environment dated 6/10/2025. Policy: In accordance with residents' rights, the facility will provide a safe, clean and comfortable and home like environment, allowing the residents to use his or her personal belongings to the extent possible. This includes ensuring that the residents can receive care and services safely and that the physical layout of the facility maximizes residence independence and does not pose a safety risk. Policy explanation and compliance guidelines; 1. The facility will create and maintain, to the extent possible, and home like environment that de-emphasizes the institutional character of the setting. 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent injury for 1 of 4 residents reviewed for accidents. (Resident #3)The facility did not provide adequate supervision for smoking to Resident #3, who was assessed to not be a safe smoker. This failure could place residents who smoked at risk for injury from burns.Findings Included: Face sheet dated 06/17/2026 indicated Resident #3 was admitted on [DATE], with diagnoses of raynaud's syndrome with gangrene (blood vessels squeeze shut due to cold or stress), chronic obstructive pulmonary disease (lung disease making hard to breathe), hypertension (high blood pressure).Care plan review showed, . has been assessed to require supervision when smoking and .will not smoke without supervision.Smoking assessment, dated 4/20/2026, showed resident unable to hold cigarette safely, extinguish cigarette safely, use ashtray to extinguish a cigarette.Observation on 6/17/2026 at 10:10 am, showed 4 residents in the smoking area. No staff were present. Resident #3 was observed smoking a cigarette, unsupervised.Interview on 6/17/2026 at 3:06 pm, CNA A stated when residents from the 300 hall go to smoke, a staff from that hall should be supervising. She stated if not, then a staff on the 200 hall would be informed to supervise the residents. She stated she failed to ask a 200 hall staff member to supervise the residents during their smoke break. She stated residents should be supervised during smoke breaks to prevent any burns.Interview on 6/17/2026 at 3:21 pm, Nurse B stated Resident #3 is supposed to be supervised because he has not been deemed to be a safe smoker.Interview on 6/18/2026 at 2:34 pm, Resident #3 stated he had the cigarette on him.Observation on 6/18/2026 showed that Resident #3 cigarettes were locked and secured.Record review of Resident Smoking Policy showed, Must be supervised at the posted times by staff the entire time they are smoking.

Based on observations, interviews, and record reviews, the facility failed to ensure resident were free of significant medication errors for 1 of 7 (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors and received medication as prescribed by a physician on 8/29/2025. LVN A administered Resident #2's medications to Resident #1. This resulted in administration of two schedule IV-controlled substances: non prescribed medications: Temazepam 22.5 mg, Phenobarbital 129.6 mg, levothyroxine 75 mcg, Tamsulosin 0.4 mg, Levetiracetam 1250 mg, Oxcarbazepine 300 mg, Mirtazapine 7.5 mg, Risperdal 1 mg and prescribed Quetiapine (Seroquel) 800 mg which was a dose 32 times greater than prescribed for Resident #1. This medication error resulted in a change of condition, hospitalization and ICU stay for hypothermia, hypotension, and metabolic encephalopathy. The resident returned to the facility on 8/31/2025. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 9/04/2025 at 6:00 p.m. The IJ template was provided to the facility on 9/04/2025 at 6:07 p.m. While the IJ was removed on 9/07/2025 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor the implementation of the plan of removal. This failure could place residents at risk for medication errors and could result in side effects, a decline in health, hospitalization and/or death. The findings included: Record review of Resident #1's face sheet dated 9/03/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), cardiomyopathy (disease of the heart muscle) and schizophrenia (serious mental health condition that affects how people think feel and behave). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated a severe cognitive impairment with behaviors that included rejection of care less than daily. Resident #1's functional status was listed partial assistance showering/bathing and supervision for oral care and eating. Record review of Resident #1's BIMS evaluation dated 9/02/2025 revealed a score of 15 which indicated the resident was cognitively intact. Record review of Resident #1's progress notes dated 8/29/2025 at 7:50 p.m. as a late entry revealed the DON documented: Medication given to wrong Resident. She documented normal vital signs, alert and oriented with no change to mentation (Mental activity or the process of thinking). Hospice RN notified with new orders to hold all medications for the rest of the evening and for the next morning. Monitor for 72 hours for any complications or reactions. Record review of Resident #1's progress notes dated 8/29/2025 at 8:35 p.m. documented as a late entry revealed: Medication Error with blood pressure 70/40 (low), HR 72 (normal), oxygen saturation 98% on room air. A temperature was not documented. Level of consciousness: not arousable. Resident not responsive to voice or touch, called 911, hospice and DON. Record review of an incident report for Resident #1 dated 8/29/2025 written by the DON revealed: Resident was accidently given the wrong medication during med-pass. Nurse (LVN A) mistakenly administered the wrong medication, I thought I handed her the right pill cup then I turned around and saw her medication on the med cart. Immediate action taken immediately assessed Resident #1 for complications and none noted, called DON and she stated to call hospice and RP. RN from hospice stated to monitor resident. Vital signs BP 110/72 (normal), HR 74 (normal) respirations 16 (normal) oxygen saturation 98% on room air (normal) with no injuries noted post incident. The documentation indicated Resident #1 was oriented to person, place, time and situation (normal cognition). Record review of Resident #1's Hospice notes dated 8/30/2025 revealed on Friday 8/29/2025 at 7:59 p.m. LVN A reported a medication error. Hospice physician notified.hold meds except carbidopa/levodopa and monitor Q1hr (every hour). Send to ED if vital signs change or sedation occurs. 9:03 p.m. LVN A reported EMS activated, secondary to hypotension. (low blood pressure). Record review of Resident #1's physician order summary for August 2025 revealed the following medication orders:Carbidopa-Levodopa 25/100 mg give 3 tablets four times a day related to neuroleptic induced parkinsonism with a start date of 6/17/2025.Divalproex (Depakote) sodium oral tablet delayed relates 500 mg, give 2 tablets by mouth two times a day for seizures with a start date of 8/15/2025Entacapone oral tablet 200 mg, give one tablet by mouth four times a day for Parkinson's disease with a start date of 5/08/2025.Lacosamide oral tablet 50 mg, give tablet by mouth two times a day with a start date of 6/17/2025.Quetiapine fumarate oral tablet 25 mg, give 1 tablet by mouth at bedtime for depression.Hydrocodone-acetaminophen oral tablet 10/325 mg, give 0.5 tablet by mouth every 8 hours as needed for pain with a start date 8/29/2025. Record review of Resident #1's Medication Audit, dated 9/03/2025 revealed LVN A documented the following medications were administered on 8/29/2025 at 7:35 p.m. (medications ordered for Resident #1):Lacosamide 50 mg-2 tablets (used to treat seizures)Carbidopa-Levodopa 25/100 mg-3 tablets (Parkinson's)Entacapone 200 mg-1 tablet (Parkinson's)Divalproex (Depakote) 500 mg-2 tablets (seizures)Quetiapine (Seroquel) 25 mg-1 tablet (antipsychotic used to treat schizophrenia) Record review of Resident #1's Narcotic Administration Record for hydrocodone-acetaminophen 10/325 mg revealed LVN A signed out one dosage (0.5 mg) of the narcotic on 8/29/2025 at 8 p.m. Record review of Resident #1's August 2025 MAR revealed hydrocodone-acetaminophen 10/325 mg tablet, give 0.5 tablet every 8 hours as needed was not documented as administered. Record review of Resident #2's face sheet dated 9/05/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: hypothyroidism, schizophrenia, and epilepsy. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated he was cognitively intact with no documented behaviors. He required was independent or required supervision for ADL care. Record Review of Resident #2's Medication Audit, dated 9/03/2025 revealed LVN A documented the following medications were administered on 8/29/2025 at 7:34 p.m. (medications intended for Resident #2, but administered to Resident #1 as medication error): 1. Levothyroxine 75 mcg-1 tablet (used to treat hypothyroidism)2. Phenobarbital 64.8 mg- 2 tablets (a barbiturate, Class IV controlled substance, used for seizures)3. Tamsulosin 0.4 mg-1 capsule (used for incontinence)4. Levetiracetam 1250 mg-2 tablet (used for seizures)5. Oxcarbazepine 300 mg-1 tablet (used for seizures and/or bi-polar disorder)6. Temazepam 22.5 mg-1 tablet (a benzodiazepine, Class IV controlled substance used for insomnia)7. Mirtazapine 7.5 mg (used for anxiety/depression)8. Risperdal 1 mg-1 tablet (schizophrenia)9. Quetiapine (Seroquel) 400 mg- 2 tablets (antipsychotics used to treat schizophrenia) Record review of a handwritten statement dated 8/29/2025, signed by LVN A revealed:7:25 p.m.-realized meds given to (Resident #1) were meds for (Resident #2).7:30 p.m.-called DON. Was instructed to call the resident's physician and RP.7:40 p.m.-hospice was called, talked to RN. Was instructed to monitor resident and wait for RN to call back with orders.7:50 p.m. RN from hospice called back with orders from hospice physician. Orders were to hold all medications, monitor for 72 hours, hold morning medications. If any adverse reactions occur call 911.8:00 p.m.-Checked on Resident #1. Resident woke up easily, talked to this nurse, went back to sleep. Vitals taken BP 110/72 (normal), HR 74 (normal), oxygen saturation 98% on room air (normal).8:35 p.m.- Checked on resident again. Resident was difficult to wake. Not responsive to voice or touch. Manual BP 70/40 (low), HR 72 (normal) oxygen 97% on room air (normal).8:50 p.m.- Called 911, notified DON, notified RN hospice9:00 p.m.-Paramedics arrived at 9:00 p.m., left at 9:10 p.m. Record review of Resident #1's hospital records dated 8/31/2025 revealed the resident was admitted to the hospital due to inadvertent administration of another patient's medication while at her nursing facility. The records reflected, This resulted in acute encephalopathy, hypothermia. She received several doses of Narcan (medication used to reverse opioid overdose) which did not seem to change the patient's clinical course significantly. The hospital MD called the nursing facility and confirmed medications (given) as follows: Quetiapine 800 mg (a dosage 32 times greater than ordered by Resident #1's physician), Levetiracetam 1250 mg, Mirtazapine 7.5 mg, Oxcarbazepine 300 mg, Phenobarbital 129.6 mg, Risperdal 1 mg, Temazepam 22.5 mg, Levothyroxine (no dose specified), and questions mark hydrocodone. Nursing facility staff stated this (hydrocodone) may not have been administered as it was a later dose for this patient. Urine drug screen noted positive for opioids, TCA's (tricyclic antidepressants) and benzos (benzodiazepines). The patient was later noted to be obtunded and hypothermic .transfer to ICU. She was very lethargic but followed commands in all extremities. She would attempt to open eyes but could not open them fully. After arriving in the ICU, the patient's mental status worsened .she was given an additional dose of Narcan with no significant response. She was noted to be hypotensive and required norepinephrine. [NAME] was put in place given her hypothermia. Assessment/Plan: accidental overdose, EEG on 8/30-moderate encephalopathy-supportive care, discussed with poison control, hypotension: likely additive effect of sedating medications, hypothermia, secondary to thermal dysregulation given multiple neuroleptic medications and acute encephalopathy. Record review of form 3613-A Provider Investigative Report dated 9/04/2025 [BH6] revealed the facility self-reported a medication error when charge nurse LVN A self-reported she gave the wrong medication to Resident #1. The report indicated the medication error occurred on 8/29/2025 at 7:10 p.m. and Resident later became lethargic and was hypotensive (low blood pressure) and was sent to the hospital for evaluation on 8/29/2025 at 9:12 p.m. The report indicated Resident #1 was given several doses or Narcan at the hospital and was monitored for hypotension and metabolic encephalopathy. The report indicated it was an isolated incident, LVN A received counseling, a written warning, and additional training. The findings were confirmed. During an observation and interview on 9/03/2025 at 1:57 p.m., Resident #1 was observed moving around her room. She was awake and alert. She was able to correctly identify the correct time and year, had knowledge of the current president, knew her location and was able to recall what she had for lunch. Resident #1 stated on Friday (8/29/2025), she could not remember what time, she was near the 200-hallway nurse's station. She stated she remembered someone giving her medicine and then a short time later they gave her some more. She stated she remember someone saying her name and then it was lights out and she did not remember anything else until she woke up in the hospital. She stated when she woke up in the hospital, the hospital staff told her, her blood pressure was dangerously low, and her temperature was very low. She stated they also told her she had received someone else's medication that was really strong, in addition to her own medication. Resident #1 stated staff was now pouring out her medication and identifying each pill. She stated she was taking the medication and had not refused any. She described the person who gave her medication as female but was unable to recall her name and could not remember if she had seen the staff since the incident. She stated she was not able to describe any of the medication given to her. She stated she did not pay much attention. She stated the same person had approached her twice with the medication and she trusted them and just took it. She stated taking medication was just part of the routine, even when it was given twice. She stated they might give her a water pill one time and then something else at a later time. Resident #1 stated since she had returned to the facility, she felt fine and was back to herself with no lingering effects. During an interview on 9/03/2025 at 5:41 p.m., LVN A stated on 8/29/2025 at 7:25 p.m. she gave Resident #1, Resident #2's medication in error. She stated she was standing with the med cart near Resident #1's doorway speaking with the resident. She stated she remembered preparing and passing meds to another resident and then preparing meds for both Resident #1 and Resident #2 at the same time on top of the medication cart [BH7] and she got the two medication cups confused. She stated she was trying to give medications to two residents at the same time, got distracted and made a mistake. She stated Resident #2 had approached her asking for his medication. LVN A stated immediately after Resident #1 had consumed the pills, she turned around, saw the other medication cup with contained two Depakote pills that belonged to Resident #1 and realized her error. LVN A stated she did not give Resident #1 her pills. She stated she had pulled Resident #1's normal evening pills, plus hydrocodone. She stated she threw all the pills in the sharps container but did not have any witnesses. She stated she was panicking and was focused on Resident #1. She stated no other staff were around. She stated she immediately called the DON who told her to call the hospice physician and notify them. She stated she called hospice and told them Resident #1 was okay and that her vitals were normal. She stated the hospice RN gave her orders from the hospice physician to monitor the resident as she saw fit anywhere from every 15 minutes to one hour, to hold the rest of her medication for that evening and if there were any adverse reactions to send her out (send to the emergency room). LVN A stated at first, she was okay but when she checked on her at 8:25 p.m., Resident #1 was lethargic. LVN A stated she tried to obtain a blood pressure and at first was unable to get one. She stated she was finally able to get a manual blood pressure reading of 70/40 (low). She stated at 8:25 p.m., Resident #1 was unresponsive. LVN A stated it looked like Resident #1 was sleeping in her bed but there was something about her eyes that did not look normal. She stated her eyes were cracked open a little and she knew they were not normal. She stated she took the rest of her vital signs which were all normal. She described her breathing as normal but breathing very deeply and a little slower. LVN A stated she performed a sternal rub, which made the resident open her eyes. She stated the resident was not communicating. LVN A stated she notified hospice and called 911. She stated she was honest on the 911 call and with EMS personnel. She told them what happened. She stated she recognized she made a mistake, and it was important for her to be honest so they would know how to appropriately treat Resident #1. LVN A stated the DON told her she was glad she had reported it immediately. She stated she was written up and was told they needed to go over what happened. She stated she received an in-service on the medication 5 rights (of administration). She stated ADON O shadowed her on her next shift watching her perform medication pass to ensure she was doing everything correctly. LVN A stated she administered Levothyroxine 25 mg, Seroquel 800 mg, Keppra 1250 mg, Risperdal 50 mg, mirtazapine 7.5 mg, phenobarbital 65 mg, temazepam 22.5 mg, Buspar 20 mg and tamsulosin 7.25 mg. She stated those are the medications she remembers giving. LVN A stated she couldn't remember for sure if she gave hydrocodone but thinks she probably did not. She stated she thinks it was part of the wasted medications because she does not remember giving it to Resident #1. LVN A stated the whole situation scared her and she had been very concerned about Resident #1's outcome and wellbeing. She stated she kept in contact with the hospital post incident until she knew she was recovering. LVN A stated she was trained to administer medications to the right person, right dose, right time, right medication with the right documentation. She stated she was trained to pull one patient's med, take it to the resident, watch them take it, throw away the cup before moving on to the next patient. She stated it did not happen like that because she made a mistake. She stated she had no excuses for it. LVN stated she was fairly new to the facility. She had completed nurse competencies upon hire in June 2025? which included a medication pass which she passed. She stated it was not an intentional act, and she was not trying to harm Resident #1. She stated she was not okay until she learned Resident #1 was okay. LVN A stated it was important to give the right medication to the right resident so they could live. During an interview on 9/04/2025 at 12:46 p.m., Resident #1's RP stated she was informed by an unknown person at an unknown time that Resident #1 was given too many medications. She stated she was given a list of the medications that should not have been given verbally. The RP stated Resident #1 ended up in the hospital in ICU, mostly because she could not stay warm and because of the medications. The RP stated when Resident #1 woke up in ICU she was her regular self which was about 12 hours later. The RP stated Resident #1 just had to sleep and let the medications work out of her system. She stated Resident #1 was back at the facility doing her normal activities and doing fine. The RP stated Resident #1 had not expressed any issues or concerns about staff. The RP stated she thought there should be better safeguards at the facility and believes there to be some sort of reprimand going on. She described Resident #1's as picking and choosing what she wanted to remember. She stated she could typically remember things that had occurred within the past two weeks but not necessarily things of the past with accuracy. During an interview on 9/04/2025 at 12:47 p.m., the hospice case manager stated the hospice RN was not available for interview. She stated the RN had documented notes in the hospice record. During an interview on 9/04/2025 at 1:23 p.m., the hospice physician stated he did receive notification from the hospice RN of the medication error. He stated the hospice RN sent him a list of medications that Resident #1 had received. He stated he gave orders to watch vitals and watch for sedation. He stated approximately 40 minutes later Resident #1 was sent to the ER. He stated it was important to avoid medication errors because it could cause side effects and the scheduled III and scheduled IV medications and other medications, such as non-prescribed medications could cause complications. He stated hydrocodone was not on his list of medications given, however probarbital, Risperdal, mirtazapine, oxcarbazepine, and levothyroxine were that he could remember. He stated the facility monitored her vital signs and sent her to out when she had a change. The hospice physician stated Resident #1's hospital stay was directly related to the medication error. During an interview on 9/04/2025 at 1:39 p.m., the DON stated LVN A absolutely did not follow the facilities policy for medication administration. She stated the facility policy indicated they were supposed to only pull one person's medication at a time. The DON stated if LVN A had done that, we would not be having a conversation. She further stated LVN A did not follow the five rights of medication administration which included the right patient, right time, right medication, right dosage and right documentation. The DON stated on 8/29/2025 at 7:31 p.m., she received a call from LVN A. She stated LVN A stated she gave Resident #2's medication to Resident #1 on accident. The DON stated she told LVN A to call hospice and the RP and she asked if Resident #1 was okay. The DON stated LVN A said yes. She stated LVN A called back and told me hospice gave orders to monitor Resident #1. The DON stated she told LVN A, Resident #1 needed monitoring for 72 hours, she told her she needed to write a statement and notify her of any changes. The DON said LVN A was freaking out, but med errors occur all the time. She stated she spoke with LVN A several times. The DON said at 9:16 p.m., LVN A notified her that Resident #1 was experiencing hypotension (low blood pressure) and was hard to rouse. The DON said she told LVN A she needed to send her house, even though she was on hospice she needed to go to the hospital. The DON said Resident #1 received Narcan and was treated in ICU for metabolic encephalopathy. She stated the facility self-reported the incident because of the serious injury. She stated she notified the Administrator, and he agreed. The DON stated she participated in the investigation. She found that LVN A had two medication cups on the top of the med cart, and she went and grabbed the wrong cut. The DON stated LVN A realized it right away and called her. The DON stated there were a million different reasons med errors occur. She stated there are lots of distractions, nurses try to multitask while doing med pass. The DON stated she told LVN A she had a lot of integrity for admitting it. The DON stated she had no concerns about the way the change of condition was handled. She stated Resident #1 was monitored and sent out pretty quickly when a change of condition was noted. The DON stated the facility did not have a SW that was working, they had just hired one who was still training. She stated she had spoken to Resident #1 in the hallway and asked how she was doing. She said Resident #1 indicated she was glad to be back. She stated she did not ask her any specific questions just a general how you are doing. She stated to her knowledge Resident #1 had not expressed a desire to speak to anyone about the incident. The DON stated the next day, ADON O in-serviced LVN A on the five rights of safe administration and watched her do med pass. The DON stated LVN A was current on her competencies and there had been no concerns with the med pass observation. The DON denied any other complaints about medication administration or complaints or grievances about LVN A. The DON stated LVN A was written up, she was provided more education. She was instructed to write out a timeline which she did. The DON stated she helped LVN A put the notes in the computer. She stated she reviewed LVN A's notes to make sure it was accurate. The DON stated to avoid reoccurrence they were providing in-service education to all staff who administer meds. She stated they had not completed the training at the time of the interview. She stated their goal was to watch a med pass with all staff who perform medications which had not been completed. She stated today (9/04/2025, after surveyor entrance on 9/03/2025), they completed a med cart review. The DON stated she had provided 1:1 counseling to LVN A and would have her sign the write up today. She stated the medication error was an isolated event. The DON stated she ensures residents are free from harm by ensuring the facility policies are being followed and ensuring staff was competent. She stated she was available to staff at all times, even at night and had an open-door policy. She stated it was important for Resident's to receive the right medications to treat chronic illness and because it was detrimental if medications were not dispensed properly. During an interview on 9/04/2025 at 5:30 p.m., the Administrator stated he became aware of the medication error by phone call from the DON. He stated he was not a clinical person, so a lot of the investigation of the incident fell on the DON, although he provided oversite. The Administrator stated he could not specify if there was serious harm, but he knows Resident #1 was being watched for something very serious. The Administrator stated the facility ensured the incident was isolated, that everyone else was fine. He stated LVN A was distraught and knew what she had done wrong. He stated he was surprised to learn Resident #1 had to be sent to the hospital. The Administrator stated he had not spoken to Resident #1 since she had returned to the hospital but did inquire to staff who reported she was not having any difficulties. He stated he did self-report the incident as required. He stated LVN A was new to the facility, they had not had any complaints from residents or families. He stated although medication errors are fairly common for nurses, he could not remember the last time the facility had a medication error. The Administrator stated he communicated with residents during rounding and ensured residents were free from harm by being involved in clinical stand-up meetings. He stated he reviews facility incidents in the evenings for the next business day. The Administrator stated safety was important. He stated LVN A made the mistake and the facility was responsible. When asked if she followed facility policy for medication administration, he stated he did not know the details of how the medication error occurred. He stated the DON, who was clinical could answer the question better. The Administrator stated the facility had not held an AD HOC QAPI meeting to discuss the incident. He stated he had a conversation with the Medical Director. The Administrator stated the Medical Director gave directions to the facility, but he was going to decline to answer on what the direction was because he was not qualified to speak on it. The Administrator stated he was confirming on the investigative report the medication error by LVN A and stated there was no intent to harm. Record review of a facility Medication Administration Policy In-Service dated 8/22/2025-8/25/2025 (prior to medication error) which covered the facility policy, following physician orders precisely, including parameters, notifying the physician promptly for any variance or concerns revealed: LVN A had signed the in-service record as completed. Record review of LVN A's Nursing Orientation and Competency Checklist dated 7/11/2025 revealed she had successfully completed a med-pass video, med pass with supervision by preceptor (a teacher or instructor) and medication pass skills check off. Record review of a facility policy, titled Medication Administration last revised 5/07/2025 revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.3. Identify resident 10. Ensure that the six rights of medication administration are followed. a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form dose, route and time. 14. Remove medication from source.15. Administer medication as ordered in accordance with manufacturer specifications 19. Observe resident consumption of medication. Record review of a facility policy, titled Medication Errors last revised 05/07/2025 revealed: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Definitions: Significant medication error means one which causes the resident discomfort or jeopardized his/her health and safety. Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. according to physician orders c. In accordance with accepted standards and principles which apply to professionals providing services 6. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration b. Right resident and right documentation. The Administrator was notified of an IJ on 09/04/2025 at 6:00 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 09/05/2025 at 5:39 p.m. and included the following: Correction for the Resident Affected Immediate clinical response (COMPLETED 8/29/25): Resident assessed; EMS/transfer to ED for hypotension. Drug name/strength/route/quantity/time and vitals documented in EMR and incident record. Notifications (COMPLETED 8/29/25): Attending provider, responsible party, DON/Administrator, and Hospice were notified and documented. Protection on return: Enhanced monitoring per medical director (e.g., every shift x 72 hours, focused assessments as indicated, provider follow-up, and care plan update with specific risk reduction interventions. Resident #1 spoke with Social Services Director on 9/4 and Director of Nursing and with a licensed Social Worker, with Hospice. Resident #1 offered counseling services. She refused psych services and is going to see the Chaplain through Hospice. Identification of Other Residents Potentially Affected Cart sweep & product control completed by DON/ADON: All carts involved on unit secured; any loose/pre-popped pills destroyed per facility guidelines and documented on a medication cart sweep log. Lookback review: Full set of vitals ordered q -shift for all residents residing on the 200 hall x3days beginning 9/4/25. Facility wide spot-checks completed: Unannounced inspection of all med carts/rooms for pre-popping, unlabeled cups/bags; findings logged and corrected immediately. Safe Surveys conducted by the SS Director on 9/5 for residents on 200 hall regarding comfort with staff administering medicationsSystemic Changes to Prevent Recurrence Education & competency (to be COMPLETED by 9/4/25 or prior to next scheduled shift) by DON/Designee. Mandatory in-service for all licensed nurses/medication aides on pre-popping prohibition, two identifier verification, error reporting, and cart security; return demonstration med pass competency for every nurse. Targeted coaching & corrective action: Involved nurse was removed from independent med pass and was trained, re-educated, and monitored/supervised by the ADON until she demonstrated competency in the Six Riof Medication Pass. Pharmacy partnership: Consultant Pharmacist to conduct focused storage/handling rounds monthly x 3 months. Monitoring to Ensure Ongoing Compliance (QAPI) Med pass observations will be completed by DON/Designee 3x weekly x3 weeks, weekly x 3 weeks, then monthly x 3 months at random throughout the facility or until substantial compliance is achieved. Results/Discrepancies reported to QAPI ADHOC QAPI held on 9/5/25. The surveyor verification of the Plan of Removal on 09/07/2025 was as follows: Record review of Resident #1's progress note dated 8/29/2025 at 7:25 p.m. (documented as a late entry) by LVN A stated a medication error occurred. The DON and Hospice RN were notified of the error. Vital signs were documented all within normal limits. LVN A documented at 7:35 pm she noted Resident #1 was lethargic with low blood pressure of 70/40. Hospice notified who advised to send to the hospital. Record review of a facility incident report dated 8/29/2025 at 7:25 p.m. stated Resident #1 was accidently given the wrong medication during med-pass by handing the resident the wrong medication cup. Assessment and notifications documented. -During an interview on 9/07/2025 at 11:56 a.m., stated LVN A made the original notifications to hospice, DON and the RP and were documented in Resident #1's progress notes on 8/29/2025. -Record review of Resident #1's progress notes dated 8/31/2025 revealed the resident received an assessment, monitoring for falls and instructions not to get up unassisted to prevent falls after re-admission from the hospital. (8/32/2025) Resident #1's provider was notified of her return from hospi

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure for accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Resident #14) reviewed for medications and pharmacy services. The facility failed to ensure Resident #14 morning meds were disposed of appropriately when the resident refused the medications on 9/06/2025 by MA P. The facility failed to ensure Resident #1's hydrocodone was appropriately wasted and documented when it was removed from original container on 8/29/2025 by LVN A. These deficient practices could put residents at risk for medication errors. The findings included: Record review of Resident #14's face sheet, dated 9/06/2025 revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included severe dementia, anxiety disorder, restlessness and agitation. Record review of Resident #14's modified quarterly MDS dated [DATE] revealed a BIMs score of 4 which indicated a severe cognitive impairment with no behavior symptoms. His ADL function was listed as set up assistance. Record review of Resident #14's care plan revealed was on hospice care with interventions which included administer medications and treatments as ordered. A plan of care for behavior problems with intervention which included administer medications as ordered and behavior monitoring. A plan of care for resistance to care such as care refusals related to dementia with interventions which included: if resident resists with ADL's, reassure resident, leave and return 5-10 minutes later and try again. Record review of Resident #14's September MAR revealed the following medications were marked as refused by MA P: Fluoxetine 20 mg-give 2 capsules by mouth one time a day for depressionLisinopril 2.5 mg-give one tablet by mouth in the morning for hypertension.Provera 2.5 mg-give one tablet by mouth one time a day for lower testosterone levels related to dementia. Depakote Sprinkles delayed release 125 mg-give 3 capsules by mouth two times a day related to dementiaLorazepam 0.5 mg-give one tablet by mouth three times a day for anxiety and agitations related to anxiety disorder. During an observation on 9/06/2025 at 4:05 pm of the medication cart on 100 hallway assigned to MA P revealed a medication cup with pudding and crushed meds mixed with the pudding in the second drawer of the medication cart. The medication cup had the Resident #14's first name handwritten on the cup. During an interview on 9/06/2025 at 4:11 p.m., MA P stated the medication in the pudding belonged to Resident #14 and it was his morning medications. She stated Resident #14 had allowed her to take his vital signs this morning but when she went to administer the medication he refused, pushed it away and tried to hit her. She stated she put it in the medication cart to give it later. MA P stated the medication included Depakote, fluoxetine, lisinopril, Provera and lorazepam 0.5mg (controlled substance). She stated she had signed the medication off in the medical record. MA P stated she had received the in-service training on medication administration. She stated she thought as long as the name was on the cup it was okay to keep it. MA P stated she told LVN C what she was doing and the LVN said it was fine. MA P stated she learned in training as long as the resident name was on the cup that it was fine to keep and hold on to. During an interview on 9/06/2025 at 4:22 p.m., LVN C stated MA P had informed her Resident #14 had refused medication. She stated she did not know MA P held the meds mixed in pudding in the cart. She stated she should have had MA P and herself wasted (disposed) the medications together because of the risk for medication error with pre-dispensed medications. 2. Record review of Resident #1's face sheet dated 9/03/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), cardiomyopathy (disease of the heart muscle) and schizophrenia (serious mental health condition that affects how people think feel and behave). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated a severe cognitive impairment with behaviors that included rejection of care less than daily. Resident #1's functional status was listed partial assistance showering/bathing and supervision for oral care and eating. Record review of Resident #1's care plan dated 7/15/2025 revealed she was on hospice care with interventions to observe for pain and administer pain medications as ordered by a physician. Record review of Resident #1's BIMS evaluation dated 9/02/2025 revealed a score of 15 which indicated the resident was cognitively intact. Record review of Resident #1's physician order summary for August 2025 revealed the following medication order: Hydrocodone-acetaminophen oral tablet 10/325 mg, give 0.5 tablet by mouth every 8 hours as needed for pain with a start date 8/29/2025. Record review of Resident #1's Narcotic Administration Record for hydrocodone-acetaminophen 10/325 mg revealed LVN A signed out one dosage (0.5 mg) of the narcotic on 8/29/2025 at 8 p.m. Record review of Resident #1's August 2025 MAR revealed hydrocodone-acetaminophen 10/325 mg tablet, give 0.5 tablet every 8 hours as needed was not documented as administered. Record review of Resident #1's hospital records dated 8/31/2025 revealed the resident was admitted to the hospital due to inadvertent administration of another patient's medication while at her nursing facility. The hospital MD called the nursing facility and confirmed medications which included eight medications and a question mark for hydrocodone. Nursing facility staff stated this (hydrocodone) may not have been administered as it was a later dose for this patient. Urine drug screen noted positive for opioids, TCA's (tricyclic antidepressants) and benzos (benzodiazepines). During an interview on 9/03/2025 at 1:45 p.m., Resident #1 stated on Friday 8/29/2025 she was approached by an unknown staff member and given medications two times in a short period of time. She stated she was not sure what she was given as she trusted the staff and just took the medications. During an interview on 9/04/2025 at 1:30 p.m., LVN A stated she signed Resident #1's hydrocodone out on the narcotic record. She stated she does not believe she administered the hydrocodone to the resident. She stated pulled the hydrocodone and intended to give it when she made a medication error with Resident #1. She stated she was more worried about caring for Resident #1 than she was about documentation or the disposal of medication. She stated she threw the hydrocodone in the sharps container but did not have another staff member witness the wasting of the medication as required for a narcotic or correct any documentation. She stated she was trained to have another nurse witness the waste (disposal) with her and then document the medication waste with double signatures. During an interview on 9/04/2025 at 1:39 p.m. the DON stated she had reviewed the narcotic record for Resident #1's hydrocodone which indicated the medication was documented as removed at 8:00 pm on 8/29/2025. The DON stated she does not believe the hydrocodone was given to Resident #1 and the time did not match when it was actually pulled. She stated LVN A documented on the narcotic record when the time it was supposed to be given rather than the time it was given. The DON stated she had reviewed with LVN A. The DON stated LVN A should document the medication at the actual time the medication was given. During an interview on 9/07/2025 at 3:01 p.m., the DON stated medications should be wasted and discarded if not administered to avoid confusion. Record review of a facility policy, titled Medication Administration last revised 5/07/2025 revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.3. Identify resident 10. Ensure that the six rights of medication administration are followed. a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form dose, route and time. 14. Remove medication from source.15. Administer medication as ordered in accordance with manufacturer specifications 19. Observe resident consumption of medication.

Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 7 residents reviewed for medical records 1. The facility failed to ensure LVN A documented Resident #1s medication error, medications given, assessment, vitals, change of condition, contact with MD and RP, follow up orders, or transfer to the hospital by EMS on 8/29/2025. 2. The facility failed to upload Resident #1's hospital records from the 8/29/2025 hospital stay into the permanent medical record. 3. The facility failed to ensure LVN A documentation of medication administration accurately reflected any medications given on 8/29/2025. These failures placed residents at risk for delayed or inaccurate medical information which could result in a lack of continuity of care. The findings included:Record review of Resident #1's face sheet dated 9/03/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), cardiomyopathy (disease of the heart muscle) and schizophrenia (serious mental health condition that affects how people think feel and behave). Record review of a handwritten statement (not part of the medical record) dated 8/29/2025, signed by LVN A revealed:7:25 p.m.-realized meds given to (Resident #1) were meds for (Resident #2).7:30 p.m.-called DON. Was instructed to call the resident's physician and RP.7:40 p.m.-hospice was called, talked to RN. Was instructed to monitor resident and wait for RN to call back with orders.7:50 p.m. RN from hospice called back with orders from hospice physician. Orders were to hold all medications, monitor for 72 hours, hold morning medications. If any adverse reactions occur call 911.8:00 p.m.-Checked on Resident #1. Resident woke up easily, talked to this nurse, went back to sleep. Vitals taken BP 110/72 (normal), HR 74 (normal), oxygen saturation 98% on room air (normal).8:35 p.m.- Checked on resident again. Resident was difficult to wake. Not responsive to voice or touch. Manual BP 70/40 (low), HR 72 (normal) oxygen 97% on room air (normal).8:50 p.m.- Called 911, notified DON, notified RN hospice9:00 p.m.-Paramedics arrived at 9:00 p.m., left at 9:10 p.m. Record review of Resident #1's permanent medical record revealed no entries were made by LVN A for events on 8/29/2025 about the resident's medication error, which medications she gave to Resident #1, her assessment, follow up assessments, vitals, change of condition, contact with hospice MD and RP or follow up orders, or transfer to the hospital by EMS as viewed on 9/03/2025. A late entry was made by the DON on 9/03/2025. Record review of Resident #1's progress notes revealed on 8/31/2025 Resident #1 returned to the facility from a local hospital. Record review of Resident #1's medical record revealed the hospital records for 8/29/2025 had not been uploaded into the electronic record when viewed on 9/03/2025 and again on 9/04/2025. During an interview on 9/04/2025 at 11:11 a.m., LVN B reviewed Resident #1's medical record and stated she did not see the events of 8/29/2025 documented by LVN A. She stated there was an entry of events made on 9/03/2025 by the DON (surveyor arrived at facility on 9/03/2025). She stated she was unable to locate the hospital records for Resident #1 in the medical record. LVN B stated she had reviewed paper copies of the hospital records. She stated they were most likely in the DON's office. She stated the facility did not have a medical records person. She stated their process was to give any documents for upload to a member of management. She stated she wasn't sure who was responsible. LVN B stated they didn't have a basket or folder to put the medical records in at the nurse's station. LVN B stated they were trained to document events when they happen. She stated having accurate medical records was important for continuity of care, so they know what was going on with the patient (resident) at the time. During an interview on 9/04/2025 at 11:27 a.m., ADON N stated she was not certain where Resident #1's hospital records were located and would have to look for them. During an interview on 9/04/2025 at 1:30 p.m., LVN A stated she did not document on Resident #1's medical record the medication error, assessment, vitals signs, notifications of hospice or RP, or transfer to the hospital because she was not sure what to write in the medical record. She stated she thought she was not supposed to document the error. She stated she wrote out a statement with the same information. She acknowledged by stating that her statement was not part of the medical record. She stated on 9/03/2025 (after surveyor arrival) she sat with the DON and reviewed what should be documented. She stated the DON helped write in the medical record. LVN A stated she was trained to document in the patient's (Resident's) medical record. She stated a change of condition should be document so they know what happened, so they keep good records, to document changes and so they could track improvement or decline. During an interview on 9/04/2025 at 1:39 p.m., the DON stated she had heard that medication errors should not be documented in the medical record. She stated after reviewing, she put it in Resident #1's medical record on 9/03/2025. The DON stated LVN A should have documented vitals, assessments and transfer out of the facility, as well as notification but she thought LVN A was scared. The DON stated LVN A wrote on a piece of paper verbatim what occurred. The DON stated it was important for this information to be included in the resident's medical record for a historical view of change of condition. During an interview on 9/07/2025 at 3:01 p.m., the DON stated the facility did not have a medical records person or position. She stated the ADON was responsible for uploading any records into the medical record. She stated the process for upload when coming back from a medical visitor or hospital visit was for records to be left in a box near the ADON's office. She stated the ADON would then upload withing a week to 10 days depending on what was going on at the facility. The DON stated she had not reviewed the facility policy on medical records. The DON stated notes on medical care should be documented the same shift they occurred. Record review of Resident #1's Medication Audit, dated 9/03/2025 revealed LVN A documented the following medications were administered on 8/29/2025 at 7:35 p.m. (medications ordered for Resident #1): Lacosamide 50 mg-2 tablets (used to treat seizures) Carbidopa-Levodopa 25/100 mg-3 tablets (Parkinson's) Entacapone 200 mg-1 tablet (Parkinson's) Divalproex (Depakote) 500 mg-2 tablets (seizures) Quetiapine (Seroquel) 25 mg-1 tablet (antipsychotic used to treat schizophrenia) Record review of Resident #1's August MAR revealed lacosamide, carbidopa-levodopa, entacapone, divalproex and quetiapine had been documented as administered to the resident by LVN A. During an interview on 9/03/2025 at 5:41 p.m., LVN A stated her normal activity when dispensing medications was to document administration as she pops the medication. She stated if the resident refuses medication she would come back write a note and unclick the documentation (press a button on the electronic medical record). LVN A stated on 8/29/2025 she documented administering Resident #1's evening meds. She stated she made a medication error and accidently administered Resident #2's medications to Resident #1. She stated she did not give Resident #1 the medication she had signed off as administered. LVN A stated she did not go back and correct the resident MAR to indicate the medications had not been administered because she was panicking, and documentation was the least thing on her mind. She stated the medication error occurred at 7:25 p.m., and she didn't sign off Resident #1's medications until 7:25 p.m. because she just clicked the meds. She stated they were yellow which indicated it was time to administer them, so she just clicked them off. She stated she was trained to document when the medication was pulled and not after it was given. She stated if she was honest, she had not looked at the facility policy for medication administration in a while. During an interview on 9/04/2025 at 1:39 p.m., the DON stated medications should not be documented until after the medication was given in a perfect world. The DON stated as a nurse, she knew it was easy to sign them off when they are popped (removed from blister pack). The DON stated she was not aware LVN A was documenting before administration at the time, but she was aware of it now and was retraining staff. Record review of a facility policy, titled Medication Administration last revised 5/07/2025 revealed: 10. Ensure that the six rights of medication administration are followed: f. Right documentation 20. Sign MAR after administered. 21. If medication is a controlled substance, sign narcotic book. 23. Correct any discrepancies and report to nurse manager.

Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from abuse, neglect, misappropriation of resident property and exploitation for 7 of 7 residents (Residents #65, #19, #20, #44, #54, #23, and Unknown) reviewed for abuse. The facility failed to ensure Resident #65 was not injured after entering Resident #19's room on 6/23/2025, when Resident #19 had known aggressive behaviors related to other residents entering his room. The facility failed to ensure Resident #20 was protected from abuse after entering Resident #19's room on 7/5/2025. The facility failed to ensure Resident #44 was not injured after entering Resident #19's room on 7/5/2025. An IJ was identified on 7/24/2025 related to Resident #19 (items 1-3). The IJ template was provided to the facility on 7/24/2025 at 4:24 PM. While the IJ was removed on 7/26/2025 at 10:20 PM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm without immediacy because the facility needed to evaluate the effectiveness of corrective actions. The facility failed to protect Resident #54 from physical abuse by Resident #23 on 6/18/2025. The facility failed to protect an unknown resident from verbal abuse by Resident #23. These failures lead to physical injury, psychosocial harm, continued abuse, and decreased quality of life. Findings included: 1. Record review of Resident #19's face sheet, dated 7/22/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included anxiety disorder, vascular dementia (a progressive disorder that impairs a person's reasoning, memory, and other thinking abilities), and post-traumatic stress disorder (a mental disorder resulting from experienced trauma that causes flashbacks, severe anxiety, and/or uncontrollable thoughts). Record review of Resident #19's quarterly MDS submitted 4/19/2025 reflected a BIMS score of 03, indicating severe cognitive impairment. Section E (behavior) of the MDS revealed Resident #19 exhibited no behavioral symptoms, including physical behaviors directed towards others. Record review of Resident #19's comprehensive care plan, date printed 7/22/2025, revealed the following:Focus: [Resident #19] is/has potential to be physically aggressive r/t anger, dementia, poor impulse control. 2/10/25- ambulating in hallway with peer, peer punched resident in right shoulder. immediately separated. unable to verbalize details of event. stated no no no one hit me. I'm the one who is mad. Resident involved in an altercation with another resident. [sic] date initiated 11/14/2024, revision on 3/09/2025 Interventions: Administer medications as ordered . assess and anticipate resident's needs . provide physical and verbal cues to alleviate anxiety . [Resident #19] and peer immediately separated . psych doctor to review meds . psychiatric/psychogeriatric consult as indicated . report to provider any changes in behavior related to altercation . when [Resident #19] becomes agitated or is the receiver of peer aggressions: intervene before agitation escalates . The comprehensive care plan did not contain interventions related to maintaining the personal space of Resident #19 or known triggers of aggression. Record review of Resident #65's face sheet, dated 7/25/2025 reflected resident was a male age [AGE] admitted on [DATE] and discharged (aggression with another resident-sent to Psychiatric Hospital Unit) 4/18/2025 and re-admitted on [DATE] with diagnoses that included: Alzheimer's ( a progressive neurological disease that primarily affects memory, thinking , and behavior), dementia, (loss of cognitive functioning-thinking, remembering and reasoning) HTN (hypertension), and pseudobulbar affect (changes in mood). The face sheet also indicated Resident #65 was discharged from the facility on 7/11/2025 at 15:37 to other. Record review of Resident #65's Quarterly MDS, dated [DATE] reflected the resident's BIMS score was 3, indicative of severe impairment in cognition. The resident was ambulatory with no range of motion impairment. Record review of Resident #65's Care Plan, undated, revealed, the goals and interventions included: Goal: behavior management: interventions-minimize triggers, anticipate needs, de-escalate, and medication management. Also, seek alternate placement (6/24/25). As needed [6/23/25], 1:1 monitoring during episodes of increased behaviors and aggression. Record review of Resident #65's MAR, dated June 2025 reflected, psychotropic given medications given as ordered. Record review of Resident #65's Nurse Note dated 6/24/25 at 3:32 AM, authored by LVN J read, Resident entered other resident ['] s room [R#19] when we [LVN J and CNA K] heard noise of a loud bang. Upon entering he [R#65] was still holding on to other residents' shirt [R#19] and they went to the ground landing on [there] bottom. I told them to stop and let go. They did and got up without incident. [R#65] noted to have open laceration] . to top of head. We walked him into his room. I cleaned and dressed it. Decision was made to send him to local E.D. He came back with 12 staples which will need to be removed in 5 to 7 days. Report given to me was his CT scan of head was negative. Record review of Resident #65's risk management reported dated 6/23/25 at 10:36 PM authored by LVN J reflected: vitals were normal: BP was 134/59, pulse was 90, respiration was 22, temperature was 98, and O2 was 97 %. LVN J provided first aide to Resident #65. LVN J assessed for injury; cleaned and dressed the wound. Record review of Resident #65's elopement evaluation dated 5/10/25 reflected: resident had wandering behaviors that were likely to affect the safety or well-being of self/others. Record review of Resident #65's Care Plan dated 5/09/25 for the focus of wandering behavior listed the interventions as: monitoring, provide one to one care if the resident was agitated or triggered. Also, other interventions included: redirection, and visual reminders outside the resident's room to assist with correct room location. Record review of Resident#65's ER record, dated 6/23/25 at 11:14 PM reflected: R#65 presented at ER with laceration to the left frontal scalp from an altercation with another resident (R#19). CT scan performed was negative. Treatment given to R#2 was 12 staples to the head laceration and discharged back to the facility. Discharge diagnosis was Laceration of scalp. Observation and interview on 6/25/25 at 11:17 AM, R#65 was ambulatory and walking in the secure unit halls; there were 12 stapples present on left side of scalp; old blood present color dark red to black. R#65 was alert and oriented to self. The Resident stated, I hit my head .someone push me or hit my head .someone pushed me down .do not remember when it happened .I feel safe here Yes, they watch me . The resident stated that he had pain to is head. [The resident could not describe the level of the head pain.] The resident stated he had no complaints about the secure unit or his safety. Observation revealed 1:1 monitoring by CNA AR. During interview on 6/25/25 at 12:12 PM, LVN A stated she was not a witness to the incident on 6/23/25. LVN A stated R#65 liked to pace the hallways in the secure unit; and it was the first time an altercation occurred in the past month (she had been on duty only one month). LVN A stated that residents were kept safe by monitoring and routine checks LVN A stated she attended the ANE training in the past and the message was to report immediately. LVN A stated once the situation was safe, the facility needed to call the MD and the RP. During telephone interview on 6/25/25 at 4:05 PM, LVN J stated the timeline was correct. LVN J stated that she was making assessments of both residents and providing first aide to R#65 and vitals were stable for both residents. LVN J stated that it did not come to my head to call the police. LVN J stated preventative measures were in place prior to the incident on 6/23/25 included: monitoring, checking on conflicts, and de-escalating residents. LVN J stated the additional intervention put in place on 6/24/25 was placing R#65 on 1:1 when he returned from the ER. 2. Record review of Resident #20's face sheet, dated 07/25/2025, reflected a [AGE] year-old resident with an initial admission date of 02/28/2014, and a most recent admission date of 02/02/2025, with diagnoses which included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), hypertension (a condition in which the force of the blood against the artery walls is too high), and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms). Record review of Resident #20's Quarterly MDS Assessment, dated 05/19/2025, reflected Resident #20 had a BIMS score of 0, indicating severe cognitive impairment. Record review of the facility's incident report revealed that on 7/5/2025 at 4:06 PM, Resident #20 entered Resident #19's room. Staff walked in and witnessed Resident #20 getting up off of the floor. Both residents stated that Resident #19 pushed Resident #20. Record review of Resident #19's progress notes revealed the following documentation written by LVN A on 7/5/2025 at 4:54 PM: [Resident #19] being protective of room found [Resident #20] in room and had him leave. As [Resident #20] was leaving [Resident #19] pushed him down and [Resident #20] was seen crawling out of room. Nurse and Aide went to hall and [Resident #20] got up and went to his room up set and cussing. Nurse noted no injuries and client voiced no pain. Nurse explained to [Resident #19] that he does not do that and if not happy about something tell us. [sic] The progress note was marked as struck from the medical record on 7/07/2025 at 10:51 AM due to incorrect documentation. Resident #19 was interviewed on 7/22/2025 at 11:24 AM. He was unable to recall any incidents with other residents. He denied any negative interactions with other residents since admission to the facility. Resident #20 was unable to be interviewed due to cognitive decline. In an interview with LVN A on 7/23/2025 at 3:35 AM. She stated she was the primary nurse for Residents #19 and #20 at the time of the incident on 7/05/2025. She stated that the incident between Residents #19 and #20 occurred as she had documented in the progress note. She stated that she was instructed by an unknown administrator to remove the documentation from the medical record because an unknown portion of it was incorrect. She was unsure what part of the note was determined to be incorrect and by whom the instruction was given. She stated that after Resident #20 was pushed by Resident #19, Resident #20 was not injured, but that he was mad. 3. Record review of Resident #44's admission Record, dated 06/24/2025, reflected the resident was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included unspecified dementia (a general term for impaired ability to remember, think, or make decisions), depression, and history of falling. Record review of Resident #44's Significant Change MDS, dated [DATE], reflected the resident had a BIMS score of 0, indicating severe cognitive impairment. Further review reflected the resident had a fall in the last month, but did not reflect that the resident had a major injury such as a bone fracture. Record review of Resident #44's Care Plan, dated 07/28/2025, reflected it did not address wandering behaviors. Focus areas related to falls were initiated on 02/09/2025 and were addressed with preventative measures, or interventions, including: rounding frequently to assess for falls unreported by resident (initiated 05/12/2025), therapy as ordered (initiated 05/12/2025), PT consult for strength/mobility (initiated 05/20/2025), follow post-fall policy (initiated 05/20/2025), call bell in reach (initiated 02/09/2025), and perform transfer assistance as needed (initiated 05/19/2025). Record review of the facility incident report dated 7/5/2025 revealed an incident occurred at approximately 9:00 PM between Residents #19 and #44. Resident #44 was found in Resident #19's room with a bleeding head wound that required 10 staples at the local emergency department. Neither resident was able to verbalize at the time of the incident what occurred to cause the injury to Resident #44. In an interview with LVN A on 7/23/2025 at 3:35 PM, she stated she was not present at the time of the incident between Residents #19 and #44. She stated she saw blood on the headboard of the bed in Resident #19's room, and she speculated that Resident #19 had pulled Resident #44 out of the bed forcibly but she did not know with certainty what actually occurred. In an interview with RN B on 7/24/2025 at 5:47 PM, she stated she was the primary nurse for Residents #19 and #44 at the time of the incident. She said she was providing care for a different resident, when a CNA alerted her that Resident #44 was in Resident #19's room and bleeding. She stated she notified 911 and provided first aid to Resident #44 and that neither resident reported aggression or an act of violence. She stated Resident #19 told her repeatedly that Resident #44 had attempted to take his [Resident #19's] shoes, but he did not state that he had assaulted Resident #44. During an interview on 6/25/25 at 3:22 PM, the DON stated methods used to keep residents safe in the secure unit included: frequent monitoring, camera's, re-direction, and de-escalation. In an interview with LVN C on 7/23/2025 at 5:16 PM, she reported Resident #19 had exhibited aggressive facial expressions and aggressive posturing at another resident on the previous evening (7/22/2025) at approximately 7:00 PM. She stated a male resident walked too closely to Resident #19, and Resident #19 responded in a manner that she felt displayed an intention of wanting to engage in a fight with the other resident. She stated she had a CNA escort Resident #19 to his room and the behavior was de-escalated. LVN C also stated Resident #19 had unpredictable aggressive episodes and that the only method of controlling his behavior was through his prescribed medication. She reported a known trigger of aggression was other residents entering his room. She stated most of the residents were aware that they were not to enter Resident #19's room but that confused residents or residents new to the facility required redirection and increased supervision to prevent them from entering Resident #19's room. In an interview with the DON on 7/24/2025 at 3:12 PM, she stated staff provided monitoring to prevent physical aggression from Resident #19. She reported Resident #19 was put on one-to-one observation on the night of 7/5/2025 until he was able to be moved to a different room on the unsecured hall. She stated the room change was due to other residents wandering into Resident #19's room on the secured unit. She stated there had been no additional incidents of aggression since Resident #19 changed rooms. In an interview with CNA G on 7/24/2025 at 1:13 PM, she stated Resident #19 could become agitated if other residents asked him too many questions or followed him too closely. She stated she had not been advised from any nursing staff of any specific things that may cause aggressive behavior from Resident #19. In an interview with the psychiatric NP, NP D, on 7/25/2025 at 10:24 AM, she stated she had not been told by facility staff of the incidents between Resident #19 and Residents #20 and #44. She stated the staff could possibly prevent future incidents of abuse by Resident #19 by performing frequent rounding. In an interview with the Admin on 7/24/2025 at 5:00 PM, he stated the facility investigations of the incidents on 6/23/2025 and 7/5/2025 were inconclusive of abuse as the incidents were not witnessed by facility staff and the residents involved had cognitive impairment. He did not feel there were any deficiencies in the care provided to any of the residents involved in the incidents. In a subsequent interview on 7/31/2025 at 7:45 PM, the Admin reiterated to the survey team that he did not feel any of the incidents involving Resident #19 qualified as abuse to other residents. He stated the survey team was harming Resident #19 by classifying the behaviors as abusive towards the other residents, and he felt the only solution to protect other residents was to discharge any resident who has behaviors. Record review of the facility policy titled Abuse, Neglect, and Exploitation, revised 6/30/2025, revealed the following: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental aguish, which can include staff to resident abuse and certain resident to resident altercations . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. This was determined to be an Immediate Jeopardy (IJ) on 7/24/2025 at 4:06 PM, and the Administrator was provided with the IJ Template on 07/24/2025 at 4:24 PM. The plan of removal was accepted on 07/25/2025 at 9:02 AM and reads as follows: 1. Immediate Removal of Resident #19 from General Population On 7/24/2025 at 5:30 PM, Resident #19 placed on 1:1 supervision until he is evaluated by physician and psychiatric entities. A physician was notified, and a psychiatric consultation was requested by DON/Designee to evaluate ongoing aggressive behavior. Resident #19 remains under ongoing supervision, with documentation every 15 minutes by person providing 1:1 supervision, reviewed by licensed staff until seen by physician and psychiatric services. Staff providing 1:1 has been in serviced by DON/Designee on how to approach a resident with dementia. 2. Resident Safety Measures Implemented A full head-to-toe assessment was conducted for Residents #65, #20, and #44 immediately after each incident. Physician and family notifications were completed for all three residents. Residents were monitored for signs of trauma, pain, or behavioral changes, and care plans updated accordingly. Wandering residents are being redirected more proactively, with visual cues and barriers, stop sign to deter residents from entering installed on Resident #19's door as of 7/24/2025 by 5:30 PM. 3. Care Plan Reviews and Revisions All residents with behaviors or at risk of wandering had their care plans reviewed and revised on 7/24/2025 - 7/25/2025. Resident #19's care plan now includes: Do-not-enter signage, behavior monitoring every shift in the residents TAR, and escalation protocols if aggression is observed. 4. Staffing Adjustments and Assignments Housekeeping, laundry, and dietary personnel were also notified and instructed to knock prior to entering resident 19's room and announcing themselves. 5. Staff Education and Re-Education All facility staff (licensed and unlicensed) completed in-service training by administrator/designee on: abuse prevention, identifying and managing resident-to-resident aggression, reporting protocols for abuse and injuries of unknown origin, and interventions/supervision for dementia-related behaviors. Behavior monitoring added to all residents to be recorded on the residents TAR each shift. Licensed nurses in-serviced on documenting behavior monitoring on the TAR. Education sessions were conducted on 7/24/2025 and will be ongoing prior to the start of their next shift, and upon hire Sign-in sheets and post-tests were collected and reviewed for comprehension. 6. Monitoring and Quality Assurance Daily monitoring audits for supervision of Resident #19 began on 7/24/2025 and continue under the direction of the DON/designee. The Administrator and DON perform daily safety rounds for 7 days to ensure there are no visible signs of injury or distress without documentation, then weekly for 4 weeks. All incidents and near-misses reviewed in daily morning stand-up meetings for 14 days. 8. Policy Review and Update The facility's Abuse Prevention and Investigation Policies were reviewed by the QA Committee on 7/24/2025, no changes were made ADHOC QAPI An ADHOC QAPI meeting was held with the medical director on 7/24/25 regarding the immediate jeopardy issued for abuse. The facility's POR verification was as follows: 1. Resident #19 was observed to have one to one level of supervision on 7/25/2025 at 9:47 AM, 7/25/2025 at 2:12 PM, 7/25/2025 at 3:06 PM, and 7/26/2026 at 4:33 PM. The documentation completed by the staff member providing one to one observation was reviewed on 7/25/2025 at 10:00 and observed to have been initiated 7/24/2025 at 6:00 PM with documentation of Resident #19's observed behavior occurring every 15 minutes. Record review of Resident #19's progress notes revealed Resident #19 was assessed by NP D on 7/25/2025 at 1:08 PM. In an interview on 7/26/2025 at 6:13 PM, the MD stated that she and NP D were already evaluating Resident #19 for aggressive behaviors. She stated Resident #19 was not aggressive during any of the incidents relayed to her. In an interview on 7/26/2026 at 8:33 PM, the Admin, DON, and corporate nurse stated Resident #19 would remain on one to one observation until Resident #19 was assessed by the MD. 2. A laminated sign was observed to be posted on Resident #19's door on 7/25/2025 at 9:44 AM. The sign contained a graphic of a stop sign and text that read please knock and announce yourself before entering. Record review of Resident #65, #20, and #44's documented assessments did not reveal head-to-toe assessments correlating with the dates of the incidents. Documentation of the assessments was requested from the Admin on 7/25/2025 at 5:16 PM. Record review of Resident #19, #20, and #44's comprehensive care plans on 7/26/2025 revealed updates to include monitoring for signs of trauma, pain, or behavioral changes. Record review of the facility incident reported, dated 7/5/2025, reflected Resident #44's family and the MD were contacted after the incident. The facility handwritten attestation from LVN A dated 7/5/2025 indicating Resident #20 received a head-to-toe assessment at the time of the incident. In an interview on 7/26/2025 at 12:50 PM, the DON stated a head-to-toe assessment was performed by staff any time there was a reported incident because the documentation was built into the risk management assessments. She stated the head-to-toe assessments were included in the incident reports, but a separate head to toe assessment was not completed by the primary nurses for the incidents. She stated Resident #20 was assessed by LVN A, Resident #44 was assessed by RN B, and Resident #65 was assessed by LVN J. She also stated Resident #20 did not have an associated incident report for the incident on 7/5/2025, as Resident #20 was observed crawling on the ground so the staff could not be certain what occurred. She explained that many residents at the facility crawl on the ground. In an interview with LVN A on 7/26/2025 at 3:29 PM, she stated she performed a head-to-toe assessment on Resident #20 when she discovered him crawling on the ground. In an interview on 7/26/2026 at 5:30 PM, Resident #65's RP stated she was not aware Resident #65 had been involved in an altercation with another resident on 6/23/2025. In an interview on 7/26/2025 at 6:23 PM, the DON stated Resident #65's RP was unable to be reached at the time of the incident, and the social worker had initiated a wellness check in order to make contact with the RP and obtain consent for transfer of Resident #65 to a different facility. In an interview with the MD on 7/26/2025 at 6:13 PM, she stated she was notified after all three incidents involving Resident #19 occurred. In an interview on 7/26/2025 at 7:46 PM, Resident #20's RP stated she was notified by the facility of the incident on 7/5/2025 when it occurred. In an interview on 7/26/2025 at 8:16 PM, Resident #44's RP stated she was notified by the facility of the incident on 7/5/2025 when it occurred. 3. Record review of care plans for residents the facility determined were at risk for wandering/elopement was performed on 7/25/2025 and 7/26/2025 for 19 residents. The care plans were updated to include interventions related to wandering and elopement. Record review of Resident #19's care plan, date printed 7/25/2025 at 7:00 PM, reflected the following updates: If the resident becomes physically aggressive: call 911 only if resident or others are in immediate danger and facility protocols are exhausted. (revised 7/25/2025) Interventions: behavior monitoring (initiated 7/24/2025), one-on-one supervision until seen by psychiatric services and MD (initiated 7/24/2025), place do not enter signage on resident's door (initiated 7/24/2025) Focus: [Resident #19] exhibits episodes of physical or verbal aggression that poses a risk to self, others, or property (initiated 7/25/2025) Interventions: Use de-escalation strategies: speak calmly and clearly (initiated 7/25/2025) In an interview on 7/26/2025 at 12:50 PM, the DON revealed all residents' TARS were updated to include behavior monitoring for symptoms to include itching, wandering, and aggression. Residents with known aggression had a second behavior monitoring tool added to their TAR specific to aggression. 4. Record review of the staff in-service related to knocking and announcement of entry revealed 80 staff signatures. In an interview with the Admin on 7/26/2025 at 3:00 PM, he stated the in-service related to knocking was completed for housekeeping, laundry, and dietary department staff. The following staff were interviewed to verify receipt of the in-service related to knocking: HSK AF, HSK AG, and LA AT on 7/26/2025 at 2:09 PM all confirmed they had received the in-service. They stated they were instructed to knock before entering any resident's room, including Resident #19. They were also instructed on managing dementia related behaviors and to notify nursing staff if any residents were observed with abnormal behaviors. The Dietary Manager on 7/25/2025 at 1:57 PM, confirmed the DON provided training for the entire dietary staff on resident privacy- knocking and announcing before entry (especially Resident #19's door), abuse and neglect and resident to resident aggression prevention. She stated she monitored resident's behaviors during meals and would report any concerns to the nursing staff. AS on 7/25/2025 at 2:39 PM stated she received the in-service for knocking, as well as abuse and neglect training and resident-to-resident aggression prevention. AO, AP, and AQ on 7/25/2025 at 4:45 PM confirmed training on resident-to-resident intervention, abuse and neglect, and knocking on residents' doors and announcing before entry (including Resident #19's door). 5. Record review of the in-service training documents on 7/25/2025 at 10:15 reflected an in-service for resident-to-resident aggression prevention, an associated quiz for staff members regarding resident-to-resident aggression, and the facility policy titled Abuse, Neglect, and Exploitation for staff review (5 total pages). Record review of the facility's order listing report dated 7/25/2025, reflected a report for all residents in the facility had an order that read: Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every day and night shift. Record review of staff in-service sheet for resident-to-resident aggression prevention and abuse/neglect, both dated 7/24/2025, reflected 90 staff member signatures. Record review of staff in-service sheet for documenting behavior symptoms, dated 7/25/2025, reflected 17 out of 17 nurses were in-serviced. Record review of staff in-service sheet for approaching residents with dementia reflected 90 signatures. In an observation of an in-services on 7/25/2025 at 5:30 PM and 5:52 PM, ten staff members were observed receiving in-service training on interventions and supervision for residents with dementia related behaviors. On 7/26/2025, 29 out of 99 staff members (23 day shift and 6 night shift, 29% total) were interviewed to confirm receipt of the above listed in-services. In an interview with the Admin on 7/26/2025 at 3:00 PM, he reported a total of 99 staff members with 78 working day shift hours and 21 working night shift hours. He stated the DON educated the staff on the in-services. In a subsequent interview with the Admin and corporate nurse on 7/26/2025 at 8:03 PM, they stated staff who had not yet received the in-service training had been notified that must receive the in-services prior to working their next shifts. 6. Record review of the unnamed document identified by the facility as the weekly behavior monitoring tool for Resident #19 indicated no concerns with Resident #19's behavior on 7/25/2025 or 7/26/2025. In an interview with the DON on 7/26/2025 at 6:30 PM, she stated the facility was monitoring Resident #19 daily and she was overseeing the one to one observation. In an interview with the Admin on 7/26/2025 at 7:03 PM, he stated he was performing daily safety rounds every day for 7 days and daily monitoring audits, as reflected in the weekly monitoring tool previously mentioned. He reported he was overseeing the DON and her oversight of the one-to-one observation. 8. Record review of the facility's ad hoc QAPI meeting summary and agenda dated 7/24/2025 reflected attendance by the Admin, DON, corporate nurse, and MD. The agenda included review of the facility's abuse policy. In an interview on 7/26/2025 at 1:06 PM, the DON and corporate nurse stated the QAPI review of the abuse policy did not lead to any changes of the policy. While the IJ was removed on 7/26/2025, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm without immediacy because the facility needed to evaluate the effectiveness of corrective actions. 4. Record review of Resident #23's face sheet, dated 7/22/2025, reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Relevant diagnoses included disruptive mood dysregulation disorder (chronic irritability and frequent temper outbursts), bipolar disorder (mood instability), and unspecified dementia (a progress disorder that impairs thought processes, including memory and reasoning). Record review of Resident #23's quarterly MDS, submitted 4/29/2025, reflected a BIMS score of 14, indicating intact cognition. Record review of Resident #23's progress notes revealed the following documentation by LVN AU on 6/19/2025 at 9:24 AM: [LVN AU] was notified by activity director that patient was hitting another patient that was in her bed. [LVN AU] asked patient what happened she stated she was in my bed so I hit her. No injuries noted or reported at this time. Called [Resident #23's family member] with no answer and voicemail is full at this time. Record review of Resident #54's face sheet, dated 7/25/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included unspecified dementia, bipolar disorder (severe mood swings), and cognitive communication deficit. Record review of Resident #54's quarterly MDS submitted 4/16/2025, reflected a BIMS score of 06, indicating moderately impaired cognition. Record review of the facility investigation report reflected the facility self-reported the incident to the SSA on 6/19/2025. The investigation documentation reported no significant injuries to either resident. The result of the facility investigation was listed as inconlusive. As a result of the investigation, Resident #23 was moved to a private room on a different hall. Resident #23 declined to participate in an attempted interview on 7/22/2025 at 1:00 PM. Resident #54 was interviewed on 7/23/2025 at 8:33 AM, and she was unable to recall the incident. The Activities Director was interviewed on 7/25/2025 at 5:57 PM. She stated she was the staff member who initially discovered Resident #23 physically assaulting Resident #54. She reported she was walking down the hallway and Resident #54 was laying in Resident #23's bed. Resident #23 was on top of Resident #54 and striking her repeatedly in the face/head using her hands and shouting get out of my bed. The Activities Director st[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (Residents #19 and #44) investigated for accidents. The facility failed to ensure Resident #19 received adequate supervision to prevent physical aggression towards other residents. The facility failed to ensure Resident #44's received adequate supervision to prevent falls with interventions to prevent further injury when the resident had falls at the facility on 05/12/2025, 05/19/2025, 05/23/2025, and on 07/23/2025 and unwitnessed injuries on 05/01/2025 and 07/05/2025. The falls on 05/12/2025 and 07/23/2025 both resulted in hip fractures. An Immediate Jeopardy was identified on 07/29/2025. The IJ template was provided to the facility on 7/29/2025 at 4:46 PM. While the IJ was removed on 7/31/2025, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm without immediacy because the facility needed to evaluate the effectiveness of corrective actions. This failure could lead to physical injury, psychosocial harm, and decreased quality of life. Findings included:1.Record review of Resident #19's face sheet, dated 7/22/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included anxiety disorder, vascular dementia (a progressive disorder that impairs a person's reasoning, memory, and other thinking abilities), and post-traumatic stress disorder (a mental disorder resulting from experienced trauma that causes flashbacks, severe anxiety, and/or uncontrollable thoughts). Record review of Resident #19's quarterly MDS submitted 4/19/2025 reflected a BIMS score of 03, indicating severe cognitive impairment. Record review of Resident #19's comprehensive care plan, date printed 7/22/2025, revealed the following:Focus: [Resident #19] is/has potential to be physically aggressive r/t anger, dementia, poor impulse control. 2/10/25- ambulating in hallway with peer, peer punched resident in right shoulder. immediately separated. unable to verbalize details of event. stated no no no one hit me. I'm the one who is mad. Resident involved in an altercation with another resident. [sic] date initiated 11/14/2024, revision on 3/09/2025Interventions: Administer medications as ordered . assess and anticipate resident's needs . provide physical and verbal cues to alleviate anxiety . [Resident #19] and peer immediately separated . psych doctor to review meds . psychiatric/psychogeriatric consult as indicated . report to provider any changes in behavior related to altercation . when [Resident #19] becomes agitated or is the receiver of peer aggressions: intervene before agitation escalates .The comprehensive care plan did not contain interventions related to maintaining the personal space of Resident #19 or known triggers of aggression. Record review of the facility's incident reports from 1/22/2025 through 7/22/2025 revealed the following:On 6/23/2025 around 9:30 PM, Resident #65 wandered into Resident #19's room. Staff walked in and found both residents holding each other's shirts, and Resident #65 had a 7centimeter bleeding laceration to his head that required 12 stitches to repair. Resident #65 told staff he was assaulted by Resident #19.On 7/05/2025 at 4:06 PM, Resident #20 entered Resident #19's room. Staff walked in and witnessed Resident #20 getting up off of the floor. Both residents stated that Resident #19 pushed Resident #20. On 7/05/2025 at about 9:00 PM, Resident #44 went into Resident #19's room. Resident #44 obtained an unwitnessed head injury while in Resident #19's room that required 10 staples to repair. Neither Resident #19 nor #44 were able to explain to staff what occurred to cause the injury. Record review of the facility census revealed Resident #19 resided in the men's secured unit during the above listed incidents, and he was moved to an unsecured, mixed gender hall on 7/09/2025. In an interview with Resident #19 on 7/22/2025 at 11:24 AM, he was unable to recall any incidents with other residents and denied any negative interactions. In an interview with LVN A on 7/23/2025 at 3:35 PM, she stated that all staff are aware of Resident #19's territorial behavior. She recalled the two incidents on 7/5/2025 and attributed both to aggression from Resident #19 as a result of the other residents entering Resident #19's room. She was unsure what interventions were in Resident #19's care plan related to preventing aggression. LVN C was interviewed on 7/23/2025 at 5:16 PM and reported awareness of Resident #19's history of aggressive behavior. She stated she observed aggressive behavior including facial expression and posturing from Resident #19 toward another resident on the previous day (7/22/2025) but had not witnessed any other behaviors since Resident #19 had moved into the unsecured hall. LVN C stated Resident #19's aggressive behavior towards other residents was unpredictable and unable to be prevented. She stated all staff, and most residents were aware that they should not enter Resident #19's room. She was unsure what interventions were in Resident #19's care plan related to preventing aggression. In an interview with CNA F on 7/24/2025 at 10:42 AM, he stated Resident #19 was known to exhibit aggressive behaviors in the secured unit only when other residents would enter Resident #19's room. CNA F stated Resident #19's aggression was defensive in nature, and he was otherwise docile. In an interview with CNA G on 7/24/2025 at 1:13 PM, she reported awareness of Resident #19's history of aggressive behavior but denied witnessing any aggression since Resident #19 had moved rooms into the unsecured hall. She stated Resident #19 would become aggressive if he was asked too many questions or if other residents followed him. In an interview with CNA H on 7/24/2025 at 1:56 PM, she stated Resident #19 would become physically aggressive when other residents would enter his room or touch his belongings. She stated because she knew that Resident #19 would become aggressive when others entered his personal space, she would maintain supervision on the secured unit of Resident #19's door to try to prevent other residents from entering Resident #19's room. CNA H stated she was not explicitly instructed to perform this supervision, but she did it because she knew that the behavior could trigger aggression from Resident #19. In an interview with the DON on 7/24/2025 at 3:12 PM, she stated staff provided monitoring to prevent physical aggression from Resident #19. She reported Resident #19 was put on one-to-one observation on the night of 7/5/2025 until he was able to be moved to a different room on the unsecured hall. She stated the room change was due to other residents wandering into Resident #19's room on the secured unit. She stated there had been no additional incidents of aggression since Resident #19 changed rooms. In an interview with the Admin on 7/24/2025 at 5:00 PM, he stated the facility investigations of the incidents on 6/23/2025 and 7/5/2025 were inconclusive as the incidents were not witnessed by staff. He did not feel there were any deficiencies in care provided to any of the residents involved in the incidents. In an interview with RN B on 7/24/2025 at 5:47 PM, she stated she had not observed aggressive behavior from Resident #19 on any other incidents other than the evening of 7/5/2025. She stated she was in another resident's room providing care at the time of the incident on 7/5/2025, and she was alerted of Resident #44's injury by a CNA who heard shouting from Resident #19's room. She stated Resident #19 was given one to one observation on the night of 7/5/2025 due to the aggression with Resident #44 but did not require that level of observation any other time she cared for him. 2. Record review of Resident #44's admission Record, dated 06/24/2025, reflected the resident was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included unspecified dementia (a general term for impaired ability to remember, think, or make decisions), depression, and history of falling. Record review of Resident #44's Significant Change MDS, dated [DATE], reflected the resident had a BIMS score of 0, indicating severe cognitive impairment. Further review reflected the resident had a fall in the last month, but did not reflect that the resident had a major injury such as a bone fracture. Record review of Resident #44's Care Plan, dated 07/28/2025, reflected no addressing of wandering behaviors. Focus areas related to falls were initiated on 02/09/2025 and were addressed with preventative measures, or interventions, including: rounding frequently to assess for falls unreported by resident (initiated 05/12/2025), therapy as ordered (initiated 05/12/2025), PT consult for strength/mobility (initiated 05/20/2025), follow post-fall policy (initiated 05/20/2025), call bell in reach (initiated 02/09/2025), and perform transfer assistance as needed (initiated 05/19/2025). Record review of Resident #44's Orthopedic Surgeon Visit, dated 07/25/2025, reflected there was a, small fracture within the greater trochanter with the assessment/plan stating, He may weight-bear as tolerated with a walker and needs to be supervised as he had a difficult standing with me at bedside today. [sic] Record review of Resident #44's Order Summary Report, dated 07/26/2025, reflected Per [Orthopedic Surgeon] WBAT with a walker and staff assistance as well as information related to Resident #44's follow-up appointment with the orthopedic surgeon. Observation on 07/28/2025 at 11:30 AM, Resident #44 was observed on the hallway of the locked unit standing and walking away from his wheelchair. In a subsequent observation on 7/29/2025 at 9:07 AM, Resident #44 was observed resting in bed in his room. There was no walker present in the room. Interview with the Clinical Nurse Specialist from the orthopedic surgeon's office on 7/29/2025 at 8:17 AM revealed the resident was assessed by the surgeon on 7/25/2025. The surgeon diagnosed the resident with a new fracture to an area separate from the original fracture that occurred in May 2025. The surgeon recommended Resident #44 to be weight bearing as tolerated, use a walker when ambulating with staff supervision, and limit abduction of the left leg as much as possible. Interview on 7/29/2025 at 8:51 AM with PT Director, she stated the new directives for Resident #44 from the physician included weight bearing as tolerated using a walker. She also stated that the therapy department educated the staff verbally and left a walker in Resident #44's room for use. She was unsure if the care plan had been updated, and she stated the process for communicating changes to the nursing staff from the therapy department was to have conversations with the CNAs and nurses. Interviews with CNA F and LVN A on 7/29/2024 at 9:00 AM revealed Resident #44 was not able to use the call light as he did not understand how it functioned and continuously pressed the call button. In an interview with MDS Nurse on 7/29/2025 at 9:40 AM, she stated the post fall policy included all interventions performed by nursing after a fall, including assessments, notification, and documentation per the company policy. Interview with CNA F on 7/29/2025 at 8:58 AM, stated the nurse instructed him to encourage Resident #44 to limit ambulation. CNA F stated Resident #44 used a wheelchair and not a walker. He was not aware of limitations or precautions related to positioning. Interview with LVN A on 7/29/2025 at 9:01 AM, she reported Resident #44 did not have a walker in his room and had been using a wheelchair. She stated he was weight bearing as tolerated and using the wheelchair frequently. She was not aware of recommendations for Resident #44 to limit leg positions or to use walker when ambulating. Interview with ADON R on 07/29/2025 at 10:30 AM, she stated there were no interventions after Resident #44's ortho appointment and he could ambulate and bear weight as tolerated using his walker and with supervision. Interview with ADON Q on 07/29/2025 at 10:40 AM, she stated she told staff Resident #44 was allowed to be weight bearing as tolerated with staff assistance and he had to have a walker. She stated other nursing staff were informed when communicating in report. Interview with DON on 07/29/2025 at 10:40 AM, revealed care plan meetings were held quarterly or when family requested care plan meetings and that it was important to have everyone involved in the care plan meetings. The DON did not state why the care plan was not updated or revised after each fall. Record review of facility policy titled, Comprehensive Care Plans, dated 6/30/2025, reflected, Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions initially and when changes are made. Record review of the facility policy titled Abuse, Neglect, and Exploitation, revised 6/30/2025, revealed the following: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation of resident properly, and exploitation that achieves: .B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more like to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms . D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; . This was determined to be an Immediate Jeopardy (IJ) and the Administrator was provided with the IJ Template on 07/29/2025 at 4:46 PM. A Plan of Removal was requested at this time. The plan of removal was accepted on 07/31/2025 at 6:57 PM and reads as follows: Deficiency:The facility failed to develop and implement a comprehensive, person-centered care plan for Resident #44 that addressed his medical, nursing, and psychosocial needs, including fall risk, cognitive impairment, and post-orthopedic care. The resident had multiple unwitnessed falls, including with injuries. 1. Corrective Actions Taken for Resident #44: Resident #44's care plan was reviewed by IDT and revised by MDS to include fall prevention strategies, post-fall and orthopedic care instructions. The family was notified of new care plan interventions. 2. Identification of Other Residents at Risk: Residents with falls, wandering and behaviors in the last 14 days were audited and care plans were reviewed/updated accordingly. 3. Systemic Changes to Prevent Recurrence: IDT was in-serviced on 7/30/2025 regarding updating care plans and fall prevention protocols. Licensed Nurses were in serviced by DON/Designee beginning on 7/30/25 ongoing until 100% of working licensed nurses are in-serviced on where to look for care plan changes and new interventions. CNAs were in-serviced by DON/Designee beginning on 7/30/25 ongoing until 100% of working CNAs on where to look for care plan changes and interventions. The DON/Designee will review new orders and recommendations each business day and ensure care plans are updated for all residents with falls, wandering or behaviors. The Director of Nursing/Designee will review all new falls for care plan documentation, therapy recommendations, assistive devices, and staff communication on each new business day. The DON/Designee will validate communication through clinical rounds and review of written 24 nursing shift report during clinical standup meetings. Licensed nursing staff will be in-serviced beginning on 7/30/25 ongoing until 100% of working licensed nurses are in-serviced to communicate changes in behavior on the written 24-hour shift change report. The administrator will attend clinical stand up weekly to ensure communication is taking place. Monitoring and Quality Assurance: Findings will be reviewed by the Quality Assurance Process Improvement Committee for three months. Ad HOC QAPI Meeting Held:7/30/25 The facility's POR Verification was as follows:1. Record review of Resident #44 Care Plan on 7/31/2025 at 8:05 AM, reflected new interventions to include, May use wheelchair if Resident #44 prefers., Resident #44 is at risk for wandering and elopement. Discourage Resident #44from entering other residents' rooms. and Per Ortho WBAT with walker and staff/PT/OT assistance. Resident may use WC per preference Interview on 07/31/2025 at 10:20 AM, the DON stated that Resident #44's Care Plan was reviewed and revised with the IDT team to include fall prevention strategies, post-fall and orthopedic care instructions. The DON also stated Resident #44's Kardex was updated to reflect their POC. The DON stated the MDS Nurse updated Resident #44's Care Plan. Interview on 7/31/2025 at 4:07 PM, the Administrator stated he was present for the IDT care plan meeting. The Administrator stated the IDT team is the administrator, the medical director, the director of nursing. Observation on 7/31/2025 at 5:35 PM revealed Resident #44 self-propelling in wheelchair in the hallway. Further observation revealed a walker in Resident #44's room. Resident #44 was observed being redirected away from other resident rooms. Record review of Resident #44 Progress Note dated 07/29/2025 at 6:19 PM reflected, Care conference with IDT and Resident RP via phone to discuss plan of care and new fall and wandering related interventions. IDT informed RP of interventions in place. RP agrees with interventions and requests that staff provides a busy board for Resident to keep him busy. RP states that Resident has always paced, even prior to dementia and RP would not like staff to restrict him from doing that. However, she would like staff to redirect Resident out of other Residents rooms and unsafe environments. IDT informed RP of medication list per her request. Resident RP states that she would like staff to be sure and offer Resident fluids due to a history of dehydration prior to admission to this facility. Resident RP states that she would like staff to notify her immediately when a fall occurs. Rp will call if any other issues arise and staff will notify RP with any changes or concerns. Interview on 07/31/2025 at 9:01 AM, Resident #44's RP stated she was involved in the resident's new care plan. Interview on 07/31/2025 at 3:53 PM, the DON stated that Resident #44's RP was notified of the new interventions added to Resident #44's Care Plan. 2. Record review of facility Incident By Incident Type log reflected there were 12 falls between 07/17/2025 and 07/31/2025. Further review reflects that of these 12 falls, 6 were unwitnessed, and 6 were witnessed. Record review of 58% (7 of 12) of Residents with falls, wandering and behaviors in the last 14 days reflected that their care plans were reviewed and updated accordingly. Record review reflects all care plan updates were implemented between 7/22/2025 and 7/31/2025. Further review reflected 58% of Residents with falls, wandering and behaviors in the last 14 days had updates to their Kardex to accurately reflect their Care Plan. Record review reflected an audit form, created by the facility; to track and trend falls for the last 14 days. Interview on 7/31/2025 at 10:20 AM, the DON and ADON R stated care plan updates were completed on all residents with falls in the last 14 days. The DON stated they had updated all Kardex's. 3. Interview on 07/31/2025 at 3:51 PM, the DON stated the IDT team was in-serviced on updating care plans in a timely fashion, the expectations for each staff member to appropriately complete the Kardex, in-servicing of staff, and care plans. Interview on 7/31/2025 at 4:07 PM, the Administrator stated that the in-service was completed by the Regional Corporate Nurse and discussed updating care plans. Interview on 7/31/2025 at 4:19 PM, the Regional Corporate Nurse stated the Administrator was in the IDT team meeting regarding care plans. Record review of Fall Prevention In-Service Training reflected that 100% of the IDT team was in-serviced on 07/29/2025 on, protocols for identifying residents at risk, implementing appropriate interventions, and complying with post-fall procedures to ensure resident safety and regulatory compliance. Further review reflects the IDT team was in-serviced on 07/29/2025 on, To educate all Interdisciplinary Team (IDT) members on their role in the timely review, revision, and communication of resident care plan updates, ensuring compliance with F656 and delivery of person-centered care. Interview on 07/31/2025 at 10:37 AM, LVN N stated she typically works 6 AM - 6 PM, and was in-serviced on finding changes in the care plan in the Kardex and care profile and was able to describe situations which warranted inclusion in the 24-hour report. Interview on 07/31/2025 at 1:29 PM, LVN V stated she typically works 6 PM - 6 AM, and was in-serviced on care plan changes and interventions, LVN V stated she felt comfortable looking for changes made to care plans. Interview on 7/31/2025 at 1:33 PM, LVN W stated she typically works 6 AM - 6 PM and was trained on care plan changes and interventions. LVN W stated she felt comfortable with communicating care plan changes with other nursing staff. Interview on 7/31/2025 at 2:09 PM, RN X stated she typically works 6 PM - 6 AM and was in-serviced on care plan changes and interventions. RN X was able to demonstrate how to view any changes or updates in care plans or Kardex. Interview on 7/31/2025 at 3:00 PM, MDS Nurse stated she typically works at the facility 2 of 5 days a week between 8 AM and 5 PM, and was familiar with care plan changes, as she typically implements the care plan changes. Interview on 7/31/2025 3:50 PM, the DON stated there are less than 5 staff who still need to be in-serviced, and they will be in-serviced prior to beginning their next shift on the floor taking care of residents. The DON stated the staff who have not been in-serviced are because they are not currently working and have not responded to phone call attempts to complete in-servicing. Interviews were completed on 07/31/2025 between 10:30 AM and 5:15 PM with 1 of 4 Medication Aide's, 7 of 25 CNA's, 4 of 13 LVN's, and 1 of 2 RNs to verify completion of in-servicing for a total of 11 of 49 staff members. Staff members interviewed were staff who worked all shifts. Record review of in-service titled, Viewing the Kardex in PointClickCare (PCC), reflected, how to properly access and interpret the Kardex in PCC to ensure resident care aligns with current care plans. Record review of in-service sign-in reflected that 18 of 20 Licensed Nurses were in-serviced by the DON on the in-service titled, Viewing the Kardex in Point Click Care (PCC) Interview on 07/31/2025 at 10:43 AM, MA Y stated that she typically works 6 AM - 6 PM, and received in-servicing on care plan changes, looking in the point of care, and looking in the kardex. Interview on 07/31/2025 at 10:44 AM, CNA G stated they typically work the 6 AM - 6 PM shift and received in-servicing on care plan changes and interventions, looking at the Kardex, and looking at the care plan itself. Interview on 07/31/2025 at 12:45 PM, CNA S stated they typically work 6 PM - 6 AM and received in-servicing on care plan changes and interventions, to include the Kardex. Interview on 7/31/2025 at 1:05 PM, CNA T stated they typically work 6 AM - 6 PM and was in-serviced on care plan changes and interventions to include accessing the Kardex for resident's care plan interventions. Interview on 7/31/2025 at 1:13 PM, CNA U stated they typically work 6 AM - 6 PM and received in-servicing on care plan changes and interventions and knew how and where to review the residents POC. Interview on 7/31/2025 at 3:31 PM, CNA Z stated they typically work 6 AM - 6 PM and received training on care plan changes, interventions, and reviewing the Kardex. Interview on 7/31/2025 at 3:33 PM, CNA AA stated they typically work 6 AM - 6 PM, and received training on reviewing the Kardex and implementing care plan changes. Interview on 7/31/2025 at 3:37 PM, CNA AB stated they typically work 6 PM - 6 AM and had recently received training on the Kardex, resident behaviors, and new interventions. Interview on 7/31/2025 3:50 PM, the DON stated there are less than 5 staff who still need to be in-serviced, and they will be in-serviced prior to beginning their next shift on the floor taking care of residents. The DON stated the staff who have not been in-serviced are because they are not currently working and have not responded to phone call attempts to complete in-servicing. Record review of in-service titled, Viewing the Kardex in PointClickCare (PCC), reflected, how to properly access and interpret the Kardex in PCC to ensure resident care aligns with current care plans. Record review of in-service sign-in reflected that 24 of 29 CNA's were in-serviced by the DON on the in-service titled, Viewing the Kardex in Point Click Care (PCC) Interview on 07/31/2025 at 3:41 PM, the DON stated the ADON would be the designee if she was not available, and she will be checking 24-hour reports each day to review for behaviors or changes that need to be placed on the care plan and place. The DON stated she had reviewed all new orders and would continue to do so each business day and would check any orders occurring over the weekend that were not emergent on Monday morning. Record review reflected, Daily Sign-Off Calendar for the DON/Designee to review new orders and recommendations each business day and ensuring that all care plans are updated. Further review reflected the DON had signed off on new orders and recommendations on 7/30/2025 and 7/31/2025. Interview on 07/31/2025 at 3:43 PM, the DON stated the ADON would be the designee if she was not available. The DON stated that typically staff will call her when a resident falls, and she will review the 24-hour report and risk management on Monday and update as needed. Record review reflected, Daily Sign-Off Calendar for the DON/Designee to review all new falls for care plan documentation, therapy recommendations, assistive devices, and staff communication. Further review reflected the DON had signed off on new orders and recommendations on 7/30/2025 and 7/31/2025. Interview on 07/31/2025 at 3:45 PM, the DON stated that clinical standup meetings typically happen in the morning Monday through Friday. The nurse for the unit will discuss the 24-hour report with the DON and discuss any changes, as well as rounding throughout the day at the facility. Record review reflected, 24-Hour Report dated 07/31/2025, reflected the DON reviewed and signed off on the written 24-hour nursing shift report. Interview on 07/31/2025 at 10:37 AM, LVN N stated she typically works 6 AM - 6 PM, and was in-serviced on finding changes in the care plan in the Kardex and care profile and was able to describe situations which warranted inclusion in the 24-hour report. Interview on 07/31/2025 at 1:29 PM, LVN V stated she typically works 6 PM - 6 AM, and was in-serviced on changes in resident care plans, behaviors, and communicating those behaviors on the 24-hour report. Interview on 7/31/2025 at 1:33 PM, LVN W stated she typically works 6 AM - 6 PM and was trained on documenting changes in behaviors in the 24-hour shift change report. Interview on 7/31/2025 at 2:09 PM, RN X stated she typically works 6 PM - 6 AM and was in-serviced on communicating any changes on the nurses' 24-hour report and it was something she was comfortable doing. Interview on 7/31/2025 at 3:00 PM, MDS Nurse stated she typically works at the facility 2 of 5 days a week between 8 AM and 5 PM and received education on communicating via the 24-hour report. Record review of facility in-service titled, In-service Training: Communicating Behavior Changes on 24-Hour Shift Report reflected, All licensed nurses are responsible for reporting observed behavioral changes during their shift and documenting these changes on the facility's written 24-hour shift change report. Record review of facility in-service sign-in sheet for the in-service, Communicating Behavior Changes on 24-Hour Shift Report reflected that 18 of 20 licensed nursing staff were in-serviced on communicating changes in behavior on the 24-hour shift change report. Interview on 7/31/2025 at 4:07 PM, the Administrator stated he always attends stand up meetings. Interview on 7/31/2025 at 6:13 PM, the DON stated the Administrator had attended the stand-up meetings. Interview on 07/31/2025 3:48 PM, the DON stated she was part of the QAPI Committee and will review monthly any complications they may have to identify trends and identify a process to better take care of residents. The DON stated they go through falls, admissions, and any other concerns. Interview on 7/31/2025 at 4:07 PM, the Administrator stated he is in the QAPI Committee, and they look for trends. Interview on 7/31/2025 at 4:17 PM, the Regional Corporate Nurse stated they would monitor any incidents and accidents during the three-month period and discuss any behaviors. Interview on 7/31/2025 at 3:47 PM, the DON stated she was in the Ad HOC QAPI meeting on 7/29/2025. Additional members included the Administrator, Director of Rehabilitation, and the Corporate Nurse, as well as an ADON. Interview on 7/31/2025 at 4:07 PM, the Administrator stated he was in the Ad HOC QAPI meeting on 7/29/2025. Record review of Ad HOC QAPI meeting summary provided by the facility, dated 07/29/2025, reflected that the administrator, DOR, Corporate Nurse, ADON were in the Ad HOC QAPI meeting. On 07/31/2025 at 6:57 PM, the Administrator was informed the IJ was removed, however the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimum harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observations, interviews, and record reviews, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen. Ground beef at 71 degrees F (danger zone temperature) and frozen shelled eggs were being used to prepare meatloaf for the lunch meal on 6/11/24. The ground beef and shelled eggs were not thawed correctly. An IJ was identified on 06/11/24. The IJ template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 06/12/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm that is not immediate jeopardy because the facility needed to install new refrigerators, safely store foods, and establish temperature logs for the refrigerators. The failure could place residents at risk for food borne illnesses related to cooking meals that were not properly stored and from food that was in the danger zone temperatures prior to cooking. The findings included: Observation of the break room refrigerator (being used temporarily due to walk-in refrigerator not working) at 9:15 AM on 6/11/24 revealed that 3 10-pound containers of ground beef were inside. The temperature on the gauge inside the refrigerator was 54 degrees F. [NAME] A took the temperature of the break room refrigerator with the beef inside with his thermometer, and it read 71 degrees F. Also, observation of the non-working walk-in refrigerator revealed containers containing various food liquids. Observation and interview on 6/11/24 at 9:15 AM revealed kitchen staff stated they were placing items out on the countertop to defrost. Observation revealed the kitchen staff placed 3 10 pound containers of meat and 24 broken eggs on the kitchen counter for cooking. During an interview on 6/11/24 at 9:15 AM, [NAME] A stated that the second walk-in refrigerator went out sometime Sunday (6/9/24) night. [NAME] A stated the walk in refrigerator number one was not working for over one year and was being used to store pantry items. [NAME] A stated that refrigerated foods [eggs] should not be frozen and then thawed for cooking. [NAME] A stated that items that could present food borne illness problems and thawed out included: vegetables, eggs, meats, salad dressings, and mixed fruits. [NAME] A stated that no temperature log was posted on the temporary break room refrigerator and he did not know when the 3 containers of hamburger meat thawed out; or were put in the temporary refrigerator. [NAME] A stated that the AC was not working in the kitchen. [air temperature of the kitchen taken by [NAME] A read 81 degrees F]. [NAME] A stated that he was responsible for taking temperature logs and had not recorded temperatures for the temporary break room refrigerator on 6/11/24. [NAME] A stated he intended to cook the 3 containers of hamburger meat and the frozen eggs from the freezer that were broken because he followed orders [from the FSS]. Attempted call on 06/11/24 at 9:20 AM, the facility Dietician (B) did not respond; message left to call surveyor. During an observation on 06/11/24 at 9:20 AM, the FSS directed [NAME] A not to prepare the lunch meal because it was unsafe and posed a risk of food borne illnesses to residents. [NAME] A stopped preparing the lunch meal. Record review of the menu for 6/11/24 revealed that meatloaf was to be served for lunch. Observation and interview on 6/11/24 at 9:30 AM revealed 3 10-pound containers of ground beef on the counter. The ground beef read 71 degrees F (temperature taken by [NAME] A at surveyor's request). [NAME] A said that the ground beef was supposed to be used for lunch but was unsafe. Additionally observed were 24 whole eggs which had previously been frozen and were now sitting on the countertop to defrost with the shell cracked for preparation, along with the ground beef, for a meatloaf lunch meal. [NAME] A stated the eggs were frozen and came from one of the freezers. [NAME] A stated that the broken eggs sitting on the table counter could develop bacteria. [NAME] A stated that the temperature of the meat should not be 71 degrees F and thawed in a non-working refrigerator. [NAME] A stated it was unsafe to cook the meat but he was ordered by the FSS to prepare the lunch meal on 6/11/24. During an interview on 6/11/24 at 10:00 AM, Kitchen Aide B stated, she became aware of the break room refrigerator not working on 6/11/24. Kitchen Aide B stated the plan for cooking the lunch meal was to thaw out the food items (eggs and meat) at room temperature. Kitchen Aide B stated the walk in refrigerator went out on Sunday (6/9/24). Kitchen Aide B stated the plan was to cook items from the temporary break room refrigerator for the noon meal (6/11/24). Kitchen Aide B stated that it was not a good idea to cook items from a refrigerator that was not working and the temperature was unknown; and residents could be affected with illnesses. Kitchen Aide B stated they did not know what staff put the 3 10 pound containers of hamburger meat in the temporary refrigerator or when the placement occurred. In an interview on 6/11/2024 at 10:05 AM, the FSS stated that she and the Administrator (after the surveyor's entrance) decided to cater meals because of food borne illnesses the items from the nonworking refrigerators could present to residents. The FSS stated all 78 residents eat from the kitchen except one. The FSS stated that all items in the break room refrigerator and walk-in refrigerator would be discarded. The FSS stated she did not know the time the 3 containers of meat in the temporary refrigerator thawed out because there were no temperature logs for the break room refrigerator. The FSS stated that she was responsible for checking that the cooks documented temperatures on temperature logs at least daily. The FSS stated that the plan for meals prior to the surveyor's arrival was to use items frozen in the freezers and the items from the nonworking break room refrigerator that contained the 3 10 pound containers of hamburger meat. In an interview with the Administrator at 10:15 AM on 6/11/24, she stated that the decision to cater meals was made at 9:38 AM on 6/11/24 - after surveyor intervention. Observation on 6/11/24 at 11:30 am revealed that the temporary break room refrigerator was not present in the kitchen and there were no food items in the non-working walk-in refrigerator. During an interview on 6/11/24 at 11:31 am, the FSS stated that all items in the temporary refrigerator and the non-working walk-in refrigerator were discarded. The FSS stated that she made the documentation [daily log] on the non-working walk-in refrigerator on 6/9/24 when the temperature reading recorded was 65 degrees F. The FSS stated she informed the Administrator of the non-working walk-in refrigerator and a decision was made to move the break room refrigerator into the kitchen. The FSS stated that no temperatures for the temporary refrigerator were taken once it was placed in the kitchen; and no temperature log posted on the refrigerator. The FSS stated that food temperatures in the danger zone should not be cooked because of the risk of food borne illnesses to residents. The FSS stated the danger zone for food temperatures was above 41 degrees F and below 135 degrees F. During telephone interview on 6/11/24 at 3:30 PM, [NAME] C stated, they worked on 6/10/24 and left duty at 8:30 PM. [NAME] C stated that during their shift the break room refrigerator was brought into the kitchen from the employee's lodge; and no temperature log was present. [NAME] C stated that there were no meats in the temporary refrigerator; and any placement of meats had to occur after he left duty on 6/10/24 at 8:30 PM. [NAME] C stated that it would take about 24 hours for frozen 3-10 pound containers of meat to thaw out. [NAME] C stated he did not know who put the 3 10 pound containers of meat rolls in the temporary break room refrigerator and the time the storage occurred. [NAME] C stated that he took a reading of the walk-in refrigerator on 6/8/24 and it read 52 degrees F. [NAME] C stated he told no one about the walk-in refrigerator and not being within the range of 40-45 degrees F on 6/08/24. [NAME] C stated that he was not aware that facility may have purchased the 3 10 pound containers of meat rolls on either 6/10/24 or 6/11/24. During an interview on 6/11/24 at 3:58 PM, the Administrator stated, the 3 10 pound containers were not purchased on 6/10/24 or 6/11/24 from a local vendor. The Administrator stated the 3 10 pound containers of meat were frozen and stored in the freezers. During telephone interview on 6/12/24 at 9:00 am, Dietician D stated: she became aware of the refrigeration issues on 6/11/24 after the entrance of the surveyor. She stated that the assigned dietician to the facility ( Dietician E) was on vacation which started on 6/9/24 and the facility was aware. Dietician D stated that she provided guidance to the facility on the catered meals involving regular, mechanical soft, and puree during the emergency. Dietician D stated it was unsafe to cook meats that had a reading of 71 degrees and frozen cracked eggs should not be cooked because of the danger of food borne illnesses. Dietician D added that any refrigerator in the kitchen required temperature logs to include the temporary break room refrigerator brought in from the employee break area. Further, Dietician D stated that frozen milk or frozen eggs should not be served to residents and should be discarded. In interviews on 06/14/24 from 12:57 PM to 1:52 PM. LVN I (12:52 PM), LVN J (1:40 PM) and LVN K (1:52 PM) stated that there were 20 combined residents out of a census of 78 on 06/10/24 that were considered immune compromised which made them more susceptible to food-borne illness Record review of kitchen's non-working walk-in refrigerator temperature readings from temperature log were: 6/08/24 taken by [NAME] C was 52 F and on 6/09/24 taken by the FSS was 65 F. Record review of facility's food truck delivery invoice dated 6/10/24 revealed delivery of food items that did not contain delivery of 3 10 pound containers of hamburger meat. Record review of facility's Food Preparation and Service policy dated revised April 2019 read: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices .Foods will not be thawed at room temperatures Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese .the danger zone for food temperatures is between 41 (degrees) F and 135 (degrees) F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness .The longer foods remain in the 'danger zone' the greater the risk of harmful pathogens. Therefore, PHF (potentially hazardous food) must be maintained below 41 (degrees ) F and above 135 (degrees) F. Record review of website https://www.fda.gov/food/buy-store-serve-safe-food/what-you-need-know-about-egg-safety revealed: Fresh eggs, even those with clean, uncracked shells, may contain bacteria called Salmonella that can cause foodborne illness, often called 'food poisoning.' Proper storage of eggs can affect both quality and safety .Store promptly in a clean refrigerator at a temperature of 40 F or below. Use a refrigerator thermometer to check .Bacteria that can cause illness grow quickly at warm temperatures (between 40 F and 140 F) . Record review of website https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/big-thaw-safe-defrosting-methods revealed: Raw or cooked meat, poultry or egg products, as any perishable foods, must be kept at a safe temperature during the big thaw. They are safe indefinitely while frozen. However, as soon as they begin to thaw and become warmer than 40 F, bacteria that may have been present before freezing can begin to multiply Perishable foods should never be thawed on the counter, or in hot water and must not be left at room temperature for more than two hours. The Administrator and the DON were notified of the Immediate Jeopardy on 06/11/24 at 5:15 pm and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 6/11/24 at 9:13 PM and reflected the following: FACILITY: Facility ID Number: SURVEY TYPE: Annual Survey SURVEY DATE: 6/11/2024 Plan for REMOVAL Plan to remove immediate jeopardy. F812 No contaminated foods were prepared or provided to any residents. Food was discarded immediately upon observation of incorrect temperature. Industrial refrigeration was ordered on 6/10/2024. Due to be delivered 6/13/2024. A refrigeration truck was ordered and will be delivered 6/11/2024 for cold storage. Food truck delivered 6/11/2024. The physician was notified of the alleged deficiency on 6/11/24 at 5:35pm. There were no new orders obtained. [NAME] was educated and suspended pending investigation. Dietary Staff has been educated on food temperatures, preparation, and service for all residents. Dietary Staff will notify the Administrator immediately if an occurrence of incorrect temperatures or questions/issues regarding food service and will follow procedures. Procedures include checking refrigerator temperatures daily, following policy and procedures for Food Preparation and Service. 6/11/2024 0830am Interventions set in place to include catered food for residents for 3 meals per day. Contact and notification for recommendations from RD E 6/11/2024 605pm RNC assessed all residents in facility for any GI symptoms including nausea, vomiting, diarrhea. No symptoms noted. There was no concern identified. The interviews were completed. 6/11/2024, 5:35p Ad-Hoc QAPI meeting was held on with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations) and Marketing Director, LVN to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. On 6/11/2024 the Administrator completed 1:1 in-service with Dietary Manger on Food Preparation and Service policy. Staff educated by administrator on 6/11/2024 on Food Preparation and Service policy. On 6/12/2024 Dietary manager in-serviced by Registered dietician [RD H]. RD also in-service dietary staff as well. Starting on 6/11/2024, the facility leadership (Administrator, Director of Nursing, and Regional Director) will complete education with all staff on Food Preparation and Service, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences, keep residents safe. The training was initiated on 6/11/2024 and will be completed on 6/11/2024. Staff will not be allowed to work until they receive training. The policy pertaining to Food Preparation and Services was reviewed on 6/11/2024 by the NHA (Nursing Home Administrator), Marketing Director, LVN, DON (Director of Nursing), RDO (Regional Director of Operations), and Medical Director. Starting on 6/11/2024, IDT (Interdisciplinary team), including Administrator, DON, Activity Director, Marketing Director, HR, BOM will meet daily after rounds Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any Kitchen refrigerators or temperatures were out of appropriate range. The findings will be immediately brought to the Administrator for further action, if necessary. Grievances will be reviewed during morning meetings with Administrator and IDT team members for any follow-up needed. All grievances will be entered into the Grievance Log by Administrator and investigation form will be filled out accordingly. 6/11/2024 Administrator will monitor kitchen daily by doing rounds during business days for any change in kitchen refrigerator temperatures she will monitor on weekend days for one month and then random audits will be provided thereafter. An audit sheet of rounding will be kept in a binder specified for follow up. Admin or designee will conduct audits for daily rounds for one month then periodically thereafter. Administrator will be notified by staff of any issues noted in the dietary department. 6/11/2024 Administrator will monitor refrigerator temperatures daily during business days and weekend manager will monitor on weekends for appropriate functioning and temperature utilizing a thermometer placed in refrigerator. 6/11/2024 RDO will provide physical oversight at facility weekly x4 weeks and then random reviews after. The RDO will provide oversight of the Administrator to ensure the items on the removal plan are reviewed and completed by 6/11/2024. Verification of Plan of Removal: Key Observations: Observation on 6/12/24 at 8:00 AM of the facility's parking lot revealed the presence of a refrigerated truck trailer. Observation on 6/12/24 at 1:05 PM of kitchen revealed: the non-working walk-in refrigerator was totally empty. Further observation of three freezers revealed food items and liquids, for instance milk, and eggs that could not be frozen, that came from the temporary employee room refrigerator and the food shipment on 6/9/24 were not present in latter freezers. Observation on 6/11/24 at noon and to 6/12/24 at 6 PM all meals had been catered. Key Interviews: During an interview on 6/12/24 at 8:29 AM, the FSS stated [NAME] A resigned on 6/11/24. The FSS stated a refrigerated truck trailer parked in the facility's parking lot arrived on 6/12/24 at 2:00 am. The FSS stated permission had not been granted by upper management to start cooking on site; meals were catered. The FSS stated she discussed the diet needs for residents on puree and mechanical soft with the dietician. During telephone interview on 6/12/24 at 9:00 am, Dietician D stated: she provided guidance to the facility on the catered meals involving regular, mechanical soft, and puree during the emergency (IJ). During a group interview on 6/12/24 at 4:40 PM, Dietary Aide F, the FSS, Dishwasher G , and [NAME] C, stated: they received training on to notify the Administrator immediately if an occurrence of incorrect temperatures or questions/issues regarding food service and will follow procedures. Procedures included checking refrigerator temperatures daily, following policy and procedures for Food Preparation and Service. Highlights of the training was that refrigerators needed to have temperature logs and any food in the food danger zone (41 degrees F and 135 degrees F) and to notify the FSS before cooking once temperatures were taken. The FSS stated once she was notified of any danger zone issues her plan was to dispose of the food and notify the dietitian. The group stated the training was provided by Dietician H. During an interview on 6/12/24 at 4:51 PM, Dietician H stated he trained all 8 dietary staff and the top three highlights of the training were: safe food temperatures, storage and keeping track of refrigerator temperatures especially danger zone temperatures. In interviews on 06/12/2024 from 5:30 PM. to 6:00 PM with 4 day shift (6 AM. to 2 PM.) 2 activities, 1 HR, 1 marketing, 6 evening shift (2 PM. to 10 p.m.) nursing staff (1 LVNs, 2 CNAs) and 3 kitchen staff; and 4 night staff (10 PM to 6 AM) 1 NA, 1 LVN, 1 CNA, and 1 CMA revealed they had been in-serviced on food temperatures, danger zones temperatures, food storage, and the Food Preparation and Service policy. During an interview on 6/12/24 at 5:50 pm, the Administrator stated that issues involving food storage, food temperatures and/or refrigerator logs would be follow-up for investigation if issues or grievances were raised. During an interview on 6/11/24 at 6:00 pm, the RDO stated that she would provide physical oversight at the facility weekly x4 weeks and then random reviews after. During telephone interview on 6/12/24 at 6:07 PM, the Medical Director stated she was notified of the IJ on 6/11/24 and issued no new orders. During an interview on 6/12/24 at 7:20 PM, [NAME] C stated, the back-up plan in case the new refrigerators went out in the future was to release a refrigerated truck until the issues with the refrigerators were fixed or new refrigerators purchased. During an interview on 6/12/24 at 7:22 PM, the FSS stated: the back-up plan in case the new refrigerators went out in the future was to release a refrigerated truck until the issues with the refrigerators were fixed or new refrigerators purchased. During an interview on 6/12/24 at 7:25 PM, the Administrator stated the back-up plan was to re-lease a refrigerated truck until the issues with the new refrigerators were resolved. During an interview on 6/12/24 at 7:58 PM, the DON stated: RNC assessed all residents in facility for any GI symptoms including nausea, vomiting, diarrhea. No symptoms noted and there was no concerns identified. During a joint interview on 6/12/24 at 8:00 PM, the RRC (regional reimbursement consultant, RN) and the RNC completed 100 % assessment of residents for GI issues and no issues surfaced requiring contacting the MD for new orders. Key Record Reviews: Record review of facility signed in sheet dated 6/12/24 revealed all dietary staff (total of 8) received training on food storage and temperature safety and temperature logs. Record review of GI assessments dated 6/11/24 revealed 78 residents were assessed and no issues noted. Record review of facility's education on food service revealed the training started 6/11/24 around 10: 00 AM and completed on 6/11/24 for a total staff of 78. [facility had 3 shifts: 6 AM-2PM, 2PM-10PM, and 10PM-6 AM]. Record review of facility's purchased order dated 6/10/24 revealed anticipated date of two refrigerators was 6/13/24. On 06/12/2024 at 8:32 PM, the Administrator was informed the POR was validated and immediacy was removed. However, the facility remained out of compliance at a severity of no actual harm that is not immediate and a scope of pattern due to the facility's need to install two new refrigerators, safely store food track deliveries, implement food temperature logs on the new refrigerators, and audit and monitor food temperatures in the preparation of meals.

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. NA I failed to ask for assistance on 04/28/2024 when leaving Resident #1 unattended, that resulted in a fall with injury. This failure could place residents at risk of accidents and potential harm. Findings include: Record review of Resident #1's Resident Face Sheet, dated 05/07/2024, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Parkinson's disease with dyskinesia (a disorder of the nervous system that affects movement, including tremors), Dementia (a general term for impaired ability to remember, think, or make decisions), Ataxic gait (impaired balance or coordination when walking), and age-related physical debility (weakness). Resident #1 was noted as on Hospice. Record review of Resident #1's quarterly MDS, assessment dated [DATE], revealed her cognitive status was mildly impaired and she required supervision or touching assistance while eating, when going from sitting to standing, and while transferring from chair to chair. Record review of Resident #1's care plan revealed, on start date of 08/08/2024, Resident #1 was noted as requiring assist of 1 staff to transfer and was unable to obtain and maintain a sitting balance with an approach for frequent turning and repositioning. A problem with start date of 08/09/2023, Resident #1 was noted to be at risk for falls due to a diagnosis of Parkinson's disease and an approach was noted on the same date for increased staff supervision with intensity based on resident need. Another problem with start date 08/09/2023, edited 04/20/2024 was noted as Resident #1 with potential for complications related to diagnosis of Parkinson's disease, including poor balance, .poor coordination, tremors, .and gait disturbances. Approaches dated 08/09/2023 included assess/ record/ report to MD prn s/sx of Parkinson's complications: poor balance, .poor coordination, .tremors . and a second to encourage daily exercise, mobility as tolerated. A problem and approach with start date of 09/15/2023 indicated Resident #1 had a prior fall on 09/15/2023. The approach included staff were to provide assistance as needed for Resident #1 when transferring and staff were to document Resident #1's ADL performance and the assistance provided by staff per facility policy. On problem start date of 02/22/2024 and edited 04/20/2024, Resident #1 was noted to be at risk for pressure ulcer due to activity and being chairfast and an approach was noted on 02/22/2024 to consider posture alignment, weight distribution, balance stability, and pressure relief when positioning in chair or wheelchair. Record review of Resident #1's Fall Risk note, dated 01/02/2024 revealed her mental status was with intermittent confusion, poor recall, judgement, and safety awareness; had adequate vision, required assistive devices, had impaired mobility, received antihypertensive medication (medication to treat high blood pressure), had no falls in the past three months, and had a psychiatric or cognitive condition such as dementia. Her fall risk score was calculated at 11.0, indicating she was at risk. Record review of Resident #1's hospice visit note, dated 03/20/2024 and written by Hospice RN E, revealed She is found in dining room with her head on dining room table and is asleep Pt is unaware of her surroundings and dependent of all her care .she tires easily and prefers to sleep over anything else. Record review of Resident #1's hospice visit note, dated 03/27/2024 and written by Hospice RN E, revealed she is being assisted up and into her wc for her lunch meal upon arrival. She is unaware of her surroundings and usually only says she wants to lay down .She is max assist during transfers as she can no longer assist. She is dependent of all ADLs, incontinent of B/B without awareness and requires hands on assist during meals .She is assisted into the dining room in her wc, she cannot self propel. Record review of Resident #1's hospice comprehensive assessment and plan of care update report, dated 03/27/2024 and written by Hospice SW F, revealed Pt needs assistance with most ADLs. She is no longer able to make needs known or follow simple commands. Pt is bed bound. When staff do get her out of bed, she is max assist due to weakness a not being able to bear weight. Record review of Resident #1's nursing note, dated 04/18/2024 and written by LVN G, revealed Pt tends to lean to R side of w/c . Record review of Resident #1's nursing note, dated 04/19/2024 and written by LVN H, revealed Resident noted to lean heavily to right side while up in wheelchair. Has arm 'dangling' over the arm of the wheelchair. Has to be repositioned by staff often. Record review of Resident #1's nursing note, dated 04/28/2024 at 12:52 p.m. and written by LVN G, revealed Pt was at dining room table in her w/c when she leaned over forward and fell to the floor. Pt has large hematoma to L side of forehead and open wound on top of her head. Pt in and out of conscious. Applied pressure to stop bleeding, called 911 and sent pt to ER for eval. Attempted to notify family, [RP's] voicemail was full. Notified [Hospice D] Hospice, [ADON A]. Record review of Resident #1's nursing note, dated 04/28/2024 at 05:35 p.m. and written by LVN G, revealed Pt has laceration to top of L side scalp that has been glued. New order to monitor s/s of infection. Pt also has bruising to R knee and hand. Pt is alert and answers questions appropriately .Notified Hospice that pt has arrived and they will come and eval today. Record review of Resident #1's local hospital documentation, dated 04/28/2024, revealed CT scans of the brain and spine were performed and revealed a large left frontal scalp contusion/hematoma (bruise including from larger blood vessels) without a fracture on the scalp and no acute spine abnormality. Discharge instructions were noted for a closed head injury and for a laceration (cut in the skin) repair of the scalp. Record review of Resident #1's Neurological Record, dated 04/28/2024 to 04/30/2024, revealed neuros were started on 04/28/2024 at 05:00 p.m. and completed on 04/30/2024. During an observation and interview on 05/02/2024 at 02:23 p.m. revealed Resident #1 lying in bed with her eyes closed. Resident #1 with visible bruising to face from distance of doorway. Upon closer inspection, Resident #1 noted to have had bruising to face, eyes, and a large bump on her forehead. She was observed to have hair matted with appearance of dried blood in the front and dark purple spots visible through the hair. Attempted interview revealed she was capable of nodding head for yes and no but was unable to answer questions regarding what happened to her. Resident #1 indicated she had pain and then placed her hand on the large bump with bruise on her forehead. No bruising, scratches, or injuries were noted to the back of her head. A laceration with dried blood was observed from mid-scalp to front of where her forehead met her hair line. An additional laceration or possibly only dried blood noted to extend from the right side of the scalp to approximately one inch above her ear. No active bleeding noted. Bruising was noted on both of Resident #1's hands and forearms. No other skin injuries noted. During an observation on 05/07/2024 at 02:24 p.m. revealed Resident #1 lying in bed and provided care by nursing staff. Resident appeared dressed, groomed, and clean. Resident #1 observed to be repositioned in her bed following the provision of care. Resident #1 was not observed out of bed, including in Geri chair during observation period. During an interview on 05/02/2024 at 02:43 p.m. CNA B revealed Resident #1 could make her needs known and could answer questions. CNA B revealed Resident #1 had a fall and had been kept in bed to rest since the injury. CNA B revealed Resident #1 was normally up in her wheelchair but had lately been falling asleep really easily in her wheelchair. CNA B stated that she did not witness Resident #1's fall. During an interview on 05/02/2024 at 02:45 p.m. LVN G revealed Resident #1 tended to lean forward in her wheelchair and liked to lean her head on the table. LVN G stated that Resident #1 was not falling asleep, it was just something she liked to do. LVN G stated Resident #1 had dementia and responded when spoken to and was capable of making her needs known. She revealed Resident #1 was wheelchair bound and unable to self-propel, reliant on staff to push her. LVN G stated Resident #1 had a habit of pushing herself away from the table when she was finished. LVN G revealed Resident #1 had a fall the other day (date unknown) while she was on duty. LVN G stated that she was seated in the nurses' station when she heard a sudden commotion and staff yelling for assistance. LVN G revealed she immediately ran to the dining room (located in close proximity to the nurses' station) to see what happened. LVN G stated that a CNA was present in the room with multiple other staff. LVN G revealed that she did not see the fall but did hear the commotion and when she arrived in the dining room, Resident #1 was lying on the ground. LVN G stated that Resident #1 was rolled over and immediately started to bleed from her head. LVN G stated that she grabbed supplies, applied pressure to the wound to stop the bleeding, and completed an assessment while checking for additional injuries. LVN G revealed another staff member called 911 while she was assessing the resident. LVN G revealed Resident #1 was sent out to the hospital without delay but that she had noted Resident #1 to have a laceration to her scalp and a large bump on her forehead. LVN G stated the wheelchair should have been locked while the resident was eating but did not know if it was or not. LVN G revealed that Resident #1's laceration was closed with glue at the hospital and that she started neuro checks on Resident #1 the same night as her return from the hospital. LVN G revealed Resident #1 was unable to say what had happened and did not answer when asked. During an interview on 05/02/2024 at 03:12 p.m. the Resident #1's RP stated that there was no neglect in this situation. He stated that the family was upset because the facility would not provide them with information. He stated that Resident #1 was declining, and she falls asleep a lot. He stated that she fell asleep and rolled out of her chair. He did not respond when asked if he witnessed the fall but stated that this was what she did, she falls. During an interview on 05/07/2024 at 11:16 a.m. NA I revealed she had placed Resident #1, who was in her wheelchair, a small distance away from the dining room table on 04/28/2024 but had noted that Resident #1 was leaning forward. NA I stated that she had locked Resident #1's wheelchair but then stepped away with the plan to quickly see if Resident #1 had anything in her room to prop her up. She revealed that by the time she had returned, Resident #1 had fallen. NA I did not mention having requested another staff member to monitor Resident #1 upon leaving her in the wheelchair, but stated that a CNA was present in the dining room. NA I stated that from where she was when Resident #1 fell , she was able to hear a loud bang and the CNA call out to the nurse. NA I revealed Resident #1 fell around 2 minutes after she left her. NA I revealed that upon her return to the dining room, the nurses were checking Resident #1's vitals and putting pressure to the injury on her head. NA I revealed that it appeared that Resident #1 only hit her head on the floor and did not hit the table because there was only blood found on the floor. During an interview on 05/07/2024 at 12:07 p.m. LVN G revealed Resident #1 tended to lean herself over and did not have trunk control (the ability to control her upper body). LVN G stated that staff were always having to bring her back up. LVN G revealed that fall interventions for Resident #1 included Resident #1 to have some padding on the side of her when sitting in the wheelchair and was to be pushed up to the table. LVN G revealed her observations of Resident #1 when responding to her fall on 04/28/2024 was that Resident #1 was alert, opening her eyes, and had not passed out. LVN G stated she knew that the wheelchair had been locked but was unsure on Resident #1's position to the table, but that Resident #1 had to have been far enough away from the table to fall forward and hit her head on the floor under the table and not hit the table. LVN G revealed she was aware that one of the aides had gone to get Resident #1 something to stop her from falling but that Resident #1 fell immediately after. During an interview on 05/07/2024 at 01:31 p.m. the Hospice RN E revealed she was contacted on 04/28/2024 of Resident #1's fall and transfer to the emergency department for further evaluation on a laceration that was bleeding on the top of her head. Hospice RN E revealed that she requested the weekend hospice nurse be contacted for further updates, specifically if Resident #1 was to return to the facility because she would need to be assessed by the weekend hospice nurse upon return. The Hospice RN E revealed the weekend hospice nurse reassessed Resident #1 on 04/28/2024 upon her return from the hospital and a scheduled over the counter pain medication was ordered. She revealed that she was able to see Resident #1 on the next day and the hospice doctor ordered a controlled pain medication at that time for one week. During an interview on 05/07/2024 at 01:31 p.m. the Hospice SW F revealed she had gone to see Resident #1 monthly since her admission onto Hospice D but that when she would see her Resident #1 was either in bed or in the dining room with her head on the table. During an interview on 05/07/2024 at 05:53 p.m. the DON revealed she was not present in the facility at the time of Resident #1's fall but that her fall was due to Resident #1's lack of trunk control, which was progressive (developing gradually) and causing her to become weaker and weaker. The DON revealed that Resident #1's posturing (ability to hold a posture) continued to decline (worsening) and that she thought that Resident #1 did not like to be alone. The DON revealed that even when Resident #1 appeared exhausted or weak, she would be adamant about being up. She stated that prior to the fall, she felt Resident #1 was at risk for a fall but not to the point that the wheelchair was identified as having been inappropriate. The DON stated that prior to Resident #1's fall on 04/28/2024, Resident #1's focus had been on her having had a poor appetite and not on her posturing or concerns for fall risk. The DON stated that immediately after being notified of Resident #1's fall, she called the rehabilitation director and the Hospice RN E regarding Resident #1's positioning and they decided that a Geri chair was the safest option for Resident #1. The DON stated that she interviewed staff after the fall and CNA C had stated that she was in the dining room at the time of the fall, had just looked at Resident #1, turned around to pick up meal tickets at the table, and when she turned around again, she could see Resident #1 falling but was not able to get to her fast enough. The DON stated that it was not uncommon for residents to be seated at the tables by themselves as staff are getting trays and tickets prepped for meal service. Record review of Resident #1's Fall Risk note, dated 05/02/2024 at 03:22 p.m. was noted to be related to her fall on 04/28/2024. The note revealed her mental status was with alert and oriented or comatose or persistent vegetative state, had poor vision, had decreased muscular coordination, required assistive devices, had impaired mobility, received antidepressants, cardiovascular medication, and narcotics; had one or two falls in the past three months, and had a neuromuscular/functional condition such as decline in functional status, Parkinson's, and unsteady gait. Her fall risk score was calculated at 16.0, indicating she was at risk. Referral was noted as other- fall interventions in place, hospice updated and plan of care was noted as updated with note the resident was provided with a Geri-chair related to the progression of weakness and poor trunk control. Record review of Resident #1's nursing note, dated 05/02/2024 at 03:13 p.m. and written by LVN G, revealed Fall discussed with IDT team in morning meeting. Discussed benefits versus risks of resident being up in wheelchair due to her forward/ hunched posture and poor trunk control. Both therapy and nursing determined resident's current wheelchair, or even a high back wheelchair is not safe at this time. Resident's trunk and core control strength has continued to slowly decline which ultimately is the cause of the fall on 4/28/24. Team will continue to reach out to [family member] to discuss his input on her current plan of care and concerns regarding positioning and safety in her wheelchair. Neuro checks in place related to fall with head laceration. Will continue to refrain from getting resident up to wheelchair until continued discussion is had with resident's husband and hospice. Record review of Resident #1's hospice visit note report, visit date noted as 05/03/2024 and written by Hospice RN E, revealed All care is being provided to the pt in bed, she does have a Geri chair in the room when she is able and willing to try and get out of bed though currently recommended to rest so she is able to heal .Teaching done with [family member] regarding fall prevention and EOL care. Advised the pt is no longer able to hold her torso in upright position and has poor judgement. Record review of facility policy, Falls and Fall Risk, Managing, dated revised March 2018, revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .2. Resident conditions that may contribute to the risk of falls include: .c. delirium and other cognitive impairment; .i. functional impairments; .3. Medical factors that contribute to the risk of falls include: .e. balance and gait disorders; etc. Record review of in-service document on facility policy Falls and Fall Risk, Managing, provided to the investigator on 04/06/2024 and reported to have been completed on 04/28/2024 revealed signatures for 7 of 9 Nurse Aides, 10 of 10 Certified Nurse Aides, 2 of 3 Certified Medication Aides, 9 of 11 Licensed Vocational Nurses, 3 of 3 Registered Nurses, both the DON and the Director of Rehabilitation, and 22 of 31 non-clinical staff with those missing either in housekeeping or the dietary departments. NA I was noted as having completed the training. Resident #1's care plan revealed, on problem start date of 09/15/2023, revealed inclusion of notation 04/28/2024- Fall from wheelchair with a laceration to head with two approaches with start date of 05/02/2024, I will be evaluated for the most appropriate type of wheelchair related to poor trunk control and unsafe self-positioning while sitting up in a wheelchair. and I will utilize a Geri chair (rolling chair designed for someone with difficulty sitting upright) instead of a regular wheelchair for increased safety. I lack core strength, which puts me at a higher risk for falls in a wheelchair versus a Geri chair. Time of care plan entry unable to be determined due to lack of time stamp and care plan not accessed by investigators until 05/07/2024. During an interview on 05/07/2024 at 11:16 a.m. NA I revealed Resident #1's current fall preventions included a Geri chair and because it had been observed that she leans forward, staff were trying to not get her out of bed except upon her or her family member's request.

Based on observation, interview and record review the facility failed to provide comfortable and safe temperature levels maintained within a range of 71 to 81 degrees Fahrenheit for 7 of 7 residents (Resident #s 1, 2, 3, 5 on Hall 100 Male Secured Unit) and (Resident #s 4, 6, 7 - Hall 200) reviewed for environment. The facility presented with 2 non-functioning Heating Ventilation and Air Conditioning [HVAC] systems, which resulted in cold resident room interior temperatures (low 50s - 60s Fahrenheit) for residents living in 100 Hall (Male Secured Unit) and 200 Hall. Facility leadership was aware the HVAC systems were not adequately functioning since October 2023. An Immediate Jeopardy (IJ) situation was identified on 01/17/24. While the IJ was removed on 01/22/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia). The findings were: Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located: Date: Low High 1/12/2024 29 F 59 F 1/13/2024 24 F 61 F 1/14/2024 16 F 28 F 1/15/2024 14 F 30 F 1/16/2024 15 F 34 F 1/17/2024 13 F 52 F Interview on 01/16/2024 at 2:34 PM, the administrator stated the facility's heating units for 100 Hall (Male Secured Unit) and 200 Hall were not functioning and pending replacement. The administrator stated 2 portable heating units had been placed at both ends of the 100 Hall (Male Secured Unit) and one large space heater was placed at the end of 200 Hall until the facility's permanent heating units could be replaced. The administrator also said portable heaters were purchased and offered to residents who wanted one in their room in response to staff and residents complaining of cold temperatures within the building on the night of 1/13/2024. Observation on 01/16/2024 at 3:06 PM of 100 Hall (Secured Men's) revealed 2 temporary heating units (THU) located at both ends of the hall. Further observation revealed the THU at the beginning of 100 Hall was running at a setting of 80 F and indicated room temperature (Hallway) of 69 F. Observation of the THU at the end of 100 Hall revealed the THU was not running. Observation and interview on 01/16/2024 at 3:09 PM, Resident #1 was observed walking 100 Hall (Male Secured Unit) and lead this investigator his room. Resident #1 indicated his room was cold and would get colder at night. Resident #1 proceeded to show this investigator 4 blankets on his bed he was utilizing in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 01/16/2024 at 3:14 PM, Resident #2 (100 Hall - Male Secured Unit) was observed lying in his bed. Resident #2 was observed wearing gloves and when asked why, Resident #2 responded, because I like them! When asked if the resident was cold at night, he responded, Yes! When asked how the resident was doing in an attempt to stay warm, he responded, The blankets. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 01/16/2024 at 3:16 PM, Resident #3 (100 Hall - Male Secured Unit) was observed sitting in the secured dining area in his wheelchair. During the interview, Resident #3 said that this week had been, really cold. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation on 01/16/2024 at 3:38 PM revealed a space heater at the end of Hall 200.The space heater was on and glowing. The room temperature in this hall felt uncomfortably cold while wearing a jacket. Observation and interview on 01/16/2024 at 3:40 PM, Resident #4 (200 Hall) was asked about the temperature of her room and indicated she had been, Very cold, and said she had been using multiple blankets in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 01/17/2024 at 7:38 AM, facility staff were observed wearing winter-clothing in the building which consisted of extra layers and ski hats. At this time, an unknown staff shouted, It's cold in there, 50 degrees. Observation and interview on 01/17/2024 at 7:44 AM, Resident #1 was observed lying in his bed with a blanket over his head. A reading of the room's temperature revealed a temperature of 56 F. During an interview at this time, Resident #1 was asked if he was cold and responded, Yes The resident stated he did not sleep well because his room was cold. Observation and interview on 01/17/2024 at 7:57 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #1's bed which revealed a temperature reading of 56 F. LVN B confirmed the temperature in Resident #1's room was 56 F and responded, Oh wow, that's cold. Observation and interview on 01/17/2024 at 7:44 AM, Resident #5 was observed lying in bed with a navy blue blanket over his head (photo taken). A reading of the room's temperature revealed a temperature of 51 F. During an interview at this time, Resident #5 was asked how he was doing and responded, Cold. When asked if the Resident #5 felt tired, he responded, Yeah, I can't sleep. Observation and interview on 01/17/2024 at 7:58 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #5's bed which revealed a temperature reading of 51 F. During an interview at this time, LVN B was asked what the temperature should be to be considered comfortable to which she responded, Around 70 F. Observation and interview on 01/17/2024 at 8:07 AM with Staff C, this investigator pointed a thermal thermometer laser at the wall closest to Resident #4's bed which revealed a temperature reading of 51 F. Staff C confirmed the temperature for Resident #4's room was 51 F. During an interview at this time, Staff C said Resident #4 had requested to be moved to a new location due to feeling cold in her room. Staff C mentioned another resident, Resident #7 - Hall 200, had also requested to be moved because she was cold in her room. Interview and observation on 01/17/2024 at 9:50 PM, the Maintenance Supervisor and this investigator compared thermal temperature guns and confirmed their readings matched within +/-.3 degrees F. The Maintenance Supervisor's thermal temperature gun was orange and black (IR1 Infrared Thermometer), The Maintenance Director was asked what the room temperatures should be and responded, Around 75 F in the winter and around 70 F in the summer. Interview and observation on 01/17/2024 at 10:00 AM, the Maintenance Supervisor measured Resident #1's room (100 Hall - Male Secured Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 61 F. During an interview at this time, the Maintenance Supervisor said, It feels chili in here, I would need more blankets and double socks. Interview and observation on 01/17/2024 at 10:04 AM, the Maintenance Supervisor measured Resident #5's room (100 Hall - Male Secured Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #5's which revealed a temperature of 61 F. Resident #5 was observed still lying in bed with blankets over his head. A space heater was observed in this resident's room and was emitting heat but the room still felt cold. During an interview at this time, Resident #5 was asked if he was still cold to which he responded, Ya. At this time, the Maintenance Director said, Even with a space heater the room still feels cold. I don't see why the main heating unit (for 100 Hall) wasn't fixed before the cold weather. Interview on 01/17/2024 at 10:15 AM, the administrator stated she had moved all but 1 resident on 200 Hall from the second half of 200 Hall to other locations including the first half of 200 Hall. The Administrator also stated she had closed the smoke barrier doors located in the middle of 200 Hall in an effort to prevent cold air coming down the first half of the 200 hall. Additionally, the Administrator said all residents on the 100 Hall (Male Secured Unit) were moved to the 100 Hall (Female Secured Unit) and indicated that section of 100 Hall had a HVAC. Interview and observation on 01/17/2024 at 10:29 AM, the Maintenance Supervisor measured Resident #7's room (200 Hall) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 57.7 F. Resident #6 was observed lying in her bed under layers of blankets. During an interview at this time, Resident #6 was asked how she was doing to which she responded, I'm cold. The Maintenance Director then said, Ya, it's cold, I wouldn't want to be in there. The Maintenance Director then confirmed Resident #7's room was on the first half of 200 Hall that was supposed to be the side residents were moved to because it was warmer than the second half of 200 Hall. The Maintenance Supervisor agreed it felt much colder in the resident's room than in the hall. Interview on 01/17/2024 at 4:45 pm with the Chief Operations Officer (COO) and the administrator revealed the facility discovered in October 2023 the HVAC for 100 Hall Male Secured Unit and 200 Hall were not adequately functioning. The administrator indicated the facility had been in the process of replacing the units since then but there had been delays. The administrator further stated she anticipated the heating units for 200 Hall and 100 Hall (Male Secured Unit) would be replaced by 01/19/2024. Record review of facility policy, Quality of Life - Homelike Environment, (Revised May 2017), stated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . 2. The facility and staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .h. Comfortable and safe temperatures (71 F - 81 F) . Record review of website, https://www.nia.nih.gov/health/safety/cold-weather-safety-older-adults , dated, 01/03/2024 , stated: Older adults have a higher chance of being affected by cold weather. Changes that come with aging can make it harder for older adults to be aware of their body becoming too cold, which can turn into a dangerous health issue quickly. Hazards of cold weather include falls on wintry surfaces; injury caused by freezing (frostbite); and hypothermia, a medical emergency that occurs when your body temperature gets too low. Being informed and taking certain actions can help lessen risks during the colder months . Staying warm indoors. About 20% of injuries related to exposure to cold occur in the home. Here are some tips to help keep warm: Even mildly cool homes with temperatures from 60 to 65 F can lead to hypothermia in older adults. This was determined to be an Immediate Jeopardy on 01/17/24 at 5:50 PM. The administrator and COO were notified. The administrator was provided the Immediate Jeopardy template on 01/17/24 at 6:00 PM . The following Plan of Removal submitted by the facility was accepted on 01/19/24 at 2:00 PM: Plan for REMOVAL The facility failed to provide a safe, clean, comfortable, and homelike environment, to include maintenance services necessary to maintain comfortable and safe temperature levels, for 1 of 1 facility reviewed for a safe, clean, comfortable, and homelike environment. F584 1- On 1/17/2024 Residents on 100 unit (men's secure unit) were moved to warm secure unit. Residents on 200 hallway cold areas were moved to warm side of the unit by IDT. Units that are not holding temperature of 71 degrees Fahrenheit were temporarily closed by Maintenance Director. 2- On 1/17/2024 Maintenance Director ordered and paid for heating units repairs which are scheduled for 1/22/204 to be installed due to a delay in the crane delivery. Per the contractor all work on the HVAC units will be repaired on the same day as arrival. 3- On 1/17/2024 Social Worker/Designee notified RPs of the room changes. 4- On 1/17/2024 Director of Nursing/Designee assessed residents for s/s of hypothermia or sleep deprivation due to feeling cold - no negative findings noted. The Medical Director updated on findings by Administrator on 1/17/2024. 5- On 1/17/2024 COO (Chief Operating Officer) completed 1:1 in-service with Administrator and Maintenance Director on emergency readiness, inclement weather preparedness, and s/s of hypothermia. 6- On 1/17/2024 Director of Nursing/Designee initiated in-services with staff of identifying s/s of hypothermia, timely notification of Administrator/Supervisor when noting patients room/residents' areas feel cold or residents/staff/visitors complaints of feeling cold, residents' sleep deprivation, and cold-related injuries (hypothermia) due to cold temperatures in the facility. Staff will not be allowed to work until they receive training, including agency staff and PRN. Anyone who is not able to receive training will not be allowed to work until the in servicing is completed. 7- Ad-Hoc QAPI meeting was held on 1/17/2024, with the Medical Director, NHA (Nursing Home Administrator), DON, and Maintenance Director to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policies pertaining to Emergency readiness were reviewed on 1/17/2024 by the NHA (Nursing Home Administrator), DON, and Medical Director. 8- Starting on 1/17/2024, IDT (Interdisciplinary team), including Administrator, Activity Director, DON, Social Worker, Admission manager, MDS, and Maintenance Director will meet with residents daily to identify if any residents have sleep deprivation and s/s of hypothermia due to cold temperatures Monday through Friday, and Manager on Duty on Saturday, Sunday, until heating units are repaired. Any issues or concerns will be brought up to the Administrator immediately and IDT team members for any follow-up needed. Residents' room temps will be taken daily to ensure compliance by Maintenance Director or designee until HVAC units are installed. If any room temperatures are below 71 degrees; the Administrator will be contacted and the resident will be offered another room that is above 71 degrees. Temperatures of the rooms will be taken 2xs a day and temps recorded in the temperature spreadsheet in maintenance book until HVAC units are installed. Residents' temperature will be taken daily to ensure no signs or symptoms of hypothermia. 9-The Administrator/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks until heating units are repaired. This was initiated on 1/17/2024. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. 10- The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed.[sic] The facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: -Observations on 01/19/2024 of 200 Hall, between 3:15 PM and 3:17 PM revealed room temperatures between 71.4 F to 74.4 F. Further observation reviewed smoke barrier doors were closed in the middle of 200 Hall to prevent the escape of warm air. Observations on 01/19/2024 of 100 Hall, between 3:18 PM and 3:19 PM revealed room temperatures between 71.4 F to 74.4 F. Observations on 01/19/2024 at 3:20 PM revealed 100 Hall (Male Secured Unit) had been completely vacated by all residents. Interview on 01/19/2024 at 4:08 PM, the Maintenance Director stated 3 HVAC three units had been ordered and paid for and had heard they would be installed on Monday 01/22/2024. Record review at this time supported the information provided specific to this interview. Observation on 01/22/2024 at 2:00 PM, HVAC staff were observed over 200 Hall working on the HVAC Unit on the roof. Interview on 01/22/2024 at 2:05 PM, the administrator stated the new HVAC unit was being in-stalled over 200 Hall and said HVAC installers were in the process of custom fitting the plenum and anticipated both units would be completely installed by cob. Record review of the facility's Electronic Resident Database under section, Progress Notes. Revealed documentation inputted by the facility's social worker indicating RP and/or attempted RP notifications for residents that had been moved to a different room. Interview and record review on 01/19/2024 at 3:42 PM, the DON stated she assessed all residents impacted by the cold weather to ensure they did not have s/s of hypothermia. Record review of facility documentation supported this statement. Interview on 01/19/2024 at 3:53 PM, the administrator stated the emergency preparedness in-service covered inclement weather and other items specific to disasters. This included checking the generator, making sure an evacuation plan was in place, extra blankets were available, and a phone roster for staff in-case of an emergency. Regarding hypothermia, the administrator said this can be determined by body temperature, vital signs, and alert/oriented status. Interview on 01/19/2024 at 4:00 PM, the Maintenance Director stated he would look for drowsiness, confusion, shivering, memory loss et specific to hypothermia. Regarding emergency preparedness, the Maintenance Director said he was instructed to make sure there were adequate blankets, an addendum to have heaters, check room temps periodically throughout the day. He said he was also in-serviced regarding inclement weather, specifically ensuring thermostats were set properly, windows were to be shut, the generator was adequately working, et. He further stated the generator was tested on [DATE] and added a solution to prevent gelling of the gasoline. Interview with the administrator on 01/22/2024 at 5:44 PM, the administrator said that if conditions were extreme, heaters would be used as needed. The Administrator stated they would be placed in the hallways within the line of sight of nurses/aides). The administrator said this was indicated in her emergency preparedness manual. Record review of sign in sheets on 01/22/2024 provided by the administrator revealed information that supported this interview. Interview on 01/19/2024, the Corporate Nurse stated staff that have been in-serviced by person or via telephone were documented on a list and said that staff who have not yet received the in servicing will not be able to work. Record review of a 3 page document titled, Employee Roster, generated on 01/17/2024, revealed a list of all facility staff. Further review of this document revealed signatures next to staff who had completed the trainings. This list also showed attempts to contact 6 staff but had been unsuccessful. Observations and interviews on 01/18/2024 thru 01/22/2024 of resident rooms where residents were temporarily transferred 100 Hall (Women's Secured Unit) and the first half of 200 Hall (before smoke barrier doors) measured above 71 degrees F and it was noticeably a comfortable temperature in those resident rooms. Interviews with a sample of staff (CNAs, LVNs, RNs, DON - from all 3 facility shifts), the Maintenance Director, and administrative staff 01/19/2024 thru 01/22/2024 revealed staff had been in-serviced specific to the Plan of Removal and knew to immediately notify the administrator if they noticed an unusual occurrence, which included if the heat went out in the building. Staff were also able to explain their familiarity with signs and symptoms of hypothermia and indicated they would provide blankets, warm liquids, and ensure all doors and windows were closed to keep the heat inside. Record review of sign in sheets on 01/22/2024 provided by the administrator revealed information that supported this interview. Interview on 01/19/2024 at 4:06 PM, the Maintenance Director stated he had been checking room temps 4 times daily to ensure compliance and said the nurses were also checking room temps in the evening utilizing his thermal temperature gun (the same thermal temperature gun utilized during previous temperature observations with this investigator). Record review facility documentation revealed monitoring was occurring in accordance to this plan. Interview on 01/18/2024 at 4:42 PM, the administrator said she would be monitoring 5 residents a week for 4 weeks and would be monitoring residents daily to ensure there were not signs or symptoms of hypothermia or other potential adverse reactions related to cold weather or new interventions. She said they would be utilizing a resident roster daily to document this information. Record review of documentation on 01/22/2024 provided by the administrator revealed information that supported this interview. Interview on 01/18/2024 at 4:29 PM, the COO stated she would be frequenting the facility once per month to provide oversite to the Administrator to ensure items on the plan of removal are reviewed and completed. The administrator was informed the Immediate Jeopardy was removed on 01/22/2024. The facility remained out of compliance at a severity of potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place .

Based on observation, interview, and record review, the facility failed to ensure that each resident had the right to be free from abuse for 1 of 3 (Resident #3) residents reviewed for abuse. The facility failed to protect Resident #3 from verbal abuse by an unknown staff member. The facility failed to protect Resident #3 from verbal abuse by LVN J. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 12/19/2023 at 11:03 a.m. While the IJ was removed on 12/21/2023, the facility remained out of compliance at no actual harm that is not immediate with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of Resident #3's Face Sheet, dated 12/11/2023 revealed Resident #3 was a [AGE] year-old male, admitted to the facility on [DATE]. Resident #3's preferred language was English. Resident #3's diagnoses included dementia (a general term for impaired ability to remember, think, or make decisions), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and cognitive communication deficit (difficulty communicating due to injury to the brain). Record review of Resident #3's MDS, assessment date 11/04/2023 revealed Resident #3 had a BIMS score of 06 and was severely cognitively impaired. During an observation on 12/05/2023, a state investigator observed an unknown staff member speaking patronizingly to Resident #3. The state investigator overheard the unknown staff member tell Resident #3, don't coughing sound at me, go back to your room. During an interview with Resident #3 on 12/07/2023, Resident #3 stated that one staff member talks to me bad, she said that I have to stay in my room, that she can get me locked up in jail or get me committed. He revealed that staff told him he was stupid because he had COVID-19. He stated that the staff are not gods, to talk to him like that. He continued to state that we are just like them, and should be spoken to as such. Record review of Resident #5's Face Sheet, dated 12/08/2023 revealed Resident #5 was an [AGE] year-old male, initially admitted to the facility on [DATE] with diagnoses of dementia (a general term for impaired ability to remember, think, or make decisions), Alzheimer's disease (a progressive disease that affects memory and other important mental functions), and muscle wasting and atrophy (shrinking of muscle or nerve tissue). Record review of Resident #5's MDs, assessment date 09/21/2022 revealed Resident #5 had a BIMS score of 05 and was severely cognitively impaired. Record review of facility Provider Investigation Report signed 12/11/2023 revealed the facility ADMIN reported an incident involving Resident #5 to HHSC on 12/04/2023. The report revealed Resident #5 was found to have a bruise of unknown origin to his right inner thigh. The report revealed Resident #5 was unable to recall how the bruise occurred. The report revealed staff were interviewed and unable to identify the cause of the bruise. The report revealed the investigation findings were inconclusive and staff training on abuse and neglect, and bed positioning and transferring were conducted. Record reviews of facility Employee Roster dated as generated 12/05/2023 revealed the facility had 70 employees. Record review of in-service training report dated 12/04/2023, topic noted as Abuse & Neglect/ Bed Positioning/ Transferring revealed 23 signatures. Comparison of legible typed and signed names on the in-service training report to the facility Employee Roster indicated 22 of 70 facility staff were trained, including 14 of the 43 clinical staff. One name typed and signed on the in-service document was illegible. Record review of Resident #4's Face Sheet, dated 12/11/2023 revealed Resident #4 was a [AGE] year-old female, initially admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), and nightmare disorder (a sleep disorder that involves frequent and disturbing dreams that cause anxiety, fear, or sleep disturbance). Record review of Resident #4's MDS, assessment date 09/21/2023 revealed Resident #4 had a BIMS score of 10 and was moderately cognitively impaired. Record review of facility Provider Investigation Report signed 12/14/2023 revealed the facility ADMIN reported an incident involving Resident #4 to HHSC on 12/07/2023. The report revealed Resident #4 reported an allegation of abuse to the ADMIN on 12/07/2023, reporting CNA C had pushed her into the wall of her room around 10:00 p.m. on 12/06/2023. The report revealed the ADMIN interviewed CNA C, who denied the alleged interaction with Resident #4 and suspended CNA C pending the investigation into the incident. The report revealed Resident #4 had no noted bruising from alleged incident. The investigation findings were noted as unconfirmed. The report revealed the ADMIN continued ongoing abuse and neglect staff training and that CNA C decided to not return to the facility following the suspension. Record review of facility Provider Investigation Report signed 12/15/2023 revealed the facility ADMIN reported an incident involving Resident #3 to HHSC on 12/08/2023. The report revealed the ADMIN on 12/07/2023 witnessed LVN J tell Resident #3 that she was going to hit him and observed LVN J pointing directly at Resident #3, which caused him to back away from her. The report revealed the ADMIN terminated LVN J's employment, contacted the police regarding the incident, notified the Texas Board of Nursing, and continued ongoing abuse and neglect staff training. The investigation findings were noted as confirmed. Record review of facility in-service training report dated 12/09/2023, topic noted as Red Events & Notifications and Abuse & Neglect & Reporting revealed 28 signatures. Comparison of legible typed and signed names on the in-service training report to the facility Employee Roster, dated as generated 12/05/2023 indicated 22 of 70 staff were trained, including 18 of 43 clinical staff. Additional names were noted as agency staff with one illegible typed and signed name. Record review of facility in-service training report dated 12/18/2023, topic noted as Abuse & Neglect & Abuse Prevention revealed 12 signatures. Comparison of legible typed and signed names on the in-service training report to the facility Employee Roster, dated as generated 12/05/2023, to the in-service training report dated 12/04/2023, and to the in-service training report dated 12/09/2023 revealed two (2) staff were trained on 12/18/2023 that were not trained on 12/04/2023 or 12/09/2023, one (1) additional new legible name was not identified on the facility employee roster, and one (1) name was illegible typed and signed. During an interview with Resident #4's RP on 12/14/2023 at 03:25 p.m., he revealed that Resident #4 had told him that she had reported the incident that occurred 12/06/2023 p.m. to the night charge nurse but that nothing was done following her report. Resident #4's RP stated that he came to the facility on [DATE] to raise hell. He stated that he was excited that they contacted the state and reported the incident but was upset that the police department did not interview Resident #4 even though she cannot make a cognizant report. Resident #4's RP stated that Resident #4 does not feel safe living in the facility due to another resident that stalks her and comes into her room at night but that the incident on 12/06/2023 was the first time something of that nature had occurred. Resident #4's RP stated he was delighted with how the facility had addressed the incident. During an interview with Resident #3 on 12/19/2023, he revealed at the time of the incident on 12/07/2023, he had felt threatened and fearful. Record review of facility policy Abuse Prevention Program, dated as revised 02/2023, revealed the policy statement, Our residents have the right to be free from abuse, neglect, exploitation, or mistreatment including injuries of unknown sources, and misappropriation of resident property, corporal punishment and involuntary seclusion. Record review of facility policy Abuse and Neglect- Clinical Protocol, dated as revised March 2018, revealed the following definition, 1. 'Abuse' is defined at 483.5 as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. An Immediate Jeopardy (IJ) was identified on 12/19/2023 at 11:03 a.m. The IJ template was provided to the ADMIN on 12/19/2023 at 05:20 p.m. and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 12/20/2023 at 03:13 p.m. and included the following: Plan of Removal F600 Residents # 3, 4, and 5 assessed by RN for any s/s of abuse, physician was notified of the alleged deficiency on 12/19/23. There were no new orders obtained. The affected residents' responsible party was notified by the Administrator of alleged deficiencies and plan of correction. Administrator/Designee completed Safe surveys for all residents on 12/19/2023 - no other residents were identified with sign or symptoms of abuse, including humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Medical Director was updated on the findings by Administrator on 12/19/2023. Administrator and DON have been in-serviced on 12/19/2023 by Regional Nurse Consultant (RNC) on Abuse and Neglect prevention. Staff have been educated on abuse and neglect by the Administrator and DON starting on 12/19/2023 to include the definitions of verbal and mental abuse and reporting. Staff will not be allowed to work until they receive training. Agency staff will be in-serviced by DON or designee on abuse and neglect to include the definitions of verbal and mental abuse and reporting before taking an assignment. In-servicing will be completed by 5pm on 12/20/23 by DON/designee. Anyone who is not able to receive training will not be allowed to work until the in-servicing is completed. All staff will be interviewed by Administrator/designees after the in-service is completed for them to repeat back what was abuse/neglect with definitions are and what is reporting. Ad-Hoc QAPI meeting was held on 12/19/2023, with the Medical Director, NHA (Nursing Home Administrator), DON, and ADONs to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policies pertaining to Abuse were reviewed on 12/19/2023 by the NHA (Nursing Home Administrator), DON, and Medical Director. Starting on 12/19/2023, IDT (Interdisciplinary team), including Administrator, Activity Director, DON, ADONs, Social Worker, Admission manager, and MDS will meet with residents daily to identify if any residents have allegation of abuse, including humiliation, intimidation, fear, shame, agitation, and decreased quality of life Monday through Friday, and Manager on Duty on Saturday, Sunday, and Holidays. Any issues or concerns will be brought up to the Administrator immediately and IDT team members for any follow-up needed. The Administrator/designee will monitor compliance by completing an audit of ten (10) residents per week for four (4) weeks. This was initiated on 12/19/2023. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring the facility plan of removal was as followed: Interviews with Resident #3 and Resident #4 on 12/20/2023 between 05:22 p.m. to 08:06 p.m. were performed. Resident #3 and Resident #4 both indicated that they felt safe, confirmed that they had both had a head-to-toe assessment performed on them the day prior, 12/19/2023, and that they were notified that the facility was under immediate jeopardy due to the concern for abuse. Resident #4 stated she felt relief CNA C was gone and that she did not get severely hurt during the incident. Interview with Resident #3 RP on 12/20/2023 at 04:50 p.m. revealed he had been contacted the facility administrator after the incident and was told that the alleged perpetrator was terminated. He revealed that the facility administrator had stated that the facility had a zero tolerance for abuse. Resident #3 RP revealed he had no current concerns regarding abuse at the facility. Interview with Physician A on 12/20/2023 at 04:56 p.m. and record review of Resident Face Sheets for Resident #3, Resident #4, and Resident #5, revealed the facility medical director was the same physician as the attending physician, Physician A, for Resident #3, Resident #4, and Resident #5. Physician A confirmed he was notified of the Immediate Jeopardy for Abuse on 12/19/2023 and stated due to the notification, he performed re-evaluations on the noted residents on 12/19/2023. Interview with Resident #4 RP on 12/20/2023 at 05:05 p.m. revealed he and a family member were in contact with the facility administrator the day before, 12/19/2023. Resident #4 RP stated that he felt the facility was taking the reported abuse seriously. Attempt to contact Resident #5 RP on 12/20/2023 at 05:09 p.m. was unsuccessful. Interview with the DON on 12/20/2023 at 07:00 p.m. confirmed she had completed an in-service training on abuse on 12/20/2023. The DON stated the training covered different types of abuse, who to report abuse to, signs and symptoms for various types of abuse, and documenting abuse. The DON revealed that if she felt a report of abuse was not followed up or reported appropriately, she would discuss her concern with the ADMIN, possibly get the regional involved, follow up with corporate, or contact the state hotline. Interview with the ADMIN on 12/20/2023 at 08:08 p.m. confirmed she had completed an in-service training on abuse with the RNC the day prior, 12/19/2023 and was providing abuse staff trainings on 12/20/2023. The ADMIN stated the training covered abuse and neglect, reporting the incident, ensuring a complete investigation, the proper channels in the investigation, and the roles of everyone in the investigation. Interviews with facility staff on 12/20/2023 between 05:30 p.m. to 07:35 p.m. revealed 3 CNAs (CNA A, CNA B, and CNA D) from 6A-6P shift, 3 CNAs (CNA E, CNA F, and CNA L) from 6P to 6A shift, 3 CMAs (CMA B, CMA C, and CMA D) from 6A to 6P shift, 3 LVNs (LVN A and LVN G) from the 6A to 6P shift, and 12 additional staff from various departments (AA, AD, DOM, DON, FS A, FS B, FS C, HR, LAU A, LVN H, LVN M, and SW) verified that they had attended an in-service abuse training provided 12/19/2023 or 12/20/2023 that reviewed types of abuse, examples of different types of abuse, and who to report suspected abuse to. Facility staff confirmed they were asked questions or required to provide examples of different types of abuse and explain how they would report suspected abuse as part of the training. Interviews with agency staff on 12/20/2023 between 07:14 p.m. to 08:24 p.m. revealed 5 CNAs (CNA G, CNA H, CNA I, CNA J, and CNA K) and 5 LVNs (LVN B, LVN D, LVN P, LVN T, and LVN U) verified that they had attended an in-service abuse training provided 12/19/2023 or 12/20/2023 prior to starting their shift on those specific days. The agency staff described the abuse training as reviewing the definitions of the various forms of abuse and neglect, examples of the various forms of abuse, how to document suspected abuse, the requirement of reporting suspected abuse immediately, and to whom they should report abuse. They confirmed they were asked to describe different types of abuse, who they should report abuse to, and give examples of abuse during their trainings. During an interview on 12/21/2023 at 12:08 p.m., Resident #12 said he was asked on 12/20/2023 by facility staff about concerns regarding his safety or if he had experienced any form of abuse. He added that he felt safe in the facility and if he felt unsafe or felt he was being abused he would report it to the administrator. Interview with staff CMA B from 6A-6P shift on 12/21/2023 at 01:23 p.m. revealed she had received an in-service training on abuse on 12/19/2023. CMA B described the training as about what abuse was and what to watch for, and was asked to describe what abuse was to the trainer. CMA B stated the facility abuse coordinator was the ADMIN and revealed she felt comfortable reporting abuse with no concerns of retaliation. During an interview on 12/21/2023 at 01:45 p.m., Resident #9 said he was asked on 12/20/2023 by facility staff about concerns regarding his safety or if he had experienced any form of abuse. He added that he felt safe in the facility and if he felt unsafe or felt he was being abused he would report it to the nurse. During an interview on 12/21/2023 at 01:48 p.m., Resident #10 said she was asked on 12/20/2023 by facility staff about concerns regarding her safety or if she had experienced any form of abuse. She added that she did not feel safe in the facility but did not want to talk about it. The resident refuses to answer any questions related to her statement of feeling unsafe in the facility. Resident #10 said if she felt unsafe or felt she was being abused she would report it to the staff. During an interview on 12/21/2023 at 02:06 p.m., Resident #11 said she was asked on 12/20/2023 by facility staff about concerns regarding her safety or if she had experienced any form of abuse. She added that she felt safe in the facility and if she felt unsafe or felt she was being abused she would report it to the administrator or the social worker. Interview with staff CNA M from 6P-6A shift on 12/21/2023 at 04:18 p.m. revealed she had received an in-service training on abuse on 12/19/2023. CNA M stated the training covered the requirement to immediately report any suspicions of abuse, of any kind, to the administrator or charge nurse. CNA M stated she felt comfortable reporting abuse and if she had concerns about an abuse allegation not being investigated, she would report the allegation to state. Record reviews of Resident #3 progress notes dated 12/19/2023 revealed he had received a head-to-toe assessment documented by the DON and had met with the SW, who documented that she had interviewed him on his safety in the community. The SW note indicated Resident #3 reported he felt safe with the staff. Record review of Resident #4 progress notes dated 12/19/2023 revealed she had received a head-to-toe assessment documented by the DON and had met with the SW, who documented that she had interviewed her on her safety in the community. The SW note indicated Resident #4 reported she feels safer than she did before she reported the allegation of abuse. Record review of Resident #5 progress notes dated 12/19/2023 revealed he had received a head-to-toe assessment documented by the DON and was seen by the SW. The head-to-toe assessment included documentation of the Resident #5's known bruise. The SW note indicated Resident #5 was noted as resting comfortable without signs of pain or discomfort. Record review of facility document In-service Training Report, dated 12/19/2023 and received 12/20/2023 at 05:10 p.m. revealed a notation as having been conducted by the ADMIN, covering the topic of Abuse In-service: Reporting, Investigation, Signs, with 61 facility staff noted as having had received the in-service training. The training documentation also include copies of facility policies: Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures, date revised 02/2023, Reporting Abuse to Facility Management, date revised 02/2023, Recognizing Signs and Symptoms of Abuse/Neglect, date revised 02/2023, Preventing Resident Abuse, date revised 02/2023, Investigating Unexplained Injuries, date revised 02/2023, and Abuse Prevention Program, date revised 02/2023. Record review of DON statement dated 12/19/2023 revealed she had received telephone education from the RNC related to abuse and neglect which included policy review, the investigation process, safeguarding residents, intervention implementation, staff education, and reporting standards. The document was signed by the DON and the RNC. Record review of ADMIN statement dated 12/19/2023 revealed she had received telephone education from the RNC related to abuse and neglect which included policy review, the investigation process, safeguarding residents, intervention implementation, staff education, and reporting standards. The document was signed by the ADMIN and the RNC. Record review of Ad-Hoc QAPI meeting sign-in documentation, received 12/20/2023 revealed attendance by the AD, the ADMIN, the DOM, the DON, LVN E, LVN H, LVN M, and the SW. Record review of facility document Audit of 10 Residents Per Week x 4 Weeks, received 12/20/2023 revealed tracking form with notation to be completed by Admin/Designee with the date, resident name, and concerns noted during the audit. Record review of facility document Resident Bed List Report dated 12/20/2023 was provided by the ADMIN on 12/20/2023 and designated as the document the IDT would be utilizing to complete the daily IDT monitoring of residents. The document revealed a listing foreach resident with the room the resident was assigned, the assigned manager for each resident, and a signature line.

Based on observation, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 3 residents. 1. Resident #6 had one unauthorized, unchaperoned elopement event on 07/21/2023. 2. Resident#7 had one unauthorized, unchaperoned elopement event on 07/30/2023. 3. Resident #8 had one unauthorized, unchaperoned elopement event on 10/26/2023. The non-compliance was identified as past non-compliance IJ. The first non-compliance began on 07/21/2023 and ended on 07/23/2023. The second non-compliance began on 07/30/2023 and ended on 08/04/2023. The third non-compliance began on 10/26/2023 and ended on 10/27/2023. The facility had corrected the noncompliance before survey began. This failure could place residents at risk for harm, injury, or death due to elopement. The findings included: 1. Record review of Resident #6's Face Sheet, dated 12/06/2023 revealed Resident #6 was a [AGE] year-old female, initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a progressive disease that affects memory and other important mental functions), paranoid schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking), insomnia (trouble falling and/or staying asleep), wandering (traveling aimlessly from place to place), and age-related osteoporosis (brittle and fragile bones). Record review of Resident #6's BIMS Observation Detail List Report, date completed 07/21/223 at 07:35 a.m. revealed Resident #6 had a BIMS score of 11.0 indicating moderate cognitive impairment. Record review of Resident #6's MDS, assessment date 09/03/2023 revealed a BIMS score of 9.0 indicating moderate cognitive impairment and Wandering Presence & Frequency noted under Behavior documented as 0. Behavior not exhibited. Record review of Resident #6's comprehensive person-centered care plan, reflected Resident #6 had a problem, initiated 07/18/2023 and edited 07/25/2023, of Potential/ high risk for injury R/T identified elopement risk factors and or exit seeking behavior AEB: Resident pushed emergency exit button and then attempts to exit the facility. She was successful in her attempt one time. Approaches included Resident educated on signing out prior to leaving the facility for any reason., Assess/ record/ report to MD risk factors for potential elopement such as: wandering, repeated requests to leave facility, attempts to leave facility., and Consider placement on secure unit if wandering, elopement attempts continue. Record review of Resident #6's Safety Events-Elopement report date completed 07/21/2023 at 07:42 a.m. revealed Resident #6 found on Water Street across from Notre Dame church. Resident #6 was noted as no sustained injuries. Resident #6 was noted as having had elopement attempts in the past that were unsuccessful, repeatedly opened doors/setting off alarms on secured doors, and having had verbalized statements about leaving. Resident #6 noted for change in mental status or new onset with anxiety and hallucinations. Resident noted for having Alzheimer's disease, psychiatric diagnosis of schizophrenia, and paranoid schizophrenia. Measures noted as taken was one on one with interventions noted as effective. Record review of Resident #6 elopement Risk Assessment date completed 06/30/2023 at 08:38 p.m. revealed total score of 20 with not if score is 5 or greater, the resident is at risk for elopement. Care Plan Interventions noted as: Consider placement in secured unit. Assessment revealed Resident #6's physician, Resident #6, and Resident #6's RP were notified of the results of the assessment on 06/30/2023. Record review of Resident #6's Elopement Risk Assessment date completed 07/25/2023 at 06:46 a.m. revealed total score of 20 with note if score is 5 or greater, the resident is at risk for elopement. Care Plan Interventions noted as: involve psychosocial and/or activity program, redirect resident, and Consider placement in a secured unit. Assessment revealed Resident #6's physician, Resident #6, and Resident #6's RP were notified of the results of the assessment on 07/21/2023. Record review of Resident #6's progress note, dated 07/21/2023 at 07:51 a.m. revealed nursing note describing elopement with resident noted to have been returned to the facility, having denied injury and pain, and now on one to one per administrator's instruction. Record review of nursing note dated 07/21/2023 at 09:40 a.m. revealed full skin assessment provided to Resident #6 at 06:00 a.m. with no skin issues identified and reported complaint of muscle pains due to walking so far. Record review of nursing note dated 07/21/2023 at 02:08 p.m. revealed Resident evaluated by the IDT team regarding 100 secure unit and resident not appropriate at this time. Resident alert and able to voice needs and reports she was going to the Medicaid office down the street. Record review of nursing note 07/22/2023 at 06:01 a.m. revealed Resident has been cooperative with staff. No exit seeking behaviors noted. Has been monitored every 15 minutes and remained in line of site with staff. Record review of nursing note 07/24/2023 at 01:38 p.m. revealed Resident #6 diagnosed with dysuria (painful urination) and a urinalysis and culture with sensitivities was ordered. Record review of nursing note 07/26/2023 at 04:03 p.m. revealed DON spoke with Resident #6's physician regarding recent elopement attempt, with physician stating no action to be taken and no new orders given. Record review of facility Provider Investigation Report signed 07/26/2023 revealed the facility ADMIN reported an incident involving Resident #6 to HHSC on 07/21/2023. The report revealed an unsecured door was identified on 07/21/2023 at approximately 05:30 a.m. when a CNA was returning into the facility following taking trash out from the shift. The investigation summary stated the facility investigation revealed per Resident #6 and staff interviews, Resident #6 discovered the emergency release button on the exit door next to the administrator's office and exited the building using the emergency button while staff were busy doing other tasks. The facility received a phone call from a good Samaritan who reported observing the resident walking in the near area. The staff were noted as having responded immediately and returned Resident #6 to the facility at approximately 06:00 a.m. The event was noted as spanning 15 to 20 minutes from the door having been found unsecured to Resident #6 having been returned to the facility. A head-to-toe assessment was noted as having been completed with no treatment or transfer required. Provider actions taken included: alarm covers noted to have been placed over the emergency button, Resident #6 and her RP educated on appropriate sign-out procedures, an IDT meeting was held with Resident #6's RP to determine plan of care and if any changes needed to be made, and staff in-services on abuse, emergency exit button, and elopement initiated. Record review of a Frequent Monitoring Flowsheet for Resident #6 dated 07/21/2023 - 07/22/2023 with 06:00 a.m. on 07/21/2023 to 06:00 a.m. on 07/22/2023 noted as completed. Record review of facility in-service training report signed 07/23/2023, topic noted as Care of Behavioral/ dementia/ Alzheimer's/ cognitively impaired and Elopement revealed 42 signatures. Record review of facility in-service training report signed 07/23/2023, topic noted as Emergency exit button- if this is activated- immediately do a head count and secure doors at once. Locations of said buttons- what to do to re-engage- pull & turn button revealed 48 signatures. Observation of Resident #6 on 07/21/2023 at 02:08 p.m. revealed resident sitting in wheelchair in room next to bed. Resident observed with two nursing staff attending her with her providing limited responses to staff during interaction. Record review of MapQuest, accessed 12/27/2023 revealed facility distance to location noted of where Resident #6 was found on 07/21/2023 was 0.3 miles away. Record review of www.timeanddate.com/weater for Kerrville, Texas on 07/21/2023 from 04:51 a.m. to 06:51 a.m. was 78-80 degree Fahrenheit, clear to sunny with 0 to 7 mph wind and visibility noted as 10 miles. 2. Record review of Resident #7's Face Sheet, dated 12/06/2023 revealed Resident #7 was a [AGE] year-old male, admitted to the facility on [DATE] and discharged on [DATE]. Resident #7 diagnoses included atrial fibrillation (a quivering, irregular heartbeat), age-related physical debility (weakness), restlessness and agitation, and Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors). Record review of Resident #7's BIMS Observation Detail List Report, date completed 08/02/2023 at 01:06 p.m. revealed a BIMS score of 13.0 indicating cognitively intact. Record review of Resident #7's MDS, assessment date 06/16/2023 revealed Wandering Presence & Frequency noted under Behavior documented as 0. Behavior not exhibited. Record review of Resident #7's comprehensive person-centered care plan reflected Resident #7 had a problem, initiated 07/17/2023 and edited 07/31/2023, of Potential/ high risk for injury R/T identified elopement risk factors and or exit seeking behavior AEB: Impaired cognition/ and or daily decision making, length of say < (less than) one year, elopement history, and exit seeking/ elopement history/ episodes. Approaches included Continuous one on one care by staff due to elopement risk and Sent to [medical center] 07/29/2023 for Altered mental status .discussed placement wishes with resident. Record review of Resident #7's Elopement Risk Assessment, date completed 08/02/2023 at 01:24 p.m. revealed a total score of 17, with document note if the score is 5 or greater, the resident is at risk of elopement. Care Plan Interventions included: Routine monitoring of resident, Involve Psychosocial and/or Activity Program, Redirect resident, and Consider placement in a secured unit. Resident #7's physician noted as receiving notification of the assessment on 07/30/2023 at 12:45 p.m. Record review of Resident #7's progress note dated 07/29/2023 at 11:02 a.m. revealed nursing note of CNA report that Resident #7 became physically aggressive and attempted to leave out the front door resulting in call to transfer Resident #7 to local medical center for physical aggression and wanting to leave in confused mental status. Record review of nursing note dated .07/29/2023 at 02:39 p.m. revealed local medical center completed labs, revealing no abnormality, was ready to discharge Resident #7 back to the facility, and DON recommended to schedule a telephone psychosocial visit for Resident #7. Record review of nursing note dated 07/29/2023 at 06:45 p.m. revealed Resident #7 had returned to the facility. Record review of nursing note dated 07/29/2023 at 08:15 p.m. revealed Resident #7 was observed in the parking lot outside the facility but was noted as heading back inside on his own at the time of observation. Record review of nursing note dated 07/30/2023 at 09:31 a.m. revealed staff had kept resident insight since he first got up that morning and had no signs of distress. Record review of nursing note dated 07/30/2023 at 10:52 a.m. by DON revealed Resident #7's physician did not make any changes to Resident #7's plan of care at that time. Record review of nursing note dated 07/30/2023 at 12:10 p.m. revealed staff had maintained a direct line of sight on Resident #7 that morning, he had progressively become more verbally aggressive to staff and others, he would not listen to reasoning, and could be overheard talking at the nursing station when the nurse (writing of the note) and the CNA left the nursing station. Record review of nursing note dated 07/30/2023 at 12:18 p.m. revealed facility received call from local fire department reporting that Resident #7 was at the fire department in his wheelchair and asking for them to help him get away from the people who were trying to murder him at that place. Record review of nursing note dated 07/30/2023 at 12:45 p.m. revealed Resident #7 was at the fire station, observed to be in a delusional state, refusing to return to the facility, and taken by emergency services to the local hospital at 12:40 p.m. Record review of administrator note dated 07/30/2023 at 12:56 p.m. revealed the ADMIN had a telephone conversation with Resident #7 on 07/29/2023 regarding being found in the parking lot on 07/29/2023 evening. Resident #7 stated he got outside through the front door after a visitor exited because he wanted some fresh air and reported that he knew he would be coming back when he went out. The note revealed the ADMIN discussed the sign-out policy and procedure with Resident #7 who stated he would follow the procedure. Record review of nursing note dated 07/30/2023 at 04:57 p.m. revealed the facility received a call from the local hospital that Resident #7 refused to return to the facility. Record review of nursing note dated 07/30/2023 at 05:53 p.m. revealed Resident #7 was returning to the facility due to medical order. Record review of nursing note dated 07/30/2023 at 09:34 p.m. revealed Resident #7 returned to the facility. Record review of nursing note dated 07/31/2023 at 05:20 p.m. revealed Resident #7 on constant one on one with staff member since return from hospital the prior night. Note revealed an alternate placement option had been found for Resident #7 to transfer to and the option had been communicated to Resident #7. No distress was noted. Record review of nursing note dated 08/01/2023 at 09:06 a.m. revealed Resident #7 remained on one to one and had attempted to go to the exit door twice during the night but was redirectable. Record review of psych note encounter dated 08/01/2023 at 10:05 a.m. revealed Resident #7 reported depression from being in the facility and occasional increased anxiety. Ordered Sertraline 25 mg daily for depression. Record review of Elopement Risk assessment dated as completed on 08/02/2023 at 01:08 p.m. revealed score of 17, with document note indicating if score is 5 or greater, the resident is at right of elopement. Care Plan Interventions noted as: routine monitoring of resident, involve psychosocial and/or activity program, redirect resident, and consider placement in a secured unit. Notification noted as physician on 07/29/2023 at 06:45 p.m. and phone disconnected for family/responsible party. Record review of nursing note dated 08/03/2023 at 03:11 p.m. revealed Resident #7 remained on one to one care, was wandering through the facility, and denied pain or distress. Discharge planning noted for medication continuation and setting up home care. Record review of facility Provider Investigation Report signed 08/07/2023 revealed the facility ADMIN reported an incident involving Resident #7 to HHSC on 07/31/2023. The report revealed the incident occurred on 07/30/2023 at 12:18 p.m. The report revealed Resident #7 left the facility without notifying staff and was discovered approximately two blocks from the facility. Upon discovery at 12:30 p.m., a LVN attempted to perform a nursing assessment on Resident #7. He refused and was then sent to the hospital ER for evaluation. Facility investigation revealed Resident #7 stated that he applied intense pressure to the exit door next to the administrator's office, while ensuring he was unobserved, and went out the door to the fire department. The report revealed Resident #7 was observed by staff in the facility 8 minutes prior to having been discovered at the fire department. Upon discovery, Resident #7 stated he left without notifying staff by stating I just wanted to and refused to return to the facility. Upon return from the hospital for evaluation, Resident #7 was placed on one on one observation and an alternate placement was secured for his transfer on 08/07/2023. Provider actions noted included security of all doors were evaluated and a wireless door sensor alarm was placed on the door Resident #7 eloped from with in-servicing of staff initiated. Record review of facility in-service training report dated 07/31/2023, topic noted as Elopement revealed 45 signatures. Record review of facility in-service training report dated 07/31/2023, topic noted as Behavioral Aggression in the Cognitively Impaired revealed 48 signatures. Record review of facility in-service training report dated 08/04/2023, topic noted as Exit Door by Administrator office is now alarmed. If alarm is heard, report to exit at once., revealed 39 signatures. Record review of MapQuest, accessed 12/27/2023 revealed facility distance to location noted of where Resident #6 was found on 07/30/2023 was 0.1 miles away. Record review of www.timeanddate.com/weater for Kerrville, Texas on 07/30/2023 from 11:51 a.m. to 12:51 p.m. was 94-95 degree Fahrenheit, sunny with 0 to 6 mph wind and visibility noted as 10 miles. 3. Record review of Resident #8's Face Sheet, dated 12/06/2023 revealed a [AGE] year-old male admitted to the facility initially on 05/09/2023 with diagnoses of personal history of transient ischemic attack (a brief, stroke-like attack that resolves itself), cerebral infarction (a disruption in the brain's blood flow) without residual deficits (conditions left behind), muscle wasting and atrophy (shrinking of muscle or nerve tissue), and dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #8's MDS, assessment date 09/05/2023 revealed a BIMS score of 8.0 indicating moderate cognitive impairment and Wandering Prescence & Frequency noted under Behavior documented as 0. Behavior not exhibited. Record review of Resident #8's comprehensive person-centered care plan reflected Resident #8 had a problem, initiated 10/26/2023 and edited 10/27/2023, of Potential/ high risk for injury R/T identified elopement risk factors and or exit seeking behavior AEB: impaired cognition/ and or daily decision making; length of stay < (less than) one year; elopement history; independent locomotion; decreased safety awareness; exit-seeking/elopement history/ episodes. Approaches included Resident moved to 111B in the locked unit for safety, Assess/ record/ report to MD risk factors for potential elopement such as: wandering, repeated requests to leave facility, attempts to leave facility., Supervise closely and make regular compliance rounds whenever resident is in room. Resident is a 1:1, and The facility works .to assist with guardianship for residents d/t financial and medical decision-making needs .D/T no safe discharge location. Unable to get consent for memory care unit as resident refuses. Record review of Resident #8's Elopement Risk Assessment, completed date 05/10/2023 at 11:02 a.m. revealed a total score of 15, with document note if the score is 5 or greater, the resident is at risk of elopement. Care Plan Interventions included: routine monitoring of resident, redirect resident, and consider placement in a secured unit. Resident #8's physician, Resident #8, and family/ RP noted as having received notification of the assessment on 10/25/2023. Record review of Resident #8's Elopement Risk Assessment, completed date 10/27/2023 at 11:53 a.m. revealed a total score of 15, with document note if the score is 5 or greater, the resident is at risk of elopement. Care Plan Interventions included: routine monitoring of resident. Resident #8's physician, Resident #8, and family member noted as having received notification of the assessment on 05/10/2023 at 11:00 a.m. Record review of Resident #8's nursing note, dated 10/26/2023 revealed at 11:25 p.m. Resident #8 was identified as missing. The staff had found Resident #8's wheelchair next to an exit door with a book propping the door open. The police, administrator, and DON were notified. The police arrived at the facility at 12:01 a.m. and following a discussion with the nurse and administrator, left to search for Resident #8. A CNA located Resident #8's cell phone number, called him, and Resident #8 answered the phone and stated he was in the creek behind the facility and with a friend. Resident #8 was observed coming out of the creek with a police office. He stated, I was trying to make the great escape and got stuck in the creek. Resident #8 was noted as being covered in mud and soaked with water. Resident #8 noted to having an abrasion to his right elbow, left hand/knuckles, the left hand was purple, and both knees were red. Resident #8 noted to be put on a one on one and stated I'm going to continue to escape, next time it'll be during the day. Record review of Resident #8 nursing note dated 10/26/2023 at 12:50 a.m. revealed resident assessed for injury, multiple abrasions and redness noted. Record review of Resident #8 nursing note dated 10/26/2023 at 02:58 p.m. revealed x ray revealed torn scapholunate ligament tear (partial tear or stretch) in left wrist. Record review of Resident #8 nursing note dated 10/26/2023 at 04:40 p.m. revealed Resident #8's physician present to examine resident. Resident #8's left write still has range of motion and was to wear a soft support wrap or ACE wrap. Resident #8 reported area is tender during range of motion but that in general he has no pain. Record review of Resident #8 nursing note dated 10/26/2023 at 04:54 p.m. revealed Resident #8 remained on one on one care due to elopement. Resident #8 denied distress but stated I will do it again when I get the chance. Record review of Resident #8 nursing note dated 10/27/2023 at 12:53 p.m. revealed Resident #8 was moved to the locked unit for his safety. He was noted as no longer on one to one due to being in the secure unit. Resident stated Do you think this room will keep me here? Good luck, I'll get out of here too. Record review of facility Provider Investigation Report signed 11/01/2023 revealed the facility ADMIN reported an incident involving Resident #8 to HHSC on 10/26/2023. The report revealed the incident occurred on 10/25/2023 at 11:43 p.m. Report revealed on 10/25/2023 around 10:00 p.m. an exit door was noted as propped open, nursing staff initiated a roster check for all residents, and discovered Resident #8 was not found in the facility. Report revealed the police department was notified and was able to locate the resident and return him to the facility. Resident #8 was assessed by the LVN on duty and EMS with noted abrasions to his right elbow, left hand/knuckles, and both knees. Bruising was noted on Resident #8's left hand, which resulted in the physician ordering an x-ray and a torn ligament in the left hand was identified. Resident was noted as being placed on a one to one due to his elopement risk and ordered to the secure unit for safety. Record review revealed facility document Elopement Drill Record dated 10/26/2023 which revealed Resident #8 was noted as missing at 11:25 p.m. on 10/25/2023, he was last seen at 09:45 p.m. on 10/25/2023, and located in 2 hours. Report revealed the weather conditions as raining and muddy. Actions taken included: searched rooms, searched outside, called contacts, Administrator, DON, ADON. Called police. Corrective Action taken revealed resident on one on one initiated. Report signed by 9 staff: the two facility ADONs (both LVNs), a LVN, three CNAs, the Maintenance Director, the Activity Assistant, and a nurse aide. Record review of facility in-service training report dated 10/26/2023, topic noted as Elopement revealed 40 signatures. Record review of facility in-service training report dated 10/26/2023, topic noted as Door Propping revealed 43 signatures. Record review of MapQuest, accessed 12/27/2023 revealed facility distance to location noted of where Resident #8 was found on 10/25/2023 was approximately 150 feet away. Record review of www.timeanddate.com/weater for Kerrville, Texas on 10/25/2023 from 08:51 p.m. to 12:20 a.m. was 69-78 degree Fahrenheit, overcast to light rain with fog, with 6 to 15 mph wind and visibility noted as 1 to 10 miles. Observation on 12/06/2023 from 03:35 p.m. to 03:45 p.m. revealed the facility to be parallel to a main city street with two driving entrances from the main street to the facility parking lot. The facility's main entry/exit door of facility was located off the right of the facility with the primary parking lot and a private street. Across the private street was a walled off construction site for new homes/complex. The primary parking lot at the facility entrance was noted to be full of approx. 20 cars. Toward the right and back of the facility was a private property with home and a river. The private property was located between the facility and the river. Along the outside of the facility on all sides is a small facility road with 3 secured doors to the back (toward the river/private property) and with enclosed patio toward the back. To the left of the facility is a creak. At the main road, the creak had around a 1.5-foot decline in elevation over around 3 feet. The creek quickly drops in depth, around 20 feet distance from the main road, the creek had a steep drop-off from level ground to around 16 feet drop and around 5 feet across. The main street was observed to be moderately busy with 2-way, 1 road each direction. An estimated 20 cars passed at the time of observation in under 5 minutes. No sidewalks or easy to walk grass within a minimum 1 block for each way and for each side of the road from the facility. The fire station was observed to be 0.3 miles from facility, took around 10 minutes to walk with a brief stop to observe the creek. The main street curved slightly during walk to the fire station resulting in the fire station and traffic on the road not being visible for greater than 1 block. The fire station was located on the main street, across the street without any sidewalks for travel if in wheelchair until arrival. No stop signs, lights, or traffic signs upon the main street when walking this direction. During an observation and interview with Resident #8 on 12/08/2023 at 02:35 p.m., Resident #8 was observed to be standing and walking around his room without assistance but with a wheelchair observed parked next to his bed. Resident #8 stated he did not fall into a creek. Resident #8 stated that he used to be a carpenter and while he was touring his prior hall, he noticed that one of the exit door handles was installed backwards, with the lock on the wrong side of the door/building. He stated that he tried the door and found it to be unlocked. He stated he exited the building because he was just wanting to explore his surroundings and didn't know he was breaking the law. Resident #8 stated he couldn't really see because it was dark and had started to rain, causing his glasses to fog up. Resident #8 stated his walking cane became stuck in the mud after he walked across the parking lot and he tried to call 911 but he didn't know how to operate his new cell phone. Resident #8 stated he finally contacted a family member, who called 911 for him and by the time the police arrived he was back in the parking lot. Resident #8 stated that they moved him to his current hall (secure unit) for my safety. Resident #8 stated that he wasn't trying to go anywhere, just explore his environment. Interview with the Mnt A on 12/08/2023 at 03:08 p.m. revealed the facility entry/exit doors were secured and require a code for entry and exit. The Mnt A stated the entry/exit doors have an emergency exit button located near ceiling and would automatically release if the facility was on generator power or the fire alarm was activated. The Mnt A stated the only door that does not have a code for entry/exit is the door in the lobby, next to the administrator's office. The Mnt A stated the lobby door is not considered an entry/exit door and due to a past recommendation had an alarm installed on it in case a resident forces it open. The Mnt A stated the alarm was installed on the lobby door following a resident elopement. The Mnt A stated the facility entry/exit doors daily by either himself or the maintenance director. Interview with the Mnt Dir on 12/14/2023 at 04:14 p.m. revealed the facility entry/exit doors are checked every morning and afternoon by himself or the maintenance assistant, who will act as his back-up. The Mnt Dir revealed an alarm was placed on the door next to the administrator's office (lobby door) after an elopement in July but then upgraded after the last elopement due to the administrator's request that the alarm be louder. The Mnt Dir stated that after the last upgrade, the alarm on the lobby door can be heard throughout the facility. Record review of facility policy Wandering, Unsafe Resident, noted as revised August 2014 revealed The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Policy Interpretation and Implementation included: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk facture related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Record review of facility policy Elopements, noted as revised December 2007 revealed Staff shall investigate and report all cases of missing residents. The non-compliance was identified as past non-compliance IJ. The first non-compliance began on 07/21/2023 and ended on 07/23/2023. The second non-compliance began on 07/30/2023 and ended on 08/04/2023. The third non-compliance began on 10/26/2023 and ended on 10/27/2023. The facility had corrected the non-compliance before the survey began. The facility implemented interventions to prevent further elopement risks such as discharging residents, upgrading the volume on one of the doors, and educating staff.

Based on observation, interview, and record review, the facility failed to ensure nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for two (Resident #1 and Resident #2) of two residents reviewed for the administration of medications via and caring for a central line. As of 12/08/2023, there was no evidence the facility completed nursing training or competency skills checkoffs for the 9 LVNS (LVN A, LVN B, LVN D, LVN F, LVN H, LVN I, LVN K, and LVN L) prior to the provision of medication via Resident #1's PICC line. An Immediate Jeopardy (IJ) was identified on 12/08/2023 at 03:31 p.m. While the IJ was removed on 12/09/2023 at 02:08 p.m., the facility remained in violation at a scope of pattern and a severity of no actual harm with the potential for more than minimal harm that is not immediate due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for adverse outcomes to resident care and/or services and may also include the potential for physical and psychosocial harm. Findings included: Record review of Resident #1's Face Sheet, dated 12/08/23, revealed the resident was admitted on [DATE] with the following diagnosis: Acute hematogenous osteomyelitis (infection in the bone caused by bacteria), left tibia (anterior bone of the lower leg) and fibula (bone located next to the tibia) Record review of Resident #1's MDS, dated [DATE], revealed the resident had a BIMS score of 15 (suggesting intact cognition). Record review of Resident #1's Care Plan, dated 11/30/2023, revealed the following: Problem: resident has amputation to: L AKA. Receiving antibiotics Cefazolin 2gm/100 mL Q8 IV via PICC line to R arm. Record review of Resident #1's Prescription Order, dated 11/27/2023, revealed Normal Saline Flush (sodium chloride 0.9 % (flush) syringe; a.m.t: 10 mL; injection. Special Instructions: Flush with 10 mL before each dose, 20 mL after each dose and Q shift to maintain patency. Record review of Resident #1's Prescription Order, dated 11/28/2023, revealed cefazolin (antibiotic) in dextrose piggyback (An IV piggyback is a small bag of solution attached to a primary infusion line or intermittent venous access device to deliver medication over a specified period of time); 2 gram./100 mL; a.m.t: 1 unit; intravenous. Every 8hrs times 35 days. Record review of Resident #1's MAR, dated 12/01/2023 - 12/10/2023 revealed cefazolin was administered on: 12/01/2023 at 12:00 a.m. by LVN I 12/01/2023 at 08:00 a.m. by LVN A 12/01/2023 at 04:00 p.m. by LVN A 12/02/2023 at 12:00 a.m. by LVN B 12/02/2023 at 08:00 a.m. by LVN A 12/02/2023 at 04:00 p.m. by LVN A 12/03/2023 at 12:00 a.m. by LVN C 12/03/2023 at 04:00 p.m. by LVN A 12/04/2023 at 12:00 a.m. by LVN B 12/04/2023 at 08:00 a.m. by LVN F 12/04/2023 at 04:00 p.m. by LVN F 12/05/2023 at 12:00 a.m. by LVN D 12/05/2023 at 08:00 a.m. by LVN A 12/05/2023 at 04:00 p.m. by LVN A 12/06/2023 at 12:00 a.m. by LVN D 12/06/2023 at 08:00 a.m. by LVN A 12/06/2023 at 04:00 p.m. by LVN A 12/07/2023 at 12:00 a.m. by LVN D 12/07/2023 at 08:00 a.m. by CMA A 12/07/2023 at 04:00 p.m. by CMA A 12/08/2023 at 06:00 a.m. by LVN G 12/08/2023 at 02:00 p.m. by CMA A 12/08/2023 at 10:00 p.m. by LVN N 12/09/2023 at 06:00 a.m. by LVN N 12/09/2023 at 02:00 p.m. by LVN O 12/09/2023 at 10:00 p.m. by LVN R 12/10/2023 at 06:00 a.m. by LVN R 12/10/2023 at 02:00 p.m. by LVN N Record review of Resident #1's MAR, dated 12/01/2023 - 12/10/2023 revealed saline flush was administered on: 12/01/2023 day shift by LVN A 12/01/2023 night shift by LVN B 12/02/2023 day shift by LVN A 12/02/2023 night shift by LVN C 12/03/2023 day shift by LVN A 12/03/2023 night shift by LVN B 12/04/2023 day shift by LVN F 12/04/2023 night shift by LVN D 12/05/2023 day shift by LVN A 12/05/2023 night shift by LVN D 12/06/2023 day shift by LVN A 12/06/2023 night shift by LVN D 12/07/2023 day shift by CMA A 12/07/2023 night shift by LVN H 12/08/2023 day shift by LVN G 12/08/2023 night shift by LVN N Record review of Resident #2's Face Sheet, dated 12/11/23, revealed the resident was readmitted on [DATE] with the following diagnosis: Osteomyelitis (infection in the bone caused by bacteria), and methicillin resistant staphylococcus aureus infection (infection difficult to treat due to resistance to antibiotics). Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 11 (suggesting moderate impairment). Record review of Resident #2's Prescription Order, dated 12/08/2023, revealed levofloxacin solution; 25 mg/mL; a.m.t: 750mg; intravenous; once a day. Record review of Resident #2's MAR, dated 12/01/2023 - 12/11/2023 revealed levofloxacin was administered on: 12/08/2023 at 12:00 a.m. by LVN H, 12/08/2023 at 08:00 a.m. by LVN G, and During an interview on 12/08/2023 at 08:03 a.m., CMA A said she did not administer antibiotics or flushes via Resident #1's PICC. She added that she must have initialed the MAR by mistake because the IV antibiotics were only administered by the LVNs. During an interview on 12/08/23 at 11:00 a.m., the Administrator was asked for personnel records, including competencies and certifications, for LVN H, CMA A, and LVN G. During an interview 12/08/23 at 02:00 p.m. the RNC said the facility did not have a policy for medication administration via IV. During an interview on 12/08/2023 at 02:43 p.m., LVN G confirmed she had administered cefazolin to resident #1 at 02:00 p.m. During observation and interview on 12/08/2023 at 01:45 p.m., Resident #1 was sitting on his bed, clean and groomed, he had no visible injuries, PICC was noted to the right upper arm with dressing initialed by the DON, dated 12/05/2023, and surgical wound was noted to the left leg s/p AKA. Resident #1 said the PICC was doing fine, no infections. During an interview on 12/08/2023 at 03:30 p.m., LVN E said she did not know if the facility had policies/procedures regarding central lines. She also said she did not know if central line competency evaluations were completed or who could administer medications via central lines. During an interview on 12/08/2023 at 3:24 p.m., the DON said any licensed nurse was able to administer medications via a central line. She said the LVNs did have competency evaluations and was looking for them but was unable to find any. She added the ADONs might have some. The DON said she did not know if the facility had a policy regarding central lines. During an interview on 12/08/2023 at 03:28 p.m., LVN H said she was not aware of any policy regarding medication administration via central lines and did not know if the LVNs had had competency evaluations because the facility did not have residents with PICCs in the past. During observation and interview on 12/08/2023 at 05:27 p.m., Resident #2 was sitting up in bed, clean and groomed, he had no visible injuries, PICC was noted to right upper arm. Resident #2 said he was doing well. He said he received his medications on time and had no issues with the PICC. An Immediate Jeopardy (IJ) was identified on 12/08/2023 at 3:31 p.m. The IJ template was provided to the ADMIN on 12/08/2023 at 07:33 p.m. and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 12/09/2023 at 02:08 p.m. and included the following: Plan of Removal 483.35 Resident # 1 assessed by RN for any s/s of infection to the IV site or changes in condition, physician was notified of the alleged deficiency on 12/8/23. There were no new orders obtained. The affected resident's responsible party was notified by the Administrator of alleged deficiencies and plan of correction. Resident #2 with Central Line was also assessed by RN on 12/8/2023 for any s/s of infection to the IV site or changes in condition, physician was notified of no findings. No new orders were obtained. On 12/8/2023 Regional Nurse Consultant completed 1:1 education with Director of Nursing and Administrator on Central Line policies and procedures, including competencies for Central Line. Licensed staff have been educated on Central Line care policies and medication administration. Licensed nurses will have competency verification on Central Line care by Director of Nursing/designee starting on 12/8/2023. Staff will not be allowed to work until they receive training. The DON has completed the competencies with ADONs & MDS Coordinator. The team. then provided the education to the licensed staff prior to their shift start which was led by the DON. Starting 12/8/23, Director of Nursing/designee will complete education and competencies for all nurses on central line care and medication upon hire and at least annually. Starting 12/8/2023, the Director of Nursing /designee will review staffing schedule daily to verify that there is a licensed nurse on the schedule every shift with completed central Starting 12/8/2023, the Director of Nursing /designee will review staffing schedule daily to verify that there is a licensed nurse on the schedule every shift with completed central line competencies. The administrator will confirm when the DON is not available. If the nurse does not have competencies, the ADONs & MDS Coordinator who have been checked off, provide the training to staff, including agency. CMA G received 1:1 education by Director of Nursing on medication administration within her scope of practice and medication documentation error, timely notification of medication documentation error to licensed nurse. We completed education with CMA G on 12/8/23. The additional CMAs employed completed prior to the start of their shift. Ad-Hoc QAPI meeting was held on 12/8/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, and RNC (Regional Nurse Consultant) to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to Central Line care and competencies were reviewed on 12/8/2023 by the NHA (Nursing Home Administrator), DON (Director of Nursing), RNC, and Medical Director. Starting on 12/8/2023, only licensed nurses who have completed Central Line competencies will administer medications and provide central line care to residents with Central Lines. Any issues or concerns will be brought up to the Administrator and IDT team. members for any follow up needed. 12/8/23 the Director of Nursing or designee will monitor compliance daily (Monday through Friday) and Manager on Duty (Saturday and Sunday) that any residents in facility who have Central Line and have orders for medications or/and flushes, will have licensed nurse who has competencies and training to provide Central line care tasks. An audit sheet for patients with Central Line catheters will be kept in a binder specified for follow up. Administrator audits binder compliance weekly. The Administrator/designee will monitor compliance by completing audit of ten (5) residents per week for four (4) weeks. This was initiated on 12/8/2023. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The RNC will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring the facility plan of removal was as followed: Interview of LVN E on 12/09/2023 at 05:10 p.m. revealed she had received training on the facility policies and procedures regarding central line care yesterday, 12/08/2023. LVN E stated the training revealed LVNs can provide medications through a central line if trained and certified on it, medication aides cannot, and only RNs can change bandages on central lines. LVN E confirmed the DON completed a competency review on 12/09/2023 on her regarding central line care. Interview of CMA A on 12/09/2023 at 05:13 p.m. revealed she had received training on the facility policies and procedures regarding central line care yesterday, 12/08/2023. CMA A stated that the training consisted of the rules for administering medications, the CMA's scope of practice, her charting responsibilities, to follow the rights of medication administration, and to double check everything when administering and documenting medications. CMA A stated that she was told that central line medications and dressings were out of her scope of practice and only to be completed by nurses. CMA A revealed she had received training on the facility policies and procedures regarding timely reporting of a medication error yesterday, 12/08/2023 and was told that as soon as she identified an error, to report it immediately to the DON, next in charge nurse, and followed by the ADMIN. Interview of LVN H on 12/09/2023 at 05:17 p.m. revealed she had received training on the facility policies and procedures regarding central line care during the first week of her employment and then again two to three weeks ago. LVN H stated that she was trained to be capable of checking and clearing a central line and providing certain medications via central line. LVN H revealed she was notified that LVNs were not allowed to perform dressing changes on or draw blood through a central line in Texas. Stated that the LVN scope of practice differed from her prior employment in Nebraska. LVN H revealed her competency review consisted of a step-by-step procedural review of central line care. Interview of LVN O on 12/09/2023 at 05:24 p.m. revealed she had received training on facility policies for central line care prior to the current day's shift (06:00 a.m. to 06:00 p.m.). LVN O confirmed that the training included flushing and cleaning central lines, administering antibiotics, medication administration, hand hygiene, and that an LVN and RN can put medications thought the IV but only the RN can perform dressing changes. LVN O stated she did not provide services to facility residents prior to receiving the training for that day. LVN O confirmed the facility did complete a competency review for central line care prior to working her shift. Interview of LVN P on 12/09/2023 at 05:30 p.m. revealed she had received training on facility policies for central line care prior to the current day's shift (06:00 a.m. to 06:00 p.m.). LVN P stated that the training included that only RNs can change the PICC line or do bandages changes, LVNs and RNs can administer medications through the PICC line, discussed IVs, and reviewed the dos and don'ts on medication administration. LVN P confirmed she did not provide services to facility residents prior to receiving the training for that day. LVN P confirmed the facility did complete a competency review for central line care prior to working her shift. Interview of LVN Q on 12/09/2023 at 05:33 p.m. revealed she had received training on facility policies for central line care prior to the current day's shift (06:00 a.m. to 06:00 p.m.). LVN Q stated that the training included basic procedures for hand washing, providing flushes, 6 (six) rights of medication administration, priming different types of medications, and what an LVN can do, provide medications through a central line, versus what an RN can do which included supervision, the cleaning, dressing, and removing of a central line. LVN Q confirmed she did not provide services to facility residents prior to receiving the training for that day. LVN Q confirmed the facility did complete a competency review for central line care prior to working her shift. Interview of the DON on 12/09/2023 at 05:47 p.m. revealed she had reviewed the facility policies and procedures regarding central line care which included how to administer IV medications and how to flush a central line. The DON confirmed the RNC reviewed the scope of practice regarding the delegations of responsibility, such as only RNs would be allowed to change dressings for central lines and that she could delegate the in-service trainings to her ADONs following the completion of their training. Interview of LVN M on 12/09/2023 at 05:59 p.m. confirmed she had received training on the facility policy and procedures regarding central line care on 12/08/2023, which included the facility rules for administering medications, the nurses' scope of practice, and charting. LVN M stated the facility training included that central line care, including dressing changes was only to be performed by registered nurses and not within her scope of practice. LVN M revealed that the training included review of medication error reporting, that if a medication was mistaken or administered wrong to immediately report the error to the DON, next would be the charge nurse, and third would be to report the error to the ADMIN. Interview of LVN R on 12/09/2023 at 06:18 p.m. revealed she had received training on facility policies for central line care prior to the current day's shift (06:00 p.m. to 06:00 a.m.). LVN R stated that the training included the 6 rights of mediation administration, the procedure of providing medications through a central line, and that removing the midline or PICC line and dressing changes must be performed by an RN, not LVN. LVN R confirmed she did not provide services to facility residents prior to receiving the training for that day. LVN R confirmed the facility did complete a competency review for central line care prior to working her shift. Interview of LVN K on 12/09/2023 at 06:55 p.m. revealed she had received training on facility policies for central line care prior to the current day's shift (06:00 p.m. to 06:00 a.m.). LVN K stated that the training included administering medications, right patient, right dose, spike before administering, that LVNs and RNs can provide medications through a central line but not a medication aide, and that the RN is required to complete most of the tasks for dressing changes. LVN K confirmed she did not provide services to facility residents prior to receiving the training for that day. LVN K confirmed the facility did complete a competency review for central line care prior to working her shift. Interview of LVN D on 12/09/2023 at 07:02 p.m. revealed she had received training on facility policies for central line care prior to the current day's shift (06:00 p.m. to 06:00 a.m.). LVN D stated that the training included medication administration, where medications are stores, identifying the correct medication, correct dosage, medication documentation, flushing IVs, and that LVNs can administer medications though the PICC lines but only RNs can change the dressings. LVN D confirmed she did not provide services to facility residents prior to receiving the training for that day. LVN D confirmed the facility did complete a competency review for central line care prior to working her shift. Interview of LVN A on 12/10/2023 at 01:21 p.m. revealed she had received training on facility policies for central line care prior to the current day's shift (06:00 a.m. to 06:00 p.m.). LVN A stated that the training included PICC line dressings, making sure the RNs were doing the dressing changes, review of medication administration including the 6 rights, infection control of medication administration including IV medication administration, medication storage, and medication labeling. LVN A stated the training also included a review of what she would be allowed to do, remove peripherals and what we were not allowed to do, remove any type of central line or perform dressing changes per facility policy. LVN A revealed she had received prior training at the facility approximately one (1) year prior and had an overdue IV certification, which she received from a company over two years ago. LVN A confirmed she did not provide services to facility residents prior to receiving the training for that day. LVN A confirmed the facility did complete a competency review for central line care prior to working her shift. Interview of LVN I on 12/10/2023 at 03:24 p.m. revealed she had received training on facility policies for central line care prior to the current day's shift (06:00 a.m. to 06:00 p.m.). LVN I stated that the training included only RNs can administer medications via a central line but LVNs can administer through a PICC, only RNs can do dressing changes per facility policy, if there are any problems with the dressing to immediately contact the facility DON, the process for holding medications, and IV administration. LVN I confirmed she did not provide services to facility residents prior to receiving the training for that day. LVN I confirmed the facility did complete a competency review for central line care prior to working her shift. Interview of LVN N on 12/10/2023 at 03:37 p.m. revealed she had received training on facility policies for central line care yesterday, 12/09/2023. LVN N stated that the training included medication rights, infection control, IV medication administration procedure, what the RN can do versus what an LVN can do per this facility such an LVN cannot change dressing or change the caps, anything that would manipulation the line. LVN N revealed she was IV certified. LVN N confirmed she did not provide services to facility residents prior to receiving the training for her shift, 12/10/2023 from 06:00 a.m. to 06:00 p.m. LVN N denied that the facility completed a competency review for central line care prior to working her shift. Interview of LVN L on 12/10/2023 at 06:30 p.m. revealed she had received training on facility policies for central line care prior to the current day's shift (06:00 p.m. to 06:00 a.m.). LVN L stated that the training included IVs but could not recall clearly. LVN L stated she had previously completed an IV certification course, around 2016 or 2017. LVN L confirmed she did not provide services to facility residents prior to receiving the training for that day. LVN L confirmed the facility did complete a competency review for central line care prior to working her shift. Interview of LVN G on 12/11/2023 at 09:56 a.m. revealed she had received training on facility policies for central line care on Friday, 12/08/2023. LVN G stated that the training included administering IV medications, flushing the PICC line, that LVNs were not allowed to change dressings or central lines, only RNs, and that LVNs and RNs were allowed to provide medications through the central line. LVN G revealed she had previously earned an IV certification. LVN G confirmed she did not provide services to facility residents prior to receiving the training for her shift on Monday, 12/11/2023 from 06:00 a.m. to 06:00 p.m. LVN G confirmed the facility did complete a competency review for central line care prior to working her shift. Interview of LVN S on 12/11/2023 at 11:05 a.m. revealed she had received training on facility policies for central line care on Friday, 12/08/2023. LVN S stated that the training included the procedures to follow in regard to safety and infection precaution, the steps for medication administration and flushes, and that LVNs and RNs can provide medications through central line, but RNs are responsible for changing the dressings. LVN S revealed she had a current IV certification. LVN S confirmed she did not provide services to facility residents prior to receiving the training for her shift on Monday, 12/11/2023 from 06:00 a.m. to 06:00 p.m. LVN S confirmed the facility did complete a competency review for central line care prior to working her shift. Record review of Resident #1's Face Sheet revealed Resident #1 was his own resident representative. Interview of Resident #1 on 12/11/2023 at 11:38 a.m. revealed he did not recall having been assessed on 12/08/2023. Resident #1 did not express any concerns regarding the care he had received and stated that he had been receiving his medications on time and had not had any issues with his PICC line. Interview of Resident #1's and Resident #2's physician on 12/11/2023 at 11:48 a.m. revealed he had been notified by the ADMIN on Friday, 12/08/2023. The physician revealed he had no concerns regarding the nursing care his residents had been provided and had not identified any concerns with the dressing changes or function of the central line when he last assessed either resident. Record review of Resident #2's Face Sheet revealed Resident #2 was his own resident representative. Interview of Resident #2 on 12/11/2023 at 12:58 p.m. revealed he recalled that he had been assessed and had been told that staff were receiving training regarding his PICC line, the medication, and the use of the pump. Resident #2 denied concern regarding the care he had been receiving. Interview of Resident #1's family member on 12/11/2023 at 01:47 p.m. revealed she had been notified by the ADMIN on Friday (12/08/2023) night that the state investigators had identified a concern regarding IV administration at the facility. Interview of RN A on 12/11/2023 at 06:08 p.m. revealed she had received training on facility policies for central line care today, 12/11/2023 prior to her 6:00 p.m. to 6:00 a.m. shift and over the phone on Friday, 12/08/2023. RN A stated that the training consisted of a review of facility policies on central line care and procedures and medication administration. RN A stated she was told that only an RN can complete dressing changes but LVNs can administer medications. RN A confirmed she did not provide services to facility residents prior to receiving the training for that day. RN A confirmed the facility did complete a competency review for central line care prior to working her shift. Interview of LVN C on 12/12/2023 at 08:59 a.m. revealed she had received training on facility policies for central line care last week prior to starting her 6:00 p.m. to 6:00 a.m. shift. LVN C stated that the training included the 5 rights for medication administration, medication documentation, that LVNs were able to provide medications through a PICC line, and that she did not believe LVNs were allowed to mess with central lines or perform the dressing changes. LVN C confirmed she did not provide services to facility residents prior to receiving the training for that day. LVN C stated she did not recall if the facility completed a competency review for central line care. Interview of ADMIN on 12/12/2023 at 04:53 p.m. revealed that the three (3) CMAs that were out due to COVID and two (2) LVNs that had not received the in-service trainings and competency reviews would be trained and receive their competency evaluations prior to their next shift. Observation on 12/13/2023 at 02:45 p.m. revealed a binder labeled Plan of Removal: IV Therapy & Med Admin, dated 12/08/2023. Binder found to include the IJ Template, printout of emails regarding the development of the POR, in-services associated with POR, document of Ad-HOC QAPI meeting, IV Competency Tracking for Waterside Nursing and Rebab document, and four (4) weeks of PICC/Central Line/IV Monitoring Tool document. Record review of in-service documentation dated from 12/08/2023 to 12/11/2023 revealed 21 staff members of 26 received in-service trainings. Three (3) CMAs were out due to COVID isolation protocols and two (2) LVNs were out due to PRN staffing schedule and had not worked during the observation period. Eighty percent (80%) of staff were found to have been in-serviced. Record review of Resident #1's Resident Progress Notes dated 12/08/2023 revealed entry by the DON at 07:03 p.m. with documentation of a completed head to toe assessment, including review of the PICC insertion site with no redness or drainage, swelling, or signs or symptoms of infection to the central line. The progress note included documentation of the physician and family notification of patient status. A progress note entry by the RNC at 07:41 p.m. revealed documentation of notification to Resident #1's family that the DON had completed an assessment of the IV site with no signs or symptoms of infection noted, timely administration of medication, and assurance of the charge nurse's competency checkoffs for IV medication administration. Record review of Resident #2's Resident Progress Notes dated 12/08/2023 revealed entry by the DON at 07:03 p.m. with documentation of a completed head to toe assessment, including review of the PICC insertion site with no redness or drainage, swelling, or signs or symptoms of infection to the central line. The progress note included documentation of the physician and family notification of patient status. A progress note entry by the RNC at 07:41 p.m. revealed documentation of notification to Resident #1's family that the DON had completed an assessment of the IV site with no signs or symptoms of infection noted, timely administration of medication, and assurance of the charge nurse's competency checkoffs for IV medication administration. Record review of facility document titled New Hire & Annual Nurse Orientation & Competencies received 12/11/2023, revealed IV listed under competency. Record review of facility document titled IV Competency Tracking for Waterside Nursing and Rehab received 12/11/2023, revealed a listing of facility nursing staff, including agency staff with highlight and notations for staff that had completed Medication Administration training (noted for all staff) , IV Medication Administration training (noted for LVNs), Primary Infusion training (noted for LVNs), Flush Vascular Access (noted for LVNs), Central Dressing Change (noted for RNs only), Needleless Connector Change (noted for RNs only), and IV Certification. Record review of facility documents titled Charge Nurse Assignment dated 12/08/2023, 12/09/2023, 12/10/2023, and 12/11/2023 received 12/11/2023, revealed facility administration highlighting LVNs and CMAs noted on the daily Charge Nurse Assignment sheet if they were noted on the IV Competency Tracking form for having had completed the IV Competency trainings. Record review of facility documents titled PICC/Central Line/IV Monitoring Tool for Week of 12/11/2023, PICC/Central Line/IV Monitoring Tool for Week of 12/18/2023, PICC/Central Line/IV Monitoring Tool for Week of 12/25/2023, and PICC/Central Line/IV Monitoring Tool for Week of 01/01/2024 received 12/11/2023, revealed tracking forms with notation to be completed and dated by the ADMIN. The tracking documents indicated the ADMIN would notate up to ten (10) resident names, review when their IV order was received, that the nurse checkoffs were completed, schedule was correct with the checkoffs, the competency check off log was updated, and that the facility was in compliance per policy. Record review of AdHoc QAPI document, undated, revealed deficit practice identified as Failed to ensure that nursing staff had competencies for IV medication administration. with date it will be accomplished as 12/08/2023. Document signed by medical director, the ADMIN, the DON, and the RNC. Record review of facility documents titled Staff Education/Orientation Policies and Procedures, noted as discipline nursing with competency of medication administration, dated as revised 07/01/2013, revealed completed forms for LVN R on 12/09/2023, Record review of facility policy, Competency of Nursing Staff, dated as revised May 2019 revealed: 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. 2. In addition, licensed nurses and nursing assistance employed (or contracted0 by the facility will: a. participate in a facility-specific, competenc [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure all residents were free from abuse for 2 of 6 residents (Residents #1 and #5) reviewed for abuse in that: The facility staff failed to implement adequate interventions to ensure Resident #1 did not enter other resident rooms, which caused him to be abused by Resident #2 and Resident #3. Eventually, Resident #1 was pushed by Resident #3 and Resident #1 broke his right hip and his left index finger. Resident #1 was no longer independent after breaking his hip. The facility failed to implement adequate interventions to ensure Resident #5 felt safe at the facility after he was pushed by resident #3. This failure resulted in identification of an Immediate Jeopardy (IJ) on 3/17/23. While the IJ was removed on 3/19/23, the facility remained out of compliance level of actual harm with a scope identified as isolated until interventions were put in place to ensure residents were free from abuse. This failure could place residents at risk for abuse from other residents. The findings were: Record review of Resident #1's face sheet, dated 3/15/23, revealed Resident #1 was originally admitted to the facility on [DATE] with diagnoses of unspecified dementia [a general term for impaired ability to remember, think, or make decisions], unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, pain, unspecified, and hypocalcemia (History of) [low levels of calcium in the blood.] Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 did not have a BIMS score because Resident #1 was rarely/never understood. Record review of Resident #1's care plan, obtained 3/15/23, revealed the following: - Problem last updated 11/2/22: Behavior problem related to: Dementia AEB [As Evidenced By:] Roams into others rooms. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. One of the interventions was last updated on 11/2/22 read: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. - Problem last updated 1/18/23: Resident resides in secure unit and is at risk for injury from wandering in an unsafe environment R/T [related to] impaired safety awareness. Resident is at risk for injury from others while residing in secure unit D/T [due to] altered cognition. This problem area had the following goal: Dignity will be maintained and resident will wander about unit without occurrence of any injury over the next quarter. One of the interventions last updated on 1/18/23 was: Keep environment free from possible hazards. This problem area also had the following goal dated 1/18/23: Activities director to monitor/discuss activity preference. This problem area also had the following goal dated 1/18/23: Allow resident to choose activities inside and outside that don't pose a safety risk. Record review of activities documentation from 2/1/23 to 3/14/23 revealed Resident #1 had outside activity, which was outside (walk), as early as 2/2/23. Other activities that took place outside of the locked unit, like bingo were seen documented as early as 2/6/23 and a coffee social on 2/15/23. Record review of Resident #2's face sheet, dated 3/15/23, revealed Resident #2 was originally admitted to the facility on [DATE] with diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, depression, unspecified, Type 2 diabetes mellitus without complications, and unspecified dementia with behavioral disturbance. Further record review of this document revealed Resident #2 was discharged on [DATE]. Record review of Resident #2's Discharge MDS, dated [DATE], revealed Resident #2 had a BIMS score of 3, signifying severe cognitive impairment. Record review of Resident #2's care plan, obtained 3/15/23, revealed the following: - Problem last updated 11/17/22: [Resident #2] is territorial of room/personal belongings r/t: Dementia with Behaviors. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. This problem area had the following intervention dated 11/3/22: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. - Problem area last updated 1/4/23: Behavior problem related to: Dementia with behaviors AEB: Physical and Verbal aggression towards others. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. This problem area had the following interventions dated 1/4/23: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. Record review Resident #3's face sheet, dated 3/15/23, revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of other lack of coordination, unspecified dementia, unspecified severity, with other behavioral disturbance, anxiety disorder, unspecified, unspecified psychosis not due to a substance of known physiological condition, and persistent mood [affective] disorder [a persistent and usually fluctuating disorders of mood which can last for many years that involve considerable distress and disability], unspecified. Record review of Resident #3's 5-day MDS, dated [DATE], revealed Resident #3 had a BIMS score of 9, signifying moderate cognitive impairment. Record review of Resident #3's care plan, obtained 3/15/23, revealed the following: - Problem dated 3/10/23: Behavior problem related to: Dementia AEB: Physical Aggression/Verbal aggression. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily through next review date. This problem area had the following interventions dated 3/10/23: intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. Record review of Resident #5's face sheet, dated 3/15/23, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], unspecified, other abnormalities of gait and mobility, other lack of coordination, weakness, other malaise, and muscle wasting and atrophy not elsewhere classified, unspecified site. Record review of Resident #1's incident report, dated 2/15/23 and written by LVN E, revealed the following: Brief Description of Incident: hit by another resident [Resident #2] in the head Description of injury: laceration [cut] over left eye . At 2:25 pm this nurse heard loud voices coming from . another resident's room, this resident [Resident #1] came out of the room, this nurse asked the other resident [Resident #2] what was the problem, the other resident [Resident #2] stated that he [Resident #2] hit this [sic] because he repeatedly told him [Resident #1] to get out of his [Resident #2's] room but he [Resident #1] refused. [sic] Record review of Resident #2's nursing progress note, dated 2/15/23 and written by LVN E, revealed the following: this nurse heard loud voices coming from this resident's [Resident #2's] room, another resident [Resident #1] . came out of the room, this nurse asked the resident [Resident #2] what was the problem, resident [Resident #2] stated he hit the other [Resident #1] because he [Resident #2] repeatedly told him [Resident #1] to get out of his [Resident #2's] room but he refused. Record review of Resident #1's incident report, dated 3/9/23 and written by LVN F, revealed the following: Patient went into another patient room when the Aggressor Punched other patient in the nose . Nurse was notified by CNA Patient was seen walking up and down hall with Excessive bleeding coming down from nose and another patient verbalized to her he came into his room and 'he got what he deserved.' Record review of Resident #2's nursing progress note, dated 3/9/23 and written by LVN F, revealed the following: Nurse was notified by CNA Patient admitted to hitting another patient in the nose verbalized He got what he deserved because he walked into his room. Record review of Resident #2's electronic health record revealed no 30-day discharge notice dated prior to his discharge on 3/10/23. Record review of Resident #5's nursing progress note, dated 3/11/23 at 10:31 a.m. and written by LVN F, revealed the following: Patient requested to [NAME] [sic] to nurse out in 'secret' He feels unsafe around another resident and would like for him to leave him alone. Nurse spoken [sic] to other resident and separated the two nurse will continue to monitor patients. Record review of Resident #5's nursing progress note, dated 3/11/23 and written at 10:31 a.m. by LVN F, revealed Rm changed to 116B. Record review of Resident #3's nursing progress note, dated 3/11/23 at 10:42 a.m. and written by LVN F, revealed the following: Patient seen trying to shove roommate into his room. When asked patient to please leave other patient alone he does not want to be in the room he shouted, 'I didn't touch him, I don't have blood on my hands.' Nurse talked to patient about keeping his hands to himself and patient understood. Record review of Resident #3's nursing progress note, dated 3/11/23 at 4:06 p.m. and written by LVN F, revealed the following: Patient arguing and yelling at other patients in the hall, Nurse instructed patient to sit at nurse station for 1:1 Observation. For behavior problems. Record review of Resident #1's incident report, dated 3/12/23 and written by LVN C, revealed the following: Brief description of incident: wandered to another resident room, pushed to the floor by another resident [Resident #3] . 3/12/23 at 9:29 a.m This hour resident [Resident #1] sent out to ER to evaluate/tx [treat.] Pushed to floor by another resident [Resident #3.] Record review of Resident #3's nursing progress note, dated 3/12/23 and written by LVN C, revealed the following: This am [a.m., meaning morning,] Resident voiced 'I didn't do it. I have no blood on my hands' A commotion could be heard during resident smoke hour. This resident shouted, 'get outta my room'! Then a slapping noise. This writer check the hall another resident [Resident #1] on the floor. That resident [Resident #1] is unable to communicate the incident related to DX. Record review of Resident #1's hospital physician progress note, dated 3/13/23, revealed the following: Presents after was wondering about other patients room, was pushed, fall, subsequent inability to stand up, brought to the ED [Emergency Department] which showed nondisplaced fracture of right femoral neck [right broken hip] as well as fracture of [left] proximal second digit [broken index finger.] He is scheduled to have surgical correction his afternoon. Record review of Resident #1's hospital X-ray results, dated 3/13/23, revealed total right hip arthroplasty [hip replacement] without hardware complication. Record review of Resident #1's Physical Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following short-term goals: -Patient able to perform sit <>[to] stand 3x [3 times] mod A [Moderate Assistance] to improve safety with transfers . PLOF [Prior Level of Function] (prior to onset) Independent. Baseline (3/15/23) dependent. -Patient able to stand with BUE [Bilateral Upper Extremities, meaning both arms] 1 minute min A [minimal assistance] to improve safety with transfers . PLOF (prior to onset) independent for most of the day. Baseline (3/15/23) unable limited by pain. Further record review of this same Physical Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following long-term goals: -Patient able to perform supine [lying on bed face-up] <> [to] sit supervision to decrease caregiver assistance . PLOF (prior to onset) independent. Baseline (3/15/23) dependent. -Patient able to transfer bed <> [to] W/C [wheelchair] supervision to decrease caregiver assistance and risk for falls . PLOF (prior to onset) independent. Baseline (3/15/23) unable. Admit on stretcher to facility. Limited by pain. -Patient able to ambulate [walk] with FWW [four wheel walker] 150' [150 feet] with supervision to decrease risk for falls . PLOF (prior to onset) independent no device. Baseline (3/15/23) unable. Record review of Resident #1's Occupational Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following short-term goals: -Patient will increase activity tolerance for functional activities of choice to 20 min in order to w/o [without] signs/symptoms of physical exertion increased participation with ADL tasks . PLOF Prior to onset) 20 min. Baseline (3/15/23) 30-60 seconds. -Patient will safely perform self feeding tasks with Set-up (A) with use of for initiation/termination of tasks in order to facilitate self esteem through increased independence with tasks . PLOF (prior to onset) S/U [set up.] Baseline (3/15/23) Min (A) [Minimal Assistance] -Patient will complete toilet/commode transfers with Modified Independence for clothing management with recognition of safety hazards . PLOF (prior to onset) MI [Modified Independence.] Baseline: Max (A) [Max Assistance]. Further record review of this same Occupational Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following long-term goals: -Patient will complete hygiene and grooming tasks while standing at sink with Modified Independence for initiate/termination of tasks with recognition of safety hazards in order to facilitate ability to live in environment with least amount of supervision and assistance . PLOF (prior to onset) Modified Independence. Baseline (3/15/23) Max (A). -Patient will safely perform toileting tasks using grab bars with Modified Independence for clothing management with recognition of safety hazards . PLOF (prior to onset) MI. Baseline (3/15/23) Max (A). -Patient will safely and efficiently perform LB [Lower Body] Dressing with Modified Independence with use of for initiation/termination of tasks in order to be able to return to prior level of living . PLOF (prior to onset) MI. Baseline (3/15/23) Max (A) Record review of Daily Schedule, dated 3/12/23, revealed the facility had 1 LVN, 1 CMA, and 1 CNA on 3/12/23. A second CNA was seen noted for the locked unit, but the second CNA's name scratched out and moved to another unit. Record review of the facility's current staff roster, provided on 3/15/23, revealed the facility had 17 CNAs, 11 Nurse Aides, 4 CMAs, 9 LVNs, and 1 RN. Including the non-clinical staff, the facility had 65 total employees. Record review of the facility's uploaded files from TULIP for Intake #411419 (which was the incident involving Resident #1 and Resident #2 on 3/9/23), revealed the following in-services conducted on the following dates: -On 3/9/23, the facility educated 14 staff members on Falls and Unmanageable Residents. -On 3/9/23, the facility also educated 22 staff members on Prevention of Abuse and Neglect. However, of the 22 staff members, 2 staff members signed their names twice for a total of 20 staff members. Of these now 20 staff members, 14 were the same staff members educated on Falls and Unmanageable residents. Only 6 new staff members received this education. -On 3/13/23, the facility also educated 13 staff members on Abuse Reporting. -On 3/13/23, the facility also educated 13 staff members on Managing Fall Risk. The 13 staff members on this in-service were the same 13 staff members who were educated on Abuse Reporting. During an observation and interview on 3/15/23 at 1:11 p.m., Resident #1 was seen in bed, awake, alert, and fully-dressed. CO H was at Resident #1's bedside and CO H stated Resident #1 may not be able to answer questions due to his diagnosis of dementia. An interview was attempted with Resident #1. When asked if he had any issues with other residents, Resident #1 answered, yes, but he did not elaborate on his answer when this surveyor prompted Resident #1 to elaborate. CO H stated Resident #1 was attacked 3 times last week and stated Resident #1's last attack was on Sunday, 3/12/23. CO H stated she received a call from CO J and they both went to a local emergency department. CO H stated, the story they told [CO J] is that the nurse was out on the patio and she heard someone yell 'get out of here.' She [the nurse] went to investigate and [Resident #1] was on the floor. And that's when the hip was broken . They [the facility] promised me they were going to keep [Resident #1 and Resident #2] separate and keep [Resident #1] safe. During an interview on 3/15/23 at 3:11 p.m., NA G stated if [Resident #3] sees anyone walking by, he'll try to pick a fight. Usually Resident #5 is afraid of Resident #3. In a follow-up interview on 3/15/23 at 3:20 p.m., NA G stated she had heard [Resident #2] had struck [Resident #1.] NA G stated Resident #2 was no longer in the facility. During an interview on 3/17/23 at 9:21 a.m., Resident #5 stated he did not feel safe in the facility. Resident #5 stated the other residents make him feel unsafe and have hurt him before. Resident #5 did not provide the names of the other residents who had hurt him. During an interview on 3/17/23 at 9:22 a.m., LVN C stated she ensured the safety of residents in the facility's locked unit by frequently monitoring the residents. LVN C stated she currently had 2 CNAs, but she was supposed to have a 3rd CNA that was supposed to come in later. When asked how they ensured Resident #1's safety, LVN C stated frequent re-direction all the time . to the best of our ability educate the residents that it's not intentional on his part to invade their space. LVN C stated [Resident #2] could go for a good amount of time [without being aggressive] and then slowly start to show the signs and then explode. When asked how they managed Resident #2's aggressive behavior, LVN C stated they spoke with [Resident #2] firmly. LVN C stated after Resident #2 struck Resident #1 they had temporarily moved Resident #1 to the women's side until lunch the next day, 3/10/23, after Resident #2 was discharged . LVN C stated only new interventions she was aware of for [Resident #1] was to consider alternative placement but it was difficult to find alternative placement for Resident #1 due to his wandering. Continuing the interview on 3/17/23 at 9:22 a.m., LVN C stated Resident #3's aggressive behavior was new for Resident #3. LVN C stated she believed Resident #3 may be mimicking Resident #2's aggressive behavior. LVN C stated, [Resident #3] somehow got attached to him and he was always calling out for [Resident #2.] And I found that extremely odd because [Resident #3] was becoming dependent on [Resident #2.] [Resident #3] felt safe around him. LVN C stated prior to 3/12/23, Resident #3 was approaching other residents with the intent to push them over, but when [Resident #3] was aware he was being watched by the facility staff, he would leave the other residents alone. LVN C confirmed she was working on 3/12/23, the day Resident #3 pushed Resident #1. LVN C stated, We were short [a staff member] that day. I remember because I had to take them out to smoke because usually a CNA would do it. So to keep the [other residents] calm I went and initiated the smoke [smoke break.] So I let them [the residents] out and then it happened. LVN C stated after Resident #3 pushed over Resident #1 and caused Resident #1 to break his hip they made sure [Resident #3] stayed away from the others. During an interview on 3/17/23 at 10:48 a.m., LVN I stated he was currently the primary nurse for Resident #1. LVN I stated Resident #1 was currently on physical therapy and occupational therapy, which was new for Resident #1. LVN I stated Resident #1 could previously walk independently and currently cannot bear weight on his broken hip. During an interview on 3/17/23 at 12:28 p.m., the DOR stated Resident #1 was currently on physical therapy and occupational therapy for his broken right hip. The DOR stated Resident #1 never required therapy before because he was ambulatory [able to walk] without any device and was independent with ADLs prior to his broken hip. The DOR stated Resident #1 was currently bed-bound at this point. He was independent, but now he's dependent. During an interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated his current role at the facility was a Nurse Manager due to the fact the facility did not have a DON and ADON. The Director of Marketing LVN stated the facility ensured the safety of residents in the locked unit by frequent monitoring. The Director of Marketing LVN stated if 2 residents had a physical altercation the staff would ensure the altercation doesn't happen again by monitoring continuously. When asked about the incident involving Resident #1 and Resident #2 on 2/15/23, the Director of Marketing stated he could not recall much about the incident as that was around the time he began to become more involved in nurse management. The Director of Marketing LVN stated after the incident we did our frequent monitoring and then our redirection and then provided activities on the unit. Continuing the interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated a resident was considered unmanageable when medication management failed to manage a resident's behavior and once that was identified the facility would find alternative placement. The Director of Marketing LVN stated Resident #2 was very nice . but he would have his spurts where if an individual invaded his space too closely, he might get a little aggressive . He was more of a verbal yelling and screaming. Just whenever his personal space was invaded. The Director of Marketing LVN stated to manage Resident #2's aggression they provided activities for him. We have an activity assistant back there [in the unit] to encourage to do activities throughout the day. The Director of Marketing LVN stated the facility had attempted to discharge Resident #2 to other nursing homes but was denied. The Director of Marketing LVN stated he was unsure if the facility ever issued a 30 day discharge notice to Resident #2. When asked about what happened between Resident #1 and Resident #2 on 3/9/23, the Director of Marketing LVN stated the facility sent out Resident #2 to the hospital for medical clearance but Resident #2 was sent back. The facility then scheduled Resident #2 to be sent out to another local hospital and when transportation arrived Resident #2 became combative, law enforcement was involved, Resident #2 was arrested and was currently not in the facility. The Director of Marketing LVN stated afterwards the facility initiated in-services on abuse, neglect, and resident-to-resident altercation. The Director of Marketing LVN stated the facility continued their current interventions from 2/15/23 for Resident #1 which included redirection, music therapy, providing more staff in the locked unit, and posting an identification marker on his Resident #1's room to help Resident #1 find where his room is. Continuing the interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated Resident #3 had a diagnosis of dementia, anxiety, unspecified psychosis, and persistent mood disorder. The Director of Marketing LVN stated from admission until these recent events he's been very pleasant and after Resident #3 pushed Resident #1 the facility provided redirection, a calming environment, and scheduled a psychiatric evaluation for Resident #3 after he returned to the facility on [DATE]. The Director of Marketing LVN stated the ideal staffing in the locked unit was 1 nurse and 2 CNAs, but on 3/12/23, the locked unit was short 1 CNA. The Director of Marketing LVN stated he did not feel the short-staffing contributed to Resident #1's incident on 3/12/23. When asked about the incident on 3/12/23, the Director of Marketing LVN stated the initial report was not made to him but to the facility's former MDS Nurse who was no longer employed at the facility. The Director of Marketing LVN stated, the only thing I remember is that the resident stated he didn't do it. I know [the former MDS Nurse] set up for [Resident #3] to be sent to [a local hospital] to be evaluated for psychiatric treatment and he came back. When asked if the facility implemented new interventions for Resident #3, the Director of Marketing LVN stated, just our general intervention. Just to provide a calm environment, redirection, and continuous monitoring. When asked if they implemented anything new for the staff, the Director of Marketing LVN stated, I know they did some in-services on abuse and neglect. The Director of Marketing LVN stated Resident #1 was independent before his incident on 3/12/23. When asked if they implemented anything new for Resident #1, the Director of Marketing LVN stated, we did incorporate a lot of activities that were off the unit to change his environment for him. The Director of Marketing LVN stated, I think they did everything they could have done to ensure the safety of all residents in this facility. They followed the procedures meant to be implemented in these situations. During an interview on 3/17/23 at 3:05 p.m., the Administrator stated he had been the Administrator at the facility since early February 2023 and was currently the abuse coordinator. The Administrator stated they ensured the safety of residents in their locked unit by supervision and increased activities. The Administrator stated he did not recall if the facility had implemented any interventions for the locked unit after the incident involving Resident #1 and Resident #2 on 2/15/23. The Administrator stated he was not too familiar with Resident #2 beyond the incident between Resident #1 and Resident #2 on 3/9/23. The Administrator stated he was not aware of any new interventions for Resident #2 prior to 3/9/23. The Administrator stated he was aware the facility had attempted to discharge Resident #2 before 3/9/23 but with no success. The Administrator stated aside from in-servicing, the facility did not make any major changes after the incident between Resident #1 and Resident #2 on 3/9/23. Continuing the interview on 3/17/23 at 3:05 p.m., the Administrator stated he heard Resident #3 became aggressive towards Resident #5 prior to Resident #3 pushing over Resident #1 on 3/12/23. The Administrator stated on 3/12/23 he was notified of the incident between Resident #3 and Resident #1 and he came on-site the same day to conduct safe surveys with other residents. When asked if there were any interventions in place to ensure Resident #1's safety, the Administrator stated, just the 15-minute check thing that we've done. I'll tell you what the problem is, it's the size of the hall . Most everyone has dementia and some of those guys get into people's personal space and some people don't like it. And [Resident #1] does that. He'll enter people's personal space and these guys-they have dementia too and I assume they don't like it. The Administrator stated he was unsure if there were any considerations to place Resident #1 in another facility. When asked if he felt the facility had done everything they could to ensure Resident #1's safety, the Administrator stated, I don't think I could have done anything to make that not happen. An updated education for the facility's incident report on 3/12/23 was requested at this time. In a follow-up interview on 3/17/23 at 5:47 p.m., the Marketing Director LVN stated the facility's education on 3/9/23 carried over to the incident on 3/12/23. During an interview on 3/18/23 at 10:45 a.m. with the Administrator, this surveyor requested for a copy of a 30-day discharge for Resident #2, if one was available. In a follow-up interview on 3/18/23 at 11:03 a.m., LVN C stated she was aware Resident #3 attempted to push Resident #5 before and heard Resident #3 raised a fist at Resident #5. LVN C stated Resident #5 felt unsafe around Resident #3 and wanted to change rooms. In a follow-up interview on 3/18/23 at 11:15 a.m. with CO H, CO H stated, [Resident #1] walks and always has. That honestly is my biggest concern . He used to sit up by himself and stand and now he can't do that . Something that he's never done before that's really concerned me is that I went to move his hair out of his eyes and he flinched. And that broke my heart. He knows I'd never lay a hand on him . He sleeps a lot more. He never used to sleep during the day. He was always up and walking. During an interview on 3/18/23 at 11:59 a.m., the Assistant Activities Director stated she conducted activities for the locked unit. The Assistant Activities Director stated she was told to do more activities with the men's locked unit, but added, I'm still making it work because she was trying to balance doing activities for the men and women's locked unit. When asked about any new changes to their activities schedule, the Assistant Activities Director stated the facility started having weekly outings on Thursdays since 3/2/23. The Assistant Activities Director stated off-unit activities had been implemented since October 2022. The Assistant Activities Director state the facility's off-unit activities included coffee socials on Tuesday, and bingo on Tuesdays and Thursdays. When asked about Resident #1, the Assistant Activities Director stated the resident liked to go for walks and she would take him to walk through the dining hall and outside at least 2 or 3 times per week for 30 minutes. During an interview and record review on 3/18/23 at 12:28 p.m., the Assistant Activities Director stated she was asked to pass to this surveyor a print-out of Resident #2'nursing and physician progress notes with highlighted portions indicating the facility's unsuccessful attempts to discharge Resident #2. No 30-day discharge notice was provided with this print-out and there was no documentation in the progress notes that indicated a 30-day discharge notice was provided. Record review of a facility policy titled, Preventing Resident Abuse, dated February 2014, revealed the following, Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse . The facility's goal is to achieve and maintain an abuse-free environment. Record review of Resident #1's signed admission agreement, dated 10/19/23, revealed the following: Each Resident has the right to be free from verbal, sexual, mental and physical abuse, corporal punishment, and involuntary seclusion. The Administrator was notified of an IJ on 3/17/23 at 5:48 p.m. and was given a copy of the IJ Template and a Plan of Removal was requested. The Plan of Removal was accepted on 3/18/23 at 4:00 p.m. and included the following: Residents #2 is no longer in the facility. Resident # 1 and # 3 assessed by RN and support was provided as accepted, physician was notified of the alleged deficiency on 3/17/23. There were no new orders obtained. Affected residents' responsible parties were notified by Administrator of alleged deficiencies and plan of correction. Resident #3 was sent to psychiatric hospital for evaluation on 3/12/2023 and again on 3/17/2023 for evaluation and possible me [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that nursing staff had the specific competencies and skill sets necessary to care for residents needs for 1 of 5 (Resident #1) reviewed for CPR and Code Blue. Facility did not have a process in place to ensure staff were trained to initiate CPR and Code Blue(The term code blue is an emergency code used to describe the critical status of a patient. Staff may call a code blue if a patient goes into [CONDITION(S)],. LVN A failed to initiate CPR upon finding Resident #1 unresponsive with no pulse or respirations. This failure resulted in the identification of Immediate Jeopardy (IJ) on [DATE] at 5:38 p.m. While the IJ was removed on [DATE] the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of its corrective systems. This failure could place residents who are a full code at risk of not receiving necessary life sustaining measures which could result in death. The findings included: Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old female with an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This causes changes in urination, fatigue, swelling of feet, high blood pressure, and loss of appetite.), Acquired [CONDITION(S)] [CONDITION(S)] ([CONDITION(S)] [CONDITION(S)] is a disorder in which red blood cells are destroyed faster than they can be made. The destruction of red blood cells is called hemolysis.), peripheral vascular disease (is a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm.), Type 2 diabetes mellitus(A condition results from insufficient production of insulin, causing high blood sugar.), orthopedic aftercare following surgical amputation both lower limbs, dependence on renal [CONDITION(S)](When your kidneys fail, [CONDITION(S)] keeps your body in balance by: removing waste, salt and extra water to prevent them from building up in the body), and depression, unspecified. Advanced Directive indicated Full Code (full code allows for all interventions needed to restore breathing or heart functioning, including chest compressions, CPR, a defibrillator, and a breathing tube.) on face sheet. Record review of Resident #1 initial MDS dated [DATE] revealed a BIMS score of 10, which indicated cognitively impaired. (Scores closer to 0 indicate severe cognitive impact whilst scores closer to 15 indicate an intact cognitive response: 08 - 12: moderately impaired.) Section GG: Mobility indicated able to turn self in bed, required mild assist of 1 with transfers to wheelchair. Record review of Resident #1 Care plan start date of [DATE] revealed problem: Resident /or family member has requested Full code status. Goal: Full code status will be honored through next review date. Approach: Notify MD/family of any change in condition. Observe for change of condition. Refer to hospice as needed or desired. Staff will be aware of where to locate Code status information. Staff will initiate CPR and notify EMS for transport to hospital. Record review of progress notes written by LVN A on [DATE] at 4:46 a.m. revealed, resident found unresponsive and called all available staff to room, CPR initiated, and call placed to EMS.5:10 a.m. EMS here this nurse (LVN A) writer assisted with CPR EMS transported resident to {local er} at this time. 6:00 a.m. Called report to local hospital ER and she reports that resident has passed. And that family notified daughter is on her way to hospital and spouse cannot come.] Record review of Resident #1's admission agreement signed by legal representative on [DATE] page 14, titled; Cardiopulmonary Resuscitation (CPR)Determinator revealed an x beside statement: YES, I do wish CPR efforts in the event of [CONDITION(S)]. I agree to full 911 protocol and transportation to the nearest hospital. Record review of Resident #1's hospital medical record titled Emergency Department Report dated [DATE] revealed Resident #1 arrived at local emergency room at approximately 5:24 a.m. on [DATE] via EMS with CPR in progress. Her initial heart rhythm asystole, with CPR in progress and intubated. There were no obtainable vital signs. Resident #1 was pronounced deceased at 5:31 a.m. on [DATE] by emergency room physician. During an interview on [DATE] at 5:06 a.m. with LVN A revealed she received report from LVN D for the 10:00 p.m. to 6:00 a.m. shift beginning on [DATE] and there were no issues regarding Resident #1. She further revealed at around 1:30 a.m. on [DATE] Nurse aide B, told me that (resident #1) was gurgling. I (LVN A) went and checked on (Resident #1) at about 1:45 a.m. and she was sleeping, no distress, her respirations were unlabored and so I (LVN A) did not want to disturb her. I took her temperature, and it was normal. LVN A further revealed on the morning of [DATE] around 4:46 a.m., Resident #1 was found unresponsive by Nurse Aide B and Hospitality Aide C who informed LVN A of Resident #1 not breathing and having no pulse. LVN A stated she went to Resident #1's room immediately when she was informed of the concern about Resident #1. She said she checked Resident #1 and found no pulse or respirations. LVN A stated she told Nurse Aide B and Hospitality Aide C, I am going to go get the crash cart and call for extra staff in building to help us, and to see if she (Resident #1) is a full code or a DNR. LVN A revealed she then left the room leaving Nurse Aide B and Hospitality Aide C with Resident #1. 4:54 a.m. LVN A stated she did an overhead page on the facility intercom which she said: All staff come to hall 200 for assistance, all staff come to hall 200 for assistance. LVN A further revealed at approximately 4:55 a.m. LVN D and CNA E immediately responded to the nurse's station on hall 200, LVN A then directed both to Resident #1's room. LVN A stated about 4:56 a.m. LVN D and CNA E took crash cart to Resident #1's room and CNA E began CPR on Resident #1 after LVN D determined there was no pulse or respirations present for Resident #1. At 5:10 a.m. LVN A stated EMS arrived and took over CPR from LVN D and CNA E. Resident #1 was transported via ambulance to local hospital emergency room where she was declared deceased at 5:31 a.m. LVN A further revealed she did not stay with Resident #1 and perform CPR when she determined by assessment that Resident #1 had no pulse or respirations. She further revealed she should have stayed with Resident #1 and sent other staff to call for help and get the crash cart. When asked why she did not call a code blue over the intercom, instead of saying All staff come to hall 200 for assistance, she stated I do not know I just wanted to get help. When asked if it was required for staff to have an active CPR card and training, she stated she did not know but she was CPR certified since June of 2022. During an interview on [DATE] at 3:32 a.m. LVN D confirmed LVN A called on the overhead speaker, All staff come to hall 200 for assistance, all staff come to hall 200 for assistance. He further revealed LVN A did not call a Code Blue overhead. He stated he and CNA E performed CPR on Resident #1 until EMS arrived. When asked if it was a requirement at the facility to have an active CPR certification, he stated he was not sure. He stated at this time he did not have one, but he knew how to do CPR and call Code Blue. During an interview on [DATE] at 4:05 a.m. with Nurse Aide B she revealed first had gone into Resident #1's room to check on her for rounds about 1:30 a.m. on the morning of [DATE]. She stated when she found Resident #1, she was making a gurgling noise and was slumped over in her bed appearing to be sleeping. She stated she informed the nurse (LVN A) who later checked her. She stated no other issues on rounds occurred until about 4:45 a.m. when she went into Resident #1's room and found her not breathing. Nurse Aide B stated she told Hospitality Aide C to go and get the nurse (LVN A) quickly because she wasn't breathing, and she could not feel a pulse. Nurse Aide B stated she repositioned Resident #1's head and raised her head with a pillow to help her breath. She revealed LVN A and Hospitality Aide C arrived in room approximately a minute after sending Hospitality Aide C to get help. Nurse Aide B stated LVN A assessed Resident #1 and stated she is not breathing. Nurse Aide B stated she told Nurse Aide B and Hospitality Aide C, I am going to go get the crash cart and call for extra staff in building to help us, and to see if she (Resident #1) is a full code or a DNR. LVN A then left the room leaving Nurse Aide B and Hospitality Aide C with Resident #1. Nurse Aide B stated she heard an overhead page on the facility intercom which she said: All staff come to hall 200 for assistance, all staff come to hall 200 for assistance. Nurse Aide B further revealed at approximately 4:55 a.m. LVN D and CNA E responded to Resident #1's room with the crash cart and stated LVN D stated she was a full code. CNA E began CPR on Resident #1 after LVN D determined there was no pulse or respirations present for Resident #1. Nurse Aide B stated she and Hospitality Aide C left the room to go and take care of the other residents. When asked why she did not start CPR or call a Code Blue on Resident #1, Nurse Aide B stated, I am not CPR certified, and I do not know how to do that. She further revealed she felt that LVN A should have stayed with Resident #1 and sent her and Hospitality Aide to get the crash cart and find out if Resident #1 was a full code or DNR. During an interview on [DATE] at 5:37 a.m. a.m. with Hospitality Aide C she revealed about 4:45 a.m. when she went into Resident #1's room with Nurse Aide B and saw that Nurse Aide B had a startled look on her face. She stated she asked Nurse Aide B what was wrong, and she stated she (resident #1) is not breathing. Hospitality Aide C stated Nurse Aide B told her to go and get the nurse (LVN A) quickly because she (resident #1) wasn't breathing, and she could not feel a pulse. Hospitality Aide C revealed she and LVN A arrived in room approximately in a minute. Hospitality Aide C stated LVN A checked Resident #1 and stated she is not breathing. Hospitality Aide C stated she told Nurse Aide B and herself, I am going to go get the crash cart and call for extra staff in building to help us, and to see if she (Resident #1) is a full code or a DNR. LVN A then left the room leaving Nurse Aide B and Hospitality Aide C with Resident #1. Hospitality Aide C stated she heard an overhead page on the facility intercom which she said: All staff come to hall 200 for assistance, all staff come to hall 200 for assistance. Hospitality Aide C further revealed at approximately 4:55 a.m. LVN D and CNA E responded to Resident #1's room with the crash cart and she heard LVN D stated she was a full code. CNA E began CPR on Resident #1 after LVN D determined there was no pulse or respirations present for Resident #1. Hospitality Aide C stated she and Nurse Aide B left the room to go and take care of the other residents. When asked why she did not start CPR or call a Code Blue on Resident #1, Hospitality Aide C stated, I do not know how to do that. She stated, why didn't the LVN stay with the resident and send one of us to get the crash cart and find out if Resident #1 was a full code or DNR? During an interview on [DATE] at 6:15 a.m. the facility DON revealed: a Code Blue should be called overhead when a resident is found unresponsive. She further revealed the primary nurse should stay with the resident if they are found unresponsive and perform the appropriate treatments. The DON further revealed she was investigating the death of Resident #1 which had occurred on [DATE]. She further revealed she had initiated an in-service on [DATE] regarding crash cart locations, AED devices, how to call a Code Blue and who should lead a Code Blue. She stated she had approximately 14 staff who had signed the in-service but could not locate it at time of investigation. She stated it was not a requirement for nursing staff to have a CPR certification to work at the facility. She stated staff have not been regularly trained or in-serviced on CPR, Code Blue, or crash carts. The DON further stated the failure to understand the appropriate code for the resident could cause residents to receive a delay in life sustaining measures and possibly die. During a phone interview on [DATE] at 10:59 a.m. CNA F she was working on the secure unit of 100 hall, and she heard someone on the overhead intercom but could not understand the sentence that was being said. She stated, I did not here Code Blue called. CNA F stated she went to see what was happening on the 200 hall where the resident (resident #1) was located but did not stay because there was another nurse and another aide there. When asked if she was CPR certified she stated no. During an interview on [DATE] at 11:35 a.m. with CNA E she revealed she was working on the 300 hall when around 4:50 a.m. she heard on the facility overhead intercom, something like come to the 200 hall. She stated she thought at first it was an in-service. She further revealed she went with LVN D to the 200 hall nurses' station and was told to go to Resident #1's room with the crash cart and that Resident #1 was a Full code and not breathing. She stated she was CPR certified and after the nurse (LVN D) and she determined there was no pulse or respirations, she started CPR while the LVN (D) pulled items off the crash cart. She stated that her and LVN D continued CPR until EMS arrived, and they took over. CNA E stated she never felt a pulse or respirations from Resident #1. She stated she then left the room. During an interview on [DATE] at 9:45 a.m. the COO stated per facility policy, it does not specify who initiates CPR. The DON was present during the interview and stated the strongest and most qualified person would begin CPR on a resident. During an interview on [DATE] at 12:01 p.m. the facility DON stated all Licensed staff will be certified on Wednesday [DATE] by having training for CPR certification provided at the facility and cna's are not required to have training but are encouraged to. During an interview on [DATE] at 3:00 p.m. with facility ADON she revealed there was no actual paper just a visual walk around and reference to where things are for Employee new hire training regarding crash carts and general information. During an interview on [DATE] at 3:15 p.m. with facility DON she revealed there was no actual paper for Employee new hire training regarding crash carts and general information. She stated I go and show new staff where the crash cart is, the disaster book and doctor phone numbers. During an interview on [DATE] at 2:40 p.m., when asked why the immediacy was identified, the DON stated, In our scope of practice of nursing, upon hire, CPR is not required. It's not like we failed to check a book because it's not mandated. Record review of facility policy titled: Cardiopulmonary Resuscitation Code Blue, dated [DATE] revealed: Policy: Basic Life Support will be delivered to any resident in need of this service, who does not have a DNR order in place. All licensed staff will be trained in basic life support. The Nurse Supervisor at the time of the incident will determine the initiation of basic life support and direct staff to assist and to activate the emergency response system, by calling CODE BLUE. Procedure (For One Person Rescue) 1. The nurse will verify the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Determine unresponsiveness by tapping or gently shaking the resident and shouting, Are you okay?.3. Call out for help: Alert the staff with a call for a CODE BLUE, room number and building location.4. Delegate a specific person to check the resident's chart for DNR or Full Code status. If the resident is a Full Code, the designee should overhead page and report a CODE BLUE and the location of the incident, three times in a succession overhead and through the phone system. Available CPR certified personnel, especially RNs should report to that location. The designated person should call the paramedics/ambulance, attending physician and administrative personnel if available. The designee should report back to you as soon as possible with an update. During an interview on [DATE] at 9:58 a.m., the DON and the COO stated prior to surveyor intervention the facility had not checked to see if staff had active CPR certification cards in their personnel files and in-services related to CPR/Code Blue were not completed. During an interview on [DATE] at 2:46 p.m., the Regional Nurse Consultant, informed Investigator #2, the facility utilized the Nurse Orientation Form, when on-boarding new staff. Record review of the facility's Nurse Orientation Form, undated did not address CPR competency, CPR certification, or Code Blue. Record review of LVN A's employee personnel file revealed no evidence of staff education or competency for CPR or Code Blue. LVN D and CNA E's employee personnel file revealed no record of staff education or competency regarding CPR or Code Blue. Record review of 3 LVN, 1 certified nurse aide, 1 hospitality aide and 1 aide employee personnel files revealed there was no facility training for staff related to CPR or Calling CODE BLUE and there was no system in place to ensure competency of staff. Record review of facility's policy, Cardiopulmonary Resuscitation Code Blue dated [DATE] revealed: Policy: Basic Life Support will be delivered to any resident in need of this service, who does not have a DNR order in place. All licensed staff will be trained in basic life support. Section titled Procedure: 3) Call out for help, Alert staff with a call for a CODE BLUE, room number and building location. The DON, the Regional Nurse Consultant, and the Regional Director of Operations were notified on [DATE] at 5:20 p.m. an Immediate Jeopardy was identified due to the above failures and the IJ template was provided. The facility's plan of removal (POR) was accepted on [DATE] at 10:00 A.M. and included: PLAN OF REMOVAL Name of facility: [Facility name] Date: [DATE] Immediate action: On [DATE] LVN A was re-educated by the director of nursing regarding calling a code blue and actions to take per the facility policy Code Blue from the facility Disaster and Emergency Preparedness manual. On [DATE] LVN A participated in a mock code blue return demonstration. On [DATE], the chief operations officer and the regional nurse consultant again, educated LVN A on the Code Blue policy and managing the process as the CPR certified personnel in the facility at the time of the Code Blue. On [DATE], the director of nurses and human resources audited all licensed nursing personnel files to validate CPR certification. A list was compiled based on audits for nurses needing CPR certification to ensure a CPR licensed personnel is available on every shift in a 24hr/period. On [DATE], the regional director of operations secured CPR training with a certified American Heart Association instructor. The training will be conducted on [DATE] at 11:00AM for charge nurses not having current CPR certification. This will validate that current charge nurses at the facility have CPR certification. On [DATE] the director of nursing began 1:1 training with the charge nurses on calling a Code Blue and their responsibility and actions to take per the facility policy Code Blue. All facility staff received an in-service on Code Blue. This training was completed by end of day [DATE]. Facility plans to ensure continued compliance: Upon hire, the facility will verify that newly hired nurses have CPR certification. If they do not have CPR certification, they will be required to work with a CPR certified nurse. The DON/ADON will identify which charge nurses are CPR certified on the schedule. The daily staffing schedule to identify which charge nurses are CPR certified will be available at the nurses' station. New employees hired will receive the Emergency Preparedness training, including Code Blue. and a minimum of annually. Code Blue policy states that a CPR certified person will initiate and direct the staff per their certification. Code Blue policy is in the Disaster and Emergency Preparedness Manual and is available at the nurses' station and is educated on hire and annually. Nurses receiving CPR certification are aware of how to perform CPR, this is their training, along with the facility policy from the Emergency Preparedness training manual. The facility policy will continue to be followed per protocol and will be updated as needed. HR will solicit a copy of a licensed nurse CPR upon hire and place in their personnel file. HR will be responsible for tracking of CPR certifications and will bring any concerns to the administrator for guidance. Administrator will verify upon new hires that they either have or do not have a CPR certification as a second check. Annually the Administrator will conduct a Code Blue training which will be maintained in the in-service binder. The director of nursing/designee will review all Code Blue's that occur within twenty-four (24) hours for one (1) month and randomly thereafter, to identify any concerns. The administrator/director of nursing will validate that corrections are made for any concerns. The administrator/designee will bring any concerns or trends regarding CPR to the monthly Quality Assurance Performance Improvement (QAPI) meeting for tracking, trending, and further interdisciplinary team (IDT) recommendations. On [DATE] to [DATE] the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the IJ by: Observation on [DATE] at 10:00 a.m. revealed the Code Blue policy was seen in the 300 Hall nurses station. Medication Aide G was able to locate the CPR policy. Observation on [DATE] at 10:38 a.m. revealed crash cart was at the 200 Hall nurses station. LVN H was able to locate the crash cart and the CPR policy. Observation on [DATE] at 10:42 a.m. revealed crash cart was at the 100 Hall nurses station. LVN I was able to locate the crash cart and the CPR policy. During an interview on [DATE] 11:55 a.m., the DON stated LVN A attended 4 mock codes. Record review on [DATE] of an Inservice titled, Mock Codes, revealed 11 LVN's ,10 CNA's, and 1 CMA had signed an inservice for Mock Codes. During an interview on [DATE] at 6:04 p.m., the Regional Nurse Consultant stated the facility will be utilizing their CPR Code Blue policy for the new hires. During an interview on [DATE] at 2:08 p.m. LVN A stated she received education on Code Blue, Code Blue Policy, and Crash Cart. During an interview on [DATE] at 2:40 p.m., the DON stated she and HR/ABOM performed the audit for CPR certification for the nurses. During an interview on [DATE] at 1:06 p.m., the ABOM stated she did an audit for CPR certification for the nurses. The ABOM stated she checked CPR certification during the new hire process and she kept a copy of the CPR Certifications in a binder which would be sectioned by months. The ABOM stated this binder will be evaluated daily in the morning meeting. During an interview on [DATE] at 1:25 p.m., the Administrator stated he verified CPR certifications of new hires through the CPR certification binder, which will be reviewed daily in the morning meeting. During an interview on [DATE] at 2:40 p.m., the DON stated she used the Code Blue audit log form to review Code Blues that occur in the facility and information will be passed onto the administrator, the regional clinical VP, and also the QAPI. Interviews conducted on [DATE] revealed all 5 staff members who attended the CPR class stated they attended the class and were able to state what was taught, who was teaching the class, and CPR procedure. Interviews conducted from [DATE] - [DATE] revealed 17 of 17 charge nurses were able to identify how to call a code blue overhead, where the crash carts were located( on the left side of each nurses station on 100 hall and 200 hall and left side of hall 300 midway closet.) Record review of facility's education from [DATE] to [DATE] revealed 15 of the facility's nurses received education. Record review of facility's in-service, 1:1 Return Demonstration of Code, dated [DATE], revealed LVN A's Signature of attendance dated: [DATE]. Record review of facility's in-service, Code Blue, dated [DATE], revealed an education in-service was performed by the DON and ADON with regarding Code Blue Policy. LVN A's signature was seen on the attendance sheet. Record review of LVN A's personnel file revealed LVN A had a CPR card issued [DATE] with an expiration date of ,d+[DATE]. Record review of an untitled facility document, dated [DATE], revealed LVN A was educated on [DATE] by the Regional Nurse Consultant and the COO. Signatures of all 3 personnel are on the bottom of the page. Record review of facility's list, CPR Audit, undated, revealed the facility performed an audit on all licensed nursing personnel. 5 nurses did not have a valid CPR certification. Record review of sign-in sheet, undated, revealed 5 staff members attended the CPR class. Record review of facility's policy, CARDIOPULMONARY RESUSCITATION CODE BLUE, dated [DATE] revealed the facility had a policy on the procedure for code blue. Record review of staffing schedule, dated [DATE], revealed the licensed staff scheduled work had CPR next to their names, indicating they were CPR certified. Record review of in-service binder revealed an Emergency Preparedness training was scheduled for July. Record review of facility's QAPI agenda, undated, revealed the following items are on the agenda: education on code blue . 1 on 1 in-service on code blue, mock code and Timely initiating of code blue/CPR . CPR class, 1 on 1 in-service, mock code CPR cert audit. On [DATE] at 10:00 a.m., the Regional Nurse Consultant was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interviews and record reviews, the facility failed to provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident requiring such emergency care and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A failed to immediately start and continuously provide CPR when she determined Resident #1 did not have a pulse or respirations on [DATE]. LVN A did not know the code status of Resident #1 and CPR was not performed immediately. Resident expired at the local hospital emergency roiagnom on [DATE]. The failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE] at 10:00 a.m. , the facility remained out of compliance at harm with a scope identified as a due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure placed residents who requested a full code status at risk of not receiving necessary life-saving measures, which could result in death. Findings included: Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old female with an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), Acquired [CONDITION(S)] [CONDITION(S)] ([CONDITION(S)] [CONDITION(S)] is a disorder in which red blood cells are destroyed faster than they can be made.), peripheral vascular disease (is a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm.), Type 2 diabetes mellitus(A condition results from insufficient production of insulin, causing high blood sugar.), orthopedic aftercare following surgical amputation both lower limbs, dependence on renal [CONDITION(S)](When your kidneys fail, [CONDITION(S)] keeps your body in balance), and depression, unspecified. The face sheet indicated the resident had a Full Code (full code allows for all interventions needed to restore breathing or heart functioning, including chest compressions, CPR, a defibrillator, and a breathing tube.) status. Record review of Resident #1 initial MDS dated [DATE] revealed a BIMS score of 10, which indicated cognitively impaired. Section GG: Mobility indicated able to turn self in bed, required mild assist of 1 with transfers to wheelchair. Record review of Resident #1 Care plan start date of [DATE] revealed problem: Resident /or family member has requested Full code status. Goal: Full code status will be honored through next review date. Approach: Notify MD/family of any change in condition. Observe for change of condition. Refer to hospice as needed or desired. Staff will be aware of where to locate Code status information. Staff will initiate CPR and notify EMS for transport to hospital. Record review of Resident #1's progress notes authored by LVN A on [DATE] at 4:46 a.m. revealed, resident found unresponsive and called all available staff to room, CPR initiated, and call placed to EMS.5:10 a.m. EMS here this nurse (LVN A) writer assisted with CPR EMS transported resident to [local hospital] at this time. 6:00 a.m. Called report to local hospital ER and she reports that resident has passed. And that family notified daughter is on her way to hospital and spouse cannot come. Record review of Resident #1's hospital medical record titled Emergency Department Report dated [DATE] revealed Resident #1 arrived at local emergency room at approximately 5:24 a.m. on [DATE] via EMS with CPR in progress. Her initial heart rhythm asystole, with CPR in progress and intubated. There were no obtainable vital signs. Resident #1 was pronounced deceased at 5:31 a.m. on [DATE] by emergency room physician. During an interview on [DATE] at 5:06 a.m. with LVN A revealed she received report from LVN D from the 10:00 p.m. to 6:00 a.m. shift beginning on [DATE] and there were no issues regarding Resident #1. She further revealed at around 1:30 a.m. on [DATE] Nurse aide B, told me that (resident #1) was gurgling. I (LVN A) went and checked on (Resident #1) at about 1:45 a.m. and she was sleeping, no distress, her respirations were unlabored and so I (LVN A) did not want to disturb her. I took her temperature, and it was normal. LVN A further revealed on the morning of [DATE] around 4:46 a.m., Resident #1 was found unresponsive by Nurse Aide B and Hospitality Aide C who informed LVN A of Resident #1 not breathing and having no pulse. LVN A stated she went to Resident #1's room immediately when she was informed of the concern about Resident #1. She said she checked Resident #1 and found no pulse or respirations. LVN A stated she told Nurse Aide B and Hospitality Aide C, I am going to go get the crash cart and call for extra staff in building to help us, and to see if she (Resident #1) is a full code or a DNR. LVN A revealed she then left the room leaving Nurse Aide B and Hospitality Aide C with Resident #1. LVN A stated at 4:54 a.m. she did an overhead page on the facility intercom which she said: All staff come to hall 200 for assistance, all staff come to hall 200 for assistance. LVN A further revealed at approximately 4:55 a.m. LVN D and CNA E immediately responded to the nurse's station on hall 200, LVN A then directed both to Resident #1's room. LVN A stated about 4:56 a.m. LVN D and CNA E took crash cart to Resident #1's room and CNA E began CPR on Resident #1 after LVN D determined there was no pulse or respirations present for Resident #1. At 5:10 a.m. LVN A stated EMS arrived and took over CPR from LVN D and CNA E. Resident #1 was transported via ambulance to local hospital emergency room where she was declared deceased at 5:31 a.m. LVN A further revealed she did not stay with Resident #1 and perform CPR when she determined by assessment that Resident #1 had no pulse or respirations. She further revealed she should have stayed with Resident #1 and sent other staff to call for help and get the crash cart. When asked why she did not call a code blue over the intercom, instead of saying All staff come to hall 200 for assistance, she stated I do not know I just wanted to get help. She stated she was CPR certified since June of 2022. LVN A further revealed she knew as a nurse CPR was important and if not done properly a person could die. During an interview on [DATE] at 3:32 a.m., LVN D stated LVN A called on the overhead speaker, All staff come to hall 200 for assistance, all staff come to hall 200 for assistance. He further revealed LVN A did not call a Code Blue overhead. He stated he and CNA E performed CPR on Resident #1 until EMS arrived. When asked if it was a requirement at the facility to have an active CPR certification, he stated he was not sure. He stated at this time he did not have one, but he knew how to do CPR and call Code Blue. During an interview on [DATE] at 11:35 a.m., CNA E stated she was working on the 300 hall on [DATE] around 4:50 a.m. when she heard on the facility overhead intercom, something like come to the 200 hall. She stated she thought at first it was an in-service. She further revealed she went with LVN D to the 200 hall nurses' station and was told to go to Resident #1's room with the crash cart and that Resident #1 was a Full code and not breathing. She stated she was CPR certified and after the LVN D and she determined there was no pulse or respirations, she started CPR while the LVN D pulled items off the crash cart. She stated her and LVN D continued CPR until EMS arrived, and they took over. CNA E stated she never felt a pulse or respirations from Resident #1. She stated she then left the room. During an interview on [DATE] at 4:05 a.m., Nurse Aide B she revealed first had gone into Resident #1's room to check on her for rounds about 1:30 a.m. on the morning of [DATE]. She stated when she found Resident #1, she was making a gurgling noise and was slumped over in her bed appearing to be sleeping. She stated she informed the nurse (LVN A) who later checked her. She stated no other issues on rounds occurred until about 4:45 a.m. when she went into Resident #1's room and found her not breathing. Nurse Aide B stated she told Hospitality Aide C to go and get the nurse (LVN A) quickly because she wasn't breathing, and she could not feel a pulse. Nurse Aide B stated she repositioned Resident #1's head and raised her head with a pillow to help her breath. She revealed LVN A and Hospitality Aide C arrived in room approximately a minute after sending Hospitality Aide C to get help. Nurse Aide B stated LVN A assessed Resident #1 and stated she was not breathing. Nurse Aide B stated she told Nurse Aide B and Hospitality Aide C, I am going to go get the crash cart and call for extra staff in building to help us, and to see if she (Resident #1) was a full code or a DNR. LVN A then left the room leaving Nurse Aide B and Hospitality Aide C with Resident #1. Nurse Aide B stated she heard an overhead page on the facility intercom which she said: All staff come to hall 200 for assistance, all staff come to hall 200 for assistance. Nurse Aide B further revealed at approximately 4:55 a.m. LVN D and CNA E responded to Resident #1's room with the crash cart and LVN D stated Resident #1 was a full code. CNA E began CPR on Resident #1 after LVN D determined there was no pulse or respirations present for Resident #1. Nurse Aide B stated she and Hospitality Aide C left the room to go and take care of the other residents. When asked why she did not start CPR or call a Code Blue on Resident #1, Nurse Aide B stated, I am not CPR certified, and I do not know how to do that. She further revealed she felt that LVN A should have stayed with Resident #1 and sent her and Hospitality Aide to get the crash cart and find out if Resident #1 was a full code or DNR. During an interview on [DATE] at 5:37 a.m. a.m., Hospitality Aide C revealed about 4:45 a.m. on [DATE] when she went into Resident #1's room with Nurse Aide B and saw Nurse Aide B had a startled look on her face. She stated she asked Nurse Aide B what was wrong, and she stated Resident #1 was not breathing. Hospitality Aide C stated Nurse Aide B told her to go and get the LVN A quickly because Resident #1 wasn't breathing, and she could not feel a pulse. Hospitality Aide C revealed she and LVN A arrived in room approximately in a minute. Hospitality Aide C stated LVN A checked Resident #1 and stated she was not breathing. Hospitality Aide C stated she told Nurse Aide B and herself, I am going to go get the crash cart and call for extra staff in building to help us, and to see if she (Resident #1) is a full code or a DNR. LVN A then left the room leaving Nurse Aide B and Hospitality Aide C with Resident #1. Hospitality Aide C stated she heard an overhead page on the facility intercom which she said: All staff come to hall 200 for assistance, all staff come to hall 200 for assistance. Hospitality Aide C further revealed at approximately 4:55 a.m. LVN D and CNA E responded to Resident #1's room with the crash cart and she heard LVN D stated she was a full code. CNA E began CPR on Resident #1 after LVN D determined there was no pulse or respirations present for Resident #1. Hospitality Aide C stated she and Nurse Aide B left the room to go and take care of the other residents. When asked why she did not start CPR or call a Code Blue on Resident #1, Hospitality Aide C stated, I do not know how to do that. She stated, why didn't the LVN stay with the resident and send one of us to get the crash cart and find out if Resident #1 was a full code or DNR? During an interview on [DATE] at 6:15 a.m., the DON stated a Code Blue should be called overhead when a resident was found unresponsive. She further revealed the primary nurse should stay with the resident if they are found unresponsive and perform the appropriate treatments. The DON further revealed she was investigating the death of Resident #1 which had occurred on [DATE]. She stated she had initiated an in-service on [DATE] regarding crash cart locations, AED devices, how to call a Code Blue and who should lead a Code Blue. She stated she had approximately 14 staff who had signed the in-service but could not locate it at time of investigation. She stated it was not a requirement for nursing staff to have a CPR certification to work at the facility. She stated staff have not been regularly trained or in-serviced on CPR, Code Blue, or crash carts. The DON further stated the failure to understand the appropriate code for the resident could cause residents to receive a delay in life sustaining measures and possibly die. Record review of LVN A's employee personnel file revealed no evidence of staff education or competency list of performing CPR or Code Blue. Record review of CPR card provided by DON revealed LVN A had received CPR certification [DATE]. Further record review of employee personnel files for LVN D and CNA E revealed neither had education for competency list of performing CPR and Code Blue. During an interview on [DATE] at 9:45 a.m., the COO stated per facility policy, it does not specify who initiates CPR. The DON who was present during the interview, stated the strongest and most qualified person would begin CPR on a resident. During an interview on [DATE] at 12:01 p.m., the DON stated all Licensed staff will be certified on Wednesday [DATE] by having training for CPR certification provided at the facility and CNAs are not required to have training but are encouraged to. During an interview on [DATE] at 3:00 p.m., the ADON stated there was no actual paper for general orientation, just a visual walk around and reference to where things are for Employee new hire training regarding crash carts and general information. During an interview on [DATE] at 3:15 p.m., the DON she stated there was no actual paper for Employee new hire training regarding crash carts and general information. She stated she showed new staff where the crash cart , the disaster book, and doctor phone numbers were located. During an interview on [DATE] at 2:40 p.m., the DON stated she believed an immediacy was identified due to a lack of communication and clarification of staff roles during Resident #1's code blue. Record review of facility's policy, Cardiopulmonary Resuscitation Code Blue, dated [DATE] revealed: Policy: Basic Life Support will be delivered to any resident in need of this service, who does not have a DNR order in place. All licensed staff will be trained in basic life support. The Nurse Supervisor at the time of the incident will determine the initiation of basic life support and direct staff to assist and to activate the emergency response system, by calling CODE BLUE. Procedure (For One Person Rescue) 1. The nurse will verify the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Determine unresponsiveness by tapping or gently shaking the resident and shouting, Are you okay?.3. Call out for help: Alert the staff with a call for a CODE BLUE, room number and building location.4. Delegate a specific person to check the resident's chart for DNR or Full Code status. If the resident is a Full Code, the designee should overhead page and report a CODE BLUE and the location of the incident, three times in a succession overhead and through the phone system. Available CPR certified personnel, especially RNs should report to that location. The designated person should call the paramedics/ambulance, attending physician and administrative personnel if available. The designee should report back to you as soon as possible with an update. The DON, facility Regional Nurse Consultant, and the Regional Director of Operations were notified on [DATE] at 4:20 p.m. an Immediate Jeopardy situation was identified due to the above failures and the IJ template was provided. The facility's plan of removal (POR) was accepted on [DATE] at 10:00 a.m. and included: 1.On [DATE] LVN A was re-educated by the director of nursing regarding calling a code blue and actions to take per the facility policy Code Blue from the facility Disaster and Emergency Preparedness manual. (See attached policy). Included in this training was a mock code blue return demonstration. 2.On [DATE], the facility social worker completed a 100% house audit on resident code statuses to validate correctness and completeness. Any concerns were corrected immediately. 3. On [DATE] the director of nursing began 1:1 training with the charge nurses on calling a Code Blue and their responsibility and actions to take per the facility policy Code Blue. Facility nurses will receive this training to be completed at 100% by end of day [DATE]. 4. On [DATE], the director of nursing began educating nursing staff and the interdisciplinary team (IDT) via a mock code blue training scenario. Nursing staff will receive the training vs a mock training scenario to be completed at 100% by end of day [DATE]. Facility plan to ensure continued compliance New employees hired will receive the Code Blue training upon hire and a minimum of annually. The director of nursing/designee will conduct mock code blue drills to be completed all shifts, quarterly and as needed. The director of nursing/designee will review all Code Blue's that occur within twenty-four (24) hours for one (1) month and randomly thereafter, to identify any concerns. Any concerns will be corrected immediately. The administrator/designee will bring concerns or trends will to the monthly Quality Assurance Performance Improvement (QAPI) meeting for tracking, trending, and further interdisciplinary team (IDT) recommendations. On [DATE] the surveyor confirmed the facility implement their plan of removal sufficiently to the remove the IJ by: Record review of in-service titled 1:1 Return Demonstration of Code with LVN A's Signature of attendance dated: [DATE]. Record review of Staff Development in-service attendance Sheet dated [DATE] performed by the DON and ADON with subject Code Blue Policy. LVN A with Signature of attendance. Record review of in-service titled Code status/crash cart dated [DATE] with LVN A by the COO via telephone. Record review of LVN A's employee file revealed there is no copy of CPR card or in-service regarding facility codes. This was made available on [DATE] to Investigator #2. Record review of audit of Resident Roster for code status performed by Social Worker on [DATE] revealed 90 resident medical records checked and validated for correctness and completeness. Record review of 10 sampled charts were reviewed with not issues related to DNR/Full code status. Interview on [DATE] at 1:38 p.m., the SW sated she had done code status audits on all residents in the facility and validated complete accurate records. She stated Full code was Highlight green and DNR was Red on the paper chart face sheet. In process by SW. Record review of in-service record title 1:1 Return Demonstration of Code performed by DON from [DATE] through [DATE] revealed signatures of attendance by licensed staff for 15 of 17 licensed nurses from facility. Interviews on [DATE] from 1:00p.m. to 2:00 p.m. with 13 staff (11 LVN's and 2 RN's) on the 6AM-2PM shift indicated they were correctly able to identify how to call a Code Blue overhead and where crash carts are all located (on the left side of each nurse's station on 100 hall and 200 hall and left side of hall 300 midway closet.) Interviews and record reviews of LVN's, CNA's and RNs on duty during time of investigation revealed staff were able to describe change of condition of residents and that code status was found in residents electronic file on the face sheet. Staff were able to describe CPR and to immediately start CPR if they did not know a resident's code status. Interviews on [DATE] from 2:00 p.m. to 4:00 p.m. with all nursing staff(1 RN, 2 LVN's,1 CMA,5 CNA's) working 2:00 p.m-10:00 p.m. revealed staff were able to describe change of condition of residents and that code status was found in residents electronic file on the face sheet. Staff were able to describe CPR and to immediately start CPR if they did not know a resident's code status. Interviews on [DATE] from 10:00 p.m.- 6:00 a.m. with all nursing staff (2 LVN's and 4 CNA's) revealed staff were able to describe change of condition of residents and that code status was found in residents electronic file on the face sheet. Staff were able to describe CPR and to immediately start CPR if they did not know a resident's code status. On [DATE], the director of nursing began educating nursing staff and the interdisciplinary team (IDT) via a mock code blue training scenario. Nursing staff will receive the training vs a mock training scenario to be completed at 100% by end of day [DATE]. A. Record review of Inservice Attendance Sheet, titled: Code Blue, began [DATE] presented by the DON and ADON revealed signatures of attendance by 24 staff, to include 6:00 a.m.-2:00 p.m. shift:1 medication aide, 3 CNA's, 6 LVN's,3 department heads. 2:00 p.m.-10:00 p.m.-1 RN, 1LVN, 2 dietary aides, 2 CNA's, 10:00 p.m.-6:00 a.m. shift- 1 LVN, 1 RN, 1 CNA. B. Record review of facility employee and agency sample which included: (RN's 2 of 2, LVN's 4 of 14, CNA's 1 of 9, Agency CNA's 7 of 7) files revealed active CPR cards.

Based on observations, interviews and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Residents #1) reviewed for abuse when it failed to provide required structures and processes in order to meet the needs of the residents in that: The facility failed to prevent Resident #1 from having flies and maggots on her and in her room by not repairing a window screen hole, which allowed flies to come in the room. An Immediate Jeopardy Immediate Jeopardy) is interpreted as a crisis situation in which the health and safety of individual(s) are at risk) was identified to have occurred on 6/15/2022. While the IJ was removed on 6/17/2022, the facility remained out of compliance at a level of potential harm with a scope identified as isolated until interventions were put in place to ensure and prevent pest infestation inside and on residents had occurred. This deficient practices could place residents at risk of not receiving the necessary care and place them at risk of a decline in health and/or death. Findings included: Record review of Resident #1's face sheet, computer dated 6/14/2022, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It's often diagnosed as either the right or left after a stroke) affecting right dominant side, altered mental status unspecified, anxiety disorder, [CONDITION(S)](a chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, [MEDICATION(S)] (sputum) production and wheezing.), post -traumatic stress disorder, borderline personality disorder, [CONDITION(S)] disorder unspecified. Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated she was cognitively intact. Resident #1's required x2 staff for transfers and turning in bed, and during incontinent care. No documentation of wounds on resident. Section E behaviors indicated Resident #1 had behaviors related to refusal of care at times. Record review of Resident #1's care plan dated 6/1/2022 revealed the following: 1. Problem start date: 6/1/2022, behavior problem related to [CONDITION(S)], anxiety. Hoards personal belongings, food, and various other items on self and bed. Goal: Will have behavior identified so that staff may intervene quickly with listed interventions daily, through next review date: target date 9/11/2022. Approach: Administer medications as ordered and monitor for side effects, effectiveness. Explain all procedures before starting to help resident adjust to changes, intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Refer to psychiatrist /psychologist as needed. Problem start date :6/14/2022. 2. Problem start date: 6/14/2022: Behavioral symptoms; Resident is no compliant with cleaning of room. Resident has potential for negative impact on health r/t failure to recommended treatment. Long term goal: resident /RP (responsible party) will have knowledge of potential for harm related to refusal to follow recommended protocols and will have wishes respected through next quarter. Approach: document non- compliance as needed, educate on importance of cleanliness, respect resident wishes in making choices. 3. Problem start date:2/17/2022 category Behavioral symptoms: resident is non-compliant with: personal hygiene regimen, medication regimen, diet/nutritional needs/interventions, pericare, assistance with ADL's . Goal: Resident /RP will have knowledge of potential for harm related to refusal to follow recommended treatments /md orders and will have wishes respected . Approach: allow choices if able, document noncompliance as needed, educate on recommended treatments/md orders as needed, monitor and document ,notify md/rp as needed, respect resident wishes in making choices. Record review of Resident #1's electronic medical record from the psychology progress notes dated 3/3/2022 revealed the reason for referral was Resident #1 presented with [CONDITION(S)] with [CONDITION(S)], general anxiety disorder, and borderline personality disorder. Staff reported agitation and aggressive behaviors. Her mental status exam revealed she was anxious, oriented x4(person, place, time, self). Resident #1 agreed to further psychotherapy sessions. Treatment plan reflected was to decrease aggressive behaviors, reduction of isolation, and encourage participation for group and individual activities in facility. The estimated visits for goals were 6-12 months. Record review of Resident #1's electronic medical record nurse's notes authored by Registered Nurse F dated 6/4/2022 at 2:31 p.m. revealed 0815{a.m.) pt (patient) found in room in bed surrounded by trash in the bed and on the floor with numerous flies in room, I asked why there was trash everywhere pt stated, 'I've just been throwing it in the trashcan, they must have moved it.' Pt c/o (complaint of) numerous horsefly bites spo2(SpO2 stands for peripheral capillary oxygen saturation, an estimate of the amount of oxygen in the blood.)=97 on 02(oxygen) 2lxnc(2 liters per nasal cannula of oxygen) hr(heart rate)=98 pain=9/10 to legs, was already medicated temp(temperature)=98.1 [degrees Fahrenheit]. Record review of Resident #1's electronic medical record nurse's notes authored by LVN G on 6/10/2022 at 4:35 a.m. revealed staff members assisted the resident with self-care due to incontinence. Staff members noted maggots to her perineum(an area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum ) and vaginal area. Staff members removed visible maggots off the resident, resident was wiped clean, and the bedding was changed. No areas of skin irritation were noted and Resident #1 denied pain or discomfort. Resident #1 phoned the police department on her personal cell phone, complained of discomfort during care, and both parties hung up the phone. The primary physician was notified. No new orders were given by physician. No medical treatment was required. During an observation and interview on 6/14/2022 at 1:29 p.m. with Certified Medication Aide (CMA) A, revealed flies in Resident #1's room and on Resident #1. Upon entering Resident #1's room there was a heavy smell of urine. CMA A stated , there is a smell of urine in this room (resident #1's room) because she (resident #1) does not let the staff change her in the normal every 2 hours and as needed time frame. CMA A stated, We have a problem with flies, there have been flies for about a month in her room, because she (Resident #1) keeps food open in her room, on her bed and will not let us cover it or remove it. CMA A stated Resident #1 frequently refused care from certain staff members to provide her incontinent care. When asked CMA A had ever seen maggots on Resident #1, she stated, No I just heard the night shift found some on her the other day. Investigator and CMA A observed a hole in the window screen in Resident #1's room on 6/14/2022 at 1:29 p.m. When asked if she knew there was a hole in the window screen, CMA A stated no. She stated she did not think to look at the window screen. She stated if she saw something broken, she would have informed the Maintenance Director or put it in the maintenance logbook which were located at the nurse's station on each side of the building. She stated she had seen the Maintenance Director spray insecticide in Resident #1's room for insects within the past week. During an observation and interview on 6/14/2022 at 1:30 p.m. Resident #1 was observed to be in her room in bed. She was awake and alert to person and surroundings. Immediate observation upon entrance to Resident #1's room by the Investigator revealed a full trash can near Resident #1's bed which was full of incontinent wipes and trash , this with a smell of urine permeating from trash can, 5 flies on Resident #1. Two flies were on her left arm, 2 on her blanket which was covering her body and 1 was on the sheet that was over her bed mattress. Resident #1 was asked if she was aware of the flies in her room and she stated, Yes they are always here. They come in through the door of my room. Not the window. I did not have maggots those were wet cracker pieces the other day. When asked where the maggots or alleged cracker pieces were on her body, she stated, I don't know what you are talking about , I just had crackers on my bed and some had fallen underneath me when I was eating them. Further observation revealed Resident unkept, with a package of crackers opened on her bed with crumbs on the bed sheets. The resident had a urine odor. Observation of Resident #1's bed revealed approximately 2 feet from the room window. Observed the window to be open approximately 4 inches from the bottom of the windowsill. Further observation of the window revealed the screen had a 2-inch x 1-inch open hole at the bottom left corner of the screen. There were 2 flies coming in through the window screen hole and a trail of small brown ants on the windowsill coming into Resident #1's room. Interview with Resident #1 revealed she was aware of the flies and stated she did not like them. She stated maintenance had sprayed for bugs, this week but spray would not kill flies. She further stated, a fly swatter would work, but I cannot handle one, I am not fast enough. When investigator asked Resident #1 why her window was open she stated, I like the fresh air coming in. The Investigator asked if her window could be closed at this time to prevent flies from entering the room and Resident #1 stated yes. When asked if she knew there was a hole in the window screen, she stated no. During an observation in Resident #1's room and interview on 6/14/2022 at 1:35 p.m. with the Interim Administrator, she stated Resident #1 had flies in her room and on her body. The Interim Administrator further observed and confirmed there was a hole at the bottom left corner of the window screen. When asked if she knew there was a hole in the window screen, she stated no. Upon immediate intervention by the investigator, Resident #1 was moved to another room with Resident #1's consent. During an interview on 6/14/2022 at 2:30 p.m. the facility Maintenance Director stated he was aware of Resident #1's window screen having a hole in it for approximately three weeks. He stated he had ordered window screen supplies, but they had not come in yet. When asked if he had considered changing the screen out with another screen or patching the screen, he stated no. He further stated he had sprayed insecticide in Resident #1's room on 06/10/2022. When asked what the insecticide was for he stated it covers multiple insects to include ants and flies. He stated Resident #1 still had flies attracted to her because she kept food products opened in her room. When asked why Resident #1 kept her window open , he stated , I don't know .The temperature is hot outside and the air conditioning works in her room. Record review of the maintenance log dated 1/1/2022- 6/14/2022 revealed no documentation of a hole in resident room [ROOM NUMBER]. Record review of the facility's pest control book provided by Maintenance Director dated 6/10/2022 revealed maintenance sprayed insecticide in Resident #1's room for ants. No documentation of insecticide utilized for flies. During an interview on 6/14/22 at 2:45 p.m. LVN B stated she heard from multiple staff members that staff on the night shift had found maggots and flies on Resident #1 on 6/10/2022. She stated she was aware Resident #1 would refuse incontinent care at times and would keep food in her bed. She stated Resident #1 had been on another hall (hall 300) prior to her being on her current hall (hall 200). LVN B stated she had not worked with Resident #1 prior to 6/14/2022. During a phone interview on 6/14/22 at 8:04 p.m. LVN G stated she worked the 10:00 p.m. to 6:00 a.m. shift on the 6/09/2022 into the morning of 6/10/2022. She stated at approximately 4:30 a.m. on the morning of 6/10/2022, 2 staff members, CNA E and Resident Aide H were assisting Resident #1 with care due to her being incontinent. LVN G stated CNA E and Resident Aide H noted maggots to Resident #1's perineum and vaginal area. She stated CNA E and Resident Aide H removed visible maggots off the resident, the resident was wiped clean, and her bedding was changed. LVN G stated CNA E told her there were ants on Resident #1's bed also. She stated there were no areas of skin irritation reported to her. She stated she was told by CNA E that Resident#1 phoned the local police department and the nearby city police department on her personal cell phone and complained of discomfort during care. She stated Resident #1 frequently called 911 to complain of care and issues at the facility that she did not like. LVN G stated she notified Resident #1's primary physician and received no orders. She stated she reported the occurrence to the oncoming nurse, LVN I. When asked if she saw the maggots herself, she stated no CNA E had thrown all the linens and cleaning materials away before she could do an assessment on Resident #1 and to see the maggots When asked if there was a hole in Resident #1's window screen, she stated she did not look or notice one. She stated she did see the window to her room opened on the day of the reported maggots, but that was nothing unusual as she kept her window open most of the time . She stated she did not think to look at the window screen to see if there was a hole in it for flies to enter. She stated she informed the oncoming nurse, LVN I, of ants on Resident #1's floor, under her bed and asked her to inform maintenance to spray insecticide. When asked if Resident #1 was moved to another room due to the ants and flies/maggots she stated no , I did not think about moving her. The aides (E and H) just cleaned up everything. When asked how staff communicates any item that needed repairing or if they saw bugs, she stated they had a communication book for the Maintenance Director to check at each nurse's station and also would tell the oncoming shift, since I work night shift. When asked if she had ever seen flies on Resident #1, she stated she could not recall seeing any. She stated there were fly swatters at the nurse's station to use because there were flies in the facility at times. When asked if the facility was doing anything about the ants or flies, LVN G stated , I assume they are. When asked LVN G how she thought the ants and maggots/flies could have gotten on Resident #1's perineum she stated she felt that since Resident #1 refuses incontinent care and cleaning of her room [NAME] frequently, they probably were attracted to her. She further revealed Resident #1 kept open food products and drinks in her room so the ants and flies/maggots could be attracted to that. During an interview on 6/14/2022 at 3:00 p.m. with the Interim Administrator and the DON, both stated the incident with Resident #1 having flies and maggots on her was not reported to HHSC. When asked why it was not reported, the Interim Administrator stated she was not at the facility on 6/10/2022, it was the previous Administrator who is no longer here. The DON stated she was not aware she needed to report the incident regarding Resident #1. The DON stated Resident #1 was not harmed, so I did not report it. The Interim Administrator stated the facility had been in contact with the assigned Ombudsman regarding Resident #1. During an interview on 6/15/2022 at 9:11 a.m. the facility Maintenance Director stated he had sprayed insecticide in Resident #1's room on 6/10/2022 after it was reported to him by staff that there were ants under Resident #1's bed. He stated he saw ants when he sprayed on 6/10/2022. He stated he knew Resident #1 had flies in her room but he thought it was because she had food in her bed. He further stated he did not think about looking at the window or the window screen to see where the flies were coming from. He stated he felt that the ants were coming from the window. During an interview on 6/15/2022 at 9:30 a.m. the facility DON stated she was told on the morning of 6/10/2022 by LVN I that Resident #1 had maggots on her that morning. She stated she went to ask Resident #1 if she could do a full body assessment on her and the resident agreed. The DON stated while performing the assessment she found 3 maggots on Resident #1's abdominal fold. She further revealed she provided teaching to Resident #1 regarding hoarding food and refusing personal care. She stated she requested a total bed bath for Resident #1, but Resident #1 refused. The DON stated it was care planned that Resident #1 refused many things like medications, care and people coming in her room. She stated the resident also refused peri care at that time. The DON further revealed Resident #1 would not go to the shower room to have showers. She stated Resident #1 refused bed bathes more often than not. The DON stated when Resident #1 would let staff bath her , it was a bed bath.The DON stated she notified MHDD and had a teleconference with them and Resident #1. The DON stated during the teleconference Resident #1 denied having anxiety. She stated she requested for MHDD to find placement for Resident #1 due to her refusing care. The DON stated she was not aware of any flies in Resident #1's room prior to the incident on 6/10/2022. The DON stated when she did the assessment, she did see fly activity in room but could not remember how many. She stated she could not remember if she saw any flies post incident. When asked the DON how she thought the ants and maggots/flies could have gotten on Resident #1's perineum she stated she felt that since Resident #1 refuses incontinent care and cleaning of her room [NAME] frequently, they probably were attracted to her. She further revealed Resident #1 kept open food products and drinks in her room so the ants and flies/maggots could be attracted to that. During a phone interview on 6/15/2022 at 11:17 a.m. CNA E stated on 6/10/2022 at approximately 4:30 a.m., Resident #1 had 4 maggots, which were moving, on her peri area and 3 underneath her back on her bed which were moving. She stated, we (CNA E and Resident aide H) were performing incontinent care on Resident #1. CNA E stated she did not tell Resident #1 there were maggots on her to protect her dignity. She stated she did not think to look at the window screen to see if there was a hole in it for flies to enter. CNA E stated Resident #1 had flies in her room for about a month prior to finding maggots. She stated she had told the Maintenance Director there were flies in Resident #1's room but could not remember what date. She stated she was aware of the maintenance work logbook on each nurse's station but did not write in it. She stated she told the charge nurse( LVN G) to communicate to maintenance. During a phone interview with Resident #1's Primary Physician on 6/15/2022 at 11:25 a.m. he stated he was aware that Resident #1 had maggots on her on Friday 6/10/2022. He stated, This resident refuses care such as incontinent care, bathing , and changes of clothing from staff and has behavioral issues. He further stated I cannot have her in emergency commitment to an acute psychiatric facility because she does not meet the criteria. She is not of harm to herself or others. She does refuse her medications except for her pain medication. He stated the facility had given Resident #1's Responsible Party a 30-day notice to discharge, but there were no facilities that would take Resident #1 due to her behaviors and refusal of care. The Primary Physician stated he was seeing Resident #1 weekly for mental health services due to no psychology/psychiatrist services available at this time. He further revealed he did not provide any new orders for Resident #1, because he felt there was none needed. During a phone interview on 6/15/2022 at 1:23 p.m. the prior Administrator stated she was working on 6/10/2022 as the facility Administrator and further revealed that was her last day at the facility. She stated she was aware of Resident #1 having flies and maggots on her the morning of 6/10/2022. She stated she did not report it to HHSC because there was no harm to the resident. She stated she contacted the assigned ombudsman regarding Resident #1's behaviors regarding refusing incontinent care, bathing and also the flies and maggots that were on Resident #1. She stated the Maintenance Director had sprayed pesticide in Resident #1's room on 6/10/2022. She stated she knew of no other time Resident #1 had flies on her. During an interview on 6/15/2022 at 2:38 p.m. RN F stated approximately 2 weeks ago he went into Resident #1's room in the morning and found Resident #1 in bed with trash in the bed and on the floor. He stated there were numerous flies in the room. He stated he asked the resident why there was trash everywhere and she replied, I threw it on the floor. They moved my trashcan. He stated she was complaining about numerous horsefly bites on her. He stated he did not see any fly bites on her. When asked what he did when he saw the numerous flies in her room, he stated he got housekeeping to clean the room. When asked what he did when the resident said she had horsefly bites, he stated he asked her to let him see them and she refused. He stated the resident refused care from staff frequently, not allowing them to provide incontinent care or to bath her. He stated he did not think to look at the window screen to see if the flies were coming in through it. He stated he would have shut the window and informed the Maintenance Director of any concerns. When asked if he was aware of a hole in the window screen, he stated he was not. This was determined to be an Immediate Jeopardy (IJ) on 6/15/2022 at 3:56 p.m. The facility Interim Administrator and DON were notified. The Interim Administrator was provided with the IJ template on 6/15/2022 at 3:56 p.m. On 6/15/2022 the facility provided a plan of removal titled: Plan of Removal. The plan of removal was accepted on 6/16/2022 at 2:20 p.m. It is documented as follows: PLAN OF REMOVAL Date: June 15, 2022 Immediate action On 6/14/22 resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER] per surveyor request. Resident was offered alternate placement today and refused. Resident has been consistently calling the police who called the facility at 1:30 pm notifying Administration that the resident had made many calls to the police during the day on 6/15/22. Police came to the facility at 5:30 p.m. assisting EMS related to a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident refused to leave and became combative with EMS and staff and back up police arrived on seen taking resident to ER and the police reported to Regional Director of Operations that they filed charges against the resident for silent 911 calls and seized her cell phone. Resident frequently refused care, window coverings for her room, demanded window to be up, and resident continuously kept opened food around her body in the bed and would become verbally and physically combative when staff tried to remove it. Resident returned to the facility on [DATE] at approximately 8:00PM after receiving a medical clearance from [hospital name]. Residents residing in the facility have the potential to be affected by the alleged deficient practice. Housekeeping staff thoroughly cleaned residents' previous room [ROOM NUMBER] on 6/14/22 at 3:00 p.m. Maintenance checked window and made sure screen was intact and on new room [ROOM NUMBER] prior to patient move, no concerns were identified. On 6/15/22 at 2:00 p.m. the Maintenance Director checked every screen on every window in the facility and identified that fourteen screens were needed or needed repair. The Regional Director of Operations ordered the items to repair the screens from HD Supply on 6/15/22 at 2:20 p.m. Facility's Plan to ensure compliance quickly On 6/15/22 Regional Director of Operations assigned managers to round and audit all halls to check windows and verify all windows were closed and screens were intact. Pest Control was called for an additional spray (previously sprayed 5/28 [2022]and room [ROOM NUMBER] sprayed again on 6/10 [2022]) and it is scheduled for 6/17/22. Medical Director and attending for resident was notified of the alleged condition of the resident and said, resident is allowed to make her own decisions, even if they are poor decisions. Medical Director gave a new order to send out resident to [hospital name] for evaluation and resident refused and has done so numerous times. Police assisted EMS with removing resident to [hospital name] case #[number]. IDT team met on 6/15/22 and reviewed/revised individual care plans for resident. Head to toe was completed by DON and Reviewed and Approved ADON with surveyor with consent from resident on 6/15/22 at 10:30 a.m. and no skin abnormalities were identified. During interview with the surveyor, Resident #1 was pleasant and proceeded to compliment individual staff members and give suggestions for improvement. 30-day discharge letter was issued by previous Administrator on 4/13/22 due to her creating an unsafe environment for herself and other residents. Resident #1 appealed the discharge through the Ombudsman. Resident #1 later retracted appeal stating she wanted to discharge from the facility. The facility began searching for alternate placement and she was denied by thirteen facilities and was accepted by out-of-town facility, but resident refused. On 6/15/22 at 4:15 p.m. the Director of Nursing, called RP (responsible party) and talked to resident about placement at [alternate facility name] and both again refused. The Ombudsman has made routine visits to the resident and is also aware of the attempts and has also assisted with trying to find placement. The facility staff received education from the Director of Nursing and the Regional Nurse Consultant that was initiated on 6/15/22 regarding: Identifying Abuse and Neglect, Safe, Clean, Homelike Environment, and identifying rooms that could attract pests because of cleanliness and/or food sources. All facility staff will receive these educations and will be required to receive it before beginning their next assigned shift. Currently, approximately 40% of staff have received the education with an expected completion date of 6/18/22. PRN staff will be expected to complete the training before starting their next assigned shift. All housekeeping staff (100%), including the housekeeping manager, received education on all the above, 100% of interdisciplinary team staff have received this education. On 6/16/22, the director of nursing and the regional nurse consultant did interviews with a sampling off each hall of interview able residents to determine if they had any concerns regarding abuse, neglect, or cleanliness of the building. No concerns were identified. The interdisciplinary team rounded the entire building again, on 6/16/22 at approximately 8:30am to identify rooms needing cleaning of clutter and/or food sources that could attract pests. Any concerns were corrected immediately. Hall 300's window screens have been repaired and completed. There are nine (9) additional windows requiring new screens and they have been ordered and confirmation received on 6/16/22 that they have shipped. If received by 6/17/22, then the remaining (9) windows will be completed in entirety by 6/19/22. The entire facility was sprayed by pest control on 5/28/22 and another scheduled spray is scheduled (for whole facility) on 6/17/22. The spray that occurred on 6/10/22 was only for room [ROOM NUMBER] for Resident #1. Resident #1 has returned to the facility with the following interventions. 1. Moved to another room, screen is in good condition 2. Behavior tracking, and progress notes are being completed by nursing staff and will continue until the DON deems appropriate to remove her from every shift progress notes. Behavior tracking will continue every shift. 3. The DON will monitor residents' hygiene and food hoarding behaviors, daily, during regular business hours, and write a progress note. This will continue daily for 2 weeks and randomly thereafter or when concerns are identified. 4. A care conference will be scheduled when the ombudsman is available to discuss further discharge plans, per the resident's prior request. 5. The Medical Director (resident's MD) will visit the resident on routine schedules checks and when there are concerns 6. Concerns will be brought to the attention of the Regional Director of Operations for further recommendations Continued compliance: The Regional Director of Operations on 6/15/22 in-serviced the maintenance on outside facility rounds and monitoring windows/screens. Maintenance Supervisor is going to audit the screens weekly for one month and monthly thereafter and any concerns will be brought to the attention of the Administrator. The Regional Director of Operations on 6/15/22 also in serviced the Housekeeping Director regarding notifying the Administrator for any resident refusing to have their room cleaned. The Administrator will bring any concerns to the monthly quality assurance performance improvement (QAPI) meeting for tracking, trending, and further interdisciplinary team recommendations. On 6/16/2022 at 2:15 p.m. the POR was accepted, and verification by Investigator began. Verification of POR 6/16/2022: Record review of the invoice provided by the Interim Administrator dated 6/15/2022 revealed a purchase order of screen frames x 20, screen (48x100ft) x2, and assorted window screen supplies for repairs. Record review of a detailed invoice provided by the RN Consultant from the facility's contracted pest control dated 6-17-2022 revealed in the general comments: This account has 4 ILTS (insect light traps) that are inoperable. Record review of the facility's policy dated 2001 revised February 2014: Titled Preventing Resident Abuse; Policy statement revealed Our facility will not condone any form of resident abuse and will continually monitor our facilities policies, procedures, training programs, systems, etc. to assist in preventing resident abuse. Record Review of the facility's policy dated 2001 and revised 2008, Titled Pest control; policy statement revealed Our facility shall maintain an effective pest control program. Policy interpretation and implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 3. Windows are screened at all times.5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. POR verification: Observation on 6/15/2022 at 10:00 a.m. and 6/16/2022 2:00 p.m. of the window screens in rooms [ROOM NUMBERS] of Resident #1 revealed they were in good condition with no holes or tears. 1. Observation on 6/17/2022 at 1:00 p.m. of Resident #1's new room [ROOM NUMBER], after being moved closer to the nurse's station, revealed no tears or holes in her window screen. 2. Behavior tracking, and progress notes were being completed by nursing staff and would continue until the DON deemed appropriate to remove her from every shift (10p.m. to 6:00 a.m. and 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.) progress notes. Behavior tracking would continue every shift. Verification: Record review on 6/17/2022 of Resident #1's 6/1/2022 to 6/17 2022 MAR/TAR revealed behavior tracking occurred every shift.(10p.m. to 6:00 a.m. and 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.) (. Record review of Resident #1's 6/1/2022 to 6/17 2022 electronic progress notes revealed nurses documenting Resident #1's ADL's and behaviors every shift. Interview on 6/17/2022 at 2:30 p.m. with the DON and Regional Nurse Consultant revealed processes such as DON and designee to review documentation daily ,were in place for monitoring behavioral resident documentation. 3. The DON would monitor Resident #1's hygiene and food hoarding behaviors, daily, during regular business hours, and write a progress note. This would continue daily for 2 weeks and randomly thereafter or when concerns were identified [TRUNCATED]

Based on interview, observation, and record review the facility failed to not employ individuals who have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Staff Member A was working in the facility as a charge nurse with an inactive/ expired nursing license and had no yearly background check or license verification in her employee file; Staff Member A had disciplinary action against her nursing license for abuse of residents. These failures resulted in an identification of an IJ on [DATE] at 6:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of no actual harm with a potential for more than minimal harm with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. These failures placed residents at risk for abuse and neglect, emotional injury, and psychological harm. The findings were: Record review of Staff Member A's employee file revealed she was hired in February of 2019 and the facility had not checked her background since [DATE]. Record review of Staff Member A's Green File Checklist (employee file checklist) dated [DATE] revealed reference verification was left unchecked, which indicated Staff Member A did not have her references checked upon hire. Record review of Staff Member A's employee file revealed she had not had her EMR/NAR registry checked by the facility since [DATE]. Record review of Staff Member A's record of employee counseling dated [DATE] revealed she was counseled regarding abuse, neglect, and exploitation which described Staff Member A standing outside a resident room (unnamed) being unprofessional and viewed as yelling and screaming at the resident. Further review revealed Staff Member A did not think her actions would have been a cause for the potential harm of a resident. Record review of Staff Member A's disciplinary action orders from the Board of Nursing dated [DATE] revealed on or about [DATE] Staff Member A was verbally abusive to a resident's husband which the Nursing Board determined was likely to cause emotional injury to the resident (unnamed). Further review revealed on or about [DATE] Staff Member A was verbally abusive to another resident (unnamed) and the Board of Nursing determined Staff Member A's conduct was likely to cause emotional injury to the resident and could have interfered or disrupted the resident's treatment. Further review revealed the Board of Nursing felt the evidence received was sufficient to prove Staff Member A violated laws and disciplinary action would take place against her license and Staff Member A agreed to complete remedial education courses ordered by the Board of Nursing within one year of the orders (effective on [DATE], and Staff Member A signed the notarized orders on [DATE]. Record review of Staff Member A's nursing license report dated [DATE] revealed her license status was delinquent (inactive due to a failure to renew) as of [DATE]. Further review revealed a disciplinary action placed by the Board of Nurse Examiners on Staff Member A's nursing license on [DATE]. Record review of Resident #1's face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 11 which meant Resident number one had a moderately impaired cognition status (has trouble learning new things but could still participate in everyday activities. Further review revealed Resident #1 depended on staff members for her activities of daily living. Record review of Resident #1's care plan dated [DATE] revealed she needed assistance from staff with activities of daily living (eating, getting dressed, and toileting) with interventions which included explaining all procedures, conversations with care, and not rushing the resident during care. In an interview on [DATE] at 1:10 p.m. the DON revealed Staff Member A worked in the facility as a full-time charge nurse on the evening shift and was scheduled to work the floor starting at 2:00 p.m. The DON denied Staff Member A had an inactive nursing license or any disciplinary action against her nursing license. In an interview on [DATE] at 2:00 p.m. the ABOM revealed she oversaw employee files and running background checks, employee misconduct registry checks, and checks for the licensure status of any licensed staff, such as nurses, in the facility. The ABOM confirmed Staff Member A's employee file had no documented evidence of a background check since 2019, and revealed she was not aware EMR/NAR checks were supposed to be completely yearly on employees until recently. The ABOM confirmed Staff Member A did not have documented evidence in her employee file of her nursing license being verified until [DATE] when the ABOM noticed it was missing from the file. The ABOM revealed if she looked up a person's nursing license online which read not active or delinquent (expired due to a failure to renew) usually no one reviewed it after her, even when she tried to report it to the current or previous DONs. The ABOM revealed nurses should not work as charge nurses in the facility without active licenses to practice. The ABOM revealed she was unsure of the regulations or facility expectations regarding employee files and periodic checks for background, employee misconduct registry, or license verifications. In an interview on [DATE] at 2:20 p.m. MA G revealed Staff Member A was the charge nurse on the hall she worked for at least the past year. MA G revealed during the evening shift in the facility Staff Member A was the only assigned charge nurse on the hall when they were scheduled as full-time employees in the facility. In an interview on [DATE] at 2:45 p.m. the Administrator revealed she was ultimately in charge of ensuring employee files were in compliance, including background and licensure verification checks, but she did not know what the facility's corporate company expected from her for the monitoring of compliance of employee files. When asked how she monitored compliance of the employee files for background checks, license verifications, and EMR/NAR checks, the Administrator said, good question, and did not provide an answer. An observation on [DATE] at 3:10 p.m. revealed Staff Member A wore a facility name tag with LVN on listed as her job title. In an interview on [DATE] at 3:15 p.m. Staff Member A revealed she worked full-time in the facility as a charge nurse and provided care to residents on the facility's evening shift scheduled from 2:00 p.m. to 10:00 p.m. When asked about her nursing license status Staff Member A revealed it was active. Staff Member A revealed she had renewed her license in 2020, and she usually verified the status of her license using her mobile cell phone. Staff Member A searched her phone and confirmed her nursing license status was listed as inactive as of [DATE]. Staff Member A could not explain why her nursing license was not active, and confirmed she had worked in the facility as a full-time charge nurse since [DATE] and provided care to residents which included assessments, taking orders from doctors, diabetic care, and insulin injections, and caring for residents nursing needs. Staff Member A confirmed the Board of Nursing placed disciplinary action on her nursing license in response to allegations against her of abuse but revealed she had only completed part of the orders from the Board of Nursing. Staff Member A revealed she had not checked the status of her nursing license since she thought she had paid to renew it, Staff Member A also confirmed she had a disciplinary action from the facility for not informing them of the disciplinary action against her license and a facility counseling (write-up) over abuse and neglect, but could not recall when. Staff Member A confirmed it was illegal to practice nursing without an active nursing license. An observation on [DATE] at 3:45 p.m. revealed Staff Member A still had possession of the nursing cart keys and was working her assigned floor in the facility as a charge nurse. In an interview on [DATE] at 3:48 p.m. Staff Member A revealed she had just informed the ADON of her inactive nursing license and the ADON responded we don't have anyone to cover you (on the floor). Staff Member A revealed she went back to her assigned floor to continue her shift at that time. In an interview on [DATE] at 3:55 p.m. Resident #1 was alert and oriented to herself, the facility, and the time, Resident #1 described Staff Member A's description accurately. Resident #1 revealed Staff Member A had not been good to her and was onto her constantly, Resident #1 further revealed Staff Member A was very rude to her and she was afraid of Staff Member A, but she had not reported her feelings to the facility for an unknown reason. Resident #1 became tearful and would not elaborate on why she was afraid of Staff Member A, Resident #1 stopped the interview. In an interview on [DATE] at 4:13 p.m. the ABOM revealed when she checked license verifications on the computer and usually no one reviewed the status of the licenses. The ABOM revealed she had reported Staff Member A's license status which included being expired and had disciplinary action ordered by the Board of Nursing to 2 past and the current DON (the ABOM revealed she reported Staff Member A's licensure status to the DON on [DATE]), but nothing had been done to address it. The ABOM revealed she had not reported Staff Member A's nurse licensure status to the Administrator. An observation at the facility's 300 hall nurses' station on [DATE] at 4:20 p.m. revealed Staff Member A gave the nursing cart keys to another nurse on duty and left the facility. Record Review of Staff Member A's timesheet dated [DATE] revealed she clocked in to work at 1:59 p.m. and clocked out of work at 4:08 p.m. In an interview on [DATE] at 5:15 p.m. the DON stated, I'll be honest . the ABOM showed it [Staff Member A's licensure information] to me recently (before the investigator's entry), but I did not understand the Board of Nursing orders. The DON confirmed she had not acted of Staff Member A's inactive nursing license until [DATE], after it was brought to the facility's attention by the State Investigator. In an interview on [DATE] at 2:30 p.m. the Administrator confirmed she was ultimately responsible for ensuring the employee files were in compliance to include background checks, EMR checks, and licensure verifications, but was unaware Staff Member A had an expired license or any disciplinary action against her license for abuse until [DATE]. The Administrator revealed if a staff member had an inactive license they should not be allowed to work in the licensed capacity in the facility. The Administrator revealed she and the DON were not aware of Staff Member A's expired nursing licensure or Board of Nursing orders on Staff Member A's license until a couple days ago, the day before you got here ([DATE]). The Administrator revealed the only reason she could think for Staff Member A being on the schedule as a charge nurse even after the facility was made aware of her expired licensure status was because they were short-staffed. The Administrator said nurses practicing in the facility without an active license was dangerous to the residents who lived there because something bad could happen under the unlicensed staffs care, but I don't want to think about what could have happened. The Administrator revealed after she and the DON were made aware of Staff Member A's inactive nursing license the DON planned to talk to Staff Member A about why she had not renewed her nursing license, but then the current investigation started, and the DON never spoke to Staff Member A. The Administrator confirmed Staff Member A worked as a charge nurse on [DATE] evening shift. The Administrator revealed the ABOM worked in the facility before she started and she assumed the ABOM kept the employee files compliant, and she never checked behind the ABOM to ensure background checks, EMR/NAR checks, or licensure verifications were completed once a year. In an interview on [DATE] at 3:15 p.m. the ADON revealed Staff Member A came to her on [DATE] sometime before 4:00 p.m. and told her she had an expired license and she thought she needed to leave the facility. The ADON revealed she told Staff Member A to hold on while she spoke with the DON. The ADON revealed she assumed nurse licensure was behind due to the COVID-19 pandemic and had not questioned any nurse licensure statuses. In an interview on [DATE] at 2:00 p.m. the DON revealed nurses should not practice without an active license because it could be assumed the staff with an inactive license failed to complete the required continuing education to renew their license and that placed residents at risk for potential harm. Record Review of the facility's Job Description document for LVN (no date) revealed the LVN must have a valid state license to practice nursing in the facility. Record review of the facility's hiring procedures dated [DATE] revealed before an offer of employment could be made, the candidate must complete a background check, verification of past employment and a CNA/CMT registry check (NAR/EMR registry check). Record review of the facility's hiring procedures dated [DATE] revealed if the employee was a LVN it was necessary to include a copy of his/her license in the employee's file and to make sure his/her license was not expired. Further review revealed LVN licensures must remain up to date and the Department Heads must keep a file on each employee to serve as a reminder to have the employees renew licenses. Record review of the facility's Background Screening Investigations policy dated [DATE] revealed the facility would complete background checks, reference checks, and criminal conviction investigation checks on direct access employees (any person who had direct access to residents of a long-term care facility). Further review revealed for any licensed person who applied for a position which involved direct access to residents would have his/her licensing board contacted to determine if any sanctions (a threatened penalty for disobeying a low or rule) had been assessed against his/her license and if there was any information which indicated the person had been found guilty of abuse, neglect, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Staff Member A's employee timesheet dated from [DATE] to [DATE] revealed she regularly worked more than 40 hours per week in the facility as an LVN. Record review of the facility's inservice attendance sheet dated [DATE] revealed staff were trained on understanding/reporting of abuse and neglect. Further review revealed Staff Member A did not attend the training. Record review of the facility's Abuse Prevention Program policy dated [DATE] revealed residents had the right to be free from abuse and neglect. Further review revealed the facility conducted employee background checks and would not knowingly employ any person who had been found guilty of abuse, neglecting, or mistreating people. The facility Administrator was notified an IJ had been identified on [DATE] at 6:35 p.m. The IJ template was provided, and a plan of removal was requested. The following Plan of Removal was accepted on [DATE] at 5:57 p.m. Immediate action - On [DATE] at 4:00 pm, Staff member A was suspended and will be terminated from her job related to not following her stipulations from the board of nursing of taking Abuse classes. On [DATE] at 4:30 pm, the human resources clerk was terminated from her position for not following facility procedures for completing annual background and EMR/NAR checks. - On [DATE], the facility administrator reported an allegation of abuse to HHSC regarding the surveyor's concerns after speaking to a facility resident (Resident #1). A facility investigation is ongoing currently. The resident involved in the reportable allegation was provided emotional support initially on [DATE] by the director of nursing and the regional nurse consultant. Interviews have been completed by the social worker with no other concerns. An abuse and neglect in-service was started for all staff on [DATE] with a completion date of [DATE]. Any staff not receiving this training will be required to receive it before starting their next assigned shift. The identified perpetrator has been suspended and will be terminated. The facility social worker will make visits to the resident involved in the reportable allegation twice a week for two (2) weeks and randomly thereafter. The social worker will make appropriate referrals to professional counseling if deemed necessary. - On [DATE], the regional director of operations re-educated the administrator and the director of nursing on their responsibility for validating that upon hire, monthly, and annually that the appropriate checks are completed; licensed staff spreadsheet for renewals (monthly), DPS Background and EMR/NAR checks (upon hire and annually) are completed. On [DATE] at 4:30 pm, the administrator began running license verification checks on all licensed employees as well as nurse aide registry checks. This task was completed on [DATE]. On [DATE] employee misconduct registry and DPS background checks were completed on all facility staff including licensed staff. Any concerns were corrected immediately and brought to the attention of the regional director of operations. A human resources representative from a sister facility assisted the facility with this process. - Human resources will complete a DPS Background, EMR/NAR, and license verification (if applicable) on new employees and again every January, all staff will have a DPS Background and EMR/NAR completed. The facility will keep a spreadsheet with license expiration dates and human resources will check and notify the employee at the beginning of each month if their license requires renewal and follow up by re-checking for renewal. The administrator will check off by initialing all checks and reviewing the spreadsheet monthly, addressing any concerns identified. - New candidates for employment will not be hired if they have abuse stipulations on their license. Other new employee candidates with stipulations that are not related to abuse will be hired on a case-by-case basis after the approval of the regional director of operations. - The regional director of operations and the regional nurse consultant will monitor a sample of new employee's paperwork to validate that all the required checks (DPS background, EMR/NAR, and license renewal verification) during their scheduled monthly facility visits. Any concerns will be corrected immediately. - The administrator will bring any concerns to the monthly quality assurance performance improvement (QAPI) meeting for tracking, trending, and further interdisciplinary (IDT) team recommendations. Monitoring of the facility's plan of removal (POR) included: In an interview on [DATE] at 1:15 p.m. the Administrator confirmed Staff Member A had been suspended on [DATE] at 4:00 p.m. and removed from resident care and had since been terminated from employment with the facility as a charge nurse. The Administrator confirmed the facility ' s human resources clerk had been terminated on [DATE]. Record review of Staff Member A ' s Personnel Action Request form dated [DATE] revealed her termination from the facility was active on [DATE]. Record review of the ABOM ' s (human resources clerk) Personnel Action Request form revealed her termination from the facility was active on [DATE]. In an interview on [DATE] at 1:15 p.m. the Administrator confirmed she reported 2 resident concerns related to abuse to HHSC and received intake numbers, the facility investigation was ongoing. The Administrator confirmed almost all staff had been trained on A/N/E as of [DATE] and almost all licensed staff had been trained on their licensure responsibility. The Administrator revealed there were no negative psychosocial effects observed for Resident #1 related to fear Staff Member A as she had continued her regular daily routines and was comfortable with all other staff members, and the SW would be following Resident #1 twice a week for 2 weeks to assess for psychosocial changes and report them to the facility Administration and make referrals as needed. Interviews with staff members on [DATE] from 1:30 p.m. to 4:15 p.m. (interviews included- the Dietary Manager, a Laundry Staff, LVN B, LVN C, LVN D, CNA E, the Transporter, the DON, LVN F, the Wound Care Nurse) revealed they were inserviced on A/N/E and the licensed staff were able to confirm they were educated on their licensure responsibilities and demonstrated knowledge of A/N/E reporting, prevention, and identification. Record review of the facility's training attendance record dated [DATE] revealed greater than 90 percent of the facility staff had been inserviced on A/N/E. Record review of the facility ' s training attendance record dated [DATE] revealed greater than 90 percent of the licensed staff had been inserviced on their licensure responsibilities and consequences of working without an active license. Record review of the facility's investigation paperwork revealed the facility generated an HHSC incident intake on [DATE] and the investigation was ongoing. Record review of Resident #1 ' s progress note dated [DATE] revealed she was calm and participated in her daily routine without signs of any psychological/emotional stress. In an interview on [DATE] at 1:15 p.m. the Administrator confirmed she received re-education on her responsibility to ensure background checks, EMR/ NAR checks, and licensure verifications were in compliance, and demonstrated knowledge of the expectations for staff EMR/NAR checks, and licensure verifications. In an interview on [DATE] at 2:00 p.m. the DON confirmed she had also been re-educated on her responsibility to ensure background checks, EMR/ NAR checks, and licensure verifications were in compliance, and demonstrated knowledge of the expectations for staff EMR/NAR checks, and licensure verifications. . Record review of the facility's in-service attendance sheet dated [DATE] revealed the Administrator and the DON were educated on their responsibilities to ensure background checks, EMR/ NAR checks, and licensure verifications were in compliance. In an interview on [DATE] at 1:15 p.m. the Administrator confirmed licensure verification were run on all active licensed staff members, EMR/NAR and background checks were completed on all active staff members Record review of 100 percent of the facility's employee files on [DATE] revealed all EMR/NAR checks and background checks were completed and complaint. Further review revealed licensed staff had up to date licensure verifications and the earliest license expiration was noted to be at the end of [DATE], there were no concerns for expired licenses. In an interview on [DATE] at 1:30 p.m. the Administrator revealed there had been no new employees hired since [DATE], and a spreadsheet had been created with all licensed current employees and their licensure expiration dates, and each employee would be notified in the beginning of the month their licensure was set to expire to ensure they were proactive in renewing their licenses. The Administrator revealed she would be checking the spreadsheet monthly. Record review of the facility's employee licensure spreadsheet revealed employee names, their date of birth, license type, license number, and the next date of expiration. In an interview on [DATE] at 1:30 p.m. the Administration confirmed applicants would not be hired if they had anything associated with abuse on their licenses or in their backgrounds, and any concerns not related to abuse still would have to be approved by regional staff. In an interview on [DATE] at 1:45 p.m. the Administrator confirmed the regional staff visited once a month and with their visits moving forward, they would monitor a sample of new employee files to validate compliance and correct any concerns immediately. Record review of the facility ' s audit forms revealed a blank form to be used by regional staff monthly for random employee file checks (EMR/NAR, background checks, and licensure verification). In an interview on [DATE] at 1:30 p.m. the Administrator revealed the licensure spreadsheet as well as any other concerns for employee file compliance would be discussed monthly at the facility ' s QAPI meetings (no end date at this time), and any concerns would be addressed. On [DATE] at 2:47 p.m. the Administrator was notified the IJ was removed. The facility remained out of compliance at a potential actual harm with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observations, interview and record review, the facility failed to ensure residents were free from abuse for 4 (Residents #1, #2, #3, and #4) of 32 residents who resided in the secure unit reviewed for abuse, in that: 1. Resident #2 had a non-consensual sex act with Resident #1. 2. Resident #3 and #4 resided in facility's secured unit and were found alone in the unit's shower room, Resident #3's pants were down, and his penis exposed, Resident #4 was seated in front of #3. These failures resulted in identification of Immediate Jeopardy (IJ) on 10/4/20. While the IJ was removed on 10/09/2020, the facility remained out of compliance at a severity identified as no actual harm with a potential for more than minimal harm, with a scope identified as isolated while the facility continued to monitor the effectiveness of their plan of removal and the interventions put in place to ensure residents were being monitored and assessed for signs of any sexual abuse. Findings include: 1. Record review of Resident #1's face sheet, dated 10/3/20, revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed that her BIMS score of 0, indicating her cognition was severely impaired, she had disorganized thinking, and she exhibited physical behavioral symptoms towards other and other behavioral symptoms not directed at other. Resident #1 had a history of [REDACTED]. Resident #1 did not use a mobility device. Record review of Resident #1's care plan, dated 9/29/20, revised dated 10/3/20 at 9:32 a.m. revealed Problem: behavioral symptoms, resident had been having sexual contact with male residents. Goal: Resident will not have unwanted advances or sexual contact with male residents. Intervention: per family: attempt to stop sexual contact situations prior to behavior. If entering room and resident was already engaging in consensual sexual behavior contact, provide privacy and document incident. Problem: behavior problem related to high risk sexual behavior and attempt to have intercourse with male residents. Goal: will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review. Interventions: provide a program of activities that is of interest and accommodates resident status to remove from high risk situation and refer to psychiatrist/psychologist as needed and administer medications as ordered and monitor for side effects, effectiveness. Problem: behaviors-resident at times exhibits behaviors in which she is very friendly with male residents. In the past this had been seen as flirtatious by others, or that they have misunderstood this to be flirtatious causing conflict within social relationships. Goal: Resident will have had fewer episodes of these behaviors reported by the next review date; AEB(as evidenced by) visual observation by staff, and fewer reported social/relationship conflicts related to these behaviors. Intervention: Administer medications as ordered, monitor for effects/effectiveness, and report to MD prn, intervene as need to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to another location as needed, encourage resident to use healthy boundaries, monitor behavior episodes and attempt to determine underlying cause, documents behavior and potential causes and refer to psychiatrist/psychologist as needed. Record review of Resident #2's face sheet, dated 10/3/20, revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed in his BIMS score was 3, indicating his cognition was severely impaired. Further documentation on the MDS revealed Resident #2 exhibited verbal behavior symptoms directed toward others and other behavioral symptoms not directed toward others. Record review of Resident #2's care plan dated 9/16/20 revealed problem: Resident resides in secure unit and is at risk for injury from wandering in an unsafe environment related to dementia, AEB impaired safety awareness, Resident is at risk for injury form others while residing in secure unit due to altered cognition. Intervention to monitor and intervene as needed to protect the rights and safety of resident and remove from situation and take to another location as needed. Problem: Behavioral symptoms, behavior problems related to: sexual behaviors toward others. Interventions-intervene as needed to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to another location as needed, refer to psychiatrist/psychologist as needed, observe resident frequently and observe location, keep in common area when out of bed. Record review of Resident #1's nurse note dated 9/28/20 at 6:33 p.m. by LVN C revealed this nurse was alerted by the other nurse on the floor that she heard yelling coming from the back-dining room, she went to look and saw a female resident cringing and, yelling, No! No! leave me alone!. When the nurse walked to the dining area, Resident #2 had his penis out and was attempting to have sexual intercourse with Resident #1. In an interview on 10/2/20 at 5:00 p.m., with LVN C stated she worked in the secure unit and stated Resident #1 and Resident #2 were in a sexual relationship two weeks ago and they were both consenting adults. {there were no documents in Resident #1 and #2 records stating they were consenting adults}. Further interview with LVN C revealed that Resident #1 and Resident #2 had hypersexuality issues. Further interview with LVN C revealed, Resident #2, had been destructive with facility property, he would get naked, pull his pants down and was receiving hormonal medication ([MEDICATION NAME] 1mg by mouth every day and [MEDICATION NAME] 125mg delayed release oral sprinkle capsule one by mouth twice a day.) LVN C stated the staff re-directed Resident #1 and Resident #2 immediately when found. Further interview with LVN C revealed she was aware that both Resident #1 and Resident #2 were cognitively impaired, as evidenced by their BIMS scores. Observation on 10/2/20 at 5:30 p.m., revealed Resident #1 and Resident #2 both resided in the secure unit, they were both ambulatory and not interview able. Further observation revealed Resident #2 was sleeping in his room and Resident #1 was sitting in the back room with other residents and staff. In an interview on 10/2/20 at 5:17 p.m., CNA B stated she worked in the secure unit and at times, she would see Resident #2 take his penis out of his pants in front of Resident #1. CNA B stated she would ask Resident #2 to pull his pants up. In an interview on 10/3/20 at 12:06 p.m., LVN C stated CNA E reported that he caught 9/28/2020 .Resident #2 with his genitalia out and his penis in Resident #1's anal area. He stated he did not know if Resident #2 had penetrated Resident #1's anus or vagina. LVN C stated that she separated the residents and Resident #1 became aggressive by hitting staff and walking fast away from staff. LVN C reported the incident to the DON and made a nurse note on 9/28/2020 at 6:20 p.m. in the chart. The LVN C stated she did not assess Resident #1, did not send her to the hospital, did not call the police. However, she did call the families of both residents. LVN C stated she talked to Resident #1 family and the family member stated they were aware of her history of sexual behavior and to let her continue if she was in a sexual relationship with another resident. LVN C stated both Resident #1 and Resident #2's care plans had post incident directions to visually check each resident every 15-minutes for 24 to 48 hours. In an interview on 10/3/20 at 12:53 p.m., CNA E stated that CNA B had told him Resident #2 was raping Resident #1 on 9/28/2020 6:20 p.m., CNA E did not witness the two residents engaging in sex. CNA E stated on 9/30/2020 Resident #1 was incontinent, her perineum area was red, and she did not seem as active as she normally was. CNA E stated Resident #1 was continent prior to this incident. CNA E stated he reported the sexual encounter of Resident #1 and Resident #2 that had occurred on 9/28/2020 to LVN F. CNA E stated he was not sure if he reported the redness to a nurse and he had not witnessed Resident #2 and Resident #1 having sex. In an interview on 10/3/20 at 1:53 p.m., LVN F stated that Resident #2 had sexual behaviors since he was admitted to the facility on the secure unit. LVN F stated, the moment Resident #2 moved into the secure unit, Resident #2 began seeking Resident #1. LVN F stated she was not a witness to the sexual inappropriateness of Resident #1 and Resident #2 that occurred on 9/18/2020 at 6:20 p.m. LVN F stated when she came back to work on 9/29/20, Resident #1 and Resident #2 were on 15-minute checks because they were caught together, and staff re-directed them. LVN F stated on 10/3/20, a CNA (unknown) found Resident #1's clothing in Resident #2's bathroom, tucked behind the toilet. This was not reported by the previous shift. LVN F usually gets daily resident information by looking at the resident charts. LVN F stated, Resident #2 had new orders since she had been off to increase [MEDICATION NAME] and add an additional hormone medication. LVN F stated she was not sure if an incident report was completed for Resident #1 and Resident #2, due to the sexual incident. LVN F stated the skin reports were completed on each resident once a week by the nurses. LVN F stated the family of Resident #1 had told the staff that if Resident #1 was involved in a sexual encounter to let her do it. LVN F stated she recently found out Resident #1 had a [DIAGNOSES REDACTED].#1's face sheet and had reported it to the DON for direction. Upon reporting, LVN F said the DON changed the subject. LVN F stated she noticed Resident #1 had frequent incontinent episodes about 2 weeks ago but could not remember how many. LVN F stated she was not trained for residents with sexual seeking behaviors before she came to the secure unit. In an interview on 10/3/20 at 2:40 p.m., the DON stated she had started working in April 2020. The DON revealed she was aware of the Resident #1's and Resident #2's sexual seeking and behavior diagnoses. The DON stated Resident #1 had several incidents with another resident in the past, which she could not remember name and had moved Resident #1 to the secure unit due to increase in agitation. The DON stated no incident report was done for the incidents between Resident #1 and Resident #2 because Resident #1's family said it was ok. The DON stated she did not notify the police or the State agency to report these two incidents with Resident #1 and Resident #2. The DON stated she was aware of Resident #2 sexual behaviors since he was admitted on [DATE] and placed him on the secure unit. When asked about protecting Resident #1 from sexual abuse, the DON stated that Resident #1 was participating and consenting. The DON stated she was not aware of the notation in the nurses notes that documented that Resident #1 was overheard saying no and to stop. The DON stated she did not review the notes and it would be impossible to look at every resident note. The DON stated staff had told me Resident #1 and Resident #2 were laying down together and naked. {Record review of Resident #1 and #2 medical records found no signed documents by family members regarding consensual sex between Resident #1 and Resident #2.} In an interview on 10/3/20 at 2:58 p.m., the MDS Nurse G, and the DON and Administrator present, MDS Nurse G stated Resident #1 and Resident #2's sexual behavior were consensual and both were enjoying themselves. The MDS Nurse G stated the Responsible party of Resident #1 revealed it was ok and maybe this was their way of comforting themselves. The DON and Administrator then stated they were not aware of any anal sex or inappropriateness. There was no documentation in Resident #1 or Resident #2's chart legally granted the decision-making power related to sexual activity for both residents. In an interview on 10/3/20 at 4:42 p.m., the DON stated she was not aware that Resident #1 had a [DIAGNOSES REDACTED].#2 in the secure unit because, he was an elopement risk. DON was asked if she felt that she placed the female residents at risk, knowing Resident #2's [DIAGNOSES REDACTED].#2. In an interview on 10/3/20 at 4:45 p.m., CNA B stated she witnessed Resident #1 and Resident #2 in bed under the covers with Resident #2 penis out and she reported the incident to an unknown nurse and then went back to work. In an interview on 10/3/20 at 5:19 p.m., CNA H, stated she did not witness Resident #1 and Resident #2 having sex but they were both being monitored for sexual behaviors. CNA H said she saw Resident #1's clothing in Resident #2's private bathroom on 10/3/20 and she felt this was because Resident #1 had gone into Resident #2's room. In an interview on 10/4/20 at 2:16 p.m. LVN I stated, she worked on the secure unit. She revealed that she has not had specific training related to residents with sexual behaviors who are cognitively impaired. LVN I also said that she worked on the secure unit. She stated that she had worked at facility for over a year. She revealed Resident # 2 was on the secure unit and she had not witnessed him having any sexual behaviors but was aware that he had a history of [REDACTED].#2 had sexual behaviors and could easily attack the vulnerable female, secure unit residents. LVN I stated that she and the other staff watched Resident #2 closely. LVN I said that she did not understand why he was placed in the secure unit when he had a history sexual behavior and diagnoses. LVN I stated that the staff were concerned that Resident #2 was allowed to be in the secure unit because of his sexual seeking behaviors. LVN I said that she could not remember if she had reported any incidents with Resident #2, but she felt that management already knew about his incidents. When she was asked how she knew that management was aware, LVN I stated, because the care plan team has meetings and it has to be brought up in there. In an interview on 10/4/20 at 2:20 p.m. ADON N said, I do not know much about what is going on at this time. I have been here two weeks and I am currently covering the nurse for the secure unit until she gets here. ADON N stated that since he was new he did not know all of the routines. There had been a nurse call in sick, so he stated he was working until a replacement got there. He was going to receive report from the off going day nurse. In an interview on 10/4/20 at 3:00 p.m., CNA J stated, she worked on the secure unit and has worked at the facility for about 6 months. She stated that she had heard that there had been some issues of sexual behavior with Resident #2, but she had not seen any. She stated that she is fearful for the female residents because Resident #2 cannot always be watched when the staff are doing other jobs duties. CNA J further said that she had no special training for secure unit related to sexual behaviors of residents. Record review of Facility Event Summary Report dated 8/1/20 to 10/3/20 revealed no documentation for Resident #1 or Resident #2 regarding sexual encounter on 9/28/20. Further review of Facility Summary Report revealed Aggressive behavior-sexual behavior by Resident #3 with a female resident on 9/6/2020. In an interview on 10/4/20 at 6:00 p.m. the Administrator and DON both said the Facility Event Summary Report should be reviewed by the Administration team daily. The Administrator confirmed that she had not looked at it daily. Further investigation revealed the DON stated that she had not looked at it daily either. The Administrator and DON both stated the Facility Event Summary Report is a tool that identifies events and incidents that are out of the ordinary for the residents. If an entry is not on the list, then the nurse did not create an incident for that event. The Administrator and DON confirmed that LVN C did not create an event or incident on 9/28/20 for Resident #1 and Resident #2's sexual encounter. Observation on 10/5/2020 at 2:45 p.m., surveyor observed Resident #1 walk from the center dining room in the secure unit , towards the maintenance man ,who was standing at the nurses station. She approached him and stated hey cutie. He stepped back and politely stated hello. Resident #1 giggled and at the same time the maintenance man left the secure unit. Interview on 10/5/2020 at 2:50 p.m. with LVN F stated, see this is how she (Resident #1) does, she sees a man and she goes straight to him. Observation on 10/5/2020 at 3:00 p.m. revealed Resident #1 walking with sitter beside her. Resident#1 easily agitated when redirected from going into other resident's rooms. In an interview on 10/5/20 at 3:00 p.m. CNA H stated she was providing a 1:1 for Resident #1 to observe her and redirect her, if needed. CNA H stated that she was observing for any signs of sexual seeking behavior. CNA H said that she felt that management would not listen to staff on the secure unit. CNA H stated that she felt that whenever the CNA's would tell the nurse of behaviors of the residents, nothing was done. CNA H said that the staff in the secure unit did not have any special training /in-services done on how to work or handle residents with sexual behaviors. She stated general in-services are done but not specific ones for secure unit residents and their issues. Record review on 10/7/2020 at 11:00 a.m., of facility staff training revealed no specific training related to sexual behaviors of residents in the secure unit for staff. Observation on 10/6/2020 at 11:30 a.m. of secure unit revealed residents in wheelchairs in main area with staff reminding residents to continue social distance. Observed Resident #1 walking in hall with sitter walking behind her. Resident carrying a stuffed cat. In an interview on 10/08/20 at 4:20 p.m., LVN C stated, she had recalled an incident of sexual behavior with Resident #1 and Resident #2. LVN C stated the CNA.'s told her about it. LVN C stated she could not remember which CNA's had told her or what date it was. LVN C stated she did not do any assessment on either Resident and replied, I am new at working in nursing homes and I did not really know what to do. I had another nurse here to tell me who to call so I called the family members and the physician of both Residents. LVN C further said, I have not been trained on sexual behaviors with residents. LVN C stated that she comes to work, tries to do her job and then go home. She stated that she has not asked for any training on sexual behaviors with residents. She stated, I really couldn't tell you anything about care plans, I am so busy. 2. Record review of Resident #3's undated face sheet revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 1, which indicated a severe cognitive impairment. Record review of Resident #3's care plan, dated 9/15/20, revealed Resident #3 had cognitive loss/dementia and was unable to make daily decisions without cues /supervision due to dementia. On 6/12/20 the care plan revealed that Resident #3 have behavior symptoms, related to physical aggression to others (hitting, kicking). No sexual behaviors documented. Record review on 10/5/20 of Resident #4's undated face sheet revealed admission date of [DATE] with [DIAGNOSES REDACTED]. Record review on 10/5/20 of Resident #4's Annual MDS dated [DATE] revealed a BIMS score of 1, which indicated a severe cognitive impairment. Record review of Resident #4's care plan dated 9/15/20 revealed the resident was at risk for COVID due to non- compliance with wearing his face mask when out of his room. Problem area of falls was revised 8/26/20 resident had experienced fall when ambulating in dining room without her walker. No sexual behaviors documented. Record review of Resident #3's nurse notes, dated 9/6/20, at 8:02 p.m. by Nurse C, Resident was found in shower room with female resident. They were facing each other. Staff did not see anything had happened. Told him to leave shower room and assisted female out of shower room to dining room. 15-minute checks done during shift of Resident #3. There was no noted documentation of notification to family, physician or administration and an incident report was not generated. Record review of Resident #4's nurse notes, dated 9/6/20, revealed, Resident was found in the shower room with a male resident #3. CNA E and CNA Q went in to wash their hands when they discovered (Resident #3) with his pants down and (Resident #4) sitting on a trash can in front of (Resident #3). (Resident #3) immediately ran out of the shower room after pulling his pants up as per CNA E (Resident #4) would not talk at the time of the incident. Resident #3 told the CNA's that (Resident #4) raped him. CNA Q said there was no sign of Resident #3 resisting. Notes stated would keep a close watch on these two residents (Resident #3 and #4) and try to talk to Resident #4 when there is privacy. No follow up note was in Resident #3's file regarding incident after 9/6/20. In an interview on 10/2/20 at 5:17 p.m., CNA B stated she worked in the secure unit. CNA B further revealed that there were two other residents in the secure unit (Resident #3 and Resident #4) that had a sexual encounter with each other. CNA B stated she did not know of Resident #3 and Resident #4 had been reported to Administration. In an interview on 10/3/20 at 12:06 p.m., LVN C stated she was aware of two other residents (Resident #3 and Resident #4) that also had sexual behaviors. Observation on 10/4/2020 at 2:30 p.m. revealed Resident #3 in outside west smoking area , with staff in attendance. In an interview on 10/4/2020 at 2:16 p.m. LVN I stated she had worked in the secure unit. She stated that she has been working there over a year. LVN I revealed Resident #2 was on the 100 hall and that she had not witnessed him having any sexual behaviors but was aware that he had. LVN I stated that she was also concerned Resident #3, who is in the secure unit, had sexual seeking behaviors and could easily attack vulnerable female residents in the secure unit. LVN I stated that she was aware of Resident #3 having sexual activities with female Resident #4 but could not recall the date. LVN I stated that she and the staff watched Resident #3 closely in the secure unit because staff was aware that Resident #3 had sexual seeking behaviors. LVN I stated, I do not understand why he (Resident #3) is here if he had sexual behavior diagnosis. LVN I stated that she could not remember if she had reported the incident to the DON or Administrator, but she felt that they knew. In an interview on 10/4/2020 at 5:40 pm with Administrator stated there was no report sent to HHSC regarding a sexual encounter with Resident #3 and Resident #4. In an interview on 10/3/20 at 1:53 p.m., LVN F stated, she was not trained to work with residents who have sexual seeking behaviors, before she came to the secure unit. In an interview on 10/4/20 at 2:16 p.m., LVN I stated she worked on secure unit. She revealed that she had not had specific training related to residents with sexual behaviors who are cognitively impaired. LVN I also said that she worked on the secure unit. She stated that she had worked at facility for over a year. In an interview on 10/4/20 at 3:00 p.m., CNA J said that she had no special training for secure unit related to sexual behaviors of residents. In an interview on 10/5/20 at 10:00 a.m. the Administrator stated that there is no special training for behaviors different for secure unit vs the general population. Administrator further revealed that the previous ADON had in-services with staff, but the evidence of documentation of in-services to provide for surveyor review could not be found. Facility did not provide evidence of documentation of in-services regarding special training for sexual behaviors in the secure unit to surveyor before exit on 10/9/2020. Interview on 10/5/2020 at 11:10 a.m. with ADON M revealed she did not know if there was specific training on the secure unit related to residents with sexual behaviors who are cognitively impaired. Interview on 10/5/20 at 2:45 p.m., Medication Aide K stated, she had not been trained for residents with sexual type behaviors and worked in the secure unit. In an interview on 10/5/20 at 3:00 p.m. CNA H stated the staff in the secure unit did not have any special training /in-services provided to them on how to work or handle residents with sexual behavior. She stated general in-services were done but not specific ones for secure unit residents and their issues. In an interview with DON on 10/7/2020 at 10:00 a.m., stated there is no specific training for staff related to sexual behaviors of residents on the secure unit. In an interview with the Regional RN on 10/7/2020 at 10:00 a.m., stated there is no specific training for staff related to sexual behaviors of residents on the secure unit. In an interview with Administrator on 10/7/2020 at 10:00 a.m., stated there is no specific training for staff related to sexual behaviors of residents on the secure unit. In an interview on 10/08/20 at 4:20 p.m., LVN C said, I have not been trained on sexual behaviors with residents. Record review of facilities All Staff Binder and Nurse in service binder revealed no specific in service or training for staff on secure unit related to sexual behaviors. Record Review of facility Nursing Services Policy and Procedure Manual dated 2001 -Revised 4 /2010 revealed Titled: Staff Development Program -All personnel must participate in initial orientation and regularly scheduled in-service training classes. Section 1. Staff Development is defined as initial orientation, followed by regularly scheduled in service training programs . 3. The primary purpose of our facility's in-service training program is to provide our employees with an in-depth review of our established operational policies and procedures, their positions, methods and procedures to follow in implementing assigned duties, and to provide up to date information that will assist in providing quality care. Record review of facility policy: Titled Abuse and Neglect -Clinical Protocol dated 2001 with revision 2014, Section 1. Titled Assessment and Recognition. 1. The nurse will assess the individual and document related findings. Assessment data is to include: Injury assessment. 2. The nurse will report findings to physician. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Administrator was notified of an IJ on 10/04/20 at 9:50 p.m. and was given a copy of the IJ Template and a Plan of Removal was requested. The Plan of Removal accepted on 10/6/20 at 9:59 a.m. included the following: {Written as quoted from Plan of Removal provided by facility.} The administrator notified the Kerrville police department (intake # 049) on October 5, 20{20} regarding the sexual incident between two residents at the facility. The female victim's responsible party and physician were notified of this incident as well as the perpetrator's responsible party and physician. A full body assessment was performed on the female resident on 10/4/2020 to identify any problems and no redness or swelling of the genital or anal area was identified. Alternate placement referral for the male perpetrator to a sister facility that has all male secured unit residents was completed on 10/5/2020. The physician at the receiving facility will assess the male resident for the STD ([MEDICAL CONDITION]) that may have been transmitted through sexual contact with the female victim. The facility is assessing where a door might be placed to create two separate secured units with a female and male separate population area; this will occur on 10/6/20. The female resident will be kept in line of sight until the door can be placed and if any concerns are identified will be placed on 1:1 with facility staff. The physician ordered a urinalysis that was negative on 9/29/2020. The facility will place the resident on a toileting program to improve incontinence with the results reviewed weekly by the director of nursing/designee and revised as necessary. Psychological services (Psychological services are direct services performed by a licensed psychologist, as specified by state law and licensure. Psychological services include evaluation, psychotherapy, consultation, and behavioral treatment) have been solicited to come and assess and provide emotional support to the resident before 10/9/2020. Any concerns will be brought to the immediate attention of the administrator. Secured unit staff will be trained to conduct a huddle at the beginning of each shift and as needed to discuss behaviors with all secured unit residents requiring extra monitoring and rounding. A form will be used to document huddle attendance and the process will be monitored by the director of nursing and unit managers. Administrator stated that Resident #1 and Resident #2 will be monitored, and staff would intervene, if behaviors occurred again. Administrator said the staff will be educated. Administrator further said the residents would be allowed privacy and both families was ok with that plan. The Administrator stated they were going to work on discharging Resident #2 due to numerous behaviors. A full-body assessment was completed on all female residents residing on the secured unit by the nursing administrative staff and by the licensed nursing staff completed on October 4, 2020. Any concerns from those assessments will be reported to HHSC, the responsible parties, and the physician. On 10/5/2020, the administrator and the director of nursing met with the nursing staff from the secured unit to re-educate them on identifying predatory sexual behaviors and reporting immediately to the administrator when there are any concerns. Included in this training will be the immediate notification of physician and responsible party which will be reviewed for completion by the administrator. Staff will be educated that fifteen (15) minute checks are not appropriate for monitoring residents with exacerbations of behaviors. Residents identified with sexual exacerbations or another concerning behaviors will be kept either in line of sight or 1:1 oversight until the behavior is under control as deemed by the administrative team. Any secured unit staff member not initially receiving this information will be required to meet with the administrator/director of nursing before starting their next assigned shift. Care plans were reviewed and updated on 10/5/20 to reflect any predatory sexual behaviors. On 10/4/20, the Regional Director of Operations re-educated the administrator and t (TRUNCATED)

Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse were thoroughly investigated, failed to take corrective action and prevent further potential abuse and failed to report results of investigations in accordance with State law for 4 (Resident #1, #2, #3 and #4) of 4 residents reviewed for abuse, in that: 1. LVN C failed to investigate and report Resident #1 sexual abuse encounter by Resident #2 and Resident #4 sexual encounter by Resident #3 to the Administrator. 2. The Administrator failed to investigate and report Resident #1 sexual abuse encounter by Resident #2 and Resident #4 sexual encounter by Resident #3 to HHSC and local authorities. This deficient could place residents at risk for physical and psychosocial harm, decline in health and/or death. On 10/9/20 at 9:21 a.m., the Administrator, Regional Director of Operations, Regional Nurse Consultant, and DON were informed the IJ was removed. While the IJ was removed on 10/09/2020, the facility remained out of compliance at a severity identified as no actual harm with a potential for more than minimal harm, with a scope identified as isolated while the facility continued to monitor the effectiveness of their plan of removal and the interventions put in place to ensure residents were being monitored and allegations of abuse were being thoroughly investigated and reported. Findings include: 1. Record review of Resident #1's nurse notes showed that LVN C, who was on duty on 9/28/20, did not report to management an allegation of sexual abuse between Resident #1 and Resident #2. Nurse's notes dated 9/28/20 revealed the sexual encounter between Resident #1 and Resident #2; however, there was not detail or follow up by LVN C for assessments and signs of any sexual abuse. In an interview on 10/08/20 at 4:20 p.m., LVN C stated, she had recalled an incident of sexual behavior with Resident #1 and Resident #2. LVN C stated the CNAs told her about it. LVN C stated she could not remember which CNAs had told her or what date it was. LVN C stated she did not do any assessment on either Resident and replied, I am new at working in nursing homes and I did not really know what to do. I had another nurse here to tell me who to call so I called the family members and the physician of both Residents. LVN C further said, I have not been trained on sexual behaviors with residents. LVN C stated that she comes to work, tries to do her job and then go home. She stated that she has not asked for any training on sexual behaviors with residents. She stated, I really couldn't tell you anything about care plans, I am so busy. Record review of Resident #1's face sheet dated 10/3/20 revealed she was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed in section cognitive patterns was documented severely impaired, section on [MEDICAL CONDITION] was documented as disorganized thinking, section on Behavior was documented she exhibited physical behavioral symptoms towards other and other behavioral symptoms not directed at other, and wandering, section Functional Status was documented as requiring supervision, section Functional Limitation in Range of Motion was documented as no impairment, section on Mobility Devices was documented as not requiring, section on Bladder and Bowel was documented as always continent, Record review of Resident #1's care plan dated 9/29/20, revised dated 10/3/20 at 9:32 a.m. revealed Problem: behavioral symptoms, resident had been having sexual contact with male residents. Goal: Resident will not have unwanted advances or sexual contact with male residents. Intervention: per family: attempt to stop sexual contact situations prior to behavior. If entering room and resident was already engaging in consensual sexual contact, provide privacy and document incident. Problem: behavior problem related to high risk sexual behavior and attempt to have intercourse with male residents. Goal: will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review. Interventions: provide a program of activities that is of interest and accommodates resident status to remove from high risk situation and refer to psychiatrist/psychologist as needed and administer medications as ordered and monitor for side effects, effectiveness. Problem: behaviors-resident at times exhibits behaviors in which she is very friendly with other male residents. In the past this had been seen as flirtatious by others, or that they have misunderstood this to be flirtatious causing conflict within social relationships. Goal: Resident will have had fewer episodes of these behaviors reported by the next review date; AEB visual observation by staff, and fewer reported social/relationship conflicts related to these behaviors. Intervention: Administer medications as ordered, monitor for effects/effectiveness, and report to MD prn, intervene as need to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to another location as needed, encourage resident to use healthy boundaries, monitor behavior episodes and attempt to determine underlying cause, documents behavior and potential causes and refer to psychiatrist/psychologist as needed. Record review of Resident #1's progress note dated 9/28/20 at 6:33 p.m. by LVN C revealed this nurse was alerted by the other nurse on the floor that she heard yelling coming from the back-dining room, she went to look and saw a female resident cringing and yelling No! No! leave me alone! When the nurse walked to the dining area, Resident #2 had his penis out and was attempting to penetrate Resident #1's anus. Residents were directed, and family called. They will be put on 15-minute checks for 24 to 48 hours. Record review of Resident #2's face sheet dated 10/3/20 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's telephone order dated 10/2/20 revealed to stop [MEDICATION NAME] 125 mg 2 tabs by mouth twice a day and start [MEDICATION NAME] 125 mg 4 tabs by mouth twice a day for mood-high risk sexual behavior and start [MEDICATION NAME] 5 mg by mouth for sexually inappropriateness-high risk heterosexual behavior. Record review of Resident #2's Quarterly MDS dated [DATE] revealed in section cognitive patterns was documented as severely impaired, section Behavior was documented as exhibited verbal behavior symptoms directed toward others and other behavioral symptoms not directed toward others. Record review of Resident #2's care plan dated 9/16/20 revealed problem: resident resides in secure unit and is at risk for injury from wandering in an unsafe environment related to dementia, AEB impaired safety awareness, Resident is at risk for injury form others while residing in secure unit due to altered cognition. Intervention to monitor and intervene as needed to protect the rights and safety of resident and remove from situation and take to another location as needed. Problem: Behavioral symptoms, behavior problems related to: sexual behaviors toward others. Interventions-intervene as needed to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to another location as needed, refer to psychiatrist/psychologist as needed, observe resident frequently and observe location, keep in common area when out of bed. Awareness and age-related debility and wandering, section Functional Status was documented as supervision to limited assistance, section Balance During Transitions and Walking was documented as not steady, only able to stabilize with staff assistance for walking, moving from seated to standing position, turning around, moving on and off toilet, surface to surface transfer, section mobility devices not required. Record review of Resident #3's face sheet on 10/5/20 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS on 10/5/20 dated 9/12/20 revealed a BIMS score of 1. This indicated cognitive impairment. Record review of Resident #3's care plan dated 9/15/20 Resident at risk for COVID due to non-compliance with wearing he's facemask when out of his room. 9/10/20 cognitive loss /dementia, resident unable to make daily decisions without cues /supervision due to dementia. 6/12/20 Behavior symptoms, related to physical aggression to others (hitting, kicking). No sexual behaviors documented. Record review of Resident #3's progress notes dated 9/6/20 at 8:02 p.m. by Nurse C, Resident was found in shower room with female resident. They were facing each other. Staff did not see anything had happened. Told him to leave shower room and assisted female out of shower room to dining room. 15-minute checks done during shift. No noted documentation of notification to family, physician or administration. Record review on 10/5/20 of Resident #4's face sheet revealed admission date of [DATE] with [DIAGNOSES REDACTED]. Record review on 10/5/20 of Resident #4's Annual MD'S dated 9/6/20 revealed a BIMS score of 1. This is cognitively impaired. Record review of Resident #4's care plan dated 9/15/20 Resident at risk for COVID due to non-compliance with wearing his facemask when out of her room. Falls revised 8/26/20 resident has experienced fall when ambulating in dining room without her walker. No sexual behaviors documented. Record review of Resident #4's progress notes dated 9/6/20 revealed: Resident was found in the shower room with a male resident #3. 2 CNAs, E, Q went in to wash their hands when they discovered Resident #3 with his pants down and Resident #4 sitting on a trash can in front of Resident #3. Resident #4 immediately ran out of the shower room after pulling his pants up as per CNA E Resident #4 would not talk at the time of the incident. Resident #3 told the CNAs that Resident #4 raped him. CNA Q said there was no sign of Resident #3 resisting. Noted stated would keep a close watch on these two residents (#3 and #4) and try to talk to Resident #4 when there is privacy. No follow up note in resident #3's file regarding incident after 9/6/20. In an interview on 10/3/20 at 1:53 p.m., LVN F stated that Resident #2 had sexual behaviors since he was admitted to the facility on the secure unit. LVN F stated, the moment Resident #2 moved into the secure unit, Resident #2 began seeking Resident #1. LVN F stated she was not a witness to the sexual inappropriateness of Resident #1 and Resident #2 that occurred on 9/18/2020 at 6:20 p.m. LVN F stated when she came back to work on 9/29/20, Resident #1 and Resident #2 were on 15-minute checks because they were caught together, and staff re-directed them. LVN F stated on 10/3/20, a CNA (unknown) found Resident #1's clothing in Resident #2's bathroom, tucked behind the toilet. This was not reported by the previous shift. LVN F usually gets daily resident information by looking at the resident charts. LVN F stated, Resident #2 had new orders since she had been off to increase [MEDICATION NAME] and add an additional hormone medication. LVN F stated she was not sure if an incident report was completed for Resident #1 and Resident #2, due to the sexual incident. LVN F stated the skin reports were completed on each resident once a week by the nurses. LVN F stated the family of Resident #1 had told the staff that if Resident #1 was involved in a sexual encounter to let her do it. LVN F stated she recently found out Resident #1 had a [DIAGNOSES REDACTED].#1's face sheet and had reported it to the DON for direction. Upon reporting, LVN F said the DON changed the subject. LVN F stated she noticed Resident #1 had frequent incontinent episodes about 2 weeks ago but could not remember how many. LVN F stated she was not trained for residents with sexual seeking behaviors before she came to the secure unit. Interview on 10/4/2020 at 2:16 p.m., with LVN I stated she had worked on the secure unit. She stated that she has been working there over a year. She stated that she was concerned that Resident #2 and also Resident #3 because they had sexual behaviors and could easily attack the vulnerable female residents in the secure unit. She stated that she was aware of resident #3 performing sexual activities with Resident #4 She stated that she did not understand why they were there if they had sexual behavior diagnosis. During interview she was asked if she had reported this to the DON or Administrator and she stated that she could not remember if she had directly, but she felt that they knew. Interview on 10/4/2020 at 3:00 p.m. with CNA J, revealed she worked on the secure unit and had been working for about 6 months at this facility. Further investigation revealed her identifying Resident #3, who was outside smoking and Resident #2 who was in the sitting area at the end of hall 100 in the secure unit, with a sitter near him. She stated that she had heard from different staff that there had been some issues of sexual behavior with Resident #2, but she had not seen any. She stated that she had heard from staff, Resident #3 had sexual seeking behaviors. She stated that she is fearful for the female residents in the secure unit because these two men cannot always be watched if they are performing their other jobs. 2. In an interview on 10/3/20 at 2:40 p.m. the DON stated, she had started working in April 20. The DON stated she was aware of the Resident #1's and Resident #2's sexual inappropriateness by staff and placed them on 15-minute checks and notified both families. The DON stated Resident #1 had several incidents with another resident this was investigated by the state and she moved Resident #2 to the secure unit due to increase elopement attempts. The DON stated no incident report was done for the incident between Resident #1 and Resident #2 because the family stated it was ok. The DON stated she did not do an investigation or notify the police or the State to report the incident with Resident #1 and Resident #2. The DON stated that she was not aware of Resident #3 and Resident #4 having any sexual behaviors. In an interview on 10/4/20 at 1:00 p.m. the Administrator confirmed that she was not informed of sexual encounter of Resident #1, #2, #3, #4, so she did not initiate an investigation or report it to HHSC. Interview on 10/4/20 at 1:00 p.m. with the Administrator confirmed she would follow the HHSC provider letter regarding timeframe to report and investigate future allegations of abuse. In an interview on 10/4/2020 at 1:00 p.m. with the Administrator she stated, we use the State and Federal Guidelines for reporting incidents, there is not an in-house policy. Record review of Long-Term Care Regulatory Provider Letter Number: PL 18-20 (replaces PL 13-04 and 18-07) Title: Incident Reporting Requirements date issued 9/17/2018 revealed, 2.0 Policy Details & Provider Responsibilities. A provider must: report reportable incidents to CII; ensure a thorough investigation is conducted and documented in the PIR; and submit the POIR to CII within the regulatory timeframes that applies to the provider type. In addition to reporting an incident, a provider must investigate, or ensure that an investigation was completed, to determine why it occurred, what actions the provider will take in response to the incident and what changes will be made to help prevent a similar incident from occurring. The Administrator was notified of an IJ on 10/04/20 at 9:50 p.m. and was given a copy of the IJ Template and a Plan of Removal was requested. The Plan of Removal accepted on 10/6/20 at 9:59 a.m. included the following: {Written as quoted from Plan of Removal provided by facility.} The administrator notified the Kerrville police department (intake # 049) on October 5, 20{20} regarding the sexual incident between two residents at the facility. The female victim's responsible party and physician were notified of this incident as well as the perpetrator's responsible party and physician. A full body assessment was performed on the female resident on 10/4/2020 to identify any problems and no redness or swelling of the genital or anal area was identified. Alternate placement referral for the male perpetrator to a sister facility that has all male secured unit residents was completed on 10/5/2020. The physician at the receiving facility will assess the male resident for the STD ([MEDICAL CONDITION]) that may have been transmitted through sexual contact with the female victim. The facility is assessing where a door might be placed to create two separate secured units with a female and male separate population area; this will occur on 10/6/20. The female resident will be kept in line of sight until the door can be placed and if any concerns are identified will be placed on 1:1 with facility staff. The physician ordered a urinalysis that was negative on 9/29/2020. The facility will place the resident on a toileting program to improve incontinence with the results reviewed weekly by the director of nursing/designee and revised as necessary. Psychological services (Psychological services are direct services performed by a licensed psychologist, as specified by state law and licensure. Psychological services include evaluation, psychotherapy, consultation, and behavioral treatment) have been solicited to come and assess and provide emotional support to the resident before 10/9/2020. Any concerns will be brought to the immediate attention of the administrator. Secured unit staff will be trained to conduct a huddle at the beginning of each shift and as needed to discuss behaviors with all secured unit residents requiring extra monitoring and rounding. A form will be used to document huddle attendance and the process will be monitored by the director of nursing and unit managers. Administrator stated that Resident #1 and Resident #2 will be monitored, and staff would intervene, if behaviors occurred again. Administrator said the staff will be educated. Administrator further said the residents would be allowed privacy and both families was ok with that plan. The Administrator stated they were going to work on discharging Resident #2 due to numerous behaviors. A full-body assessment was completed on all female residents residing on the secured unit by the nursing administrative staff and by the licensed nursing staff completed on October 4, 2020. Any concerns from those assessments will be reported to HHSC, the responsible parties, and the physician. On 10/5/2020, the administrator and the director of nursing met with the nursing staff from the secured unit to re-educate them on identifying predatory sexual behaviors and reporting immediately to the administrator when there are any concerns. Included in this training will be the immediate notification of physician and responsible party which will be reviewed for completion by the administrator. Staff will be educated that fifteen (15) minute checks are not appropriate for monitoring residents with exacerbations of behaviors. Residents identified with sexual exacerbations or another concerning behaviors will be kept either in line of sight or 1:1 oversight until the behavior is under control as deemed by the administrative team. Any secured unit staff member not initially receiving this information will be required to meet with the administrator/director of nursing before starting their next assigned shift. Care plans were reviewed and updated on 10/5/20 to reflect any predatory sexual behaviors. On 10/4/20, the Regional Director of Operations re-educated the administrator and the director of nurses on notifying the corporate team of any allegations of abuse immediately so that urgent issues may be addressed timely and residents protected. On 10/5/20, the administrator initiated an abuse and reporting in-service to facility staff concentrating on sexual predatory behaviors and the need to immediately report any concerns to the administrator. Any staff not receiving this initial education will be required to receive it before starting their next assigned shift. On 10/4/20, the Regional Nurse Consultant re-educated the administrator and the director of nursing about reviewing the facility activity report to identify any concerns in documentation and/or behaviors on the secured unit and other units in the facility. The administrator and the director of nursing will make daily rounds, during regular business hours, on the secured unit to identify any concerns and to solicit information from nursing staff on any concerns relating to resident behaviors. The weekend supervisor will be responsible for making twice a day rounds in the secure unit to identify any concerns. Any identified problems will be brought to the attention of the administrator immediately upon discovery. The regional nurse consultant will review the facility activity report twice a week for one month and randomly thereafter to identify any concerns in facility documentation. The administrator will bring any concerns or trends to the monthly Quality Assurance Performance Improvement meeting for tracking, trending, and further Interdisciplinary Team Recommendations. Plan of Removal was verified by: Verification on 10/5/20 revealed Administrator notified local police department regarding the sexual incident between Resident #1 and Resident #2 at the facility. Residents #1, #2's responsible parties and physicians were notified of sexual encounter on 9/28/2020 of Resident #1 and Resident #2. Documentation in resident's files were reviewed to verify on 10/8/2020. Full body assessment was performed on 10/4/20 to identify any problems and no redness or swelling of the genital or anal area was identified on Resident #1. Urinalysis was ordered and was negative on 9/29/20. Documentation in nurse's notes was reviewed to verify on 10/8/2020. All female residents (20 of 20) had skin assessment done on 10/5/20 with no negative outcomes documented. Documentation in residents' files were reviewed to verify on 10/8/2020. In an interview on 10/5/20 at 9:45 a.m. with LVN F revealed, Resident #2 was transferring on 10/5/20 to a sister facility's male secure unit. In an interview on 10/4/20 at 5:00 p.m., the Administrator stated, a sitter for Resident #2 was started on 10/4/20. Administrator stated the facility is planning to move Resident #2 to a sister facility but had not pursued further due to Covid-19. Alternate placement referral for the male perpetrator to sister facility that was all male secured unit residents was completed on 10/5/2020. The physician at the receiving facility will assess the for the STD that may have been transmitted through sexual contact with the female victim. Review of Regional RN notes validated this. All female residents in secure unit were separated from all male residents in the secure unit on 10/8/2020. Female residents were on the west side of the secure unit and male residents were on the east side of the secure unit. Resident #1 will be kept in line of sight until the door could be placed and if any concerns are identified will be placed on 1:1 with facility staff: Resident #1 had 1:1 sitter for 4 full days all shifts until unit was officially secured. Observations, interviews and record reviews had validated this. Resident #1 placed on toileting program to improve incontinence with the results reviewed weekly by the DON/designee and revised as necessary. Regional RN provided documentation on Resident toileting program and results for 2 days. Plan is for 1 week of program and see if any improvement of Resident's bowel and bladder incontinence. Currently day 3. Regional RN in serviced 4 out of 6 nurses. Regional RN will in service last 2 LVN's on 10/8/2020. CNA's were informed of Resident's changes every shift by LVNs. Interviews, observations and record review validated this on 10/8/2020. Observations of Resident #1 regarding toileting program were done on 10/6/2020, 10/7/2020, and 10/8/2020. Staff were reminding Resident #1 every 2 hours to toilet and documented in nurses notes outcomes. Psychiatric services have been solicited to come and assess and provide emotional support to the Resident #1 before 10/9/20. A psychiatric visit by provider was done on 10/2/20 and 10/5/20 for Resident #1 with a plan to continue monitoring. Documentation in residents' files were reviewed to verify on 10/8/2020. Secured unit staff were trained to conduct a huddle at the beginning of each shift and as needed to discuss behaviors with all secured unit residents requiring extra monitoring and rounding. A form was to be used to document huddle attendance and the process was monitored by the director of nursing and unit managers. Documentation on report sheet was reviewed to verify on 10/8/2020. Monitoring forms being utilized on each shift. 80% of staff working this unit have been in serviced and facility will continue to in service until all staff completed training. Interviews and record reviews of facility training book validated this. On 10/4/20, the Administrator and the DON met with nursing staff from the secured unit to re-educate them on identifying predatory sexual behaviors and reporting immediately to the administrator when there are concerns. Included in this training, immediate notification of physician and responsible party which will be reviewed for completion by the Administrator. Also included in this training staff will be educated that fifteen-minute checks are not appropriate for monitoring residents with exacerbations of behavior. Record review of Facility All Staff Binder revealed Abuse and Neglect policies and reporting dated 10/2/2020. Subject: Definitions and reporting, Presented by: Administrator. 11- nursing staff, 7ancillary staff (housekeeping/dietary), and 3 Therapy department staff attended. Record review of inservice on 10/4/2020 of Notifying Corporate Team of Abuse Allegations with Subject: Notify Regional Director of Operations regarding abuse, presented by Regional Director of Operations, signed by Administrator and DON. Care plans of Resident #1, #2, #3 were reviewed and updated on 10/5/20 to reflect any predatory sexual behaviors. On 10/4/2020 the corporate Regional Director of Operations re-educated administrator and DON on reporting. Interview and Record review of facility training book validated this. On 10/5/20, the Administrator initiated an abuse and reporting in service to facility staff concentrating on sexual predatory behaviors and the need to immediately report. Interviews and Record reviews of facility training book validated this. Regional Director of Operations re-educated Administrator and DON on reviewing the facility activity report to identify any concerns in documentation and /or behaviors on the secured unit and other units of the facility. Regional RN in serviced DON and Administrator on Facility Activity Report signed 10/4/20. Interviews and record review of training book validated this. The Administrator and DON will make rounds, during regular business hours on the secured unit to identify any concerns and to solicit information from nursing staff on any concerns relating to resident behaviors. Weekend supervisor will be responsible for making twice a day rounds. Any identified problems will be brought to the attention of the administrator immediately upon discovery. The regional nurse consultant will review the facility activity report twice a week for one month and randomly thereafter to identify any concerns: Documentation on was Administrator/DON rounding log was reviewed to verify on 10/8/2020. Facility Activity report (report identifies any resident incident or event logged into system by nurse) will be monitored in the AM by the Administrator / DON /RRN review 2 x a week and prn. Interviews and record reviews of facility training book verified this. Interviews on 10/8/2020 at 2:15 p.m. were conducted on the secure unit with staff for verification of training occurring regarding sexual behaviors of residents. This was verified by 3 LVN's and 4 CNA's that the Regional RN had done this. Record review of facility training records on 10/8/2020 at 2:30 p.m. revealed inservices on abuse and neglect and behaviors had occurred beginning 10/4/2020 and were continuing as of 10/8/2020. The Administrator will bring any concerns or trends to the monthly QAPI meeting for tracking, trending. Phone call to Administrator or Don is required by staff not an app or email or text. QAPI is scheduled for 10/8/2020. Interviews and record reviews of facility training book validated this by interview with Administrator and Corporate Registered Nurse on 10/8/2020. During an interview on 10/8/20 at 10:30 a.m., Regional Nurse Consultant, stated a designee was monitoring daily and the monitoring tool was given to the Administrator to be reviewed. The DON stated the Administrator was provided the monitoring tool on a daily basis to be reviewed. Record review of facility policy: Titled Abuse and Neglect - Clinical Protocol dated 2001 with revision 2014, Section 1. Titled Assessment and Recognition. 1. The nurse will assess the individual and document related findings. Assessment data is to include: Injury assessment. 2. The nurse will report findings to physician. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. On 10/9/20 at 9:21 a.m., the Administrator, Regional Director of Operations, Regional Nurse Consultant, and DON were informed the IJ was removed. While the IJ was removed on 10/09/2020, the facility remained out of compliance at a severity identified as no actual harm with a potential for more than minimal harm, with a scope identified as isolated while the facility continued to monitor the effectiveness of their plan of removal and the interventions put in place to ensure residents were being monitored and allegations of abuse were being thoroughly investigated and reported.

Based on interview and record review, the facility failed to immediatley consult with the resident's physician; and notify, consistent with his or her authority when a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 2 residents reviewed (Resident #1), in that: Facility failed to notify physician when Resident #1 had a change in condition was no longer combative and became sleepy and refused to eat. This failure could affect residents who did not receive medications as ordered and could result in a change in condition and a decline in health. Findings included: Review of Resident #1's face sheet revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had other behavioral symptoms not directed towards other and rejected care 1 to 3 days. Cognitive sklills for decision making were severly impaired. Review of for Resident #1's discharge medication orders dated 03/22/19 from a local revealed a physician order [REDACTED]. Titrate to 3 bowel movements (BM) per day. Hold for greater than 3 stools per day. Review of Resident #1's new admission orders [REDACTED]. Further review of orders revealed dosage was different from hospital order and did not include titration to bowel movement instructions. Review of the (MONTH) 2019 MAR for Resident #1 revealed the physician order [REDACTED]. The medication was scheduled to be administered at 6 am, 11 am, 4 pm and 8 pm. At time of exit on 4/26/2019 the (MONTH) 2019 MAR could not be located by the facility. Further review of the (MONTH) 2019 MAR revealed that the medication [MEDICATION NAME] was not initialed as given on: 4/1/19 at 4 pm or 8 pm 4/2/19 was not initialed as given at 4 pm or 8 pm 4/3/19 the 11 am dose was marked as held and not initialed as given at 4 pm or 8 pm 4/4/19 was not initialed as given at 4 pm or 8 pm 4/5/19 was not initialed as given at 4 pm or 8 pm 4/7/19 the medication was initialed as held at 8 pm 4/9/19 was initialed as held at 11 am 4 pm and 8 pm 4/10/19 was initialed as held on 4 pm and 8 pm 4/11/19 the medication was initialed as held at 11 am 4 pm and 8 pm 4/12/19 the medication was not initialed as given at 11 am 4/13/19 the medication was not initialed as given at 8 pm Further review of Resident #1's MAR for (MONTH) 2019 revealed that the order for [MEDICATION NAME] had been changed on 4/15/19 to 60 ml PO QID titrate to 3 BMs a day, hold if greater than 3 BMs, as ordered upon hospital discharge. The medication was scheduled to be administered at 8 am 12 pm 4 pm and 8 pm. Review of the administration of the medication revealed that [MEDICATION NAME] for 4/15/19 was initialed as held at 12 pm and not initialed as given at 4 pm. On 4/16/19 the medication was initialed as held at 8 am, not initialed as given as 12 pm. Review of the medication [MEDICATION NAME] for Resident #1 supplied from the pharmacy revealed that the label for the medication indicated: give 15 ml by mouth before meals and at bedtime. [MEDICATION NAME] solution 10 gm/15 ml. Review of a ER Physician's note dated 4/16/19 revealed that Resident #1 presented by EMS from a local nursing home for evaluation of altered mental status. The nursing home reports that over the course of the last several days Resident #1 has been declining with decreased urine output over the course of 4-5 days. He has no oral intake since last night. The nursing home reports that Resident #1's physician recommended patient be DNR however a family members who is medical power of attorney did not want to make any decisions until she can come to town on 4/19/19. Review of laboratory report dated 4/16/19 from a local hospital for Resident #1 revealed that critical lab values including an elevated sodium at 167, elevated BUN, Creatinine, Lactic Acid and an elevated WBC at 30.2. Review of a Physician Consultation Report signed by the physician from a local hospital and dated 4/17/19 for Resident #1 revealed diagnostic impression is consistent with [MEDICAL CONDITION]ly secondary to infection versus hyperammonemia. Review of a Neurology Consultation Report signed by the physician from a local hospital dated 4/18/19 for Resident #1 revealed a note I think this is a case of metabolic [MEDICAL CONDITION]. Interview with CNA A on 4/25/19 at 3:35 pm revealed that Resident #1 was initially combative and resistant with care. Approximately one week before the resident was discharged from the hospital the resident was only wanting to sleep and Resident #1 no longer wanted to eat. Further interview with CNA C revealed that she didn't do anything different when she noticed the change in the resident's behaviors. Interview with CNA B on 4/25/19 at 3:50 pm revealed that Resident #1's behaviors became combative after admission and then the resident went into a very deep sleep. CNA B revealed that the day before his discharge to the hospital on [DATE] that she thought Resident #1 looked like a dead body. Further interview with CNA B revealed that she had informed RN C of the resident's condition. Interview with RN C on 4/25/19 at 3:15 pm revealed that she had been informed from the previous shift (day shift) that Resident #1 had a change of condition and was no longer waking up for meals or to eat approximately one week before his discharge to the hospital on [DATE]. RN C stated that the day shift had been in contact with the resident's family who indicated he slept late and was more awake in the evenings. RN C indicated that she instructed the CNAs to get Resident #1 out of bed after dinner had been served to the other residents so she could spend time getting him to eat and drink. RN C indicated that Resident #1 always eats or drinks something on her shift and that he was awake for approximately 2 hours on the evening shift. Further interview revealed that RN C had not notified the physician or nurse practitioner in charge of the resident's care about his change of condition. RN C stated that she did not notice if the resident was urinating or having bowel movements. RN C said the CNAs were supposed to notify her if there was anything unusual and nobody had notified her of anything. RN C confirmed that she had administered [MEDICATION NAME] as per the directions on the MAR and was unaware that the medication should have been titrated based on bowel movements. Interview on 4/25/19 at 9:35 am with LVN D revealed that she first noticed a change in condition for Resident #1 on 4/5/19. LVN D said she noticed that the resident became sleepy and was no longer eating breakfast or lunch and was not staying awake when was up in his wheelchair. LVN D notified the physician's office and received orders for lab work which included an ammonia level which came back abnormally high. New orders for [MEDICATION NAME] were received on 4/15/19 (day before discharge to the hospital). On 4/16/19 LVN D indicated that she was walking by Resident #1's room and noticed that he didn't look right. LVN D revealed that she called the resident's name from the door several times and he didn't respond. She was on her way to do something (does not remember what) and she went to complete that task. LVN [NAME] said that approximately 30 minutes later indicated Resident #1 didn't look well so she went into Resident #1's room to perform an assessment and vital signs. Resident #1 was responsive to pain only and would not open his eyes. LVN D placed a call to the physician and waited for instructions. LVN D indicated that approximately 2 hours had passed from the time of the assessment to the time that EMS arrived at the facility. LVN D indicated that the delay in notifying EMS was because the resident was a full code and the family had indicated that they might be interested in making the resident a DNR. Interview on 4/25/19 on 9:40 am with LVN [NAME] revealed that Resident #1 had become very combative and then sleepy on approximately 4/5/19. On 4/16/19 she noticed that Resident #1 did not look good and notified his nurse LVN D. LVN [NAME] indicated that Resident #1 was not in her care and she was not responsible for him. LVN [NAME] stated that in the past when a resident had a change of condition or behavior that staff would get a UA (urinalysis) to check for a urinary tract infection but since the new antibiotic stewardship program had come out they were not allowed to get a UA without a specific cause and a change of behavior was not a good enough reason to get one. Further interview with LVN [NAME] on 4/25/19 at 1:26 pm revealed that on the morning of 4/16/19 at approximately 10:00 am, she noticed that Resident #1 did not look well. She notified his nurse LVN D of Resident #1's condition and an assessment was performed. Interview with the DON on 4/26/19 at 11:09 am revealed that any resident change of condition should be documented in the resident's record and the physician should be immediately notified. Any change in level of consciousness required an immediate call to the physician. An LVN should perform a routine assessments. The LVN should notify a RN for any condition or assessment that was outside normal. Further interview revealed that he was aware that Resident #1 was not eating. The DON confirmed that Resident #1's medication [MEDICATION NAME] had been transcribed and given to the resident incorrectly. Interview on 4/26/19 at 9:28 am with the Medical Director confirmed that the dosage of [MEDICATION NAME] Resident #1 was receiving at the hospital and which was indicated on the discharge medication list from the local hospital should have been followed at the facility and not changed. Review of a facility policy titled Acute Condition Changes Clinical Protocol dated 2001 revealed 7. The nursing staff will contact the Physician and request a prompt response (within approximately one-half hour or less). Review of a facility policy titled Change in a Resident's Condition or Status dated (MONTH) (YEAR) revealed 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff b. impacts more than one area of the resident's health status c. requires interdisciplinary review or revision to the care plan and d. ultimately is based on the judgment of the clinical staff .

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 2 Residents (Resident #1) reviewed for new admission orders [REDACTED] 1. The facility failed to administer Resident # 1's Lactose as ordered upon hospital discharge resulting in a change of condition for Resident #1, including an altered mental status which resulted in a decline in health and hospitalization in an intensive care unit at a local hospital on [DATE]. 2. The facility failed to follow Resident #1's hospital discharge medication instructions for [MEDICATION NAME]. 3. The facility failed to transcribe Resident #1's new admission medication orders for for [MEDICATION NAME] 60 ml QID (four times a day) which included orders to titrate the medication to 3 bowel movements a day into the electronic record and failed to correctly transcribe the orders onto paper MARS . This failure could place residents with new admission orders [REDACTED]. Findings included: Review of a face sheet for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of for Resident #1's discharge medication orders dated 03/22/19 from a local revealed a physician order [REDACTED]. Titrate to 3 bowel movements (BM) per day. Hold for greater than 3 stools per day. Review of Resident #1's new admission orders [REDACTED]. Further review of orders revealed dosage was different from hospital order and did not include titration to bowel movement instructions. Review of the (MONTH) 2019 MAR for Resident #1 revealed the physician order [REDACTED]. The medication was scheduled to be administered at 6 am, 11 am, 4 pm and 8 pm. At time of exit on 4/26/2019 the (MONTH) 2019 MAR could not be located by the facility. Further review of the (MONTH) 2019 MAR revealed that the medication [MEDICATION NAME] was not initialed as given on: 4/1/19 at 4 pm or 8 pm 4/2/19 was not initialed as given at 4 pm or 8 pm 4/3/19 the 11 am dose was marked as held and not initialed as given at 4 pm or 8 pm 4/4/19 was not initialed as given at 4 pm or 8 pm 4/5/19 was not initialed as given at 4 pm or 8 pm 4/7/19 the medication was initialed as held at 8 pm 4/9/19 was initialed as held at 11 am 4 pm and 8 pm 4/10/19 was initialed as held on 4 pm and 8 pm 4/11/19 the medication was initialed as held at 11 am 4 pm and 8 pm 4/12/19 the medication was not initialed as given at 11 am 4/13/19 the medication was not initialed as given at 8 pm Further review of Resident #1's MAR for (MONTH) 2019 revealed that the order for [MEDICATION NAME] had been changed on 4/15/19 to 60 ml PO QID titrate to 3 BMs a day, hold if greater than 3 BMs, as ordered upon hospital discharge. The medication was scheduled to be administered at 8 am 12 pm 4 pm and 8 pm. Review of the administration of the medication revealed that [MEDICATION NAME] for 4/15/19 was initialed as held at 12 pm and not initialed as given at 4 pm. On 4/16/19 the medication was initialed as held at 8 am, not initialed as given as 12 pm. Review of the medication [MEDICATION NAME] for Resident #1 supplied from the pharmacy revealed that the label for the medication indicated: give 15 ml by mouth before meals and at bedtime. [MEDICATION NAME] solution 10 gm/15 ml. Interview with CNA A on 4/25/19 at 3:35 pm revealed that Resident #1 was initially combative and resisted care. CNA A further revealed Approximately one week before the resident was discharged from the hospital the resident was only wanting to sleep. Resident #1 no longer wanted to eat. The interview further revealed that she didn't do anything different when she noticed the change in the resident's behaviors. Interview with CNA B on 4/25/19 at 3:50 pm revealed that Resident #1 became combative after admission and then the resident went into a very deep sleep. CNA B revealed that the day before his discharge to the hospital on [DATE] that she thought Resident #1 looked like a dead body. Further interview with CNA B revealed that she had informed her charge nurse RN C of the residents condition. RN C stated she would check on the resident. Interview with RN C on 4/25/19 at 3:15 pm revealed that she had been informed from the previous shift (day shift) that Resident #1 had a change of condition and was no longer waking up for meals or to eat approximately one week before his discharge to the hospital on [DATE]. RN C stated that day shift had been in contact with the residents family who indicated he slept late and was more awake in the evenings. RN C indicated that she instructed the CNAs to get Resident #1 out of bed after dinner had been served to the other residents so she could spend time getting him to eat and drink. RN C indicated that Resident #1 always eat or drink something on her shift and that he was awake for approximately 2 hours on evening shift. Further interview revealed that RN C had not notified the physician or nurse practitioner in charge of the residents care about his change of condition. RN C stated that she did not notice if the resident was urinating or having bowel movements. The CNAs were supposed to notify her if there was anything unusual and nobody had notified her of anything. RN C confirmed that she had administered [MEDICATION NAME] as per the directions on the MAR and was unaware that the medication should be titrate to bowel movements. Interview on 4/25/19 at 9:35 am with LVN D revealed that she first noticed a change in condition for Resident #1 on 4/5/19. She noticed that the resident became sleepy and was no longer eating breakfast or lunch and was not staying awake when he placed in his wheelchair. Resident #1 started spitting out his medications. She notified the physician's office and received orders for lab work (4/5/19) which included an ammonia level which came back abnormally high at 81. New orders for [MEDICATION NAME] were received on 4/15/19 (day before discharge to the hospital). On 4/16/19 LVN D indicated that she was walking by Resident #1's room and noticed that he didn't look right. LVN D revealed that she called the resident's name from the door several times and he didn't respond. She was on her way to do something (does not remember what) and she went to complete that task. Approximately 30 minutes later LVN [NAME] indicated that Resident #1 didn't look well so she went into Resident #1's room to perform an assessment and vital signs. Resident #1 was responsive to pain only and would not open his eyes. LVN D placed a call to the physician and waited for instructions. LVN D indicated that approximately 2 hours had passed from the time of the assessment to the time that EMS arrived at the facility. LVN D indicated that the delay in notifying EMS was because the resident was a full code and the family had indicated that they might be interested in making the resident a DNR. Interview on 4/25/19 on 9:40 am with LVN [NAME] revealed that Resident #1 had become very combative and then sleepy on approximately 4/5/19. On 4/16/19 she noticed that Resident #1 did not look good and notified his nurse LVN D. LVN [NAME] indicated that Resident #1 was not in her care and she was not responsible for him. LVN [NAME] stated that in the past when a resident had a change of condition or behavior that staff would get a UA to check for a urinary tract infection but since the new antibiotic stewardship program had come out they were not allowed to get a UA without a specific cause and a change of behavior was not a good enough reason to get one. Interview on 4/25/19 at 4:26 pm with RN F confirmed that he had admitted Resident #1 and was responsible for transcribing his medications orders onto MAR's and into the computer. Further interview revealed that he faxed the medication orders to the physician but doesn't remember for sure if he put them into the computer. RN F stated that was a long time ago and he couldn't remember talking to a doctor about Resident #1's medications or not. RN F stated nurses don't go around making up orders. Interview with the ADON on 4/26/19 at 10:23 am confirmed that the medication [MEDICATION NAME] had been transcribed incorrectly into the computer and the MAR. Further interview with the ADON revealed that LVN A had informed him of the resident wasn't eating. The facility had drawn lab work which indicated an elevated ammonia level at 81 and new orders for [MEDICATION NAME] were received from the physician on 4/15/19. The ADON had instructed the LVN to keep an eye on Resident #1. Interview with the DON on 4/26/19 at 11:09 am revealed that any resident change of condition should be documented in the resident's record and the physician should be immediately notified. Any change in level of consciousness required an immediately call to the physician. An LVN should before routine assessments. The LVN should notify a RN for any condition or assessment that is outside normal. Further interview revealed that he was aware that Resident #1 was not eating. The DON confirmed that Resident #1's medication [MEDICATION NAME] had been transcribed and given to the resident incorrectly. Interview on 4/26/19 at 9:28 am with the Medical Director confirmed that the dosage of [MEDICATION NAME] Resident #1 was receiving should have been carried out as written on the hospital discharge instruction sheet. Review of a facility policy title Medication and Treatment Orders dated (MONTH) (YEAR) revealed 9. Orders for medications must include name and strength of drug, number of doses, start and stop date and /or specific duration of therapy, dosage and frequency of administration, route of administration, clinical condition or symptoms for which the medication is prescribed and any interim follow up requirements.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibited neglect for 4 of 15 residents (#3, #4, #6 & #7) who were reviewed for neglect in that: 1. LVN R (Charge Nurse) and LVN D (Unit Manager) did not ensure that 2 prescriptions, [MEDICATION NAME] and [MEDICATION NAME] (used for [MEDICAL CONDITION]) were available or that Resident #7 received the medications for 2 days. Resident #7 was diagnosed with [REDACTED]. Resident #7 had 9 [MEDICAL CONDITION] before she was sent out to the hospital. 2. Resident #4 had a change in condition, increased pain, nausea and vomiting in the last two weeks of [DATE]. She also had a critical lab result on [DATE] that was not followed up on for five days. She was sent to the hospital on [DATE] after staff was prompted by family members and she was diagnosed with [REDACTED]. 3. Nursing staff did not use a bed alarm (an identified intervention) and provide adequate supervision for Resident #6 (who was in the locked unit) and who had experienced multiple falls. 4. Nursing staff did not use a low bed, a mat to the bedside and did not ensure the bed alarm was on (identified interventions) for Resident #3 who had a history of [REDACTED]. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at a scope of pattern at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. These deficient practices could affect 17 residents who had a fall during March and [DATE] in the 100 hall; 7 residents with a [MEDICAL CONDITION] disorder and 94 residents who could experience a significant change in condition and could result in serious medical complications [REDACTED]. The findings were: 1. Review of Resident #7's medical face sheet (undated) revealed she was admitted into the facility on [DATE] at 13:00 (1:00 p.m.). Review of Resident #7's admission orders [REDACTED]. Further review revealed an order for [REDACTED]. Review of a Nursing Admission Intake Form dated [DATE] revealed Resident #7 had a VNS implant on her left side to control [MEDICAL CONDITION]. There was not a plan to address the use of the VNS implant. Review of an Interim Plan of Care dated [DATE] did not address the fact that Resident #7 had a [MEDICAL CONDITION] disorder, a VNS implant and how staff was going to ensure her needs were met. Review of a H & P dated [DATE] revealed Resident #7 was transferred into the facility from a hospital with a severe sz d/o. Resident #7's assessment and plan for her [MEDICAL CONDITION] disorder included orders for [MEDICATION NAME] ER, [MEDICATION NAME] and [MEDICATION NAME] level in AM. Review of a MAR indicated [REDACTED]. Review of an incident/accident report dated [DATE] at 12:10 a.m. revealed Resident #7 was lying in bed and was noted having atonic-clonic [MEDICAL CONDITION] activity at 12:10 p.m. Further review revealed her VNS magnet was utilized and Resident #7 stopped having [MEDICAL CONDITION] activity. The NP was notified at this same time. Review of a nurse's note dated [DATE] at 12:10 a.m. read: Resident was lying in bed having atonic-clonic [MEDICAL CONDITION]. This nurse used VNS magnet and resident stopped seizing after fifteen seconds. The NP notified of [MEDICAL CONDITION]. Informed him that resident missed two doses of [MEDICATION NAME] due to pharmacy not delivering after repeated attempts to let pharmacy know that residents ' [MEDICATION NAME] and [MEDICATION NAME] have not arrived. The NP informed this nurse that pharmacy has to have written scripts faxed over to them and that this writer will have to take care of getting scripts for resident in AM. This writer called the pharmacy and asked if this nurse could get [MEDICATION NAME] out of the emergency kit. The pharmacy informed this writer that only an agent can do this and that this writer is not an agent and that the NF does not have a controlled emergency medicine kit. Resident resting quietly in bed after [MEDICAL CONDITION]. VS WNL and are as follows: 99, 88, 22, ,[DATE] and 02 sat of 98% on RA. Tracks this writer's hand and tries to push b/p cuff away from her. Tolerating [DEVICE] feeding water flushes and meds well. Call light within reach. Will cont to monitor resident closely. Review of a second incident/accident report dated [DATE] at 5:45 a.m. revealed Resident #7 having multiple tonic-clonic [MEDICAL CONDITION] approximately 30 seconds each. LVN R wrote she witnessed the resident having 3 [MEDICAL CONDITION] within approximately ,[DATE] minutes. Review of an incident/accident investigation follow-up dated [DATE] read Resident #7 experienced uncontrolled tonic-clonic [MEDICAL CONDITION] activity. VNS magnet utilized & [MEDICAL CONDITION] activity would stop for time then would restart. Total of 9 [MEDICAL CONDITION] prior to going to ER. The summary of investigation revealed the pharmacy had not delivered the [MEDICATION NAME] and [MEDICATION NAME] for Resident #7. The NP was notified of the [MEDICAL CONDITION] activity at 12:10 a.m. and the PCP was notified at 6:15 a.m. Review of a nurse's note dated [DATE] at 7:15 a.m. read: Resident was found in bed @ 5:45 a.m. seizing and had vomited all over her hospital gown. This writer used magnet for VNS and resident stopped seizing after 30 seconds. Resident had two more [MEDICAL CONDITION] in a ten minute period. NF supervisor notified PCP ordered that resident be sent into hospital for assessment and evaluation. Resident had six more [MEDICAL CONDITION] over the next 30 minutes before EMS arrived. Resident would come out of [MEDICAL CONDITION] after magnet was used over VNS, but would go into another [MEDICAL CONDITION], just a few minutes afterwards. All [MEDICAL CONDITION] have been tonic-clonic in nature. VS were taken before EMS arrived and are as follows: ,[DATE], 100, 24 and 100.7. Family member will be contacted by supervisor. Interview on [DATE] at 11:14 a.m. with LVN I revealed she assisted with Resident #7's transfer to the hospital on [DATE]. She learned Resident #7 had a [MEDICAL CONDITION] at midnight and then in the morning during shift change. She was told Resident #7 missed 2 doses of [MEDICATION NAME] but when she looked at the MAR indicated [REDACTED]. LVN I stated she called the NP who was not returning her calls so LVN/Unit Manager D told her to call the PCP who then provided orders to send the resident out to a local hospital. Interview on [DATE] at 11:38 a.m. with LVN O revealed she also assisted with Resident #7's transfer to the hospital on [DATE] due to the resident experiencing multiple [MEDICAL CONDITION]. LVN O stated she learned the NP was called at midnight regarding Resident #7's condition and he did not want to send the resident out to the hospital. He stated he would come into the facility to see the resident in the morning. LVN O stated Resident #7 had experienced 10 [MEDICAL CONDITION] by the time she reported to work at 6:00 a.m. on [DATE]. LVN O stated she let LVN D know about the resident's [MEDICAL CONDITION] activity. LVN D stated it was normal for her but then LVN O told her Resident #7 had not received the [MEDICATION NAME]. LVN D then advised LVN O to send Resident #7 out to the hospital. LVN O stated the procedure for obtaining medications included: upon admission the nurse on duty would check the medications with the physician and make changes as needed. The nurse would then immediately fax the physician orders [REDACTED]. The receiving nurse would check the inventory sheet against the medications upon arrival to the facility. Any discrepancies would be noted on the inventory sheet. LVN O stated the orders for [MEDICATION NAME] and [MEDICATION NAME] were not filled. She stated she understood the PCP was in the facility when Resident #7 was admitted , but the PCP did not write the scripts for the medications. LVN O stated she heard LVN I on the phone with the PCP who asked for a [MEDICATION NAME] for Resident #7. LVN O stated they did not have controlled medications in their emergency kits. Interview on [DATE] at 8:26 p.m. with LVN R revealed she worked on [DATE], [DATE] and [DATE] as the night charge nurse for Resident #7. LVN R stated she had worked at the facility for 3 weeks and had worked various shifts on different halls. LVN R stated she received limited training on the facility's medication pass policy and on their admission process. She stated Resident #7's medications dribbled in early morning on [DATE]. She realized later during the evening shift on the same date that 2 medications, [MEDICATION NAME] and [MEDICATION NAME], had not arrived. LVN R stated on the morning of [DATE] she did not pass the information on during report to LVN P during shift change. She commented she intended to but did not so she called the pharmacy. She learned she needed a written prescription for [MEDICATION NAME] because it was a controlled medication and the PCP did not write a script for it. Furthermore, the facility did not have any controlled medications in the E-kit and even if they did she was not an agent; did not have the authority or code to get into the E-kit. LVN R stated she called the NP after Resident #7 had her first [MEDICAL CONDITION] at midnight. The NP also told her she needed a written prescription for the [MEDICATION NAME] and would have to wait until he came to the facility in the morning. He stated she did not have to send Resident #7 out to the hospital. She let him know that Resident #7 had an order for [REDACTED]. LVN R stated Resident #7 then had a series of [MEDICAL CONDITION] before shift change at 6:00 a.m. She stated LVN D and LVN I had arrived and she asked them to help her with Resident #7. LVN R expressed a great deal of remorse and stated she felt very bad because of her mistake. She commented she felt so overwhelmed. She stated it was a very busy night; she had 2 admissions and a resident who was actively dying [MEDICAL CONDITION] that evening. LVN R stated one of the new admissions was very aggressive and the other one clung on to her medication cart the entire evening. He appeared to be paranoid and delusional. LVN R stated and then she had Resident #7 who was having [MEDICAL CONDITION]. She stated it was too much for a skeleton crew. LVN R stated she did the best that she could but in retrospect she should have called a manager for help. Also, she could have used training on what to do when medications were not delivered. LVN R stated LVN D told her she would get more help for the evening shift and would get someone to pass out medications so it would free up her time. LVN R stated they were short staffed and that administrative staff had been filling in the holes; working all the shifts that did not have sufficient staff on schedule. LVN R further stated the nurses were working 12 hour shifts instead of 8 hour shifts so that administrative staff did not have to work so much. Some of the nurses had quit. Review of a Resident Transfer Form dated [DATE] revealed Resident #7 was sent out to a local hospital via EMS stretcher with [DIAGNOSES REDACTED]. Review of a pharmacy proof of delivery with a date range from [DATE] to [DATE] revealed the facility received the prescription for [MEDICATION NAME] 97.2 mg on [DATE] at 4:57 p.m. after Resident #7 was transferred out to the hospital. Review of a lab dated [DATE] at 16:33 CT revealed Resident #7's [MEDICATION NAME] level was 15.5; the reference range was 10XXX,[DATE].0. Review of a hospital admission form dated [DATE] revealed Resident #7 was admitted into the hospital at 14:55 (2:55 p.m.) with chief complaint: ,[DATE] [MEDICAL CONDITION] since midnight, history of [MEDICAL CONDITION]. Review of hospital note dated [DATE] revealed Resident #7 was sent in from NF for sz since midnight per EMS. Pt had ,[DATE] sz. per staff. out of meds missed 2 doses of [MEDICATION NAME]. awake/non-verbal. normal for her. skin is pale. EMS reported 3 [MEDICAL CONDITION] approximately 30 seconds each. Interview on [DATE] at 5:12 p.m. with Resident #7's RP revealed the SW contacted her today to inform her the facility would not be able to accept the resident back into the facility due to her history of [MEDICAL CONDITION]. Resident #7's RP questioned why the facility's position changed in 2 days. The RP stated she learned on [DATE] that Resident #7 had not received her medications for 2 days and was sent out to the hospital because her son went to visit Resident #7 that day. She stated she was really upset when she was told the Dr. said it could wait until the morning. She stated she did not want it to happen to anyone else. Interview on [DATE] at 9:46 a.m. with LVN D/Unit Manager and the ADON revealed they did not have interdisciplinary team meetings to discuss more challenging admissions. LVN D and the ADON stated they were not always informed of and did not always provide input regarding new admissions. LVN D stated typically they asked for a new resident's H & P, medication list, nurse's notes, labs and asked about the resident's behaviors to determine if a resident was an appropriate placement. LVN D stated she audited Resident #7's chart when she was admitted into the facility but failed to inquire if the medications had been filled. She learned that not all staff was aware that [MEDICATION NAME] was a controlled medication and it required a written prescription (not a triplicate). The ADON stated LVN R was not trained to handle Resident #7's condition and LVN D stated the managers failed to explain to LVN R how to obtain medications right away. LVN D stated the PCP wrote a prescription for the [MEDICATION NAME] on the morning of [DATE]. Furthermore, upon receiving additional information about Resident #7's condition, they determined Resident #7 was not an appropriate placement. LVN D confirmed they should have obtained all necessary medical history prior to admitting Resident #7. LVN D also confirmed that Resident #7 did not receive [MEDICATION NAME] or [MEDICATION NAME] while she was at the facility and even though her [MEDICATION NAME] lab showed that her level was within normal limits, the facility failed to provide Resident #7 with the quality care she needed. LVN D further stated that Resident #7 required care from a neurologist which the facility did not have available for the resident. Interview on [DATE] at 10:05 a.m. with Resident #7's PCP revealed she saw Resident #7 upon admission into the facility. She confirmed she did not write the prescription for the [MEDICATION NAME] while at the facility; she stated it was an oversight. She stated she had a discussion with the NP regarding Resident #7's [MEDICAL CONDITION] activity on the morning of [DATE]. He told her he thought a triplicate prescription was needed for the [MEDICATION NAME]. He was also not aware of Resident #7's severe [MEDICAL CONDITION] disorder nor was the facility. However, the PCP stated the facility should have known her history and mentioned they relied on staff to provide the resident's medical history. The PCP mentioned many of the nurses at the facility were new and commented the facility was short staffed. The PCP stated the facility did not contact her about Resident #7's admission otherwise she would have told them she was not an appropriate placement. She stated Resident #7 had a VNS implant indicating she had a severe [MEDICAL CONDITION] disorder with 3 failed forms of treatment which were the qualifying factors for having a VNS implant. The PCP stated that Resident #7 required a neurologist to follow her care which was not available through the facility. Resident #7 also required on-going specialized care from RN nursing staff. The PCP stated she talked with the admitting physician at the local hospital who expressed great concern for Resident #7 stating she was very sick upon arrival. He stated she was in status meaning she was seizing without stopping and any treatment provided was not helping. Once she stabilized, he sent her to another hospital where she would receive the specialized care she needed. The PCP stated Resident #7 should have been sent out to the hospital after her first [MEDICAL CONDITION] at midnight based on her [MEDICAL CONDITION] disorder and on the fact that she had not received her [MEDICATION NAME] medication. The PCP stated Resident #7 could have died . Interview on [DATE] at 4:30 p.m. with the ADM and DON confirmed they did not have interdisciplinary meetings to discuss more difficult admissions. The DON stated she accepted Resident #7 as a new admission without obtaining all of the necessary medical background in order to make an informed decision. The ADM and the DON confirmed that Resident #7 was not an appropriate placement and that the facility did not have the resources to meet her needs. Interview on [DATE] at 2:25 p.m. with LVN D confirmed that a care plan was not developed to address Resident #7's [MEDICAL CONDITION] disorder or how to provide care via the VNS. LVN D stated they did not know that Resident #7 had a VNS implant or that her condition was not stable until they received additional information after she was in the facility. Furthermore, staff was not trained on the use of the VNS. LVN D stated usually there would be an order providing instructions its use. Interview on [DATE] at 2:46 p.m. with LVN R revealed she had personal experience in using a VNS. She stated LVN P also showed her to run the wand over the VNS to stimulate it which pulled the resident out of the [MEDICAL CONDITION]. LVN P told her that Resident #7's RP provided her with basic instructions. LVN R stated administrative staff did not provide any instructions or literature on how to use the VNS. Review of a policy titled Changes in Resident Condition dated 2008 read: For life-threatening events: Call 911 if initial assessment indicates that such action is necessary. Review of a policy titled, Standards of Nursing Practice dated 2005 read: We believe the use of the nursing process ensures appropriate care and services for each resident. The delivery of nursing care in the facility is based on a thorough assessment of the resident to identify his or her care needs. Once resident needs are identified, a comprehensive care plan is developed to attain individualized resident goals. The care plan is implemented by the interdisciplinary team and is continually evaluated for effectiveness. The care plan is updated as necessary to meet the resident's needs. Review of a facility policy titled, Admission to the Facility revised during [DATE] read: The facility will only admit residents referred by physician's orders [REDACTED]. Objectives: Admit residents whose needs can be me by the facility; Ensure that appropriate medical and financial records are provided to the facility prior to or upon admission. Responsibility: The facility will follow the established admission policy. The Administrator will review admissions periodically to determine if the policy is being followed. Review of a facility policy titled, Pharmacy Services dated [DATE] read: The intent of these requirements is that: In order to meet the needs of each resident, the facility accurately and safely provides or obtains pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed pharmacist; to serve at the consultant pharmacist. Review of a facility policy titled, Medication Administration revised during [DATE] read: Resident Medications are administered in an accurate, safe, timely, and sanitary manner. FUNDAMENTAL INFORMATION: New Medication Starts-Begin new medication orders timely. Begin routine orders on the same day ordered, unless the next dose would be normally given the next day. 2. Review of Resident #4's medical face sheet dated [DATE] revealed she had a [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and had other diagnoses, such as chronic pain and kidney disease. Review of Resident ;#4's physician orders [REDACTED]. She also had an order for [REDACTED]. Review of Resident #4's Quarterly MDS assessment with an assessment reference date of [DATE] revealed she scored a ,[DATE] on her BIMS making her cognitively intact. Review of Resident #4's Care Plan -Pain initiated on ,[DATE], and updated on [DATE] revealed that Resident #4 under the Problem section, had actual pain related to skin ulcer/wound and chronic disease process. Under the section titled Goal, Resident #4 will have reduced pain as measured by verbal expression and/or decrease in behaviors associated with pain .will verbally express increased satisfaction with pain control. Review of Resident #4's Medication Administration Record [REDACTED]. Review of Resident #4's Medication Administration Record [REDACTED]. She was given Tylenol two tablets on ,[DATE] and ,[DATE] along with her [MEDICATION NAME]. Section on the MAR's for result, and describe was noted effective for all but two of the PRN pain or nausea medications given in March. Two results sections were left blank. Review of Resident #4's clinical record revealed she had lab work completed on [DATE] which indicated a critical result of BUN of 88 which was called in to the facility and read back. This report also indicated it was faxed to renal on [DATE] by LVN II. Review of Resident #4's SBAR (Situation, Background, Assessment and Recommendations) Communication Form and Progress Note dated [DATE] for her transfer to the hospital revealed patient lethargic, presents with nausea/vomiting and dark urine. Review of Resident #4's hospital progress note dated [DATE] revealed she was admitted with back pain, nausea, decreased appetite and dehydration. She had foul smelling drainage from her wound to her sacrum and her urine cultures were positive for proteus mirabilis [MEDICAL CONDITION]. Her BUN (blood, urea and nitrogen level) was 91, normal range (,[DATE]). Review of Resident #4's hospital consultation report dated [DATE] revealed she had further [DIAGNOSES REDACTED]. She had a [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] and a history of chronic pai[DIAGNOSES REDACTED], and a history of [DIAGNOSES REDACTED] with a [MEDICAL CONDITION] in 2010. She required multiple debridement procedures eventually resulting in an [MEDICAL CONDITION] and a left renal stent placed in [DATE]. She was brought to the emergency room by EMS on [DATE] with complaint of severe pain in her buttock area along with nausea, vomiting, dyspepsia and generalized body weakness .she had lost her appetite and had decreased her oral intake. She was [MEDICAL CONDITION] a heart rate of 121, low-grade fever of 99.5 and blood pressure of ,[DATE]. Her creatinine was elevated to 3.78, over her baseline of 1XXX,[DATE].1. Interview on [DATE] at 1:40 p.m. with LVN II, revealed he faxed Resident #4's lab work results for [DATE] on [DATE] to the physician's company. Interview on [DATE] with Resident #4's physician, revealed that he did not recall getting notified of a critical BUN for Resident #4 and that if he had he would have had them repeat the lab or start an intravenous line on the resident for fluids. He said his company would have a record of the fax. No record was found by the company of a fax on Resident #4 with critical lab results from [DATE] to the date she was sent to the hospital on [DATE]. He said that he had come in and checked the resident and found no issues with her wound. He said that he had given her as much pain medication as he could and that he had to consider not just physical but psychological underlying reasons for pain with Resident #4. Observation on [DATE] at 11:00 a.m. of Resident #4 revealed she was sitting up in her wheel chair in her room, she had an indwelling urinary catheter that was draining straw colored urine and she appeared comfortable. In an interview at this same time, she said that before she was sent out to the hospital on [DATE] she kept telling staff that she was having more pain. She said she was not eating and that she was nauseated and throwing up. Interview on [DATE] at 1:00 p.m. with LVN S, he said that he worked with Resident #4 the week prior to her going to the hospital on [DATE], and that she looked lethargic and pale, not drinking, and complaining of nausea and vomiting. He said he did not think to call the physician about her nausea and vomiting. He said Resident #4 had the emesis basin next to her and that her mother was at the bedside. Interview on [DATE] at 2:00 p.m. with Resident #4 revealed that she was in so much pain two weeks prior to being sent out to the hospital that she did not talk to anyone which she liked to do, she did not do her coloring in her adult coloring book and did not sit up. She said that maybe one nurse out of 3 would evaluate her pain on a scale of ,[DATE], and if she could've rated her pain at that time it was greater than a 10. She said that the pain medication during that time was never effective and that she even had Tylenol given to her in addition to her pain medications because the nurses did not have anything else to give her. Interview on [DATE] at 10:00 a.m. with LVN E revealed that on [DATE] she was working and that Resident #4 appeared lethargic, and she checked her lab work. She said that she had not notified the physician of Resident #4's nausea and vomiting, only the lab result. She said that she saw the critical lab result from [DATE] and called the physician ' s office and received a STAT order for labs to be drawn, which was not written on a physician's orders [REDACTED]. Interview on [DATE] at 2:00 p.m. with CNA G who worked with Resident #4 the week prior to her being sent to the hospital revealed that Resident #4's pain was unbearable and she was asking for pain medication. She said that Resident #4 was acting out of it a few days prior to being sent out and she reported it a few times to the charge nurse. She said that she arrived on one shift and Resident #4 was vomiting and could barely sit up and was in tears. Interview on [DATE] at 2:30 p.m. with CNA F who worked with Resident #4 the week prior to her being sent to the hospital revealed that Resident #4's pain was constant and more than usual. She said she reported it to the nurses and Resident #4 was given her pain medication. She said Resident #4 was still in pain and she seemed to be worse. She said Resident #4 got to the point where the CNA could not even touch the bed, she refused her shower, her appetite decreased, she cancelled an appointment and she did not get out of bed. She said that her urine was sometimes bloody and dark, and that all they could do was report it to the nurses. Interview on [DATE] at 2:45 p.m. with CNA H who worked with Resident #4 in the days prior to her being sent to the hospital revealed that Resident #4's condition had changed. She said that something was different and that she had seen her in pain before, but this time she could not even touch the bed without Resident #4 crying out and she refused her shower. CNA H said that Resident #4 did not want to get up and her urine was pinkish red and that her ostomy would bleed also. She said that her pain medication was not effective during that time and that she was so disoriented she could not find her phone charger and it was sitting on her chest. She said Resident #4 was also throwing up. Interview on [DATE] at 2:55 p.m. with LVN P who worked with Resident #4 the week prior to Resident #4 being sent out revealed that Resident #4 was in excruciating pain and that she notified the physician and he came in and checked her wound (no documentation to support this). She said Resident #4's catheter kept coming out and that she thought about sending Resident #4 to the hospital but the physician did not think that it was necessary. She said he did not order anything else because he said she was on as much pain medication as he could order. She said that she notified her DON who thought that Resident #4 would feel better if she tried to get up out of bed. She said they tried to get the resident up out of bed and she refused. She said that she did not use a pain scale to rate pain effectiveness. Interview on [DATE] at 3:00 p.m. with the Clinical Regional Director revealed that it is what the resident thinks for pain medication to be effective when considering the effectiveness of pain medication. Interview on [DATE] at 3:40 p.m. with Resident #4's mother revealed that the Saturday prior to her going to the hospital on [DATE], she visited her daughter and that her daughter's pain was different. She said that her daughter was not eating, urine was almost red cloudy and thick and that she sat there for an hour and her daughter did not have any output. She said that her grandson came back on Sunday [DATE] and that was when she was sent out to the hospital upon her grandson's request. Interview on [DATE] at 4:00 p.m. with LVN O revealed that Resident #4's family prompted her to send the resident to the hospital on [DATE]. She said that when she went in and looked at Resident #4 her lips were dry and cracked and she had not eaten breakfast and she normally ate good. She said that she did not notify the physician of the residents increased nausea and vomiting because she was being medicated for it. She said her urine was reddish yellow and she was pale and clammy. Review of Resident #4's nurse's notes for [DATE] revealed that no new notes had been written from [DATE] to [DATE]. Review of Resident #4's nurse's note from [DATE] at 0400 revealed Resident had a small brownish clear emesis. Medicated as ordered. [MEDICAL CONDITION] leaking due to stool and pressure in bag. Changed entire [MEDICAL CONDITION]. Review of Resident #4's PRN Pain Medication Administration Record [REDACTED]. Post medication assessment scores ranged from two 0's, one 1, six 2's, eleven 3's, ten 4's and one 5. Review of facility policy revision date [DATE] on Pain Management revealed under Fourth Step: Putting the Plan into Action .to be successful your team must be consistent; everyone must provide the same type of care to the resident every day, and be proactive to make sure that the resident achieves relief and remains free of pain. Monitoring the resident and communicating with each and every team member regarding the pain management for your identified residents is crucial .Fifth Step: Re-evaluate on a regular basis .you need to re-evaluate the resident on a regular basis. This will be done each time you administer a pain medication to the resident, evaluating the effectiveness of a medication and making changes if the me

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibited neglect for 5 of 15 residents (#3, #4, #5, #6 & #7) who were reviewed for neglect in that: 1. LVN R (Charge Nurse) and LVN D (Unit Manager) did not ensure that 2 prescriptions, [MEDICATION NAME] and [MEDICATION NAME] (used for [MEDICAL CONDITION]) were available or that Resident #7 received the medications for 2 days. Resident #7 was diagnosed with [REDACTED]. Resident #7 had 9 [MEDICAL CONDITION] before she was sent out to the hospital. 2. Resident #4 had a change in condition, increased pain, nausea and vomiting in the last two weeks of [DATE]. She also had a critical lab result on [DATE] that was not followed up on for five days. She was sent to the hospital on [DATE] after staff was prompted by family members and she was diagnosed with [REDACTED]. 3. Nursing staff did not use a bed alarm (an identified intervention) and provide adequate supervision for Resident #6 (who was in the locked unit) and who had experienced multiple falls. 4. Nursing staff did not use a low bed, a mat to the bedside and did not ensure the bed alarm was on (identified interventions) for Resident #3 who had a history of [REDACTED]. 5. The ADM did not report that Resident #5 had an unwitnessed fall, resulting in a major injury, to DADS. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at a scope of pattern at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. These deficient practices could affect 17 residents who had a fall during March and [DATE] in the 100 hall; 7 residents with a [MEDICAL CONDITION] disorder and 94 residents who could experience a significant change in condition and could result in serious medical complications [REDACTED]. The findings were: 1. Review of a facility policy titled, Abuse and Neglect Prohibition dated [DATE] read: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect. The facility will report such allegations to the state, in accordance with state regulation. Review of Resident #7's medical face sheet (undated) revealed she was admitted into the facility on [DATE] at 13:00 (1:00 p.m.). Review of Resident #7's admission orders [REDACTED]. Further review revealed an order for [REDACTED]. Review of a Nursing Admission Intake Form dated [DATE] revealed Resident #7 had a VNS implant on her left side to control [MEDICAL CONDITION]. There was not a plan to address the use of the VNS implant. Review of an Interim Plan of Care dated [DATE] did not address the fact that Resident #7 had a [MEDICAL CONDITION] disorder, a VNS implant and how staff was going to ensure her needs were met. Review of a H & P dated [DATE] revealed Resident #7 was transferred into the facility from a hospital with a severe sz d/o. Resident #7's assessment and plan for her [MEDICAL CONDITION] disorder included orders for [MEDICATION NAME] ER, [MEDICATION NAME] and [MEDICATION NAME] level in AM. Review of a MAR indicated [REDACTED]. Review of an incident/accident report dated [DATE] at 12:10 a.m. revealed Resident #7 was lying in bed and was noted having atonic-clonic [MEDICAL CONDITION] activity at 12:10 p.m. Further review revealed her VNS magnet was utilized and Resident #7 stopped having [MEDICAL CONDITION] activity. The NP was notified at this same time. Review of a nurse's note dated [DATE] at 12:10 a.m. read: Resident was lying in bed having atonic-clonic [MEDICAL CONDITION]. This nurse used VNS magnet and resident stopped seizing after fifteen seconds. The NP notified of [MEDICAL CONDITION]. Informed him that resident missed two doses of [MEDICATION NAME] due to pharmacy not delivering after repeated attempts to let pharmacy know that residents ' [MEDICATION NAME] and [MEDICATION NAME] have not arrived. The NP informed this nurse that pharmacy has to have written scripts faxed over to them and that this writer will have to take care of getting scripts for resident in AM. This writer called the pharmacy and asked if this nurse could get [MEDICATION NAME] out of the emergency kit. The pharmacy informed this writer that only an agent can do this and that this writer is not an agent and that the NF does not have a controlled emergency medicine kit. Resident resting quietly in bed after [MEDICAL CONDITION]. VS WNL and are as follows: 99, 88, 22, ,[DATE] and 02 sat of 98% on RA. Tracks this writer's hand and tries to push b/p cuff away from her. Tolerating [DEVICE] feeding water flushes and meds well. Call light within reach. Will cont to monitor resident closely. Review of a second incident/accident report dated [DATE] at 5:45 a.m. revealed Resident #7 having multiple tonic-clonic [MEDICAL CONDITION] approximately 30 seconds each. LVN R wrote she witnessed the resident having 3 [MEDICAL CONDITION] within approximately ,[DATE] minutes. Review of an incident/accident investigation follow-up dated [DATE] read Resident #7 experienced uncontrolled tonic-clonic [MEDICAL CONDITION] activity. VNS magnet utilized & [MEDICAL CONDITION] activity would stop for time then would restart. Total of 9 [MEDICAL CONDITION] prior to going to ER. The summary of investigation revealed the pharmacy had not delivered the [MEDICATION NAME] and [MEDICATION NAME] for Resident #7. The NP was notified of the [MEDICAL CONDITION] activity at 12:10 a.m. and the PCP was notified at 6:15 a.m. Review of a nurse's note dated [DATE] at 7:15 a.m. read: Resident was found in bed @ 5:45 a.m. seizing and had vomited all over her hospital gown. This writer used magnet for VNS and resident stopped seizing after 30 seconds. Resident had two more [MEDICAL CONDITION] in a ten minute period. NF supervisor notified PCP ordered that resident be sent into hospital for assessment and evaluation. Resident had six more [MEDICAL CONDITION] over the next 30 minutes before EMS arrived. Resident would come out of [MEDICAL CONDITION] after magnet was used over VNS, but would go into another [MEDICAL CONDITION], just a few minutes afterwards. All [MEDICAL CONDITION] have been tonic-clonic in nature. VS were taken before EMS arrived and are as follows: ,[DATE], 100, 24 and 100.7. Family member will be contacted by supervisor. Interview on [DATE] at 11:14 a.m. with LVN I revealed she assisted with Resident #7's transfer to the hospital on [DATE]. She learned Resident #7 had a [MEDICAL CONDITION] at midnight and then in the morning during shift change. She was told Resident #7 missed 2 doses of [MEDICATION NAME] but when she looked at the MAR indicated [REDACTED]. LVN I stated she called the NP who was not returning her calls so LVN/Unit Manager D told her to call the PCP who then provided orders to send the resident out to a local hospital. Interview on [DATE] at 11:38 a.m. with LVN O revealed she also assisted with Resident #7's transfer to the hospital on [DATE] due to the resident experiencing multiple [MEDICAL CONDITION]. LVN O stated she learned the NP was called at midnight regarding Resident #7's condition and he did not want to send the resident out to the hospital. He stated he would come into the facility to see the resident in the morning. LVN O stated Resident #7 had experienced 10 [MEDICAL CONDITION] by the time she reported to work at 6:00 a.m. on [DATE]. LVN O stated she let LVN D know about the resident's [MEDICAL CONDITION] activity. LVN D stated it was normal for her but then LVN O told her Resident #7 had not received the [MEDICATION NAME]. LVN D then advised LVN O to send Resident #7 out to the hospital. LVN O stated the procedure for obtaining medications included: upon admission the nurse on duty would check the medications with the physician and make changes as needed. The nurse would then immediately fax the physician orders [REDACTED]. The receiving nurse would check the inventory sheet against the medications upon arrival to the facility. Any discrepancies would be noted on the inventory sheet. LVN O stated the orders for [MEDICATION NAME] and [MEDICATION NAME] were not filled. She stated she understood the PCP was in the facility when Resident #7 was admitted , but the PCP did not write the scripts for the medications. LVN O stated she heard LVN I on the phone with the PCP who asked for a [MEDICATION NAME] for Resident #7. LVN O stated they did not have controlled medications in their emergency kits. Interview on [DATE] at 8:26 p.m. with LVN R revealed she worked on [DATE], [DATE] and [DATE] as the night charge nurse for Resident #7. LVN R stated she had worked at the facility for 3 weeks and had worked various shifts on different halls. LVN R stated she received limited training on the facility's medication pass policy and on their admission process. She stated Resident #7's medications dribbled in early morning on [DATE]. She realized later during the evening shift on the same date that 2 medications, [MEDICATION NAME] and [MEDICATION NAME], had not arrived. LVN R stated on the morning of [DATE] she did not pass the information on during report to LVN P during shift change. She commented she intended to but did not so she called the pharmacy. She learned she needed a written prescription for [MEDICATION NAME] because it was a controlled medication and the PCP did not write a script for it. Furthermore, the facility did not have any controlled medications in the E-kit and even if they did she was not an agent; did not have the authority or code to get into the E-kit. LVN R stated she called the NP after Resident #7 had her first [MEDICAL CONDITION] at midnight. The NP also told her she needed a written prescription for the [MEDICATION NAME] and would have to wait until he came to the facility in the morning. He stated she did not have to send Resident #7 out to the hospital. She let him know that Resident #7 had an order for [REDACTED]. LVN R stated Resident #7 then had a series of [MEDICAL CONDITION] before shift change at 6:00 a.m. She stated LVN D and LVN I had arrived and she asked them to help her with Resident #7. LVN R expressed a great deal of remorse and stated she felt very bad because of her mistake. She commented she felt so overwhelmed. She stated it was a very busy night; she had 2 admissions and a resident who was actively dying [MEDICAL CONDITION] that evening. LVN R stated one of the new admissions was very aggressive and the other one clung on to her medication cart the entire evening. He appeared to be paranoid and delusional. LVN R stated and then she had Resident #7 who was having [MEDICAL CONDITION]. She stated it was too much for a skeleton crew. LVN R stated she did the best that she could but in retrospect she should have called a manager for help. Also, she could have used training on what to do when medications were not delivered. LVN R stated LVN D told her she would get more help for the evening shift and would get someone to pass out medications so it would free up her time. LVN R stated they were short staffed and that administrative staff had been filling in the holes; working all the shifts that did not have sufficient staff on schedule. LVN R further stated the nurses were working 12 hour shifts instead of 8 hour shifts so that administrative staff did not have to work so much. Some of the nurses had quit. Review of a Resident Transfer Form dated [DATE] revealed Resident #7 was sent out to a local hospital via EMS stretcher with [DIAGNOSES REDACTED]. Review of a pharmacy proof of delivery with a date range from [DATE] to [DATE] revealed the facility received the prescription for [MEDICATION NAME] 97.2 mg on [DATE] at 4:57 p.m. after Resident #7 was transferred out to the hospital. Review of a lab dated [DATE] at 16:33 CT revealed Resident #7's [MEDICATION NAME] level was 15.5; the reference range was 10XXX,[DATE].0. Review of a hospital admission form dated [DATE] revealed Resident #7 was admitted into the hospital at 14:55 (2:55 p.m.) with chief complaint: ,[DATE] [MEDICAL CONDITION] since midnight, history of [MEDICAL CONDITION]. Review of hospital note dated [DATE] revealed Resident #7 was sent in from NF for sz since midnight per EMS. Pt had ,[DATE] sz. per staff. out of meds missed 2 doses of [MEDICATION NAME]. awake/non-verbal. normal for her. skin is pale. EMS reported 3 [MEDICAL CONDITION] approximately 30 seconds each. Interview on [DATE] at 5:12 p.m. with Resident #7's RP revealed the SW contacted her today to inform her the facility would not be able to accept the resident back into the facility due to her history of [MEDICAL CONDITION]. Resident #7's RP questioned why the facility's position changed in 2 days. The RP stated she learned on [DATE] that Resident #7 had not received her medications for 2 days and was sent out to the hospital because her son went to visit Resident #7 that day. She stated she was really upset when she was told the Dr. said it could wait until the morning. She stated she did not want it to happen to anyone else. Interview on [DATE] at 9:46 a.m. with LVN D/Unit Manager and the ADON revealed they did not have interdisciplinary team meetings to discuss more challenging admissions. LVN D and the ADON stated they were not always informed of and did not always provide input regarding new admissions. LVN D stated typically they asked for a new resident's H & P, medication list, nurse's notes, labs and asked about the resident's behaviors to determine if a resident was an appropriate placement. LVN D stated she audited Resident #7's chart when she was admitted into the facility but failed to inquire if the medications had been filled. She learned that not all staff was aware that [MEDICATION NAME] was a controlled medication and it required a written prescription (not a triplicate). The ADON stated LVN R was not trained to handle Resident #7's condition and LVN D stated the managers failed to explain to LVN R how to obtain medications right away. LVN D stated the PCP wrote a prescription for the [MEDICATION NAME] on the morning of [DATE]. Furthermore, upon receiving additional information about Resident #7's condition, they determined Resident #7 was not an appropriate placement. LVN D confirmed they should have obtained all necessary medical history prior to admitting Resident #7. LVN D also confirmed that Resident #7 did not receive [MEDICATION NAME] or [MEDICATION NAME] while she was at the facility and even though her [MEDICATION NAME] lab showed that her level was within normal limits, the facility failed to provide Resident #7 with the quality care she needed. LVN D further stated that Resident #7 required care from a neurologist which the facility did not have available for the resident. Interview on [DATE] at 10:05 a.m. with Resident #7's PCP revealed she saw Resident #7 upon admission into the facility. She confirmed she did not write the prescription for the [MEDICATION NAME] while at the facility; she stated it was an oversight. She stated she had a discussion with the NP regarding Resident #7's [MEDICAL CONDITION] activity on the morning of [DATE]. He told her he thought a triplicate prescription was needed for the [MEDICATION NAME]. He was also not aware of Resident #7's severe [MEDICAL CONDITION] disorder nor was the facility. However, the PCP stated the facility should have known her history and mentioned they relied on staff to provide the resident's medical history. The PCP mentioned many of the nurses at the facility were new and commented the facility was short staffed. The PCP stated the facility did not contact her about Resident #7's admission otherwise she would have told them she was not an appropriate placement. She stated Resident #7 had a VNS implant indicating she had a severe [MEDICAL CONDITION] disorder with 3 failed forms of treatment which were the qualifying factors for having a VNS implant. The PCP stated that Resident #7 required a neurologist to follow her care which was not available through the facility. Resident #7 also required on-going specialized care from RN nursing staff. The PCP stated she talked with the admitting physician at the local hospital who expressed great concern for Resident #7 stating she was very sick upon arrival. He stated she was in status meaning she was seizing without stopping and any treatment provided was not helping. Once she stabilized, he sent her to another hospital where she would receive the specialized care she needed. The PCP stated Resident #7 should have been sent out to the hospital after her first [MEDICAL CONDITION] at midnight based on her [MEDICAL CONDITION] disorder and on the fact that she had not received her [MEDICATION NAME] medication. The PCP stated Resident #7 could have died . Interview on [DATE] at 4:30 p.m. with the ADM and DON confirmed they did not have interdisciplinary meetings to discuss more difficult admissions. The DON stated she accepted Resident #7 as a new admission without obtaining all of the necessary medical background in order to make an informed decision. The ADM and the DON confirmed that Resident #7 was not an appropriate placement and that the facility did not have the resources to meet her needs. Interview on [DATE] at 2:25 p.m. with LVN D confirmed that a care plan was not developed to address Resident #7's [MEDICAL CONDITION] disorder or how to provide care via the VNS. LVN D stated they did not know that Resident #7 had a VNS implant or that her condition was not stable until they received additional information after she was in the facility. Furthermore, staff was not trained on the use of the VNS. LVN D stated usually there would be an order providing instructions its use. Interview on [DATE] at 2:46 p.m. with LVN R revealed she had personal experience in using a VNS. She stated LVN P also showed her to run the wand over the VNS to stimulate it which pulled the resident out of the [MEDICAL CONDITION]. LVN P told her that Resident #7's RP provided her with basic instructions. LVN R stated administrative staff did not provide any instructions or literature on how to use the VNS. Review of a policy titled Changes in Resident Condition dated 2008 read: For life-threatening events: Call 911 if initial assessment indicates that such action is necessary. Review of a policy titled, Standards of Nursing Practice dated 2005 read: We believe the use of the nursing process ensures appropriate care and services for each resident. The delivery of nursing care in the facility is based on a thorough assessment of the resident to identify his or her care needs. Once resident needs are identified, a comprehensive care plan is developed to attain individualized resident goals. The care plan is implemented by the interdisciplinary team and is continually evaluated for effectiveness. The care plan is updated as necessary to meet the resident's needs. Review of a facility policy titled, Admission to the Facility revised during [DATE] read: The facility will only admit residents referred by physician's orders [REDACTED]. Objectives: Admit residents whose needs can be me by the facility; Ensure that appropriate medical and financial records are provided to the facility prior to or upon admission. Responsibility: The facility will follow the established admission policy. The Administrator will review admissions periodically to determine if the policy is being followed. Review of a facility policy titled, Pharmacy Services dated [DATE] read: The intent of these requirements is that: In order to meet the needs of each resident, the facility accurately and safely provides or obtains pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed pharmacist; to serve at the consultant pharmacist. Review of a facility policy titled, Medication Administration revised during [DATE] read: Resident Medications are administered in an accurate, safe, timely, and sanitary manner. FUNDAMENTAL INFORMATION: New Medication Starts-Begin new medication orders timely. Begin routine orders on the same day ordered, unless the next dose would be normally given the next day. 2. Review of Resident #4's medical face sheet dated [DATE] revealed she had a [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and had other diagnoses, such as chronic pain and kidney disease. Review of Resident ;#4's physician orders [REDACTED]. She also had an order for [REDACTED]. Review of Resident #4's Quarterly MDS assessment with an assessment reference date of [DATE] revealed she scored a ,[DATE] on her BIMS making her cognitively intact. Review of Resident #4's Care Plan -Pain initiated on ,[DATE], and updated on [DATE] revealed that Resident #4 under the Problem section, had actual pain related to skin ulcer/wound and chronic disease process. Under the section titled Goal, Resident #4 will have reduced pain as measured by verbal expression and/or decrease in behaviors associated with pain .will verbally express increased satisfaction with pain control. Review of Resident #4's Medication Administration Record [REDACTED]. Review of Resident #4's Medication Administration Record [REDACTED]. She was given Tylenol two tablets on ,[DATE] and ,[DATE] along with her [MEDICATION NAME]. Section on the MAR's for result, and describe was noted effective for all but two of the PRN pain or nausea medications given in March. Two results sections were left blank. Review of Resident #4's clinical record revealed she had lab work completed on [DATE] which indicated a critical result of BUN of 88 which was called in to the facility and read back. This report also indicated it was faxed to renal on [DATE] by LVN II. Review of Resident #4's SBAR (Situation, Background, Assessment and Recommendations) Communication Form and Progress Note dated [DATE] for her transfer to the hospital revealed patient lethargic, presents with nausea/vomiting and dark urine. Review of Resident #4's hospital progress note dated [DATE] revealed she was admitted with back pain, nausea, decreased appetite and dehydration. She had foul smelling drainage from her wound to her sacrum and her urine cultures were positive for proteus mirabilis [MEDICAL CONDITION]. Her BUN (blood, urea and nitrogen level) was 91, normal range (,[DATE]). Review of Resident #4's hospital consultation report dated [DATE] revealed she had further [DIAGNOSES REDACTED]. She had a [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] and a history of chronic pai[DIAGNOSES REDACTED], and a history of [DIAGNOSES REDACTED] with a [MEDICAL CONDITION] in 2010. She required multiple debridement procedures eventually resulting in an [MEDICAL CONDITION] and a left renal stent placed in [DATE]. She was brought to the emergency room by EMS on [DATE] with complaint of severe pain in her buttock area along with nausea, vomiting, dyspepsia and generalized body weakness .she had lost her appetite and had decreased her oral intake. She was [MEDICAL CONDITION] a heart rate of 121, low-grade fever of 99.5 and blood pressure of ,[DATE]. Her creatinine was elevated to 3.78, over her baseline of 1XXX,[DATE].1. Interview on [DATE] at 1:40 p.m. with LVN II, revealed he faxed Resident #4's lab work results for [DATE] on [DATE] to the physician's company. Interview on [DATE] with Resident #4's physician, revealed that he did not recall getting notified of a critical BUN for Resident #4 and that if he had he would have had them repeat the lab or start an intravenous line on the resident for fluids. He said his company would have a record of the fax. No record was found by the company of a fax on Resident #4 with critical lab results from [DATE] to the date she was sent to the hospital on [DATE]. He said that he had come in and checked the resident and found no issues with her wound. He said that he had given her as much pain medication as he could and that he had to consider not just physical but psychological underlying reasons for pain with Resident #4. Observation on [DATE] at 11:00 a.m. of Resident #4 revealed she was sitting up in her wheel chair in her room, she had an indwelling urinary catheter that was draining straw colored urine and she appeared comfortable. In an interview at this same time, she said that before she was sent out to the hospital on [DATE] she kept telling staff that she was having more pain. She said she was not eating and that she was nauseated and throwing up. Interview on [DATE] at 1:00 p.m. with LVN S, he said that he worked with Resident #4 the week prior to her going to the hospital on [DATE], and that she looked lethargic and pale, not drinking, and complaining of nausea and vomiting. He said he did not think to call the physician about her nausea and vomiting. He said Resident #4 had the emesis basin next to her and that her mother was at the bedside. Interview on [DATE] at 2:00 p.m. with Resident #4 revealed that she was in so much pain two weeks prior to being sent out to the hospital that she did not talk to anyone which she liked to do, she did not do her coloring in her adult coloring book and did not sit up. She said that maybe one nurse out of 3 would evaluate her pain on a scale of ,[DATE], and if she could've rated her pain at that time it was greater than a 10. She said that the pain medication during that time was never effective and that she even had Tylenol given to her in addition to her pain medications because the nurses did not have anything else to give her. Interview on [DATE] at 10:00 a.m. with LVN E revealed that on [DATE] she was working and that Resident #4 appeared lethargic, and she checked her lab work. She said that she had not notified the physician of Resident #4's nausea and vomiting, only the lab result. She said that she saw the critical lab result from [DATE] and called the physician ' s office and received a STAT order for labs to be drawn, which was not written on a physician's orders [REDACTED]. Interview on [DATE] at 2:00 p.m. with CNA G who worked with Resident #4 the week prior to her being sent to the hospital revealed that Resident #4's pain was unbearable and she was asking for pain medication. She said that Resident #4 was acting out of it a few days prior to being sent out and she reported it a few times to the charge nurse. She said that she arrived on one shift and Resident #4 was vomiting and could barely sit up and was in tears. Interview on [DATE] at 2:30 p.m. with CNA F who worked with Resident #4 the week prior to her being sent to the hospital revealed that Resident #4's pain was constant and more than usual. She said she reported it to the nurses and Resident #4 was given her pain medication. She said Resident #4 was still in pain and she seemed to be worse. She said Resident #4 got to the point where the CNA could not even touch the bed, she refused her shower, her appetite decreased, she cancelled an appointment and she did not get out of bed. She said that her urine was sometimes bloody and dark, and that all they could do was report it to the nurses. Interview on [DATE] at 2:45 p.m. with CNA H who worked with Resident #4 in the days prior to her being sent to the hospital revealed that Resident #4's condition had changed. She said that something was different and that she had seen her in pain before, but this time she could not even touch the bed without Resident #4 crying out and she refused her shower. CNA H said that Resident #4 did not want to get up and her urine was pinkish red and that her ostomy would bleed also. She said that her pain medication was not effective during that time and that she was so disoriented she could not find her phone charger and it was sitting on her chest. She said Resident #4 was also throwing up. Interview on [DATE] at 2:55 p.m. with LVN P who worked with Resident #4 the week prior to Resident #4 being sent out revealed that Resident #4 was in excruciating pain and that she notified the physician and he came in and checked her wound (no documentation to support this). She said Resident #4's catheter kept coming out and that she thought about sending Resident #4 to the hospital but the physician did not think that it was necessary. She said he did not order anything else because he said she was on as much pain medication as he could order. She said that she notified her DON who thought that Resident #4 would feel better if she tried to get up out of bed. She said they tried to get the resident up out of bed and she refused. She said that she did not use a pain scale to rate pain effectiveness. Interview on [DATE] at 3:00 p.m. with the Clinical Regional Director revealed that it is what the resident thinks for pain medication to be effective when considering the effectiveness of pain medication. Interview on [DATE] at 3:40 p.m. with Resident #4's mother revealed that the Saturday prior to her going to the hospital on [DATE], she visited her daughter and that her daughter's pain was different. She said that her daughter was not eating, urine was almost red cloudy and thick and that she sat there for an hour and her daughter did not have any output. She said that her grandson came back on Sunday [DATE] and that was when she was sent out to the hospital upon her grandson's request. Interview on [DATE] at 4:00 p.m. with LVN O revealed that Resident #4's family prompted her to send the resident to the hospital on [DATE]. She said that when she went in and looked at Resident #4 her lips were dry and cracked and she had not eaten breakfast and she normally ate good. She said that she did not notify the physician of the residents increased nausea and vomiting because she was being medicated for it. She said her urine was reddish yellow and she was pale and clammy. Review of Resident #4's nurse's notes for [DATE] revealed that no new notes had been written from [DATE] to [DATE]. Review of Resident #4's nurse's note from [DATE] at 0400 revealed Resident had a small brownish clear emesis. Medicated as ordered. [MEDICAL CONDITION] leaking due to stool and pressure in bag. Changed entire [MEDICAL CONDITION]. Review of Resident #4's PRN Pain Medication Administration Record [REDACTED]. Post medication assessment scores ranged

Based on observation, interview and record review the facility failed to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 12 residents (#4) whose care was reviewed in that: Resident #4 had a change in condition, increased pain, nausea and vomiting in the last two weeks of March 2016. She also had a critical lab result on 3/29/16 that was not followed up on for five days. She was sent to the hospital on [DATE] after staff was prompted by family and she was diagnosed with [REDACTED]. This deficient practice resulted in an Immediate Jeopardy (IJ) on 5/4/16. The IJ was removed on 5/18/16. The facility remained out of compliance at a scope of pattern at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. This deficient practice could affect 94 residents who could experience a significant change in condition and could result in serious medical complications [REDACTED]. The findings were: Review of Resident #4's medical face sheet dated 4/26/16 revealed she had a [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and had other diagnoses, such as chronic pain and kidney disease. Review of Resident #4's physician orders [REDACTED]. She also had an order for [REDACTED]. A PRN order of [MEDICATION NAME] 325mg two tablets by mouth every six hours for pain was ordered on [DATE]. Review of Resident #4's Quarterly MDS assessment with an assessment reference date of 3/14/16 revealed she scored a 15/15 on her BIMS making her cognitively intact. Review of Resident #4's Care Plan -Pain initiated on 2/15, and updated on 5/6/16 revealed that Resident #4 under the Problem section, had actual pain related to skin ulcer/wound and chronic disease process. Under the section titled Goal, Resident #4 will have reduced pain as measured by verbal expression and/or decrease in behaviors associated with pain .will verbally express increased satisfaction with pain control. Review of Resident #4's Medication Administration Record for February 2016 revealed she received [MEDICATION NAME] 10/325 mg one tab by mouth 33 times, no [MEDICATION NAME] for nausea and no Tylenol. Review of Resident #4's Medication Administration Record for March 2016 revealed she received [MEDICATION NAME] 10/325 mg one tab by mouth 51 times, [MEDICATION NAME] 25mg tablet for nausea on 3/14, 3/23, 3/26, 3/27, 3/29, 3/30 and twice on 3/17. She was given Tylenol two tablets on 3/5 and 3/19 along with her [MEDICATION NAME]. Section on the MAR's for result, and describe was noted effective for all but two of the PRN pain or nausea medications given in March. Two results sections were left blank. Review of Resident #4's clinical record revealed she had lab work completed on 3/29/16 which indicated a critical result of BUN of 88 which was called in to the facility and read back. This report also indicated it was faxed to renal on 3/30/16 by LVN II. Review of Resident #4's SBAR (Situation, Background, Assessment and Recommendations) Communication Form and Progress Note dated 4/3/16 for her transfer to the hospital revealed patient lethargic, presents with nausea/vomiting and dark urine. Review of Resident #4's hospital progress note dated 4/5/16 revealed she was admitted with back pain, nausea, decreased appetite and dehydration. She had foul smelling drainage from her wound to her sacrum and her urine cultures were positive for proteus mirabilis [MEDICAL CONDITION]. Her BUN (blood, urea and nitrogen level) was 91, normal range (7-25). Review of Resident #4's hospital consultation report dated 4/8/16 revealed she had further [DIAGNOSES REDACTED]. She had a [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] and a history of chronic pai[DIAGNOSES REDACTED], and a history of [DIAGNOSES REDACTED] with a [MEDICAL CONDITION] in 2010. She required multiple debridement procedures eventually resulting in an [MEDICAL CONDITION] and a left renal stent placed in October 2013. She was brought to the emergency room by EMS on 4/3/16 with complaint of severe pain in her buttock area along with nausea, vomiting, dyspepsia and generalized body weakness .she had lost her appetite and had decreased her oral intake. She was [MEDICAL CONDITION] a heart rate of 121, low-grade fever of 99.5 and blood pressure of 105/63. Her creatinine was elevated to 3.78, over her baseline of 1.8-2.1. Interview on 5/5/16 at 1:40 p.m. with LVN II, revealed he faxed Resident #4's lab work results for 3/29/16 on 3/30/16 to the physician's company. Interview on 5/6/16 with Resident #4's physician, revealed that he did not recall getting notified of a critical BUN for Resident #4 and that if he had he would have had them repeat the lab or start an intravenous line on the resident for fluids. He said his company would have a record of the fax. No record was found by the company of a fax on Resident #4 with critical lab results from 3/29/16 to the date she was sent to the hospital on [DATE]. He said that he had come in and checked the resident and found no issues with her wound. He said that he had given her as much pain medication as he could and that he had to consider not just physical but psychological underlying reasons for pain with Resident #4. Observation on 5/5/16 at 11:00 a.m. of Resident #4 revealed she was sitting up in her wheel chair in her room, she had an indwelling urinary catheter that was draining straw colored urine and she appeared comfortable. In an interview at this same time, she said that before she was sent out to the hospital on [DATE] she kept telling staff that she was having more pain. She said she was not eating and that she was nauseated and throwing up. Interview on 5/5/16 at 1:00 p.m. with LVN S, he said that he worked with Resident #4 the week prior to her going to the hospital on [DATE], and that she looked lethargic and pale, not drinking, and complaining of nausea and vomiting. He said he did not think to call the physician about her nausea and vomiting. He said Resident #4 had the emesis basin next to her and that her mother was at the bedside. Interview on 5/6/16 at 2:00 p.m. with Resident #4 revealed that she was in so much pain two weeks prior to being sent out to the hospital that she did not talk to anyone who she liked to, she did not do her coloring in her adult coloring book and did not sit up. She said that maybe one nurse out of 3 would evaluate her pain on a scale of 1-10, and if she could've rated her pain at that time it was greater than a 10. She said that the pain medication during that time was never effective and that she even had Tylenol given to her in addition to her pain medications because the nurses did not have anything else to give her. Interview on 5/5/16 at 10:00 a.m. with LVN E revealed that on 4/2/16 she was working and that Resident #4 appeared lethargic, and she checked her lab work. She said that she had not notified the physician of Resident #4's nausea and vomiting; only the lab results. She said that she saw the critical lab result from 3/29/16 and called the physician ' s office and received a STAT order for labs to be drawn, which was not written on a physician's orders [REDACTED]. Interview on 5/5/16 at 2:00 p.m. with CNA G who worked with Resident #4 the week prior to her being sent to the hospital revealed that Resident #4's pain was unbearable and she was asking for pain medication. She said that Resident #4 was acting out of it a few days prior to being sent out and she reported it a few times to the charge nurse. She said that she arrived on one shift and Resident #4 was vomiting and could barely sit up and was in tears. Interview on 5/5/16 at 2:30 p.m. with CNA F who worked with Resident #4 the week prior to her being sent to the hospital revealed that Resident #4's pain was constant and more than usual. She said she reported it to the nurses and Resident #4 was given her pain medication. She said Resident #4 was still in pain and she seemed to be worse. She said Resident #4 got to the point where the CNA could not even touch the bed, she refused her shower, her appetite decreased, she cancelled an appointment and she did not get out of bed. She said that her urine was sometimes bloody and dark, and that all they could do was report it to the nurses. Interview on 5/5/16 at 2:45 p.m. with CNA H who worked with Resident #4 in the days prior to her being sent to the hospital revealed that Resident #4's condition had changed. She said that something was different and that she had seen her in pain before, but this time she could not even touch the bed without Resident #4 crying out and she refused her shower. CNA H said that Resident #4 did not want to get up and her urine was pinkish red and that her ostomy would bleed also. She said that her pain medication was not effective during that time and that she was so disoriented she could not find her phone charger and it was sitting on her chest. She said Resident #4 was also throwing up. Interview on 5/6/16 at 2:55 p.m. with LVN P who worked with Resident #4 the week prior to Resident #4 being sent out revealed that Resident #4 was in excruciating pain and that she notified the physician and he came in and checked her wound (no documentation to support this). She said Resident #4's catheter kept coming out and that she thought about sending Resident #4 to the hospital but the physician did not think that it was necessary. She said he did not order anything else because he said she was on as much pain medication as he could order. She said that she notified her DON who thought that Resident #4 would feel better if she tried to get up out of bed. She said they tried to get the resident up out of bed and she refused. She said that she did not use a pain scale to rate pain effectiveness. Interview on 5/6/16 at 3:00 p.m. with the Clinical Regional Director revealed that it is what the resident thinks for pain medication to be effective when considering the effectiveness of pain medication. Interview on 5/6/16 at 3:40 p.m. with Resident #4's mother revealed that the Saturday prior to her going to the hospital on [DATE], she visited her daughter and that her daughter's pain was different. She said that her daughter was not eating, urine was almost red cloudy and thick and that she sat there for an hour and her daughter did not have any output. She said that her grandson came back on Sunday 4/3/16 and that was when she was sent out to the hospital upon her grandson's request. Interview on 5/6/16 at 4:00 p.m. with LVN O revealed that Resident #4's family prompted her to send the resident to the hospital on [DATE]. She said that when she went in and looked at Resident #4 her lips were dry and cracked and she had not eaten breakfast and she normally ate good. She said that she did not notify the physician of the residents increased nausea and vomiting because she was being medicated for it. She said her urine was reddish yellow and she was pale and clammy. Review of Resident #4's nurse's notes for March 2016 revealed that no new notes had been written from 3/15/16 to 3/30/16. Review of Resident #4's nurse's note from 3/30/16 at 0400 revealed Resident had a small brownish clear emesis. Medicated as ordered. [MEDICAL CONDITION] leaking due to stool and pressure in bag. Changed entire [MEDICAL CONDITION]. Review of Resident #4's PRN Pain Medication Administration Record for evaluation of pain using a scale of 1-10 revealed that only 31 pain evaluation assessments for March had taken place. Post medication assessment scores ranged from two 0's, one 1, six 2's, eleven 3's, ten 4's and one 5. Review of facility policy revision date August 2012 on Pain Management revealed under Fourth Step: Putting the Plan into Action .to be successful your team must be consistent; everyone must provide the same type of care to the resident every day, and be proactive to make sure that the resident achieves relief and remains free of pain. Monitoring the resident and communicating with each and every team member regarding the pain management for your identified residents is crucial .Fifth Step: Re-evaluate on a regular basis .you need to re-evaluate the resident on a regular basis. This will be done each time you administer a pain medication to the resident, evaluating the effectiveness of a medication and making changes if the medication or approach is not effective. The ADM and DON were notified on 5/4/16 at 4:45 p.m. that an Immediate Jeopardy was identified. The facility's Plan of Removal was accepted on 5/18/16 at 2:25 p.m. and it included: 1. All Nursing Staff in serviced on Changes of Condition to include Pain and [MEDICAL CONDITION] on 4/29/16. 2. All Nurse's aides in serviced that if a resident has a change that they note, they are to inform the nurse and complete a interact 4 Stop and Watch Tool which is a tool for all staff to communicate changes to the licensed nurse related to behaviors, communication, decline in ADL's, Pain, oral intake or LOC. A sleeve has been added to the 24 hour report binder for all stop and watches to be put into. These will be reviewed during the clinical daily meeting, by the DON and Nurse Managers, with follow up actions, as necessary. All nurses and aides will be in serviced when a resident's condition is not improving, they will collaborate with the nurse manager for that hall, and/or DON. This will be completed 5/17/16. 3. All Nursing staff will be in serviced on pain assessments to be more thorough and use an approved tool (scale of 1-10), or Facial Scale) for both their pre-intervention assessment and post intervention assessment. Assessments of pain as well as interventions and assessment of effectiveness need to be documented in the PRN Pain Form and/or the nurses' notes. Nurses also in serviced that if a resident complains of increased pain, that this is an indicator of a possible change in condition. All nurses cautioned not be become de-sensitized to Chronic Pain patients. The nurse will then use the SBAR (Situation/Background/Appearance/Review and Notify) Communication Form as a guide when they call/notify physician. Nurses informed that if a residents condition does not improve after the physician is notified (new orders implemented) that they are to reattempt communication with the physician and notify the DON or nurse manager and document all attempts. The nurse manager will attempt to rectify the situation with that physician and if that fails will involve the Medical Director, as necessary. Nurse Managers will identify residents on a pain management program and review their MARS and Charts for compliance every week for 2 months using a Pain Management System Validation. Issues will be reported to QAPI with follow up actions as necessary. 4. Nurses will clarify if there are labs that need to be drawn prior to sending a resident to an appointment. All appointments will be reviewed by the nurse manager at the end of the week for the up-coming week using the Daily Stand Up Meeting Guidelines. Labs will be written in the record as orders from whichever doctor is ordering it. Lab orders will be logged into the Lab Tracking Auditing System with daily review by nurse managers and follow up as necessary. All nurses have been in serviced on the expectations that labs will be completed as ordered and MD will be notified of results in a timely manner. Critical Labs will be called to the physician immediately upon receipt of lab results. Physician notifications and new orders will be documented on the lab itself, in the nurse's notes and on the physician order [REDACTED]. The weekend supervisor will review the 24 hour reports on weekends and ensure the physician has been notified of critical labs and resident change of conditions and appropriate interventions are implemented actions as necessary. 5. All nurses will be in serviced on the procedures to order/re-order medications. If a medication does not come in stat for new residents or on the next run for reorders-nurses are to call the pharmacy and document proof of who they spoke to as well as notify MD that medication was not delivered and ask if there are new orders, and document this conversation,. Nurses will document all attempts to obtain the medication. Nurse Manager review all telephone orders daily and ensure all physician orders [REDACTED]. Pharmacy issues will be brought up to the DON and/or Administrator for resolution. 6. All potential admissions will be reviewed by a nurse manager. If the resident is clinically complex, or requires specialty care beyond the norm for the facility-the potential resident's information will be reviewed by the interdisciplinary team to include the medical director. As appropriate and feasible, complex or specialty residents will be visited by a facility representative to assist in a fully informed decision as to whether the facility can meet that resident's needs. The facility will define specialty residents that we will not take such as residents on ventilators. Resident admission denials will be discussed as part of the QAPI. Training opportunities will be examined to see if the facility can obtain training to meet the needs of specialty type residents. Training will occur prior to accepting those residents. 7. Staff will be reminded that the lines of communication to the Director of Nursing and Administrator are always open for the good of the residents. Staff will know how to get a hold of either one of these leaders, 24 hours a day as necessary. On 5/18/16 the Surveyor confirmed the plan of removal had been sufficiently implemented to remove the Immediate Jeopardy by interviewing: 5 CNAs regarding identifying a change of condition and who they reported the changes to and using the Stop-n-watch process. 5 nurses were interviewed regarding assessing a resident with a change in condition; what steps to take including calling the physician to ensure the resident received necessary care; process in addressing critical labs and contacting the physician ensuring critical information was relayed to the physician; assessing level of pain in residents. An in-service dated 4/29/16 and 4/30/16 regarding Recognizing and Reporting Changes in a Resident's Physical Condition was reviewed and contained the names of 59 staff who attended. An in-service dated 5/5/16 regarding Critical Labs was reviewed and contained the names of 19 staff who attended. An in-service dated 4/29/16 and 4/30/16 regarding Infection Control was reviewed and contained the names of 59 staff who attended. On 5/18/16 at 2:25 p.m. the Administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of pattern at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. Interviews with 5 nursing staff on day and evening shift on 5/18/16 revealed that they had been in-serviced about identifying and reporting residents change in condition. Review of a form titled universe completed by the facility on 5/6/16 revealed there were 7 residents with a [MEDICAL CONDITION] disorder. Review of a Form CMS-672 dated 4/18/16 revealed the census was 94.

Based on interview and record review the facility failed to ensure that residents were free of any signficant medication errors for 1 of 15 residents (#7) whose medication records were reviewed in that: LVN R (Charge Nurse) and LVN D (Unit Manager) did not ensure that 2 prescriptions, [MEDICATION NAME] and [MEDICATION NAME] (used for [MEDICAL CONDITION]) were available or that Resident #7 received the medications for 2 days. Resident #7 had 9 [MEDICAL CONDITION] before she was sent out to the hospital. This deficient practice resulted in an Immediate Jeopardy (IJ) on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at a scope of pattern at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. This deficient practices could affect 7 residents with a [MEDICAL CONDITION] disorder and could result in serious medical complications [REDACTED]. The findings were: Review of Resident #7's medical face sheet (undated) revealed she was admitted into the facility on [DATE] at 13:00 (1:00 p.m.). Review of Resident #7's admission orders [REDACTED]. Further review revealed an order for [REDACTED]. Review of a Nursing Admission Intake Form dated [DATE] revealed Resident #7 had a VNS implant on her left side to control [MEDICAL CONDITION]. Review of a H & P dated [DATE] revealed Resident #7 was transferred into the facility from a hospital with a severe sz d/o. Resident #7's assessment and plan for her [MEDICAL CONDITION] disorder included orders for [MEDICATION NAME] ER, [MEDICATION NAME] and [MEDICATION NAME] level in AM. Review of a MAR dated [DATE] revealed Resident #7 did not receive [MEDICATION NAME] or [MEDICATION NAME] on [DATE] (evening meds) and on [DATE] (all doses). Review of an incident/accident report dated [DATE] at 12:10 a.m. revealed Resident #7 was lying in bed and was noted having atonic-clonic [MEDICAL CONDITION] activity at 12:10 p.m. Further review revealed her VNS magnet was utilized and Resident #7 stopped having [MEDICAL CONDITION] activity. The NP was notified at this same time. Review of a nurse's note dated [DATE] at 12:10 a.m. read: Resident was lying in bed having atonic-clonic [MEDICAL CONDITION]. This nurse used VNS magnet and resident stopped seizing after fifteen seconds. The NP notified of [MEDICAL CONDITION]. Informed him that resident missed two doses of [MEDICATION NAME] due to pharmacy not delivering after repeated attempts to let pharmacy know that residents ' [MEDICATION NAME] and [MEDICATION NAME] have not arrived. The NP informed this nurse that pharmacy has to have written scripts faxed over to them and that this writer will have to take care of getting scripts for resident in AM. This writer called the pharmacy and asked if this nurse could get [MEDICATION NAME] out of the emergency kit. The pharmacy informed this writer that only an agent can do this and that this writer is not an agent and that the NF does not have a controlled emergency medicine kit. Resident resting quietly in bed after [MEDICAL CONDITION]. VS WNL and are as follows: 99, 88, 22, ,[DATE] and 02 sat of 98% on RA. Tracks this writer's hand and tries to push B/P cuff away from her. Tolerating [DEVICE] feeding water flushes and meds well. Call light within reach. Will cont to monitor resident closely. Review of a second incident/accident report dated [DATE] at 5:45 a.m. revealed Resident #7 having multiple tonic-clonic [MEDICAL CONDITION] approximately 30 seconds each. LVN R wrote she witnessed the resident having 3 [MEDICAL CONDITION] within approximately ,[DATE] minutes. Review of an incident/accident investigation follow-up dated [DATE] read Resident #7 experienced uncontrolled tonic-clonic [MEDICAL CONDITION] activity. VNS magnet utilized & [MEDICAL CONDITION] activity would stop for time then would restart. Total of 9 [MEDICAL CONDITION] prior to going to ER. The summary of investigation revealed the pharmacy had not delivered the [MEDICATION NAME] and [MEDICATION NAME] for Resident #7. The NP was notified of the [MEDICAL CONDITION] activity at 12:10 a.m. and the PCP was notified at 6:15 a.m. Review of a nurse's note dated [DATE] at 7:15 a.m. read: Resident was found in bed @ 5:45 a.m. seizing and had vomited all over her hospital gown. This writer used magnet for VNS and resident stopped seizing after 30 seconds. Resident had two more [MEDICAL CONDITION] in a ten minute period. NF supervisor notified PCP ordered that resident be sent into hospital for assessment and evaluation. Resident had six more [MEDICAL CONDITION] over the next 30 minutes before EMS arrived. Resident would come out of [MEDICAL CONDITION] after magnet was used over VNS, but would go into another [MEDICAL CONDITION], just a few minutes afterwards. All [MEDICAL CONDITION] have been tonic-clonic in nature. VS were taken before EMS arrived and are as follows: ,[DATE], 100, 24 and 100.7. Family member will be contacted by supervisor. Interview on [DATE] at 11:14 a.m. with LVN I revealed she assisted with Resident #7's transfer to the hospital on [DATE]. She learned Resident #7 had a [MEDICAL CONDITION] at midnight and then in the morning during shift change. She was told Resident #7 missed 2 doses of [MEDICATION NAME] but when she looked at the MAR she found that Resident #7 had not received her medications for 2 days. LVN I stated she called the NP who was not returning her calls so LVN/Unit Manager D told her to call the PCP who then provided orders to send the resident out to a local hospital. Interview on [DATE] at 11:38 a.m. with LVN O revealed she also assisted with Resident #7's transfer to the hospital on [DATE] due to the resident experiencing multiple [MEDICAL CONDITION]. LVN O stated she learned the NP was called at midnight regarding Resident #7's condition and he did not want to send the resident out to the hospital. He stated he would come into the facility to see the resident in the morning. LVN O stated Resident #7 had experienced 10 [MEDICAL CONDITION] by the time she reported to work at 6:00 a.m. on [DATE]. LVN O stated she let LVN D know about the resident's [MEDICAL CONDITION] activity. LVN D stated it was normal for her but then LVN O told her Resident #7 had not received the [MEDICATION NAME]. LVN D then advised LVN O to send Resident #7 out to the hospital. LVN O stated the procedure for obtaining medications included: upon admission the nurse on duty would check the medications with the physician and make changes as needed. The nurse would then immediately fax the physician orders [REDACTED]. The receiving nurse would check the inventory sheet against the medications upon arrival to the facility. Any discrepancies would be noted on the inventory sheet. LVN O stated the orders for [MEDICATION NAME] and [MEDICATION NAME] were not filled. She stated she understood the PCP was in the facility when Resident #7 was admitted , but the PCP did not write the scripts for the medications. LVN O stated she heard LVN I on the phone with the PCP who asked for a [MEDICATION NAME] for Resident #7. LVN O stated they did not have controlled medications in their emergency kits. Interview on [DATE] at 8:26 p.m. with LVN R revealed she worked on [DATE] to [DATE] as the night charge nurse for Resident #7. LVN R stated she had worked at the facility for 3 weeks and had worked various shifts on different halls. LVN R stated she received limited training on the facility's medication pass policy and on their admission process. She stated Resident #7's medications dribbled in early morning on [DATE]. She realized later during the evening shift on the same date that 2 medications, [MEDICATION NAME] and [MEDICATION NAME], had not arrived. LVN R stated on the morning of [DATE] she did not pass the information on during report to LVN P during shift change. She commented she intended to but did not so she called the pharmacy. She learned she needed a written prescription for [MEDICATION NAME] because it was a controlled medication and the PCP did not write a script for it. Furthermore, the facility did not have any controlled medications in the E-kit and even if they did she was not an agent; did not have the authority or code to get into the E-kit. LVN R stated she called the NP after Resident #7 had her first [MEDICAL CONDITION] at midnight. The NP also told her she needed a written prescription for the [MEDICATION NAME] and would have to wait until he came to the facility in the morning. He stated she did not have to send Resident #7 out to the hospital. She let him know that Resident #7 had an order for [REDACTED]. The NP stated it was not necessary; the lab could also be drawn as scheduled. LVN R stated Resident #7 then had a series of [MEDICAL CONDITION] before shift change at 6:00 a.m. She stated LVN D and LVN I had arrived and she asked them to help her with Resident #7. LVN R expressed a great deal of remorse and stated she felt very bad because of her mistake. She commented she felt so overwhelmed. She stated it was a very busy night; she had 2 admissions and a resident who was actively dying [MEDICAL CONDITION] that evening. LVN R stated one of the new admissions was very aggressive and the other one clung on to her medication cart the entire evening. He appeared to be paranoid and delusional. LVN R stated and then she had Resident #7 who was having [MEDICAL CONDITION]. She stated it was too much for a skeleton crew. LVN R stated she did the best that she could but in retrospect she should have called a manager for help. Also, she could have used training on what to do when medications were not delivered. LVN R stated LVN D told her she would get more help for the evening shift and would get someone to pass out medications so it would free up her time. LVN R stated they were short staffed and that administrative staff had been filling in the holes; working all the shifts that did not have sufficient staff on schedule. LVN R further stated the nurses were working 12 hour shifts instead of 8 hour shifts so that administrative staff did not have to work so much. Some of the nurses had quit. Review of a Resident Transfer Form dated [DATE] revealed Resident #7 was sent out to a local hospital via EMS stretcher with [DIAGNOSES REDACTED]. Review of a pharmacy proof of delivery with a date range from [DATE] to [DATE] revealed the facility received the prescription for [MEDICATION NAME] 97.2 mg on [DATE] at 4:57 p.m. after Resident #7 was transferred out to the hospital. Review of a lab dated [DATE] at 16:33 CT (after the resident was transferred out to the hospital) revealed Resident #7's [MEDICATION NAME] level was 15.5; the reference range was 10XXX,[DATE].0. Review of a hospital admission form dated [DATE] revealed Resident #7 was admitted into the hospital at 14:55 (2:55 p.m.) with chief complaint: ,[DATE] [MEDICAL CONDITION] since midnight, history of [MEDICAL CONDITION]. Review of hospital note dated [DATE] revealed Resident #7 was sent in from NF for sz since midnight per EMS. Pt had ,[DATE] sz. per staff. out of meds missed 2 doses of [MEDICATION NAME]. awake/non-verbal. normal for her. skin is pale. EMS reported 3 [MEDICAL CONDITION] approximately 30 seconds each. Interview on [DATE] at 5:12 p.m. with Resident #7's RP revealed the SW contacted her today to inform her the facility would not be able to accept the resident back into the facility due to her history of [MEDICAL CONDITION]. Resident #7's RP questioned why the facility's position changed in 2 days. The RP stated she learned on [DATE] that Resident #7 had not received her medications for 2 days and was sent out to the hospital because her son went to visit Resident #7 that day. She stated she was really upset when she was told the Dr. said it could wait until the morning. She stated she did not want it to happen to anyone else. Interview on [DATE] at 9:46 a.m. with LVN D/Unit Manager and the ADON revealed LVN D audited Resident #7's chart when she was admitted into the facility but failed to inquire if the medications had been filled. She learned that not all staff was aware that [MEDICATION NAME] was a controlled medication and it required a written prescription (not a triplicate). The ADON stated LVN R was not trained to handle Resident #7's condition and LVN D stated the managers failed to explain to LVN R how to obtain medications right away. LVN D stated the PCP wrote a prescription for the [MEDICATION NAME] on the morning of [DATE]. LVN D confirmed that Resident #7 did not receive [MEDICATION NAME] or [MEDICATION NAME] while she was at the facility and even though her [MEDICATION NAME] lab showed that her level was within normal limits, the facility failed to provide Resident #7 with the quality care she needed. Interview on [DATE] at 10:05 a.m. with Resident #7's PCP revealed she saw Resident #7 upon admission into the facility. She confirmed she did not write the prescription for the [MEDICATION NAME] while at the facility; she stated it was an oversight. She stated she had a discussion with the NP regarding Resident #7's [MEDICAL CONDITION] activity on the morning of [DATE]. He told her he thought a triplicate prescription was needed for the [MEDICATION NAME]. The PCP stated she talked with the admitting physician at the local hospital who expressed great concern for Resident #7 stating she was very sick upon arrival. He stated she was in status meaning she was seizing without stopping and any treatment provided was not helping. Once she stabilized, he sent her to another hospital where she would receive the specialized care she needed. The PCP stated Resident #7 should have been sent out to the hospital after her first [MEDICAL CONDITION] at midnight based on her [MEDICAL CONDITION] disorder and on the fact that she had not received her [MEDICATION NAME] medication. The PCP stated Resident #7 could have died . Review of a facility policy titled, Pharmacy Services dated [DATE] read: The intent of these requirements is that: In order to meet the needs of each resident, the facility accurately and safely provides or obtains pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed pharmacist; to serve as the consultant pharmacist. Review of a facility policy titled, Medication Administration revised during [DATE] read: Resident Medications are administered in an accurate, safe, timely, and sanitary manner. FUNDAMENTAL INFORMATION: New Medication Starts-Begin new medication orders timely. Begin routine orders on the same day ordered, unless the next dose would be normally given the next day. The ADM and DON were notified on [DATE] at 4:45 p.m., that an Immediate Jeopardy was identified. The facility's Plan of Removal was accepted on [DATE] at 2:25 p.m. and it included: 1. All Nursing Staff in serviced on Changes of Condition to include Pain and [MEDICAL CONDITION] on [DATE]. 2. All Nurse's aides in serviced that if a resident has a change that they note, they are to inform the nurse and complete a interact 4 Stop and Watch Tool which is a tool for all staff to communicate changes to the licensed nurse related to behaviors, communication, decline in ADL's, Pain, oral intake or LOC. A sleeve has been added to the 24 hour report binder for all stop and watches to be put into. These will be reviewed during the clinical daily meeting, by the DON and Nurse Managers, with follow up actions, as necessary. All nurses and aides will be in serviced when a resident's condition is not improving, they will collaborate with the nurse manager for that hall, and/or DON. This will be completed [DATE]. 3. All Nursing staff will be in serviced on pain assessments to be more thorough and use an approved tool (scale of ,[DATE]), or Facial Scale) for both their pre-intervention assessment and post intervention assessment. Assessments of pain as well as interventions and assessment of effectiveness need to be documented in the PRN Pain Form and/or the nurses' notes. Nurses also in serviced that if a resident complains of increased pain, that this is an indicator of a possible change in condition. All nurses cautioned not be become de-sensitized to Chronic Pain patients. The nurse will then use the SBAR (Situation/Background/Appearance/Review and Notify) Communication Form as a guide when they call/notify physician. Nurses informed that if a residents condition does not improve after the physician is notified (new orders implemented) that they are to reattempt communication with the physician and notify the DON or nurse manager and document all attempts. The nurse manager will attempt to rectify the situation with that physician and if that fails will involve the Medical Director, as necessary. Nurse Managers will identify residents on a pain management program and review their MARS and Charts for compliance every week for 2 months using a Pain Management System Validation. Issues will be reported to QAPI with follow up actions as necessary. 4. Nurses will clarify if there are labs that need to be drawn prior to sending a resident to an appointment. All appointments will be reviewed by the nurse manager at the end of the week for the up-coming week using the Daily Stand Up Meeting Guidelines. Labs will be written in the record as orders from whichever doctor is ordering it. Lab orders will be logged into the Lab Tracking Auditing System with daily review by nurse managers and follow up as necessary. All nurses have been in serviced on the expectations that labs will be completed as ordered and MD will be notified of results in a timely manner. Critical Labs will be called to the physician immediately upon receipt of lab results. Physician notifications and new orders will be documented on the lab itself, in the nurse's notes and on the physician order [REDACTED]. The weekend supervisor will review the 24 hour reports on weekends and ensure the physician has been notified of critical labs and resident change of conditions and appropriate interventions are implemented actions as necessary. 5. All nurses will be in serviced on the procedures to order/re-order medications. If a medication does not come in stat for new residents or on the next run for reorders-nurses are to call the pharmacy and document proof of who they spoke to as well as notify MD that medication was not delivered and ask if there are new orders, and document this conversation,. Nurses will document all attempts to obtain the medication. Nurse Manager review all telephone orders daily and ensure all physician orders [REDACTED]. Pharmacy issues will be brought up to the DON and/or Administrator for resolution. 6. All potential admissions will be reviewed by a nurse manager. If the resident is clinically complex, or requires specialty care beyond the norm for the facility-the potential resident's information will be reviewed by the interdisciplinary team to include the medical director. As appropriate and feasible, complex or specialty residents will be visited by a facility representative to assist in a fully informed decision as to whether the facility can meet that resident's needs. The facility will define specialty residents that we will not take such as residents on ventilators. Resident admission denials will be discussed as part of the QAPI. Training opportunities will be examined to see if the facility can obtain training to meet the needs of specialty type residents. Training will occur prior to accepting those residents. 7. Staff will be reminded that the lines of communication to the Director of Nursing and Administrator are always open for the good of the residents. Staff will know how to get a hold of either one of these leaders, 24 hours a day as necessary. On [DATE] the Surveyor confirmed the plan of removal had been sufficiently implemented to remove the Immediate Jeopardy by interviewing: 5 CNAs regarding identifying a change of condition and who they reported the changes to; working with difficult residents including residents with Dementia and using the Stop-n-watch process. 5 nurses were interviewed regarding assessing a resident with a change in condtion; what steps to take including calling the physician to ensure the resident received necessary care; addressing [MEDICAL CONDITION] activity; ensuring medications were ordered and available for residents. The Interim ADON, LVN D and the ADM were interviewed: regarding the admission process. They stated unit managers would be involved in the process and the DON would make the final decision. An in-service dated [DATE] and [DATE] regarding Recognizing and Reporting Changes in a Resident's Physical Condition was reviewed and contained the names of 59 staff who attended. An in-service dated [DATE] regarding [MEDICAL CONDITION] management, long-term care was reviewed and contained the names of 56 staff who attended. On [DATE] at 2:25 p.m. the Administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of pattern at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. Review of a form titled universe completed by the facility on [DATE] revealed there were 7 residents with a [MEDICAL CONDITION] disorder.

Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering and documenting of all drugs and biologicals) to meet the needs of each resident for 1 of 15 residents (#7) whose medication records were reviewed in that: LVN R (Charge Nurse) and LVN D (Unit Manager) did not ensure that 2 prescriptions, phenobarbital and clonazepam (used for seizures) were available or that Resident #7 received the medications for 2 days. Resident #7 had 9 seizures before she was sent out to the hospital. This deficient practice resulted in an Immediate Jeopardy (IJ) on 5/4/16. The IJ was removed on 5/18/16. The facility remained out of compliance at a scope of pattern at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. This deficient practice could affect 7 residents with a seizure disorder and could result in serious medical complications [REDACTED]. The findings were: Review of Resident #7's medical face sheet (undated) revealed she was admitted into the facility on [DATE] at 13:00 (1:00 p.m.). Review of Resident #7's admission orders [REDACTED]. Further review revealed an order for [REDACTED]. Review of a Nursing Admission Intake Form dated 4/19/16 revealed Resident #7 had a VNS implant on her left side to control seizures. Review of a H & P dated 4/20/16 revealed Resident #7 was transferred into the facility from a hospital with a severe sz d/o. Resident #7's assessment and plan for her seizure disorder included orders for Clonazepam, Divalproex ER, Keppra, Phenobarbital and Phenobarbital level in AM. Review of a MAR dated April 2016 revealed Resident #7 did not receive Clonazepam or Phenobarbital on 4/19/16 (evening meds) and on 4/20/16 (all doses). Review of an incident/accident report dated 4/21/16 at 12:10 a.m. revealed Resident #7 was lying in bed and was noted having atonic-clonic seizure like activity at 12:10 p.m. Further review revealed her VNS magnet was utilized and Resident #7 stopped having seizure like activity. The NP was notified at this same time. Review of a nurse's note dated 4/21/16 at 12:10 a.m. read: Resident was lying in bed having atonic-clonic seizure. This nurse used VNS magnet and resident stopped seizing after fifteen seconds. The NP notified of seizure. Informed him that resident missed two doses of phenobarbital due to pharmacy not delivering after repeated attempts to let pharmacy know that residents ' phenobarbital and clonazepam have not arrived. The NP informed this nurse that pharmacy has to have written scripts faxed over to them and that this writer will have to take care of getting scripts for resident in AM. This writer called the pharmacy and asked if this nurse could get phenobarbital out of the emergency kit. The pharmacy informed this writer that only an agent can do this and that this writer is not an agent and that the NF does not have a controlled emergency medicine kit. Resident resting quietly in bed after seizure. VS WNL and are as follows: 99, 88, 22, 156/81 and 02 sat of 98% on RA. Tracks this writer's hand and tries to push B/P cuff away from her. Tolerating [DEVICE] feeding water flushes and meds well. Call light within reach. Will cont to monitor resident closely. Review of a second incident/accident report dated 4/21/16 at 5:45 a.m. revealed Resident #7 having multiple tonic-clonic seizures lasting approximately 30 seconds each. LVN R wrote she witnessed the resident having 3 seizures within approximately 7-10 minutes. Review of an incident/accident investigation follow-up dated 4/21/16 read Resident #7 experienced uncontrolled tonic-clonic seizure like activity. VNS magnet utilized & seizure like activity would stop for time then would restart. Total of 9 seizures prior to going to ER. The summary of investigation revealed the pharmacy had not delivered the phenobarbital and clonazepam for Resident #7. The NP was notified of the seizure activity at 12:10 a.m. and the PCP was notified at 6:15 a.m. Review of a nurse's note dated 4/21/16 at 7:15 a.m. read: Resident was found in bed @ 5:45 a.m. seizing and had vomited all over her hospital gown. This writer used magnet for VNS and resident stopped seizing after 30 seconds. Resident had two more seizures in a ten minute period. NF supervisor notified PCP ordered that resident be sent into hospital for assessment and evaluation. Resident had six more seizures over the next 30 minutes before EMS arrived. Resident would come out of seizure after magnet was used over VNS, but would go into another seizure, just a few minutes afterwards. All seizures have been tonic-clonic in nature. VS were taken before EMS arrived and are as follows: 138/57, 100, 24 and 100.7. Family member will be contacted by supervisor. Interview on 4/27/16 at 11:14 a.m. with LVN I revealed she assisted with Resident #7's transfer to the hospital on [DATE]. She learned Resident #7 had a seizure at midnight and then in the morning during shift change. She was told Resident #7 missed 2 doses of phenobarbital but when she looked at the MAR she found that Resident #7 had not received her medications for 2 days. LVN I stated she called the NP who was not returning her calls so LVN/Unit Manager D told her to call the PCP who then provided orders to send the resident out to a local hospital. Interview on 4/27/16 at 11:38 a.m. with LVN O revealed she also assisted with Resident #7's transfer to the hospital on [DATE] due to the resident experiencing multiple seizures. LVN O stated she learned the NP was called at midnight regarding Resident #7's condition and he did not want to send the resident out to the hospital. He stated he would come into the facility to see the resident in the morning. LVN O stated Resident #7 had experienced 10 seizures by the time she reported to work at 6:00 a.m. on 4/21/16. LVN O stated she let LVN D know about the resident's seizure activity. LVN D stated it was normal for her but then LVN O told her Resident #7 had not received the phenobarbital. LVN D then advised LVN O to send Resident #7 out to the hospital. LVN O stated the procedure for obtaining medications included: upon admission the nurse on duty would check the medications with the physician and make changes as needed. The nurse would then immediately fax the physician orders [REDACTED]. The receiving nurse would check the inventory sheet against the medications upon arrival to the facility. Any discrepancies would be noted on the inventory sheet. LVN O stated the orders for phenobarbital and clonazepam were not filled. She stated she understood the PCP was in the facility when Resident #7 was admitted , but the PCP did not write the scripts for the medications. LVN O stated she heard LVN I on the phone with the PCP who asked for a valium for Resident #7. LVN O stated they did not have controlled medications in their emergency kits. Interview on 4/27/16 at 8:26 p.m. with LVN R revealed she worked on 4/19/16 to 4/21/16 as the night charge nurse for Resident #7. LVN R stated she had worked at the facility for 3 weeks and had worked various shifts on different halls. LVN R stated she received limited training on the facility's medication pass policy and on their admission process. She stated Resident #7's medications dribbled in early morning on 4/20/16. She realized later during the evening shift on the same date that 2 medications, phenobarbital and clonazepam, had not arrived. LVN R stated on the morning of 4/21/16 she did not pass the information on during report to LVN P during shift change. She commented she intended to but did not so she called the pharmacy. She learned she needed a written prescription for phenobarbital because it was a controlled medication and the PCP did not write a script for it. Furthermore, the facility did not have any controlled medications in the E-kit and even if they did she was not an agent; did not have the authority or code to get into the E-kit. LVN R stated she called the NP after Resident #7 had her first seizure at midnight. The NP also told her she needed a written prescription for the phenobarbital and would have to wait until he came to the facility in the morning. He stated she did not have to send Resident #7 out to the hospital. She let him know that Resident #7 had an order for [REDACTED]. The NP stated it was not necessary; the lab could also be drawn as scheduled. LVN R stated Resident #7 then had a series of seizures before shift change at 6:00 a.m. She stated LVN D and LVN I had arrived and she asked them to help her with Resident #7. LVN R expressed a great deal of remorse and stated she felt very bad because of her mistake. She commented she felt so overwhelmed. She stated it was a very busy night; she had 2 admissions and a resident who was actively dying of cancer that evening. LVN R stated one of the new admissions was very aggressive and the other one clung on to her medication cart the entire evening. He appeared to be paranoid and delusional. LVN R stated and then she had Resident #7 who was having seizures. She stated it was too much for a skeleton crew. LVN R stated she did the best that she could but in retrospect she should have called a manager for help. Also, she could have used training on what to do when medications were not delivered. LVN R stated LVN D told her she would get more help for the evening shift and would get someone to pass out medications so it would free up her time. LVN R stated they were short staffed and that administrative staff had been filling in the holes; working all the shifts that did not have sufficient staff on schedule. LVN R further stated the nurses were working 12 hour shifts instead of 8 hour shifts so that administrative staff did not have to work so much. Some of the nurses had quit. Review of a Resident Transfer Form dated 4/21/16 revealed Resident #7 was sent out to a local hospital via EMS stretcher with [DIAGNOSES REDACTED]. Review of a pharmacy proof of delivery with a date range from 4/19/16 to 4/27/16 revealed the facility received the prescription for Phenobarbital 97.2 mg on 4/21/16 at 4:57 p.m. after Resident #7 was transferred out to the hospital. Review of a lab dated 4/21/16 at 16:33 CT (after the resident was transferred out to the hospital) revealed Resident #7's phenobarbital level was 15.5; the reference range was 10.0-40.0. Review of a hospital admission form dated 4/21/16 revealed Resident #7 was admitted into the hospital at 14:55 (2:55 p.m.) with chief complaint: 12-15 seizures since midnight, history of seizures. Review of hospital note dated 4/21/16 revealed Resident #7 was sent in from NF for sz since midnight per EMS. Pt had 12-15 sz. per staff. out of meds missed 2 doses of phenobarbital. awake/non-verbal. normal for her. skin is pale. EMS reported 3 seizures lasting approximately 30 seconds each. Interview on 4/27/16 at 5:12 p.m. with Resident #7's RP revealed the SW contacted her today to inform her the facility would not be able to accept the resident back into the facility due to her history of seizures. Resident #7's RP questioned why the facility's position changed in 2 days. The RP stated she learned on 4/21/16 that Resident #7 had not received her medications for 2 days and was sent out to the hospital because her son went to visit Resident #7 that day. She stated she was really upset when she was told the Dr. said it could wait until the morning. She stated she did not want it to happen to anyone else. Interview on 4/28/16 at 9:46 a.m. with LVN D/Unit Manager and the ADON revealed LVN D audited Resident #7's chart when she was admitted into the facility but failed to inquire if the medications had been filled. She learned that not all staff was aware that phenobarbital was a controlled medication and it required a written prescription (not a triplicate). The ADON stated LVN R was not trained to handle Resident #7's condition and LVN D stated the managers failed to explain to LVN R how to obtain medications right away. LVN D stated the PCP wrote a prescription for the phenobarbital on the morning of 4/21/16. LVN D confirmed that Resident #7 did not receive phenobarbital or clonazepam while she was at the facility and even though her phenobarbital lab showed that her level was within normal limits, the facility failed to provide Resident #7 with the quality care she needed. Interview on 4/29/16 at 10:05 a.m. with Resident #7's PCP revealed she saw Resident #7 upon admission into the facility. She confirmed she did not write the prescription for the phenobarbital while at the facility; she stated it was an oversight. She stated she had a discussion with the NP regarding Resident #7's seizure activity on the morning of 4/21/16. He told her he thought a triplicate prescription was needed for the phenobarbital. The PCP stated she talked with the admitting physician at the local hospital who expressed great concern for Resident #7 stating she was very sick upon arrival. He stated she was in status meaning she was seizing without stopping and any treatment provided was not helping. Once she stabilized, he sent her to another hospital where she would receive the specialized care she needed. The PCP stated Resident #7 should have been sent out to the hospital after her first seizure at midnight based on her seizure disorder and on the fact that she had not received her phenobarbital medication. The PCP stated Resident #7 could have died . Review of a facility policy titled, Pharmacy Services dated June 2012 read: The intent of these requirements is that: In order to meet the needs of each resident, the facility accurately and safely provides or obtains pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed pharmacist; to serve as the consultant pharmacist. Review of a facility policy titled, Medication Administration revised during June 2008 read: Resident Medications are administered in an accurate, safe, timely, and sanitary manner. FUNDAMENTAL INFORMATION: New Medication Starts-Begin new medication orders timely. Begin routine orders on the same day ordered, unless the next dose would be normally given the next day. The ADM and DON were notified on 5/4/16 at 4:45 p.m. that an Immediate Jeopardy was identified. The facility's Plan of Removal was accepted on 5/18/16 at 2:25 p.m. and it included: 1. All Nursing Staff in serviced on Changes of Condition to include Pain and Seizures on 4/29/16. 2. All Nurse's aides in serviced that if a resident has a change that they note, they are to inform the nurse and complete a interact 4 Stop and Watch Tool which is a tool for all staff to communicate changes to the licensed nurse related to behaviors, communication, decline in ADL's, Pain, oral intake or LOC. A sleeve has been added to the 24 hour report binder for all stop and watches to be put into. These will be reviewed during the clinical daily meeting, by the DON and Nurse Managers, with follow up actions, as necessary. All nurses and aides will be in serviced when a resident's condition is not improving, they will collaborate with the nurse manager for that hall, and/or DON. This will be completed 5/17/16. 3. All Nursing staff will be in serviced on pain assessments to be more thorough and use an approved tool (scale of 1-10), or Facial Scale) for both their pre-intervention assessment and post intervention assessment. Assessments of pain as well as interventions and assessment of effectiveness need to be documented in the PRN Pain Form and/or the nurses' notes. Nurses also in serviced that if a resident complains of increased pain, that this is an indicator of a possible change in condition. All nurses cautioned not to become de-sensitized to Chronic Pain patients. The nurse will then use the SBAR (Situation/Background/Appearance/Review and Notify) Communication Form as a guide when they call/notify physician. Nurses informed that if a residents condition does not improve after the physician is notified (new orders implemented) that they are to reattempt communication with the physician and notify the DON or nurse manager and document all attempts. The nurse manager will attempt to rectify the situation with that physician and if that fails will involve the Medical Director, as necessary. Nurse Managers will identify residents on a pain management program and review their MARS and Charts for compliance every week for 2 months using a Pain Management System Validation. Issues will be reported to QAPI with follow up actions as necessary. 4. Nurses will clarify if there are labs that need to be drawn prior to sending a resident to an appointment. All appointments will be reviewed by the nurse manager at the end of the week for the up-coming week using the Daily Stand Up Meeting Guidelines. Labs will be written in the record as orders from whichever doctor is ordering it. Lab orders will be logged into the Lab Tracking Auditing System with daily review by nurse managers and follow up as necessary. All nurses have been in serviced on the expectations that labs will be completed as ordered and MD will be notified of results in a timely manner. Critical Labs will be called to the physician immediately upon receipt of lab results. Physician notifications and new orders will be documented on the lab itself, in the nurse's notes and on the physician order [REDACTED]. The weekend supervisor will review the 24 hour reports on weekends and ensure the physician has been notified of critical labs and resident change of conditions and appropriate interventions are implemented actions as necessary. 5. All nurses will be in serviced on the procedures to order/re-order medications. If a medication does not come in stat for new residents or on the next run for reorders-nurses are to call the pharmacy and document proof of who they spoke to as well as notify MD that medication was not delivered and ask if there are new orders, and document this conversation,. Nurses will document all attempts to obtain the medication. Nurse Manager reviews all telephone orders daily and ensures all physician orders [REDACTED]. Pharmacy issues will be brought up to the DON and/or Administrator for resolution. 6. All potential admissions will be reviewed by a nurse manager. If the resident is clinically complex, or requires specialty care beyond the norm for the facility-the potential resident's information will be reviewed by the interdisciplinary team to include the medical director. As appropriate and feasible, complex or specialty residents will be visited by a facility representative to assist in a fully informed decision as to whether the facility can meet that resident's needs. The facility will define specialty residents that we will not take such as residents on ventilators. Resident admission denials will be discussed as part of the QAPI. Training opportunities will be examined to see if the facility can obtain training to meet the needs of specialty type residents. Training will occur prior to accepting those residents. 7. Staff will be reminded that the lines of communication to the Director of Nursing and Administrator are always open for the good of the residents. Staff will know how to get a hold of either one of these leaders, 24 hours a day as necessary. On 5/18/16 the Surveyor confirmed the plan of removal had been sufficiently implemented to remove the Immediate Jeopardy by interviewing: 5 CNAs regarding identifying a change of condition and who they reported the changes to; working with difficult residents including residents with Dementia and using the Stop-n-watch process. 5 nurses were interviewed regarding assessing a resident with a change in condition; what steps to take including calling the physician to ensure the resident received necessary care; addressing seizure activity; ensuring medications were ordered and available for residents. The Interim ADON, LVN D and the ADM were interviewed: regarding the admission process. They stated unit managers would be involved in the process and the DON would make the final decision. An in-service dated 4/29/16 and 4/30/16 regarding Recognizing and Reporting Changes in a Resident's Physical Condition was reviewed and contained the names of 59 staff who attended. An in-service dated 4/29/16 regarding Seizure management, long-term care was reviewed and contained the names of 56 staff who attended. On 5/18/16 at 2:25 p.m. the Administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of pattern at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. Review of a form titled universe completed by the facility on 5/6/16 revealed there were 7 residents with a seizure disorder.

Based on observation, interview and record review the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident for 5 of 15 residents (#2, #4, #5, #6 & #7) whose records were reviewed in that: 1. The DON did not ensure that 2 prescriptions, [MEDICATION NAME] and [MEDICATION NAME] (used for [MEDICAL CONDITION]) were available or that Resident #7 received the medications for 2 days. Resident #7 had 9 [MEDICAL CONDITION] before she was sent out to the hospital. 2. The ADM and DON did not ensure that staff was trained on the use of a VNS implant or how to care for Resident #7 who had a VNS implant to control [MEDICAL CONDITION]. This deficient practice resulted in an Immediate Jeopardy (IJ) on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at a scope of pattern at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. This deficient practice could affect 7 residents with a [MEDICAL CONDITION] disorder and 1 resident with a VNS implant and contribute to residents experiencing serious medical complications [REDACTED]. The findings were: Review of Resident #7's medical face sheet (undated) revealed she was admitted into the facility on [DATE] at 13:00 (1:00 p.m.). Review of Resident #7's admission orders [REDACTED]. Further review revealed an order for [REDACTED]. Review of a Nursing Admission Intake Form dated [DATE] revealed Resident #7 had a VNS implant on her left side to control [MEDICAL CONDITION]. There were no instructions on how to use the VNS implant. Review of an Interim Plan of Care dated [DATE] did not address the fact that Resident #7 had a [MEDICAL CONDITION] disorder, a VNS implant and how staff was going to ensure her needs were met. Review of a H & P dated [DATE] revealed Resident #7 was transferred into the facility from a hospital with a severe sz d/o. Resident #7's assessment and plan for her [MEDICAL CONDITION] disorder included orders for [MEDICATION NAME] ER, [MEDICATION NAME] and [MEDICATION NAME] level in AM. Review of a MAR dated [DATE] revealed Resident #7 did not receive [MEDICATION NAME] or [MEDICATION NAME] on [DATE] (evening meds) and on [DATE] (2 doses for [MEDICATION NAME] and 1 dose for [MEDICATION NAME]). Review of an incident/accident report dated [DATE] at 12:10 a.m. revealed Resident #7 was lying in bed and was noted having atonic-clonic [MEDICAL CONDITION] activity at 12:10 p.m. Further review revealed her VNS magnet was utilized and Resident #7 stopped having [MEDICAL CONDITION] activity. The NP was notified at this same time. Review of a nurse's note dated [DATE] at 12:10 a.m. read: Resident was lying in bed having atonic-clonic [MEDICAL CONDITION]. This nurse used VNS magnet and resident stopped seizing after fifteen seconds. The NP notified of [MEDICAL CONDITION]. Informed him that resident missed two doses of [MEDICATION NAME] due to pharmacy not delivering after repeated attempts to let pharmacy know that residents ' [MEDICATION NAME] and [MEDICATION NAME] have not arrived. The NP informed this nurse that pharmacy has to have written scripts faxed over to them and that this writer will have to take care of getting scripts for resident in AM. This writer called the pharmacy and asked if this nurse could get [MEDICATION NAME] out of the emergency kit. The pharmacy informed this writer that only an agent can do this and that this writer is not an agent and that the NF does not have a controlled emergency medicine kit. Resident resting quietly in bed after [MEDICAL CONDITION]. VS WNL and are as follows: 99, 88, 22, ,[DATE] and 02 sat of 98% on RA. Tracks this writer's hand and tries to push b/p cuff away from her. Tolerating [DEVICE] feeding water flushes and meds well. Call light within reach. Will cont to monitor resident closely. Review of a second incident/accident report dated [DATE] at 5:45 a.m. revealed Resident #7 having multiple tonic-clonic [MEDICAL CONDITION] approximately 30 seconds each. LVN R wrote she witnessed the resident having 3 [MEDICAL CONDITION] within approximately ,[DATE] minutes. Review of an incident/accident investigation follow-up dated [DATE] read Resident #7 experienced uncontrolled tonic-clonic [MEDICAL CONDITION] activity. VNS magnet utilized & [MEDICAL CONDITION] activity would stop for time then would restart. Total of 9 [MEDICAL CONDITION] prior to going to ER. The summary of investigation revealed the pharmacy had not delivered the [MEDICATION NAME] and [MEDICATION NAME] for Resident #7. The NP was notified of the [MEDICAL CONDITION] activity at 12:10 a.m. and the PCP was notified at 6:15 a.m. Review of a nurse's note dated [DATE] at 7:15 a.m. read: Resident was found in bed @ 5:45 a.m. seizing and had vomited all over her hospital gown. This writer used magnet for VNS and resident stopped seizing after 30 seconds. Resident had two more [MEDICAL CONDITION] in a ten minute period. NF supervisor notified PCP ordered that resident be sent into hospital for assessment and evaluation. Resident had six more [MEDICAL CONDITION] over the next 30 minutes before EMS arrived. Resident would come out of [MEDICAL CONDITION] after magnet was used over VNS, but would go into another [MEDICAL CONDITION], just a few minutes afterwards. All [MEDICAL CONDITION] have been tonic-clonic in nature. VS were taken before EMS arrived and are as follows: ,[DATE], 100, 24 and 100.7. Family member will be contacted by supervisor. Interview on [DATE] at 11:14 a.m. with LVN I revealed she assisted with Resident #7's transfer to the hospital on [DATE]. She learned Resident #7 had a [MEDICAL CONDITION] at midnight and then in the morning during shift change. She was told Resident #7 missed 2 doses of [MEDICATION NAME] but when she looked at the MAR she found that Resident #7 had not received her medications for 2 days. LVN I stated she called the NP who was not returning her calls so LVN/Unit Manager D told her to call the PCP who then provided orders to send the resident out to a local hospital. Interview on [DATE] at 11:38 a.m. with LVN O revealed she also assisted with Resident #7's transfer to the hospital on [DATE] due to the resident experiencing multiple [MEDICAL CONDITION]. LVN O stated she learned the NP was called at midnight regarding Resident #7's condition and he did not want to send the resident out to the hospital. He stated he would come into the facility to see the resident in the morning. LVN O stated Resident #7 had experienced 10 [MEDICAL CONDITION] by the time she reported to work at 6:00 a.m. on [DATE]. LVN O stated she let LVN D know about the resident's [MEDICAL CONDITION] activity. LVN D stated it was normal for her but then LVN O told her Resident #7 had not received the [MEDICATION NAME]. LVN D then advised LVN O to send Resident #7 out to the hospital. LVN O stated the procedure for obtaining medications included: upon admission the nurse on duty would check the medications with the physician and make changes as needed. The nurse would then immediately fax the physician orders [REDACTED]. The receiving nurse would check the inventory sheet against the medications upon arrival to the facility. Any discrepancies would be noted on the inventory sheet. LVN O stated the orders for [MEDICATION NAME] and [MEDICATION NAME] were not filled. She stated she understood the PCP was in the facility when Resident #7 was admitted , but the PCP did not write the scripts for the medications. LVN O stated she heard LVN I on the phone with the PCP who asked for a [MEDICATION NAME] for Resident #7. LVN O stated they did not have controlled medications in their emergency kits. Interview on [DATE] at 8:26 p.m. with LVN R revealed she worked on [DATE], [DATE] and [DATE] as the night charge nurse for Resident #7. LVN R stated she had worked at the facility for 3 weeks and had worked various shifts on different halls. LVN R stated she received limited training on the facility's medication pass policy and on their admission process. She stated Resident #7's medications dribbled in early morning on [DATE]. She realized later during the evening shift on the same date that 2 medications, [MEDICATION NAME] and [MEDICATION NAME], had not arrived. LVN R stated on the morning of [DATE] she did not pass the information on during report to LVN P during shift change. She commented she intended to but did not so she called the pharmacy. She learned she needed a written prescription for [MEDICATION NAME] because it was a controlled medication and the PCP did not write a script for it. Furthermore, the facility did not have any controlled medications in the E-kit and even if they did she was not an agent; did not have the authority or code to get into the E-kit. LVN R stated she called the NP after Resident #7 had her first [MEDICAL CONDITION] at midnight. The NP also told her she needed a written prescription for the [MEDICATION NAME] and would have to wait until he came to the facility in the morning. He stated she did not have to send Resident #7 out to the hospital. She let him know that Resident #7 had an order for [REDACTED]. The NP stated it was not necessary; the lab could also be drawn as scheduled. LVN R stated Resident #7 then had a series of [MEDICAL CONDITION] before shift change at 6:00 a.m. She stated LVN D and LVN I had arrived and she asked them to help her with Resident #7. LVN R expressed a great deal of remorse and stated she felt very bad because of her mistake. She commented she felt so overwhelmed. She stated it was a very busy night; she had 2 admissions and a resident who was actively dying [MEDICAL CONDITION] that evening. LVN R stated one of the new admissions was very aggressive and the other one clung on to her medication cart the entire evening. He appeared to be paranoid and delusional. LVN R stated and then she had Resident #7 who was having [MEDICAL CONDITION]. She stated it was too much for a skeleton crew. LVN R stated she did the best that she could but in retrospect she should have called a manager for help. Also, she could have used training on what to do when medications were not delivered. LVN R stated LVN D told her she would get more help for the evening shift and would get someone to pass out medications so it would free up her time. LVN R stated they were short staffed and that administrative staff had been filling in the holes; working all the shifts that did not have sufficient staff on schedule. LVN R further stated the nurses were working 12 hour shifts instead of 8 hour shifts so that administrative staff did not have to work so much. Some of the nurses had quit. Review of a Resident Transfer Form dated [DATE] revealed Resident #7 was sent out to a local hospital via EMS stretcher with [DIAGNOSES REDACTED]. Review of a pharmacy proof of delivery with a date range from [DATE] to [DATE] revealed the facility received the prescription for [MEDICATION NAME] 97.2 mg on [DATE] at 4:57 p.m. after Resident #7 was transferred out to the hospital. Review of a lab dated [DATE] at 16:33 CT revealed Resident #7's [MEDICATION NAME] level was 15.5; the reference range was 10XXX,[DATE].0. Review of a hospital admission form dated [DATE] revealed Resident #7 was admitted into the hospital at 14:55 (2:55 p.m.) with chief complaint: ,[DATE] [MEDICAL CONDITION] since midnight, history of [MEDICAL CONDITION]. Review of hospital note dated [DATE] revealed Resident #7 was sent in from NF for sz since midnight per EMS. Pt had ,[DATE] sz. per staff. out of meds missed 2 doses of [MEDICATION NAME]. awake/non-verbal. normal for her. skin is pale. EMS reported 3 [MEDICAL CONDITION] approximately 30 seconds each. Interview on [DATE] at 5:12 p.m. with Resident #7's RP revealed the SW contacted her today to inform her the facility would not be able to accept the resident back into the facility due to her history of [MEDICAL CONDITION]. Resident #7's RP questioned why the facility's position changed in 2 days. The RP stated she learned on [DATE] that Resident #7 had not received her medications for 2 days and was sent out to the hospital because her son went to visit Resident #7 that day. She stated she was really upset when she was told the Dr. said it could wait until the morning. She stated she did not want it to happen to anyone else. Interview on [DATE] at 9:46 a.m. with LVN D/Unit Manager and the ADON revealed they did not have interdisciplinary team meetings to discuss more challenging admissions. LVN D and the ADON stated they were not always informed of and did not always provide input regarding new admissions. LVN D stated typically they asked for a new resident's H & P, medication list, nurse's notes, labs and asked about the resident's behaviors to determine if a resident was an appropriate placement. LVN D stated she audited Resident #7's chart when she was admitted into the facility but failed to inquire if the medications had been filled. She learned that not all staff was aware that [MEDICATION NAME] was a controlled medication and it required a written prescription (not a triplicate). The ADON stated LVN R was not trained to handle Resident #7's condition and LVN D stated the managers failed to explain to LVN R how to obtain medications right away. LVN D stated the PCP wrote a prescription for the [MEDICATION NAME] on the morning of [DATE]. Furthermore, upon receiving additional information about Resident #7's condition, they determined Resident #7 was not an appropriate placement. LVN D confirmed they should have obtained all necessary medical history prior to admitting Resident #7. LVN D also confirmed that Resident #7 did not receive [MEDICATION NAME] or [MEDICATION NAME] while she was at the facility and even though her [MEDICATION NAME] lab showed that her level was within normal limits, the facility failed to provide Resident #7 with the quality care she needed. LVN D further stated that Resident #7 required care from a neurologist which the facility did not have available for the resident. Interview on [DATE] at 10:05 a.m. with Resident #7's PCP revealed she saw Resident #7 upon admission into the facility. She confirmed she did not write the prescription for the [MEDICATION NAME] while at the facility; she stated it was an oversight. She stated she had a discussion with the NP regarding Resident #7's [MEDICAL CONDITION] activity on the morning of [DATE]. He told her he thought a triplicate prescription was needed for the [MEDICATION NAME]. He was also not aware of Resident #7's severe [MEDICAL CONDITION] disorder nor was the facility. However, the PCP stated the facility should have known her history and mentioned they relied on staff to provide the resident's medical history. The PCP mentioned many of the nurses at the facility were new and commented the facility was short staffed. The PCP stated the facility did not contact her about Resident #7's admission otherwise she would have told them she was not an appropriate placement. She stated Resident #7 had a VNS implant indicating she had a severe [MEDICAL CONDITION] disorder with 3 failed forms of treatment which were the qualifying factors for having a VNS implant. The PCP stated that Resident #7 required a neurologist to follow her care which was not available through the facility. Resident #7 also required on-going specialized care from RN nursing staff. The PCP stated she talked with the admitting physician at the local hospital who expressed great concern for Resident #7 stating she was very sick upon arrival. He stated she was in status meaning she was seizing without stopping and any treatment provided was not helping. Once she stabilized, he sent her to another hospital where she would receive the specialized care she needed. The PCP stated Resident #7 should have been sent out to the hospital after her first [MEDICAL CONDITION] at midnight based on her [MEDICAL CONDITION] disorder and on the fact that she had not received her [MEDICATION NAME] medication. The PCP stated Resident #7 could have died . Interview on [DATE] at 4:30 p.m. with the ADM and DON confirmed they did not have interdisciplinary meetings to discuss more difficult admissions. The DON stated she and the ADM decided to accept Resident #7 as a new admission. She confirmed she did not obtain all of the necessary medical background information in order to make an informed decision. The DON stated she did not know that Resident #7 had a VNS implant and did not provide nursing staff with any training. She stated she would have provided training to ensure they understood how to use it. The ADM and the DON confirmed that Resident #7 was not an appropriate placement and that the facility did not have the resources to meet her needs. Interview on [DATE] at 2:25 p.m. with LVN D/Unit Manager confirmed that a care plan was not developed to address Resident #7's [MEDICAL CONDITION] disorder or how to provide care via the VNS. LVN D stated they did not know that Resident #7 had a VNS implant or that her condition was not stable until they received additional information after she was in the facility. Furthermore, staff was not trained on the use of the VNS. LVN D stated usually there would be an order providing instructions for its use. Interview on [DATE] at 2:46 p.m. with LVN R revealed she had personal experience on using a VNS. She stated LVN P also showed her to run the wand over the VNS to stimulate it which pulled the resident out of the [MEDICAL CONDITION]. LVN P told her that Resident #7's RP provided her with basic instructions. LVN R stated administrative staff did not provide any instructions or literature on how to use the VNS. Review of a policy titled Changes in Resident Condition dated 2008 read: For life-threatening events: Call 911 if initial assessment indicates that such action is necessary. Review of a policy titled, Standards of Nursing Practice dated 2005 read: We believe the use of the nursing process ensures appropriate care and services for each resident. The delivery of nursing care in the facility is based on a thorough assessment of the resident to identify his or her care needs. Once resident needs are identified, a comprehensive care plan is developed to attain individualized resident goals. The care plan is implemented by the interdisciplinary team and is continually evaluated for effectiveness. The care plan is updated as necessary to meet the resident's needs. Review of a facility policy titled, Admission to the Facility revised during [DATE] read: The facility will only admit residents referred by physician's orders [REDACTED]. Objectives: Admit residents whose needs can be me by the facility; Ensure that appropriate medical and financial records are provided to the facility prior to or upon admission. Responsibility: The facility will follow the established admission policy. The Administrator will review admissions periodically to determine if the policy is being followed. Review of a facility policy titled, Pharmacy Services dated [DATE] read: The intent of these requirements is that: In order to meet the needs of each resident, the facility accurately and safely provides or obtains pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed pharmacist; to serve at the consultant pharmacist. Review of a facility policy titled, Medication Administration revised during [DATE] read: Resident Medications are administered in an accurate, safe, timely, and sanitary manner. FUNDAMENTAL INFORMATION: New Medication Starts-Begin new medication orders timely. Begin routine orders on the same day ordered, unless the next dose would be normally given the next day. The ADM and DON were notified on [DATE] at 4:45 p.m. that an Immediate Jeopardy was identified. The facility's Plan of Removal was accepted on [DATE] at 2:25 p.m. and it included: 1. All Nursing Staff in serviced on Changes of Condition to include Pain and [MEDICAL CONDITION] on [DATE]. 2. All Nurse's aides in serviced that if a resident has a change that they note, they are to inform the nurse and complete a interact 4 Stop and Watch Tool which is a tool for all staff to communicate changes to the licensed nurse related to behaviors, communication, decline in ADL's, Pain, oral intake or LOC. A sleeve has been added to the 24 hour report binder for all stop and watches to be put into. These will be reviewed during the clinical daily meeting, by the DON and Nurse Managers, with follow up actions, as necessary. All nurses and aides will be in serviced when a resident's condition is not improving, they will collaborate with the nurse manager for that hall, and/or DON. This will be completed [DATE]. 3. All Nursing staff will be in serviced on pain assessments to be more thorough and use an approved tool (scale of ,[DATE]), or Facial Scale) for both their pre-intervention assessment and post intervention assessment. Assessments of pain as well as interventions and assessment of effectiveness need to be documented in the PRN Pain Form and/or the nurses' notes. Nurses also in serviced that if a resident complains of increased pain, that this is an indicator of a possible change in condition. All nurses cautioned not to become de-sensitized to Chronic Pain patients. The nurse will then use the SBAR (Situation/Background/Appearance/Review and Notify) Communication Form as a guide when they call/notify physician. Nurses informed that if a residents condition does not improve after the physician is notified (new orders implemented) that they are to reattempt communication with the physician and notify the DON or nurse manager and document all attempts. The nurse manager will attempt to rectify the situation with that physician and if that fails will involve the Medical Director, as necessary. Nurse Managers will identify residents on a pain management program and review their MARS and Charts for compliance every week for 2 months using a Pain Management System Validation. Issues will be reported to QAPI with follow up actions as necessary. 4. Nurses will clarify if there are labs that need to be drawn prior to sending a resident to an appointment. All appointments will be reviewed by the nurse manager at the end of the week for the up-coming week using the Daily Stand Up Meeting Guidelines. Labs will be written in the record as orders from whichever doctor is ordering it. Lab orders will be logged into the Lab Tracking Auditing System with daily review by nurse managers and follow up as necessary. All nurses have been in serviced on the expectations that labs will be completed as ordered and MD will be notified of results in a timely manner. Critical Labs will be called to the physician immediately upon receipt of lab results. Physician notifications and new orders will be documented on the lab itself, in the nurse's notes and on the physician order [REDACTED]. The weekend supervisor will review the 24 hour reports on weekends and ensure the physician has been notified of critical labs and resident change of conditions and appropriate interventions are implemented actions as necessary. 5. All nurses will be in serviced on the procedures to order/re-order medications. If a medication does not come in stat for new residents or on the next run for reorders-nurses are to call the pharmacy and document proof of who they spoke to as well as notify MD that medication was not delivered and ask if there are new orders, and document this conversation,. Nurses will document all attempts to obtain the medication. Nurse Manager reviews all telephone orders daily and ensures all physician orders [REDACTED]. Pharmacy issues will be brought up to the DON and/or Administrator for resolution. 6. All potential admissions will be reviewed by a nurse manager. If the resident is clinically complex, or requires specialty care beyond the norm for the facility-the potential resident's information will be reviewed by the interdisciplinary team to include the medical director. As appropriate and feasible, complex or specialty residents will be visited by a facility representative to assist in a fully informed decision as to whether the facility can meet that resident's needs. The facility will define specialty residents that we will not take such as residents on ventilators. Resident admission denials will be discussed as part of the QAPI. Training opportunities will be examined to see if the facility can obtain training to meet the needs of specialty type residents. Training will occur prior to accepting those residents. 7. Staff will be reminded that the lines of communication to the Director of Nursing and Administrator are always open for the good of the residents. Staff will know how to get a hold of either one of these leaders, 24 hours a day as necessary. On [DATE] the Surveyor confirmed the plan of removal had been sufficiently implemented to remove the Immediate Jeopardy by interviewing: 5 CNAs regarding checking alarms for functionality; making sure wheelchairs were locked; making sure all interventions were being implemented; identifying a change of condition and who they reported the changes to; working with difficult residents including residents with Dementia and using the Stop-n-watch process. 5 nurses were interviewed regarding assessing a resident with a change in condition; what steps to take including calling the physician to ensure the resident received necessary care; process in addressing critical labs, contacting the physician ensuring critical information was relayed to the physician; assessing level of pain in residents; addressing [MEDICAL CONDITION] activity; ensuring medications were ordered and available for residents. The Interim ADON, LVN D and the ADM were interviewed: regarding the admission process. They stated unit managers would be involved in the process and the DON would make the final decision An in-service dated [DATE] and [DATE] regarding Recognizing and Reporting Changes in a Resident's Physical Condition was reviewed and contained the names of 59 staff who attended. An in-service dated [DATE] and [DATE] regarding Dementia Care Series Part I: Mental Decline & Caregiving Challenges was reviewed and contained the names of 60 staff who attended. An in-service dated [DATE] regarding [MEDICAL CONDITION] management, long-term care was reviewed and contained the names of 56 staff who attended. On [DATE] at 2:25 p.m. the Administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of pattern at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. Review of a document titled, Universe completed by the facility on [DATE] revealed there were 7 residents with a [MEDICAL CONDITION] disorder. Information provided by LVN D/Unit Manager revealed there was 1 resident who had a VNS implant.

Based on interview and record review the facility failed to notify the physician immediately of a critical BUN result for 1 of 15 residents whose records were reviewed (#4) who had a change in condition; the resident's legal representative or interested family member when there was an accident involving the resident which resulted in injury for 1 of 15 residents (#2) whose records were reviewed for falls; 1 of 15 residents (#7) who had a change in condition requiring hospitalization and 2 of 15 residents (# 5 & #6) whose records were reviewed for scabies in that: 1. Nursing staff did not notify Resident #4's physician's of the abnormal critical BUN lab result for four days and the resident complained of nausea and vomiting. 2. Charge staff did not notify Resident #5's RP when diagnosed and treated for [REDACTED]. 3. Charge staff did not notify Resident #6's RP when diagnosed and treated for [REDACTED]. 4. Nursing Staff did not notify Resident #7's RP when she had multiple [MEDICAL CONDITION] and was sent out to the hospital. Resident #7 was discharged from the facility. 5. LVN DD did not notify Resident #2's RP when she had a fall resulting in injuries prior to her discharge from the facility. These deficient practices could affect 7 residents on the 300 Hall with scheduled lab tests, 19 residents in the locked unit, 7 residents diagnosed with [REDACTED]. The findings were: 1. Review of Resident #4's clinical record revealed she had labwork completed on 3/29/16 which indicated a critical result of BUN of 88 which was called in to the facility and read back. This report also indicated it was faxed on 3/30/16 by LVN II. Another note on the lab sheet read faxed to renal. Interview on 5/5/16 at 1:00 p.m. with LVN D revealed that no staff member existed with the name reported to by the lab. LVN D reported that Resident #4 sees a Nephrologist and that about a week prior to her appointment with the specialist she gets labs drawn. Interview on 5/5/16 at 1:40 p.m. with LVN II, he said that he faxed Resident #4's labwork results for 3/29/16 on 3/30/16 to the physician's company. Interview on 5/6/16 with Resident #4's physician, he said that he did not recall getting notified of a critical BUN on Resident #4 and that if he had he would have had them repeat the lab or start an intravenous line on the resident for fluids. He said his company would have a record of the fax. No record was found by the company of a fax on Resident #4 with critical lab results from 3/29/16 to the date she was sent to the hospital on [DATE]. Interview on 5/17/16 at 3:00 p.m. with the Nephrologist's Medical Assistant revealed that she called the facility on 3/29/16 to inquire about the labs to be drawn for Resident #4's appointment on 3/30/16, and she said that LVN D said the labs would be drawn prior to the appointment (no written physician order [REDACTED]. She said the labs ordered were CBC and Platelets, PTH and a Renal Panel. She said that on 3/30/16 the Resident came to the appointment and the lab results the facility faxed over were still pending, so the Nephrologist sent her back to the facility, and they never did receive the labwork. Interview on 5/5/16 at 10:00 a.m. with LVN E revealed that on 4/2/16 she was working and that Resident #4 appeared lethargic, and she checked her lab work. She said that she saw the critical lab result from 3/29/16 and called the physician ' s office and received a STAT order for labs to be drawn, which was not written on a physician's orders [REDACTED]. Review of Resident #4's Medication Administration Record [REDACTED]. Review of Resident #4's Medication Administration Record [REDACTED]. She was given Tylenol two tablets on 3/5 and 3/19 along with her [MEDICATION NAME]. Section on the MAR's for result, and describe was noted effective for all but two of the PRN pain or nausea medications given in March. Two results sections were left blank. Review of facility policy and procedure titled Laboratory Management dated August 2012 revealed in #4. If the results of the lab tests are Abnormal or Critical Values, the attending Physician/Licensed Provider will be notified immediately at the time the results are received. Date, time, and person notified should be documented on the lab report and signed by the Licensed Nurse. 2. Review of Resident #5's medical face sheet (undated) revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed her son was her RP. Review of a hospital follow up plan dated 3/17/16 revealed Resident #5 had a [DIAGNOSES REDACTED]. Review of a t.o. dated 3/18/16 revealed to d/c [MEDICATION NAME] order until seen by dermatologist. Review of a t.o. dated 4/13/16 revealed an order: apply [MEDICATION NAME] cream today from chin to toes leave for 8-12 hours then bathe; repeat in one week for a total of two treatments STAT. Interview on 4/18/16 at 4:21 p.m. with LVN N revealed the residents in the locked unit had skin rashes for the last 2 months. She stated Resident #5 came back from the hospital during March 2016 after a fall and was diagnosed with [REDACTED]. LVN N stated Resident #5 was never sent out to the dermatologist, but then all residents in the locked unit were treated for [REDACTED].#6 tested positive for scabies. LVN N stated she suspected most residents had scabies, but only 2 residents were actually tested including Resident #6. LVN N stated she was not aware of family members being notified that the residents were treated for [REDACTED]. Interview on 5/3/16 at 2:36 p.m. with Resident #5's RP confirmed he did not know his mother had been diagnosed or treated for [REDACTED]. 3. Review of Resident #6's medical face sheet (undated) revealed she was admitted into the facility on [DATE]. Further review revealed her RP was a daughter. Review of a physician progress notes [REDACTED].#6 had a [DIAGNOSES REDACTED]. Review of a t.o. dated 4/12/16 revealed an order: apply [MEDICATION NAME] cream today from chin to toes leave for 8 hours then bathe; repeat in one week for a total of two treatments STAT. Interview on 4/18/16 at 4:21 p.m. with LVN N revealed the residents in the locked unit had skin rashes for the last 2 months. She suspected other residents had scabies, but only 2 residents were actually tested including Resident #6. She stated Resident #6 was sent out for a scrape and tested positive for scabies. LVN N stated family members were not notified of residents being treated for [REDACTED]. Interview on 4/21/16 at 9:38 a.m. with LVN GG in the locked unit confirmed that families had to be notified if residents were being treated for [REDACTED].#6's chart (nurse's notes) and stated there was no documentation indicating the RP was notified that Resident #6 was treated for [REDACTED]. Interview on 4/21/16 at 10:08 with the ADON confirmed that Resident #6 was diagnosed with [REDACTED]. The ADON believed Resident #6's RP was notified that Resident #6 was diagnosed and treated for [REDACTED]. and stated there was no documentation to support the RP was notified. Interview on 5/3/16 at 3:12 p.m. with Resident #6's daughter revealed she learned that her mother was treated for [REDACTED]. The RP stated she noted all the plastic bags of clothing in one of the rooms because she could not find any clothes in her mother's room. 4. Review of Resident #7's medical face sheet (undated) revealed she was admitted into the facility on [DATE] at 13:00. Review of Resident #7's admission orders [REDACTED]. Further review revealed an order for [REDACTED]. Review of a Nursing Admission Intake Form dated 4/19/16 revealed Resident #7 had a VNS implant on her left side to control [MEDICAL CONDITION]. Review of an H & P dated 4/20/16 revealed Resident #7 was transferred into the facility from a hospital in San(NAME) TX with a severe sz d/o. Resident #7's assessment and plan for her [MEDICAL CONDITION] disorder included orders for [MEDICATION NAME] ER, [MEDICATION NAME] and [MEDICATION NAME] level in AM. Review of a MAR indicated [REDACTED]. Review of an incident/accident report dated 4/21/16 revealed Resident #7 was lying in bed and was noted having atonic-clonic [MEDICAL CONDITION] activity at 12:10 p.m. Further review revealed her VNS magnet was utilized and Resident #7 stopped having [MEDICAL CONDITION] activity. The NP was notified; the section for the RP was blank indicating contact was not made. Review of a second incident/accident report dated 4/21/16 revealed Resident #7 having multiple atonic-clonic [MEDICAL CONDITION] approximately 30 seconds each. LVN R wrote she witnessed the resident having 3 [MEDICAL CONDITION] within approximately 7-10 minutes. The PCP was notified; the section for the RP was blank indicating contact was not made. Review of an incident/accident investigation follow-up dated 4/21/16 read Resident #7 experienced uncontrolled tonic-clonic [MEDICAL CONDITION] activity. VNS magnet utilized & [MEDICAL CONDITION] activity would stop for time then would restart. Total of 9 [MEDICAL CONDITION] prior to going to ER. The summary of investigation revealed there was no [MEDICATION NAME] or [MEDICATION NAME] from pharmacy. Review of a Resident Transfer Form dated 4/21/16 revealed Resident #7 was sent out to the hospital with [DIAGNOSES REDACTED]. Interview on 4/27/16 at 5:12 p.m. with Resident #7's RP revealed no one called her to tell her that her daughter was sent out to the hospital after experiencing multiple [MEDICAL CONDITION]. The RP stated her son went to the facility to visit Resident #7 and learned she was sent out early that same morning because she did not receive all of her medications for 2 days. The RP further stated she had provided all of her and several family members contact information to the lady over medical records. The RP stated staff did not call anyone. Interview on 4/27/16 at 8:26 p.m. with LVN R revealed she worked on 4/19/16 to 4/21/16 as the charge nurse for Resident #7. LVN R stated she had worked at the facility for 3 weeks. She stated Resident #7's medications dribbled in early morning on 4/20/16. She realized during the evening shift that 2 medications, [MEDICATION NAME] and [MEDICATION NAME], had not arrived. LVN R stated that Resident #7 had her first [MEDICAL CONDITION] at midnight and then had a series of [MEDICAL CONDITION] before shift change at 6:00 a.m. on 4/21/16. She stated she initially called the NP who told her not to send the resident out but then after the series of [MEDICAL CONDITION] the PCP gave the order to send her out to the hospital. LVN R stated she did not call the RP because she understood one of the supervisors would call the RP. She mentioned LVN D/Unit Manager, LVN I and LVN O all helped with the transfer. Interview on 4/28/16 at 2:45 p.m. with LVN I revealed she called the number on Resident #7's medical face sheet and left a message. Upon reviewing the information on the face sheet, she confirmed it was not the RP's contact information. LVN I stated it was the contact information for her previous placement. 5. Review of Resident #2's medical face sheet dated 11/11/15 revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nurse's note dated 3/2/16 revealed Resident #2's RP was at the facility and expressed several concerns to staff regarding her mother's condition/history of falling. Review of an incident report dated 3/3/16 revealed Resident #2 was found on the floor mat beside the bed. Resident #2 had a skin tear to her left index finger and a hairline skin tear to her left cheek and jaw. Review of a nurse's note dated 3/3/16 revealed Resident #2 was found on floor next to her bed, head next to bed side table leaned against wall with her back. st to left cheek/jaw st to left index finger. It was noted the RP was notified. The note was written by LVN DD. Review of Resident #2's complete incident reports and nurse's notes from 3/2/16 to 3/11/16 did not reveal any other falls. Further review did not reveal any contact made with the RP during this time period. Review of a head to toe skin check dated 3/3/16 revealed Resident #2 had bruises on her right top foot, right knee, left index finger and left cheek. Review of a head to toe skin check dated 3/11/16 revealed Resident #2 had bruises on her right top foot, right knee, left inner thigh, right wrist and arm, left hand, right hand, lower lip and left cheek. Further review revealed she had [MEDICAL CONDITION] on forehead, left side of head and a bruise on left hip (old green bruise). Review of t.o. dated 3/11/16 revealed Resident #7 was discharged from the facility into another long-term care facility. Interview on 4/18/16 at 8:33 a.m. and then on 4/25/16 at 3:31 p.m. with Resident #2's RP revealed the nursing staff at the new placement provided her with an update of Resident #2's physical condition/injuries at the time of admission. The RP stated she was aware that Resident #2 had multiple falls while at the facility, but stated the last fall she was called about took place about 2 weeks prior to Resident #2's discharge. The RP stated she was not aware of all the injuries noted on her mother; her hands, fingers, knees, arms, left thigh and on her left cheek. Interview on 4/27/16 at 12:46 p.m. with LVN DD confirmed she was the charge nurse on 3/3/16, the day Resident #2 fell . LVN DD stated Resident #2 was rapidly declining during that time period; was becoming more and more confused and unsteady on her feet. She stated she found Resident #2 on the floor. The bedside table was away from the bed and Resident #2 had a bump on the side of her head and skin tears on one of her hands. She remembered a small pool of blood on the floor. LVN DD stated Resident #2 had several injuries around her face, upper and lower extremities that she could see and could remember. She stated protocol required that she call the RP, PCP and Hospice. LVN DD stated she remembered calling the PCP and Hospice, but was not sure if she called the RP. Review of a policy titled, Changes in Resident Condition dated 2008 read: The resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. Review of a daily census dated 4/18/16 revealed there were 19 residents in the locked unit. Review of a document titled universe completed by the facility on 5/6/16 revealed there 7 residents diagnosed with [REDACTED]. Information provided by the Clinical Nurse Consultant on 5/18/16 revealed there were 7 residents on 300 Hall who were scheduled for routine labs.

Based on interview and record review the facility failed to promptly notify the attending physician of laboratory results for 1 of 15 residents (#4) whose medical records were reviewed. Resident #4 had labwork completed on 3/29/16 with a critical BUN of 88, and the critical lab result was not reported to the primary physician for 5 days and was also not reported to her Nephrologist who ordered the labs. This deficient practice could affect 7 people on 300 Hall who had scheduled labs ordered. Review of Resident #4's clinical record revealed she had labwork completed on 3/29/16 which indicated a critical result of BUN of 88 which was called in to the facility and read back. This report also indicated it was faxed on 3/30/16 by LVN II. Another note on the lab sheet read faxed to renal. Interview on 5/5/16 at 1:00 p.m. with LVN D revealed that no staff member existed with the name reported to by the lab. LVN D reported that Resident #4 sees a Nephrologist and that about a week prior to her appointment with the specialist she gets labs drawn. Interview on 5/5/16 at 1:40 p.m. with LVN II, he said that he faxed Resident #4's labwork results for 3/29/16 on 3/30/16 to the physician's company. Interview on 5/6/16 with Resident #4's physician, he said that he did not recall getting notified of a critical BUN on Resident #4 and that if he had he would have had them repeat the lab or start an intravenous line on the resident for fluids. He said his company would have a record of the fax. No record was found by the company of a fax on Resident #4 with critical lab results from 3/29/16 to the date she was sent to the hospital on [DATE]. Interview on 5/17/16 at 3:00 p.m. with the Nephrologist's Medical Assistant revealed that she called the facility on 3/29/16 to inquire about the labs to be drawn for Resident #4's appointment on 3/30/16, and she said that LVN D said the labs would be drawn prior to the appointment (no written physician order [REDACTED]. She said the labs ordered were CBC and Platelets, PTH and a Renal Panel. She said that on 3/30/16 the Resident came to the appointment and the lab results the facility faxed over were still pending, so the Nephrologist sent her back to the facility, and they never did receive the labwork. Review of facility policy and procedure titled Laboratory Management dated August 2012 revealed in #4. If the results of the lab tests are Abnormal or Critical Values, the attending Physician/Licensed Provider will be notified immediately at the time the results are received. Date, time, and person notified should be documented on the lab report and signed by the Licensed Nurse. Information provided by the Clinical Nurse Consultant on 5/18/16 revealed there were 7 residents on 300 Hall who were scheduled for routine labs.