Every finding on record at Ashford Hall

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's one of one kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure food items, placed in the dry storage areas, were sealed and kept off the floor. 2. The facility failed to ensure food items placed in the refrigerator and/or freezer were dated, sealed and labeled appropriately. 3. The facility failed to ensure garbage receptacles in the kitchen had lids on them, when trash was in the containers, not being used. These failures could place residents at risk for food-borne illnesses.Findings include: In an observation on 4-7-2026 at 9:00 AM, revealed the facility's dry storage area had a few loose potato chips on the floor, 1 cart of approximately 20 bags of potato chips on the floor, one cheese puff, 14 boxes delivered with various food items sitting on the floor, and items that had fallen on the floor behind a large food shelf, were one six-pack of V-8 juice, one 13 oz can of Rykoff Sexton anchovies, one 30oz container of ground cinnamon, two 8 oz thickening dairy beverages, one 10 oz can of Rotel tomatoes, and one 4 oz container of prune juice. The facility's only walk in refrigerator, revealed there was a multi-level rolling tray with approximately 50 beverages that were unlabeled and undated. The facility's only freezer contained a tray of 25 slices of unsealed, undated, and unlabeled cheesecake. In a second storage room containing the kitchen's plasticware and storage containers, there was a used pair of latex gloves on the floor, a bag of plastic containers used to store leftovers unsealed within a few feet of a mouse trap. There were no signs of rodents or rodent droppings.In an observation on 4-7-2026 at 9:10 AM, revealed the facility's only kitchen had two large trash cans, not in use, with liners, containing trash without lids. One of the trash cans was in the dishwashing area and the other trash can was located by the back door.In an interview on 4-7-2026 at 9:15 AM, the Dietary Manager revealed a mouse had recently been caught in the room housing the plasticware and plastic containers.In an interview on 4-8-2026 at 11:30 AM, the [NAME] said she did not put the lid back on the trash can by the back door on 4-7-2026 because she was busy doing another task and forgot to. The [NAME] said it was important to keep lids on trashcans in the kitchen area because it could attract insects and might get in resident's food.In an interview on 4-8-2026 at 2:00 PM, the Dietary Manager said she had worked at the facility as a Dietary Manager for 6 years. The Dietary Manager said the reason the boxes of food were on the floor, in the dry storage area, was because the facility had food delivery, and the kitchen staff had not stocked the items yet. The Dietary Manager said she believed the reason the food items were on the floor, behind the food shelf in the dry storage area, was because someone had moved the shelf causing the food items to fall and did not pick them up. The Dietary Manager said the reason the beverages were not dated and labeled was because they were going to be used the same day. When asked, the Dietary Manager could not identify what the beverages were. The Dietary Manager said she believed the reason the cheesecake, in the freezer was not sealed, labeled, or dated, was because the cake was used the previous night and the kitchen staff did not think to seal, date, or label it. The Dietary Manager said she believed the plastic containers were not sealed due to carelessness and the latex gloves were on the floor due to a staff member overstuffing a trash bag and the gloves fell out on the floor. The Dietary Manager said the reason food items in the refrigerator, freezer, and dry storage areas should be dated, labeled, and sealed was to prevent insects or rodents from getting into them. The Dietary Manager said she was primarily responsible to ensure proper food storage was implemented and then the Dietary Aides. The Dietary Manager said her expectations were for food in the refrigerator and freezer to be sealed, dated, and labeled. Her expectations for her staff was for the food in the dry storage areas were to be kept off the floor, sealed, dated, and labeled. The Dietary Manager said the lid was not on the trash can in the dishwashing area because the Dietary Aide was putting away a mop and was not using the trash can at the time. The Dietary Manager said the reason the trash can by the back door did not have a lid on it was because the cook stopped throwing away trash and started other duties. The Dietary Manager said it was the responsibility of the dietary aide in the dishwashing area and the cook by the back door to ensure trash can lids stayed on trash cans when not in use. The Dietary Manager said it was also the Dietary Manager's responsibility to ensure that lids were kept on trash cans in the kitchen area. The Dietary Manager said if trash can lids were not kept on trash cans it could attract insects and rodents which could cause residents' food to be infected and make them sick. The Dietary Manager said it was her expectation that trash can lids stay on the trash cans when not in use. In an interview on 4-9-2026 at 4:45 PM, the CEO/Interim Administrator said the Dietary Manager was responsible to ensure proper food storage regulations were followed in the facility's only kitchen. The CEO/Interim Administrator said his expectations were for food to be kept off floors, sealed, dated, and labeled in the dry storage area, refrigerators, and freezers. The CEO/Interim Administrator said if the proper rules regarding food storage were not followed it could cause contamination and get into resident's food. He stated his expectations were for trash can lids to be kept on kitchen trash cans whenever they were not in use. The CEO/Interim Administrator said the risk of not keeping lids on trash cans was insects and rodents could get into resident's food causing illness. The CEO/Interim Administrator said the people working in the kitchen were responsible for ensuring lids were kept on kitchen trash cans. The CEO/Interim Administrator said the facility did not have a policy on trash disposal. Record review of the facility's policy, dated November 2022, and titled Food Receiving and Storage stated: Policy StatementFoods shall be received and stored in a manner that complies with safe food handling practices. Dry Food StorageNon-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). Such foods are rotated using a first in - first out system.Food in designated dry storage areas are kept at least six (6) inches off the floor (unless packaged for case lot handling, for example, dollies, pallets, racks and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 5. Food in designated dry storage areas are kept at least six (6) inches off the floor (unless packaged for case lot handling, for example, dollies, pallets, racks and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents. Refrigerated/Frozen StorageAll foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.8. Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. Foods and Snacks Kept on Nursing Units 4. Beverages are dated when opened and discarded after twenty-four (24) hours.5. Other opened containers are dated and sealed or covered during storage. Record review of the U.S. Public Health Services Food Code, dated 2022 reflected: 3-305 Preventing contamination from the premises 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD:(1) In a clean, dry location;(2) Where it is not exposed to splash, dust, or other contamination; and(3) At least 15 cm (6 inches) above the floor. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT.

Based on observation, interview and record review the facility failed to ensure the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of one maintenance room reviewed for accidents and hazards. The facility failed to ensure the door to the maintenance room located outside by the smoking area, which contained plugged power tools, harmful chemicals, and sharp tools, was secured. This failure placed residents at risk for injuries due to having access to an unsecured maintenance room.Findings include: In an observation on 4-7-2026 at 9:00 AM, the maintenance room door was left propped open and unattended by staff. The maintenance room was in a small building within 25 feet of the unlocked unalarmed dining room exit door and within 30 feet of the open smoking area. There were no barriers to block off access to the maintenance room door. There was an electric grinder, with the blade facing upward, plugged into an electrical outlet. The grinder was observed to turn on, sitting on top of sheetrock, close to the entry door. There was also a key making machine plugged into an electrical outlet with an exposed cutting blade. The maintenance room had various 5-gallon paint cans, spray paint cans with lids off, paint stripper cans, a pickaxe, and flat head axe. No residents were observed in the immediate area. Observation on 4-7-2026 at 11:00 AM, revealed the maintenance room door was still propped opened and unattended. At this time, the Director of Environmental Services was notified by the state surveyor the maintenance room door was propped open, unattended, and was a potential hazard to residents. The Director of Environmental Services radioed a staff member to secure the maintenance room door. Observation on 4-7-2026 at 11:15 AM, revealed the maintenance room door was opened about 6 inches, unattended by staff, and not secured. The door was observed to be easily accessible to residents. Observation on 4-8-2026 at 4:45 PM, the maintenance room door was closed but unlocked. The door to the maintenance room was unattended by staff and easily accessible to residents. Interview on 4-8-2026 at 4:50 PM, with the Director of Environmental Services revealed the reason the door to the maintenance room was left unlocked and unattended by staff on 4-7-2026, was because a maintenance assistant was using the electrical grinder to cut sheetrock and was called away to move something in the facility. When the Director of Environmental Services was informed the door to the maintenance room was still not secured on 4-8-2026, he had no answer for why it was not secured. The Director of Environmental Services said he was going to purchase a one-way door lock and install it on the maintenance room door. The Director of Environmental Services said he was responsible for ensuring the maintenance room door remained secured so it would not be a risk to residents. The Director of Environmental Services said the risk to residents for not securing the maintenance room door was it could potentially allow access to residents thereby exposing them to harm. The Director of Environmental Services said his expectations were to purchase and install a door lock on the maintenance room door, so the door would stay closed and always locked. Interview on 4-9-2026 at 4:45 PM, with the CEO/President Interim Administrator revealed the maintenance staff were responsible for ensuring the maintenance room door remained secured so residents did not have access to it. The CEO/President Interim Administrator said the risk to residents having access to the maintenance room was they could be harmed. The CEO/President Interim Administrator said his expectation was for the maintenance room door to remain locked when staff were not in the room. Record review of an in-service training signed by the Director of Environmental Services, dated 4-8-2026 at 9:00 AM, stated: The Maintenance is responsible for ensuring that all hazardous areas within the facility remain properly secured at all times. This includes rooms such as maintenance shops, chemical storage areas, utility closets, and any space containing potentially dangerous equipment or substances. It is essential that all locking mechanisms are functional, routinely inspected, and promptly repaired if found to be defective. The Maintenance Director must also ensure that access is limited to authorized personnel only and that keys or access codes are controlled and monitored. Any identified issues, including broken locks, unsecured doors, or access concerns, must be addressed immediately to prevent risk of injury, exposure, or regulatory noncompliance. Maintaining secure hazardous areas is critical component of environmental safety and directly supports the protection of residents, staff, and visitors. Record review of the facility's policy, dated 7-2017, titled Hazardous Areas, Devices, and Equipment stated: Policy StatementAll hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Policy Interpretation and ImplementationAs part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. Identification of HazardsA hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following:Equipment and devices that are left unattended or are malfunctioning;Devices and equipment that are improperly used or poorly maintained;Sharp objects that are accessible to vulnerable residents;Open areas or items that should be locked when not in use; .Access to toxic chemicals . Assessment and Analysis of Hazards1. Assessment and analysis of hazardous areas and equipment will include resident-specific information including identification of vulnerable residents.2. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous

Based on interview and record review the facility failed to ensure at the time each resident was admitted , the facility had physician orders for the resident's immediate care for 1 of 7 residents (Resident #12) review for physician orders upon admit. The facility failed to ensure Resident #12's hospital discharge order were followed.This failure could place residents at risk of not receiving care to meet the physical, mental, and psychosocial needs. Findings include: Record review of Resident #12's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12 had a primary diagnosis of fracture of neck, subsequent encounter (fracture of neck that received treatment). Other pertinent diagnoses included chronic obstructive pulmonary disease (COPD, progressive lung disease making it difficult to breathe), chronic respiratory failure with hypoxia (lungs unable to bring oxygen to blood or get rid of carbon dioxide), difficulty in walking, and cognitive communication deficit (impaired communication). Record review of Resident #12's progress notes reflected:01/29/2026: [AGE] year-old female with PMH significant for hypertension and COPD who presented to the ED on 1/14/2026 following a fall. CT [neck] showed fractures . Neurosurgery was consulted and she underwent [surgery] on 1/19. She developed respiratory insufficiency [post-surgery] and was admitted to the ICU. Resident continues to require skilled nursing service for [neurological] monitoring, respiratory assessment, pain management, and reinforcement of [neck] precautions to prevent complications. Record review of Resident #12's care plan, dated 3/20/2026, reflected: [Resident #12] has a fracture of cervical spine. Interventions included checking pulses on extremities (i.e. arms, legs), encourage therapy to regain abilities, monitor alignment of extremities (to not put too much pressure on side where injury to the neck was), and turn and reposition to prevent skin issues. Record review of Resident #12's hospital notes, dated 01/27/2026, reflected Discharge Instructions.Instructions: contact their office directly to schedule a hospital follow up appointment with the neurology surgeon. Further details stated Plan. From neurosurgery standpoint, the patients okay to be discharged . [sic] Will see her in neurosurgery clinic in 4 weeks for further evaluation and recommendation. During an observation and interview on 04/07/2026 at 4:35 p.m. with Resident #12, she said she wanted to see her doctor from her survey she had on her neck. Resident #12 said she fell at home and had 4 screws put in so the bones did not break again. She said the surgeon told her she needed to rehab and she had been getting physical therapy and it had gone well. Resident #12 said she was supposed to see the surgeon a couple weeks after the surgery, and it had been a couple months since the surgery. She said she did not even know who the surgeon was who did her procedure. Observation at this time revealed Resident #12 was sitting upright on her bed, did not appear to be in distress or pain. During an interview on 04/09/2026 at 9:51 a.m. with LVN B revealed when a resident admitted to the facility, nurses were expected to look at their diagnoses, diets, orders, allergies, and progress notes. LVN B said they were supposed to review orders and send them to the DON and to the doctor to get approved. He said as a charge nurse, it was his responsibility to let them know about the orders. He said the risk of not reviewing admission orders was the resident could have medication interactions, could be allergic to something, and could be hospitalized . He said if a resident needed a follow-up appointment, staff were to let the doctor, DON, transportation, and other nurses know. LVN B said a progress note needed to be made, transportation needed to be set up, the family needed to be notified of where the appointment would be. During an interview on 04/09/2026 at 11:41 a.m. with the interim DON, she said nurses were expected to go through new admitted resident's paperwork and input the medically necessary item in their chart, which included medications and diagnoses. She said nurses were expected to review orders which included their medication orders and admission orders. The interim DON said nurses were expected to communicate about follow-up appointments and set up transportation. She said the risk of residents not receiving a follow-up appointment was, they needed continuity of care. The interim DON reviewed Resident #12 and the facility's calendar and said she could not find a follow-up appointment for Resident #12. She said charge nurses were responsible for communicating the follow-up appointment and then the ADON and DON. She said she would review Resident #12's hospital paperwork and find the doctor for the follow-up appointment, to set up an appointment. During an interview on 04/09/2026 at 3:29 p.m. with RN C, she said she was working when Resident #12 admitted to the facility and was the charge nurse. RN C said she reviewed Resident #12's paperwork and could not recall about a hospital follow-up appointment. She said she was new and getting used to the (electronic) system at that time. RN C said the importance of communicating the follow-up was for continuity of care. During an interview on 04/09/2026 at 3:38 p.m. with Resident #12's MD, he said he just heard a staff member making a follow-up appointment for Resident #12. He indicated he did not know how the follow-up appointment was not in place for Resident #12 because she had been at the facility for a few months. The MD said there was a lot of recent changes in nursing staff. Record review of the facility's admission Notes policy, dated 09/2012, reflected: Policy StatementPreliminary resident information shall be documented upon a resident's admission to the facility.Policy Interpretation and Implementation1. When a resident is admitted to the nursing unit, the admitting nurse must document the following information (as each may apply) in the nurses' notes, admission form, or other appropriate place, as designated by facility protocol:a. The date and time of the resident's admission;b. The resident's age, sex, race, and marital status;c. From where the resident was admitted (i.e., hospital, home, other facility);d. Reason for the admission;e. The admitting diagnosis;f. The general condition of the resident upon admission;g. The time the attending physician was notified of the resident's admission;h. The time the physician's orders were received and verified;i. Description of any lab work completed or the time specimens were sent to the lab;j. The presence of a catheter, dressings, etc.;k. The time the dietary department was notified of the diet order;l. The time medications were ordered from the pharmacy;m. A brief description of any disabilities (i.e., blind, deaf, hemiplegia, speech impairment, paralysis, mobility, etc.);n. Any known allergies;o. Prosthesis required (i.e., glasses, dentures, hearing aid, artificial limbs, eye, etc.);p. The height and weight of the resident;q. A statement indicating that the nursing history and preliminary assessment is completed or has been started;r. Notation of any signs or symptoms of an infectious or communicable disease;s. Notation as to whether or not advance directives apply; andt. The signature and title of the person recording the data.2. This initial information-gathering precedes the complete history and physical assessment that also accompanies the resident admission process.3. The nurses' original admission note must remain on the resident's chart maintained at the nurses' station.4. Should a resident be discharged from and readmitted to the facility, new admission data must be recorded.

Based on observation, 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 1 of 7 residents (Resident #11) reviewed for comprehensive person-centered care plans. The facility failed to develop a care plan to address Resident #11's nicotine dependence. This failure could place residents at risk of not receiving services to maintain their highest practicable physical, mental, and psychosocial well-being.Findings include:Record review of Resident #11's face sheet revealed a [AGE] year-old female. Resident #11 had a primary diagnosis which included attention and concentration deficit following cerebral infarction (cognitive impairment following a stroke). Other pertinent diagnoses included cognitive communication deficit (impaired communication), need for assistance with personal care, contracture right hand (shortening or hardening of muscle, restrict join mobility), muscle weakness, and nicotine dependence. Record review of Resident #11's admission MDS, dated [DATE], revealed Resident #11 had a BIMs score of 15, which indicated cognitive ability was intact. Resident #11 was a current tobacco user. Record review of Resident #11's smoking assessment, dated 02/28/2026, revealed Resident #11 was a smoker and used a vape and was determined a safe smoker. Record review of Resident #11's care plan, dated 04/07/2026, revealed there was no care plan for her nicotine dependence or smoking status. During an observation on 04/07/2026 at 1:30 p.m. of a smoke break revealed Resident #11 used an electronic vape. During an observation on 04/08/2026 at 1:43 p.m. of a smoke break revealed Resident #11 used an electronic vape. During an interview on 04/08/2026 at 2:11 p.m. with Resident #11, she said she smoked using a vape. She said she went on smoke breaks 4 times a day. She said she had no issues with it, and staff provided her with the vape for smoke breaks. During an interview on 04/09/2026 at 11:41 a.m. with the interim DON, she said smoking assessments were done upon admission, quarterly, and with change of conditions for residents. The interim DON said whether Resident #11 was considered nicotine dependent or a smoker, it should have been in her care plan. The interim DON said nicotine was being inhaled, and it needed to be care planned because of how it could affect a medical diagnosis. She said care plans were how there was communications with all providers which included CNAs and nurses. During an interview on 04/09/2026 at 12:07 p.m. with the Activities Director, she said she did care plans and smoking assessments for residents. The Activities Director said she did the smoking care plans and Resident #11's care plan should include that she vaped. She said even vaping had to be considered smoking. She said accurate care plans were important so that the information was correct and other providers could follow it and did not want misleading information. During an interview on 04/09/2026 at 2:35 p.m. with RN A, she stated care plans were important so staff knew what care to provide to residents. She said without care plans, staff would not know anything and there would be a lack of communication between nursing shifts. Record review of the facility's Care Plan policy, dated 03/2022, reflected: Policy StatementThe interdisciplinary team is responsible for the development of resident care plans.Policy Interpretation and ImplementationResident care plans are developed according to the timeframes and criteria established by S483.21.Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).The IDT includes but is not limited to:the resident's attending physician;a registered nurse with responsibility for the resident;a nursing assistant with responsibility for the resident;a member of the food and nutrition services staff;to the extent practicable, the resident and/or the resident's representative; andother staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident.The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.Care plan meetings are scheduled at the best time of the day for the resident and family when possible.If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 7 residents (Resident #3 and Resident #4) reviewed for resident assessments.The facility failed to accurately assess Resident #3's anticoagulant medication status.The facility failed to accurately assess Resident #4's anticoagulant medication status.These failures could place residents at risk of having an inaccurate care plans and inappropriate identification of care needs. Findings include:Record review of Resident #3's quarterly MDS, dated [DATE], revealed an [AGE] year-old female, who was readmitted to the facility on [DATE]. Resident #3 had a primary diagnosis which included sepsis (body has extreme response to infection). Other pertinent diagnoses included dementia (brain disease that alters brain function and causes a cognitive decline), cognitive communication deficit (impaired communication), atrial fibrillation (his is a heart condition that causes an irregular, often rapid heart rate that can cause poor blood flow), and hypertensive heart disease with heart failure (heart unable to pump enough blood to meet body's need for blood and oxygen). Section N - Medications revealed under N0415. High-Risk Drug Classes: Use and Indication, Resident #3 was documented as she had taken an anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin) during the last 7 days or since admission/entry or reentry if less than 7 days. Record review of Resident #3's active and discontinued orders, from 01/01/2026 - 04/09/2026, revealed Resident #3 was not prescribed an anticoagulant. Resident #3 was prescribed Aspirin 81 mg chewable one tab PO daily, the start date was 04/16/2023 and the end date was 02/03/2026. Record review of Resident #3's care plan, dated 02/24/2026 revealed there was not a care plan for an anticoagulant medication. Attempted interview with Resident #3 on 04/07/2026 at 12:18 p.m., was unsuccessful, Resident #3 smiled at the state surveyor and did not respond to any questions. No concerns with Resident #3's appearance or well-being. Record review of Resident #4's quarterly MDS, dated [DATE], revealed a [AGE] year-old female, who was readmitted to the facility on [DATE]. Resident #4 had a primary diagnosis of chronic obstructive pulmonary disease (COPD; a lung disease that blocks airflow and makes it difficult to breathe). Other pertinent diagnoses included non-Alzheimer's dementia (brain damage that is caused by something like a stroke that causes memory loss), acute and chronic respiratory failure (do not have enough oxygen in blood, can develop suddenly or overtime), and metabolic encephalopathy (brain disorder that occurs when a chemical imbalance of the blood affects the brain). Section N - Medications revealed under N0415. High-Risk Drug Classes: Use and Indication, Resident #3 was documented as she had taken an anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin) during the last 7 days or since admission/entry or reentry if less than 7 days. Record review of Resident #4's active and discontinued orders, from 10/05/20265- 04/09/2026, revealed she was not ordered an anticoagulant. Record review of Resident #4's care plan, dated 04/01/2026 revealed there was not a care plan for an anticoagulant medication. During an interview on 04/08/2026 at 11:28 a.m. with Resident #4, she said she was not receiving an anticoagulant. She said she was not aware of any history of taking blood thinners or an anticoagulant. Resident #4 denied any history of having a stoke, atrial fibrillation, or blood clots. During an interview on 04/09/2026 at 1:30 p.m. with the MDS coordinators, LVN D and RN E, LVN D said when completing the medication review for the quarterly MDS assessment, he looked at the resident's medication they were given in the last 7 days. He said Resident #3 was in the hospital recently and was probably given an anticoagulant in the hospital. He reviewed Resident #3's hospital records; he said she was in the hospital from [DATE]-[DATE] and said she got heparin in the hospital, which indicated that was why Resident #3 was shown to have anticoagulant use selected on her MDS. LVN D said section N stated medication the resident had taken in the last 7 days but was unsure if hospital medication applied. LVN D said aspirin would not be considered an anticoagulant under the MDS assessment because it was an NSAID. RN E said even if a resident was in the hospital during the time period of the last 7 days and was given a medication while in the hospital, the facility could claim that medication on the MDS assessment. She gave the example if Resident #3 fell in the time period for the assessment, they could put that into the MDS. RN E said section N said medications within the last 7 days and the assessment did not state medication taken within the last 7 days in the facility. During an interview on 04/09/2026 at 4:50 p.m. with the CEO/Interim Administrator of the facility, he said the facility utilized the RAI manual for guidance when completing the MDS assessment. He said accurate MDS assessments were important because the facility wanted accurate assessments on their residents. He said if an MDS assessment was not correct, the facility would go back and update and modify the MDS assessments and make sure they were correct. Record review of the facility's Resident Assessment dated 10/2023, reflected: Policy StatementA comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements. Data from the Minimum Data Set (MDS) is submitted to the Internet Quality Improvement Evaluation System (iQIES) as required.Policy Interpretation and Implementation1. OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include.b. Quarterly Assessment.2. PPS Assessments are conducted (in addition to the OBRA required assessments) for residents for whom the facility receives Medicare Part A SNF benefits. PPS assessments provide information about the clinical condition of and SNF-level care provided for beneficiaries.4. Non-Comprehensive MDS assessments include a select number of items from the MDS used to track the resident's status between comprehensive assessments and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status . Non-comprehensive assessments include Quarterly assessments .12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews.13. All resident assessments completed within the previous 15 months are maintained in the resident's active clinical record. The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2025, reflected: SECTION N: MEDICATIONS Intent: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident. In addition, two medication sections have been added. The first is an Antipsychotic Medication Review. The second is a series of data elements addressing Drug Regimen Review. These data elements document whether a drug regimen review was conducted upon the start of a SNF PPS stay through the end of the SNF PPS stay and whether any clinically significant medication issues identified were addressed in a timely manner.

Based on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from abuse for three (Resident #2, Resident #3, and Resident #4) of five residents reviewed for abuse, in that: 1.) On 03/01/26 the facility failed to ensure that Resident #2 did not have her hair pulled by Resident # 1, resulting in Resident #2 screaming loudly in what sounded to facility staff like pain.2.) On 03/05/26 the facility failed to ensure that Resident #3 was not scratched on the face by Resident #1 resulting in redness.3.) On 03/10/26 the facility failed to ensure that Resident #4 was not verbally threatened, grabbed by the throat and her hair pulled by Resident #1 with no resulting injury. These failures could result in resident abuse and injuries.Findings include: Resident #1Review of Resident #1's Face Sheet with report date of 03/10/26, reflected she was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses in part including dementia (loss of memory, language, problem-solving and other thinking abilities), malignant neoplasm (cancer) of left breast, generalized anxiety disorder (excessive, ongoing anxiety and worry), diabetes mellitus (condition of high blood sugar), and hyperlipidemia (high levels of fat in the blood).Review of Resident #1's admission MDS dated [DATE] did not reflect any mood or behavioral symptoms except for Resident #1 reported often feeling lonely or isolated from those around her. A BIMS score of zero indicated severe cognitive impairment.Review of Resident #1's active Care Plan (undated) reflected Resident #1 was identified with a problem of Behavioral Symptoms with a start date of 08/15/25 which included symptoms of verbal aggression, physical aggression, and calling 911. Goals and approaches (interventions) were identified for behavioral symptoms including some of the following:-I will be reminded that I don't have to call 911 when other people are not behaving correctly. Remind her that staff are here to help her (Start Date: 03/04/26)-Praise [Resident #1] when behavior is appropriate. Let her know it will be a good day (Start Date 02/27/26)-Remove [Resident #1] from group activities when behavior is unacceptable. Provide in room activities (Start Date 02/27/26)-When [Resident #1] becomes verbally abusive, move to a quiet, calm environment (Start Date 02/27/26)-Administer medications: as ordered. Monitor and record effectiveness. Report adverse side effects (02/26/26-Assess whether the behavior endangers herself and/or others. Intervene if necessary (Start date 2/2026)-Avoid power struggles with [Resident #1] (Start Date 02/20/26)-Obtain a psychiatric consult/psychosocial therapy (Start Date 12/20/25)-Avoid over-stimulation e.g., noise, crowding, other physically aggressive residents (Start Date 11/25/25)-When I'm upset and exhibiting behaviors, staff will offer calming interventions by playing or providing access to preferred music by the Brothers [NAME] (Start Date 08/19/25) Resident #2Review of Resident #2's Face Sheet with report date of 03/24/26, reflected she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses in part including Alzheimer's disease (type of dementia that affects memory, thinking, and behavior), hypertension (high blood pressure), mood disorder (mental health condition of emotional disturbances), atherosclerotic heart disease (a buildup of plaque that restricts blood flow to the heart), and hyperlipidemia (high levels of fat in the blood).Review of Resident #2's Quarterly MDS dated [DATE] did not reflect any mood or behavioral symptoms except for wandering. A BIMS score of zero indicated severe cognitive impairment.Review of Resident #2's active Care Plan (undated) reflected Resident #2 was identified with a problem of Behavioral Symptoms with a start date of 02/23/24 which included symptoms of physical aggression and sexually inappropriate behaviors, with the last behavior listed on 09/04/24. The care plan identified a goal and approaches (interventions) for behavioral symptoms. Resident #3Review of Resident #3's Face Sheet (with report date of 3/24/26) reflected she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses in part including dementia (loss of memory, language, problem-solving and other thinking abilities), bipolar disorder (mental health condition causing extreme mood swings), muscle weakness, and generalized anxiety disorder (excessive, ongoing anxiety and worry).Review of Resident #3's Quarterly MDS dated [DATE] reflected Resident #3 had no behavioral or mood symptoms except for wandering and rejection of care. A BIMS score of zero reflected severe cognitive impairment.Review of Resident #3's active Care Plan (undated) reflected Resident #3 had behavioral symptoms including a history of aggression, with the last incident listed dated 10/24/25. The Care Plan identified a goal and approaches (interventions) for behavioral symptoms. Resident #4Review of Resident #4's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses in part including Alzheimer's disease (type of dementia that affects memory, thinking, and behavior), epilepsy (brain condition of recurrent seizures), mood disorder (mental health condition involving emotional disturbances), and hypothyroidism (thyroid gland does not make enough thyroid hormone).Review of Resident #4's admission MDS dated [DATE] reflected no mood or behavioral symptoms. A BIMS score of 99 reflected Resident #4 was unable to complete the interview.Review of Resident #4's Care Plan (undated) reflected the behavioral symptom of wandering. No verbal aggression, physical aggression or other behavioral symptoms were identified. Record Review of Resident #1's progress note written by RN A and dated 03/01/26 at 03:30 p.m., reflected that RN A had responded to the dining room to find that a CNA/Medication Aide (unnamed) had separated Resident #4 from Resident #2. The CNA/Medication Aide notified RN A that Resident #2 was walking in front of Resident #1 when Resident #1 suddenly stood up, ran toward Resident #2 and pulled her hair. A head-to-toe assessment was completed on both residents and there were no injuries. Resident #1 received as needed medication for anxiety. The physician, administrator, and resident representative were notified.Record review of Resident #1's progress note written by LVN B and dated 03/05/26 at 01:03 p.m., reflected that Resident #1 was observed yelling at another resident (Resident #3) and that before LVN B could get to the altercation, LVN B witnessed Resident #1 scratch Resident #3 on the face. The physician, Director of Nurses, and power of attorney were notified.Record review of Resident #1's progress note written by LVN B and dated 03/05/26 at 01:05 p.m., reflected new physician orders were received for labs and urinalysis.Record review of Resident #1's interdisciplinarian progress note dated 03/05/26 at 03:33 p.m. by RN C, reflected Resident#1's aggressive behavior of pulling another resident's hair and that a 30-day discharge notice was issued for aggression towards other residents.Record review of Resident #1's progress note written by SW D on 03/09/26 at 09:43 a.m. and 01:38 reflected the social worker sent out referrals to four behavioral health hospitals. Resident #1 was declined by three of the facilities and the fourth did not respond.Record review of Resident #1's progress note dated 03/10/26 at 04:04 a.m. by LVN E, reflected Resident #1 remained on Q15 minute observations.Record review of Resident #1's progress note dated 03/10/26 at 09:22 pm by RN F, reflected that Resident #1 had a psychiatric recommendation and received a new physician order for an anxiety medication.Record review of Resident #1's progress note written by RN B on 03/10/26 (time unknown) reflected that without provocation Resident #1 grabbed Resident #4 by the throat and pulled her hair and made the statement, stop looking at me b**** I'll cut your f***** throat. The residents were separated and the physician, the administrator, and family were notified. No injuries were reflected. During an observation and interview on 03/24/26 at 12:10 p.m., Resident #2 was observed sitting calmly and quietly in the dining area. She had no obvious signs of abuse or neglect. She could not remember or provide meaningful responses to questions about the incident. She had no bruises, scratches, or obvious signs of injury.In an interview with Resident #2's family on 04/06/26 at 11:10 a.m., they reported that Resident #2 did not experience any injury from having her hair pulled and that she did not exhibit any trauma associated signs or symptoms. They stated she was her typical self following the incident. Resident #2's family stated that the facility is very good at dealing with and separating aggressive residents when they become upset. She denied any concerns about her family member's care.During an observation and interview on 03/24/26 at 12:15 p.m., Resident #3 was observed ambulating in the dining room using her walker. She answered interview questions in an off-topic and disorganized manner. She was dressed, clean with no signs of obvious abuse or neglect. She had no bruises, scratches, or obvious signs of injury.During an interview attempt with Resident #3's family on 04/06/26, multiple calls were not answered and there was no ability to leave a voice mail.During an observation and interview on 03/24/26 at 12:20 p.m., Resident #1 was observed ambulating using a rolling walker in the hallway of the locked female unit. She stated she was hungry, and she was headed to the dining room. She could not remember or provide any details of prior aggressive behaviors. She stated, I'm fine and walked off. She was not observed demonstrating any aggressive behaviors.During an observation and interview on 03/24/26 at 12:25 p.m., Resident #4 was observed on the female locked unit. She did not respond to questions. She was observed as dressed, clean, and sitting in a wheelchair. She had no bruises, scratches, or obvious signs of injury. No obvious signs of abuse or neglect were observed.During an interview on 04/06/26 at 11:00 a.m., Resident #4's family member reported she had visited Resident #4 around the time of the incident. She stated she noted no injuries and that Resident #4 acted like her normal self. She denied witnessing any signs of trauma or distress or other changes in behavior.During an interview on 03/24/26 at 12:05 p.m., LVN B reported that she has had training on resident-to-resident abuse and dealing with difficult behaviors at this facility. She was able to describe the signs of escalation and how to intervene during altercations between residents. She stated that Resident #1's behavior had not significantly improved since the incidents of aggression on 03/05/26 and 03/10/26. She stated that Resident #1 was again seen by psychiatric services on 03/23/26 and she was ordered both an increase on one medication and a new medication for her mood. She stated that Residents are placed on Q15 minute observations following any aggressive events and that they remain on that observation for at least 72 hours. She stated that Resident #1 was placed on Q15 minute checks following the aggressive behaviors on both 03/05/26 and 03/10/26. She stated that Resident #1's behavior is random and unpredictable and that she would have benefited from having a sitter.LVN B stated that on 03/05/26 she observed Resident #1 yelling at Resident #3 and that she began running towards the altercation but that she witnessed Resident #1 scratch Resident #3's face with her fingernails before she got to them. She stated the residents were separated and that she noted that Resident #3 had red marks without any break in the skin to her face. She stated this redness remained on Resident #3's face for about 24 hours. She stated Resident #3 did not require intervention but that she was angry and agitated for about forty minutes following the incident. She stated that she notified the physician and Resident #1 was placed on Q15 minute monitoring. She stated that on 03/10/26 she witnessed Resident #1 suddenly without provocation grab Resident #4 by the throat and pull her hair. She stated that she responded immediately, redirected the residents, and Resident #4's breathing was not restricted. She stated she believes Resident #1 thinks people are looking at her and that she had yelled at Resident #4 to stop looking at her. She stated that she assessed Resident #4 and she did not have any injuries. She stated that Resident #1 was placed on Q15 minute checks. In an interview on 03/24/26 at 03:07 p.m., the DON stated that she has been the DON at this facility for two days. She stated Resident #1 was on psychiatric services and her medications were being monitored frequently and staff often had Resident #1 near the nurse's station with them. She stated that she was going to schedule a care plan meeting with her physician and psychiatric services so that medication adjustments could be reviewed comprehensively. She stated she had seen where Resident #1 had her monitoring increased to Q15 minutes when she pulled Resident #2's hair on 03/01/26. She stated she had not been aware that Resident #1 had scratched Resident #3's face on 03/05/26. She stated that she was definitely going to be making her (Resident #1) safer around everyone else in this building. She stated that the comprehensive care plan is updated by herself and the assistant directors of nurses for any acute incidents. The DON stated she intended to further update Resident #1's care plan for aggression. She stated that failing to update interventions in Resident #1's care plan would be a risk to the resident because, putting the proper care plans in place is important and the care plan is a way to communicate that plan to anyone who is providing care.In an interview on 03/24/26 at 04:00 p.m., RN A stated that on 03/01/26 she heard Resident #2 screaming loudly and she ran to the dining room where staff had separated Resident #1 from Resident #2. She stated the Medication Aide (name unknown) informed her that Resident #2 had been watching Resident #1 and that Resident #1 became angry saying she was staring at her and suddenly grabbed Resident #2 by her hair. She stated the staff were able to immediately intervene and separate the residents without incident. She stated she assessed Resident #2 and she had no bruise or signs of injuries but that she believed when she heard her scream, she was screaming in pain due to having her hair pulled. She stated Resident #2 did not require pain medication or treatment. RN A stated that she has had abuse and neglect training at this facility and would report abuse to the administrator. She stated that she has received training on dealing with difficult behaviors and resident-to-resident aggression. She stated that she notified the physician and administrator and Resident #1 was placed on Q15 minute monitoring.Record review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 reflected, Residents have the right to be free from abuse and it included the objective to, Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:.other residents.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, 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 1 of 5 residents (Resident #1) reviewed for care plans.The facility failed to develop or revise care plan interventions for Resident #1 following three episodes of aggression towards other residents on 03/01/26, 03/05/26, and 03/10/26. This failure could have placed residents at risk of not having their needs identified and met.Findings include:Review of records noted that on: 1.) On 03/01/26 Resident #2 had her hair pulled by Resident # 1, resulting in Resident #2 screaming loudly in what sounded to facility staff like pain.2.) On 03/05/26 Resident #3 was scratched on the face by Resident #1 resulting in redness.3.) On 03/10/26 Resident #4 was verbally threatened, grabbed by the throat and her hair pulled by Resident #1 with no resulting injury. Resident #1Review of Resident #1's Face Sheet with report date of 03/10/26, reflected she was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses in part including dementia (loss of memory, language, problem-solving and other thinking abilities), malignant neoplasm (cancer) of left breast, generalized anxiety disorder (excessive, ongoing anxiety and worry), diabetes mellitus (condition of high blood sugar), and hyperlipidemia (high levels of fat in the blood).Review of Resident #1's admission MDS dated [DATE] did not reflect any mood or behavioral symptoms except for Resident #1 reported often feeling lonely or isolated from those around her. A BIMS score of zero indicated severe cognitive impairment.Review of Resident #1's active Care Plan (undated) reflected Resident #1 was identified with a problem of Behavioral Symptoms with a start date of 08/15/25 which included symptoms of verbal aggression, physical aggression, and calling 911. Goals and approaches (interventions) were identified for behavioral symptoms including some of the following:-I will be reminded that I don't have to call 911 when other people are not behaving correctly. Remind her that staff are here to help her (Start Date: 03/04/26)-Praise [Resident #1] when behavior is appropriate. Let her know it will be a good day (Start Date 02/27/26)-Remove [Resident #1] from group activities when behavior is unacceptable. Provide in room activities (Start Date 02/27/26)-When [Resident #1] becomes verbally abusive, move to a quiet, calm environment (Start Date 02/27/26)-Administer medications: as ordered. Monitor and record effectiveness. Report adverse side effects (02/26/26-Assess whether the behavior endangers herself and/or others. Intervene if necessary (Start date 2/2026)-Avoid power struggles with [Resident #1] (Start Date 02/20/26)-Obtain a psychiatric consult/psychosocial therapy (Start Date 12/20/25)-Avoid over-stimulation e.g., noise, crowding, other physically aggressive residents (Start Date 11/25/25)-When I'm upset and exhibiting behaviors, staff will offer calming interventions by playing or providing access to preferred music by the Brothers [NAME] (Start Date 08/19/25) The Review of Resident #1's active Care Plan (undated) reflected the care plan contained no up updates or revisions to Behavioral Symptoms or other pertinent areas following the episodes of aggression which occurred on 03/01/26, 03/05/26, and 03/10/26.Resident #2Review of Resident #2's Face Sheet with report date of 03/24/26, reflected she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses in part including Alzheimer's disease (type of dementia that affects memory, thinking, and behavior), hypertension (high blood pressure), mood disorder (mental health condition of emotional disturbances), atherosclerotic heart disease (a buildup of plaque that restricts blood flow to the heart), and hyperlipidemia (high levels of fat in the blood).Review of Resident #2's Quarterly MDS dated [DATE] did not reflect any mood or behavioral symptoms except for wandering. A BIMS score of zero indicated severe cognitive impairment.Review of Resident #2's active Care Plan (undated) reflected Resident #2 was identified with a problem of Behavioral Symptoms with a start date of 02/23/24 which included symptoms of physical aggression and sexually inappropriate behaviors, with the last behavior listed on 09/04/24. The care plan identified a goal and approaches (interventions) for behavioral symptoms. Resident #3Review of Resident #3's Face Sheet (with report date of 3/24/26) reflected she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses in part including dementia (loss of memory, language, problem-solving and other thinking abilities), bipolar disorder (mental health condition causing extreme mood swings), muscle weakness, and generalized anxiety disorder (excessive, ongoing anxiety and worry).Review of Resident #3's Quarterly MDS dated [DATE] reflected Resident #3 had no behavioral or mood symptoms except for wandering and rejection of care. A BIMS score of zero reflected severe cognitive impairment.Review of Resident #3's active Care Plan (undated) reflected Resident #3 had behavioral symptoms including a history of aggression, with the last incident listed dated 10/24/25. The Care Plan identified a goal and approaches (interventions) for behavioral symptoms. Resident #4Review of Resident #4's Face Sheet (undated) reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses in part including Alzheimer's disease (type of dementia that affects memory, thinking, and behavior), epilepsy (brain condition of recurrent seizures), mood disorder (mental health condition involving emotional disturbances), and hypothyroidism (thyroid gland does not make enough thyroid hormone).Review of Resident #4's admission MDS dated [DATE] reflected no mood or behavioral symptoms. A BIMS score of 99 reflected Resident #4 was unable to complete the interview.Review of Resident #4's Care Plan (undated) reflected the behavioral symptom of wandering. No verbal aggression, physical aggression or other behavioral symptoms were identified. Record Review of Resident #1's progress note written by RN A and dated 03/01/26 at 03:30 p.m., reflected that RN A had responded to the dining room to find that a CNA/Medication Aide (unnamed) had separated Resident #4 from Resident #2. The CNA/Medication Aide notified RN A that Resident #2 was walking in front of Resident #1 when Resident #1 suddenly stood up, ran toward Resident #2 and pulled her hair. A head-to-toe assessment was completed on both residents and there were no injuries. Resident #1 received as needed medication for anxiety. The physician, administrator, and resident representative were notified.Record review of Resident #1's progress note written by LVN B and dated 03/05/26 at 01:03 p.m., reflected that Resident #1 was observed yelling at another resident (Resident #3) and that before LVN B could get to the altercation, LVN B witnessed Resident #1 scratch Resident #3 on the face. The physician, Director of Nurses, and power of attorney were notified.Record review of Resident #1's progress note written by LVN B and dated 03/05/26 at 01:05 p.m., reflected new physician orders were received for labs and urinalysis.Record review of Resident #1's interdisciplinarian progress note dated 03/05/26 at 03:33 p.m. by RN C, reflected Resident#1's aggressive behavior of pulling another resident's hair and that a 30-day discharge notice was issued for aggression towards other residents.Record review of Resident #1's progress note written by SW D on 03/09/26 at 09:43 a.m. and 01:38 reflected the social worker sent out referrals to four behavioral health hospitals. Resident #1 was declined by three of the facilities and the fourth did not respond.Record review of Resident #1's progress note dated 03/10/26 at 04:04 a.m. by LVN E, reflected Resident #1 remained on Q15 minute observations.Record review of Resident #1's progress note dated 03/10/26 at 09:22 pm by RN F, reflected that Resident #1 had a psychiatric recommendation and received a new physician order for an anxiety medication.Record review of Resident #1's progress note written by RN B on 03/10/26 (time unknown) reflected that without provocation Resident #1 grabbed Resident #4 by the throat and pulled her hair and made the statement, stop looking at me b**** I'll cut your f***** throat. The residents were separated and the physician, the administrator, and family were notified. No injuries were reflected. During an observation and interview on 03/24/26 at 12:10 p.m., Resident #2 was observed sitting calmly and quietly in the dining area. She had no obvious signs of abuse or neglect. She could not remember or provide meaningful responses to questions about the incident. She had no bruises, scratches, or obvious signs of injury.During an interview with Resident #2's family on 04/06/26 at 11:10 a.m., they reported that Resident #2 did not experience any injury from having her hair pulled and that she did not exhibit any trauma associated signs or symptoms. They stated she was her typical self following the incident. Resident #2's family stated that the facility is very good at dealing with and separating aggressive residents when they become upset. She denied any concerns about her family member's care.During an observation and interview on 03/24/26 at 12:15 p.m., Resident #3 was observed ambulating in the dining room using her walker. She answered interview questions in an off-topic and disorganized manner. She was dressed, clean with no signs of obvious abuse or neglect. She had no bruises, scratches, or obvious signs of injury.During an interview attempt with Resident #3's family on 04/06/26, multiple calls were not answered and there was no ability to leave a voice mail.During an observation and interview on 03/24/26 at 12:20 p.m., Resident #1 was observed ambulating using a rolling walker in the hallway of the locked female unit. She stated she was hungry, and she was headed to the dining room. She could not remember or provide any details of prior aggressive behaviors. She stated, I'm fine and walked off. She was not observed demonstrating any aggressive behaviors.During an observation and interview on 03/24/26 at 12:25 p.m., Resident #4 was observed on the female locked unit. She did not respond to questions. She was observed as dressed, clean, and sitting in a wheelchair. She had no bruises, scratches, or obvious signs of injury. No obvious signs of abuse or neglect were observed.During an interview on 04/06/26 at 11:00 a.m., Resident #4's family member reported she had visited Resident #4 around the time of the incident. She stated she noted no injuries and that Resident #4 acted like her normal self. She denied witnessing any signs of trauma or distress or other changes in behavior. During an interview on 03/24/26 at 12:05 p.m., LVN B reported that she has had training on resident-to-resident abuse and dealing with difficult behaviors at this facility. She was able to describe the signs of escalation and how to intervene during altercations between residents. She stated that Resident #1's behavior had not significantly improved since the incidents of aggression on 03/05/26 and 03/10/26. She stated that Resident #1 was again seen by psychiatric services on 03/23/26 and she was ordered both an increase on one medication and a new medication for her mood. She stated that Residents are placed on Q15 minute observations following any aggressive events and that they remain on that observation for at least 72 hours. She stated that Resident #1 was placed on Q15 minute checks following the aggressive behaviors on both 03/05/26 and 03/10/26. She stated that Resident #1's behavior is random and unpredictable and that she would have benefited from having a sitter.LVN B stated that on 03/05/26 she observed Resident #1 yelling at Resident #3 and that she began running towards the altercation but that she witnessed Resident #1 scratch Resident #3's face with her fingernails before she got to them. She stated the residents were separated and that she noted that Resident #3 had red marks without any break in the skin to her face. She stated this redness remained on Resident #3's face for about 24 hours. She stated Resident #3 did not require intervention but that she was angry and agitated for about forty minutes following the incident. She stated that she notified the physician and Resident #1 was placed on Q15 minute monitoring. She stated that on 03/10/26 she witnessed Resident #1 suddenly without provocation grab Resident #4 by the throat and pull her hair. She stated that she responded immediately, redirected the residents, and Resident #4's breathing was not restricted. She stated she believes Resident #1 thinks people are looking at her and that she had yelled at Resident #4 to stop looking at her. She stated that she assessed Resident #4 and she did not have any injuries. She stated that Resident #1 was placed on Q15 minute checks.In an interview on 03/24/26 at 03:07 p.m., the DON stated that she has been the DON at this facility for two days. She stated Resident #1 was on psychiatric services and her medications were being monitored frequently and staff often had Resident #1 near the nurse's station with them. She stated that she was going to schedule a care plan meeting with her physician and psychiatric services so that medication adjustments could be reviewed comprehensively. She stated she had seen where Resident #1 had her monitoring increased to Q15 minutes when she pulled Resident #2's hair on 03/01/26. She stated she had not been aware that Resident #1 had scratched Resident #3's face on 03/05/26. She stated that she was definitely going to be making her (Resident #1) safer around everyone else in this building. She stated that the comprehensive care plan is updated by herself and the assistant directors of nurses for any acute incidents. The DON stated she intended to further update Resident #1's care plan for aggression. She stated that failing to update interventions in Resident #1's care plan would be a risk to the resident because, putting the proper care plans in place is important and the care plan is a way to communicate that plan to anyone who is providing care.In an interview on 03/24/26 at 04:00 p.m., RN A stated that on 03/01/26 she heard Resident #2 screaming loudly and she ran to the dining room where staff had separated Resident #1 from Resident #2. She stated the Medication Aide (name unknown) informed her that Resident #2 had been watching Resident #1 and that Resident #1 became angry saying she was staring at her and suddenly grabbed Resident #2 by her hair. She stated the staff were able to immediately intervene and separate the residents without incident. She stated she assessed Resident #2 and she had no bruise or signs of injuries but that she believed when she heard her scream, she was screaming in pain due to having her hair pulled. She stated Resident #2 did not require pain medication or treatment. RN A stated that she has had abuse and neglect training at this facility and would report abuse to the administrator. She stated that she has received training on dealing with difficult behaviors and resident-to-resident aggression. She stated that she notified the physician and administrator and Resident #1 was placed on Q15 minute monitoring.

Based on interview and record review the facility failed to implement the facility's own written abuse and neglect prevention policy and procedure for one (Resident # 1) of thirteen residents reviewed for abuse and neglect. The facility did not immediately notify Resident #1's representative of an allegation of sexual abuse by The Maintenance Director on 02/19/26, causing the family to learn of the allegation when Resident #1 called to tell them that the police were at the facility, attempting to speak with her about the allegation on 02/20/26. This failure could place residents at risk of their responsible parties not having knowledge of allegations of abuse or neglect, thereby not having the emotional or logistical support of their responsible parties during an investigation.Findings included: Review of the policy Abuse Investigation and Reporting, revised July 2017, reflected: [.] Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. [.] 3. The administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. [.] 6. The administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. [.] 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: [.] c. The Resident's Representative (Sponsor) of Record; [.] Review of Resident #1's face sheet, dated 02/26/26, reflected Resident #1 was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), Alzheimer's disease, pain disorder exclusively related to psychological factors, chronic pain, depression, and unspecified sequelae of cerebral infarction (lingering effects of a stroke, which could include problems with cognition (mental ability), mood, and physical weakness.) The document listed RP A as her emergency contact and responsible party. Review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1's preferred language was Spanish, and she would need an interpreter for communication with physicians and other healthcare staff. Resident #1 was able to understand others, and to be understood by others. She had a BIMS score of 3, indicating severe cognitive deficits. Resident #1 rejected care from four to six days of a seven-day lookback period, but had no other mood or behavioral issues during that time. She was able to ambulate using a walker. Resident #1 required partial or moderate assistance (helper does less than half the effort) for toileting, showering/bathing, dressing, and putting on/taking off footwear. She only required set-up and clean-up assistance with meals. She was able to move herself around in her bed, and sit on the side of the bed, but required partial or moderate assistance for transfers, and for walking 50 feet. Resident #1's primary reason for admission to the facility was her progressive neurological condition. Review of Resident #1's care plans reflected the following:- Mood state: PHQ-9 score of five, indicating mild depression, dated 02/26/26- Activities: preference to not join group activities, and to participate in in-room, self-led activities, including watching Spanish language media.- Cognitive loss/dementia related to age, dated 09/25/24- Behavioral: resident picks at skin, dated 04/01/24- Behavioral: refusals of incontinence care and showers Review of the HHSC Provider Investigation Form and attached documentation, dated 02/26/26, reflected the facility had investigated an allegation of abuse by Resident #1, who had informed another resident that the Maintenance Director had exposed himself to her, and the other resident informed a CNA, who reported it to the Social Worker, who reported it to the Administrator. During the investigation of this allegation, Resident #1 denied ever having said such a thing, and continued to do so throughout the investigation. The facility suspended the Maintenance Director, and the Administrator (who was married to the Maintenance Director), who both returned to work after the full investigation was done. During the investigation, camera footage was reviewed, and no instances of the Maintenance Director being in Resident #1's room by himself for more than a few seconds were found. No other residents or staff reported related concerns about the Maintenance Director when interviewed. An interview on 03/03/26 at 9:25 AM with the Administrator and the Executive Assistant revealed that the police questioned the Administrator on 02/20/26 and were asking her questions about things like when she was last in Resident #1's room. The Administrator thought maybe a staff member whose employment she had terminated on 02/18/26 had probably called the police with a complaint about her, in addition to the allegation made against the Maintenance Director, and the police would not tell her what the allegation about her was, if there was one. She had already suspended herself as soon as the allegation was made against the Maintenance Director, because of her close relationship with him. She said she handed the investigation for the allegation against the Maintenance Director over to the Executive Assistant. An interview on 03/03/26 at 1:03 PM with RP A and Resident #1 revealed Resident #1 refused to use a professional interpreter over the phone and wanted RP A to interpret for her. During the interview, Resident #1 initially refused to talk about the allegation against the Maintenance Director. RP A stated on 02/20/26 Resident #1 called her, and told her the police were at the facility, trying to speak with her about the allegation, and she did not want to talk to them. She said the Administrative staff had known about the allegation since 02/19/26, and while they called her every time Resident #1 did not want to shower, or did not want to do this or that, nobody bothered to call her about this. Resident #1 then told the surveyor that the Maintenance Director had entered her room, and exposed his genitals to her, and prior to that had brought her sodas and snacks, and kissed her. Resident #1 and RP A said they had not seen that staff member since Resident #1 made that allegation. Resident #1 was unable to say when the alleged incident occurred. An interview on 03/04/26 at 1:45 PM with the Executive Assistant revealed the police spoke with the Administrator and would not say what she had been accused of. She said the number one thing when an allegation was made, was that the residents be kept safe. She said the Maintenance Director had already left for the day on 02/19/26, but was put on suspension as soon as the allegation against him was made. She said after the Administrator was questioned by the police on 02/20/26, she also had to be suspended, but she had already gone home when the allegation against the Maintenance Director was made. She said when an allegation of abuse or neglect was made, they did not make a progress note or incident report in the EMR, and the self-report and investigation itself was their documentation of the allegation. She said Resident #1 denied anything happened to her multiple times during the investigation, to multiple people. She said she and the Social Worker interviewed residents and staff as part of the investigation, and Resident #1 continued to deny anything happened, and refused to be assessed. She said RP A called her on the morning of 02/20/26, asking why the police were interrogating Resident #1, and she did meet with RP A several times on that day, but she did not contact them on 02/19/26 about the allegation against the Maintenance Director. She said the notification to the family should happen on the same day, and it was important to inform them because they have a right to be aware of what is going on with their loved one, and it provided the resident opportunity to have their support during the investigation. She said she was new to the investigation process, and still learning. An interview on 03/04/26 at 2:41 PM with RN B revealed she had been working on 02/19/26, on the 2:00 PM-10:00 PM shift, and learned about the allegation of sexual abuse of Resident #1 later in the day, around bedtime. She said she attempted to assess Resident #1, but the resident refused to be assessed, denied anything had happened, and said she did not need anyone to look at her body. She said nobody told her to notify the family or told her if they had been notified. She said when she did notify families of problems with residents, it was done as soon as she knew about the problem, but she did not always document notifying them. She said if she had been the one receiving an allegation from a resident, she would do an event (incident) report in the EMR, and would notify the Administrator, even if the resident denied it after they said it, and she would notify the responsible party. An interview on 03/04/26 at 3:01 PM with the Executive Assistant revealed she was new at reporting to HHSC, because the Administrator usually did it, and had just learned more information about the notification part of the process. She said they had a very new DON, who was still in training, and was not present on 02/19/26, and there was not a nurse manager in the building at the time she took over the investigation. She said she thought they completed the skin assessment in the EMR, but she was incorrect in thinking that. She said they were supposed to open the Incident Progress Note template in the EMR, which would have then prompted the nurse to do the clinical part of the investigation, and to make all of the notifications necessary. She said she did put a note in about speaking to the family, but she did not know to select that template. She said normally the DON or Nurse Manager on duty would also instruct the nurse what to do, but neither of them were available in the initial steps of the investigation. An interview on 03/04/26 at 3:14 PM with the Administrator revealed she was already at home on [DATE] when the police called, because she had left the facility immediately when she learned about the allegation of sexual abuse by the Maintenance Director. She said she normally would work from home, but this time she handed the investigation and reporting off to the Executive Assistant. She said normally she notified the DON when an allegation was made, and the DON would take the nursing piece of the investigation, and she would take the rest, but DON was not there, and she did not follow up on the nursing piece of the investigation, so the staff did not realize they had to open the event template, and that caused the missed notification. Normally the family would be notified immediately as part of the process of filling out the form. It's their right to know, and important for them to know of any incidents involving the resident.

Based on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from abuse for two (Resident #2 and Resident #3) of 5 residents reviewed for abuse, in that: 1.) On 11/03/25 the facility failed to ensure that Resident #2 did not have coffee thrown on him by Resident #4 resulting in redness to the face and chest which faded quickly and resolved without need for treatment. The nursing assessment completed the same day revealed no injury and no redness or other changes in skin assessment from baseline.2.) On 12/03/25 the facility failed to ensure that Resident #3 was not hit on the left side of the face/jaw with a closed fist by Resident #4 resulting in no injury. These failures could result in resident abuse and injuries.Findings include: Resident #2 Review of Resident #2's Face Sheet reflected he was a [AGE] year-old male readmitted to the facility on [DATE].Review of Resident #2's Quarterly MDS dated [DATE] reflected in part diagnoses including dementia, cellulitis of left lower limb (a spreading skin infection) and generalized muscle weakness. The MDS did not reflect any mood or behavioral symptoms. A BIMS score of six indicated severe cognitive impairment.Review of Resident #2's active Care Plan with problem start date 1/15/25 reflected Resident #2 had a history of physically and verbally aggressive behaviors. The care plan included a total of 19 interventions for aggressive behavior with intervention revisions reflected by start dates ranging from 2/19/25 to 10/29/25 and included interventions such as obtain a psych consult/psychosocial therapy, provide realistic hope to Resident #2, encourage Resident #2 to verbal feelings and fears, clarify misconceptions, etc.Review of Resident #2's Skilled Daily Nurses Note Observation completed 11/3/25 reflected the nursing assessment did not identify any injuries or changes in his skin assessment. Resident #3Review of Resident #3's Face Sheet reflected he was a [AGE] year-old male readmitted to the facility on [DATE]. Review of Resident #3's Quarterly MDS dated [DATE] reflected in part diagnoses including traumatic subdural hemorrhage (bleeding near the brain that can happen after an injury), dementia, and unsteadiness on feet. The MDS reflected mood symptoms including little interest or pleasure in doing things, and being short-tempered, easily annoyed. The MDS reflected no behavioral symptoms with the exception of wandering. A BIMS score was not conducted with Resident #3 reflected as rarely/never understood.Review of Resident #3's active Care Plan dated 10-27-25 with problem start date 10/12/25 reflected Resident #3 had a problem with the behavioral symptom of wandering. The care plan identified 12 interventions for wandering including interventions such as Resident #3 will be assessed for placement in a specially designed secure unit, Resident #3 has proper fitting and appropriate foot attire, avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents), etc.Review of Resident #3's progress note dated 12/03/25 reflected the nurse assessed no injuries following the incident with Resident #4. Resident #4Review of Resident #4's Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE].Review of Resident #4's Quarterly MDS dated [DATE] reflected in part diagnoses including dementia, bipolar disorder (mental health condition causing extreme mood swings), anxiety disorder, depression, and hypertension (elevated blood pressure). The MDS reflected the mood symptom of little interest or pleasure in doing things. The MDS reflected physical behavioral symptoms directed towards others (e.g., hitting, kicking pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). A BIMS score of 10 indicated moderate cognitive impairment.Review of Resident #4's Care Plan dated 9/18/25 with problem start date 7/13/25 reflected Resident #4 was independent with transfers, ambulation, bed mobility, dressing, and toileting. Care Plan with problem start date of 6/14/25 reflected Resident #4 had behavioral symptoms with multiple episodes of agitation and aggression towards other residents between June 2025 and December 2025. The following behavior related care plan interventions and revisions were noted: Nutritional Status: Get impatient and agitated when waiting for meals:09/18/25 Resident #4 will get his tray first and brought to his room as it comes out to avoid any agitation09/18/25 Resident #4 is to be served his coffee and tray first at each meal09/18/25 Offer alternative meal if patient dislikes the meal given Mood State: Blocks the door to his room due to he doesn't want to be bothered at night:08/08/25 Resident #4 likes to sleep throughout the night being undisturbed, his rights will be respected Impaired Decision-Making r/t Alzheimer's:7/13/25 Determine if decisions made by Resident #4 endanger him or others. Intervene if necessary7/13/25 Encourage to verbalize feelings, concerns, and fears. Clarify misconceptions7/13/25 Give objective feedback when inappropriate decisions are made. Discuss future options to improved decision making skills7/13/25 Respect his rights to make decisions7/13/25 Support and reassure him in new situations At Risk for Adverse Consequences r/t Receiving Antipsychotic Medications:7/13/25 Assess if his behavioral symptoms present a danger to him/others. Intervene as needed.7/13/25 Monitor his behavior and response to medication. Behavioral Symptoms: He is having behavior symptoms of aggression and agitation:12/03/25 Resident #4 was placed on 1:1 and sent to the hospital for evaluation7/31/25 Monitor on Q15 minute checks for aggression7/30/25 Create a safe environment by calming Resident #4 down through active listening and non-threatening body language7/30/25 Staff will maintain an open body posture and avoid sudden movements7/24/25 Encourage Resident #4 to listen to music to calm him when he has behaviors6/30/25 Give any medications ordered by physician and assess for adverse reactions to medication and efficacy of medication therapy.6/30/25 Intervention such as redirection will be used when Resident #4 is experiencing behaviors.6/30/25 Nursing will report any behavior issues to physician6/30/25 Schedule care plan meeting with Resident #4 and family or RP if indicated to address any interventions that can be implemented to help achieve happiness for the resident6/30/25 Social services will refer for psychiatric consult to evaluate for medication or behavior therapy that is needed to manage disruptive behaviors6/30/25 Staff will use individualized non medication interventions first before using medication for behaviors6/14/25 Maintain a safe distance from the patient during episodes of aggression to prevent physical harm. Review of Resident #4's physician orders with start dates 5/22/25 reflected that he was ordered the following psychotropic medications: Abilify, Prozac.Review of Resident #4's physician order dated 6/20/25 reflected Resident #4 was to be monitored for aggression towards staff and other residents every shift.Review of Resident #4's Medication Administration Record dated 11/03/25 to 12/03/25 reflected that Resident #4's behaviors including aggression, itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, staling, delusions, hallucinations, psychosis, aggression, and refusing care were routinely monitored each shift.Review of facility incident/accident log dated 10/1/25 to 12/17/25 reflected Resident #4 was involved in two Aggressive/Combative Behaviors, one on 11/13/25 and one on 12/3/25. Review of Resident #4's Behavior and Mood Events notes from 6/25/25 to 12/17/25 reflected that Resident #4 had a cluster of behaviors in July 2025 followed by approximately three months without incident. Resident #4 then experienced two incidents in November of 2025 followed by approximately 3 weeks without incidents: 12/3/25 Punched another Resident (Resident #3) in cheek.Facility actions: Resident was redirected but left the area on his own accord. Resident #4 was moved to another room in another hallway away from Resident #3 while awaiting psychiatric evaluation. A mental health warrant was obtained and the police transferred him to the hospital within a few hours. The hospital declined to accept his return to the facility and assisted the hospital to find him a group home. 11/13/25 Punched CNA in right cheek; attempted to pour coffee on CNA.Facility actions: Resident #4 was redirected and escorted back to his room He was placed on 1:1 observation and the police were notified. 11/03/25 Threw coffee into another resident's face; attempted to throw a chair at the same resident (Resident #2).Facility actions: Staff intervened immediately and placed themselves in-between the two residents sparing the amount of coffee contacting Resident #2. The residents were redirected and separated. The police were notified, and Resident #4 was placed on 1:1 observation. Transfer to the hospital for evaluation was arranged but Resident #4 refused. The care plan was updated to reflect that Resident #4 would be provided with coffee/snacks first/separate. 7/30/25 Attempting to flip table over onto residents in dining hall but staff intervened and prevented.Facility actions: Resident #4 was separated from the other residents and placed on Q15 minute checks for aggression. His care plan was updated to reflect the behavior and interventions included that staff will maintain an open posture and avoid any sudden movements and to create a safe environment by calming Resident #4 down through active listening and non-threatening language. 7/29/25 Attempted to hit two residents with a vase in the dining room, but staff intervened and prevented.Facility actions: Residents were separated, and Resident #4 went to his room where he agreed to eat. He was placed on Q15 minute monitoring from 7/29/25-8/8/25. A psychiatric evaluation was ordered. His care plan was updated on 7/30/35 as noted above. 7/29/25 Barricaded himself in his room by putting the table by the door.Facility actions: Resident was placed on Q15 minute monitoring. His care plan was updated to reflect this behavior and included that Resident #4 was independent with his activities of daily living and did not need assistance. On 8/08/25 an intervention was added that Resident #4 liked to sleep through the night being undisturbed and his rights would be respected. 7/28/25 Verbal altercation with another resident and attempting to walk around/reach and slap another resident. Staff redirected.Facility actions: Resident #4 was redirected to his room where his lunch was delivered, and he was placed on Q15 minute monitoring. 7/17/25 Shoved an LVN in the hallway into the wall stating for her to get out of his way.Facility actions: Resident on Q1 hour monitoring. 6/25/25 Barricaded himself in his room with a table against the door.Facility actions: Resident was placed on Q15 minute monitoring from 6/25/25 to 6/27/25. Review of Resident #4's progress note dated 6/14/25 reflected that he was transferred and admitted to the hospital on [DATE] due to his aggressive behavior.Review of Resident #4's progress notes reflected on 7/31/25 referrals were faxed to 3 separate behavioral health hospitals and another nursing facility.Review of Resident #4's progress notes reflected on 8/05/25 he was seen by psychiatric services with no new orders received. No further details were included.Review of psychiatric services Neurobehavioral Status Exam on 10/31/25 reflected Resident #4 had refused assessment in July 2025 and during three different assessments (dates unknown). The exam reflected recommendations for continued sobriety and supplemental Thiamine for Alcohol-Induced-Dementia.Review of Resident #4's progress note dated 11/3/25 reflected he refused transfer to the hospital for evaluation.Review of Resident #4's progress note dated 11/12/25 reflected orders were received to send Resident #4 to the hospital, but he refused to go and was placed on one-to-one monitoring.Review of Resident #4's progress notes from admission on [DATE] to transfer on 12/03/25 reflected that he was often on 15-minute monitoring and was intermittently placed on one-to-observations during periods of increased agitation/aggression.Review of Resident #4's progress notes dated from admission on [DATE] to transfer on 12/03/25 reflected that he consistently refused his medications for months despite continued attempted teaching by staff and repeated offers of ordered medications.Review of Resident #4's Medication Administration Record from 11/03/25 to 12/03/25 reflected Resident #4 consistently refused all of his medications. In an interview on 12/17/25 at 09:50 am, the ADM stated that on the 12/03/25 during activities Resident #4 had become upset because he had placed his shoes against the wall and Resident #3 had picked them up. Resident #4 then hit Resident #3 in the left jaw with his fist. The ADM stated that Resident #4 was very quick and very independent, and that the activity assistant was dealing with another resident when it occurred. She stated that Resident #3 was not injured. The ADM stated that Resident #4 was moved to another room, placed on one-to-one observation, and that a mental health warrant was obtained, and he was transferred to the hospital by the Sheriff's department within a couple of hours. She reported that the hospital medically cleared him and attempted to return Resident #4 to the facility within a few hours, but that the facility then assisted the hospital to find alternative placement for Resident #4. ADM reported that prior to this incident she had been speaking with a judge to obtain eviction orders as Resident #4 was refusing to leave the facility for discharge. She stated he was too independent to be in a nursing home. The ADM stated that Resident #4 had thrown coffee on Resident #2 in the dining room on 11/3/25 and that staff immediately intervened, and Resident #2 had not sustained any injuries. In an interview on 12/17/25 at 10:00 am the Executive Assistant reported that the facility had been trying to discharge Resident #4 because the facility could not handle his behaviors but that he had refused to leave the facility despite being accepted by multiple group homes. She stated that anytime the facility sent him to the hospital, the hospital would send him back in two hours saying he was fine when he really needed help. She stated that Resident #4 had thirteen incidents since his admission including barricading himself in his room, chasing staff, hitting staffing, and hitting other residents. She stated the facility placed him on every fifteen-minute monitoring or on one to one as needed following incidents. She stated the facility made multiple attempts to get him psychiatric care but that he refused all his medications, and he chased psychiatric services out of his room. She reported that Resident #4 had bipolar disorder but refused offered medications for months. She stated the facility catered to his needs in further attempts to mitigate behaviors and doubled his food portions and gave him a heavy snack load multiple times a day. She stated he was given a private room despite not being able to pay for it. She stated the facility had also involved his family in providing input and that the family refused for him to live with him. The Executive Assistant reported she was involved in getting the mental health warrant on the day that Resident #4 hit Resident #3 and that Resident #4 was quickly transferred to the hospital by the Sheriff's department the same day and was later discharged to a group home.In an interview on 12/17/25 at 01:10 pm, the Activity Assistant reported that during an activity on 12/03/25 she heard Resident #4 state, 'leave my shoes alone and turned and saw Resident #3 reaching for Resident #4's shoes. She stated, It happened so fast and by the time Resident #3 picked up his shoes Resident #4 jumped up and ran around the table, and I was yelling for the nurse or aide loudly. She stated that she was not able to get to the residents before Resident #4 struck Resident #3 in the face with a closed fist. She stated she did not have to separate the residents as Resident #4 then pushed away on his own down the hallway in his wheelchair. She reported the DON came to assess the residents. The Activity Assistant reported she had previously had training dealing with difficult behaviors and intervening in altercations between residents, and she was aware of separating the residents and notifying her supervisors. She reported that Resident #3 did not have any injuries from this altercation.In an interview on 12/17/25 at 02:15 pm, Resident #3 was observed as not interviewable. He made brief eye contact before walking away.In an interview on 12/17/25 at 02:17 pm Resident #2 was not interviewable due to confusion.In an interview on 12/17/25 at 10:32 a.m., the Marketing and Admissions Coordinator stated that the facility had been trying to discharge Resident #4 because he was combative and hitting others, but that Resident #4 had been refusing to leave. She stated Resident #4 was a danger to himself and others and that even the staff were afraid of him. She stated the facility had tried to intervene by accommodating his schedules, desires, and preferences, and giving him a private room without charge. She stated she did not know details of Resident #4's aggression but that she was aware that he had been aggressive towards other residents on multiple occasions. She reported that when Resident #4 was going to be returned to the facility from the hospital, they were able to assist the hospital in finding alternative placement for Resident #4.In an interview on 12/27/25 at 12:40 pm, the DON stated she had not witnessed the incident between Resident #4 and Resident #3, but that she had been told that Resident #4 had hit Resident #3 in the cheek with a closed first during activities. She stated that Resident #4 told her that he hit Resident #3 because, I just got upset. She stated Resident #3 was too confused to state any details about the incident. She stated that Resident #4 was placed on one-to-one monitoring and moved to another hall. She stated that Resident #4 had been refusing all his medications, including his psychotropic medications for months. The DON stated that Resident #4 had been refusing to discharge and refusing psychiatric services and would not talk to psychiatric services when they came. She stated the facility gave him a private room, began giving him his snacks first, gave him his trays and coffee away from other residents, provided him showers at his desired times, and accommodated him by not bothering him after 9pm as he requested. She stated Resident #4 was completely independent in his activities of daily living and needed a group home rather than a nursing home but had refused to leave on multiple occasions when they had found him group home placements. She stated he needed psychiatric services and to take his medications, but he continued to refuse these things. She stated the facility would transfer him to the hospital, but the hospital would quickly send him back without doing anything for him. She stated that Resident #4 could remember days later his actions and would state that the people he attacked, deserved it and if he could get to them, he would do it again. She stated he knew the things he was doing. She reported that Resident #4 was transferred to the hospital shortly after attacking Resident #3 and was later discharged to a group home. The DON reported that her staff immediately intervened as expected when residents were in an altercation. She stated she had done an in-service education with staff on recognizing and intervening for early signs of agitation. She stated it was her expectation for aggressive residents to be placed on monitoring and to be placed on interventions to help prevent aggressive behaviors.Review of facility staff in-service education records dated 11/02/25 reflected staff signatures were present for training on identifying and intervening with resident behaviors and review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring.In interviews on 12/17/25, a random sampling of an LVN and a CNA staff reflected staff reported receiving training on caring for residents with dementia and difficult behaviors and were able to discuss appropriate interventions for residents in altercations.The facility policy titled, Abuse, Neglect, Exploitation, and Misappropriate Prevention Program dated 2001 and revised April 2021 stated, Residents have the right to be free from abuse. and implementation included to, develop and implement policies and protocols to prevent and identify abuse.

48520 51826 Based on interviews and record reviews, the facility failed to provide pharmaceutical services, including procedures that assured the accurate accountability of controlled narcotic drugs for 1 of 2 Residents (Resident #350) reviewed for pharmacy services. The facility failed to ensure that narcotic count sheet records were consistent with the remaining amount of narcotics. The facility failed to ensure that nursing staff signatures required for the narcotic count sheet were obtained and consistent with documentation of narcotics administered to Resident #350. These failures could place residents at risk for medication errors, potentially leading to overdose of narcotic pain medications, or diversion of narcotic pain medications. Findings included: Record review of Resident #350's face sheet dated, 01/22/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of Malignant neoplasm of cervix uteri (cervical cancer). Record review of Resident #350's Admission MDS, dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. Record review of Resident #350's order summary dated 01/24/2025 reflected the following: - Hydromorphone-Schedule II liquid; 4mg/ml; Amount to Administer: 0.25 ml; oral Every Hour-PRN. Start Date: 01/04/2025 End Date: Open Ended - Hydromorphone-Schedule II liquid; 4mg/ml; Amount to Administer: 0.50 ml; oral Every Hour-PRN. Start Date: 01/04/2025 End Date: Open Ended - Hydromorphone-Schedule II liquid; 4mg/ml; Amount to Administer: 0.75 ml; oral Every Hour-PRN. Start Date: 01/05/2025 End Date: Open Ended - Hydromorphone-Schedule II liquid; 4mg/ml; Amount to Administer: 1 ml; oral Every Hour-PRN. Start Date: 01/04/2025 End Date: Open Ended Record review of Resident #350's narcotic count sheet dated January 2025 for hydromorphone reflected: - Lack of nursing staff signatures from 01/22/2025 at 1:05 PM through 01/24/2025 at 3 PM. - The most recent documentation of administered hydromorphone was on 01/24/2025 at 3 PM; the recorded left (remaining) amount was 4 ml. Observation and interview with the DON and ADON on 01/24/2025 at 4:02 PM revealed that upon the surveyor's request to review the narcotic count sheet, they identified the lack of required nursing staff signatures. Further observation of the hydromorphone count, with the DON and ADON, revealed there was 4.5ml in the bottle and 4 ml written on the narcotic count sheet. Interview with RN F on 01/24/2025 at 4:23 PM revealed she administered narcotics to Resident #350 during the 6AM-2PM shift. RN F stated that nursing staff signatures were required as part of the documentation procedure for the narcotics count sheet. She did not realize that she had not signed the narcotic count sheet. RN F discussed that the importance of signatures was to make sure the narcotics accounted for were accurate with the documented left amount on the narcotic count sheet. She stated she received training regarding controlled substances during orientation. Interview with the DON on 01/24/2025 at 4:58 PM revealed that nursing staff signatures were required as a part of the procedure when narcotics were signed out. She explained that she had worked at the facility for two weeks, but the lack of signatures was likely due to the recent hire of many new nurses that had not been trained and new nursing management oversight. The DON explained the narcotic count sheet signatures were important so that staff know who checked out the narcotic. Interview with the Administrator on 01/24/2025 at 4:58 PM revealed that the expectation for administration and record keeping of medications included signing out all narcotics, narcotic count at end of shift, and to ensure signatures were there (on the narcotic count sheet). She explained the importance of these expectations are to make sure the narcotic count was correct, that nobody stole medications, and the wrong dose was not given to residents. Interview on 01/24/25 at 5:21 PM with LVN E revealed that she administered medication to Resident #350 during the 2PM-10:30PM shift. LVN E explained that signing out narcotics allowed staff to know what time, when, and how much medication was given to the resident. She further explained that signatures show which nurse gave how much (amount of narcotic). LVN E stated that the risk of not signing the narcotic count sheet was the resident can be given too much medication, causing an overdose. Review of the facility's Controlled Substances policy, dated 2001, last modified 04/09/2024, reflected Policy Interpretation and Implementation: Handling Controlled Substances ( .) 4. ( .) an individual resident controlled substance record is made for each resident who will be receiving a controlled substance . This record contains: ( .) l. signature of nurse administering medicate . Dispensing and Reconciling Controlled Substances: 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on interviews and records reviewed, the facility failed to ensure that licensed nurses had the specific competencies, and skill sets necessary to replace a g-tube and to follow g-tube verification of placement procedure, as identified through the physician orders and facility policy for one of four residents (Resident #10) reviewed for nursing services in that: 1.The facility failed to ensure LVN A had a competency validation course before replacing Resident #10's g-tube on 01/21/25. 2.The facility failed to provide training for RN B and LVN C regarding when it was safe to feed a resident or give medications via g-tube. RN B and LVN used Resident #10's G-tube before placement was verified via x-ray or CT scan. These failures could place residents at risk of being cared for by insufficiently trained staff, resulting in serious injury or infection. Findings included: Review of Resident #10's face sheet dated 01/22/25 reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute respiratory failure with hypoxia (this is a failure to breath due to lake of oxygen), critical illness myopathy (this is a neuromuscular complication that makes muscles weak and wasting), gastrostomy malfunction, contracture of muscles (shortening of muscles that causes pain to strengthen), bacterial infection, Gastrointestinal hemorrhage (this is stomach bleeding), and other post procedural complications, disorder of digestive system, constipation, and dementia (cognitive decline) Record review of Resident #10's quarterly MDS (minimum data set), dated 12/03/24, revealed cognitive skills for daily decision making was a 0 which indicated he was severely impaired. It was further revealed he was extensively dependent on two staff for bed mobility and was totally dependent on one staff for eating. His quarterly MDS also revealed he received 51% or more of his nutrition was received from a feeding tube. Record Review of Resident #10's MAR reflected: - [Brand Name]1.5 bolus-administer 260 ml feeding via free flow QID four times a Day for unspecified protein calorie malnutrition. 260 ml administered at 08:00 AM and at 12:00 PM by RN B. Observation and interview on 01/22/25 at 08:35 AM revealed RN B providing a g-tube feeding to Resident #10, who was lying in his bed. RN B checked the residual of g-tube, then flushed the g-tube with water, and proceeded to provide Resident #10 a bolus feeding. She did not listen for bowel sounds as part of the procedure. She stated that Resident #10 had issues with his g-tube in the past, and a new g-tube that had been replaced the night before (01/21/25) by LVN A. She stated the x-ray was still pending but LVN A and the ADON had told her that it was ok to use the g-tube since the placement had been verified by checking the residual. She stated that she was aware that the x-ray had been ordered to verify the new g-tube placement. Observation on 01/22/25 at 11:34 AM revealed an x-ray tech went to Resident #10 to do the ordered x-ray. In an interview with RN B on 01/22/25 at 08:35 AM, she stated she had been at the facility for three months and this was her first nursing job. She stated she had not been checked off for competency for g-tube management, policy, and procedures. She stated that she had just started working on the hallway with Resident #10 for a week. She stated she did not listen for bowel sounds as part of the g-tube nursing assessment because she was nervous. She said she did not wait for the x-ray result before she fed him because she went with the progress note and checked the residual, and it was there. She said when she used Resident #10's g-tube, he tolerated the feeding well, meaning that on her shift, there were no bad results from her feeding him. She said the first time she gave Resident #10's bolus feeds, she panicked because the surveyor was in the room and she forgot to auscultate (acts of listening to the stomach using a stethoscope), but the next time she gave Resident #10's bolus feeds at noon, she also auscultated. She stated there was no potential risk because she had checked the residual which showed the G-tube was in the stomach. In a phone interview with LVN A on 01/24/25 at 12:13 PM, revealed she had been at the facility for eight months. She stated she had g-tube competency at another facility about six years ago. She said she was trained by the DON at another facility and had done three other g-tube replacements in the time since then. LVN A said she did not remember doing any continuing education specifically for g-tubes. She stated she had not been checked off for g-tube replacement before she replaced Resident #10's g-tube, and she did not have the training or check-off to provide for record review. She stated she did not do anything out of the scope of her practice because she had replaced g-tubes at another facility and had the physician's approval. She stated the Administrator told her, There was nothing against it as long as there was an order. She stated she called the physician and got an order to replace Resident #10's g-tube and the physician said, Yes of course as long as you know how to do it. She stated the physician did not have any follow up questions on how she would perform the procedure. She stated the physician did not stay on the phone with her to walk her through the procedure. She stated the risk of not having up-to-date training was that there could be new information about the procedure, or new risks. She said she should have been checked off for competency. In an interview with LVN C on 01/23/25 at 4:08 PM he stated he had not replaced a g-tube. He stated he had done it in school once. He stated he knew how to check for residual for the g-tube and how to auscultate but he had had no competency done at the facility. He stated the training for g-tube was from nursing school. He stated he worked with residents with G-tubes and knew what signs to look for with G-tube. In a phone interview with LVN D on 01/24/25 at 04:59 PM, she stated she had been working with LVN A the night that LVN A replaced Resident #10's g-tube. She stated she was with her in the room. She stated LVN A called the physician to inform him that Resident #10's g-tube was still leaking, and she told him that she knew how to change it. LVN D said the physician gave LVN A a verbal order over the phone to go ahead. LVN D said that LVN A asked the physician if she could also order an x-ray after she was done with g-tube replacement, to verify placement, to which the physician gave a verbal order for the x-ray, and he hung up the phone. LVN D stated the physician did not stay with LVN A on the phone during the procedure, nor did he have her go over the procedure with him verbally before she changed Resident #10's g-tube. In an interview on 01/23/2025 at 9:43 AM with the ADON revealed she had replaced g-tubes but not in several years and did not know the facility policy. She said before a g-tube was replaced a doctor's order was needed, then after the tube was replaced, she would check air, auscultation, call and get an x-ray so that they could come and verify placement before it was used. She stated she would ensure she had an order to have nothing to give by tube before placement was confirmed unless the doctor directed her differently. The ADON stated this needed to be done to ensure the medicine was going into the stomach. The ADON said prior to working at the facility she had been delegated the task of replacing a g-tube at her previous facility, and she said some tasks have to be delegated by RN. She was unsure of the facility policy of who could replace a g-tube and stated she would not change a g-tube without a doctor's order and looking at the policy to make sure it was within her scope of practice. The ADON stated she did not advise Resident #10's nurses to use the g-tube before the x-ray had been read and knew nothing about the g-tube being replaced overnight by LVN A. An interview on 01/23/2025 at 10:03 AM with the DON revealed not verifying the placement of the newly placed g-tube by x-ray before using it could cause an infection, and a person could die from that. She stated it was a serious problem, and she would never advise a nurse to go ahead and use it. She said the nurses who used the g-tube just took it upon themselves to do what they did and she had begun an investigation into it. She said she could not remember the name of the nurse who had replaced the g-tube, but she was working on referring her, and any nurse who had used the g-tube before verification. She said in the short time (approximately two weeks) she had been at the facility, she had not done any competency check-offs with the nurses. She said she had not even known replacing a g-tube was an issue , because they sent people out to get them replaced. She said she thought it was out of an LVN's scope of practice to replace a g-tube, and even if they had training, she would probably not allow it. The DON said she was not even sure she would be comfortable doing it herself, because she did not work with them regularly, and it was better to send them out and have someone who did that all the time take care of it. She expressed frustration that no nurses had called her about changing the g-tube, or about using it after it was changed. She stated The ADON told her about the g-tube, and did not say anything about telling any nurse it was OK to use it for anything. She said knowing not to use the g-tube before placement was verified correctly was nursing 101. She said at the time of this interview she had not started doing training with the nurses on g-tubes, because she was gathering the policies and training materials, and printing forms. An interview on 01/23/25 at 11:45 AM with the Administrator revealed the facility did not have any documentation of training for g-tubes for LVN A. An interview on 01/24/25 at 1:03 PM with the Administrator revealed the facility did not have any nurse competencies for g-tubes. An interview on 01/24/25 at 5:41 PM with the Administrator revealed she had not told LVN A it was OK to replace Resident #10's g-tube. She said LVN A asked if she could replace it, and she told her to call the physician and the DON and left it at that. She said she did not feel LVN A was acting out of her scope, and that LVN A had talked to the MD, who was fine with her doing it, and she was comfortable with doing it. She said normally the MD had been the only person to replace them in-house, and the nurses did not, but LVN A was concerned about Resident #10, and her biggest purpose was to take care of him. She said the staff was not following policy, and if the policy said they needed to get an x-ray first, they should have got an x-ray. She said if the physician said it was OK, and the policy said otherwise, she would call him and talk to him about the policy. She said they had not done checkoffs with the nurses regarding the g-tubes, and they should have been doing them annually, and as-needed. The Administrator stated they had a lot of change with nurse managers, and every time she had a new one, she would give them the online training, and the nursing competencies that needed to be done with staff, and they would not follow through. She said the ADON was currently working on checkoffs, and they had engaged the MD to do g-tube training with the nurses. She said the competencies were important for making sure the nurses were trained to do their job, and that they comprehended the training. She said the DON and ADON were responsible for doing the hands-on training and competencies, but she was responsible for making sure they followed through, even though she was not qualified to do the training herself. An interview on 01/24/25 at 5:03 PM with the DON revealed she thought LVN A should not have called the Administrator, who was not a nurse, and should have called her, but she did not. She said she felt the g-tube was out of her scope, because as an LVN she was working independently, and had she consulted her she would have told her she could not change a g-tube, and that the emergency room was an option for Resident #10. She said only an RN should work independently. She said the competencies were important for safety reasons, and the nurses should not do a task if they had not done a competency check-off. She said she wanted them to be trained, and safe, and not doing procedures like that without calling her first. The DON stated nobody at the facility should be doing anything without verifiable training. She said she had only been there for about two weeks but planned on doing a lot of training. Record review of The Board of Nursing Section 15.24 Nursing Engaging In Reinsertion of Permanently Placed Feeding Tubes revealed in part . The Board does allow LVNs and RNs to expand their practice beyond the basic educational preparation through post-licensure continuing education and training for certain tasks and procedures . LVNs and RNs should not engage in the reinsertion of a permanently placed feeding tube through an established tract until the LVN or RN successfully completes a competency validation course congruent with prevailing nursing practice standards. Training should provide instruction on the nursing knowledge and skills applicable to tube replacement and verification of correct and incorrect placement The nurse should complete training designed specifically for the type or types of permanent feeding tubes the nurse may need to replace, including overall patient assessment, verification of proper tube placement, and assessment of the tube insertion site . The facility has resources available to develop an educational program for initial instruction of LVNs and/or RNs, as well as for ongoing competency validation. Documentation of each nurse's initial education and ongoing competency validation should be maintained by the nurse and/or the employer in accordance with facility policies. Regardless of training, policies and procedures of the facility must also permit the nurse to engage in the procedure . 48520

Based on observation, interview and record review, the facility failed to ensure complete and accurate smoking assessments for one (Resident #26) of two residents' records reviewed for smoking assessments. The facility failed to ensure Resident #26's smoking assessments were done quarterly, and that his smoking assessments were accurate. This failure could affect residents who smoke by placing them at risk of inaccurate information, resulting in a lack of appropriate safety interventions when smoking. Findings included: Review of Resident #26's face sheet, dated 01/23/25, reflected Resident #26 was a [AGE] year-old male, admitted on [DATE], with diagnoses of Nicotine dependence, dementia, and Other epilepsy, not intractable, without status epilepticus (a seizure disorder, easily managed, and without prolonged seizures which affect consciousness.) Review of Resident #26's care plan, dated 10/13/2020, reflected: Category: Smoking; I AM a smoker and at risk for injury.; Long Term Goal Target Date: 04/05/2025; (Resident #26) will not have any injury r/t smoking thru next review.; Approach Start Date: 07/15/2021; Assist to and from designated area for smoking. Approach Start Date: 07/15/2021 Offer mosquito spray ([NAME] or natural alternative) to smokers and any outside activity. As Needed; Approach Start Date: 07/15/2021; SUPERVISE SMOKING PER FACILITY POLICY. Review of Resident #26's quarterly MDS assessment, dated 10/25/24, reflected he had clear speech, was able to be understood, and was usually able to understand others. He had minimal difficulty in hearing (ie. difficulty hearing conversation in noisy setting). The Staff Assessment for Mental Status reflected his memory was okay, and he had moderately impaired decision making capability for tasks of daily life. No indicators of psychosis, or behaviors affecting others were noted, but Resident #26 did reject care from one to three days in a seven-day look-back period. He had no range-of-motion impairment, and was independent in most ADL's and movement tasks. Resident #26 ambulated without an assistive device (cane, wheelchair, walker.) Review of Resident #26's smoking risk assessment, completed on 03/13/24 by the Activity Director, reflected Resident #26 smoked cigarettes less than hourly, and did not have any smoking problems, like lack of awareness and orientation including the ability to understand the smoking policy, problems with interpersonal interactions, or dropping smoking materials. The document also reflected Resident #26 did not have any behavioral problems related to smoking, like begging or stealing smoking materials from others, smoking cigarette butts from ashtrays, or smoking in unauthorized areas. He was able to follow the facility safe smoking policy, and was deemed a safe smoker with no referrals necessary. Review of Resident #26's smoking risk assessment, completed on 06/14/24 by the Activity Director, reflected Resident #26 was a none-smoker (sic) and had no information about smoking capability or behaviors noted. Review of Resident #26's smoking risk assessment, completed on 01/22/25 by the Activity Director, reflected Resident #26 was a none-smoker (sic) and had no information about smoking capability or behaviors noted. Review of Resident #26's smoking assessments in the electronic medical record reflected no smoking assessments dated between 06/14/24 and 01/22/25. Interview and observation on 01/22/25 at 10:42 AM revealed Resident #26 ambulating into his room while the surveyor was interviewing his roommate. When the surveyor asked Resident #26 if she could speak with him for a few minutes, he politely declined to be interviewed at that time, or any later time. Observation on 01/22/25 at 1:22 PM revealed Resident #26 seated outside in an enclosed courtyard with one other resident and a staff member (unknown identity). Resident #26's hands were steady, and he did not appear to have any problems smoking. When he was almost done with one cigarette, he asked the staff member for another. The staff member retrieved another cigarette from a pack in a metal box, and when Resident #26 finished his first, the staff member handed the second to him, and lit it for him. Observation on 01/24/25 at 8:00 AM revealed Resident #26 ambulating in the hall. He was friendly when greeted by the surveyor, and when asked how his smoke breaks were going, he said they were good, but it was cold out. He again declined to be interviewed any further. An interview on 01/24/25 at 10:02 AM with the Activity Director revealed she was responsible for arranging smoke breaks at the facility, and for doing smoking assessments. She stated the smoking assessments were supposed to be done with the quarterly reports (MDS) if it showed up in the EMR, and when they popped up, she did them. She said there was an initial assessment, which was a little different from the others. She said she marked on the assessment if someone was a safe smoker, or if they needed additional interventions to keep them safe. She said the assessment is there to determine if someone needs an apron to prevent them from dropping ashes on themselves, or any other interventions. She said along with training staff for smoke breaks, monitoring and assessing residents, and arranging breaks and acquiring and storing smoking materials, she is responsible for noting changes in the resident which could change their safe smoking status. She said the Administrator trained her, and sometimes reminded her to check smoking documentation. She said she was out sick, and in the hospital, for part of the month of June 2024, and the month of July 2024, and she might have missed something at that time . While going over Resident #26's most recent smoking assessment with her, she said she was surprised, and must have made an error on it. She said the assessments were important because they helped the staff know how to keep the residents safe. An interview with the Activity Director on 01/24/25 at 10:23 AM revealed the Activity Director returned to inform the surveyor that she did not know how, but she clearly made an error on Resident #26's smoking assessments. She said sometimes when she pulled up the EMR a smoking assessment popped up for her to do, and sometimes it did not. She said she just learned that she could add one if it did not automatically show up for her. She brought her binders, to show the surveyor how her system worked. The Activity Director said she thought she would be able to correct the 01/22/25 assessment, because it was so recent, but she could not correct the older one. She explained to the surveyor that she printed out the activity assessments, and hand wrote on the top margin if they were a smoker, and she made a big, red checkmark on the page when she completed the smoking assessment, to keep track of what she had completed. She said she knew the date it was due, but the due date the EMR printed out on the activity assessment. She said the document had the check mark on it for the smoking assessment, and she did not know what happened to the smoking assessment for September 2024. Review of the activity assessment, completed on 09/16/24, from the Activity Director's binder, reflected she had written smoker and the document had two red checkmarks on it. An interview on 01/24/25 at 2:53 PM with the ADON revealed she had not been at the facility very long, so was not familiar with the policy regarding how often the smoking assessments were done, but she knew the purpose of them was to keep residents safe. An interview on 01/24/25 at 5:03 PM with the DON revealed she had not been at the facility long, but she thought the smoking assessments would be done on admission, and as needed, if there was an issue with the resident. She said they were important because the needed to make sure the resident was safe, and the assessment would let them know if additional equipment, like an apron, would be needed. Review of the facility policy Smoking Policy - Residents, revised October 2023, reflected: Policy Statement: This facility has established and maintains safe resident smoking practices.; Policy Interpretation and Implementation ( .) 7. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). ( .) 9. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. ( .)

Based on interview and record review, the facility failed to ensure notification and receipt of Medicare Provider Non-Coverage letters (CMS 10123 or CMS 10055) which included information about their right to appeal were reviewed for Medicare Beneficiary Notification Review (Residents #71 and Resident #95). The facility failed to provide the Medicare Provider Non-Coverage letters to Resident #71 and Resident #95. This failure could place residents who receive Medicare Part A benefits at risk of not being fully informed of their right to appeal. Findings included: Record review of the document titled Beneficiary Notice - Resident discharged within the last 6 months, dated 08/24 through 12/2024 naming residents discharged from Medicare part A with benefit days remaining. Record review of the facility's Beneficiary Protection Notification indicated Resident #71's Medicare Part A skilled service start date was 08/24/2024 and last covered day of Part A service was 10/26/2024. Record review of the facility's Beneficiary Protection Notification indicated Resident #95's Medicare Part A skilled service start date was 07/27/2024 and last covered day of Part A service was 10/04/2024. Record review of Resident #71's face-sheet dated 01/24/2025, revealed a [AGE] year-old female, initially admitted to facility on 01/25/2025 and discharged from skilled services on 10/26/2024. Resident's diagnosis included: Unspecified cirrhosis of liver (a medical diagnosis that refers to a type of liver disease where the specific cause of the scarring (fibrosis) of the liver is unknown); Chronic respiratory failure with hypercapnia (a chronic condition where the body cannot effectively eliminate carbon dioxide from the blood, causing hypercapnia - CO2 - carbon dioxide levels), and End stage renal disease (a condition which the kidneys lose the ability to remove waste and balance fluids). Record review of Resident #71's quarterly MDS (Minimum Data Set) dated 12/28/2024 revealed BIMS (Brief Interview of Mental Status) score was 14/15 with memory intact. Record review of Resident #95's face-sheet dated 01/24/2025, revealed an [AGE] year-old male, initially admitted to facility on 07/27/2024, readmission on 12/21/2024 and discharged from skilled services on 10/04/2024. The resident's diagnosis included: Hypertensive urgency(a condition where the blood pressure is significantly elevated but there no evidence of acute organ damage), encephalopathy, unspecified (a condition where there is a general disturbance of brain function, but the specific cause is unknown), dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a person is presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances). Record review of Resident #95's quarterly MDS (Minimum Data Set) dated 12/27/2024 revealed BIMS (Brief Interview of Mental Status) score was 07/15 with cognitive status severely impaired. In an interview on 01/24/2025 at 3:17 pm with the Admission Coordinator revealed that the facility did not have an MDS coordinator at that time. The former MDS Coordinator, who was responsible for completing the NOMNCs, was no longer employed at the facility. The Admission Coordinator could not find the copies of the completed NOMNCs nor proof that the NOMNCs were sent. She stated providing residents with a NOMNC at the end of their Medicare Skilled Services was important because the patient had the right to be informed and know when their agreement, care, and coverage would change with the facility. In an interview on 01/24/2025 at 3:25 pm with the ADM revealed after speaking to the former MDS Coordinator, he said he left the NOMNC forms on a pile on the desk but ADM could not find them or proof that they were sent. The forms were not in a binder or anything. The former MDS Coordinator left his position in early January 2025. The residents have to be provided the NOMNCs because they had a right to appeal any financial decisions and they had a right to know what the decisions were. Facility did not provided copies of NOMNCs or evidence NOMNCs were sent by the time of exit. Record review of Form Instructions for 10123-NOMNC (Notice of Medicare Non-Coverage) revealed the following, in part: - The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. - Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process per Chapter 4, Section 260 of the Medicare Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare Managed Care Manual. - The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. - CMS requires that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. Providers are required to develop procedures to use when the beneficiary/enrollee is incapable or incompetent and the provider cannot obtain the signature of the enrollee's representative through direct personal contact. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. Record review of the facility, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised September 2022, revealed, Residents are informed in advance when changes will occur to their bills. 1. If the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage (CMS form 10123) is issued to the resident at least two calendar days before benefits end. 2. The Notice of Medicare Non-Coverage informs the resident of the pending termination of coverage and of his/her right to an expedited review by a Quality Improvement Organization. 44894

Based on observation, interview and record review the facility failed to ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of one residents (Resident #350) reviewed for nephrostomy care. The facility failed to ensure staff kept Resident #350's nephrostomy (tube placed in the back that drains urine from the kidney) bag below the kidney while the resident was in bed. This failure could place residents at risk of infection. Findings included: Record review of Resident #350's face sheet dated, 01/22/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of Malignant neoplasm of cervix uteri (cervical cancer). Record review of Resident #350's Admission MDS, dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. Record review of Resident #350's order summary dated 01/24/2025, revealed .Resident has BL Nephrostomy tube . dated 01/05/2025 . Record review of Resident #350's careplan, undated, did not indicate resident had a nephrostomy bag. Observation and interview on 01/22/2025 at 10:53 AM, revealed Resident #350 was lying in bed, and a bag with yellow fluid was on the bed near the resident's left shoulder. When the Surveyor asked what the bag was, Resident #350 said she had a nephrostomy tube. Interview on 01/23/2025 at 4:46 AM, LVN A stated Resident #350 had 2 nephrostomy tubes and the bags should be below the insertion point so that it would drain via gravity. She stated she was not sure what could happen if the bag was higher than the kidney. Interview on 01/23/2025 at 5:06 AM, CNA G stated she had been told to keep the nephrostomy bag above the kidney. Interview on 01/24/25 at 2:35 PM, RN F stated the nephrostomy bag should be below the waste for infection control and to maintain the pressure. She stated the urine could fluctuate back and it could possibly cause an infection. She said no other residents had nephrostomy tubes and the nurse was responsible for ensuring the bag was in the correct position. Interview on 01/24/25 at 4:58 PM, the DON stated the nephrostomy bag should have been draining below the kidneys and best practice was it should have been hung in a bag like a F oley [catheter bag]. The DON stated it could stop the bag from draining, cause an infection and be a dignity issue. She said staff should have been trained when the nephrostomy came into the building. Interview on 01/24/25 at 5:42 PM, the Administrator stated the bag should have been below the kidney so urine would flow. Review of facility policy titled, Nephrostomy Tube, Care of revised October 2010, revealed in part: 2. Check placement of the tubing and integrity of the tape during assessments. 1. Drainage should be below the level of the kidneys. 2. There should be no kinks in the tubing .

Based on observation, interview, and record review, the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services for one (Resident #10) of four resident's observed for checking g-tube for placement. The facility failed to verify that placement of the feeding tube for Resident #10 was confirmed by x-ray (Imaging that is taken with electromagnetic waves to show pictures of the inside of your body) upon initial insertion and that the tube length was marked and documented before it was flushed with water, medications were given, and bolus feedings were administered on 01/22/25. These failures could place residents with g-tubes at risk of aspiration pneumonia, infection, discomfort, malnutrition, and a decline in the residents' health. Findings included: Review of Resident #10's face sheet dated 01/22/25 revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute respiratory failure with hypoxia (this is a failure to breath due to lake of oxygen), critical illness myopathy (this is a neuromuscular complication that makes muscles weak and wasting), gastrostomy malfunction, contracture of muscles (shortening of muscles that causes pain to strengthen), bacterial infection, Gastrointestinal hemorrhage (this is stomach bleeding), and other post procedural complications, disorder of digestive system, constipation, and dementia (cognitive decline) Record review of Resident #10's quarterly MDS (minimum data set), dated 12/03/24, revealed cognitive skills for daily decision making was a 0 which indicated he was severely impaired. It was further revealed he was extensively dependent on two staff for bed mobility and was totally dependent on one staff for eating. His quarterly MDS also revealed he received 51% or more of his nutrition was received from a feeding tube. Record review of Resident #10's Care plan last reviewed on 12/13/24 revealed he required a tube feeding due to difficulty swallowing. The goal was for Resident #10 was to not have significant weight loss. Interventions included the resident was dependent on g-tube for tube feeding, water flushes, and medications per physician orders. The care plan further revealed Resident #10 was at risk of bleeding r/t taking antiplatelet (Aspirin). The Goal was that the resident would be free from discomfort or adverse reactions r/t antiplatelet use through the review date. Interventions were Administer the medication as ordered by the MD. Monitor for side effects and effectiveness per shift. Review of Resident #10's order summary for January 2025 reflected the following: Record Review of Resident #10's MAR dated01/01/25 to 01/22/25 reflected the following: -Aspirin tablet, chewable; 81 mg tablet; Amount to administer: 1; gastric tube daily - baclofen 20 mg tablet, three times a Day. 1, gastric tube, Three Times A Day for Contracture of muscle, unspecified site. - famotidine 20mg tablet, twice a Day. 1 gastric tube, Twice Times A Day for abdominal distension. - MiraLAX (Polyethylene glycol 3350) 17 gram/dose powder. Once a Day. 17 g oral once a day for constipation. - Senna 8.6 mg tablet. Once a Day. 2 oral, once a Day. 1 oral, gastric tube, once a day, assist with wound healing for Constipation. - Vitamin C (Ascorbic acid (vitamin c)) 500 mg tablet. Once a Day for Gastrostomy malfunction. - zinc sulfate 50 mg zinc (220 mg) tablet. Once a Day. 1 oral once a day - [Brand Name]1.5 bolus-administer 260 ml feeding via free flow QID four times a Day for unspecified protein calorie malnutrition. -May insert gastric tube due to malfunction/tear. One time. Diagnosis: gastrostomy malfunction. Start date 01/21/25-01/21/25 . -Standard Abdomen (KUB); Other test: Abdominal X-ray to confirm placement of G-tube. One time. Diagnosis: gastrostomy malfunction. Start date 01/21/25-01/21/25. Record Review of Resident #10's MAR dated01/01/25 to 01/22/25 reflected the following: -Aspirin tablet, chewable; 81 mg tablet; Amount to administer: 1; gastric tube. Administered 1/22/2025 8:41:55AM by RN B - baclofen 20 mg tablet, three times a Day. 1, gastric tube, Three Times A Day for Contracture of muscle, unspecified site. Administered 1/22/2025 8:41:55AM by RN B. - famotidine 20mg tablet, twice a Day. 1 gastric tube, Twice Times A Day for abdominal distension. Administered 1/22/2025 8:41:55AM and at 1:00 PM by RN B. - MiraLAX (Polyethylene glycol 3350) 17 gram/dose powder. Once a Day. 17 g oral once a day for constipation. Administered 1/22/2025 8:41:55AM by RN B. - Senna 8.6 mg tablet. Once a Day. 2 oral, once a Day. 1 oral, gastric tube, once a day, assist with wound healing for Constipation. Administered 1/22/2025 8:41:55AM by RN B - Vitamin C (Ascorbic acid (vitamin c)) 500 mg tablet. Once a Day for Gastrostomy malfunction. Administered 1/22/2025 8:41:55AM by RN B. - zinc sulfate 50 mg zinc (220 mg) tablet. Once a Day. 1 oral once a day - [Brand Name]1.5 bolus-administer 260 ml feeding via free flow QID four times a Day for unspecified protein calorie malnutrition. 260 ml administered at 08:00 AM and at 12:00 PM by RN B. -May insert gastric tube due to malfunction/tear. One time. Diagnosis: gastrostomy malfunction. Start date 01/21/25-01/21/25 at 11:30 PM. Order entered by LVN A. -Standard Abdomen (KUB); Other test: Abdominal X-ray to confirm placement of G-tube. One time. Diagnosis: gastrostomy malfunction. Start date 01/21/25-01/21/25 at 11:34 PM. Order entered by LVN A. Record review of Resident #10's progress notes dated 01/21/2025 by LVN A at 11:33PM, reflected Received verbal/telephone order for replacement of G-tube due to leaking/malfunction. G-tube replaced with same size 18fr 7-10 ml. Procedure tolerated well. Placement verified via air bolus/auscultation (this is a process of pushing air into the G-tube while listening with a stethoscope). Pending abdominal x-ray to confirm placement at this time. Record review of Resident #10's progress notes dated 01/22/2025 by RN B at 1:37PM, reflected Abdominal x-ray pending to confirm placement at this time. Feeding tolerated well. Active bowel sounds in all 4 quadrants. Record review of Resident #10's progress notes by LVN C dated 01/22/2025 at 6:36PM, reflected the resident Xray result was out, impression: G tube not identified, follow up with contrast or air injection (iodine-based contrast injected to enhance X-ray or CT images) suggested. gas distended bowel (this is when the abdomen becomes distended due to gas formation due to digestive problems) and increased fecal material. On assessment, the abdomen was slightly distended and R side abdominal pain. MD ADON DON notified. resident sent to the [hospital name] via EMS. family notified. Observation and interview of g-tube feeding on 01/22/25 at 08:35 AM with RN B revealed Resident #10 lying in the bed. RN B then attached the syringe with a plunger to the g-tube and checked the residual of g-tube and stated it had only 0.2 ml in it. She then removed the syringe and filled it with 30 ml of water and reattached the syringe and pushed the 30 ml of water into the g-tube using the plunger. RN B then removed the syringe plunger. After the water flush Resident #10 was given a bolus feeding (feeding method using a syringe to deliver formula through feeding tube) using the free flow method as ordered by the physician. RN B stated that she had to use the syringe plunger to help push anything that might prevent the flow of the bolus feeding. She stated that Resident #10 had issues with his g-tube in the past. She stated Resident #10 had a new g-tube that had been replaced the night before (01/21/25) by LVN A. She stated the x-ray was still pending but LVN A and the ADON had told her that it was ok to use the g-tube since the placement had been verified by checking the residual. She stated that she was aware that the x-ray had been ordered to verify the new g-tube placement. Observation on 01/22/25 at 11:34 AM revealed an x-ray tech went to Resident #10 to do the ordered x-ray. In an interview with the Nurse Practitioner on 01/23/25 07:27 AM, he stated from his experience when the g-tube was replaced it was required to complete checking the residual in the stomach, then testing the residual to make sure that it was stomach acidic stomach contents, then pushing a small amount of air into the stomach via the g-tube while listening with the stethoscope, and finally ordering a KUB x-ray. He stated in most situations if the g-tube needed to be replaced the resident was sent out so that the radiology could take images of placement thereafter. He stated if the g-tube was not confirmed, he would hold all feedings and medications until he had the x-ray was done and read. He stated if it took longer for X-ray to be done or read, then he would send the resident to ER. He stated confirming placement was necessary. He stated the risk of not waiting to confirm placement of g-tube was that medication would go in the wrong place. He stated, you could be putting chemicals into the peritoneum cavity (abdominal cavity space), perforation, or an infection in the lungs. He stated it was in your best practice to be sure of your practice. Confirm placement before use. In a phone interview with LVN A on 01/24/25 at 12:13 PM, revealed she had been at the facility for eight months. She stated she had experience putting in g-tubes and had replaced three others at other jobs prior to replacing Resident #10's g-tube. She stated Resident #10 had been having issues with his g-tube leaking for a while and they could not get him an appointment soon enough so she asked the Administrator if it was in the policy and she was not over stepping, if she could replace it. She stated the Administrator told her to go ahead and replace it. She stated the Administrator told her, There was nothing against it as long as there was an order. She stated she called the physician and got an order to replace Resident #10's g-tube and the physician said, Yes of course as long as you know how to do it. She stated the physician did not have any follow up questions on how to do it, but she asked him for an x-ray order too because that was what she had been trained to do after a g-tube was replaced for placement verification of the g-tube. LVN A stated there was no communication after the placement with the physician as she had already asked for an x-ray for verifying placement. When asked if she told the nurse on the next shift that it was OK to use the g-tube LVN A said Absolutely not! I did not tell her to use it! She stated she told RN B not to use it and to look out for the x-ray person. LVN A stated Resident #10 did not have any g-tube feedings or medications due on the rest of her shift, so she did not administer any after she replaced it. She stated the risk of not verifying the g-tube placement before using it was putting fluid in the peritoneal cavity in between the stomach and the abdominal wall, which could potentially become septic. LVN A explained [NAME] the steps in replacing the g-tube, as she was taught, and did correctly describe the process. She said if there were any issue, for example the tube did not want to go in, or the resident had any pain, or bleeding, or anything unusual happened, she would stop immediately and notify the physician. In a phone interview with LVN D on 01/24/25 at 04:59 PM, she stated she had been working with LVN A the night that LVN A replaced Resident #10's g-tube. She stated she was with her in the room. She stated LVN A called and informed the physician that the g-tube was still leaking, and she told him that she knew how to change it. The MD gave LVN A a verbal order over the phone to go ahead with the replacement and LVN A asked the physician if she could also order an x-ray after she was done to verify placement. The MD also approved an order for the x-ray before they ended the call. LVN D stated the MD did not ask LVN A to go over the procedure verbally with him on the phone and did not stay on the phone with her during the procedure. She stated LVN A was worried because Resident #10 had been having issues with his feeding tube leaking and they were not able to feed the resident without it leaking. LVN D stated she could not remember if she gave the morning shift nurse (RN B) approval to use the g-tube. She stated that she remembered LVN A telling RN B that she needed to watch for the x-ray to be done. An interview on 01/23/2025 at 9:43 AM with the ADON revealed when a g-tube was leaking she would call the doctor. She said it would depend on where it was leaking from, if it was from the stoma (opening into the stomach area) would want to look at the whole thing, or if the device was cracked, she would reach out to the doctor. The ADON stated she would do an assessment, check for residual, bowel sounds, anything physical that could be going on. She stated she had replaced g-tubes but not in several years and did not know the facility policy. She said before a g-tube was replaced a doctor's order was needed, then after the tube was replaced, she would check air, auscultation, and call to get an x-ray to verify placement before it was used. She stated she would ensure she had an order to give nothing by tube before placement was confirmed unless the doctor directed her differently. The ADON stated that needed to be done to ensure the medicine was going into the stomach. The ADON said prior to working at the facility she had been delegated the task of replacing a g-tube at her previous facility, and she said some tasks had to be delegated by RN. She was unsure of the facility policy of who could replace a g-tube and stated she would not change a g-tube without a doctor's order and looking at the policy to make sure it was within her scope of practice. The ADON stated she did not advise Resident #10's nurses to use the g-tube before the x-ray had been read and knew nothing about the g-tube being replaced overnight by LVN A. An interview on 01/23/2025 at 10:03 AM with the DON revealed when a g-tube was leaking, they called the physician to get an order to get it replaced. She stated nobody in the facility was allowed to place a g-tube, but if it had been replaced in-house by a nurse, the next thing they did was order a stat x-ray. She said using the g-tube (for feeding or medication) was not allowed until they received verification of correct placement by x-ray or CT scan. She said they could only use auscultating (listening for air sounds in the stomach with a stethoscope) and checking for residual (checking the amount of fluid in the stomach) to check placement after placement had been verified by x-ray or CT scan. The DON stated the x-ray was to make sure the g-tube was in the right spot, so it did not leak inside the body where it was not supposed to. She said when that happened, it could cause an infection, and a person could die from it. She stated it was a serious problem, and she would never advise a nurse to go ahead and use it. She said the nurses who used the g-tube just took it upon themselves to do what they did and had begun an investigation into it. The DON stated she learned at about 7:15 AM on the day of this interview that the hospital had verified placement of the g-tube, and it was in place. She said she could not remember the name of the nurse who had replaced the g-tube, but she was working on referring her, and any nurse who had used the g-tube before verification. She said in the short time (approximately two weeks) she had been at the facility; she had not done any competency checkoffs with the nurses. She said she did not know it an issue, because they sent people out to get them replaced. She said she thought it was out of an LVN's scope of practice to replace a g-tube, and even if they had training, she would probably not allow it. The DON said she was not even sure she would be comfortable doing it herself, because she did not work with them regularly, and it was better to send them out and have someone who did that all the time take care of it. She expressed frustration that no nurses had called her about changing the g-tube, or about using it after it was changed. The DON said the first she heard of it was on the night of 01/22/25, when the ADON was talking to her about Resident #10 needing to be sent to the hospital due to his abdomen being a little distended, and he was not feeling well, and was having pain. The ADON told her about the g-tube and did not say anything about telling any nurse it was OK to use it for anything. She said the ADON had been trying to get Resident #10 sent out to get the tube replaced, and she did not have any idea yet why the nurse had taken it upon herself to change it. She said knowing not to use the g-tube before placement was verified correctly was nursing 101. She said at the time of this interview she had not started doing training with the nurses on g-tubes, because she was gathering the policies and training materials, and printing forms. An interview on 01/23/25 at 10:37 AM with RN B revealed she had administered medication to Resident #10 on 01/22/25. She said she was aware that the resident's g-tube was replaced by LVN A, the night nurse. She stated the information was provided to her at shift change. She said that LVN A told her it was OK to use the g-tube, and that the ADON knew about it. RN B said she knew an x-ray had to be done. She said that LVN A verbally informed her that it was OK to use the tube, and she checked the progress note, and it was there. She said she did not wait for the x-ray result, because she went with the progress note and checked the residual, and it was there. She said when she used Resident #10's g-tube, he tolerated it well, meaning that on her shift there were no bad results from the administration. She said the first time she did it, she panicked because the surveyor was in the room, and forgot to auscultate, but the next time she did it, she also auscultated. She said she believed LVN A also fed the resident on the night shift, before she did. An interview on 01/23/25 at 12:28 PM with the MD revealed the facility tried to send Resident #10 to one hospital, but he was told the next day that hospital would not accept an electronic signature, but instead required a wet signature (a handwritten signature on paper) on the orders, and he was not in a position to do that, at that time. He said when he was in the building, they decided to send Resident #10 to a different hospital, because the first one had given them a lot of other problems with another resident they sent there, but the second hospital would not take Resident #10, because they had not placed his g-tube originally. He said Resident #10 had his g-tube for years, so it was healed, and established, and replacing it was a simple procedure. He said LVN A called him that night (01/21/25) and said that she could replace the peg tube (another name for the g-tube) and she had been trained. Resident #10 had not been able to eat because of the leaking for a couple of days, and that was serious. The MD said he told the nurse Fine. Put it in. He said they ordered an x-ray to check it, and it was fine. The next day, the ADON notified him that Resident #10's abdomen was distended. The MD said when Resident #10 went to the hospital, they said the g-tube was fine, and Resident #10 was constipated. The constipation and a distended abdomen had been an on-going problem for Resident #10, and they had done everything they could think of, medication changes, GI consults, nutritional consults, and he still had the same problem. The MD said when a g-tube was replaced, he would not necessarily wait for an x-ray to determine placement. He said it was just a hole into the stomach and Resident #10's was a mature, healed stoma. He said the stomach wall was sealed to the interior wall, stuck there, and putting a tube in there, it just goes in, and you are in there. He said there were other methods of determining placement, like listening to it, or aspirating the stomach contents out. He said one could get an x-ray, but the x-ray was not the only way to determine placement. He said he did not order the KUB, the nurses did, and he was informed after the fact. He said he did not require it, he just required them to determine the tube was in the stomach. He said the tube could not go anywhere else. The MD likened the g-tube to a Foley catheter, which would go into the bladder, because where else would it go?. He said if the g-tube had been new, under a month old, he would have required an x-ray, because it might not be healed fully. He said they usually took a week or two to completely seal where they were attached. The MD said the reason an x-ray was not necessary was that they were not reliable and did not show plastic. He said that they needed to use contrast, and the facility did not need to go to the trouble to store radioactive materials. He said nursing homes did not do that. The MD said he believed it to be in an LVNs scope of practice, and that the Texas Board of Nursing allowed nurses to place a g-tube with a physician's consent. He explained that there were two types of g-tubes, the type done initially, and those had to be replaced by a physician, but the other type could be placed by a nurse. He said that LVN A went over the procedure with him on the phone, and she knew what she was doing, and she did it correctly. He said they normally sent the residents out to get them done, because he had not been aware any of the nurses were trained to do it. The MD said LVN A had training at a prior facility and had that skill. He said there was no risk to the resident in changing it, or in feeding it, because it was a fully healed hole into the stomach. An interview on 01/23/25 at 12:12 PM, at [hospital name], the hospital nurse stated she did not see anything wrong with Resident #10's g-tube and it did not have to be replaced. The hospital nurse stated Resident #10's diagnosis was severe sepsis (this is a systemic infection that is triggered by the body's extreme response to an infection) and pneumonia, and the cause of sepsis was unknown. The hospital charge nurse stated Resident #10's did not need his g-tube replaced and the CT scan showed the tube to be in place when he arrived. Record Review of facility policy titled Confirming Placement of Feeding Tubes, revision date November 2018 reflected .revealed in part The purpose of this procedure is to ensure proper placement of an existing feeding tube prior to administering enteral feedings or medication. 1. Verify that there is a physician's order for this procedure. 2. Verify that placement of the feeding tube was confirmed by X-ray upon initial insertion and that the tube has been marked, or the tube length has been documented. Review the resident's care plan and provide for any special needs of the resident .

Based on observations, interviews, and record review the facility failed to protect the confidentiality of personal and medical records for one (RN E) of three staff observed for confidentiality of records. The facility failed to ensure RN E locked and closed the laptop during the medication pass exposing residents on the secured unit's personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity. The findings included: Observation of the secured unit on 01/09/25 at 2:55 p.m., revealed the computer on the medication cart was unlocked and unattended which displayed residents' medications that needed to be passed. The computer was unattended near room [ROOM NUMBER] with the computer facing the hall. Two staff member and three residents passed the unattended computer. A male staff member later identified as RN E approached the surveyor from the opposite end of the hall stating the cart belonged to him. RN E locked the cart, stated he was assisting another nurse and returned to the other end of the hall. In an interview on 01/09/25 at 3:04 p.m., RN E stated he accidently left the computer unlocked when he left to assist another nurse and forgot to lock the computer. RN E stated leaving the computer unlocked, with residents' information opened, could give other residents, staff and visitors unauthorized access to residents medical information. In an interview on 01/09/25 at 3:15 p.m., The DON stated she had been the facility's DON for four days. The DON stated she was not aware of the unlocked and unattended computer on the medication cart of the secured unit. The DON stated computers should be locked when unattended. The DON stated this was the responsibility of any nursing staff member who was utilizing the computer to access resident information. The DON stated she would begin to Inservice staff on resident record confidentiality and would conduct random checks to ensure computers were secured when unattended. In an interview on 01/13/25 at 2:55 p.m. the ADMIN stated it was the expectation for all computers used to access residents medical information to be locked when unattended. The ADMIN stated all nursing staff were to ensure their computers were secured when not in use, as not doing so could lead to another resident or visitors having access to residents medical information. The ADMIN stated she would in-service nursing staff on resident record confidentiality and would check computers to ensure they were locked when not in use. Record review of the facility's policy entitled Protected Health Information (PHI), Safeguarding Electronic, revised in February of 2014, read in part: Policy Statement: Electronic protected health information (e-PHI) is safeguarded by administrative, technical and physical means to prevent unauthorized access to protected health information. Policy Interpretation and Implementation: 1. This facility ensures the confidentiality, integrity and availability of all e-PHI created, maintained, received, or transmitted by our information system. 2. Threats or hazards to the security of integrity of e-PHI will identified and mitigated as soon as possible. 3. All business associates are required to comply with security standards established by our business associate agreement relative to e-PHI .

Based on interviews and record reviews the facility failed to ensure residents in the locked memory care unit were free from involuntary seclusion for one (Resident #1) of six residents reviewed for involuntary seclusion. The facility failed to obtain a physician order, documenting the clinical criteria met for placement in the secured/locked, prior to Resident #1's move to the secured unit on 11/21/24. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning, and injury. Findings included: Record review of Resident #1's face sheet, printed on 01/13/24, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses to include Unspecified dementia with behavioral disturbance(a diagnosis of dementia where the exact type of dementia cannot be determined, but the individual also exhibits noticeable behavioral disturbances like agitation, aggression, wandering, or mood swings alongside cognitive decline), Other schizoaffective disorders( rare mental illness that combines schizophrenia and a mood disorder), and dementia in other diseases classified elsewhere, severe, with mood disturbance (a medical condition that involves severe mental decline, mood changes, and interference with daily life). Record review of Resident #1's MDS assessment, dated 12/13/24, revealed Resident #1 had BIMS score of 06, which indicated a severe cognitive impairment. Section E -Behavior, question E0900. Wandering - Presence & Frequency, indicated Resident #1 had not exhibited any wandering behaviors. Record review of Resident #1's quarterly MDS assessment, dated 11/15/24, Section E -Behavior, question E0900. Wandering - Presence & Frequency, indicated Resident #1 had not exhibited any wandering behaviors. Record review of Resident #1's care plan last revised on 01/03/25, revealed the following: -Problem Start Date: 11/22/2024 Category: Behavioral Symptoms I exhibit behaviors of trying to leave the facility wanting to go to work, catch the bus or look for my [family member][name]. Goal: I will wander safely within specified boundaries in my wheelchair. Approach: Approach Start Date: 01/11/2025 Assess I for placement in a specially designed therapeutic unit. Maintain a calm environment and approach to [Residnet#1] when she is wanting to leave to get [son]. Offer her one of her babies and remind her he is coming to see her as soon as he leaves work . Place [Residnet#1 in a secure environment .Remind [Resident #1] that she does not need to leave to catch the bus, [name] will be here soon .When [Resident #1] begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.) Record review of the Orders tab of Resident #1's electronic health record revealed an order, with a start date of 01/12/25, Resident requires secured unit due to unsafe wandering and exit seeking. The order was placed in the system by ADON C. Record review of the progress notes tab of Resident #1's electronic health record revealed a progress note written on 11/21/24 at 10:48 a.m. by SW B, which read [Resident #1] will move to room [number]. Resident and family are aware of the room change. Informed [RP] today and he would not like to be present. The room change will occur today 11/21/2024. Record review of the progress notes tab of Resident #1's electronic health record from 11/01/24 through 11/22/24 did not indicate Resident #1 exhibited wandering and/or exit seeking behaviors. Record review of the Events tab of Resident #1's electronic health record revealed two fall events, dated 11/20/24 and 11/21/24. No documentation of resident behaviors, including exit-seeking behaviors, was observed. An interview was attempted with Resident #1 on 01/09/25 at 3:00 p.m., the resident was observed in the common room of the secured unit, speaking to herself. The resident did not respond to the surveyor. In a telephone interview on 01/13/25 at 12:02 p.m., the PCP stated he would have to review Resident #1's records to see his involvement in her being moved to the facility's secured unit. While reviewing her electronic health record, the PCP stated the resident had significant dementia and confusion and several falls, which did not necessitate a secured unit. The PCP stated he saw Resident #1 was transferred to the unit but did not see any discussion of the reason. The PCP stated he did not recall giving a verbal or written order to place Resident #1 on the secured unit. The PCP stated he was not aware of any wandering or elopement attempts. The PCP stated he did not know Resident #1 was capable of eloping because she was not ambulatory and was unable to propel herself in her wheelchair. In an interview on 01/13/25 at 12:35 p.m., SW B stated Resident #1 was moved to the secured unit due to her risk level for elopement. The SW B stated when a resident is to be moved to the secured unit, it was his responsibility to notify the family or the move and to also speak with the roommate and their family and to document their involvement in the move. SW B stated he was notified by nursing staff when an order to move was obtained. SW B stated he could not recall who notified him of Resident #1's order. In an interview on 01/13/25 at 12:53 p.m., ADON C stated she had been the facility's ADON since 11/25/24 and prior to that she was the charge nurse for the secured unit. ADON C stated she placed the order in the system after reconciling physician orders not in the system. ADON C stated the order was a verbal order, she believed was given to the ADMIN. ADON C stated she was not aware that an order was not received prior to Resident #1's move to the secured unit. ADON C stated all residents who required to reside on the secured unit should have a need to reside on the unit, including a physician order. ADON C stated placing a resident on the secured unit without an order would be seclusion. ADON C stated she would continue to audit all resident on the secured units' charts to ensure all orders were in place. In a telephone interview on 01/13/25 at 1:30 p.m., Resident #1's RP stated he received a call from a male facility staff member stating Resident #1 was being moved to the secured unit and a reason was not given. The RP stated he recalled receiving a call, but could not recall from who, stating Resident #1 had attempted to leave the facility, but he did not see how that was possible because Resident #1 could not walk or move too good in her wheelchair. Telephone interviews were attempted with RN A and RN D (who were nurses documented to have worked with Resident #1 on 11/20/24 and 11/21/24) on 01/13/25 from 1:40 p.m. to 1:45 p.m. but were unsuccessful. In an interview on 01/13/25 at 2:50 p.m., the ADMIN stated while on leave in November 2024, she received a call stating Resident #1 had opened the door near the Station 1 nurses' station and she was adamant about leaving to get her family memberafter recovering from a UTI. The ADMIN stated she was not aware a physician order was not obtained prior to Resident #1's move on 11/21/24. The ADMIN stated she could not recall who obtained the order, but Resident #1's PCP was aware of her move to the unit, as he had saw her while she was on the unit. The ADMIN stated it was the expectation for all residents being moved onto or from the unit, should have proper documentation and a physician order prior to being moved, as not having the order could seclude the resident. The ADMIN stated nursing staff were responsible for obtaining the physician order and document in the residents' chart, while the social worker was responsible for notifying the RP of care planning, notification of the move and coordination of the move. The ADMIN stated moves were discussed daily in the morning meetings and she planned to discuss moves more to ensure all items were in place. The ADMIN stated she would Inservice nursing staff on documentation and obtaining physician orders and the social worker on the process of moves. The ADMIN stated she would monitor all moves, as they are happening, to ensure all needed information was in the residents' chart when they are moved. Record review of the facility's policy entitled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised in April 2001, read in part: Policy statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms .

Based on observation, record review, and interviews the facility failed to assure that medications were stored in locked compartments under proper temperature controls and inaccessible to unauthorized staff and residents for one (Secured Unit Cart) of four medication carts reviewed for medication storage. The facility failed to ensure the Secured Unit medication cart was locked when left unattended by RN E. This failure could result in resident access and ingestion of medications leading to a risk for harm and possible drug diversion. Findings included: Observation of the secured unit on 01/09/25 at 2:55 p.m., revealed an unlocked and unattended medication cart near room [ROOM NUMBER]. A male staff member later identified as RN E approached the surveyor from the opposite end of the hall stating the cart belonged to him. RN E locked the cart, stated he was assisting another nurse and returned to the other end of the hall. In an interview on 01/09/25 at 3:04 p.m., RN E stated he accidently left the cart unlocked when he left to assist another nurse and forgot to lock the cart. RN E stated leaving the cart unlocked could give other residents, staff and visitors unauthorized access to medications. In an interview on 01/09/25 at 3:15 p.m., The DON stated she had been the facility's DON for four days. The DON stated she was not aware of the unlocked and unattended cart on the secured unit. The DON stated medication carts should be locked when unattended. The DON stated this was the responsibility of any nursing staff member who was assigned to the cart. The DON stated she would begin to Inservice staff on medication storage and cart security and would conduct random cart checks to ensure carts were secured when unattended. In an interview on 01/13/25 at 2:55 p.m. the ADMIN stated it was the expectation for all medication carts to be locked when unattended. The ADMIN stated all nurses and medication aides were to ensure their carts were secured when not in use, as not doing so could lead to another resident or visitors having access to the medications housed on the cart. The ADMIN stated she would in-service nursing staff on medication storage and would check carts to ensure they were secured at all times. Record review of the facility's policy entitled Security of Medication Cart, revised in April 2007, read in part: Policy Statement: The medication cart shall be secured during medication passes. Policy Interpretation and Implementation: 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry . 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on interviews and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 1 resident (Resident #1) reviewed for discharge requirements. The facility failed to ensure Resident #1 was readmitted from the hospital she was transferred to for treatment. The facility failed to provide Resident #1 a discharge notice. There was no documentation from the physician indicating the facility could not meet the Resident's needs. This failure could place residents at risk of unnecessary transfer or discharge causing their needs to go unmet. Findings included: Record review of Resident #1's face sheet dated 09/24/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on [DATE] at 12:36 PM. Resident #1's diagnoses included cerebral infarction, end stage renal disease, dependence on renal dialysis, ileostomy status, and mood disorder. Record review of Resident #1's Admission MDS, dated [DATE] revealed a BIMS score of 14 indicating intact cognition. Further review of the MDS revealed the resident's hearing was highly impaired and hearing aid/appliance was used. Record review of Resident #1's care plan, revised 05/19/2024, revealed I AM REQUIRED TO RECEIVES DIALYSIS THREE TIMES A WEEK, BUT I WILL REFUSE TO GO AND WILL BE AT RISK FOR INCREASED: SOB, CHEST PAINS, BLOOD PRESSURE, ITCHY SKIN, NAUSEA/VOMITING, AND INFECTED ACCESS SITE. I HAVE BEEN EDUCATED REGARDING THE RISK WHEN I REFUSE. Record review of Resident #1's care plan, revised 06/12/2024, revealed On 4/30/24 I started to demonstrate aggressive behaviors. I CURSE AT STAFF WHEN IM UPSET, IN PAIN OR WANT MEDICAL ATTENTION. I AM COMBATIVE WITH STAFF, YELLS AT STAFF, CALL THE STAFF BITCHES, YELL ALL NIGHT, STAY ON THE CALL LIGHT EVEN AFTER THE STAFF ANSWERED THE CALL LIGHT, on 5/13/24 I spit on staff and used profanity. I REFUSE LAB WORK. Interventions included psych consult, report any behavior issues to MD, and staff to use individualized non medication interventions such as talking about horses or nature first before using medication for behaviors. Record review of Resident #1's progress notes, dated 07/27/2024 at 12:51 pm, written by ADON A revealed Report called to [Name] Hospital ER and spoke with a nurse, and she was informed that the resident has refused dialysis since 7/18/24, she refuses meds, yells and screams throughout the night and day, that bothers other residents, throws items at staff, refuses to be changed, threatens to throw colostomy on other people, and that she is a full code, she is also hard of hearing and suggest that she be admitted to the psych services at the hospital due to her behavior, she is going by 911 to the hospital. Record review of Resident #1's progress notes, dated 07/27/2024 at 12:59 PM, written by LVN B, reflected Resident taken out of facility by [Name] non-emergency transportation as they exited through the lobby the resident swiped the entry sign and it fell , she was heard yelling through the halls and outside as this nurse was on a call. The driver was asked if help was needed as he continued to transfer resident to vehicle. Resident continued to yell and shout. This nurse noticed the van had moved forward and paused and backed up several times. This nurse went out to the van and asked the driver if everything was alright. The driver stated that he was on the phone with his dispatch because the resident had threatened to take her colostomy bag off and throw it at him. He informed this nurse he could see the bag in his rearview mirror when he looked to check on resident and he was afraid to be hit with it. This nurse called the administrator to inform her of these events. Administrator told this nurse to call 911 and have resident picked up and taken to [hospital]. This was done. DON was informed of this as well and informed this nurse to update EMS of resident refusing dialysis and having psych issues. Record review of Resident #1's progress notes, dated 07/30/2024 at 10:43 AM, written by the ABOM, reflected Due to patient's non-compliance with care and behaviors, referrals have been sent to the following facilities for placement on 7.25.24: [Name]- Denied [Name] [Name] [Name] [Name] Denied [Name] [Name] Denied [Name]- Denied Patient was sent to [Name] Hospital on 7.27.24- Admissions Director explained in detail on patient's behaviors and non-compliance of care- Patient is unhappy here and will not allow staff to give care, patient screams with profanity at all staff. I gave the hospital the list of facilities referral was sent to. Record review of Resident #'s EHR did not indicate a discharge notice was given to Resident #1 and documentation by the physician did not indicate the facility could not meet Resident #1's needs. In an interview on 09/24/24 at 1:41 PM, the Social Worker stated Resident #1 refused dialysis, and declined psych services. She stated she explained to Resident #1 that she was actively dying when refusing dialysis and offered hospice, which Resident #1 declined. The Social Worker stated Resident #1 would not participate in PT and OT and refused everything the Social Worker offered her. She said she was on vacation when Resident #1 discharged and did not know why she was discharged to the hospital. In an interview on 09/24/24 at 2:32 pm, the Administrator stated they had gotten Resident #1 from another facility, and she came with a lot of behaviors. She said she broke 3 bedside tables and would throw dishes. She said she and the Social Worker met with Resident #1. The Administrator stated Resident #1 was sent to [Name] Hospital, who called her back and said nothing was wrong and would be sending Resident #1 back to the facility. The Administrator stated she told the hospital staff no, and Resident #1 needed some help. She said she has had to do that before so that hospitals would help with the patients. The Administrator stated Resident #1 was not suicidal but refused dialysis. She said she thought the root cause was mentally, as Resident #1 did not have dementia, and no UTI. Record review of the facility's policy titled, Transfer or Discharge, Facility- Initiated revised October 2022, reflected in part: 1. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; . Notice of Transfer or Discharge (Emergent or Therapeutic Leave) 1. When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected. 2. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility. 3. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; b. The resident's health improves sufficiently to allow a more immediate transfer or discharge; c. An immediate transfer or discharge is required by the resident's urgent medical needs; or d. A resident has not resided in the facility for 30 days . Notice of Discharge after Transfer 1. If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care). 2. If the facility does not permit a resident's return to the facility (i.e., initiates a discharge) based on inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights.

Based on, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #2) of 6 residents reviewed for quality of care. The facility failed to identify and treat a wound to Resident #2's left great toe, prior to his visit to a local hospital on 06/13/24, where Resident #2 was found to have wound to his left great toe with osteomyelitis . Resident #2's left great toe was amputated on 06/18/24. An Immediate Jeopardy (IJ) situation was identified on 08/09/24. While the IJ was removed on 08/10/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. This failure could place residents at risk for delay in needed treatment and diminished quality of care. The findings included: Record review of Resident #2's face sheet, printed on 08/10/24, reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of cerebrovascular disease (conditions that affect blood flow to the brain), Partial traumatic amputation of left great toe, Osteomyelitis (bone infection), End stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), Essential hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause), and Type 2 diabetes mellitus(high blood glucose). Record review of Resident #2's quarterly MDS assessment, dated 05/24/24 reflected Resident #2 had a BIMS score of 03, which indicated a severe cognitive impairment. Section GG - Functional Abilities and Goals of the assessment indicated Resident #2 required substantial or maximal assistance with ADLs of Toileting, personal hygiene, bathing, and lower body dressing. Record review of Resident #2's care plan, dated 05/31/24, reflected the following: - Problem start date: 03/05/24 - I am a diabetic and is at risk for complications from disease process., with approaches to include Approach Start Date: 03/05/2024 - MONITOR SKIN FOR CHANGES--REDNESS, CIRCULATORY PROBLEMS, BREAKDOWN, REPORT TO M.D., R.P. and Approach Start Date: 03/05/2024 WEEKLY SKIN ASSESSMENTS. Record review of the progress notes tab of Resident #2's electronic health record reflected the following notes: - Documented by RN B on 06/13/24 at 2:55 p.m., Resident went to the dialysis, dialysis nurse called to me said he has a pus like drainage from the cvc catheter and he is confusion little bit he need to go to hospital for checkup, talked to the NP, AND DON, and try to make him ready, he said after lunch, and he refuse again, give handover to the incoming nurse . continue on plan of care. - Documented by RN B on 06/13/24 at 3:18 p.m., Resident went hospital with facility transport at 3pm. - Documented by LVN C on 06/22/24 at 7:25 p.m., Resident was readmitted to [facility] at around [5:30 p.m.] from [hospital]. Patient was brought in via stretcher and placed in room [number]. Resident is alert and verbally responsive to care. Respirations are even and unlabored. No SOB noted or s/sx of respiratory distress. Vitals are stable. BP:121/67, 83, 97.5, o2 sat 98% @ RA. Afebrile. Resident will continue to be under the care of [PCP]. All orders clarified with [PCP]. Covid test done, negative results. Current weight is 75.7 kg and height 170.2 cm. Upon head-to-toe assessment, this nurse noted patient to have a laceration on his right groin. Scabs on left knee and left thigh. Discoloration on left thigh was noted as well. A pustule noted on on left lateral thigh. Bruising on left elbow and low abdomen. Black hard tissue on right ankle was also noted. Upon report via telephone per [hospital RN], she stated that doctor from [hospital] ordered to not remove dressing on left great toe until 6/28/24 due to his amputation . Record review of the Plan of Care History, Skin tab of Resident #2's electronic health record, dated 06/01/24 through 06/13/24 and documented by CNAs C, D, E, F, G, and H reflected Resident #2's skin was clear and free of any skin problems. Record review of Resident #2's skin assessment documentation, documented by RN I on 05/27/24 at 11:39 a.m., on 06/03/24 at 12:15 p.m., and on 6/11/24 at 1:39 p.m., reflected Resident #2's skin was warm, dry, normal in color and no alteration to the skin was observed. Record review of Resident #2's local hospital records, service date of 06/13/24 reflected the following: - Documented by hospitalist on 06/13/24 at 7:23 p.m., Assessment & Plan . Leukocytosis, Left great toe wound POA . Will do Xray, wound cultures, wound care consulted; - Wound Evaluation Note documented by hospital physician on 06/14/24 at 8:11a.m., 06/14 Evaluation and Assessment: Pt presents with a chronic necrotic ulcer present at the tip of the L great toe wound. Wound initially covered with lifting dry necrotic tissue. Performed selective sharp excisional debridement with scissors to remove lifted non adherent necrotic tissue to level of necrotic tissue. After initial debridement, bone became palpable differed any further debridement. After sharp debridement, the wound measures 1.5cmx3.0cm with unknown depth. Toe nail is separating from the nail bed as well. With palpation of the wound and surrounding area able to express thick purulent drainage as well as mild foul odor present. Peri wound is dry and slightly dusky. Tissue composition is dark purple with yellow necrotic tissue, overall viability of wound is questionable. Treatment: Wound cleansed with normal saline, patted dry with sterile gauze. Applied xeroform double layer to the wound bed to assist with maintaining appropriate level of moisture and antimicrobial properties. Covered with dry gauze and secured with tape. Provided education about wound clinical presentation and plan of care while patient is admitted . Continued skilled PT wound care services are indicated for dressing changes, selective debridement as needed, management of drainage/edema, patient education and to assess progression of advanced wound products. Messaged attending MD due to clinical presentation of purulence, bone palpable and necrotic tissue present. At time of documentation, Xray suggestive of OM. MRI and podiatry consult pending. PT wound to continue monitor plan of care and assist with dressing management as appropriate. - Documented by hospitalist on 06/21/24 at 12:05 p.m., Assessment & Plan: Acute Problems: . Acute osteomyelitis of left foot . Resolved problems: *no resolved hospital problems. * Leukocytosis: Left great toe wound POA . Xray/MRI foot positive for great tie osteomyelitis . angiogram followed by left great toe amputation by podiatry on 06/18. Follow biopsy results for final determination for antibiotics. Podiatry recommends dressings to stay intact till next evaluation in 1 week to 10 days. In a telephone interview on 08/08/24 at 12:37 p.m., Resident #2's primary care physician stated he became Resident #2's facility physician on 07/02/24, which was after the amputation of his toe. The physician stated he ordered an arterial of the lower extremities on 08/02/24 and found ischemia and Peripheral Vascular Disease, which affected the blood circulation to Resident #2's foot. The physician stated without proper circulation and oxygen to the area, the wound would never heal. The physician stated he was not aware of any change of condition or skin issues prior to Resident #2's amputation, but he would have to double check the records provided to him by Resident #2's previous physician. In an interview on 08/08/24 at 2:01 p.m. with WCN J and the IDON when WCN J stated she was the facility's wound care nurse since February of 2024. WCN J stated Resident #2 had two amputations after being sent to a local hospital in June and July. WCN J stated After Resident #2's amputation of his left great toe, he had to be sent to the hospital because his surgical wound had dehisced (a surgical complication that occurs when a wound incision reopens after being stitched or stapled closed) after the sutures were removed. WCN J stated Resident #2 returned to the facility on or around 7/30/24 with the remainder of his toes amputated. WCN J stated the resident returned to the facility with what appeared to be necrotic tissue around the wound. She stated the wound was monitored, per physician orders and the resident was sent back to the hospital on 08/06/24, when the surgical wound declined. WCN J stated she was not aware of any skin integrity issues or wounds to Resident #2 left great toe prior to his amputations. In an interview on 08/08/24 at 4:02 p.m., Resident #2 stated he was well, but he did not want to go back to the facility. Resident #2 stated he had a wound on his toe before it was amputation and that he had told facility staff about his toe, but he could not recall how long the wound was there or who he reported his toe to. Resident #2 was unable to verbalize what happened to his foot. Resident #2 was seen and interviewed in his room at a local hospital. Telephone interviews were attempted on 08/09/24 from 9:12 a.m. through 9:22 a.m., with Resident #2's podiatrist, previous primary care physician, and wound care physician but were unsuccessful. In a telephone interview on 08/09/24 at 9:50 a.m., CNA G stated she was Resident #2's aide prior to the amputation of his toe. CNA G stated she checked Resident #2 every two hours and provided care as needed. CNA G stated she could not recall ever noticing a wound or skin issue to Resident #2's left toes or foot. CNA G state Resident #2 liked to keep his socks on, so she had never changed his socks and focused more on his brief. A telephone interview was attempted on 08/09/24 at 11:06 a.m. with LVN L, who was Resident #2's weekend nurse prior to the amputation of his toe but was unsuccessful. In a telephone interview on 08/09/24 at 11:20 a.m., RN K stated she was Resident #2's weekend nurse from February 2024 until June 2024. RN K stated she did not recall Resident #2 having a wound or skin integrity issue to his feet and she could not recall an aide reporting an issue to her. RN K stated if a skin integrity issue or wound it report by an aide, nurses were to assess the resident, provide first aide as needed, notify the resident physician and responsible party and carry out any orders provided. RN K stated skin assessments were to be documented as a skin progress note and they are to make a skin event if issues are noted. In an interview on 08/09/24 at 11:36 a.m., CNA C stated she was Resident #2's first shift aide in June 2024. CNA C stated Resident #2 received total care from facility staff. CNA C stated she could not recall if Resident #2 had a wound to his left great toe. CNA C stated if she had saw a wound to his toe, she would have reported to a nurse for evaluation. In an interview on 08/09/24 at 11:54 a.m., CNA E stated he was Resident #2's aide briefly when he first started to work for the facility, which was roughly 2 months ago. CNA E stated he did not recall seeing a wound to Resident #2's toes but would have reported to a charge nurse if he did. Telephone interviews were attempted on 08/09/24 at 11:56 a.m. with RN B and at 11:59 a.m. with RN I, who were Resident #2's first and second shift nurses prior to the amputation of his toe, but attempts were unsuccessful. In a telephone interview on 08/09/24 at 12:05 p.m., CNA D stated she was Resident #2's aide prior to his first amputation. CNA D stated Resident #1 was a total assist resident but could transfer himself. CNA D stated she gave the resident bed baths instead of showers and had not observed any skin integrity issues to his toes. In a interview on 08/09/24 at 12:23 p.m., the IDON stated to her knowledge Resident #2 was sent to a local hospital on 06/13/24, after returning from dialysis with pus like discharge coming from his dialysis port. The IDON stated she believed Resident #2's left great toe was black or something and it was amputated prior to his return to the facility on [DATE]. The IDON stated Resident # 2 had to be sent to the hospital two additional times due to wound complications on 07/15/24 and 08/06/24. The IDON stated she had no knowledge of Resident #2 having skin integrity issues to his left foot. The IDON stated she would have to check Resident #2's records to see if his physician was following Resident #2's foot prior to is amputation. The IDON stated if a skin integrity issue or wound is observed on a resident the aide was expected to report to a nurse. She stated the nurse was expected to assess the resident, report to the resident's physician, responsible parties, facility leadership and to carry out any orders given by the physician. The IDON stated Resident #2 had not reported any issues with his feet to her. In an interview on 08/09/24 at 12:39 p.m., the ADMIN stated she was not aware of a wound to Resident #2's left great toe prior to his hospital visit on 06/13/24. The ADMIN stated she normally communicate with hospital staff to check on the residents and no one let her know Resident #2 arrived at the facility with a wound to his left great toe. The ADMIN stated she spoke with Resident #2's primary care physician who ordered a doppler and confirmed the resident had Peripheral Vascular Disease, which was contributed to the healing process of Resident #2's surgical wounds. The ADMIN stated if a nurse identifies a skin issue they should create and event in the electronic health record, report the issue to the resident's physician and carry out treatment orders until the wound care physician could visit with the resident. The ADMIN stated all residents were to have weekly skin assessments completed and are also completed by aides during showers. The ADMIN stated this information is documented in the resident's electronic health record. The ADMIN stated it was expected for all skin integrity issues to be identified and reported to the appropriate parties, as not doing so could create a delay in needed care. The ADMIN stated she would begin to in-service staff on skin assessments and documentation to ensure all skin integrity issues were addressed as needed. Review of the facility's policy entitled Pressure Injury Risk Assessment, revised in March of 2024, read in part: The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs) . Conduct a comprehensive skin assessment with every risk assessment. a. When conducting a skin assessment, provide for the resident's privacy. b. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin . Notify attending MD if new skin alteration noted. 4. Notify family, guardian or resident update if new skin alteration noted . The identified failure was determined to be an Immediate Jeopardy (IJ) on 08/09/24 at 3:38 p.m. The Administrator and the IDON were notified. The Administrator was provided with the IJ template on 08/09/24 at 3:45 p.m. In a telephone interview on 08/09/24 at 4:42 p.m., the local hospital charge nurse stated the POA reviewed on Resident #2's hospital records, dated 6/13/24, meant present on arrival or admission. The charge nurse stated if the hospital staff wanted to document the power of attorney was notified, they use 'MPOA', as in Medical Power of Attorney. The following Plan of Removal submitted by the facility was accepted on 08/10/24 at 11:08 a.m.: On 8/9/2024 At 4:40pm Surveyor reported to the Administrator that the facility failed to identify and treat a wound to Resident #1's great toe, which lead to osteomyelitis and amputation of the toe on 6/18/2024. At 4:45pm Nurse Managers started a skin sweep of all residents; any findings will be corrected by notification to PCP for recommendation of wound orders. A referral to Wound Physician will be made. There were no negative findings. - Completion Date: 8/9/2024 On 8/9/2024 At 5:15pm In-service started for Licensed Nurses by DON/ADONS on completing Hospital Transfer Form to include if wound is present and documentation of wound. - Completion Date: 8/10/2024 On 8/09/2024 5:36pm DON/ADON's started an in-service with all Licensed Nurses, Med aides and CNA's regarding skin/wound documentation and notification in their documentation in the [electronic health record system]. Documentation will be monitored daily by DON/ADON's/Weekend Supervisor to ensure all skin issues identified were reported to the physician and treatment ordered. - Completion Date: 8/10/2024 On 8/9/2024 at 5:30pm We have added to our current system the ADON's will complete skin sweeps 3X weekly to ensure all wound/skin issues are documented. This will be monitored by the DON/Designee 3X weekly to ensure skin sweeps are completed and all negative findings corrected. Any negative findings will be corrected immediately. - Completion Date: 8/9/2024 Monitoring of the facility's implementation of the Plan of Removal revealed the following: Record review of skin assessment sheets dated 08/09/24 and 08/10/24, reflected all facility's residents, 94 in total, received a skin assessment and new skin integrity issues were reported to the resident's physician. Record review of in-services dated 08/09/24, regarding Hospital Transfer Form completion, wound documentation and skin assessment completion and documentation, reflected all facility nursing staff were in serviced in person or by phone. Interviews conducted on 08/10/24 from 12:30 p.m. through 4:26 p.m., with the ADMIN, the DON, the IDON, ADON A, ADON M, 10 CNAs, 4 MAs, 4 LVNs, and 4 RNs from various shifts revealed all interviewed staff were in serviced in person or by phone and phone in serviced staff would have to be in serviced again before their next shift. During the interviews staff could explain the facility's skin assessment and documentation and notification policies in their own words. In interviews with facility nursing leadership all staff were aware of the expectation of monitoring for skin sweeps three times a week to ensure all skin integrity issues were identified and treated, as needed in the future. The Administrator was informed the Immediate Jeopardy was removed on 08/10/24 at 5:00 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm 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 each resident received adequate supervision and assistive devices to prevent accidents for 2 of 8 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision for residents identified as a fall risk. Resident #1 sustained a skin tear to the right inner wrist on 03/14/24, a skin tear on the left inner wrist on 03/23/24, and sustained head trauma from an unwitnessed fall on 03/25/24. Resident #2 sustained blunt head trauma and a laceration above the left eyebrow from an unwitnessed fall on 03/09/24. The facility failed to implement effective care plan interventions for residents identified as a fall risk. An Immediate Jeopardy (IJ) was identified on 04/01/24. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was lowered on 04/04/24, the facility remained out of compliance at a scope of Pattern and severity level of No actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. The facility failed to oversee the implementation of resident care policies. LVN M failed to assess, evaluate, and obtain vital signs after Resident #1 fell on [DATE] per the facility's policy and procedure, Assessing Falls and Their Causes, revised March 2018. The facility failed to oversee the implementation of resident care policies. LVN A failed to initiate and document investigation of the accident on 03/28/24, when Resident #2 sustained an unwitnessed fall from her wheelchair in the Dining Area, per the facility's policy and procedure, Accidents and Incidents - Investigating and Reporting, revised July 2017. These deficient practices placed residents at considerable risk of serious injury, harm, impairment, developing complications, or death by not receiving services necessary, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Resident #1 Record review of Resident #1's Continuity of Care Document, created 03/30/24, reflected a 94 y.o. male, who admitted to the facility on [DATE] from a long-term care facility. The latest return to the facility was on 03/04/23 after a short-term acute care hospital inpatient stay with the diagnosis of Displaced fracture of base of neck of left femur. Resident #1 had a history of Repeated falls (effective date: 03/04/23); Localized swelling, mass and lump, head (effective date 03/25/24); Anxiety; COPD; unsteadiness on feet; other abnormalities of gait and mobility; dementia; and other lack of coordination. Record review of Resident #1's Annual MDS review assessment, dated 01/10/24, revealed Resident #1 had a severe cognitive impairment per staff assessment because a BIMS interview was not conducted. Resident #1's functional status required one-person extensive assistance with ADLs and a wheelchair for mobility. Record review of Resident #1's Comprehensive Care Plan, date initiated 05/31/23, reflected: Resident #1 had Frequent falls due to unsteady gait, family not allowing wheelchair, in a geri-chair, he slides from the geri-chair, and he tries to walk by self . The intervention(s) included Try and put to bed (Start date 02/19/24); involve in activities (Start date 01/16/24, 11/27/23, and 11/06/23); recline wheelchair (Start date 10/30/23); Replace Dycem in the wheelchair (start date 10/24/23); will have leg rests replaced on the wheelchair (Start date 10/15/23; will be provided a Scoop mattress on bed (Start date 10/09/23); will be provided a fall mat at bed side while in bed (Start date 09/25/23); and bed will be kept in the lowest position while in bed (Start date 09/25/23). The long-term goal indicated Resident #1 will not have no injuries from falls that require hospitalization in next 90 days (Target date: 05/04/24). Resident #1 had Potential risk for injury due to poor safety awareness. The intervention(s) included Dycem added to wheelchair (start date 01/12/23); Encourage [Resident #1] to request needed assistance in all transfers, keep call light in reach, wedge cushion to wheelchair. (Start date 01/11/23); and [Resident #1] to call for assistance with all transfers (Start date 01/11/23). The long-term goal indicated Resident #1 will be free from injury and will have safe transfers (Target date: 05/04/24). Resident #1 experienced a fall. 12/31/22. had two additional falls. 02/28/23 Injury fall. unwitnessed fall 03/15/23 . The intervention(s) included bed in lowest position to prevent falls (Start date 03/15/23); hipsters added to both hips due to frequent falls also anti-roll back brakes (Start date 01/03/23); Keep call light in reach at all times (Start date 12/23/22);and Observe frequently and place in supervised area when out of bed (Start date 12/23/22); and Provide an environment free of clutter (Start date 12/23/22). The long-term goal reflected Refer to Therapy for evaluation for treatable causes of the fall such as poor balance, muscle weakness, and poor safety awareness. (Target date: 05/04/24). Record review on 03/30/24 at 4:08 PM of Resident #1's Orders History (01/01/24 - 03/30/24) reflected: - Start date 03/06/23: Admit to hospice for Dx: Senile Degeneration of the brain on 03/04/23. - Start date 02/24/24: Resident requires secured unit due to unsafe wandering and exit seeking on 02/21/24. - Start date 03/14/24: Fall: Cleanse skin tear on right palm with NS and apply steri-strips dressing. Every Shift. - Start date 03/18/24: OT to evaluate and treat as indicated. - Start date 03/23/24: Cleanse skin tear on left arm palm with NS and apply dry dressing. Monitor for s/s of infection and dc when resolved. - Start date 03/25/24: Triple Antibiotic ointment (TAO). Apply a small amount on the affected area for 7 days. Twice A Day (7:00 AM - 10:00 AM; 5:00 PM - 7:00 PM) - Start date 03/26/24: Other Test: (Skull series due to fall with head injury). STAT.' - Start date 03/28/24: Skin Tear: Apply antibiotic ointment, cover with dressing if needed to minor cuts or skin tears until healed. Once a Day PRN. - Start date 03/28/24: 'Suspected head trauma neuro checks. Q15mins (x4); Q1H (x2); Q2H (x2); Q4H (x2); then, every shift (x3). [Previous orders were written on 03/14/24, 03/23/24, and 03/25/24] - Start date 03/30/24: 'Wound care: Forehead - Cleanse with wound cleanser and pat dry with gauze. Apply Calcium Alginate and cover with border dressing. Once a Day. 06:00 AM - 02:00 PM.' Record review of Resident #1's active Orders on 04/04/24 at 4:13 PM reflected: - Start date 04/01/24: Fall Interventions: Call light .; Encourage and assist resident for frequent rest periods .; Locate resident when up near station .; Toilet at regular intervals . Every Shift. - Start date 04/02/24: PT to evaluate and treat as indicated. LATE ENTRY effective 04/02/24 - Start date 04/03/24: Place Dycem (multipurpose non-slip material) in wheelchair to prevent resident from sliding out. Every Shift. - Start date 04/04/24: Suspected head trauma neuro checks. Q4H (x2 - 1:30 AM, 5:30 AM); then, every shift Days, Evenings, Nights (x3 - End Date 04/06/24).' Record review of Resident #1's progress notes indicated: - 03/14/24 at 12:37 PM, written by LVN L, reflected, [Resident #1] had an unwitnessed fall at 12:15 PM, was found by CNA sitting on the floor in one of the female patient's room. [Resident #1] was on a wheelchair at the time of fall. [Resident #1] unable to explain what happened . skin tear at the palm of the right hand . given Morphine 20 mg/5 mL for mild pain (PRN). Intervention includes redirecting patients, patient had non-skid socks on. - 03/28/24 at 12:48 PM, written by ADON, reflected, [ADON] noted [Resident #1] forehead, frontal aspect with fluid filled hematoma with open abrasion to center of hematoma at this time. called and spoke with [hospice services RN] and informed of area to [Resident #1's] head with visual documents provided for review. MD aware as well with zero new orders noted. attempted to reach hospice nurse to confirm that orders had not been given to her at this time. - 03/28/24 at 4:03 PM, written by ADON, reflected, [ADON] noted zero response to medically necessary orders due to [Resident #1] radiology report or area to [Resident #1] head at this time. [ADON] sent message to hospice nurse and MD requesting a return call at this time. - 03/29/24 at 11:04 AM, written by NP, reflected, [Resident #1] seen and examined per nursing staff request for report of a fall yesterday. Noted large hematoma to mid-frontal scalp area with ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising). denies any pain or headache but overall stays stable . - 04/01/24 at 8:21 PM, written by LVN A, reflected, Skull x-ray ordered for [Resident #1] r/t unwitnessed fall. Call to RP did not go through and unable to leave a voice message. - 04/02/24 at 7:28 AM, written by RN N, reflected, [Resident #1] refused to do skull series, notified MD, Administrator and [Resident #1] daughter aware. - 04/02/24 at 7:36 AM, written by RN N, reflected, [Resident #1] fell yesterday, continue on neuro checks, no delayed injuries seen. Continue to be monitored. - 04/03/24 at 7:51 PM, written by LVN A, reflected, At around 6:30 PM was notified by Speech Pathologist that [Resident #1] was on the floor in the dining room. Went to the dining area and found resident on the floor next to his wheelchair. Assessed resident, then put back to wheelchair with 2 persons assist. noticed [Resident #1] was able to unlock the armrest on the wheelchair and push it down, and probably slipped from the side . Record review of Fall Event, dated 03/23/24, linked SBAR Communication Tool (dated 03/27/24) and Resident #1's following progress notes: - 03/25/24 at 6:09 PM, written by LVN A, reflected, [Resident #1] had a fall at around 5:50 PM in the dining area, and hit his head on the floor . assessed and put back on wheelchair . [Resident #1] has a bump in the front of his head and is c/o pain on his head. MD notified via text message with a picture of the injured area and replied, Apply TAO bid for seven days. Hospice called and said they are sending a nurse at the facility to assess [Resident #1] . Neuro checks initiated. - 03/25/24 at 10:07 PM, written by LVN A, reflected, Hospice nurse did not show up . TAO applied on resident bump per MD Order, morphine 0.25 ML provided for pain. [Resident #1] currently resting on bed . in lowest position and mat on the floor. Neuro checks ongoing. - 03/26/24 at 12:52 PM, written by LVN L, reflected, [Resident #1] BP 96/50, HR 77 . rechecked at 12:50 PM, BP 117/70, HR 90 . on bedrest in supine position with legs elevated 8 - 12 inches until BP returns to baseline . - 03/26/24 at 6:45 PM, written by LVN A, reflected, Skull x-ray done at around 6:15 PM. Result pending. - 03/27/24 at 6:31 AM, written by RN O, reflected, Post fall day 2/3. [Resident #1] has a decreased in his blood pressure reading. legs were elevated 8 inches and offered fluids . Fall preventive measure implemented. - 03/27/24 at 9:13 AM, written by LVN L, reflected, [Resident #1's] x-ray results . significant findings and head CT suggested . sent to MD and hospice nurse. [Resident #1] sent to hospital accompanied by facility driver at 9:00 AM. Record review of the Fall Event dated 03/25/24, LVN A indicated the fall was NOT witnessed. [Resident #1] complained of pain 3 out of 10 [4 out of 10 = Moderate Pain - Distressing, Miserable] (to his head). Injury to the head was a bump . Resident has a bump in the front of his head and is c/o pain on his head. MD notified via text message with a picture of the injured area and replied Apply TAO (an ointment that prevent infection and aids in healing of minor cuts, scrapes, and burns) BID (twice daily) for seven days. The following progress notes were linked to the Fall Event: - 03/19/24 at 12:56 PM, written by PCP, reflected, GDR ordered to change Ambien to PRN for 14 days, Ativan changed to AM and HS (at bedtime) per pharmacist recommendation. - 03/28/24 at 12:44 PM, written by ADON, reflected, [ADON] noted [Resident #1's] CT Scan results . notified PCP of available results with impressions that indicated Advance chronic microvascular ischemic changes (brain condition cause problems with thinking, walking and mood after an injury) and moderate generalized volume loss (associated with major neurological diseases, such as a large stroke or progressive dementia) noted. Ventriculomegaly (a condition in which the brain ventricles, or fluid-filled cavities, are enlarged due to build up of cerebrospinal fluid [CSF] found with moderate or severe traumatic brain injury) . hospice requested results fax . [ADON] sent fax . Record review of video surveillance dated 03/25/24, provided by the NFA, revealed the Dining Area. A Med Aide was against the wall standing behind the medication cart approximately 5 - 6 feet in front and to the right of Resident #1 in his high back wheelchair. The Med Aid did not have a direct line of sight of Resident #1. LVN A was approximately 15 - 20 feet away, assisting a resident with eating. Resident #1 was in LVN A's direct line of sight. Resident #1 was scooting in his wheelchair, but unable to move forward past a table and chair. It appeared that there was an object that prevented him from moving forward. Resident #1 reached towards the table on his left side to try and propel forward but could only turn left. Resident #1 turned to the left twice. Resident #1's back was to the camera when it was noted that he fell forward out of the chair hitting his face/head on the floor. The Med Aide and LVN A looked up from what they were doing 4 - 5 seconds after Resident #1 fell . LVN A walked towards Resident #1 and the MA left from behind the medication cart and headed towards the hall away from the Dining Area, where the nurses' station was located. The video clip ended. Record review of Fall Event dated 03/28/24 indicated Resident #1 had an unwitnessed fall at 8:16 PM in the Dining Room. The event details stated Resident #1 went to Station 5 just prior to the fall. Resident #1's following progress notes were linked to the Fall Event: - 03/28/24 at 8:27 PM, written by LVN A, reflected, [Resident #1] found on the floor at around 7:35 PM, in the dining room. Resident was assessed and put back on wheelchair with 3-person assist. skin tear observed on [Resident #1] right hand and behind the right ear. Record review of Fall Event dated 04/01/24 indicated Resident #1 had a witnessed fall in the Dining Room. The following progress notes were linked to the Fall Event: - 04/01/24 at 11:43 AM, written by LVN M, reflected, [Resident #1] fall in the dining room with witness during Chaplain. immediately went to the dining room, observed resident sitting down on the floor by wheelchair. Assessment done and 2-person assist resident back in chair. - 04/01/24 at 2:26 PM, written by NFA, reflected, Administrator spoke with Director of Hospice Services to discuss plan of care for [Resident #1] related to falls. Administrator explained that per our Rehab Manager we requested Therapy services to be given to [Resident #1] to assist in reducing falls. Director agreed. She will schedule with their therapy department to schedule therapy services to be provided to [Resident #1] She will provide [NFA] an updated plan of care for [Resident #1] and we will continue to be aware of any further changes. - 04/01/24 at 2:42 PM, written by NFA, reflected, Update: Spoke with Director of Hospice Services, we will have our Therapy Department to treat resident to assist in reducing [Resident #1] falls. Once that is completed we will update Plan of Care. Record review of Fall Event dated 04/03/24 indicated Resident #1 had an unwitnessed fall from his wheelchair in the Dining Room at 7:21 PM. Neuro checks were initiated. A record review of hospital medical records for 03/27/24 reflected [Resident #1] arrived at the emergency department (ED) in a wheelchair on 03/27/24 at 09:04 AM. ED triage notes indicated [Resident #1] presented to the ED after a fall and need for imaging. [SNF staff] stated [Resident #1] fell the other day and got an x-ray yesterday (03/26/24) that showed possible right temporal bone nondisplaced fracture. [Resident #1] denied pain. A review of the ED physician physical exam on 03/27/24 at 10:06 AM revealed Large ecchymosis to the frontal parietal bone with an abrasion but no active bleeding . Review of medical assessment and plan dated 03/27/24 at 11:00 AM indicated final diagnoses Head Trauma. CT Scan without Contrast resulted Advance chronic microvascular ischemic changes (brain condition cause problems with thinking, walking and mood after an injury) and moderate generalized volume loss (associated with major neurological diseases, such as a large stroke or progressive dementia) noted. Ventriculomegaly (a condition in which the brain ventricles, or fluid-filled cavities, are enlarged due to build up of cerebrospinal fluid [CSF] found with moderate or severe traumatic brain injury). A review of the ED provider note entered on 03/27/24 at 12:15 PM reflected Blood pressure has been low, however [Resident #1's daughter] stated that it has been low since Monday (03/25/24) . [Resident #1] is on hospice at the nursing home. She [Resident #1's daughter] does not want [hospice] revoked and does not want further testing at this time . nursing home had a plan, and they are following it . [Resident #1] was discharged from the ED on 03/27/24 at 12:16 PM. Record review of video surveillance dated 04/01/24, revealed Resident #1 in the Dining Area propelling in his wheelchair toward the vending machine. There was a Medication Aide with back against the wall standing at a medication cart preparing and crushing medications (approximately 20 feet away from where Resident #1 fell ). 7 - 8 other residents noted in the Dining Area participated in an activity (with the Chaplain) in the center of the Dining Area. There was a pressure relief pad in the seat of [Resident #1's] wheelchair and a balled-up sheet between Resident #1 and the left arm of the wheelchair. Resident #1 scooted forward to the edge of the seat, placed his right hand on the vending machine and tried to stand. A Dycem non-slip mat was not in place [reflected as an intervention in the care plan]. Resident #1 could not stand, his knees lowered to the floor, and when tried to sit back in the wheelchair, it rolled backwards. Resident #1 fell sideways on his right side, rolled over onto his back, reached out, grabbed, and pulled the wheelchair forward. Resident #1's right foot was in the gap between the left wheel and the body of the wheelchair. Resident #1 rolled over to the right side, slowly raised his upper body, and rolled back over to his right side. The Medication Aide looked up and walked towards Resident #1. LVN M was seen stepping into the Dining Area from the hall. LVN M did not assess or evaluate Resident #1's vital signs, range of motion, or inspect for any injury before the Resident #1 was assisted back into the wheelchair by the Medication Aide and LVN M. The video clip ended. Record review of video surveillance dated 04/03/24, revealed Resident #1 sitting at a table in the Dining Area. There was no staff present. A staff in light blue scrubs was observed coming from out the hallway into the Dining Area, approached Resident #1 and then walked away. Resident #1 attempted to stand up. Resident #1 fell backwards onto his back. An individual entered from the secured doors, noted Resident #1 on the floor and headed towards the hall where the nurses' station was located. The video clip ended. During an observation on 03/30/24 between 2:00 PM - 3:00 PM, Resident #1 was observed resting quietly in a right lateral laying position in bed. Bed in the lowest position, flushed to wall with scoop mattress (edges are raised higher than the mattress center). A fall mat was noticed on the opposite side of the room away from bed. Call light on floor under the foot of the bed. There was one nurse and one CNA observed in the secured unit. During an interview on 03/30/24 at 3:00 PM, RN D stated he was the assigned nurse for Resident #1. RN D stated that he worked weekends double shifts (6A - 2P and 2P - 10P). RN D stated he placed Resident #1 to bed. RN D said that he pulled the fall mat away from the bed to assist Resident #1 to bed from the wheelchair (high back wheelchair next to the bed, pressure-relieving pad in place, no Dycem mat noted) and did not place the fall mat next to the bed. RN D picked the call light up from under the foot of the bed and placed within Resident #1's reach. RN D said that there were two nurses and three CNAs assigned to the secured unit, however he and one CNA were the only staff currently in the secured unit while the other nurse and two CNAs attended an in-service. RN D said that a resident is at risk for harm if care plan interventions were not implemented appropriately or timely. RN D said that interventions in place for Resident #1 to prevent falls included bed in lowest position, to use the call light for help, to place call light within reach, and to place the fall mat at the bedside when Resident #1 was in bed. RN D said he was not present when Resident #1 sustained a fall on 03/25/24. RN D said that Resident #1 had multiple falls and tried to keep [Resident #1] within line of sight or interact during activities to prevent falls. RN D said that Resident #1 required frequent redirection and attention to prevent falls. During an interview on 03/30/24 at 4:55 PM, the NFA stated she was still investigating the incident when Resident #1 fell on [DATE]. The NFA stated that staff must notify her immediately of any incident or accident. The NFA said if an unusual incident (possible resident abuse, neglect, mistreatment and/or unwitnessed injuries) was reported, she immediately reviewed the surveillance cameras to gather information about individuals involved and determine if staff followed protocol when reacted to an accident or incident. The NFA stated that she first learned on 03/27/24 about Resident #1's head injury sustained from a fall (on 03/25/24) and completed a facility incident self-report on-line. The NFA indicated that she did not see staff or another resident push or cause Resident #1 to fall and neglect was not identified. During an interview on 03/30/24 at 5:47 PM, the ADON indicated Resident #1 . still wants to be independent . will not ask for help. The ADON stated Resident #1 was wheelchair bound and should remain within the staff line of sight in the Dining Area to prevent falls. The ADON said there were signs posted for Resident #1 to use the call light for assistance and the wheelchair and bed lowered to prevent falls. The ADON said that Resident #1 had a fall on Monday (03/25/24) evening. The ADON said she had already left for the day when LVN A called to notify that Resident #1 had a fall and reported that he did not complain of pain and there was no injury. LVN A reported to the ADON that Resident #1 was sitting at the nurses' station and the hospice on-call nurse was notified to come assess Resident #1. The ADON said that she assessed and evaluated Resident #1 the next day (03/26/24) when she returned to work. The ADON said that she discovered a raised bump on Resident #1 forehead with an abrasion that appeared shiny where a generous amount of ointment was applied. The ADON said that she asked LVN A about the injury and what actions were taken. LVN A told the ADON that she [LVN A] texted the PCP about the fall and applied the ointment [TAO] as ordered, then notified the hospice on-call nurse, but she never showed. The ADON said that she explained to LVN A that the facility was Resident #1's primary caregiver and immediate actions should be taken when a resident sustained an apparent head injury. The ADON said that she immediately called the PCP and requested orders for a skull x-ray and labs. The ADON said she implemented the orders right away. The ADON said that she reviewed the Skull x-ray results the next morning (03/27/24). The results suggested a CT scan because a skull fracture could not be ruled out by the images. ADON said that Resident #1 was sent to the hospital accompanied by the facility van driver via the facility van. The ADON stated that she expected nurses to conduct rounds minimally every two hours and as needed, or more frequent for residents who were a high fall risk. The ADON indicated keeping residents within the line of sight and not alone in their rooms if the resident tried to act beyond their level of function. Additionally, the ADON stated that nurses should check that fall precautions were in place, residents are wearing non-slip socks or appropriate slippers/shoes, positioning, if the resident is in pain, or assist to the restroom during rounds. Record review of the text communication sent to the MD from LVN A when Resident #1 fell on [DATE] and hit his head indicated, . Resident #1 had a fall in the Dining Area and hit his head on the floor . complaining of pain on his head. He is alert. Hospice notified. LVN A attached a picture of Resident #1's head injury to the communication that revealed a raised area on the frontal region of [Resident #1's] scalp. A light purplish-blue discoloration surrounded the raised area. There was a redden scraped area at the middle of the raised area. The reply from the MD stated, Apply TAO BID for seven days. During an observation on 04/01/24 at 1:29 PM, Resident #1 was observed in a high back wheelchair propelling with his feet only, grabbing and pushing chairs out of the pathway. Resident #1 leaned forward trying to reach a sandwich from under a chair. Dycem material was not observed under Resident #1 on the seat of the wheelchair. The ADON observed Resident #1 leaning forward and went to his side to assist upright in wheelchair. When the ADON walked away, Resident #1 tried to stand up. The ADON came back over to Resident #1, assisted and repositioned Resident #1 back into an appropriate upright position in wheelchair. The ADON gave verbal reminders not to stand up or try to transfer from the wheelchair without assistance. The ADON asked a CNA to frequently observe and supervise Resident #1 while in the Dining Area. The ADON rearranged the chairs back to the tables and cleared a pathway around the tables in the Dining Area. A conversation was overheard between a nurse and the NFA that Resident #1 had a fall in the morning (04/01/24). During an interview on 04/01/24 at 4:40 PM, LVN A indicated that she worked on 03/25/24, 03/28/24, and 04/03/24, 2P - 10P shift. LVN A stated that she was assigned to Resident #1. LVN A stated that Resident #1 had unwitnessed falls on those days that she worked. LVN A stated that Resident #1 needed one-to-one supervision to prevent falls and that was not possible with 5 staff and 30 or more residents that were fall risks, required incontinent care, or demonstrated behaviors that may harm another resident. LVN A stated that she notified the MD by text about Resident #1's fall (on 03/25/24). LVN A said that she texted the MD that Resident #1 hit his head on the floor, complained of pain, that he [Resident #1] was alert, and attached a picture of Resident #1's head injury to the text. LVN A said that alert indicated that Resident #1 did not lose consciousness. LVN A said that the MD replied by text to apply TAO to the abrasion. LVN A stated that she would assess and evaluate a resident by checking vital signs, range of motion of extremities (by asking the resident to move their extremities and then moving the resident extremity), asked about pain, and look for any bruises or injuries. LVN A said that she was not sure if Resident #1 had a fall in the morning, she was not present. LVN A said that she was supposed to initiate a Fall Event report for every accident or incident. LVN A said that it was her responsibility to check on residents every two hours alternating with the CNAs to ensure resident safety, interventions were in place, and acknowledge whereabouts. During an observation and interview on 04/01/24 at 4:45 PM, the OT assisted Resident #1 from the high back wheelchair to a smaller blue wheelchair. The OT assessed and evaluated Resident #1's comfort in the chair. The OT pushed Resident #1 in the wheelchair to the Dining Area and tilted the wheelchair back enough to raise Resident #1's feet off the floor. The OT conducted a visual observation of Resident #1 in the wheelchair. During an interview, the OT stated that occupational therapy was consulted on 04/01/24 to assess and evaluate Resident #1 after multiple falls. The OT indicated that the blue wheelchair was called a tilt-in-space. The OT stated the purpose of the wheelchair was to easily reposition Resident #1 when sitting in the wheelchair to prevent falls and maintain posture when in the reclined position. The OT stated the tilt-in-space wheelchair could reduce falls; however, when in the reclined position Resident #1 could not freely propel and move about in the wheelchair. During an interview on 04/01/24 at 5:15 PM, the DOR indicated that Resident #1 was currently on service with occupational therapy after assessment and evaluation related to a fall Resident #1 had on 03/18/24. The DOR stated therapy was consulted [04/01/24] for reassessment of Resident #1 due to frequent falls. The DOR indicated supervised stand-by assistance would be an effective intervention for Resident #1 to prevent falls. Record review of an undated typed Incident Narrative revealed the MD name, address, and contact information in the heading. The Incident Narrative indicated Resident #1 resided at the SNF and was under the MD care. The Incident Narrative described Resident #1 was also a hospice patient . required assistance with ADLs, was non-ambulatory, incontinent of bowel and bladder, had extensive muscle wasting and deconditioning. The Incident Narrative indicated Due to his severe dementia . is unaware cannot walk, repeatedly stands from his wheelchair or bed, and immediately falls, which he has done multiple times. In the body of the Incident Narrative revealed [Resident #1] fell on [DATE], . sustained a superficial abrasion of the scalp in the forehead area. notified by nursing staff and ordered antibiotic to the abrasion. There was no evidence of any brain injury or neurological changes such as seizure, coma, mental status changes. The following day . developed a hematoma around the abrasion area, and determined at that time that a skull x-ray was indicated and ordered . The Incident Narrative closed with a statement of the MD's initial impression was confirmed when Resident #1 returned from the hospital without any finding other than a superficial abrasion of the scalp. The MD's typed name followed the closing, Thank you at the end of the Incident Narrative. Resident #2 Record review of Resident #2's Quarterly MDS Assessment, dated 12/07/23, reflected a 76 y.o. female, who admitted to the facility on [DATE] from a long-term care facility. Resident #2 had a history and diagnoses of Dementia with behavioral disturbance; Unsteadiness on feet; Cognitive communication deficit; and Repeated falls. Resident #2 had a severe cognitive impairment per staff assessment because a BIMS interview was not conducted. Resident #2's functional status required one-person total assistance with ADLs, two staff assist with transfers, and independent with wheelchair for mobility (03/13/24). Record review on

Based on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for 2 of 8 residents (Resident #1) reviewed for Quality of Care. Cumulative effects of LVN A's and MA V's individual failures to provide oversight of care delivery on 03/25/24, Resident #1 had an unwitnessed fall and sustained bruising, swelling, and an abrasion to the frontal scalp. The facility failed to implement interventions for Resident #1 identified as a fall risk on 12/05/22 to observe frequently and place in supervised area when out of bed (Start date 12/23/22). Resident #1 sustained unwitnessed falls in the dining room from the wheelchair on 03/14/24, 03/23/24, 03/28/24 and 04/03/24; a fall on 04/01/24 was documented as witnessed. Resident #1 had 46 documented falls since 12/05/22. The facility failed to ensure residents were protected from physical and psychosocial harm during abuse or neglect investigations. Resident #1 had an unwitnessed fall on 03/28/24 and a witnessed wall on 04/01/24. Resident #2 had an unwitnessed fall on 03/28/24. An Immediate Jeopardy (IJ) was identified on 04/01/24. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was lowered on 04/04/24, the facility remained out of compliance at a scope of Pattern and severity level of No actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. The facility failed to oversee the implementation of resident care policies. LVN M failed to assess, evaluate, and obtain vital signs after Resident #1 fell on [DATE] per the facility's policy and procedure, Assessing Falls and Their Causes, revised March 2018. The facility failed to oversee the implementation of resident care policies. LVN A failed to initiate and document investigation of the accident on 03/28/24, when Resident #2 sustained an unwitnessed fall from her wheelchair in the Dining Area, per the facility's policy and procedure, Accidents and Incidents - Investigating and Reporting, revised July 2017. These deficient practices placed residents at considerable risk of serious injury, harm, impairment, developing complications, or death by not receiving services necessary, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of the nursing schedule dated 03/25/24 revealed LVN L, CNA T, CNA J, and CNA U worked the 6A - 2P shift; MA V worked 7A - 7P. CNA W had Unpaid Time Off and CNA X was a No call, No Show; LVN A, CNA P, and CNA Q worked the 2P - 10P shift. CNA S had an excused call off. Resident #1 Record review of Resident #1's Continuity of Care Document, created 03/30/24, reflected a 94 y.o. male, who admitted to the facility on [DATE] from a long-term care facility. The latest return to the facility was on 03/04/23 after a short-term acute care hospital inpatient stay with the diagnosis of Displaced fracture of base of neck of left femur. Resident #1 had a history of Repeated falls (effective date: 03/04/23); Localized swelling, mass and lump, head (effective date 03/25/24); Anxiety; COPD; unsteadiness on feet; other abnormalities of gait and mobility; dementia; and other lack of coordination. Record review of Resident #1's Annual MDS review assessment, dated 01/10/24, revealed Resident #1 had a severe cognitive impairment per staff assessment because a BIMS interview was not conducted. Resident #1's functional status required one-person extensive assistance with ADLs and a wheelchair for mobility. Record review of Resident #1's Comprehensive Care Plan, date initiated 05/31/23, reflected: Resident #1 had Frequent falls due to unsteady gait, family not allowing wheelchair, in a geri-chair, he slides from the geri-chair, and he tries to walk by self . The intervention(s) included Try and put to bed (Start date 02/19/24); involve in activities (Start date 01/16/24, 11/27/23, and 11/06/23); recline wheelchair (Start date 10/30/23); Replace Dycem in the wheelchair (start date 10/24/23); will have leg rests replaced on the wheelchair (Start date 10/15/23; will be provided a Scoop mattress on bed (Start date 10/09/23); will be provided a fall mat at bed side while in bed (Start date 09/25/23); and bed will be kept in the lowest position while in bed (Start date 09/25/23). The long-term goal indicated Resident #1 will not have no injuries from falls that require hospitalization in next 90 days (Target date: 05/04/24). Resident #1 had Potential risk for injury due to poor safety awareness. The intervention(s) included Dycem added to wheelchair (start date 01/12/23); Encourage [Resident #1] to request needed assistance in all transfers, keep call light in reach, wedge cushion to wheelchair. (Start date 01/11/23); and [Resident #1] to call for assistance with all transfers (Start date 01/11/23). The long-term goal indicated Resident #1 will be free from injury and will have safe transfers (Target date: 05/04/24). Resident #1 experienced a fall. 12/31/22. had two additional falls. 02/28/23 Injury fall. unwitnessed fall 03/15/23 . The intervention(s) included bed in lowest position to prevent falls (Start date 03/15/23); hipsters added to both hips due to frequent falls also anti-roll back brakes (Start date 01/03/23); Keep call light in reach at all times (Start date 12/23/22);and Observe frequently and place in supervised area when out of bed (Start date 12/23/22); and Provide an environment free of clutter (Start date 12/23/22). The long-term goal reflected Refer to Therapy for evaluation for treatable causes of the fall such as poor balance, muscle weakness, and poor safety awareness. (Target date: 05/04/24). Record review on 03/30/24 at 4:08 PM of Resident #1's Orders History (01/01/24 - 03/30/24) reflected: - Start date 03/06/23: Admit to hospice for Dx: Senile Degeneration of the brain on 03/04/23. - Start date 02/24/24: Resident requires secured unit due to unsafe wandering and exit seeking on 02/21/24. - Start date 03/14/24: Fall: Cleanse skin tear on right palm with NS and apply steri-strips dressing. Every Shift. - Start date 03/18/24: OT to evaluate and treat as indicated. - Start date 03/23/24: Cleanse skin tear on left arm palm with NS and apply dry dressing. Monitor for s/s of infection and dc when resolved. - Start date 03/25/24: Triple Antibiotic ointment (TAO). Apply a small amount on the affected area for 7 days. Twice A Day (7:00 AM - 10:00 AM; 5:00 PM - 7:00 PM) - Start date 03/26/24: Other Test: (Skull series due to fall with head injury). STAT.' - Start date 03/28/24: Skin Tear: Apply antibiotic ointment, cover with dressing if needed to minor cuts or skin tears until healed. Once a Day PRN. - Start date 03/28/24: 'Suspected head trauma neuro checks. Q15mins (x4); Q1H (x2); Q2H (x2); Q4H (x2); then, every shift (x3). [Previous orders were written on 03/14/24, 03/23/24, and 03/25/24] - Start date 03/30/24: 'Wound care: Forehead - Cleanse with wound cleanser and pat dry with gauze. Apply Calcium Alginate and cover with border dressing. Once a Day. 06:00 AM - 02:00 PM.' Record review of Resident #1's active Orders on 04/04/24 at 4:13 PM reflected: - Start date 04/01/24: Fall Interventions: Call light .; Encourage and assist resident for frequent rest periods .; Locate resident when up near station .; Toilet at regular intervals . Every Shift. - Start date 04/02/24: PT to evaluate and treat as indicated. LATE ENTRY effective 04/02/24 - Start date 04/03/24: Place Dycem (multipurpose non-slip material) in wheelchair to prevent resident from sliding out. Every Shift. - Start date 04/04/24: Suspected head trauma neuro checks. Q4H (x2 - 1:30 AM, 5:30 AM); then, every shift Days, Evenings, Nights (x3 - End Date 04/06/24).' Record review of Resident #1's progress notes indicated: - 03/14/24 at 12:37 PM, written by LVN L, reflected, [Resident #1] had an unwitnessed fall at 12:15 PM, was found by CNA sitting on the floor in one of the female patient's room. [Resident #1] was on a wheelchair at the time of fall. [Resident #1] unable to explain what happened . skin tear at the palm of the right hand . given Morphine 20 mg/5 mL for mild pain (PRN). Intervention includes redirecting patients, patient had non-skid socks on. - 03/28/24 at 12:48 PM, written by ADON, reflected, [ADON] noted [Resident #1] forehead, frontal aspect with fluid filled hematoma with open abrasion to center of hematoma at this time. called and spoke with [hospice services RN] and informed of area to [Resident #1's] head with visual documents provided for review. MD aware as well with zero new orders noted. attempted to reach hospice nurse to confirm that orders had not been given to her at this time. - 03/28/24 at 4:03 PM, written by ADON, reflected, [ADON] noted zero response to medically necessary orders due to [Resident #1] radiology report or area to [Resident #1] head at this time. [ADON] sent message to hospice nurse and MD requesting a return call at this time. - 03/29/24 at 11:04 AM, written by NP, reflected, [Resident #1] seen and examined per nursing staff request for report of a fall yesterday. Noted large hematoma to mid-frontal scalp area with ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising). denies any pain or headache but overall stays stable . - 04/01/24 at 8:21 PM, written by LVN A, reflected, Skull x-ray ordered for [Resident #1] r/t unwitnessed fall. Call to RP did not go through and unable to leave a voice message. - 04/02/24 at 7:28 AM, written by RN N, reflected, [Resident #1] refused to do skull series, notified MD, Administrator and [Resident #1] daughter aware. - 04/02/24 at 7:36 AM, written by RN N, reflected, [Resident #1] fell yesterday, continue on neuro checks, no delayed injuries seen. Continue to be monitored. - 04/03/24 at 7:51 PM, written by LVN A, reflected, At around 6:30 PM was notified by Speech Pathologist that [Resident #1] was on the floor in the dining room. Went to the dining area and found resident on the floor next to his wheelchair. Assessed resident, then put back to wheelchair with 2 persons assist. noticed [Resident #1] was able to unlock the armrest on the wheelchair and push it down, and probably slipped from the side . Record review of Fall Event, dated 03/23/24, linked SBAR Communication Tool (dated 03/27/24) and Resident #1's following progress notes: - 03/25/24 at 6:09 PM, written by LVN A, reflected, [Resident #1] had a fall at around 5:50 PM in the dining area, and hit his head on the floor . assessed and put back on wheelchair . [Resident #1] has a bump in the front of his head and is c/o pain on his head. MD notified via text message with a picture of the injured area and replied, Apply TAO bid for seven days. Hospice called and said they are sending a nurse at the facility to assess [Resident #1] . Neuro checks initiated. - 03/25/24 at 10:07 PM, written by LVN A, reflected, Hospice nurse did not show up . TAO applied on resident bump per MD Order, morphine 0.25 ML provided for pain. [Resident #1] currently resting on bed . in lowest position and mat on the floor. Neuro checks ongoing. - 03/26/24 at 12:52 PM, written by LVN L, reflected, [Resident #1] BP 96/50, HR 77 . rechecked at 12:50 PM, BP 117/70, HR 90 . on bedrest in supine position with legs elevated 8 - 12 inches until BP returns to baseline . - 03/26/24 at 6:45 PM, written by LVN A, reflected, Skull x-ray done at around 6:15 PM. Result pending. - 03/27/24 at 6:31 AM, written by RN O, reflected, Post fall day 2/3. [Resident #1] has a decreased in his blood pressure reading. legs were elevated 8 inches and offered fluids . Fall preventive measure implemented. - 03/27/24 at 9:13 AM, written by LVN L, reflected, [Resident #1's] x-ray results . significant findings and head CT suggested . sent to MD and hospice nurse. [Resident #1] sent to hospital accompanied by facility driver at 9:00 AM. Record review of the Fall Event dated 03/25/24, LVN A indicated the fall was NOT witnessed. [Resident #1] complained of pain 3 out of 10 [4 out of 10 = Moderate Pain - Distressing, Miserable] (to his head). Injury to the head was a bump . Resident has a bump in the front of his head and is c/o pain on his head. MD notified via text message with a picture of the injured area and replied Apply TAO (an ointment that prevent infection and aids in healing of minor cuts, scrapes, and burns) BID (twice daily) for seven days. The following progress notes were linked to the Fall Event: - 03/19/24 at 12:56 PM, written by PCP, reflected, GDR ordered to change Ambien to PRN for 14 days, Ativan changed to AM and HS (at bedtime) per pharmacist recommendation. - 03/28/24 at 12:44 PM, written by ADON, reflected, [ADON] noted [Resident #1's] CT Scan results . notified PCP of available results with impressions that indicated Advance chronic microvascular ischemic changes (brain condition cause problems with thinking, walking and mood after an injury) and moderate generalized volume loss (associated with major neurological diseases, such as a large stroke or progressive dementia) noted. Ventriculomegaly (a condition in which the brain ventricles, or fluid-filled cavities, are enlarged due to build up of cerebrospinal fluid [CSF] found with moderate or severe traumatic brain injury) . hospice requested results fax . [ADON] sent fax . Record review of video surveillance dated 03/25/24, provided by the NFA, revealed the Dining Area. A Med Aide was against the wall standing behind the medication cart approximately 5 - 6 feet in front and to the right of Resident #1 in his high back wheelchair. The Med Aid did not have a direct line of sight of Resident #1. LVN A was approximately 15 - 20 feet away, assisting a resident with eating. Resident #1 was in LVN A's direct line of sight. Resident #1 was scooting in his wheelchair, but unable to move forward past a table and chair. It appeared that there was an object that prevented him from moving forward. Resident #1 reached towards the table on his left side to try and propel forward but could only turn left. Resident #1 turned to the left twice. Resident #1's back was to the camera when it was noted that he fell forward out of the chair hitting his face/head on the floor. The Med Aide and LVN A looked up from what they were doing 4 - 5 seconds after Resident #1 fell . LVN A walked towards Resident #1 and the MA left from behind the medication cart and headed towards the hall away from the Dining Area, where the nurses' station was located. The video clip ended. Record review of Fall Event dated 03/28/24 indicated Resident #1 had an unwitnessed fall at 8:16 PM in the Dining Room. The event details stated Resident #1 went to Station 5 just prior to the fall. Resident #1's following progress notes were linked to the Fall Event: - 03/28/24 at 8:27 PM, written by LVN A, reflected, [Resident #1] found on the floor at around 7:35 PM, in the dining room. Resident was assessed and put back on wheelchair with 3-person assist. skin tear observed on [Resident #1] right hand and behind the right ear. Record review of Fall Event dated 04/01/24 indicated Resident #1 had a witnessed fall in the Dining Room. The following progress notes were linked to the Fall Event: - 04/01/24 at 11:43 AM, written by LVN M, reflected, [Resident #1] fall in the dining room with witness during Chaplain. immediately went to the dining room, observed resident sitting down on the floor by wheelchair. Assessment done and 2-person assist resident back in chair. - 04/01/24 at 2:26 PM, written by NFA, reflected, Administrator spoke with Director of Hospice Services to discuss plan of care for [Resident #1] related to falls. Administrator explained that per our Rehab Manager we requested Therapy services to be given to [Resident #1] to assist in reducing falls. Director agreed. She will schedule with their therapy department to schedule therapy services to be provided to [Resident #1] She will provide [NFA] an updated plan of care for [Resident #1] and we will continue to be aware of any further changes. - 04/01/24 at 2:42 PM, written by NFA, reflected, Update: Spoke with Director of Hospice Services, we will have our Therapy Department to treat resident to assist in reducing [Resident #1] falls. Once that is completed we will update Plan of Care. Record review of Fall Event dated 04/03/24 indicated Resident #1 had an unwitnessed fall from his wheelchair in the Dining Room at 7:21 PM. Neuro checks were initiated. A record review of hospital medical records for 03/27/24 reflected [Resident #1] arrived at the emergency department (ED) in a wheelchair on 03/27/24 at 09:04 AM. ED triage notes indicated [Resident #1] presented to the ED after a fall and need for imaging. [SNF staff] stated [Resident #1] fell the other day and got an x-ray yesterday (03/26/24) that showed possible right temporal bone nondisplaced fracture. [Resident #1] denied pain. A review of the ED physician physical exam on 03/27/24 at 10:06 AM revealed Large ecchymosis to the frontal parietal bone with an abrasion but no active bleeding . Review of medical assessment and plan dated 03/27/24 at 11:00 AM indicated final diagnoses Head Trauma. CT Scan without Contrast resulted Advance chronic microvascular ischemic changes (brain condition cause problems with thinking, walking and mood after an injury) and moderate generalized volume loss (associated with major neurological diseases, such as a large stroke or progressive dementia) noted. Ventriculomegaly (a condition in which the brain ventricles, or fluid-filled cavities, are enlarged due to build up of cerebrospinal fluid [CSF] found with moderate or severe traumatic brain injury). A review of the ED provider note entered on 03/27/24 at 12:15 PM reflected Blood pressure has been low, however [Resident #1's daughter] stated that it has been low since Monday (03/25/24) . [Resident #1] is on hospice at the nursing home. She [Resident #1's daughter] does not want [hospice] revoked and does not want further testing at this time . nursing home had a plan, and they are following it . [Resident #1] was discharged from the ED on 03/27/24 at 12:16 PM. Record review of video surveillance dated 04/01/24, revealed Resident #1 in the Dining Area propelling in his wheelchair toward the vending machine. There was a Medication Aide with back against the wall standing at a medication cart preparing and crushing medications (approximately 20 feet away from where Resident #1 fell ). 7 - 8 other residents noted in the Dining Area participated in an activity (with the Chaplain) in the center of the Dining Area. There was a pressure relief pad in the seat of [Resident #1's] wheelchair and a balled-up sheet between Resident #1 and the left arm of the wheelchair. Resident #1 scooted forward to the edge of the seat, placed his right hand on the vending machine and tried to stand. A Dycem non-slip mat was not in place [reflected as an intervention in the care plan]. Resident #1 could not stand, his knees lowered to the floor, and when tried to sit back in the wheelchair, it rolled backwards. Resident #1 fell sideways on his right side, rolled over onto his back, reached out, grabbed, and pulled the wheelchair forward. Resident #1's right foot was in the gap between the left wheel and the body of the wheelchair. Resident #1 rolled over to the right side, slowly raised his upper body, and rolled back over to his right side. The Medication Aide looked up and walked towards Resident #1. LVN M was seen stepping into the Dining Area from the hall. LVN M did not assess or evaluate Resident #1's vital signs, range of motion, or inspect for any injury before the Resident #1 was assisted back into the wheelchair by the Medication Aide and LVN M. The video clip ended. Record review of video surveillance dated 04/03/24, revealed Resident #1 sitting at a table in the Dining Area. There was no staff present. A staff in light blue scrubs was observed coming from out the hallway into the Dining Area, approached Resident #1 and then walked away. Resident #1 attempted to stand up. Resident #1 fell backwards onto his back. An individual entered from the secured doors, noted Resident #1 on the floor and headed towards the hall where the nurses' station was located. The video clip ended. During an observation on 03/30/24 between 2:00 PM - 3:00 PM, Resident #1 was observed resting quietly in a right lateral laying position in bed. Bed in the lowest position, flushed to wall with scoop mattress (edges are raised higher than the mattress center). A fall mat was noticed on the opposite side of the room away from bed. Call light on floor under the foot of the bed. There was one nurse and one CNA observed in the secured unit. During an interview on 03/30/24 at 3:00 PM, RN D stated he was the assigned nurse for Resident #1. RN D stated that he worked weekends double shifts (6A - 2P and 2P - 10P). RN D stated he placed Resident #1 to bed. RN D said that he pulled the fall mat away from the bed to assist Resident #1 to bed from the wheelchair (high back wheelchair next to the bed, pressure-relieving pad in place, no Dycem mat noted) and did not place the fall mat next to the bed. RN D picked the call light up from under the foot of the bed and placed within Resident #1's reach. RN D said that there were two nurses and three CNAs assigned to the secured unit, however he and one CNA were the only staff currently in the secured unit while the other nurse and two CNAs attended an in-service. RN D said that a resident is at risk for harm if care plan interventions were not implemented appropriately or timely. RN D said that interventions in place for Resident #1 to prevent falls included bed in lowest position, to use the call light for help, to place call light within reach, and to place the fall mat at the bedside when Resident #1 was in bed. RN D said he was not present when Resident #1 sustained a fall on 03/25/24. RN D said that Resident #1 had multiple falls and tried to keep [Resident #1] within line of sight or interact during activities to prevent falls. RN D said that Resident #1 required frequent redirection and attention to prevent falls. During an interview on 03/30/24 at 4:55 PM, the NFA stated she was still investigating the incident when Resident #1 fell on [DATE]. The NFA stated that staff must notify her immediately of any incident or accident. The NFA said if an unusual incident (possible resident abuse, neglect, mistreatment and/or unwitnessed injuries) was reported, she immediately reviewed the surveillance cameras to gather information about individuals involved and determine if staff followed protocol when reacted to an accident or incident. The NFA stated that she first learned on 03/27/24 about Resident #1's head injury sustained from a fall (on 03/25/24) and completed a facility incident self-report on-line. The NFA indicated that she did not see staff or another resident push or cause Resident #1 to fall and neglect was not identified. During an interview on 03/30/24 at 5:47 PM, the ADON indicated Resident #1 . still wants to be independent . will not ask for help. The ADON stated Resident #1 was wheelchair bound and should remain within the staff line of sight in the Dining Area to prevent falls. The ADON said there were signs posted for Resident #1 to use the call light for assistance and the wheelchair and bed lowered to prevent falls. The ADON said that Resident #1 had a fall on Monday (03/25/24) evening. The ADON said she had already left for the day when LVN A called to notify that Resident #1 had a fall and reported that he did not complain of pain and there was no injury. LVN A reported to the ADON that Resident #1 was sitting at the nurses' station and the hospice on-call nurse was notified to come assess Resident #1. The ADON said that she assessed and evaluated Resident #1 the next day (03/26/24) when she returned to work. The ADON said that she discovered a raised bump on Resident #1 forehead with an abrasion that appeared shiny where a generous amount of ointment was applied. The ADON said that she asked LVN A about the injury and what actions were taken. LVN A told the ADON that she [LVN A] texted the PCP about the fall and applied the ointment [TAO] as ordered, then notified the hospice on-call nurse, but she never showed. The ADON said that she explained to LVN A that the facility was Resident #1's primary caregiver and immediate actions should be taken when a resident sustained an apparent head injury. The ADON said that she immediately called the PCP and requested orders for a skull x-ray and labs. The ADON said she implemented the orders right away. The ADON said that she reviewed the Skull x-ray results the next morning (03/27/24). The results suggested a CT scan because a skull fracture could not be ruled out by the images. ADON said that Resident #1 was sent to the hospital accompanied by the facility van driver via the facility van. The ADON stated that she expected nurses to conduct rounds minimally every two hours and as needed, or more frequent for residents who were a high fall risk. The ADON indicated keeping residents within the line of sight and not alone in their rooms if the resident tried to act beyond their level of function. Additionally, the ADON stated that nurses should check that fall precautions were in place, residents are wearing non-slip socks or appropriate slippers/shoes, positioning, if the resident is in pain, or assist to the restroom during rounds. Record review of the text communication sent to the MD from LVN A when Resident #1 fell on [DATE] and hit his head indicated, . Resident #1 had a fall in the Dining Area and hit his head on the floor . complaining of pain on his head. He is alert. Hospice notified. LVN A attached a picture of Resident #1's head injury to the communication that revealed a raised area on the frontal region of [Resident #1's] scalp. A light purplish-blue discoloration surrounded the raised area. There was a redden scraped area at the middle of the raised area. The reply from the MD stated, Apply TAO BID for seven days. During an observation on 04/01/24 at 1:29 PM, Resident #1 was observed in a high back wheelchair propelling with his feet only, grabbing and pushing chairs out of the pathway. Resident #1 leaned forward trying to reach a sandwich from under a chair. Dycem material was not observed under Resident #1 on the seat of the wheelchair. The ADON observed Resident #1 leaning forward and went to his side to assist upright in wheelchair. When the ADON walked away, Resident #1 tried to stand up. The ADON came back over to Resident #1, assisted and repositioned Resident #1 back into an appropriate upright position in wheelchair. The ADON gave verbal reminders not to stand up or try to transfer from the wheelchair without assistance. The ADON asked a CNA to frequently observe and supervise Resident #1 while in the Dining Area. The ADON rearranged the chairs back to the tables and cleared a pathway around the tables in the Dining Area. A conversation was overheard between a nurse and the NFA that Resident #1 had a fall in the morning (04/01/24). During an interview on 04/01/24 at 4:40 PM, LVN A indicated that she worked on 03/25/24, 03/28/24, and 04/03/24, 2P - 10P shift. LVN A stated that she was assigned to Resident #1. LVN A stated that Resident #1 had unwitnessed falls on those days that she worked. LVN A stated that Resident #1 needed one-to-one supervision to prevent falls and that was not possible with 5 staff and 30 or more residents that were fall risks, required incontinent care, or demonstrated behaviors that may harm another resident. LVN A stated that she notified the MD by text about Resident #1's fall (on 03/25/24). LVN A said that she texted the MD that Resident #1 hit his head on the floor, complained of pain, that he [Resident #1] was alert, and attached a picture of Resident #1's head injury to the text. LVN A said that alert indicated that Resident #1 did not lose consciousness. LVN A said that the MD replied by text to apply TAO to the abrasion. LVN A stated that she would assess and evaluate a resident by checking vital signs, range of motion of extremities (by asking the resident to move their extremities and then moving the resident extremity), asked about pain, and look for any bruises or injuries. LVN A said that she was not sure if Resident #1 had a fall in the morning, she was not present. LVN A said that she was supposed to initiate a Fall Event report for every accident or incident. LVN A said that it was her responsibility to check on residents every two hours alternating with the CNAs to ensure resident safety, interventions were in place, and acknowledge whereabouts. During an observation and interview on 04/01/24 at 4:45 PM, the OT assisted Resident #1 from the high back wheelchair to a smaller blue wheelchair. The OT assessed and evaluated Resident #1's comfort in the chair. The OT pushed Resident #1 in the wheelchair to the Dining Area and tilted the wheelchair back enough to raise Resident #1's feet off the floor. The OT conducted a visual observation of Resident #1 in the wheelchair. During an interview, the OT stated that occupational therapy was consulted on 04/01/24 to assess and evaluate Resident #1 after multiple falls. The OT indicated that the blue wheelchair was called a tilt-in-space. The OT stated the purpose of the wheelchair was to easily reposition Resident #1 when sitting in the wheelchair to prevent falls and maintain posture when in the reclined position. The OT stated the tilt-in-space wheelchair could reduce falls; however, when in the reclined position Resident #1 could not freely propel and move about in the wheelchair. During an interview on 04/01/24 at 5:15 PM, the DOR indicated that Resident #1 was currently on service with occupational therapy after assessment and evaluation related to a fall Resident #1 had on 03/18/24. The DOR stated therapy was consulted [04/01/24] for reassessment of Resident #1 due to frequent falls. The DOR indicated supervised stand-by assistance would be an effective intervention for Resident #1 to prevent falls. Record review of an undated typed Incident Narrative revealed the MD name, address, and contact information in the heading. The Incident Narrative indicated Resident #1 resided at the SNF and was under the MD care. The Incident Narrative described Resident #1 was also a hospice patient . required assistance with ADLs, was non-ambulatory, incontinent of bowel and bladder, had extensive muscle wasting and deconditioning. The Incident Narrative indicated Due to his severe dementia . is unaware cannot walk, repeatedly stands from his wheelchair or bed, and immediately falls, which he has done multiple times. In the body of the Incident Narrative revealed [Resident #1] fell on [DATE], . sustained a superficial abrasion of the scalp in the forehead area. notified by nursing staff and ordered antibiotic to the abrasion. There was no evidence of any brain injury or neurological changes such as seizure, coma, mental status changes. The following day . developed a hematoma around the abrasion area, and determined at that time that a skull x-ray was indicated and ordered . The Incident Narrative closed with a statement of the MD's initial impression was confirmed when Resident #1 returne [TRUNCATED]

Based on interview and record review, the facility failed to ensure residents 1 of 14 residents (Resident #1) were free from neglect. The facility failed to provide adequate wound care monitored by a physician for 30 days for Resident #1 with a Stage IV pressure sacral ulcer, skin tear of right knee, and pressure ulcer of left foot. The resident was sent to the hospital by the facility after with symptoms of lethargy, disoriented, anorexia and hypotensive. Resident was admitted to the hospital ICU as septic, had fluid overload with shortness of breath. The facility neglected Resident #1 daily wound care treatment and wound care management by physician services. These failures could place residents at risk for neglect due to facility not providing needed care and services. An Immediate Jeopardy (IJ) was identified on 3/20/2024. The ED was notified and provided with the IJ template on 3/20/2024 at 5:36 PM. While the Immediate Jeopardy was removed on 3/22/2024, the facility remained out of compliance at a scope of pattern and a severity level of actual harm with the potential for more than minimal harm, due to the facility's need to implement and monitor the effectiveness of its corrective systems. Findings included: Record review of resident's electronic medical record history and physical revealed Resident #1 is an [AGE] year-old, female with a history of hypertension, pressure ulcer of sacral region, chronic respiratory failure with hypoxia (Chronic Obstructive Pulmonary Disease), dysphagia (difficulty swallowing), and end stage renal disease (kidney failure/dialysis required for blood filtration). Record review of resident's Nurse 24-hour Report identified two small skin tears on sacrum on 1/4/2024. Record review of resident's Care Plan on dated 5/5/2023 states Resident #1 is at risk for skin breakdown/pressure ulcer/injury. Record review of Specialty Physician Wound Evaluation and Management Summary revealed Stage 3 sacrum pressure wound (resolved on 7/28/2023) for Resident #1. Electronically signed by Physician A on 7/28/2023. Record review of resident's Nurse 24-hour Report identified two small skin tears on sacrum on 1/4/2024. Record review of resident's wound management notes document a sacral pressure ulcer for 5/11/2023, 6/1/2023, and 2/1/2024. This revealed a lapse weekly documented skin checks for Resident #1 from 2/7/2024 to 3/4/2024. Record review of Nursing Administration History: 2/7/2024 to 3/4/2024 physicians orders for wound care administration for sacrum: (Cleanse with NS or wound cleanser, pat dry, apply alginate calcium and cover with dry dressing daily.) Notes documented by LVN A and RN E from 2/10/2024 to 3/2/2024 Not Administered: To be done by wound nurse. Record review of LVN A progress note dated 3/4/2024 stated wound size is 1.7 x 1.2 cm, edges black in color. In an interview with the facility ADON B on 3/19/2024 at 1:20 PM stated she was hired on 2/15/2024 and Resident #1 transitioned to my roster the same day I discharged her to the hospital due to her nurse notifying me of her change in condition on 3/5/2024. Her assigned nurse said her wound dressing was soiled and she changed it before EMS arrived on 3/5/2024. The investigator asked, where are the Bath sheets? Because I did not see them documented in the EMR skin assessments. ADON stated, Look on my watch this will change. That is a problem we have been working on. We have started in-services at the beginning of March with CNAs documenting skin assessments during ADL care. Yes, we are really working on improving documentation and making sure CNAs documenting what they see. In a phone interview with the facility contracted wound care Physician A on 3/19/2024 at 1:30 PM he stated he approved the telephone orders for Resident #1's sacral pressure wound requested by ADON C on 2/7/2024 . Physician A stated, I go to the facility every Thursday. I don't recall seeing that patient because I don't have any notes or any evidence of her making it to the rounding list. Not sure why if it was forgotten or if she was out of the building. For some reason she never made it. I just approved the order through a call. I don't know why she was never on the list. When I go into the building, they give me a list of everyone, and I make sure I see everyone. If someone was supposed to be there that's not there, there's no way for me to just, out of the top of my mind, troubleshoot. Who is this person? Unless it's someone I've seen the week before, I would ask them did this person go home? Why are we not seeing this person, for whatever reason. She had told me that patient was supposed to be seen, but somehow, she was not on the list. The resident was never on the list. I'm not sure why. In a phone interview with the Responsible Party (RP) on 3/19/2024 at 4:30 PM she stated, Resident #1 would call me in the middle of the night in excruciating pain. She told the nurses continually that she was an excruciating pain. One would think the nurses communicated that to somebody so somebody would have taken care of this prior to her suffering for a month in excruciating pain. I don't understand how it went on that long. In a phone interview with Resident #1's facility Primary Care Physician B on 3/20/2024 at 10:19 AM he stated he was not aware of any of Resident #1's wounds. In an interview with the facility ADON B on 3/20/2024 at 12:10 PM she stated, After researching the issues in documentation in skin assessments and other areas, we are still in-servicing CNA's and those giving ADL care we educated them on using the skin note and the POC to identify issues, also to verbally communicate to the nurses. For nurses we initiated the Events feature in the EMR template to be sure and educated them how use this feature when they identify problem. Nurses open the event fill it out and leave it open so we (DON/ADON's/ED) can follow up and complete it and investigate to see you know what needs to be done. Nurses were educated that if they find a skin concern, they have to notify the doctor get an order notify the family, their doctor and ED. The investigator asked, what is your expectation when a resident has not been seen by the wound care doctor? We instructed them to speak up and they should be involving their primary care doctor here in the facility as well in case something happens, or you know if something doesn't get sent or doesn't get caught. You know both providers need to be involved in the care, so nothing is overlooked. Even if their primary care provider is not in the facility. If a resident has a wound, nurses need to say they have a resident with a wound and need a referral consult to a wound care provider. In an interview and EMR template review with the facility ED on 3/21/2024 at 2:18 PM she stated, I identified back on January 31, 2024 that we needed to set up a protocol with the nurses to do weekly skin assessments for residents due on Mondays during the 6:00 AM to 2:00 PM shift. So, when a nurse goes into their dashboard, they can see what skilled nursing is due in a residents' chart in the EMR platform. Nurses would add a skin assessment which was called the weekly body observation. Unfortunately, it was not setup in a way, so the nurse managers (DON and ADONs) were responsible for auditing for these skin assessments, to make sure the assessments were done. That audit feature has been corrected for the ADON's and will be ready for the new DON when she starts in February. In fact, we discovered skin assessments still weren't getting done because it came up in a compliance audit after you (Investigator) entered the facility for this investigation. So, we began in-servicing the nurses on skill charting and documenting skin assessments in their progress notes. Now we have created a template in the EMR platform that uses checkmarks, to describe the nurses' findings during skin assessments and it turns into progress note. Now when I log into the EMR and see my scheduled compliance reports; I can pull these skilled tasks dated from 3/20/2024 and on. Moving forward, I will address any incomplete tasks in the morning meetings. I now, can see exactly what is going on the clinical side. I have set a lot of our skilled scheduled assessments, referrals, and other tasks to alert me so I can see exactly what was not done and from there I can follow up the nurse managers and the nurse responsible. I can no longer solely depend on the DON and ADON's to monitor assessment audits. I want to monitor it too. I can look at referrals and see if everything has been done so that will the event will trigger the consult or put in order. I have access to all now, so I can just go in and see if referrals have been done or rather if a consult or referral has not been done. Referral consults must be submitted through the wound care physician consultants' website. That's a manual process. Eventually, we want to get where our EMR system does feed referrals to their system. Now in my dashboard I can look at the order and see what was done and not done daily. As soon as identify a referral was not made, I'm immediately on the phone with the consultants, saying you have wound care consult in house. This was determined to be an Immediate Jeopardy (IJ) on 3/20/2024 at 11:45 AM. The ED and ADONs were notified. The ED was provided with the IJ template on 3/20/2024 at 5:36 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 3/21/2024 at 1:48 PM: Plan of Removal On 3/14/2024 ADON's completed an in-service for Change of Condition using our SBAR should be c ompleted on any change of condition. Progress Notes should be completed every shift for the next 3 days following SBAR. 3/20/2024 3/18/2024 Administrator started reviewing resident 1 records, in-services were started to include Abuse, Neglect and Reporting. On 3/19/2024 at 5:00pm ADON's started a skin sweep of all residents, any negative findings were corrected by orders added and referrals were made to Wound Physician. On 3/19/2024 4:40pm ADON's started an in-service with all Licensed Nurses, Med aides and C.N.A's regarding skin/wound documentation and notification in their documentation in the POC. 3/20/2024 On 3/20/2024 at 9:00am ADON assisted Administrator in reviewing the events our system has available. On 3/20/2024 the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X4 Weeks after admissions or re-admissions. Quarterly thereafter. 3/20/2024 The Administrator/DON will pull the Event reports daily to ensure all orders are in place and referral completed for Wound Physician to see on their next rounds. Administrator/DON will follow up after each round conducted by the physician to ensure resident was seen and orders carried out. Any negative finding will be corrected immediately. 3/20/2024 All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. 3/21/2024 On 3/14/2024 ADON's completed an in-service for Change of Condition using our SBAR should be completed on any change of condition. Progress Notes should be completed every shift for the next 3 days following SBAR. 3/20/2024 3/18/2024 Administrator started reviewing resident 1 records, in-services were started to include Abuse, Neglect and Reporting. On 3/19/2024 at 5:00pm ADON's started a skin sweep of all residents, any negative findings were corrected by orders added and referrals were made to Wound Physician. On 3/19/2024 4:40pm ADON's started an in-service with all nursing staff regarding skin/wound documentation and notification in include documentation in POC. 3/20/2024 On 3/20/2024 at 9:00am ADON assisted Administrator in reviewing the events our system has available. On 3/20/2024 the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. 3/20/2024 On 3/20/2024 at 9:00am ADON assisted Administrator in reviewing the events our system has available. On 3/20/2024 the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. 3/20/2024 All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. 3/21/2024 Record review of facility Change in a Resident's Condition or Status Policy Statement (Revised 2021): Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, ., resident rights, etc.). 2. A significant change of condition is a major decline or improvement in the resident's status that: c. requires interdisciplinary review and/or revision to the care plan. Record review of facility Resident Rights Policy Statement (Revised 2016): Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation; 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: f. communication with and access to people and services, both inside and outside the facility. Record review of facility policy (Revised 2017): Abuse, Neglect, and Reporting: Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation - Role of the Administrator: 5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Reporting 2. An alleged violation of abuse, neglect, .will be reported immediately, but not later than: a. two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. Monitoring of POR Record review of the facility's In-service dated 3/14/2024 completed by facility ADON's for Change of Condition using Situation, Background, Assessment, and Recommendation (SBAR). Record review of the facility's In-Service dated 3/19/2024 completed by ADON's regarding skin/wound documentation and notification in their documentation in the Point of Contact (POC). Record review of Plan of Correction (internal for facility) provided by ED The Administrator/DON will pull the Event reports daily to ensure all orders are in place and referral completed for Wound Physician to see on their next rounds. Administrator/DON will follow up after each round conducted by the physician to ensure resident was seen and orders carried out. Any negative finding will be corrected immediately. ADON assisted Administrator in reviewing the events our system has available. On 3/20/2024 the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. (signed by the ED) Record review of the facility's Change in Condition Policy (copied for evidence) - No concerns noted. Interviews were conducted on 3/21/2024 at various times to include staff from various shifts. Interviews with ED, CNA A, CNA B, CMA A, LVN B, RN A, RN B, RN C, RN D, ADON A, ADON B to verify the in-services were conducted and to validate the staffs understanding of the trainings for Abuse, Neglect , and Exploitation, the importance skin/wound documentation and notification in their documentation in the Point of Contact. No concerns were found regarding the understanding of the requirements, training materials or expectations. All interviewed staff were able to communicate their understanding and proficiency of the in-services. On 3/22/2024 at 12:50 PM Investigator notified ED the immediacy was removed and conducted the exit. Immediate Jeopardy (IJ) was identified on 3/20/2024. While the IJ was removed on 3/22/2024, the facility remained out of compliance at a lowered severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern as the facility continued to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review, the facility failed to ensure residents received treatment and care according to professional standards of care and the care plan to prevent pressure ulcers or develop new ulcers for 1 of 14 residents (Resident #1) reviewed for pressure ulcers. The facility failed to provide adequate wound care monitored by a physician for 30 days for Resident #1 with a Stage IV pressure sacral ulcer, skin tear of right knee, and pressure ulcer of left foot. The resident was sent to the hospital by the facility after with symptoms of lethargy, disoriented, anorexia and hypotensive. Resident was admitted to the hospital ICU as septic, had fluid overload with shortness of breath. The facility failed to add the resident to wound care physicians list of patients for pressure ulcers. These failures could place residents at risk of development of additional pressure ulcers and further health decline. Findings included: Record review of resident's electronic medical record history and physical revealed Resident #1 is an [AGE] year-old, female with a history of hypertension, pressure ulcer of sacral region, chronic respiratory failure with hypoxia (Chronic Obstructive Pulmonary Disease), dysphagia (difficulty swallowing), and end stage renal disease (kidney failure/dialysis required for blood filtration). Record review of resident's Care Plan dated [DATE] states Resident #1 is at risk for skin breakdown/pressure ulcer/injury . On turning/repositioning program. Record review of Specialty Physician Wound Evaluation and Management Summary revealed Stage 3 sacrum pressure wound (resolved on [DATE]) for Resident #1. Electronically signed by Physician A on [DATE]. Record review of resident's Nurse 24-hour Report identified two small skin tears on sacrum on [DATE]. Record review of resident's wound management notes document a sacral pressure ulcer for [DATE], [DATE], and [DATE]. This revealed a lapse weekly documented skin checks for Resident #1 from [DATE] to [DATE]. Record review of Nursing Administration History: [DATE] to [DATE] physicians orders for wound care administration for sacrum: (Cleanse with NS or wound cleanser, pat dry, apply alginate calcium and cover with dry dressing daily.) Notes documented by LVN A and RN E from [DATE] to [DATE] Not Administered: To be done by wound nurse. Record review of LVN A progress note dated [DATE] stated wound size is 1.7 x 1.2 cm, edges black in color. In an interview with the facility ADON A on [DATE] at 12:56 PM she stated she was hired on [DATE] and was not assigned Resident #1, I am assigned to the 100 hall. I did round with the wound care doctor (Physician A), but I didn't see Resident #1 on the wound management log. The day that the wound was brought to my attention by ADON B it was a very flustering day . Because I was like, how could this be missed? The honest truth, I don't know. I saw wound care orders, but that's it. The terminated ADON C discovered the wound [DATE] and did not refer resident to physician monitored wound care services. In an interview with the facility ADON B on [DATE] at 1:20 PM stated she was hired on [DATE]. Resident #1 transitioned to my roster the same day I discharged her to the hospital due to her nurse notifying me of her change in condition on [DATE]. Her assigned nurse said her wound dressing was soiled and she changed it before EMS arrived on [DATE]. In a phone interview with the facility contracted wound care Physician A on [DATE] at 1:30 PM he stated he approved the telephone orders for Resident #1's sacral pressure wound requested by ADON C on [DATE] . Physician A stated, I go to the facility every Thursday. I don't recall seeing that patient because I don't have any notes or any evidence of her making it to the rounding list. Not sure why if it was forgotten or if she was out of the building. For some reason she never made it. I just approved the order through a call. I don't know why she was never on the list. When I go into the building, they give me a list of everyone, and I make sure I see everyone. If someone was supposed to be there that's not there, there's no way for me to just, out of the top of my mind, troubleshoot. Who is this person? Unless it's someone I've seen the week before, I would ask them did this person go home? Why are we not seeing this person, for whatever reason. She had told me that patient was supposed to be seen, but somehow, she was not on the list. The resident was never on the list. I'm not sure why. Record review of physician orders dated [DATE] revealed, Sacrum: cleans with Normal Saline or wound cleanser, pat dry, apply alginate calcium and cover with dry dressing daily. Electronically signed by Physician A on [DATE]. In a phone interview with the Responsible Party (RP) on [DATE] at 4:30 PM she stated, Resident #1 would call me in the middle of the night in excruciating pain. She told the nurses continually that she was an excruciating pain. One would think the nurses communicated that to somebody so somebody would have taken care of this prior to her suffering for a month in excruciating pain. I don't understand how it went on that long. In a phone interview with Resident #1's facility Primary Care Physician B on [DATE] at 10:19 AM he stated he was not aware of any of Resident #1's wounds . Record review of ER records revealed that the resident was septic, had fluid overload with shortness of breath and the resident as admitted to the ICU on [DATE] and continued to decline after discharge to hospice. The hospital advised the family not to readmit the resident back to the facility and assisted the family with finding home hospice care were the resident expired on [DATE]. In an interview with the facility with ED on [DATE] at 5:37 PM she stated that ADON C was terminated on [DATE] with License Referral and the DON was demoted to Care Plan Coordinator on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The ED was notified and provided with the IJ template on [DATE] at 5:36 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm with the potential for more than minimal harm, due to the facility's need to implement and monitor the effectiveness of its corrective systems . The Plan of Removal (POR) was accepted on [DATE] at 1:48 PM, and indicated the following: Plan of Removal On [DATE] ADON's completed an in-service for Change of Condition using our SBAR should be completed on any change of condition. Progress Notes should be completed every shift for the next 3 days following SBAR. [DATE] [DATE] Administrator started reviewing resident 1 records, in-services were started to include Abuse, Neglect and Reporting. On [DATE] at 5:00pm ADON's started a skin sweep of all residents, any negative findings were corrected by orders added and referrals were made to Wound Physician. On [DATE] 4:40pm ADON's started an in-service with all Licensed Nurses, Med aides and C.N.A's regarding skin/wound documentation and notification in their documentation in the POC. [DATE] On [DATE] at 9:00am ADON assisted Administrator in reviewing the events our system has available. On [DATE] the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X4 Weeks after admissions or re-admissions. Quarterly thereafter. [DATE] The Administrator/DON will pull the Event reports daily to ensure all orders are in place and referral completed for Wound Physician to see on their next rounds. Administrator/DON will follow up after each round conducted by the physician to ensure resident was seen and orders carried out. Any negative finding will be corrected immediately. [DATE] All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. [DATE] On [DATE] ADON's completed an in-service for Change of Condition using our SBAR should be completed on any change of condition. Progress Notes should be completed every shift for the next 3 days following SBAR. [DATE] [DATE] Administrator started reviewing resident 1 records, in-services were started to include Abuse, Neglect and Reporting. On [DATE] at 5:00pm ADON's started a skin sweep of all residents, any negative findings were corrected by orders added and referrals were made to Wound Physician. On [DATE] 4:40pm ADON's started an in-service with all nursing staff regarding skin/wound documentation and notification in include documentation in POC. [DATE] On [DATE] at 9:00am ADON assisted Administrator in reviewing the events our system has available. On [DATE] the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. [DATE] On [DATE] at 9:00am ADON assisted Administrator in reviewing the events our system has available. On [DATE] the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. [DATE] All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. [DATE] Record review of facility Change in a Resident's Condition or Status Policy Statement (Revised 2021): Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, ., resident rights, etc.). 2. A significant change of condition is a major decline or improvement in the resident's status that: c. requires interdisciplinary review and/or revision to the care plan. Record review of facility Resident Rights Policy Statement (Revised 2016): Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation; 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: f. communication with and access to people and services, both inside and outside the facility. Monitoring of POR Record review of the facility's In-service dated [DATE] completed by facility ADON's for Change of Condition using Situation, Background, Assessment, and Recommendation (SBAR). Record review of the facility's In-Service dated [DATE] completed by ADON's regarding skin/wound documentation and notification in their documentation in the Point of Contact (POC). Record review of Plan of Correction (internal for facility) provided by ED, [NAME]- The Administrator/DON will pull the Event reports daily to ensure all orders are in place and referral completed for Wound Physician to see on their next rounds. Administrator/DON will follow up after each round conducted by the physician to ensure resident was seen and orders carried out. Any negative finding will be corrected immediately. ADON assisted Administrator in reviewing the events our system has available. On [DATE] the new form for Pressure Sore/Stasis Ulcer was updated in the system and added to the events for the nurses to start using. In-service was started with all Licensed Nurses to complete the event when a Pressure Sore/Stasis Ulcer is present. The Braden Scale for Predicting Pressure Sore risk will be completed X 4 Weeks after admissions or re-admissions. Quarterly thereafter. All Licensed Nurses will be checked off for wound care for ADON's. DON/ADON's will complete observation wound care weekly for each nurse to ensure they are completing it correctly. (Signed by the ED) Record review of the facility's Change in Condition Policy (copied for evidence) - No concerns noted. Interviews were conducted on [DATE] at various times to include staff from various shifts. Interviews with ED, CNA A, CNA B, CMA A, LVN B, RN A, RN B, RN C, RN D, ADON A, ADON B to verify the in-services were conducted and to validate the staffs understanding of the trainings for Abuse, Neglect , and Exploitation, the importance skin/wound documentation and notification in their documentation in the Point of Contact. No concerns were found regarding the understanding of the requirements, training materials or expectations. All interviewed staff were able to communicate their understanding and proficiency of the in-services. On [DATE] at 12:50 PM Investigator notified ED the immediacy was removed and conducted the exit. Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a lowered severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern as the facility continued to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for nine (Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9) of eleven residents reviewed for infection control. 1. The facility allowed Resident #1, to be transported to a doctor's visit at a hospital by his father who was not an essential caregiver, had not been trained by the facility on infection control and PPE protocol, and had not provided the facility with evidence of a COVID negative test within the past 14 days. Resident #1 returned from the doctor's visit and was placed back in his room with his roommate in a cold zone. Resident #1 and his roommate, Resident #6, subsequently tested positive for COVID-19 along with five additional residents on the same hall. 2. The facility failed to quarantine Residents #2, #3, #4, #5 and #7 after they tested positive for COVID-19 and continued to cohort them on the same unit with residents who had tested negative for COVID-19. 3. The facility failed to ensure that nurses and medication aides monitored Residents #2, #3, #4, #5, #6, #7, #8 and #9's signs and symptoms of COVID-19 once a shift and documented their findings on the MAR per the physicians' orders and facility's COVID-19 policy. 4. The facility failed to ensure a floor tech was tested for COVID-19 per the local county positive rate of twice a week. He refused to be tested for the second weekly test that occurred on 11/20/20. The facility allowed the floor tech to continue working after his refusal to test. 5. The facility failed to ensure hospice staff provided a negative COVID-19 test conducted within the last 14 days prior to allowing the hospice staff to care for Resident #8. Resident #8 tested positive for COVID-19 on 11/24/20 along with her roommate, Resident #9. An Immediate Jeopardy (IJ) was identified on 11/24/20 The facility was provided with the IJ template on 11/24/20. While the IJ was lowered on 11/27/20, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures could result in residents being exposed to COVID-19 which could lead to infection, serious illness, hospitalization , or even death. Findings included: 1.Review of Resident #1's quarterly MDS Resident assessment dated [DATE] revealed he was a 55-year- old male admitted to the facility on [DATE] and readmitted on [DATE] from another nursing facility. He had moderate cognitive impairment, clear speech and hearing and no indicator of mood concerns. His active [DIAGNOSES REDACTED]. Review of Resident #1's nursing notes in November 2020 reflected: 11/16/2020 11:39 AM- This writer called (local hospital) to determine time and reason for his apt today. They explained it was for his hand at 1130. (CS), transportation unable to take resident. But father ok to take resident to apt, as he is an essential caregiver. Resident had an attitude when he found out his father was coming. Resident calmed down and did let his father take him to appt. 11/21/2020 09:02 AM (Recorded as Late Entry on 11/21/2020 09:12 AM) Entered residents room for v/s check and feeding and noticed respiratory distress, every time patient breathed in he grunted but denied pain, bp 125/82 left arm., p. 134 with s1& s2 noted regular rhythm., resp 28 even/labored breathing., temp 102.3 and o2 77% ra so I applied oxygen via nc., only went up to 80% called NP she said to send resident out to hospital., called 911, called DAD, called DON, administration aware., suctioned [MEDICAL CONDITION] a small amount of yellow mucous noted., o2 sat went up to 80%., when ambulance arrived sat still in the 80s and his temp was 104.8 on the ambulance thermometer., When getting onto the stretcher resident said, I feel dizzy. 11/23/2020 08:14 AM Around 0810, hospital called and notified this writer than resident is positive for COVID. ADON notified, Admin notified. Admin instructed this writer to let SW notify resident's dad. 11/23/2020 09:22 AM SW spoke with pt's dad regarding where they went the day pt had an appt outside of the facility. Dad verbalized that after pt's appt, they stopped at Wendy's to use the restroom. SW asked if they sat to eat at Wendy's or anywhere else, pt's dad verbalized no, but he was asking me for a burger and I know better than that and said no. Pt's dad is aware that pt is COVID positive and in the hospital at this time. Administrator and DON have been notified. On 11/24/20 at 4:30 PM, the ADM was asked to locate the essential caregiver documentation and negative COVID-19 test for Resident #1's father. An interview with the ADM on 11/24/20 at 5:05 PM revealed Resident #1's father never did a COVID-19 test because he never came to the facility to visit him as an essential caregiver. She was asked why he was allowed to transport Resident #1 to a doctor's appointment in the community when the facility had a van driver for that task. She said Resident #1 was adamant his father drive him, and it was his right. An interview with CS on 11/26/20 at 3:22 PM revealed she was not aware Resident #1 needed to be transported to his doctor's appointment until ten minutes before he was supposed to be there. She said his appointment was not listed in the facility transport book. She said when the nurse notified her he needed transport, CS told her she was already transporting another resident from a different hall and the policy was that she could not transport residents from two different halls at the same time for infection control reasons. CS said, Typically, when I have transported (Resident #1) before, I know of (the appointment), I call and confirm. It should have been cancelled and rescheduled by me. She said in the past, there was always a facility escort for Resident #1, like a CNA, to make sure they were keeping him away from people because he would wander and talk to people. CS said she had never seen Resident #1's father transport before, until this last doctor's appointment. Review of the facility's Essential Caregiver visits kept in a binder at the front desk for 11/16/20-11/25/20 revealed there was an essential caregiver designation form dated 09/29/20 for Resident #1 where he indicated he wanted his father to be named as an essential caregiver. However, there was no supporting training documentation, COVID attestation form or negative COVID-19 test. Interview with LVN A on 11/24/20 revealed that Resident #6 had just tested positive for COVID-19 through a rapid test completed by the staff. She said he was Resident #1's roommate and was on hall 100. Review of Resident #6's face sheet dated 11/27/20 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. He was Spanish speaking and had active [DIAGNOSES REDACTED]. An interview with ADON K on 11/27/20 at 1:40 PM revealed the doctor's office did not alert the facility what time Resident #1's appointment was, they had called his father the day prior to notify him. She said Resident #1's father called the facility and said he had a voice mail from the doctor's office that he did not understand. ADON K then called the doctor's office and they confirmed he had an appointment for his hand. She said she called the facility transport staff who told her she was booked and could not take Resident #1. ADON K said she thought Resident #1's father was an essential caregiver and did not know he was not. She said Resident #1 was upset because he did not want to go with his father but he said if he was already at the facility to take him, he would just go. ADON K said it was hard to get in with this doctor office at the hospital because if an appointment was missed, it took a while to get another one. ADON K then said, There was a lapse in communication. I thought his dad was an essential caregiver because I thought he had gone through the training. An interview with the ADM on 11/24/20 at 12:01 PM revealed on 11/21/20, Resident #1 began to have a decline in his condition. Since Resident #1 had a trach, he was sent out to the hospital. The ADM said the facility did not complete a rapid COVID test on Resident #1 before he was sent to the ER but she did verify that he tested positive while at the hospital for COVID. She said Resident #1 was ambulatory and was the type of individual who would visit with other residents and staff, liked to chit chat, and was out and about the facility. She said he would wear his mask, but every once in a while, he would wear it down around his neck. She said the other residents on that same hall were tested on [DATE] by the facility with a rapid test and five of them were positive for COVID. She revealed this was the first outbreak of COVID for residents in the building since March 2020. She completed a root cause analysis and saw that Resident #1 had gone to a doctor's appointment on 11/16/20 at the hospital. He was transported by his father. His father initially told the ADM they only went to the doctor's appointment and back to the facility. Resident #1 tested negative for COVID on 11/17/20 through the facility testing. She said when Resident #1 then had a decline and was sent out to the hospital several days later, his father confessed they had stopped at a fast food restaurant and went inside. The ADM said in hindsight, maybe she should have placed Resident #1 on quarantine for 14 days when he came back from the doctor's appointment and maybe the outbreak could have been prevented. The ADM said as of 11/20/20, there were 35 residents on Hall 100 who were presently on quarantine and four residents positive for COVID-19 on Hall 200. The remaining 55 residents were on Hall 400 which was a cold hall. An interview with the DON on 11/24/20 at 6:07 PM revealed when she and the management team mapped out the outbreak, they realized everyone around Resident #1 on Hall 100 was testing positive through the preliminary rapid test. She said Resident #1 was the kind of individual who would stand at other residents' doors and walk around. She said Resident #1 and Resident #2's rooms were adjacent to each other but Resident #2 was non-ambulatory. She stated Resident #3 was the only resident down at the other end of Hall 100, but she must have gotten COVID-19 from Resident #1 because she socialized with him. The DON said she did not know why Resident #1's father was allowed to take him to a doctor's appointment in the community because normally the facility's driver would do it. She said the only family that came to the facility were essential caregivers and no other families had taken a resident out for doctors' appointments. The DON said in order to be considered an essential caregiver, the person had to be trained by her. She educated those individuals on PPE, donning and doffing techniques to prevent contamination and demonstrated how to complete proper handwashing as well as notifying the essential caregivers not to take off their masks and eat with the resident when in their rooms. She said she also informed the essential caregivers there was to be no physical contact with any person in the facility and if they needed anything, they were to call the front desk. She said the individual also had to present a negative COVID-19 test; at that point, she approved them as an essential caregiver. The DON said Resident #1's father had not been verified an essential caregiver. An interview with the ADM on 11/24/20 at 6:21 PM revealed she knew Resident #1 was transported to a doctor's appointment by his father because she saw him leaving the facility with him. She inquired what they were doing, the father said he was taking him to the doctor. The ADM said she agreed and said they had to come right back. The ADM was asked how did she know that Resident #1's father was not COVID positive at that time. She stated she did not know but the residents had a right to visit their families. The ADM then acknowledged the risk of Resident #1 going out with his father, who was not vetted as an essential caregiver, into the community where the COVID-19 rate was around 15%. The ADM agreed that when a resident was offsite with a family member in the community, there was no way to determine what contacts the resident had and if proper PPE was worn and social distancing observed. An interview with the weekend Front Desk Receptionist A on 11/25/20 at 11:17 AM revealed for essential caregiver visits, when a family member came to the front door and wanted to visit their loved one, she confirmed who they were, then confirmed they had a face shield, gloves and mask. She said the facility provided the isolation gowns. She stated the essential caregiver then had to sign into the kiosk system and complete a temperature check. She then would let the charge nurse or CNA know one of their residents had a visitor and they needed to come and escort them to the resident's room. She said there was a time limit of 2 hours for the essential caregiver visits. She said the negative COVID tests for essential caregivers were kept up to date in a binder at the front desk. She was asked about Resident #1's father taking him out of the facility to a doctor's appointment. She responded she had never had anyone leave with a family member on my watch. An interview with Front Desk Receptionist I on 11/27/20 at 3:02 PM revealed the family could not just take a resident out of the facility, the family member had to come in the facility and sign in through the system. Then, if they were wanting to take the resident out in the community and to a doctor's appointment, for example, We at the front desk must check to ensure they are an essential caregiver, have attestation form, trained on PPE and a negative test for covid within past two weeks. If not, they cannot take the resident or visit with them. There is no alternative. It is the rule. We make it very clear in our paperwork. She said she did not know why Resident #1's father was allowed to take him out for an appointment and she was not present when that happened. 2. An interview with LVN A on 11/24/20 at 4:42 PM revealed she was working on the quarantine hall 200. She said Resident #2 was the first individual to test positive for COVID-19. She said he did not leave his room and was bedfast and did not talk. He was bolus fed and did not have a roommate. LVN A said when he tested positive, he was moved to the COVID isolation hall on Friday 11/20/20. She said she worked that day and had taken care of him, took his vitals and fed him. She said he ran a fever during her shift. LVN A said she went with him to the COVID unit as his nurse since he was the only resident there on the unit at that time. She stated when she came back to work on 11/23/20 on the 2:00 PM-10:00 PM shift, she was on the COVID unit with him, but was then asked shortly after her shift started to help moved him back to his original room on Hall 100. She said she went to his room to help put a face mask on but he did not understand and kept pulling it off. She said she did not understand why he was being moved back to the quarantine unit and not staying on the COVID unit. She said she was worried about cross contamination but was following directives given to her by management. LVN A said when she arrived at work on 11/24/20, Resident #2 had been moved back to the COVID hall. LVN A said on the 100 hall, presently on quarantine, the residents came and went out of their rooms due to their cognition. She said they ate in their rooms some of the time, but they will freak out because they are kept in their rooms, so they will come out and it is hard to control them because you don't want to restrain them, but we have to watch them. She said there was one nurse and one aide for the quarantine hall for about 34 residents, many who had wandering behaviors and were entering other residents' rooms. An interview with LVN J on 11/26/20 at 4:49 PM revealed she had been the charge nurse for the COVID isolation unit since Monday, 11/23/20. She said the week prior, she had worked on station 100 Monday through Friday. She said Resident #1 was fine on 11/19/20 and 11/20/20, his change in condition happened over the weekend. She said Resident #2 got a fever on Friday 11/20/20 and was moved to the COVID unit. She stated when she came to work Monday 11/23/20, he was back in his old room on 100 hall, then he was taken back to the COVID isolation unit. She said, Something happened and they moved him back. She said no one explained to her why he was moved back and forth. LVN J said the next residents to come to the COVID isolation unit were Resident #5, then Resident #7, then Resident #4, all on the same 2-10 Monday shift on 11/23/20. She said when Resident #5 came to the COVID isolation unit that day, he started displaying signs of labored breathing and had a fever. She stated he was not feeling okay, he kept saying he had general body pain that could not be relieved with pain medication. LVN J notified the doctor, who said to send him to the ER. Interview with the DON at 6:20 PM at 11/24/20 revealed Resident #2 was the first resident to test positive for COVID-19 and had initially been moved to the COVID isolation hall and was running a fever on Friday 11/20/20. The DON said the decision was made not to move Residents #3, #4, #5, #6 and #7 off Hall 100, who subsequently tested positive that same weekend through a rapid test because we didn't want to have the group of them scattered on two different halls, so we moved (Resident #2) back to the 100 hall. She said Resident #2 went back to his regular room, and the others that were positive were kept together. The DON said, We had to get them to a point where stuff was ready and then move them out. The DON said they tried to keep the residents who were positive for COVID in their rooms during that time frame. She said she was not working in the facility that weekend but was in correspondence via phone with the nursing staff. The DON said, The wanderers were a challenge. We had one staff on that side trying to keep them in their rooms. She said the other residents on Hall 100 had all been tested on [DATE] and were all negative with the exception of the six already identified with COVID. She said the COVID unit, which had previously not been in use as a hot zone, was housing residents who were new admissions for quarantine and there were some logistics to moving those residents from that hall who had completed their 14-day quarantine. The DON said on Monday 11/23/20, all the COVID positive residents (Residents #2, #3, #4, #5 and #7) were moved to the COVID isolation unit. An interview with ADON K on 11/27/20 at 1:40 PM revealed the week prior on Hall 100, Resident #2 was first to test positive on 11/19/20 or 11/20/20 and he was moved to the COVID hall that same day. ADON K said, I do not understand why he was moved back to his room. It was not my decision. He should have never been moved, he should have stayed over here where we could have isolated him. She said she did not know when Resident #2 was moved back to Hall 100 or when he was moved back to Hall 200. She said, When he was moved back to 100, the residents back there will not stay in their rooms no matter how much you try, they will wander into other people's rooms. Observation of Hall 100 (quarantine hall) on 11/25/20 at 3:07 PM revealed multiple residents were coming out of their rooms ambulating on the hall, some sat down in the living room, some attempted to leave the hall towards the front of the facility. The residents outside of their rooms were constantly having to be redirected by the staff to go back to their rooms, to which they would and then come back out again within moments. An observation and interview with CNA H on 11/25/20 at 3:37 PM revealed she was redirecting several female residents who did not have masks on, to go back to their rooms. CNA H said she did not normally work on Hall 100, which was the quarantine hall. She said constantly having to redirect the residents was basically what she had to do during her shift, redirect the wanderers. 3. Review of Resident #2's quarterly MDS resident assessment dated [DATE] revealed he was a 58-year- old male admitted to the facility on [DATE] and readmitted on [DATE] from an acute hospital. He had unclear speech, was rarely understood, and had severely impaired cognition. He was totally dependent on staff for all ADLs. He used a wheelchair for mobility. His active [DIAGNOSES REDACTED]. He had a swallowing disorder which included coughing or choking during meals or when swallowing medications and required tube feedings. Review of Resident #2's progress notes dated 11/23/20 at 3:47 PM revealed, the SW called resident's son to notify him that Resident #2 was being moved to station 2 relating to being COVID positive. A note dated 11/24/20 at 10:55 AM reflected Resident #2's COVID-19 POC test was positive and he had been placed in quarantine unit. Review of Resident #2's November MAR reflected he was not monitored on 11/18/20, 11/19/20 and 11/20/20 during the 2-10PM shift for the following signs and symptoms of COVID: pulse, respirations, blood pressure, pain scale, and results. On 11/20/20 on the 6A-2P shift, the RN documented on the MAR that Resident #2 was running a fever of 99.1. No vitals were taken on the next shift with the exception of his temperature which had increased to 100.7. Resident #2 tested positive for COVID-19 on 11/20/20. Review of Resident #3's face sheet dated 11/27/20 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Review of Resident #3's November 2020 MAR reflected she was not monitored on 11/18/20, 11/19/20 and 11/20/20 during the 2-10PM shift for the following signs and symptoms of COVID: pulse, respirations, blood pressure, pain scale and results. Resident #3 tested positive for COVID-19 on Sunday 11/22/20. Review of Resident #4's face sheet dated 11/27/20 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Review of Resident #4's November 2020 MAR reflected she was not monitored on 11/18/19 (1st and 2nd shifts), and on 11/19/20 through 11/20 on the 2nd shift (2PM-10PM) for the following signs and symptoms of COVID: pulse, respirations, blood pressure, pain scale and results. Resident #4 tested positive for COVID-19 on Sunday 11/22/20. Review of Resident #5's face sheet dated 11/27/20 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] from a psychiatric hospital. His active [DIAGNOSES REDACTED]. Review of Resident #5's November 2020 MAR revealed he was not monitored for signs and symptoms of COVID (to include pulse, respirations, blood pressure, pain and results) on the following dates: 11/13/20, 11/17/20, 11/18/20 and 11/20/20 on the 6A-2P shift, and 11/18/20, 11/19/20 and 11/20 on the 2P-10P shift. His temperature on 11/22/2020 at 6:48 PM was documented as 103.6 °F, which was the day he tested positive for COVID-19. Review of Resident #5's nursing progress notes revealed, on 11/23/20 at 4:30 PM he complained of general body weakness and pain in his chest. Upon assessment, the nurse heard rattling in his chest, notified the physician and Resident #5 was sent to the ER. Review of Resident #6's face sheet dated 11/27/20 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. He was Spanish speaking and had active [DIAGNOSES REDACTED]. Review of Resident #6's November 2020 MAR revealed he was not monitored for signs and symptoms of COVID (to include pulse, respirations, blood pressure, pain and results) on the following dates: 11/17/20 through 11/20/20 on the 6A-2P. He was also not monitored on 11/18/20, 11/19/20 and 11/20/20 during the 2P-10P shift. Additionally, he was not monitored on the 6A-2P shift on 11/24/20. He tested positive for COVID-19 on 11/24/20. Review of Resident #7's face sheet dated 11/27/20 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Review of Resident #7's November 2020 MAR revealed she was not monitored for signs and symptoms of COVID (to include pulse, respirations, blood pressure, pain and results) on the following dates: 11/17/20 and 11/18/20 on the 6A-2P shift, and on 11/18/20-11/20/20 on the 2P-10P shift. Resident #7 tested positive for COVID-19 on 11/22/20. Review of Resident #8's face sheet revealed she was a [AGE] year-old female on hospice services who admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Review of Resident #8's November 2020 MAR revealed she was not monitored for signs and symptoms of COVID (to include pulse, respirations, blood pressure, pain and results) on the following dates: 11/19/20 overnight shift and 11/20/20 on the 6A-2P shift. She was also not monitored on 11/23/20 during the 2P-10P shift. She tested positive for COVID-19 on 11/24/20. Review of Resident #9's face sheet dated 11/27/20 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. Review of Resident #9's November 2020 MAR revealed she was not monitored for signs and symptoms of COVID (to include pulse, respirations, blood pressure, pain and results) on the following dates: 11/19/20 overnight shift and 11/20/20 on the 2P-10P shift. She was also not monitored on 11/23/20 during the 2P-10P shift. She tested positive for COVID-19 on 11/24/20. In an interview with LVN J on 11/26/20 at 4:49 PM LVN J was asked about the MAR for Residents #1, #2, #3, #4, #5, #6 and #7 not being monitored for the 2-10 shift for signs and symptoms of COVID where she had initialed it was not done. She said she checked the temperature and oxygen saturation levels, if they were within normal limits, she did not do anything else. She said, I would not check BP if they did not have blood pressure meds because a lot of those residents would not let me or are running around on the floor. It would force them to sit down. She said if oxygen saturation was above 95 and the resident was not complaining of anything, she did not feel a need to continue with the other aspects of the COVID monitoring assessment. She said she did not monitor respirations or lung sounds. An interview with ADON K on 11/27/20 at 1:40 PM revealed ADON K was asked who monitored the nursing staff who completed COVID monitoring on the residents' MARs. She said, I am doing my best, but right now I am not doing nurse manger because I am on the floor, as well as the other ADON and DON. She said the DON had been trying to tell the ADONs to make sure it was getting done, but I have been working the floor on 100 and it is very hard on every resident with falls, skins tears, families calling. ADON K then said, It's really auditing every day. They remind us often to oversee it, but I am trying to do the work of a charge nurse on the floor. We have limited staff so I am pulled to the floor trying to make sure I get my stuff done. 4. Review of the facility's rapid POC test completed for the week of 11/15/20-11/22/20 revealed Floor Tech D only had one COVID test completed for the week. An interview with Floor Tech D on 11/25/20 at 1:55 PM revealed he refused to be tested on Friday 11/20/20 for a rapid COVID-19 test at the facility. He said he was working and had other things to do. He said he asked the ADM if he could refuse it and she said yes, so he did. He said he had been tested already that week. He said he worked Friday 11/20/20, not the weekend, but did work 11/23/20-11/25/20. He said when he was at work the day prior (11/24/20), he realized staff and residents had tested positive for COVID, so he asked MR if she could test him. She did and he was negative. An interview with the ADM on 11/25/20 at 2:05 PM revealed told Floor Tech D that he could refuse the COVID test on 11/20/20. The ADM said she was told by the local county health department the facility staff only had to test once a week, and the second COVID test was optional. She said when the county's positivity rate was over 10%, staff had to be tested twice a week. She was not sure when the county went over 10%. She said if a staff member refused to be tested or was not available, then her guidance from the health department was to monitor their symptoms and screen them when they came to work, and they could work and just wait for the next facility testing date. She said when the facility went to twice a week testing, she had a very hard time getting staff to come up on their off days to get that second test. She said some did not have money for gas, some did not want to come on their day off. She said, But if we screen them before they work, they can come on the floor, even if they have not had that second test for the week. An interview with ADON G on 11/25/20 at 2:49 PM revealed the facility tested twice a week on Wednesday and Fridays and Saturdays for weekend staff that did not make it in during the week. She said if staff refused to be tested or could not make the testing day, they had to be tested before they worked to keep everyone safe. She said it was ultimately up to the discretion of the administrator if they could work. She said the receptionist kept a list of staff who did not test and management tried to reach out to them before they came in and to let them know they needed to be tested before they came in. ADON G said the ADM had been doing most of the COVID monitoring. Regarding a change in resident vitals, ADON G said if a resident had a change in vitals, such as an elevated blood pressure, elevated pulse, she expected the medication aide to notify the nurse, the nurse then notified the doctor, DON and ADM so we are all on the same page. An interview with MR on 11/26/20 at 2:45 PM revealed as of 11/23/20, the requirement was to test facility staff twice a week because of the new COVID positive cases in the building. She said they had been testing twice a week in October 2020 but went to a mandatory once a week November 2020. She said her directives came from the ADM, who stated she had been told through her sources that when Dallas County was over ten percent COVID positivity rate, the nursing home had to test their staff twice a week, but only one was mandatory. MR said as a result, she tested staff twice a week, but they only had to test once a week if they wanted. MR said the rule had always been if a staff member could not test, then they could not work until they produced a negative COVID-19 test from that same week in order to work at the facility. If they could not produce the negative test results, they were taken off the schedule. She said the ADM and front desk staff tracked who tested and who did not and alerted the ADON's and they were supposed to be taken off the schedule. MR said she was off on vacation when the facility tested the staff, so she was not aware that Floor Tech D did not complete a 2 (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #2) of four residents reviewed for supervision. The facility failed to provide Resident #2 adequate supervision to prevent elopement after she displayed exit seeking behavior and elopement attempts. Resident #2 eloped on 03/11/20 and was found by the police. The facility did not implement any additional measures to prevent further elopements and Resident #2 eloped again on 04/07/10 and 04/10/20. An Immediate Jeopardy (IJ) was identified on 05/13/20. While the IJ was removed on 05/15/20, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. The administrator was provided the IJ Template on 05/13/20. This failure could place residents at risk of elopement, resulting in physical harm, injury, emotional distress, or even death. The findings included: Review of Resident #2's face sheet revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #2's quarterly MDS assessment, dated 02/25/20 revealed her cognitive skills were severely impaired. The resident was assessed as having wandering behaviors daily. Resident #2 required supervision with walking and transferring. The resident used no mobility devices. [DIAGNOSES REDACTED]. Review of Resident #2's Care Plan, last revised 03/15/20, revealed the resident had eloped on 03/11/20, but the Care Plan indicated the problem began on 01/02/20 due to an initial elopement attempt that was investigated. Interventions began on 01/02/20 reflecting the resident had a wanderguard and it would be checked every shift for placement, alarm system checked by maintenance every shift to ensure proper functioning, the resident's name will be posted in binder at nurses station with residents at risk of elopement, staff will be aware of Resident #2 watching the door as she was preparing to exit. A second elopement was documented on the care plan as having occurred on 03/11/20, and the available intervention listed was that Resident #2 would be placed on one-on-one observation for three days to ensure no further elopement attempts were made. There were no other elopements or interventions listed for the resident after the 03/11/20 date. Review of the facility's Event Report, dated 03/11/20 and completed by LVN D, revealed Resident #2 eloped from the building and walked all the way to the street. Police found the resident and returned her to the facility. The report indicated Resident #2 always wants to go home to see her parents. The resident's family member told the facility staff that Resident #2 would elope at any slight opportunity. According to the report, Resident #2 was last seen by the assigned staff at the nurses station when the aide went to provide care for another resident. The resident was placed on 15 minute checks. Review of the facility's Provider Investigation Report (PIR) related to Resident #2's elopement, dated 03/15/20, revealed Resident #2 was seen at the atrium doors on 03/11/20 when EMTs entered the facility with an empty stretcher to pick up a resident. The paramedics spoke with Resident #2 when they entered and then she exited the facility. The PIR summary revealed Resident #2 was found two blocks from the facility searching for her former house. According to the PIR two ladies had stopped to talk to the resident and then called 911 because they felt she was confused. The police had already been notified by the facility and were looking for the resident. Review of Resident #2's clinical record reflected a Q-15 Minute Log dated 03/11/20 with all dates and times for the first, second, and third shift filled out. There were no other available Q-15 Minute logs for the month of March 2020 or April 2020. Review of Resident #2's progress note, dated 04/07/20 and documented by LVN D, revealed Resident #2 eloped at approximately 5:00 p.m. on 04/07/20. The resident was found by a staff member on the street behind the facility. According to the progress note Resident #2 exited through the back door at station four by the TV area. Staff said they did not hear the alarm on the door sound. The alarm was tested and was found to be turned off. The note indicated the resident had been seen by another resident and was observed by a staff member who was in the parking lot. The resident was returned to the building and she continued to say she wanted to go home. Review of the facility's event report, dated 04/10/20 and created by RN A, revealed Resident #2 was located offsite at the intersection of two streets. The event report indicated Resident #2 had unsuccessful elopement attempts in the past as well as successful elopement attempts. According to the event report Resident #2 had a history of [REDACTED]. Resident #2 exhibited agitation, anxiety, and confusion when exit seeking. The resident's [DIAGNOSES REDACTED]. Notes documented in the event report revealed when staff checked Resident #2's room to provide care, the resident was not in her room. The staff checked every room and then announced a Code Purple, indicating a missing resident. Staff searched throughout the facility and outside of the facility but were unable to locate her. RN A called 911 to report Resident #2 missing and gave a description of Resident #2. After hearing the description of the resident, the police informed RN A they had found the resident at the intersection of the two streets. Later the police called and provided the address so someone from the facility could come pick up the resident. Review of Mapquest.com on 06/01/20, revealed the intersection at which Resident #2 was found following her elopement on 04/10/20 was 1.4 miles and a 34 to 35 minute walk depending on the route taken. The walk would have required the Resident #2 to cross a major busy intersection with a lane going in each direction and a median splitting the lanes. Review of the facility's Provider Investigation Report, dated 04/10/20, Resident #2 was not in her room when staff checked on her. The staff began searching and announced a Code Purple, informing staff there was a missing resident. The police were called and they told staff they had found the resident near an intersection. Review of Resident #2 progress note, dated 04/10/20 at 9:19 p.m. and documented by RN A, revealed when the staff went to Resident #2's room to change here, the resident was not in the room. According to the note, the staff checked the hallway and informed the nurse. Staff began searching every room and announced a Code Purple, which indicated a resident was missing. The note indicated RN A contacted 911 and police were notified of the missing resident. RN A was informed by the police Resident #2 had found at the intersection of two streets. CNA staff went to pick up the resident. Interview with LVN D on 05/13/20 at 2:52 p.m. revealed Resident #2 eloped twice while he was working. The first time occurred on 03/11/20. He stated the resident was standing at the door when the paramedics came in the door and she walked out the atrium door. LVN D said there was no alarm on the door so the resident could have exited without the paramedics entering the facility. LVN D said Resident #2 eloped again on 04/07/20. He said she exited the door, and a resident saw her. A staff member was in the facility's parking lot, saw the resident, and brought the resident back into the building. LVN D said the resident continued to exit seek. Interview with RA E on 05/13/20 at 3:23 p.m. revealed she was in the facility parking lot on 04/07/20 at 5:00 p.m. when she observed Resident #2 walking in the street that runs in front of the facility. RA E stated Resident #2 was near the warehouse located next to the facility. The CNA approached Resident #2 and returned her to the facility. Interview with RN A revealed Resident #2 had eloped during her shift on 04/10/20. She said the resident was very anxious and had wandered and twice before on that evening she had tried to exit the facility. RN A stated Resident #2 was taken to her room by CNA B after 7:30 p.m., but when he returned to check on Resident #2, she was not in her room. RN A stated the police were notified, and when she described the resident, the police reported they had someone matching that description. The RN reported the facility did not have a Secure Unit. Interview with CNA B on 05/13/20 at 4:57 p.m. revealed he was the CNA working with Resident #2 when she eloped on 04/10/20. He said he assisted Resident #2 to bed and then returned ten minutes later to check on her, but the resident was not in the room. He said staff searched throughout the facility, and RN A called the police. He stated Resident #2 had been located by the police. CNA B stated staff were equired to check on the resident every ten minutes prior to this elopement. CNA B reported that they do not know what door she exited that evening. Interview with CNA C on 05/13/20 at 3:35 p.m. revealed she had worked with Resident #2. She said Resident #2 often cried in the evening and it the resident's crying and exit seeking worsened. CNA C said she was working the evening of 04/10/20 when Resident #2 eloped. She said when the nurse called the police, she was informed that the police officers were with the resident. CNA C said she went to pick up the resident from a residential area where the resident was waiting with the police. She said she did not remember the time, but she knew it was dark when she arrived to get the resident. CNA C said someone had turned off the door alarm and did not turn it back on so it did not sound when Resident #2 eloped. CNA C said she did not have a key to turn the alarm off and turn it back on. CNA C stated when the alarm was on if Resident #2 tried to exit the doors at the ends of the hallway, the alarm would sound. She stated that a key was necessary to turn the alarm off once it was activated and the key was also used to re-alarm the door. Interview with CNA F on 05/14/20 at 12:07 p.m. revealed she was working one time when the resident eloped, but she was not working the resident's hall. The CNA explained in the evenings Resident #2 would begin sun-downing and she would try to exit through the doors. She stated Resident #2 would become physical if staff attempted to intervene. The resident was moved to another hall because it was smaller than the hall she was living on. CNA F said Resident #2 had been this way since she admitted to the facility on [DATE]. Interview with LVN G on 05/15/20 at 11:45 a.m. revealed when the door alarms sound, a key must be inserted in the door and turned one way to turn the alarm off. She said to reactivate the alarm, the key must be turned the opposite direction, and it will beep three times indicating the alarm has been reset. She said Resident #2 had attempted to elope three or four times this morning, setting the alarms off. Review of the facility's policy for Wandering and Elopements, revised March 2019, revealed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The administrator was informed of the immediate jeopardy on 05/13/20 and was provided with the IJ template. A Plan of Removal was also requested at that time. The following Plan of Removal was accepted 05/15/20: On 5/13/2020 at 8:30 pm Station 100-Already put in place 1 employee will be posted in the center of the station to watch the doors at both ends of the station to include the corridor door leaving station 100 for all shifts. Corridors are closed on each station due to ensuring if a resident or employee test positive for [MEDICAL CONDITION] it will not be transported to another station in our facility. Same staff work on same stations. Front lobby door monitored by the receptionists. Station 200 has no residents on the station. Station 300 has no residents on the station. Station 400 an employee will be posted in the center of the station to watch the doors at the end of the station to include the corridor door leaving station 400. Station 500 an employee will be posted in the center of the station to watch the doors at the end of the station to include the corridor door leaving station 500 going to station 400 and door going to station. The doors are closed on station 500 and to the corridor going to station 300 due to this is a quarantine unit. This was our temporary plan and ending at 2 pm on 5/14/2020 due to we have completed the training with our Hospitality aide to monitor all door every 15 mins. (See next paragraph) On 5/14/2020 at 2:00 PM going forwarded Director of Nursing / Maintenance Director already put a plan in place to provide training to our hospitality aide to round in facility every 15 mins to check all door alarms to ensure they are armed and wander guard alarms working correctly. All door alarm keys have been removed from each Charge Nurse to ensure they do not have the ability to turn off the alarms. Hospitality aide and Maintenance will be the only persons who will have the alarm keys and the wander guard alarm to check the doors. If the alarm sounds the hospitality aide will be responsible to re-set it. Charge Nurse will call a code purple and complete a head count. We will have a hospitality aide in the facility 24 hours a day, 7 days a week. This plan will remain in place until all doors have wander guard alarms installed and reprogrammed to ensure alarms reengages after 3-5 seconds. All new hires and PRN employees will be trained at the beginning of their shift. On 5/13/2020 Maintenance Supervisor already put in place training with all employees to ensure everyone is aware of how to operate door alarms. Maintenance also trained problems with the alarms to report it immediately to the maintenance department. All new hires and PRN employees will be trained at the beginning of their shift. On 5/13/2020 already put in place the Administrator has provided training to the Maintenance Department, Maintenance Assistant and the Housekeeping Supervisor to ensure the alarms are checked 2X daily to ensure door alarms are working correctly to include the wander guard doors, 7 days a week. New hires and PRN employees will be trained at the beginning of their shift. On 5/13/2020 already in place the Director of Nursing started new elopement assessments on each resident to ensure everyone who was at risk had a wander guard on. Completed on 5/14/2020. On 5/13/2020 plan already in place for all new admission will be placed on our quarantine unit for 14 days. Admitting Nurse will complete elopement assessment immediately upon admission. If the resident is at risk a wander guard will be placed on the resident and their information will be placed in our elopement binder at each station. Director of Nursing begun training on 5/13/2020. New hires and PRN employees will be trained prior to their shift starting. Monitoring of the plan of removal included the following: Reviews were made of the newly completed elopement risk assessments for all residents in the facility. Interview with HA G on 05/14/20 revealed she was responsible for checking every door, wanderguards and alarms in the facility every 15 minutes. HA G said she was the only staff with a key to the door alarms to turn off the alarms and reactivate the alarms. She said to turn the alarm off, she had to put the key in the door alarm and turn the key to turn it on, she reversed the direction of the key to reactivate the alarm. HA G stated there were green indicator lights when the alarms were off, and the alarm displayed red indicator lights when the alarm was on. Interview with HA K on 05/15/20 at 11:09 a.m. revealed she was responsible for checking all of the doors every 15 minutes to ensure the alarms were set and the wanderguards were on. HA K said they had one staff each shift that was responsible for that task. HA K stated a head count must be completed if an alarm went off. Interview with HA G on 05/15/20 at 11:09 a.m. revealed she was called in to observe Resident #2 as she had been trying to elope. HA G said she had tried to elope 05/14/20 at approximately 7:00 p.m. but the resident was stopped. Interview with CNA E on 05/15/20 at 11:40 a.m. revealed she had been trained on the new elopement protocol. The CNA explained that there was one person per shift responsible for checking the doors. That person had the key to the alarm and must turn off the alarm and reactivate the alarm. Following the alarm sounding, a head count must be completed. Interview with LVN H on 05/15/2020 at 11:45 a.m. revealed she had been trained to call a Code LVN H reported the only staff that could turn off the alarm and reactivate it was the hospitality aide who had been assigned the duty. Residents who were newly admitted must be assessed for elopement risk. She added if a resident was an elopement risk, their information was placed in a binder at the nurses' station. Resident #2 had set off the alarms that morning three or four times. Interview with CNA I on 05/15/20 at 2:46 p.m. revealed the designated hospitality aide was responsible for checking any door alarms. He said if an alarm sounded, a head count must be completed immediately. Interview with the Housekeeping/Laundry Supervisor on 05/15/20 at 2:42 p.m. revealed she had been assigned to check the alarms on the doors two times daily in addition to the 15minute checks. Interview with the Assistant Maintenance Director on 05/15/2020 at 3:10 p.m. revealed he has been assigned to check the door alarms to ensure they were activated and working two times daily. Interview with LVN J on 05/15/2020 at 2:46 p.m. revealed when a new admit entered the facility the admitting nurse must immediately complete an elopement assessment. She said if the alarm sounded, staff must the staff immediately did a head count. If someone was missing, an elopement would be announced. An Immediate Jeopardy (IJ) was identified on 05/13/20hile the IJ was removed on 05/15/20, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. The administrator was provided the IJ Template on 05/13/20.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free from accident hazards as was possible and each resident received adequate supervision to prevent accidents for two (Residents #1 and #2) of nine residents reviewed for supervision. 1. Driver A failed to assist Resident #1, who was in a wheelchair, off the facility van after returning to the facility after the resident's dialysis treatment. Resident #1 was left in the van without supervision with the windows rolled up from approximately 3:45 PM to approximately 5:00 PM. The temperature outside was approximately 85 degrees. Resident #1 had to crawl out of her wheelchair and from the back of the van to the driver's side door to open the door and push the horn. Resident #1 was crying, anxious and in pain when she was found. The resident was still fearful and upset about the incident after her discharge from the facility. 2. The facility failed to ensure drivers checked the van after transporting residents to appointments to ensure no residents were left unattended in the van and continued to transport Resident #2 to appointments after the incident. 3. The facility failed to train the drivers on ensuring no residents were left unattended in the facility van after the incident with Resident #1 and continued to transport Resident #2 to appointments. An Immediate Jeopardy (IJ) was identified on 05/25/16. While the IJ was removed on 05/27/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures could affect all 130 residents, who could be transported in the facility van at any time, by placing them at risk for neglect, injuries, pain and stress on their well-being and causing other serious mental/physical harm and/or death. Findings included: Review of Resident #1's Face Sheet, received 05/25/16, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating no cognitive impairment. Resident was alert and to name, place and time. Resident required the assistance of one person assist with activities of daily living. Review of Resident #1's Care Plan dated 04/11/16, revealed Resident #1 had anxiety and cognitive loss, difficulty understanding and delusions regarding staff plotting against her. Interview with LVN F on 05/26/16 at 11:49 AM revealed resident #1 was alert and oriented X3. She stated when Resident #1 ambulated, it was slow and steady with use of a rolling walker. LVN F revealed Resident #1 carried O2 with her. The Resident was transported to dialysis in her wheelchair with the O2 tank attached to the back of the wheelchair. Interview with the PT on 05/26/16 at 11:25 AM revealed Resident #1 required supervision with a rolling walker. The PT stated therapy was working with Resident #1 to rebuild the resident's stamina since the resident was on oxygen. Review of Resident #1's Dialysis Communication Record dated 05/07/16, revealed her blood pressure was 138/81, Temperature at 98.4. There was no time as to when her vitals were taken. There was no time indicating when the resident left to go to dialysis or returned to the facility. Resident #1's nurses' notes dated 05/07/16, timed at 4:31 PM and signed by LVN D revealed Dietary aide reported a pt (patient) was on the van blowing the horn immediately in the middle of doing blood sugars I stopped what I was doing and followed dietary aide to the back. Pt was at the front of the van sitting down sounding the horn off. Pt had driver side door open and crying and stating the van driver forgot about me and left me on the van for hours after coming back from dialysis. Pt was assisted to the back of the van to her w/c then assisted into her w/c X3 assist. Pt assisted back to her room and assessed. DON notified order to monitor pt. alert and oriented to name, place and time. Pupils are unequal and reactive to light. Head and neck within normal limits bilat upper and le weak. (sic) Color pink warm to touch. Fair turgor. Old bruising to abdomen and 3 + edema to bilat feet. pt was offered water and juice pt stated she wanted 7up and it was given to her. pt is being assessed every hour x2 then every 2 hours. Pt uses a w/c and rolling walker with assist. Resp even non labored with O2 at 3l/nc with O2 stat 98%, 98.2 138/69 89 20 cough noted nonproductive. Pt requested pain pill 2 hydrocodone given and pt wanted anxiety pill after 30 in which it was given. Dialysis center notified about the time pt left dialysis center worker states pt got off machine at 3:15 and she doesn't know exactly what time she was picked up. I spoke with the driver after assessing pt and he stated I got distracted cause I usually park in the front and some reason I went to park at the back I just forgot and I apologized to her and I'm truly sorry it happened. At 6:45pm 143/78 89 20 98.7 O2 stat 98% on 3L/NC. Interview with Resident #1 via telephone on 05/25/16 at 4:31 PM revealed Resident #1 stated she was trapped in the van for at least an hour (05/07/16). Resident #1 stated the driver pulled to the back of the facility, which he had never done before. The driver then got out of the van and into another vehicle and drove away. Resident #1 stated she remembered thinking to herself surely he is not going to leave me in here. Resident #1 stated she finally figured out how to unstrap herself from her wheelchair and made it to the front of the van. She made it to the driver's seat and opened the door for air and began honking the horn. Resident #1 stated she had been honking the horn for 20 to 25 minutes until someone came to help her. Resident #1 stated she could not breathe because it was so hot and she did not have any oxygen. Resident #1 revealed she was sweating and crying when staff finally found her. She stated the nurse did an assessment but she was such in shock she could not tell them her back was hurting and she hurt her heel. Resident #1 stated the Administrator came to talk to her the following Tuesday (05/10/16) and told her she would be back to get her statement but never returned. During the interview Resident #1 became upset and began crying when she told the investigator what had happened. www.weatherundergrond.com Weather History for KDFW on 05/25/16, revealed on 05/07/16 at 3:53 PM outside temperature was 84.0 degrees with 35% humidity. www.accueweather.com forecast on 05/25/16 revealed on 05/07/16 high temperature of 85 degrees. www.weather.com on 05/25/16, revealed, the Department of Geosciences San Francisco University - Estimator Vehicle Interior Air Temperature vs Elapsed Time by revealed outside temperature of 85 degrees after 10 minutes the interior of the vehicle will reach 104 degrees; 20 minutes will reach 114 degrees; 30 minutes will reach 119 degrees; 40 minutes will reach 123 degrees; 50 minutes will reach 126 degrees; 60 minutes will reach 128 degrees; over an hour interior temperature will reach 130 degrees. Interview with LVN D on 05/25/16 at 8:38 AM, revealed Resident #1 usually returned to the facility from dialysis between 4:10 PM and 4:15 PM. LVN D explained she was just about to call the dialysis to see what was going on when someone from dietary came and told her someone was in the facility vehicle. LVN D stated it was 4:15 PM when the dietary aide came and told her there was someone in the vehicle because she remembered looking at the time. LVN D explained she followed the dietary aide out and saw Resident #1 in the vehicle. LVN D stated the facility driver left the resident in the vehicle, got into his personal vehicle and drove off. LVN D stated Housekeeper H and a dietary aide found Resident #1 in the vehicle. The dietary aide heard Resident #1 honking the horn of the vehicle. LVN D revealed Resident #1 was sitting in the driver's side of the vehicle with the door open. LVN D explained Resident #1 had unstrapped herself from the wheelchair at the back of the van and walked to the front of the van to the driver's side. LVN D stated Resident #1 was discovered in the van at 4:15 PM. Interview with LVN D on 05/25/16 at 9:57 AM revealed the resident was wearing short sleeves and pants that were light material. Interview with Dietary Aide I on 05/25/16 at 8:45 AM revealed it was around dinner time when he heard the honking of the horn. Dietary Aide I stated he thought it was maintenance working on the van. Then about 30 minutes later he went outside to take the trash out and heard the honking again. Dietary Aide I stated that was when he saw the resident (Resident #1) in the vehicle waiving her hands and pulling on her shirt like she was hot. Dietary Aide I stated he then went to check on the resident and told Dietary Aide J who came out to the van. Dietary Aide I stated he stayed with the resident while Dietary Aide J went to go get the nurse. Dietary Aide I stated it was around 5:00 PM when the resident was found in the van. Interview with Housekeeper H on 05/25/16 at 8:45 AM revealed the resident (Resident #1) was in the driver's seat of the van. Housekeeper H stated she was able to unlock the back of the van manually and lower the lift. She then assisted getting Resident #1 back into her wheelchair and lowered the wheelchair with the resident in it out of the van using the lift. Housekeeper H stated it was around 5:00 PM when resident was found in the van. Review of the written statement by Housekeeper H dated 05/09/16, revealed On Saturday the 7th at around 5:00 PM (Dietary Aide J) from dietary came and told me there was a patient in the bus alone. I went outside and opened up the back door to the bus and got inside then helped her get into her wheelchair for the bench seat. I was able to get her to the lift and out of the bus. I then brought her to the nurse on station 2. I believe I saw him (Driver A) come back from dialysis around 3:30. Interview with Dietary Aide J, the cook and Dietary Aide K on 05/25/16 at 1:09 PM revealed they heard honking around 3:30 PM and kept looking out the window to see where the honking was coming from. When asked how they knew it was 3:30 PM, she (Dietary Aide K) stated because that was what time they go on break. Dietary Aide K stated at around 5:00 PM Dietary Aide I told her (Dietary Aide J) there was someone in the van. They stated when she (Dietary Aide K) went out to the van and the resident was waiving her arms for help. They stated the resident was crying and upset. Dietary K stated Resident #1 told her she unfastened herself from the wheelchair and crawled to the driver's seat. She (Dietary Aide K) stated the driver's side door was opened but the resident could not get out. Dietary K stated she continually heard the honking from 3:30 PM until 5:00 PM when Resident #1 was found. Review of the written statement signed by Dietary Aide I, Dietary Aide J and Dietary Aide K, dated 05/09/16 revealed On May 7, 2016 (Dietary Aide K and Dietary Aide J) were taking out brake (sic) when we first heard the honking. It was around 3:30 PM and we would look around and see if we say (sic) anybody. We were like that until around 5 PM. When (Dietary Aide I) told us there was somebody stuck inside the bus. We rushed outside. I (Dietary Aide K) ran one to look for nurses and (Dietary Aide J) ran the other to look for maintenance or housekeeping people. And (Dietary Aide I) stayed with the resident to calm her down. Me (Dietary Aide K), (Dietary Aide I and Dietary Aide K), stayed to help the nurses and (Housekeeper H) to take the resident out of the bus. And after that we went back to work and the nurses to the resident back to her hall. Observation of the kitchen exit to the back parking lot on 05/25/16 at 1:15 PM revealed there is was a door leading to the back parking lot with a small window approximately 10 in x 10 in. When looking out the window someone would be are able to see the passenger side, front half of the van. The tinting on the van windows was dark and it would be difficult to see if someone was sitting in the driver's side of the vehicle. Resident #1's MAR dated 05/07/16 reflected Xanax (anti-anxiety) 0.25 mg was administered to her at 6:00 PM on 05/07/16. The MAR also reflected PRN Norco 10-325 mg; was administered at 9:40 PM for bilateral leg pain on 05/07/16; at 5:59 AM on 05/08/16 for bilateral leg pain; and on 05/09/16 at 11:29 AM for bilateral leg pain. The four days prior to the incident, Resident #1 did not request any PRN pain medication. Resident #1's nurses' notes dated 05/07/16, timed at 7:51 PM and signed by LVN E revealed the following: Resident's family member .came to facility and was very upset that (Resident #1) was left on the van for an hour with windows rolled up and when driver was asked he said he forgot . Dialysis Center was called and stated that Resident has been picked up around 3:45pm . Resident evaluated and assessed - vital signs within normal limit, but expressed fear and insecurity. Resident also requested to go home with the daughter (family member) who declined that (he/she) was going for work in the night and later Resident asked for Xanax - which was then administered. Nursing staff commenced on q2-3 hours checks and increased fluids for hydration. Will continue to monitor. Interview with LVN E on 05/25/16 at 9:57 AM revealed she was working as the weekend supervisor when the incident occurred. LVN E stated the resident was not upset, was not crying and did not understand what had happened. Further interview with LVN E on 05/25/16 at 2:48 PM revealed Resident #1 was found in the van between 4:15 PM and 4:30 PM. The LVN stated when she interviewed the dietary staff following the incident they were unable to give her times of when they heard the honking. LVN E stated she called the dialysis center following the incident and was told the resident got off the machine at 3:15 PM and was picked up around 3:45 PM. Resident #1's face sheet provided on 05/26/16 reflected she discharged from the facility on 05/15/16. Interview with the DON on 05/25/16 at 12:36 PM revealed there was not an incident/accident report completed on the incident because the nurse that day did not know where to put the incident under the event so everything was completed in a nurses note. Observation of the facility van on 05/25/16 at 3:00 PM revealed the van was parked in the back parking lot. The vehicle was a 15 passenger van with wheelchair access in the rear of the vehicle. Passenger entry to the van was similar to a standard school van with two steps to enter the vehicle. The driver's side entry of the van is was one step entry. Interview with the PT on 05/26/16 at 11:25 AM revealed she could not say whether Resident #1 would have been able to get out of the van and walk to the facility on her own without assistance. The PT stated Resident #1 did not work on the stairs so she could not say whether the resident could have stepped down from the van without assistance. Interview with Driver B on 05/25/16 at 3:00 PM revealed Resident #1 normally was picked up from dialysis around 3:15 PM and 3:20 PM when she is was finished. Driver B stated Resident #1 was in a wheelchair. He revealed the wheelchair would have been strapped down in the back of the van and a strap with a buckle across the resident's lap. Driver B stated Resident #1 would not have been able to open any of the doors without the key to the van except the driver's side door. Driver B stated the van heats up quickly and there is was no air circulation. Driver B stated the dialysis center was approximately five minutes away. Interview with the Dialysis Center on 05/25/16 at 3:15 PM revealed Resident #1 was unhooked from the dialysis machine at 3:15 PM. There was no record of what time Resident #1 was picked up from the dialysis center. Review of MapQuest.com on 05/25/16 revealed, driving directions revealed from the facility to the dialysis center was 2.3 miles estimated drive time of six minutes. Review of the facility's undated Investigation Summary received on 05/25/16, revealed According to dialysis center, patient was picked up from dialysis at approximately 3:45, dialysis was completed at 3:15. Driver brought resident back to facility and arrived at around 4 PM. DON received call at 4:14 PM from LVN D stating resident was found on van by one of the dietary aides. Resident was on van approximately 15 minutes after arriving back to the facility. The driver was suspended and then terminated on May 9th. Current driver in-serviced on May 12th, her first day back after being in the hospital. Review of HR documented phone conversation dated 05/09/16 revealed, (Driver A) was asked if he could explain what happened over the weekend. (Driver A) stated that he picked up the resident at about 3:45 PM, he drove from the dialysis center which took about 15 minutes. He arrived back to the facility at about 4:20 PM, he pulled in got out of the van and clocked out for break. He stated that when he returned from his lunch (5:16 PM) he was told by other staff member that a resident was found on the van. He stated he was not sure what happened to make him forget the resident. HR asked if he was distracted in any way, he stated no, I just forgot she was there. Interview with Administrator on 05/25/16 at 9:25 AM revealed Driver A stated he blacked out and did not know what happened. The Administrator stated an in-service was completed with the other facility drivers. Interview with the Maintenance Supervisor on 05/25/16 at 9:40 AM revealed there is was no formal policy in place regarding ensuring all residents are were of the van and accounted for. When a new driver was hired, they were trained to drive the van by a current driver and trained how to use the wheelchair lift. The driver training the new driver would sign off that the new employee was ready to drive the van. The Maintenance Supervisor stated the only people authorized to drive the van were himself, Driver B and Driver C. Driver B was the main driver, himself and Driver C were back-ups if Driver B is was not available. He stated all drivers must be cleared through the insurance. The Maintenance Supervisor stated there had been no formal training following the incident. He revealed that staff just talked among themselves. Interview with Driver B on 05/25/16 at 11:35 AM revealed she was asked by the Administrator to sign something that day (05/25/16) saying she was trained on 05/12/16. Driver B stated she did not receive any training on 05/12/16 or 05/25/16. Driver B stated she told the Administrator she was not going to lie. Review of Staff Development Attendance Record dated 05/12/16 revealed Driver B received verbal training regarding understand safety when transporting residents. Interview with the DON on 05/25/16 at 9:28 AM revealed following the incident an in-service was conducted with floor staff. The DON stated Resident #1 left the dialysis center around 3:45 PM and arrived at the facility around 4:00 PM. She revealed the resident was only in the van for 15 to 30 minutes. A head to toe assessment was completed and vitals checked. There were no injuries noted. Review of an undated Transportation In-Service received 05/25/16 revealed Reviewed policy with facility transportation aide (Driver B) regarding immediately removing residents from van or bus and also always checking vehicle after parking in back to ensure no resident or resident property left on vehicle. Interview with LVN F on 05/25/16 at 8:33AM revealed she had not received any in-services following the incident involving Resident #1. Interview with LVN D on 05/25/16 at 8:38AM revealed she had not received any in-services following the incident involving Resident #1. Interview with Driver B on 05/25/16 at 8:58 AM revealed she was trained to drive the van by Driver A. Driver B stated she had not received any additional training following the incident. Driver B stated when a resident was brought back from an appointment, the driver should take the resident to the nurse's station. Driver B explained a resident would not have been able to open any other door of the van other than the driver's side door without the key to the ignition. Interview with the Administrator on 05/25/16 at 10:17AM revealed there had been no new policies or procedures implemented since Resident #1 was left in the van after her dialysis appointment. Interview with the Maintenance Supervisor on 05/25/16 at 10:28 AM revealed following the incident on 05/07/16 no one drove the van until Driver B returned from leave on 05/12/16. All residents were transported by private transport. Interview with Driver B on 05/25/16 at 11:35 AM revealed she transported residents daily to various locations, doctors' appointments, the bank and the store. She stated other than Resident #1 the only other resident in the facility who had a standing weekly appointment is was Resident #2. Driver B stated a transportation book is kept for resident's scheduled appointments. Review of Resident #2's face sheet provided on 05/25/16 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Resident #2 was alert and oriented. Review of the transportation book on 05/25/16 revealed Resident #2 would have requested transportation on 05/09/16. Interview with Resident #2 on 05/25/16 at 11:27AM revealed the resident was alert and oriented. Resident #2 stated he had never been transported to his therapy appointments by a private transport. Resident #2 stated when Driver B was on leave, Driver C took him to all of his appointments. He stated he had never been driven by anyone else other than facility staff. Interview with LVN G on 05/25/16 at 12:20 PM revealed Resident #2 had never used a private transport to go his appointments. LVN G stated he had always been transported by the facility driver. LVN G stated when Driver B was out on leave, Driver C took Resident #2 to his appointments. Interview with Driver C on 05/27/16 at 8:50AM revealed he had driven the facility van. Driver C stated when Driver B was out on leave he drove Resident #2 to his appointments. Driver C stated Resident #2 was the only resident he had driven. Driver C stated he did not receive training following the incident but he received additional training over new transportation policy and abuse and neglect the past couple of days. Interview with LVN F on 05/25/16 at 11:30AM revealed the facility driver was utilized as much as possible to transport residents to appointments. The only time a private transport was used if there were appointments times overlapping. Review of Driver A's personnel file on 05/25/16, revealed a hire date of 08/13/12 as a driver, Driver A had previous incident involving the facility van on 08/11/15 when Driver A was using the vehicle for personal use and hit a telephone pole. There were no residents in the van at the time of the incident. The facility policy was reviewed with Driver A regarding use of facility vehicle. Review of Progressive Counseling Notice Form dated 05/10/16, revealed Driver A was terminated on 05/10/16. The Incident description reflected: On 05/07/16 (Driver A) has (sic) picked a resident up from an appointment and when returned to the facility got out of the bus and forgot resident inside. Resident was left in bus unattended for approximately 40 minutes until found by other employees. Review of Vehicle Business - Use Policy dated August 2012 revealed all drivers must possess a valid Texas driver's license, and required motor vehicle check and operate motor vehicles in a safe manner at all times. All occupants were required to use seat belts or other restraint devices at all times when in the vehicle. The Vehicle Business - Use policy did not include procedures to check the vehicle to ensure no residents were left on the vehicle. The facility's Abuse Prevention Program dated August 2006 revealed the policy provided did not define neglect. An IJ was identified on 05/25/16 12:06 PM. The Administrator was notified of the IJ. A Plan of Removal was requested. The facility's Transportation Policy dated 05/25/16 implemented on 05/25/16 after Immediate Jeopardy was identified, revealed the purpose of the policy is to ensure that facility nurses are made aware of the resident residing on their halls is returning from appointments. Procedure: 1. Per current procedure nursing will document transportation needs in transportation book, noting if outside transportation - our contracted company or in house transportation. 2. Nurse will document on log and in notes that resident has left the facility for appointment. If resident leaves with family or responsible party this is documented in separate sign out book. 3. In house transportation driver will contact nursing staff at facility when driver has picked up resident and is returning to facility and will give nursing approximate amount of time to return. 4. Nursing will document in notes that driver has contacted facility. 5. If resident has not arrived at facility within 15 minutes of approximated time given by driver, nurse will contact driver to receive updated time. 6. Upon arrival at facility, nurse will document in notes and on log the resident's return. 7. Nursing administration will review log during morning meeting. Review of the transportation log implemented on 05/25/16, after Immediate Jeopardy was identified, revealed facility put in place transportation log at each nurses station. Log contains resident name, place of appointment, time of appointment and time of return. Upon return the log is to be initialed by the driver that resident has been returned to the facility. Plan of Removal was accepted on 05/26/16 at 4:38PM. PLAN OF REMOVAL: Action Taken: Driver B was inserviced 05/12/16 by Administrator on transporting residents and Appropriate procedures include parking outside the hall on which the resident resides, taking resident to nurse station to check in with charge nurse and turning in any paperwork to nurse. Then going back to vehicle to park in van parking space. Driver B is weekday driver for appointments and Driver A was a weekend only driver. There are two other insured drivers- Maintenance Supervisor and Driver C. Maintenance Supervisor was inserviced on 5/25/2016 and Driver C will be inserviced upon return to work on 5/26/16 by administrator. Driver B, weekday driver correctly explained procedure for bringing residents to and from facility when questioned by administrator prior to implementation of new policy. Facility has implemented new policy on 05/25/16 regarding communication between in house drivers and nursing staff. Any resident that has routine appointments or a planned physician appointment, or transport to any other outside place requested by the resident had the potential to be affected by this alleged deficient practice by Driver A and could be affected by any future practice by facility driver. Any appointments prior to all staff receiving inservice on transportation communication will be taken by our outside transportation company. The same procedure of signing in and out by the ambulance driver will be required. Those conducting inservices are the DON, ADON, LVN E. Inservice on reporting abuse and neglect will be conducted the CEO on Thursday05/26/16 at 3:00 pm to the administrative team. Inservice begin date 5/26/16 and complete date 5/27/16, staff out on leave will be given the inservice prior to returning to work and will be ongoing with all new hires All facility staff will- be inserviced on abuse/neglect. All charge nurses, nurses, medication aides, and certified nurse aides will be inserviced on transportation communication policy and transportation policy. Inservice is being conducted written and orally by presenting abuse and neglect policy and written transportation communication policy implemented today 5/25/16 staffing in facility is 5 days per week for nurses and 4 on 2 off for nurse and med aides. As of today all the 6-2 and 2-10 nurses have been inserviced and all the aides on this shift. The 10-6 will be inserviced tonight and we have used on-shift to send mass message to all staff. Any employee that has not been inserviced by 6 pm 5/26/16 will not be allowed to work until they have been inserviced. We have four staff on leave either out of the country, maternity leave and one in medically induced coma-these employees will not be allowed to return to work until inservice completed. All PRN will complete inservice with a member of nursing administration prior to working the floor. Form will be created to keep at nursing station to ensure that all transports are being documented in and out. Nursing administration will monitor all employees that have not signed inservice prior to returning to work. Competency of the inservice will be monitored by randomly testing staff with a written test created by administrator and nursing administrator. The facility will not allow anyone to drive the facility vehicle unless that person has been added to the insurance and has completed all safety training and has demonstrated competency by written test and ride along training with Maintenance Supervisor All facility staff will be inserviced by 7pm on Thursday 05/27/16 Monitoring Administrator and nursing administration will be responsible for monitoring and will monitor for 1 day weekly for 6 weeks then monthly thereafter. Facility will assign staff member to accompany resident during transportation to and from appt to ensure safe drop off and return for 3 months and then will review in QAPI and redetermine if necessary Facility meets quarterly for QA and will add to QAPI agenda and will continue to monitor on monthly basis to ensure plan is continuing to be successful. Any facility vehicle drivers will have safety competency test quarterly, beginning 06/01/16 Administrator and nursing administration responsible for implementation of policy The date the new policies are in place 05/26/16 Interview with ADON and LVN E on 05/27/16 at 8:30AM revealed both stated they received training. Both were able to correctly describe what was learned in the training regarding identifying and reporting abuse and neglect. Review of staff in-service received 05/27/16 revealed all training was completed regarding identifying and reporting abuse and neglect and new transportation policy and log with all staff including weekend and PRN staff. Interview with facility staff on 05/27/16 (CNA K, CNA 6-2, LVN R, 6-2, CNA M, 6-2, CNA N, 6-2/2-10, CMA X 6-2/10-6, LVN G, 6-2, LVN S, 6-2, CNA O, 6-2/2-10, Housekeeper P, 8-5, Driver C (weekends), Driver B, LVN T, 6-2, LVN U 8-5, LVN V, 8-5, LVN W 6-2/10-6/weekends, LVN F, 6-2/2-10/weekends 6-6, CNA Q, 6-2/2-10) (All CNAs work 4 days on 2 days off, all aides work at least one weekend in a 30 day period.) On 05/26/16 the IJ was removed. On 05/26/16 at 4:38PM the Administrator were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope widespread because the facility still implementing its Plan of Removal. Form CMS-672, Resident Census and Conditions of Resident, dated 05/25/16, reflected the facility census of 130

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment and neglect of residents for two (Residents #1 and #2) of nine residents reviewed for neglect. 1. The Administrator failed to conduct a thorough investigation regarding alleged neglect. 2. The Administrator failed to report the incident to the State survey and certification agency in accordance with the state law. 3. Driver A failed to assist Resident #1, who was in a wheelchair, of the facility van after returning to the facility after the resident's [MEDICAL TREATMENT] treatment. Resident #1 was left in the van without supervision with the windows rolled up from approximately 3:45 PM to approximately 5:00 PM. The temperature outside was approximately 85 degrees. Resident #1 had to crawl out of her wheelchair and from the back of the van to the driver's side door to open the door and push the horn. Resident #1 was crying, anxious and in pain when she was found. The resident was still fearful and upset about the incident after her discharge from the facility. 4. The facility failed to ensure drivers checked the van after transporting residents to appointments to ensure no residents were left unattended in the van and continued to transport Resident #2 to appointments after the incident. 5. The facility failed to train the drivers on ensuring no residents were left unattended in the facility van after the incident with Resident #1 and continued to transport Resident #2 after the incident. An Immediate Jeopardy (IJ) was identified on 05/25/16. While the IJ was removed on 05/27/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures could affect all 130 residents, who could be transported in the facility van at any time, by placing them at risk for neglect, injuries, pain and stress on their well-being and causing other serious mental/physical harm and/or death. Findings included: Review of Vehicle Business - Use Policy dated August 2012 revealed all drivers must possess a valid Texas driver's license, require motor vehicle check and operate motor vehicles is a safe manner at all times. All occupants are required to use seat belts .or other restraint devices at all times when in the vehicle. The Vehicle Business - Use policy did not include procedures to check the vehicle to ensure no residents were left on the vehicle. Review of the facility's Abuse Prevention Program dated August 2006 revealed facility has policy and procedure in place for screening and training employees, identifying and investigating allegations of abuse, neglect and exploitation. 1. Should an incident or suspected incident or resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident .15. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state and local law, within five (5) working days of the reported incident. Interview with Administrator on 05/25/16 at 9:25 AM revealed the incident was not reported to the state agency because she did not know she had to report it. Interview with Dietary Manager on 05/25/16 at 9:05 AM revealed he was told to obtain written statements from his staff and give them to the Administrator. Dietary Manager stated he did not know what the Administrator did after that point. Interview with the DON on 05/25/16 at 12:36 PM revealed there was not an incident/accident report completed on the incident because the nurse that day did not know where to put the incident under the event so everything was completed in a nurses note. Review of Resident #1's Face Sheet, received 05/25/16, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating no cognitive impairment. Resident was alert and to name, place and time. Resident required the assistance of one person with activities of daily living. Review of Resident #1's Care Plan dated 04/11/16, revealed Resident #1 had anxiety and cognitive loss, difficulty understanding and delusions regarding staff plotting against her. Interview with LVN F on 05/26/16 at 11:49 AM revealed resident #1 was alert and oriented. She stated when Resident #1 ambulated, it was slow and steady with use of a rolling walker. LVN F revealed Resident #1 carried O2 with her. The Resident was transported to [MEDICAL TREATMENT] in her wheelchair with the O2 tank attached to the back of the wheelchair. Interview with the PT on 05/26/16 at 11:25 AM revealed Resident #1 required supervision with a rolling walker. The PT stated therapy was working with Resident #1 to rebuild the resident's stamina since the resident was on oxygen. Review of Resident #1's [MEDICAL TREATMENT] Communication Record dated on 05/07/16, revealed her blood pressure was 138/81, temperature at 98.4. There was no time as to when her vitals were taken. There was no time indicating when the resident left to go to [MEDICAL TREATMENT] or returned to the facility. Resident #1's nurses' notes dated 05/07/16, timed at 4:31 PM and signed by LVN D revealed Dietary aide reported a pt (patient) was on the van blowing the horn immediately in the middle of doing blood sugars I stopped what I was doing and followed dietary aide to the back. Pt was at the front of the van sitting down sounding the horn off. Pt had driver side door open and crying and stating the van driver forgot about me and left me on the van for hours after coming back from [MEDICAL TREATMENT]. Pt was assisted to the back of the van to her w/c then assisted into her w/c X3 assist. Pt assisted back to her room and assessed. DON notified order to monitor pt. alert and oriented to name, place and time. Pupils are unequal and reactive to light. Head and neck within normal limits bilat upper and le weak. (sic) Color pink warm to touch. Fair turgor. Old bruising to abdomen and 3 + [MEDICAL CONDITION] to bilat feet. pt was offered water and juice pt stated she wanted 7up and it was given to her. pt is being assessed every hour x2 then every 2 hours. Pt uses a w/c and rolling walker with assist. Resp even non labored with O2 at 3l/nc with O2 stat 98%, 98.2 138/69 89 20 cough noted nonproductive. Pt requested pain pill 2 [MEDICATION NAME] given and pt wanted anxiety pill after 30 in which it was given. [MEDICAL TREATMENT] center notified about the time pt left a worker from [MEDICAL TREATMENT] center states pt got off machine at 3:15 and she doesn't know exactly what time she was picked up. I spoke with the driver after assessing pt and he stated I got distracted cause I usually park in the front and some reason I went to park at the back I just forgot and I apologized to her and I'm truly sorry it happened. At 6:45pm 143/78 89 20 98.7 O2 stat 98% on 3L/NC. Interview with Resident #1 via telephone on 05/25/16 at 4:31 PM revealed Resident #1 stated she was trapped in the van for at least an hour (05/07/16). Resident #1 stated the driver pulled to the back of the facility, which he had never done before. The driver then got out of the van and into another vehicle and drove away. Resident #1 stated she remembered thinking to herself surely he is not going to leave me in here. Resident #1 stated she finally figured out how to unstrap herself from her wheelchair and made it to the front of the van. She made it to the driver's seat and opened the door for air and began honking the horn. Resident #1 stated she had been honking the horn for 20 to 25 minutes until someone came to help her. Resident #1 stated she could not breathe because it was so hot and she did not have any oxygen. Resident #1 revealed she was sweating and crying when staff finally found her. She stated the nurse did an assessment but she was such in shock she could not tell them her back was hurting and she hurt her heel. Resident #1 stated the Administrator came to talk to her the following Tuesday (05/10/16) and told her she would be back to get her statement but never returned. During the interview Resident #1 became upset and began crying when she told the investigator what happened. www.weatherundergrond.com Weather History for KDFW on 05/25/16, revealed on 05/07/16 at 3:53 PM outside temperature was 84.0 degrees with 35% humidity. www.accueweather.com forecast on 05/25/16 revealed on 05/07/16 high temperature of 85 degrees. www.weather.com on 05/25/16, revealed, the Department of Geosciences San Francisco University - Estimator Vehicle Interior Air Temperature vs Elapsed Time by revealed outside temperature of 85 degrees after 10 minutes the interior of the vehicle will reach 104 degrees; 20 minutes will reach 114 degrees; 30 minutes will reach 119 degrees; 40 minutes will reach 123 degrees; 50 minutes will reach 126 degrees; 60 minutes will reach 128 degrees; over an hour interior temperature will reach 130 degrees. Interview with LVN D on 05/25/16 at 8:38 AM, revealed Resident #1 usually returned to the facility from [MEDICAL TREATMENT] between 4:10 PM and 4:15 PM. LVN D explained she was just about to call the [MEDICAL TREATMENT] to see what was going on when someone from dietary came and told her someone was in the facility vehicle. LVN D stated it was 4:15 PM when the dietary aide came and told her there was someone in the vehicle because she remembered looking at the time. LVN D explained she followed the dietary aide out and saw Resident #1 in the vehicle. LVN D stated the facility driver left the resident in the vehicle, got into his personal vehicle and drove off. LVN D stated Housekeeper H and a dietary aide found Resident #1 in the vehicle. The dietary aide heard Resident #1 honking the horn of the vehicle. LVN D revealed Resident #1 was sitting in the driver's side of the vehicle with the door open. LVN D explained Resident #1 had unstrapped herself from the wheelchair at the back of the van and walked to the front of the van to the driver's side. LVN D stated Resident #1 was discovered in the van at 4:15 PM. Interview with LVN D on 05/25/16 at 9:57 AM revealed the resident was wearing short sleeves and pants that were light material. Interview with Dietary Aide I on 05/25/16 at 8:45 AM revealed it was around dinner time when he heard the honking of the horn. Dietary Aide I stated he thought it was maintenance working on the van. Then about 30 minutes later he went outside to take the trash out and heard the honking again. Dietary Aide I stated that was when he saw the resident (Resident #1) in the vehicle waiving her hands and pulling on her shirt like she was hot. Dietary Aide I stated he then went to check on the resident and told Dietary Aide J who came out to the van. Dietary Aide I stated he stayed with the resident while Dietary Aide J went to go get the nurse. Dietary Aide I stated it was around 5:00 PM when the resident was found in the van. Interview with Housekeeper H on 05/25/16 at 8:45 AM revealed the resident (Resident #1) was in the driver's seat of the van. Housekeeper H stated she was able to unlock the back of the van manually and lower the lift. She then assisted getting Resident #1 back into her wheelchair and lowered the wheelchair with the resident in it out of the van using the lift. Housekeeper H stated it was around 5:00 PM when resident was found in the van. Review of the written statement by Housekeeper H dated 05/09/16, revealed On Saturday the 7th at around 5:00 PM (Dietary Aide J) from dietary came and told me there was a patient in the bus alone. I went outside and opened up the back door to the bus and got inside then helped her get into her wheelchair for the bench seat. I was able to get her to the lift and out of the bus. I then brought her to the nurse on station 2. I believe I saw him (Driver A) come back from [MEDICAL TREATMENT] around 3:30. Interview with Dietary Aide J, the cook and Dietary Aide K on 05/25/16 at 1:09 PM revealed they heard honking around 3:30 PM and kept looking out the window to see where the honking was coming from. When asked how they knew it was 3:30 PM, she (Dietary Aide K) stated because that was what time they go on break. Dietary Aide K stated at around 5:00 PM Dietary Aide I told her (Dietary Aide J) there was someone in the van. They stated when she (Dietary Aide K) went out to the van and the resident was waiving her arms for help. They stated the resident was crying and upset. Dietary K stated Resident #1 told her she unfastened herself from the wheelchair and crawled to the driver's seat. She (Dietary Aide K) stated the driver's side door was opened but the resident could not get out. Dietary K stated she continually heard the honking from 3:30 PM until 5:00 PM when Resident #1 was found. Review of the written statement signed by Dietary Aide I, Dietary Aide J and Dietary Aide K, dated 05/09/16 revealed On May 7, 2016 (Dietary Aide K and Dietary Aide J) were taking out brake (sic) when we first heard the honking. It was around 3:30 PM and we would look around and see if we say (sic) anybody. We were like that until around 5 PM. When (Dietary Aide I) told us there was somebody stuck inside the bus. We rushed outside. I (Dietary Aide K) ran one to look for nurses and (Dietary Aide J) ran the other to look for maintenance or housekeeping people. And (Dietary Aide I) stayed with the resident to calm her down. Me (Dietary Aide K), (Dietary Aide I and Dietary Aide K), stayed to help the nurses and (Housekeeper H) to take the resident out of the bus. And after that we went back to work and the nurses to the resident back to her hall. Observation of the kitchen exit to the back parking lot on 05/25/16 at 1:15 PM revealed there is was a door leading to the back parking lot with a small window approximately 10 in x 10 in. When looking out the window someone would be able to see the passenger side, front half of the van. The tinting on the van windows was dark and it would be difficult to see if someone was sitting in the driver's side of the vehicle. Resident #1's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The four days prior to the incident, Resident #1 did not request any PRN pain medication. Resident #1's nurses' notes dated 05/07/16, timed at 7:51 PM and signed by LVN E revealed the following: Resident's family member . came to facility and was very upset that (Resident #1) was left on the van for an hour with windows rolled up and when driver was asked he said he forgot . [MEDICAL TREATMENT] Center was called and stated that Resident has been picked up around 3:45pm . Resident evaluated and assessed - vital signs within normal limit, but expressed fear and insecurity. Resident also requested to go home with the (family member) who declined that (he/she) was going for work in the night and later Resident asked for [MEDICATION NAME] - which was then administered. Nursing staff commenced on q2-3 hours checks and increased fluids for hydration. Will continue to monitor. Interview with LVN E on 05/25/16 at 9:57 AM revealed she was working as the weekend supervisor when the incident occurred. LVN E stated the resident was not upset, was not crying and did not understand what had happened. Further interview with LVN E on 05/25/16 at 2:48 PM revealed Resident #1 was found in the van between 4:15 PM and 4:30 PM. The LVN stated when she interviewed the dietary staff following the incident they were unable to give her times of when they heard the honking. LVN E stated she called the [MEDICAL TREATMENT] center following the incident and was told the resident got off the machine at 3:15 PM and was picked up around 3:45 PM. Resident #1's face sheet provided on 05/26/16 reflected she discharged from the facility on 05/15/16. Observation of the facility van on 05/25/16 at 3:00 PM revealed the van was parked in the back parking lot. The vehicle was a 15 passenger van with wheelchair access in the rear of the vehicle. Passenger entry to the van is was similar to a standard school van with two steps to enter the vehicle. The driver's side entry of the van was one step entry. Interview with the PT on 05/26/16 at 11:25 AM revealed she could not say whether Resident #1 would have been able to get out of the van and walk to the facility on her own without assistance. The PT stated Resident #1 did not work on the stairs so she could not say whether the resident could have stepped down from the van without assistance. Interview with Driver B on 05/25/16 at 3:00 PM revealed Resident #1 normally was picked up from [MEDICAL TREATMENT] around 3:15 PM and 3:20 PM when she was finished. Driver B stated Resident #1 was in a wheelchair. He revealed the wheelchair would have been strapped down in the back of the van and a strap with a buckle across the resident's lap. Driver B stated Resident #1 would not have been able to open any of the doors without the key to the van except the driver's side door. Driver B stated the van heats up quickly and there was no air circulation. Driver B stated the [MEDICAL TREATMENT] center was approximately five minutes away. Interview with the [MEDICAL TREATMENT] Center on 05/25/16 at 3:15 PM revealed Resident #1 was unhooked from the [MEDICAL TREATMENT] machine at 3:15 PM. There was no record of what time Resident #1 was picked up from the [MEDICAL TREATMENT] center. Review of MapQuest.com on 05/25/16 revealed, driving directions revealed from the facility to the [MEDICAL TREATMENT] center was 2.3 miles estimated drive time of six minutes. Review of the facility's undated Investigation Summary received on 05/25/16, revealed According to [MEDICAL TREATMENT] center, patient was picked up from [MEDICAL TREATMENT] at approximately 3:45, [MEDICAL TREATMENT] was completed at 3:15. Driver brought resident back to facility and arrived at around 4 PM. DON received call at 4:14 PM from LVN D stating resident was found on van by one of the dietary aides. Resident was on van approximately 15 minutes after arriving back to the facility. The driver was suspended and then terminated on May 9th. Current driver in-serviced on May 12th, her first day back after being in the hospital. Review of HR documented phone conversation dated 05/09/16 revealed, (Driver A) was asked if he could explain what happened over the weekend. (Driver A) stated that he picked up the resident at about 3:45 PM, he drove from the [MEDICAL TREATMENT] center which took about 15 minutes. He arrived back to the facility at about 4:20 PM, he pulled in got out of the van and clocked out for break. He stated that when he returned from his lunch (5:16 PM) he was told by other staff member that a resident was found on the van. He stated he was not sure what happened to make him forget the resident. HR asked if he was distracted in any way, he stated no, I just forgot she was there. Interview with Administrator on 05/25/16 at 9:25 AM revealed Driver A stated he blacked out and did not know what happened. The Administrator stated an in-service was completed with the other facility drivers. Interview with the Maintenance Supervisor on 05/25/16 at 9:40 AM revealed there is was no formal policy in place regarding ensuring all residents were of the van and accounted for. When a new driver was hired, they were trained to drive the van by a current driver and trained how to use the wheelchair lift. The driver training the new driver would sign off that the new employee was ready to drive the van. The Maintenance Supervisor stated the only people authorized to drive the van were himself, Driver B and Driver C. Driver B is was the main driver, himself and Driver C were back-ups if Driver B was not available. He stated all drivers must be cleared through the insurance. The Maintenance Supervisor stated there had been no formal training following the incident. He revealed that staff just talked among themselves. Interview with Driver B on 05/25/16 at 11:35 AM revealed she was asked by the Administrator to sign something that day (05/25/16) saying she was trained on 05/12/16. Driver B stated she did not receive any training on 05/12/16 or 05/25/16. Driver B stated she told the Administrator she was not going to lie. Review of an undated Transportation In-Service received 05/25/16 revealed Reviewed policy with facility transportation aide (Driver B) regarding immediately removing residents from van or bus and also always checking vehicle after parking in back to ensure no resident or resident property left on vehicle. Interview with the DON on 05/25/16 at 9:28 AM revealed following the incident an in-service was conducted with floor staff. The DON stated Resident #1 left the [MEDICAL TREATMENT] center around 3:45 PM and arrived at the facility around 4:00 PM. She revealed the resident was only in the van for 15 to 30 minutes. A head to toe assessment was completed and vitals checked. There were no injuries noted. Review of Staff Development Attendance Record dated 05/12/16 revealed Driver B received verbal training regarding understand safety when transporting residents. Interview with LVN F on 05/25/16 at 8:33AM revealed she had not received any in-services following the incident involving Resident #1. Interview with LVN D on 05/25/16 at 8:38AM revealed she had not received any in-services following the incident involving Resident #1. Interview with Driver B on 05/25/16 at 8:58 AM revealed she was trained to drive the van by Driver A. Driver B stated she had not received any additional training following the incident. Driver B stated when a resident was brought back from an appointment, the driver should take the resident to the nurse's station. Driver B explained a resident would not have been able to open any other door of the van other than the driver's side door without the key to the ignition. Interview with the Administrator on 05/25/16 at 10:17AM revealed there had been no new policies or procedures implemented since Resident #1 was left in the van after her [MEDICAL TREATMENT] appointment. Interview with the Maintenance Supervisor on 05/25/16 at 10:28 AM revealed following the incident on 05/07/16 no one drove the van until Driver B returned from leave on 05/12/16. All residents were transported by private transport. Interview with Driver B on 05/25/16 at 11:35 AM revealed she transported residents daily to various locations, doctors' appointments, the bank and the store. She stated other than Resident #1 the only other resident in the facility who had a standing weekly appointment was Resident #2. Driver B stated a transportation book is kept of resident appointments. Review of Resident #2's face sheet provided on 05/25/16 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Resident #2 is was alert and oriented. Review of the transportation book on 05/25/16 revealed Resident #2 would have requested transportation on 05/09/16. Interview with Resident #2 on 05/25/16 at 11:27AM revealed the resident was alert and oriented. Resident #2 stated he had never been transported to his therapy appointments by a private transport. Resident #2 stated when Driver B was on leave, Driver C took him to all of his appointments. He stated he had never been driven by anyone else other than facility staff. Interview with LVN G on 05/25/16 at 12:20 PM revealed Resident #2 had never used a private transport to go his appointments. LVN G stated he had always been transported by the facility driver. LVN G stated when Driver B was out on leave, Driver C took Resident #2 to his appointments. Interview with Driver C on 05/27/16 at 8:50AM revealed he had driven the facility van. Driver C stated when Driver B was out on leave he drove Resident #2 to his appointments. Driver C stated Resident #2 was the only resident he had driven. Driver C stated he did not receive training following the incident but he received additional training over abuse and neglect and transporting resident the past couple of days. Interview with LVN F on 05/25/16 at 11:30AM revealed the facility driver was utilized as much as possible to transport residents to appointments. The only time a private transport was used if there were appointments times overlapping. Review of Driver A's personnel file on 05/25/16, revealed a hire date of 08/13/12 as a driver, Driver A had previous incident involving the facility van on 08/11/15 when Driver A was using the vehicle for personal use and hit a telephone pole. There were no residents in the van at the time of the incident. The facility policy was reviewed with Driver A regarding use of facility vehicle. Review of Progressive Counseling Notice Form dated 05/10/16, revealed Driver A was terminated on 05/10/16. The Incident description reflected: On 05/07/16 (Driver A) has (sic) picked a resident up from an appointment and when returned to the facility got out of the bus and forgot resident inside. Resident was left in bus unattended for approximately 40 minutes until found by other employees. An IJ was identified on 05/25/16 12:06 PM. The Administrator was notified of the IJ at 05/25/16 12:08PM. A Plan of Removal was requested. The facility's Transportation Policy dated 05/25/16 implemented after the IJ was identified revealed the purpose of the policy is to ensure that facility nurses are made aware of the resident residing on their halls is returning from appointments. Procedure: 1. Per current procedure nursing will document transportation needs in transportation book, noting if outside transportation - our contracted company or in house transportation. 2. Nurse will document on log and in notes that resident has left the facility for appointment. If resident leaves with family or responsible party this is documented in separate sign out book. 3. In house transportation driver will contact nursing staff at facility when driver has picked up resident and is returning to facility and will give nursing approximate amount of time to return. 4. Nursing will document in notes that driver has contacted facility. 5. If resident has not arrived at facility within 15 minutes of approximated time given by driver, nurse will contact driver to receive updated time. 6. Upon arrival at facility, nurse will document in notes and on log the resident's return. 7. Nursing administration will review log during morning meeting. Review of the transportation log implemented on 05/25/16 after the IJ was identified revealed facility put in place transportation log at each nurses station. Log contains resident name, place of appointment, time of appointment and time of return. Upon return the log is to be initialed by the driver that resident has been returned to the facility. Plan of Removal was accepted on 05/26/16 at 4:38PM. PLAN OF REMOVAL: Action Taken: Driver B was inserviced 05/12/16 by Administrator on transporting residents and Appropriate procedures include parking outside the hall on which the resident resides, taking resident to nurse station to check in with charge nurse and turning in any paperwork to nurse. Then going back to vehicle to park in van parking space. Driver B is weekday driver for appointments and Driver A was a weekend only driver. There are two other insured drivers- Maintenance Supervisor and Driver C. Maintenance Supervisor was inserviced on 5/25/2016 and Driver C will be inserviced upon return to work on 5/26/16 by administrator. Driver B, weekday driver correctly explained procedure for bringing residents to and from facility when questioned by administrator prior to implementation of new policy. Facility has implemented new policy on 05/25/16 regarding communication between in house drivers and nursing staff. Any resident that has routine appointments or a planned physician appointment, or transport to any other outside place requested by the resident had the potential to be affected by this alleged deficient practice by Driver A and could be affected by any future practice by facility driver. Any appointments prior to all staff receiving inservice on transportation communication will be taken by our outside transportation company. The same procedure of signing in and out by the ambulance driver will be required. Those conducting inservices are the DON, ADON, LVN E. Inservice on reporting abuse and neglect will be conducted the CEO on Thursday05/26/16 at 3:00 pm to the administrative team. Inservice begin date 5/26/16 and complete date 5/27/16, staff out on leave will be given the inservice prior to returning to work and will be ongoing with all new hires All facility staff will- be inserviced on abuse/neglect. All charge nurses, nurses, medication aides, and certified nurse aides will be inserviced on transportation communication policy and transportation policy. Inservice is being conducted written and orally by presenting abuse and neglect policy and written transportation communication policy implemented today 5/25/16 staffing in facility is 5 days per week for nurses and 4 on 2 off for nurse and med aides. As of today all the 6-2 and 2-10 nurses have been inserviced and all the aides on this shift. The 10-6 will be inserviced tonight and we have used on-shift to send mass message to all staff. Any employee that has not been inserviced by 6 pm 5/26/16 will not be allowed to work until they have been inserviced. We have four staff on leave either out of the country, maternity leave and one in medically induced coma-these employees will not be allowed to return to work until inservice completed. All PRN will complete inservice with a member of nursing administration prior to working the floor. Form will be created to keep at nursing station to ensure that all transports are being documented in and out. Nursing administration will monitor all employees that have not signed inservice prior to returning to work. Competency of the inservice will be monitored by randomly testing staff with a written test created by administrator and nursing administrator. The facility will not allow anyone to drive the facility vehicle unless that person has been added to the insurance and has completed all safety training and has demonstrated competency by written test and ride along training with Maintenance Supervisor All facility staff will be inserviced by 7pm on Thursday 05/27/16 Monitoring Administrator and nursing administration will be responsible for monitoring and will monitor for 1 day weekly for 6 weeks then monthly thereafter. Facility will assign staff member to accompany resident during transportation to and from appt to ensure safe drop off and return for 3 months and then will review in QAPI and redetermine if necessary Facility meets quarterly for QA and will add to QAPI agenda and will continue to monitor on monthly basis to ensure plan is continuing to be successful. Any facility vehicle drivers will have safety competency test quarterly, beginning 06/01/16 Administrator and nursing administration responsible for implementation of policy The date the new policies are in place 05/26/16 Interview with ADON and LVN E on 05/27/16 at 8:30AM revealed both stated they received training. Both wer

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving neglect were thoroughly investigated and reported to the State survey and certification agency for two (Resident #1 and Resident #2) of nine residents reviewed for neglect. 1. The Administrator failed to conduct a thorough investigation regarding alleged neglect. 2. The Administrator failed to report the incident to the State survey and certification agency in accordance with the state law. Resident #1 was left in the van without supervision with the windows rolled up from approximately 3:45 PM to approximately 5:00 PM. The temperature outside was approximately 85 degrees. Resident #1 had to crawl out of her wheelchair and from the back of the van to the driver's side door to open the door and push the horn. Resident #1 was crying, anxious and in pain when she was found. The resident was still fearful and upset about the incident after her discharge from the facility. 3. The facility failed to ensure drivers checked the van after transporting residents to appointments to ensure no residents were left unattended in the van and continued to transport Resident #2 to appointments after the incident. 4. The facility failed to train the drivers on ensuring no residents were left unattended in the facility van after the incident with Resident #1 and continued to transport Resident #2 to appointments. An Immediate Jeopardy (IJ) was identified on 05/25/16. While the IJ was removed on 05/27/16, the facility remained out of compliance at a severity level of immediate jeopardy to resident health or safety and a scope of pattern due to still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures could affect the facility's one hundred thirty residents by placing them at risk for neglect by facility staff. Findings included: Review of Resident #1's Face Sheet, received 05/25/16, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating no cognitive impairment. Resident was alert and to name, place and time. Resident required the assistance of one person assist with activities of daily living. Review of Resident #1's Care Plan dated 04/11/16, revealed Resident #1 had anxiety and cognitive loss, difficulty understanding and delusions regarding staff plotting against her. Interview with LVN F on 05/26/16 at 11:49 AM revealed resident #1 was alert and oriented. She stated when Resident #1 ambulated, it was slow and steady with use of a rolling walker. LVN F revealed Resident #1 carried O2 with her. The Resident was transported to [MEDICAL TREATMENT] in her wheelchair with the O2 tank attached to the back of the wheelchair. Interview with the PT on 05/26/16 at 11:25 AM revealed Resident #1 required supervision with a rolling walker. The PT stated therapy was working with Resident #1 to rebuild the resident's stamina since the resident was on oxygen. Review of Resident #1's [MEDICAL TREATMENT] Communication Record dated 05/07/16, revealed her blood pressure was 138/81, Temperature at 98.4. There was no time as to when her vitals were taken. There was no time indicating when the resident left to go to [MEDICAL TREATMENT] or returned to the facility. Resident #1's nurses' notes dated 05/07/16, timed at 4:31 PM and signed by LVN D revealed Dietary aide reported a pt (patient) was on the van blowing the horn immediately in the middle of doing blood sugars I stopped what I was doing and followed dietary aide to the back. Pt was at the front of the van sitting down sounding the horn off. Pt had driver side door open and crying and stating the van driver forgot about me and left me on the van for hours after coming back from [MEDICAL TREATMENT]. Pt was assisted to the back of the van to her w/c then assisted into her w/c X3 assist. Pt assisted back to her room and assessed. DON notified order to monitor pt. alert and oriented to name, place and time. Pupils are unequal and reactive to light. Head and neck within normal limits bilat upper and le weak. (sic) Color pink warm to touch. Fair turgor. Old bruising to abdomen and 3 + [MEDICAL CONDITION] to bilat feet. pt was offered water and juice pt stated she wanted 7up and it was given to her. pt is being assessed every hour x2 then every 2 hours. Pt uses a w/c and rolling walker with assist. Resp even non labored with O2 at 3l/nc with O2 stat 98%, 98.2 138/69 89 20 cough noted nonproductive. Pt requested pain pill 2 [MEDICATION NAME] given and pt wanted anxiety pill after 30 in which it was given. [MEDICAL TREATMENT] center notified about the time pt left [MEDICAL TREATMENT] center worker states pt got off machine at 3:15 and she doesn't know exactly what time she was picked up. I spoke with the driver after assessing pt and he stated I got distracted cause I usually park in the front and some reason I went to park at the back I just forgot and I apologized to her and I'm truly sorry it happened. At 6:45pm 143/78 89 20 98.7 O2 stat 98% on 3L/NC. Interview with Resident #1 via telephone on 05/25/16 at 4:31 PM revealed Resident #1 stated she was trapped in the van for at least an hour (05/07/16). Resident #1 stated the driver pulled to the back of the facility, which he had never done before. The driver then got out of the van and into another vehicle and drove away. Resident #1 stated she remembered thinking to herself surely he is not going to leave me in here. Resident #1 stated she finally figured out how to unstrap herself from her wheelchair and made it to the front of the van. She made it to the driver's seat and opened the door for air and began honking the horn. Resident #1 stated she had been honking the horn for 20 to 25 minutes until someone came to help her. Resident #1 stated she could not breathe because it was so hot and she did not have any oxygen. Resident #1 revealed she was sweating and crying when staff finally found her. She stated the nurse did an assessment but she was such in shock she could not tell them her back was hurting and she hurt her heel. Resident #1 stated the Administrator came to talk to her the following Tuesday (05/10/16) and told her she would be back to get her statement but never returned. During the interview Resident #1 became upset and began crying when she told the investigator what happened. There was no statement for Resident #1 obtained by the facility regarding the incident. www.weatherundergrond.com Weather History for KDFW on 05/25/16, revealed on 05/07/16 at 3:53 PM outside temperature was 84.0 degrees with 35% humidity. www.accueweather.com forecast on 05/25/16 revealed on 05/07/16 high temperature of 85 degrees. www.weather.com <http://www.weather.com> on 05/25/16, revealed, the Department of Geosciences San Francisco University - Estimator Vehicle Interior Air Temperature vs Elapsed Time by revealed outside temperature of 85 degrees after 10 minutes the interior of the vehicle will reach 104 degrees; 20 minutes will reach 114 degrees; 30 minutes will reach 119 degrees; 40 minutes will reach 123 degrees; 50 minutes will reach 126 degrees; 60 minutes will reach 128 degrees; over an hour interior temperature will reach 130 degrees. Interview with LVN D on 05/25/16 at 8:38 AM, revealed Resident #1 usually returned to the facility from [MEDICAL TREATMENT] between 4:10 PM and 4:15 PM. LVN D explained she was just about to call the [MEDICAL TREATMENT] to see what was going on when someone from dietary came and told her someone was in the facility vehicle. LVN D stated it was 4:15 PM when the dietary aide came and told her there was someone in the vehicle because she remembered looking at the time. LVN D explained she followed the dietary aide out and saw Resident #1 in the vehicle. LVN D stated the facility driver left the resident in the vehicle, got into his personal vehicle and drove off. LVN D stated Housekeeper H and a dietary aide found Resident #1 in the vehicle. The dietary aide heard Resident #1 honking the horn of the vehicle. LVN D revealed Resident #1 was sitting in the driver's side of the vehicle with the door open. LVN D explained Resident #1 had unstrapped herself from the wheelchair at the back of the van and walked to the front of the van to the driver's side. LVN D stated Resident #1 was discovered in the van at 4:15 PM. Interview with LVN D on 05/25/16 at 9:57 AM revealed the resident was wearing short sleeves and pants that were light material. Interview with Dietary Aide I on 05/25/16 at 8:45 AM revealed it was around dinner time when he heard the honking of the horn. Dietary Aide I stated he thought it was maintenance working on the van. Then about 30 minutes later he went outside to take the trash out and heard the honking again. Dietary Aide I stated that was when he saw the resident (Resident #1) in the vehicle waiving her hands and pulling on her shirt like she was hot. Dietary Aide I stated he then went to check on the resident and told Dietary Aide J who came out to the van. Dietary Aide I stated he stayed with the resident while Dietary Aide J went to go get the nurse. Dietary Aide I stated it was around 5:00 PM when the resident was found in the van. Interview with Housekeeper H on 05/25/16 at 8:45 AM revealed the resident (Resident #1) was in the driver's seat of the van. Housekeeper H stated she was able to unlock the back of the van manually and lower the lift. She then assisted getting Resident #1 back into her wheelchair and lowered the wheelchair with the resident in it out of the van using the lift. Housekeeper H stated it was around 5:00 PM when resident was found in the van. Review of the written statement by Housekeeper H dated 05/09/16, revealed On Saturday the 7th at around 5:00 PM (Dietary Aide J) from dietary came and told me there was a patient in the bus alone. I went outside and opened up the back door to the bus and got inside then helped her get into her wheelchair for the bench seat. I was able to get her to the lift and out of the bus. I then brought her to the nurse on station 2. I believe I saw him (Driver A) come back from [MEDICAL TREATMENT] around 3:30. Interview with Dietary Aide J, the cook and Dietary Aide K on 05/25/16 at 1:09 PM revealed they heard honking around 3:30 PM and kept looking out the window to see where the honking was coming from. When asked how they knew it was 3:30 PM, she (Dietary Aide K) stated because that was what time they go on break. Dietary Aide K stated at around 5:00 PM Dietary Aide I told her (Dietary Aide J) there was someone in the van. They stated when she (Dietary Aide K) went out to the van and the resident was waiving her arms for help. They stated the resident was crying and upset. Dietary K stated Resident #1 told her she unfastened herself from the wheelchair and crawled to the driver's seat. She (Dietary Aide K) stated the driver's side door was opened but the resident could not get out. Dietary K stated she continually heard the honking from 3:30 PM until 5:00 PM when Resident #1 was found. Review of the written statement signed by Dietary Aide I, Dietary Aide J and Dietary Aide K, dated 05/09/16 revealed On May 7, 2016 (Dietary Aide K and Dietary Aide J) were taking out brake (sic) when we first heard the honking. It was around 3:30 PM and we would look around and see if we say (sic) anybody. We were like that until around 5 PM. When (Dietary Aide I) told us there was somebody stuck inside the bus. We rushed outside. I (Dietary Aide K) ran one to look for nurses and (Dietary Aide J) ran the other to look for maintenance or housekeeping people. And (Dietary Aide I) stayed with the resident to calm her down. Me (Dietary Aide K), (Dietary Aide I and Dietary Aide K), stayed to help the nurses and (Housekeeper H) to take the resident out of the bus. And after that we went back to work and the nurses to the resident back to her hall. Observation of the kitchen exit to the back parking lot on 05/25/16 at 1:15 PM revealed there is was a door leading to the back parking lot with a small window approximately 10 in x 10 in. When looking out the window someone would be able to see the passenger side, front half of the van. The tinting on the van windows was dark and it would be difficult to see if someone was sitting in the driver's side of the vehicle. Resident #1's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The four days prior to the incident, Resident #1 did not request any PRN pain medication. Resident #1's nurses' notes dated 05/07/16, timed at 7:51 PM and signed by LVN E revealed the following: Resident's family member .came to facility and was very upset that (Resident #1) was left on the van for an hour with windows rolled up and when driver was asked he said he forgot . [MEDICAL TREATMENT] Center was called and stated that Resident has been picked up around 3:45pm . Resident evaluated and assessed - vital signs within normal limit, but expressed fear and insecurity. Resident also requested to go home with the (family member) who declined that (he/she) was going for work in the night and later Resident asked for [MEDICATION NAME] - which was then administered. Nursing staff commenced on q2-3 hours checks and increased fluids for hydration. Will continue to monitor. Interview with LVN E on 05/25/16 at 9:57 AM revealed she was working as the weekend supervisor when the incident occurred. LVN E stated the resident was not upset, was not crying and did not understand what had happened. Further interview with LVN E on 05/25/16 at 2:48 PM revealed Resident #1 was found in the van between 4:15 PM and 4:30 PM. The LVN stated when she interviewed the dietary staff following the incident they were unable to give her times of when they heard the honking. LVN E stated she called the [MEDICAL TREATMENT] center following the incident and was told the resident got off the machine at 3:15 PM and was picked up around 3:45 PM. Resident #1's face sheet provided on 05/26/16 reflected she discharged from the facility on 05/15/16. Observation of the facility van on 05/25/16 at 3:00 PM revealed the van was parked in the back parking lot. The vehicle was a 15 passenger van with wheelchair access in the rear of the vehicle. Passenger entry to the van was similar to a standard school van with two steps to enter the vehicle. The driver's side entry of the van is was one step entry. Interview with the PT on 05/26/16 at 11:25 AM revealed she could not say whether Resident #1 would have been able to get out of the van and walk to the facility on her own without assistance. The PT stated Resident #1 did not work on the stairs so she could not say whether the resident could have stepped down from the van without assistance. Interview with Driver B on 05/25/16 at 3:00 PM revealed Resident #1 normally was picked up from [MEDICAL TREATMENT] around 3:15 PM and 3:20 PM when she is was finished. Driver B stated Resident #1 was in a wheelchair. He revealed the wheelchair would have been strapped down in the back of the van and a strap with a buckle across the resident's lap. Driver B stated Resident #1 would not have been able to open any of the doors without the key to the van except the driver's side door. Driver B stated the van heats up quickly and there was no air circulation. Driver B stated the [MEDICAL TREATMENT] center was approximately five minutes away. Interview with the [MEDICAL TREATMENT] Center on 05/25/16 at 3:15 PM revealed Resident #1 was unhooked from the [MEDICAL TREATMENT] machine at 3:15 PM. There was no record of what time Resident #1 was picked up from the [MEDICAL TREATMENT] center. Review of MapQuest.com on 05/25/16 revealed, driving directions revealed from the facility to the [MEDICAL TREATMENT] center was 2.3 miles estimated drive time of six minutes. Interview with Administrator on 05/25/16 at 9:25 AM revealed the incident was not reported to the state agency because she did not know she had to report it. Interview with Dietary Manager on 05/25/16 at 9:05 AM revealed he was told to obtain written statements from his staff and give them to the Administrator. Dietary Manager stated he did not know what the Administrator did after that point. Interview with the DON on 05/25/16 at 12:36 PM revealed there was not an incident/accident report completed on the incident because the nurse that day did not know where to put the incident under the event so everything was completed in a nurses note. Review of the facility's undated Investigation Summary received on 05/25/16, revealed According to [MEDICAL TREATMENT] center, patient was picked up from [MEDICAL TREATMENT] at approximately 3:45, [MEDICAL TREATMENT] was completed at 3:15. Driver brought resident back to facility and arrived at around 4 PM. DON received call at 4:14 PM from LVN D stating resident was found on van by one of the dietary aides. Resident was on van approximately 15 minutes after arriving back to the facility. The driver was suspended and then terminated on May 9th. Current driver in-serviced on May 12th, her first day back after being in the hospital. Review of HR documented phone conversation dated 05/09/16 revealed, (Driver A) was asked if he could explain what happened over the weekend. (Driver A) stated that he picked up the resident at about 3:45 PM, he drove from the [MEDICAL TREATMENT] center which took about 15 minutes. He arrived back to the facility at about 4:20 PM, he pulled in got out of the van and clocked out for break. He stated that when he returned from his lunch (5:16 PM) he was told by other staff member that a resident was found on the van. He stated he was not sure what happened to make him forget the resident. HR asked if he was distracted in any way, he stated no, I just forgot she was there. Interview with Administrator on 05/25/16 at 9:25 AM revealed Driver A stated he blacked out and did not know what happened. The Administrator stated an in-service was completed with the other facility drivers. Interview with the Maintenance Supervisor on 05/25/16 at 9:40 AM revealed there is was no formal policy in place regarding ensuring all residents are were of the van and accounted for. When a new driver was hired, they were trained to drive the van by a current driver and trained how to use the wheelchair lift. The driver training the new driver would sign off that the new employee was ready to drive the van. The Maintenance Supervisor stated the only people authorized to drive the van were himself, Driver B and Driver C. Driver B was the main driver, himself and Driver C were back-ups if Driver B is was not available. He stated all drivers must be cleared through the insurance. The Maintenance Supervisor stated there had been no formal training following the incident. He revealed that staff just talked among themselves. Interview with Driver B on 05/25/16 at 11:35 AM revealed she was asked by the Administrator to sign something that day (05/25/16) saying she was trained on 05/12/16. Driver B stated she did not receive any training on 05/12/16 or 05/25/16. Driver B stated she told the Administrator she was not going to lie. Review of Staff Development Attendance Record dated 05/12/16 revealed Driver B received verbal training regarding understand safety when transporting residents. Interview with the DON on 05/25/16 at 9:28 AM revealed following the incident an in-service was conducted with floor staff. The DON stated Resident #1 left the [MEDICAL TREATMENT] center around 3:45 PM and arrived at the facility around 4:00 PM. She revealed the resident was only in the van for 15 to 30 minutes. A head to toe assessment was completed and vitals checked. There were no injuries noted. Review of an undated Transportation In-Service received 05/25/16 revealed Reviewed policy with facility transportation aide (Driver B) regarding immediately removing residents from van or bus and also always checking vehicle after parking in back to ensure no resident or resident property left on vehicle. Interview with LVN F on 05/25/16 at 8:33AM revealed she had not received any in-services following the incident involving Resident #1. Interview with LVN D on 05/25/16 at 8:38AM revealed she had not received any in-services following the incident involving Resident #1. Interview with Driver B on 05/25/16 at 8:58 AM revealed she was trained to drive the van by Driver A. Driver B stated she had not received any additional training following the incident. Driver B stated when a resident was brought back from an appointment, the driver should take the resident to the nurse's station. Driver B explained a resident would not have been able to open any other door of the van other than the driver's side door without the key to the ignition. Interview with the Administrator on 05/25/16 at 10:17AM revealed there had been no new policies or procedures implemented since Resident #1 was left in the van after her [MEDICAL TREATMENT] appointment. Interview with the Maintenance Supervisor on 05/25/16 at 10:28 AM revealed following the incident on 05/07/16 no one drove the van until Driver B returned from leave on 05/12/16. All residents were transported by private transport. Interview with Driver B on 05/25/16 at 11:35 AM revealed she transported residents daily to various locations, doctors' appointments, the bank and the store. She stated other than Resident #1 the only other resident in the facility who had a standing weekly appointment is was Resident #2. Driver B stated a transportation book of every one's appointments. Review of Resident #2' s face sheet provided on 05/25/16 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #2' s MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Resident #2 was alert and oriented. Review of the transportation book on 05/25/16 revealed Resident #2 would have requested transportation on 05/09/16. Interview with Resident #2 on 05/25/16 at 11:27AM revealed the resident was alert and oriented. Resident #2 stated he had never been transported to his therapy appointments by a private transport. Resident #2 stated when Driver B was on leave, Driver C took him to all of his appointments. He stated he had never been driven by anyone else other than facility staff. Interview with LVN G on 05/25/16 at 12:20 PM revealed Resident #2 had never used a private transport to go his appointments. LVN G stated he had always been transported by the facility driver. LVN G stated when Driver B was out on leave, Driver C took Resident #2 to his appointments. Interview with Driver C on 05/27/16 at 8:50AM revealed he had driven the facility van. Driver C stated when Driver B was out on leave he drove Resident #2 to his appointments. Driver C stated Resident #2 was the only resident he had driven. Driver C stated he did not receive training following the incident but he received additional training over new transportation policy and abuse and neglect the past couple of days. Interview with LVN F on 05/25/16 at 11:30AM revealed the facility driver was utilized as much as possible to transport residents to appointments. The only time a private transport was used if there were appointments times overlapping. Review of Driver A 's personnel file on 05/25/16, revealed a hire date of 08/13/12 as a driver, Driver A had previous incident involving the facility van on 08/11/15 when Driver A was using the vehicle for personal use and hit a telephone pole. There were no residents in the van at the time of the incident. The facility policy was reviewed with Driver A regarding use of facility vehicle. Review of Progressive Counseling Notice Form dated 05/10/16, revealed Driver A was terminated on 05/10/16. The Incident description reflected: On 05/07/16 (Driver A) has (sic) picked a resident up from an appointment and when returned to the facility got out of the bus and forgot resident inside. Resident was left in bus unattended for approximately 40 minutes until found by other employees. Review of Vehicle Business - Use Policy dated August 2012 revealed all drivers must possess a valid Texas driver's license, and required motor vehicle check and operate motor vehicles in a safe manner at all times. All occupants were required to use seat belts or other restraint devices at all times when in the vehicle. The Vehicle Business - Use policy did not include procedures to check the vehicle to ensure no residents were left on the vehicle. The facility's Abuse Prevention Program dated August 2006 revealed Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. The individual conducting the investigation will, as a minimum: .c. Interview the person(s) reporting the incident. d. Interview any witnesses to the incident. e. Interview the resident . j. Review all events leading up to the alleged incident. Facility Abuse Prevention Program does not define abuse, neglect or misappropriation. An IJ was identified on 05/25/16 12:06PM. The Administrator was notified of the IJ. A Plan of Removal was requested. The facility's Transportation Policy dated 05/25/16 implemented on 05/25/16 after Immediate Jeopardy was identified, revealed the purpose of the policy is to ensure that facility nurses are made aware of the resident residing on their halls is returning from appointments. Procedure: 1. Per current procedure nursing will document transportation needs in transportation book, noting if outside transportation - our contracted company or in house transportation. 2. Nurse will document on log and in notes that resident has left the facility for appointment. If resident leaves with family or responsible party this is documented in separate sign out book. 3. In house transportation driver will contact nursing staff at facility when driver has picked up resident and is returning to facility and will give nursing approximate amount of time to return. 4. Nursing will document in notes that driver has contacted facility. 5. If resident has not arrived at facility within 15 minutes of approximated time given by driver, nurse will contact driver to receive updated time. 6. Upon arrival at facility, nurse will document in notes and on log the resident's return. 7. Nursing administration will review log during morning meeting. Review of the transportation log implemented on 05/25/16, after Immediate Jeopardy was identified, revealed facility put in place transportation log at each nurses station. Log contains resident name, place of appointment, time of appointment and time of return. Upon return the log is to be initialed by the driver that resident has been returned to the facility. Plan of Removal was accepted on 05/26/16 at 4:38PM. PLAN OF REMOVAL: Action Taken: Driver B was inserviced 05/12/16 by Administrator on transporting residents and Appropriate procedures include parking outside the hall on which the resident resides, taking resident to nurse station to check in with charge nurse and turning in any paperwork to nurse. Then going back to vehicle to park in van parking space. Driver B is weekday driver for appointments and Driver A was a weekend only driver. There are two other insured drivers- Maintenance Supervisor and Driver C. Maintenance Supervisor was inserviced on 5/25/2016 and Driver C will be inserviced upon return to work on 5/26/16 by administrator. Driver B, weekday driver correctly explained procedure for bringing residents to and from facility when questioned by administrator prior to implementation of new policy. Facility has implemented new policy on 05/25/16 regarding communication between in house drivers and nursing staff. Any resident that has routine appointments or a planned physician appointment, or transport to any other outside place requested by the resident had the potential to be affected by this alleged deficient practice by Driver A and could be affected by any future practice by facility driver. Any appointments prior to all staff receiving inservice on transportation communication will be taken by our outside transportation company. The same procedure of signing in and out by the ambulance driver will be required. Those conducting inservices are the DON, ADON, LVN E. Inservice on reporting abuse and neglect will be conducted the CEO on Thursday05/26/16 at 3:00 pm to the administrative team. Inservice begin date 5/26/16 and complete date 5/27/16, staff out on leave will be given the inservice prior to returning to work and will be ongoing with all new hires All facility staff will- be inserviced on abuse/neglect. All charge nurses, nurses, medication aides, and certified nurse aides will be inserviced on transportation communication policy and transportation policy. Inservice is being conducted written and orally by presenting abuse and neglect policy and written transportation communication policy implemented today 5/25/16 staffing in facility is 5 days per week for nurses and 4 on 2 off for nurse and med aides. As of today all the 6-2 and 2-10 nurses have been inserviced and all the aides on this shift. The 10-6 will be inserviced tonight and we have used on-shift to send mass message to all staff. Any employee that has not been inserviced by 6 pm 5/26/16 will not be allowed to work until they have been inserviced. We have four staff on leave either out of the country, maternity leave and one in medically induced coma-these employees will not be allowed to return to work until inservice completed. All PRN will complete inservice with a member of nursing administration prior to working the floor. Form will be created to keep at nursing station to ensure that all transports are being documented in and out. Nursing administration will monitor all employees that have not signed inservice prior to returning to work. Competency of the inservice will be monitored by randomly testing staff with a written test created by administrator and nursing administrator. The facility will not allow anyone to drive the facility vehicle unless that person has been added to the insurance and has completed all safety training and has demonstrated competency by written test and ride along training with Maintenance Supervisor. All facility staff will be inserviced by 7pm on Thursday 05/27/16. Monitoring Administrator and nursing administration will be responsible for monitoring and will monitor for 1 day weekly for 6 weeks then monthly thereafter. Facility will assign staff member to accompany resident during transportation to and from appt to ensure safe drop off and return for 3 months and then will review in QAPI and redetermine if necessary. Facility meets quarterly for QA and will add to QAPI agenda and will continue to monitor on monthly basis to ensure plan is continuing to be successful. Any facility vehicle drivers will have safety competency test quarterly, beginning 06/01/16. Administrator and nursing administration responsible for implementation of policy. The date the new policies are in place 05/26/16. Interview with ADON and LVN E on 05/2

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibit mistreatment and neglect of residents for two (Residents #1 and #2) of nine residents reviewed for neglect. 1. Driver A failed to assist Resident #1, who was in a wheelchair, off the facility van after returning to the facility after the resident's [MEDICAL TREATMENT] treatment. Resident #1 was left in the van without supervision with the windows rolled up from approximately 3:45 PM to approximately 5:00 PM. The temperature outside was approximately 85 degrees. Resident #1 had to crawl out of her wheelchair and from the back of the van to the driver's side door to open the door and push the horn. Resident #1 was crying, anxious and in pain when she was found. The resident was still fearful and upset about the incident after her discharge from the facility. 2. The facility failed to ensure drivers checked the van after transporting residents to appointments to ensure no residents were left unattended in the van and continued to transport Resident #2 to appointments after the incident. 3. The facility failed to train the drivers on ensuring no residents were left unattended in the facility van after the incident with Resident #1 and continued to transport Resident #2 to appointments. An Immediate Jeopardy (IJ) was identified on 05/25/16. While the IJ was removed on 05/27/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures could affect all 130 residents, who could be transported in the facility van at any time, by placing them at risk for neglect, injuries, pain and stress on their well-being and causing other serious mental/physical harm and/or death. Findings included: Review of Resident #1's Face Sheet, received 05/25/16, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating no cognitive impairment. Resident was alert and to name, place and time. Resident required the assistance of one person assist with activities of daily living. Review of Resident #1's Care Plan dated 04/11/16, revealed Resident #1 had anxiety and cognitive loss, difficulty understanding and delusions regarding staff plotting against her. Interview with LVN F on 05/26/16 at 11:49 AM revealed resident #1 was alert and oriented. She stated when Resident #1 ambulated, it was slow and steady with use of a rolling walker. LVN F revealed Resident #1 carried O2 with her. The Resident was transported to [MEDICAL TREATMENT] in her wheelchair with the O2 tank attached to the back of the wheelchair. Interview with the PT on 05/26/16 at 11:25 AM revealed Resident #1 required supervision with a rolling walker. The PT stated therapy was working with Resident #1 to rebuild the resident's stamina since the resident was on oxygen. Review of Resident #1's [MEDICAL TREATMENT] Communication Record dated on 05/07/16, revealed her blood pressure was 138/81, Temperature at 98.4. There was no time as to when her vitals were taken. There was no time indicating when the resident left to go to [MEDICAL TREATMENT] or returned to the facility. Resident #1's nurses' notes dated 05/07/16, timed at 4:31 PM and signed by LVN D revealed Dietary aide reported a pt (patient) was on the van blowing the horn immediately in the middle of doing blood sugars I stopped what I was doing and followed dietary aide to the back. Pt was at the front of the van sitting down sounding the horn off. Pt had driver side door open and crying and stating the van driver forgot about me and left me on the van for hours after coming back from [MEDICAL TREATMENT]. Pt was assisted to the back of the van to her w/c then assisted into her w/c X3 assist. Pt assisted back to her room and assessed. DON notified order to monitor pt. alert and oriented to name, place and time. Pupils are unequal and reactive to light. Head and neck within normal limits bilat upper and le weak. (sic) Color pink warm to touch. Fair turgor. Old bruising to abdomen and 3 + [MEDICAL CONDITION] to bilat feet. pt was offered water and juice pt stated she wanted 7up and it was given to her. pt is being assessed every hour x2 then every 2 hours. Pt uses a w/c and rolling walker with assist. Resp even non labored with O2 at 3l/nc with O2 stat 98%, 98.2 138/69 89 20 cough noted nonproductive. Pt requested pain pill 2 [MEDICATION NAME] given and pt wanted anxiety pill after 30 in which it was given. [MEDICAL TREATMENT] center notified about the time pt left [MEDICAL TREATMENT] center worker states pt got off machine at 3:15 and she doesn't know exactly what time she was picked up. I spoke with the driver after assessing pt and he stated I got distracted cause I usually park in the front and some reason I went to park at the back I just forgot and I apologized to her and I'm truly sorry it happened. At 6:45pm 143/78 89 20 98.7 O2 stat 98% on 3L/NC. Interview with Resident #1 via telephone on 05/25/16 at 4:31 PM revealed Resident #1 stated she was trapped in the van for at least an hour (05/07/16). Resident #1 stated the driver pulled to the back of the facility, which he had never done before. The driver then got out of the van and into another vehicle and drove away. Resident #1 stated she remembered thinking to herself surely he is not going to leave me in here. Resident #1 stated she finally figured out how to unstrap herself from her wheelchair and made it to the front of the van. She made it to the driver's seat and opened the door for air and began honking the horn. Resident #1 stated she had been honking the horn for 20 to 25 minutes until someone came to help her. Resident #1 stated she could not breathe because it was so hot and she did not have any oxygen. Resident #1 revealed she was sweating and crying when staff finally found her. She stated the nurse did an assessment but she was such in shock she could not tell them her back was hurting and she hurt her heel. Resident #1 stated the Administrator came to talk to her the following Tuesday (05/10/16) and told her she would be back to get her statement but never returned. During the interview Resident #1 became upset and began crying when she told the investigator what happened. www.weatherundergrond.com Weather History for KDFW on 05/25/16, revealed on 05/07/16 at 3:53 PM outside temperature was 84.0 degrees with 35% humidity. www.accueweather.com forecast on 05/25/16 revealed on 05/07/16 high temperature of 85 degrees. www.weather.com <http://www.weather.com> on 05/25/16, revealed, the Department of Geosciences San Francisco University - Estimator Vehicle Interior Air Temperature vs Elapsed Time by revealed outside temperature of 85 degrees after 10 minutes the interior of the vehicle will reach 104 degrees; 20 minutes will reach 114 degrees; 30 minutes will reach 119 degrees; 40 minutes will reach 123 degrees; 50 minutes will reach 126 degrees; 60 minutes will reach 128 degrees; over an hour interior temperature will reach 130 degrees. Interview with LVN D on 05/25/16 at 8:38 AM, revealed Resident #1 usually returned to the facility from [MEDICAL TREATMENT] between 4:10 PM and 4:15 PM. LVN D explained she was just about to call the [MEDICAL TREATMENT] to see what was going on when someone from dietary came and told her someone was in the facility vehicle. LVN D stated it was 4:15 PM when the dietary aide came and told her there was someone in the vehicle because she remembered looking at the time. LVN D explained she followed the dietary aide out and saw Resident #1 in the vehicle. LVN D stated the facility driver left the resident in the vehicle, got into his personal vehicle and drove off. LVN D stated Housekeeper H and a dietary aide found Resident #1 in the vehicle. The dietary aide heard Resident #1 honking the horn of the vehicle. LVN D revealed Resident #1 was sitting in the driver's side of the vehicle with the door open. LVN D explained Resident #1 had unstrapped herself from the wheelchair at the back of the van and walked to the front of the van to the driver's side. LVN D stated Resident #1 was discovered in the van at 4:15 PM. Interview with LVN D on 05/25/16 at 9:57 AM revealed the resident was wearing short sleeves and pants that were light material. Interview with Dietary Aide I on 05/25/16 at 8:45 AM revealed it was around dinner time when he heard the honking of the horn. Dietary Aide I stated he thought it was maintenance working on the van. Then about 30 minutes later he went outside to take the trash out and heard the honking again. Dietary Aide I stated that was when he saw the resident (Resident #1) in the vehicle waiving her hands and pulling on her shirt like she was hot. Dietary Aide I stated he then went to check on the resident and told Dietary Aide J who came out to the van. Dietary Aide I stated he stayed with the resident while Dietary Aide J went to go get the nurse. Dietary Aide I stated it was around 5:00 PM when the resident was found in the van. Interview with Housekeeper H on 05/25/16 at 8:45 AM revealed the resident (Resident #1) was in the driver's seat of the van. Housekeeper H stated she was able to unlock the back of the van manually and lower the lift. She then assisted getting Resident #1 back into her wheelchair and lowered the wheelchair with the resident in it out of the van using the lift. Housekeeper H stated it was around 5:00 PM when resident was found in the van. Review of the written statement by Housekeeper H dated 05/09/16, revealed On Saturday the 7th at around 5:00 PM (Dietary Aide J) from dietary came and told me there was a patient in the bus alone. I went outside and opened up the back door to the bus and got inside then helped her get into her wheelchair for the bench seat. I was able to get her to the lift and out of the bus. I then brought her to the nurse on station 2. I believe I saw him (Driver A) come back from [MEDICAL TREATMENT] around 3:30. Interview with Dietary Aide J, the cook and Dietary Aide K on 05/25/16 at 1:09 PM revealed they heard honking around 3:30 PM and kept looking out the window to see where the honking was coming from. When asked how they knew it was 3:30 PM, she (Dietary Aide K) stated because that was what time they go on break. Dietary Aide K stated at around 5:00 PM Dietary Aide I told her (Dietary Aide J) there was someone in the van. They stated when she (Dietary Aide K) went out to the van and the resident was waiving her arms for help. They stated the resident was crying and upset. Dietary K stated Resident #1 told her she unfastened herself from the wheelchair and crawled to the driver's seat. She (Dietary Aide K) stated the driver's side door was opened but the resident could not get out. Dietary K stated she continually heard the honking from 3:30 PM until 5:00 PM when Resident #1 was found. Review of the written statement signed by Dietary Aide I, Dietary Aide J and Dietary Aide K, dated 05/09/16 revealed On May 7, 2016 (Dietary Aide K and Dietary Aide J) were taking out brake (sic) when we first heard the honking. It was around 3:30 PM and we would look around and see if we say (sic) anybody. We were like that until around 5 PM. When (Dietary Aide I) told us there was somebody stuck inside the bus. We rushed outside. I (Dietary Aide K) ran one to look for nurses and (Dietary Aide J) ran the other to look for maintenance or housekeeping people. And (Dietary Aide I) stayed with the resident to calm her down. Me (Dietary Aide K), (Dietary Aide I and Dietary Aide K), stayed to help the nurses and (Housekeeper H) to take the resident out of the bus. And after that we went back to work and the nurses to the resident back to her hall. Observation of the kitchen exit to the back parking lot on 05/25/16 at 1:15 PM revealed there was a door leading to the back parking lot with a small window approximately 10 in x 10 in. When looking out the window someone would be able to see the passenger side, front half of the van. The tinting on the van windows was dark and it would be difficult to see if someone was sitting in the driver's side of the vehicle. Resident #1's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The four days prior to the incident, Resident #1 did not request any PRN pain medication. Resident #1's nurses' notes dated 05/07/16, timed at 7:51 PM and signed by LVN E revealed the following: Resident's family member .came to facility and was very upset that (Resident #1) was left on the van for an hour with windows rolled up and when driver was asked he said he forgot . [MEDICAL TREATMENT] Center was called and stated that Resident has been picked up around 3:45pm . Resident evaluated and assessed - vital signs within normal limit, but expressed fear and insecurity. Resident also requested to go home with the (family member) who declined that (he/she) was going for work in the night and later Resident asked for [MEDICATION NAME] - which was then administered. Nursing staff commenced on q2-3 hours checks and increased fluids for hydration. Will continue to monitor. Interview with LVN E on 05/25/16 at 9:57 AM revealed she was working as the weekend supervisor when the incident occurred. LVN E stated the resident was not upset, was not crying and did not understand what had happened. Further interview with LVN E on 05/25/16 at 2:48 PM revealed Resident #1 was found in the van between 4:15 PM and 4:30 PM. The LVN stated when she interviewed the dietary staff following the incident they were unable to give her times of when they heard the honking. LVN E stated she called the [MEDICAL TREATMENT] center following the incident and was told the resident got off the machine at 3:15 PM and was picked up around 3:45 PM. Resident #1's face sheet provided on 05/26/16 reflected she discharged from the facility on 05/15/16. Interview with the DON on 05/25/16 at 12:36 PM revealed there was not an incident/accident report completed on the incident because the nurse that day did not know where to put the incident under the event so everything was completed in a nurses note. Observation of the facility van on 05/25/16 at 3:00 PM revealed the van was parked in the back parking lot. The vehicle was a 15 passenger van with wheelchair access in the rear of the vehicle. Passenger entry to the van was similar to a standard school van with two steps to enter the vehicle. The driver's side entry of the van is was one step entry. Interview with the PT on 05/26/16 at 11:25 AM revealed she could not say whether Resident #1 would have been able to get out of the van and walk to the facility on her own without assistance. The PT stated Resident #1 did not work on the stairs so she could not say whether the resident could have stepped down from the van without assistance. Interview with Driver B on 05/25/16 at 3:00 PM revealed Resident #1 normally was picked up from [MEDICAL TREATMENT] around 3:15 PM and 3:20 PM when she is was finished. Driver B stated Resident #1 was in a wheelchair. He revealed the wheelchair would have been strapped down in the back of the van and a strap with a buckle across the resident's lap. Driver B stated Resident #1 would not have been able to open any of the doors without the key to the van except the driver's side door. Driver B stated the van heats up quickly and there was no air circulation. Driver B stated the [MEDICAL TREATMENT] center was approximately five minutes away. Interview with the [MEDICAL TREATMENT] Center on 05/25/16 at 3:15 PM revealed Resident #1 was unhooked from the [MEDICAL TREATMENT] machine at 3:15 PM. There was no record of what time Resident #1 was picked up from the [MEDICAL TREATMENT] center. Review of MapQuest.com on 05/25/16 revealed, driving directions revealed from the facility to the [MEDICAL TREATMENT] center was 2.3 miles estimated drive time of six minutes. Review of the facility's undated Investigation Summary received on 05/25/16, revealed According to [MEDICAL TREATMENT] center, patient was picked up from [MEDICAL TREATMENT] at approximately 3:45, [MEDICAL TREATMENT] was completed at 3:15. Driver brought resident back to facility and arrived at around 4 PM. DON received call at 4:14 PM from LVN D stating resident was found on van by one of the dietary aides. Resident was on van approximately 15 minutes after arriving back to the facility. The driver was suspended and then terminated on May 9th. Current driver in-serviced on May 12th, her first day back after being in the hospital. Review of HR documented phone conversation dated 05/09/16 revealed, (Driver A) was asked if he could explain what happened over the weekend. (Driver A) stated that he picked up the resident at about 3:45 PM, he drove from the [MEDICAL TREATMENT] center which took about 15 minutes. He arrived back to the facility at about 4:20 PM, he pulled in got out of the van and clocked out for break. He stated that when he returned from his lunch (5:16 PM) he was told by other staff member that a resident was found on the van. He stated he was not sure what happened to make him forget the resident. HR asked if he was distracted in any way, he stated no, I just forgot she was there. Interview with Administrator on 05/25/16 at 9:25 AM revealed Driver A stated he blacked out and did not know what happened. The Administrator stated an in-service was completed with the other facility drivers. Interview with the Maintenance Supervisor on 05/25/16 at 9:40 AM revealed there is was no formal policy in place regarding ensuring all residents were of the van and accounted for. When a new driver was hired, they were trained to drive the van by a current driver and trained how to use the wheelchair lift. The driver training the new driver would sign off that the new employee was ready to drive the van. The Maintenance Supervisor stated the only people authorized to drive the van were himself, Driver B and Driver C. Driver B was the main driver, himself and Driver C were back-ups if Driver B is was not available. He stated all drivers must be cleared through the insurance. The Maintenance Supervisor stated there had been no formal training following the incident. He revealed that staff just talked among themselves. Interview with Driver B on 05/25/16 at 11:35 AM revealed she was asked by the Administrator to sign something that day (05/25/16) saying she was trained on 05/12/16. Driver B stated she did not receive any training on 05/12/16 or 05/25/16. Driver B stated she told the Administrator she was not going to lie. Review of Staff Development Attendance Record dated 05/12/16 revealed Driver B received verbal training regarding understand safety when transporting residents. Interview with the DON on 05/25/16 at 9:28 AM revealed following the incident an in-service was conducted with floor staff. The DON stated Resident #1 left the [MEDICAL TREATMENT] center around 3:45 PM and arrived at the facility around 4:00 PM. She revealed the resident was only in the van for 15 to 30 minutes. A head to toe assessment was completed and vitals checked. There were no injuries noted. Review of an undated Transportation In-Service received 05/25/16 revealed Reviewed policy with facility transportation aide (Driver B) regarding immediately removing residents from van or bus and also always checking vehicle after parking in back to ensure no resident or resident property left on vehicle. Interview with LVN F on 05/25/16 at 8:33AM revealed she had not received any in-services following the incident involving Resident #1. Interview with LVN D on 05/25/16 at 8:38AM revealed she had not received any in-services following the incident involving Resident #1. Interview with Driver B on 05/25/16 at 8:58 AM revealed she was trained to drive the van by Driver A. Driver B stated she had not received any additional training following the incident. Driver B stated when a resident was brought back from an appointment, the driver should take the resident to the nurses's station. Driver B explained a resident would not have been able to open any other door of the van other than the driver's side door without the key to the ignition. Interview with the Administrator on 05/25/16 at 10:17AM revealed there had been no new policies or procedures implemented since Resident #1 was left in the van after her [MEDICAL TREATMENT] appointment. Interview with the Maintenance Supervisor on 05/25/16 at 10:28 AM revealed following the incident on 05/07/16 no one drove the van until Driver B returned from leave on 05/12/16. All residents were transported by private transport. Interview with Driver B on 05/25/16 at 11:35 AM revealed she transported residents daily to various locations, doctors' appointments, the bank and the store. She stated other than Resident #1 the only other resident in the facility who had a standing weekly appointment is was Resident #2. Driver B stated a transportation book is kept of resident's appointments. Review of Resident #2's face sheet provided on 05/25/16 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Resident #2 was alert and oriented. Review of the transportation book on 05/25/16 revealed Resident #2 would have requested transportation on 05/09/16. Interview with Resident #2 on 05/25/16 at 11:27AM revealed the resident was alert and oriented. Resident #2 stated he had never been transported to his therapy appointments by a private transport. Resident #2 stated when Driver B was on leave, Driver C took him to all of his appointments. He stated he had never been driven by anyone else other than facility staff. Interview with LVN G on 05/25/16 at 12:20 PM revealed Resident #2 had never used a private transport to go his appointments. LVN G stated he had always been transported by the facility driver. LVN G stated when Driver B was out on leave, Driver C took Resident #2 to his appointments. Interview with Driver C on 05/27/16 at 8:50AM revealed he had driven the facility van. Driver C stated when Driver B was out on leave he drove Resident #2 to his appointments. Driver C stated Resident #2 was the only resident he had driven. Driver C stated he did not receive training following the incident but he received additional training over new transportation policy and abuse and neglect the past couple of days. Interview with LVN F on 05/25/16 at 11:30AM revealed the facility driver was utilized as much as possible to transport residents to appointments. The only time a private transport was used if there were appointments times overlapping. Review of Driver A's personnel file on 05/25/16, revealed a hire date of 08/13/12 as a driver, Driver A had previous incident involving the facility van on 08/11/15 when Driver A was using the vehicle for personal use and hit a telephone pole. There were no residents in the van at the time of the incident. The facility policy was reviewed with Driver A regarding use of facility vehicle. Review of Progressive Counseling Notice Form dated 05/10/16, revealed Driver A was terminated on 05/10/16. The Incident description reflected: On 05/07/16 (Driver A) has (sic) picked a resident up from an appointment and when returned to the facility got out of the bus and forgot resident inside. Resident was left in bus unattended for approximately 40 minutes until found by other employees. Review of Vehicle Business - Use Policy dated August 2012 revealed all drivers must possess a valid Texas driver's license, and required motor vehicle check and operate motor vehicles in a safe manner at all times. All occupants were required to use seat belts or other restraint devices at all times when in the vehicle. The Vehicle Business - Use policy did not include procedures to check the vehicle to ensure no residents were left on the vehicle. The facility's Abuse Prevention Program dated August 2006 revealed the policy provided did not define neglect. An IJ was identified on 05/25/16 at 12:06 PM. The Administrator was notified of the IJ. A Plan of Removal was requested. The facility's Transportation Policy dated 05/25/16 implemented on 05/25/16 after Immediate Jeopardy was identified, revealed the purpose of the policy is to ensure that facility nurses are made aware of the resident residing on their halls is returning from appointments. Procedure: 1. Per current procedure nursing will document transportation needs in transportation book, noting if outside transportation - our contracted company or in house transportation. 2. Nurse will document on log and in notes that resident has left the facility for appointment. If resident leaves with family or responsible party this is documented in separate sign out book. 3. In house transportation driver will contact nursing staff at facility when driver has picked up resident and is returning to facility and will give nursing approximate amount of time to return. 4. Nursing will document in notes that driver has contacted facility. 5. If resident has not arrived at facility within 15 minutes of approximated time given by driver, nurse will contact driver to receive updated time. 6. Upon arrival at facility, nurse will document in notes and on log the resident's return. 7. Nursing administration will review log during morning meeting. Review of the transportation log implemented on 05/25/16, after Immediate Jeopardy was identified, revealed facility put in place transportation log at each nurses station. Log contains resident name, place of appointment, time of appointment and time of return. Upon return the log is to be initialed by the driver that resident has been returned to the facility. Plan of Removal was accepted on 05/26/16 at 4:38PM. PLAN OF REMOVAL: Action Taken: Driver B was inserviced 05/12/16 by Administrator on transporting residents and Appropriate procedures include parking outside the hall on which the resident resides, taking resident to nurse station to check in with charge nurse and turning in any paperwork to nurse. Then going back to vehicle to park in van parking space. Driver B is weekday driver for appointments and Driver A was a weekend only driver. There are two other insured drivers- Maintenance Supervisor and Driver C. Maintenance Supervisor was inserviced on 5/25/2016 and Driver C will be inserviced upon return to work on 5/26/16 by administrator. Driver B, weekday driver correctly explained procedure for bringing residents to and from facility when questioned by administrator prior to implementation of new policy. Facility has implemented new policy on 05/25/16 regarding communication between in house drivers and nursing staff. Any resident that has routine appointments or a planned physician appointment, or transport to any other outside place requested by the resident had the potential to be affected by this alleged deficient practice by Driver A and could be affected by any future practice by facility driver. Any appointments prior to all staff receiving inservice on transportation communication will be taken by our outside transportation company. The same procedure of signing in and out by the ambulance driver will be required. Those conducting inservices are the DON, ADON, LVN E. Inservice on reporting abuse and neglect will be conducted the CEO on Thursday05/26/16 at 3:00 pm to the administrative team. Inservice begin date 5/26/16 and complete date 5/27/16, staff out on leave will be given the inservice prior to returning to work and will be ongoing with all new hires All facility staff will- be inserviced on abuse/neglect. All charge nurses, nurses, medication aides, and certified nurse aides will be inserviced on transportation communication policy and transportation policy. Inservice is being conducted written and orally by presenting abuse and neglect policy and written transportation communication policy implemented today 5/25/16 staffing in facility is 5 days per week for nurses and 4 on 2 off for nurse and med aides. As of today all the 6-2 and 2-10 nurses have been inserviced and all the aides on this shift. The 10-6 will be inserviced tonight and we have used on-shift to send mass message to all staff. Any employee that has not been inserviced by 6 pm 5/26/16 will not be allowed to work until they have been inserviced. We have four staff on leave either out of the country, maternity leave and one in medically induced coma-these employees will not be allowed to return to work until inservice completed. All PRN will complete inservice with a member of nursing administration prior to working the floor. Form will be created to keep at nursing station to ensure that all transports are being documented in and out. Nursing administration will monitor all employees that have not signed inservice prior to returning to work. Competency of the inservice will be monitored by randomly testing staff with a written test created by administrator and nursing administrator. The facility will not allow anyone to drive the facility vehicle unless that person has been added to the insurance and has completed all safety training and has demonstrated competency by written test and ride along training with Maintenance Supervisor. All facility staff will be inserviced by 7pm on Thursday 05/27/16. Monitoring Administrator and nursing administration will be responsible for monitoring and will monitor for 1 day weekly for 6 weeks then monthly thereafter. Facility will assign staff member to accompany resident during transportation to and from appt to ensure safe drop off and return for 3 months and then will review in QAPI and redetermine if necessary. Facility meets quarterly for QA and will add to QAPI agenda and will continue to monitor on monthly basis to ensure plan is continuing to be successful. Any facility vehicle drivers will have safety competency test quarterly, beginning 06/01/16. Administrator and nursing administration responsible for implementation of policy. The date the new policies are in place 05/26/16. Interview with ADON and LVN E on 05/27/16 at 8:30AM revealed both stated they received training. Both were able to correctly describe what was learned in the training regarding identifying and reporting abuse and neglect. Interview with the DON on 05/27/16 at 9:15AM revealed she received training regarding abuse and neglect and what is was reportable. The DON stated the Administrator was to be notified immediately. Interview with Administrator on 05/27/16 at 9:20AM revealed she received training yesterday regarding identifying and reporting abuse and neglect. Review of staff in-service received 05/27/16 revealed all training was completed regarding identifying and reporting abuse and neglect and new transportation policy and log with all staff including weekend and PRN staff. Interview with facility staff on 05/27/16 (CNA K, CNA 6-2, LVN R, 6-2, CNA M, 6-2, CNA N, 6-2/2-10, CMA X 6-2/10-6, LVN G, 6-2, LVN S, 6-2, CNA O, 6-2/2-10, Housekeeper P, 8-5, Driver C (weekends), Driver B, LVN T, 6-2, LVN U 8-5, LVN V, 8-5,

Based on observation, interview and record review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (Residents #1 and #2) of nine residents reviewed for neglect. 1. The Administrator failed to implement the facility's Abuse Prevention Program by not conducting a thorough investigation when Resident #1, who was in a wheelchair, was left unsupervised in the van after returning from a [MEDICAL TREATMENT] treatment, with the windows rolled up from approximately 3:45 PM to approximately 5:00 PM. The temperature outside was approximately 85 degrees. The Administrator also failed to report the incident to the State survey and certification agency. Resident #1 had to crawl out of her wheelchair and from the back of the van to the driver's side door to open the door and push the horn. Resident #1 was crying, anxious and in pain when she was found. The resident was still fearful and upset about the incident after her discharge from the facility. 2. The Administrator failed to develop interventions and/or policies to prevent other residents from being left unsupervised in the facility van and allowed Driver C to transport Resident #2 after the incident. 3. The Administrator failed to train the facility's van drivers to ensure residents were not left unsupervised in the van after transportation. 4. The Administrator instructed facility staff to falsify records. An Immediate Jeopardy (IJ) was identified on 05/25/16. While the IJ was removed on 05/27/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures could affect all 130 residents, who could be transported in the facility van at any time, by placing them at risk for neglect, injuries, pain and stress on their well-being and causing other serious mental/physical harm and/or death. Findings included: Review of undated Investigation Summary regarding Resident #1 received 05/25/16, revealed According to [MEDICAL TREATMENT] center, patient was picked up from [MEDICAL TREATMENT] at approximately 3:45, [MEDICAL TREATMENT] was completed at 3:15. Driver brought resident back to facility and arrived at around 4 PM. DON received call at 4:14 PM from LVN D stating resident was found on van by one of the dietary aides. Resident was on van approximately 15 minutes after arriving back to the facility. The driver was suspended and then terminated on May 9th. Current driver in-serviced on May 12th, her first day back after being in the hospital. Interview with Resident #1 via telephone on 05/25/16 at 4:31 PM revealed Resident #1 stated she was trapped in the van for at least an hour (05/07/16). Resident #1 stated the driver pulled to the back of the facility, which he had never done before. The driver then got out of the van and into another vehicle and drove away. Resident #1 stated she remembered thinking to herself surely he is not going to leave me in here. Resident #1 stated she finally figured out how to unstrap herself from her wheelchair and made it to the front of the van. She made it to the driver's seat and opened the door for air and began honking the horn. Resident #1 stated she had been honking the horn for 20 to 25 minutes until someone came to help her. Resident #1 stated she could not breathe because it was so hot and she did not have any oxygen. Resident #1 revealed she was sweating and crying when staff finally found her. She stated the nurse did an assessment but she was such in shock she could not tell them her back was hurting and she hurt her heel. Resident #1 stated the Administrator came to talk to her the following Tuesday (05/10/16) and told her she would be back to get her statement but never returned. During the interview Resident #1 became upset and began crying when she told the investigator what happened. www.weatherundergrond.com Weather History for KDFW on 05/25/16, revealed on 05/07/16 at 3:53 PM outside temperature was 84.0 degrees with 35% humidity. www.accueweather.com forecast on 05/25/16 revealed on 05/07/16 high temperature of 85 degrees. www.weather.com on 05/25/16, revealed, the Department of Geosciences San Francisco University - Estimator Vehicle Interior Air Temperature vs Elapsed Time by revealed outside temperature of 85 degrees after 10 minutes the interior of the vehicle will reach 104 degrees; 20 minutes will reach 114 degrees; 30 minutes will reach 119 degrees; 40 minutes will reach 123 degrees; 50 minutes will reach 126 degrees; 60 minutes will reach 128 degrees; over an hour interior temperature will reach 130 degrees. Interview with Dietary Aide I on 05/25/16 at 8:45 AM revealed it was around dinner time when he heard the honking of the horn. Dietary Aide I stated he thought it was maintenance working on the van. Then about 30 minutes later he went outside to take the trash out and heard the honking again. Dietary Aide I stated that was when he saw the resident (Resident #1) in the vehicle waiving her hands and pulling on her shirt like she was hot. Dietary Aide I stated he then went to check on the resident and told Dietary Aide J who came out to the van. Dietary Aide I stated he stayed with the resident while Dietary Aide J went to go get the nurse. Dietary Aide I stated it was around 5:00 PM when the resident was found in the van. Interview with Housekeeper H on 05/25/16 at 8:45 AM revealed the resident (Resident #1) was in the driver's seat of the van. Housekeeper H stated she was able to unlock the back of the van manually and lower the lift. She then assisted getting Resident #1 back into her wheelchair and lowered the wheelchair with the resident in it out of the van using the lift. Housekeeper H stated it was around 5:00 PM when resident was found in the van. Interview with Dietary Aide J, the cook and Dietary Aide K on 05/25/16 at 1:09 PM revealed they heard honking around 3:30 PM and kept looking out the window to see where the honking was coming from. When asked how they knew it was 3:30 PM, she (Dietary Aide K) stated because that was what time they go on break. Dietary Aide K stated at around 5:00 PM Dietary Aide I told her (Dietary Aide J) there was someone in the van. They stated when she (Dietary Aide K) went out to the van and the resident was waiving her arms for help. They stated the resident was crying and upset. Dietary K stated Resident #1 told her she unfastened herself from the wheelchair and crawled to the driver's seat. She (Dietary Aide K) stated the driver's side door was opened but the resident could not get out. Dietary K stated she continually heard the honking from 3:30 PM until 5:00 PM when Resident #1 was found. The facility's Abuse Prevention Program dated August 2006 revealed 1. Should an incident or suspected incident or resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident .15. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state and local law, within five (5) working days of the reported incident. Review of HR documented phone conversation dated 05/09/16 revealed, Driver A was asked if he could explain what happened over the weekend. Driver A stated that he picked up the resident at about 3:45 PM, he drove from the [MEDICAL TREATMENT] center which took about 15 minutes. He arrived back to the facility at about 4:20 PM, he pulled in got out of the van and clocked out for break. He stated that when he returned from his lunch (5:16 PM) he was told by other staff member that a resident was found on the van. He stated he was not sure what happened to make him forget the resident. HR asked if he was distracted in any way, he stated, no, I just forgot she was there. Review of Progressive Counseling Notice Form dated 05/10/16, revealed Driver A was terminated on 05/10/16. Incident description: On 05/07/16 Driver A has (sic) picked a resident up from an appointment and when returned to the facility got out of the bus and forgot resident inside. Resident was left in bus unattended for approximately 40 minutes until found by other employees. Review of Vehicle Business - Use Policy dated August 2012 revealed all drivers must possess a valid Texas driver's license, require motor vehicle check and operate motor vehicles is a safe manner at all times. All occupants are required to use seat belts or other restraint devices at all times when in the vehicle. The Vehicle Business - Use policy did not include procedures to check the vehicle to ensure no residents were left on the vehicle. Interview with the Administrator on 05/25/16 at 9:25 AM revealed Driver A stated he blacked out and did not know what happened. When asked why the incident was not reported to DADS, the Administrator stated she did not know she had to report the incident. The Administrator stated in-service was completed with the other facility drivers. Interview with the DON on 05/25/16 at 12:36 PM revealed there was not an incident/accident report completed on the incident because the nurse that day did not know where to put the incident under the event so everything was completed in a nurses note. Interview with the Maintenance Supervisor on 05/25/16 at 9:40 AM revealed there is no formal policy in place regarding ensuring all residents are of the van and accounted for. When a new driver was hired they are were trained to drive the van by a current driver and trained how to use the wheelchair lift. The driver training the new driver would sign off that the new employee was ready to drive the van. The Maintenance Supervisor stated the only people authorized to drive the van were himself, Driver B and Driver C. Driver B was the main driver, himself and Driver C were back-ups if Driver B is was not available. All drivers must be cleared through the insurance. The Maintenance Supervisor stated there had been no formal training following the incident, that staff had just talked among themselves. Interview with Driver B on 05/25/16 at 8:58AM revealed Driver B stated she was trained to drive the van by Driver A. Driver B stated she had not received any additional training following the incident. Interview with Driver B on 05/25/16 at 11:35 AM revealed Driver B was asked by the Administrator to sign something that day (05/25/16) saying she was trained on 05/12/16. Driver B stated she did not receive any training on 05/12/16 or today. Driver B stated she told the Administrator she was not going to lie. Review of Staff Development Attendance Record dated 05/12/16 revealed Driver B received verbal training regarding understand safety when transporting residents. Interview with Administrator on 05/25/16 at 10:17AM revealed there have been no new policies or procedures implemented since the incident. Interview with Resident #2 on 05/25/16 at 11:27AM revealed resident is alert and oriented. Resident #2 stated he had never been transported to his therapy appointments by a private transport. Resident #2 stated when Driver B was on leave, Driver C took him to all of his appointments. Resident #2 stated he had never been driven by anyone else other than facility staff. Interview with LVN G on 05/25/16 at 12:20PM revealed Resident #2 had never used a private transport to go his appointments. LVN G stated he has always been transported by the facility driver. LVN stated when Driver B was out on leave, Driver C took Resident #2 to his appointments. Interview with Driver C on 05/27/16 at 8:50AM revealed he had driven the facility van. Driver C stated when Driver B was out on leave he drove Resident #2 to his appointments. Driver C stated Resident #2 was the only resident he had driven. Driver C stated he did not receive training following the incident with Resident#1, but he had received additional training regarding abuse and neglect and transporting residents the past couple of days. Review of undated Transportation In-Service received 05/25/16 revealed Reviewed policy with facility transportation aide (Driver B) regarding immediately removing residents from van or bus and also always checking vehicle after parking in back to ensure no resident or resident property left on vehicle. An IJ was identified on 05/25/16 12:06 PM. The Administrator was notified of the IJ at 05/25/16 12:08PM. A Plan of Removal was requested. Plan of Removal was accepted on 05/26/16 at 4:38PM. PLAN OF REMOVAL: Action Taken: Driver B was inserviced 05/12/16 by Administrator on transporting residents and Appropriate procedures include parking outside the hall on which the resident resides, taking resident to nurse station to check in with charge nurse and turning in any paperwork to nurse. Then going back to vehicle to park in van parking space. Driver B is weekday driver for appointments and Driver A was a weekend only driver. There are two other insured drivers- Maintenance Supervisor and Driver C. Maintenance Supervisor was inserviced on 5/25/2016 and Driver C will be inserviced upon return to work on 5/26/16 by administrator. Driver B, weekday driver correctly explained procedure for bringing residents to and from facility when questioned by administrator prior to implementation of new policy. Facility has implemented new policy on 05/25/16 regarding communication between in house drivers and nursing staff. Any resident that has routine appointments or a planned physician appointment, or transport to any other outside place requested by the resident had the potential to be affected by this alleged deficient practice by Driver A and could be affected by any future practice by facility driver. Any appointments prior to all staff receiving inservice on transportation communication will be taken by our outside transportation company. The same procedure of signing in and out by the ambulance driver will be required. Those conducting inservices are the DON, ADON, LVN E. Inservice on reporting abuse and neglect will be conducted the CEO on Thursday05/26/16 at 3:00 pm to the administrative team. Inservice begin date 5/26/16 and complete date 5/27/16, staff out on leave will be given the inservice prior to returning to work and will be ongoing with all new hires All facility staff will- be inserviced on abuse/neglect. All charge nurses, nurses, medication aides, and certified nurse aides will be inserviced on transportation communication policy and transportation policy. Inservice is being conducted written and orally by presenting abuse and neglect policy and written transportation communication policy implemented today 5/25/16 staffing in facility is 5 days per week for nurses and 4 on 2 off for nurse and med aides. As of today all the 6-2 and 2-10 nurses have been inserviced and all the aides on this shift. The 10-6 will be inserviced tonight and we have used on-shift to send mass message to all staff. Any employee that has not been inserviced by 6 pm 5/26/16 will not be allowed to work until they have been inserviced. We have four staff on leave either out of the country, maternity leave and one in medically induced coma-these employees will not be allowed to return to work until inservice completed. All PRN will complete inservice with a member of nursing administration prior to working the floor. Form will be created to keep at nursing station to ensure that all transports are being documented in and out. Nursing administration will monitor all employees that have not signed inservice prior to returning to work. Competency of the inservice will be monitored by randomly testing staff with a written test created by administrator and nursing administrator. The facility will not allow anyone to drive the facility vehicle unless that person has been added to the insurance and has completed all safety training and has demonstrated competency by written test and ride along training with Maintenance Supervisor All facility staff will be inserviced by 7pm on Thursday 05/27/16 Monitoring Administrator and nursing administration will be responsible for monitoring and will monitor for 1 day weekly for 6 weeks then monthly thereafter. Facility will assign staff member to accompany resident during transportation to and from appt to ensure safe drop off and return for 3 months and then will review in QAPI and redetermine if necessary Facility meets quarterly for QA and will add to QAPI agenda and will continue to monitor on monthly basis to ensure plan is continuing to be successful. Any facility vehicle drivers will have safety competency test quarterly, beginning 06/01/16 Administrator and nursing administration responsible for implementation of policy The date the new policies are in place 05/26/16 Interview with ADON and LVN E on 05/27/16 at 8:30AM revealed both stated they received training. Both were able to correctly describe what was learned in the training regarding identifying and reporting abuse and neglect. Interview with the DON on 05/27/16 at 9:15AM revealed she received training regarding abuse and neglect and what is was reportable. The DON stated the Administrator was to be notified immediately Interview with Administrator on 05/27/16 at 9:20AM revealed she received training yesterday regarding identifying and reporting abuse and neglect. Review of staff in-service received 05/27/16 revealed all training was completed regarding identifying and reporting abuse and neglect and new transportation policy and log with all staff including weekend and PRN staff. Interview with facility staff on 05/27/16 (CNA K, CNA 6-2, LVN R, 6-2, CNA M, 6-2, CNA N, 6-2/2-10, CMA X 6-2/10-6, LVN G, 6-2, LVN S, 6-2, CNA O, 6-2/2-10, Housekeeper P, 8-5, Driver C (weekends), Driver B, LVN T, 6-2, LVN U 8-5, LVN V, 8-5, LVN W 6-2/10-6/weekends, LVN F, 6-2/2-10/weekends 6-6, CNA Q, 6-2/2-10) (All CNAs work 4 days on 2 days off, all aides work at least one weekend in a 30 day period.) On 05/26/16 the IJ was removed. On 05/26/16 at 4:38PM the Administrator were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope widespread because the facility still implementing its Plan of Removal. Form CMS-672, Resident Census and Conditions of Resident, dated 05/25/16, reflected the facility census of 130 residents.

Based on interview and record review, it was determined the facility failed to ensure the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho-social well-being were provided for one (Resident #1) of three sampled residents. On 10/23/10, CNA C and CNA H reported Resident #1 had bruising of the right knee to LVN I. LVN I did not assess the resident's knee, because she thought it was the resident's skin tear (sustained on 10/21/10 during a transfer) reopening. On 10/24/10, CNA K observed Resident #1 with bruising of the right knee and reported it to her Charge Nurse. There was no evidence an assessment of the resident's knee was done. On 10/26/10, CNA L reported Resident #1's bruising, swelling and pain of the right knee to RN D. RN D assessed the resident's right knee and received orders for an x-ray to rule out a fracture. The resident had a fracture of unknown age of the right Tibia/Fibula near the knee. Resident #1 was not transferred to the hospital until 10/27/10. These failures to assess Resident #1's knee when bruising was first reported placed the resident at risk for further injury or the potential of a fat emboli. These failures could affect the facility's 148 residents and placed them at risk for not being assessed with [REDACTED]. Findings included: Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] reflected she had short-term and long-term memory problems, moderately impaired cognitive skills for daily decision-making, and was dependent on staff for bed mobility, dressing, toilet use and personal hygiene. The MDS assessment reflected Resident #1 was not transferred. Review of an Incident/Accident Report dated 10/21/10 and timed at 11:00 a.m. and signed by the Administrator, revealed Resident #1 sustained a skin tear, "1 inch x 0.5 inch." The diagram on the report reflected the location of the skin tear was on Resident #1's right lateral ankle. The report reflected, "Resident was being hoyer lift from bed to geri chair." The report was signed by LVN A. The attached Investigation Report dated 10/21/10 reflected the skin tear was observed after CNA B and CNA C transferred the resident using a Hoyer lift. "Resident was being hoyer lifted from bed to Geri-chair-skin tear noted after transfer." An attached witness statement signed by CNA B revealed, "We aides were getting resident up and her leg hit the chair. She got a skin tear on rt (right) shin." An attached witness statement signed by CNA C revealed, "Me and ____ (CNA B) and ____ (CNA H) were getting ____ (Resident #1) out her bed to her chair. When her leg scrap (sic) the chair." Review of an Incident/Accident Report dated 10/26/10 (five days after the 10/21/10 skin tear) and signed by the Administrator, revealed Resident #1 was "...noted to have swelling, green-blue-purple discoloration on the R (right) patella (knee cap) to shin area. And it is warm to touch." The Incident/Accident Report was completed by RN D. The attached Investigation Report reflected under the heading, "Could anything have been done to avoid this incident or prevent future incidents like this one?" was written, "N/A (not applicable)." An attached witness statement dated 10/26/10 and signed by RN D reflected, "Resident noted to have Blue-Purple-and green discoloration on the right knee cap to shin. C/O (complains of) pain when touched. Warm to touch and (with) blisters in some areas (with) clear drainage and swelling. The area measures 18 cm long by 9 cm wide. Skin intact. NP (Nurse Practitioner)...notified @ 6:59 a.m. and daughter (POA) (power of attorney) contacted message left. POA (with) return call at 7:05 a.m." A written statement attached to the report and dated 10/26/10 and completed by CNA L reflected she was changing the resident and observed a blue-purple bruise on the right knee cap and reported the bruising to the nurse. There was no mention of the previous incident (skin tear to ankle) included in this report. There were no additional statements regarding Resident #1's injuries other than those written on 10/26/10 by RN D and CNA L. There was no evidence staff who provided care previously to Resident #1 were identified and interviewed regarding her injuries. Review of Daily Skilled Nurse's Notes dated 10/21/10 revealed the following entries: "11 a.m. Resident transferred out of bed x 2 CNA's Hoyer Lift. Total care, except feeding feeds self at times. However noted not feeding self has been assisted by staff. Resident to be OOB (out of bed) for meals. At risk for wt. (weight) loss and skin breakdown. Mineral oil was applied to (lower) ext (extremities) prior to transfer. __ (No) open areas. Skin tear noted on R (right) lower leg by CNAs assigned after transfer. Care provided per protocol. N/O (new order) executed." Signed by LVN A. 11:52 a.m. - "____ (family) notified about skin tear. __ (No) concerns voiced. (up) in Geri-chair (without) distress" and was signed by LVN A. 2:00 p.m. - "Resident refuses to go to bed. States 'No' I'll go back later. Watching TV (with) other residents. __ (No) distress. Denies pain or discomfort." Signed by LVN A. Further review of the Daily Skilled Nurse's Notes and Nurse's Notes revealed no additional entries after 10/21/10 until 10/26/10, which reflected the following: Nurse's Notes: 10/26/10 (no time) "Resident noted to have Blue-purple and green discoloration on the R knee cap (patella) to shin area. The area of discoloration measures 18 cm long by 9 cm wide. Skin intact, area c (with) swelling, warm to touch and c some portions of blisters c (with) clear drainage. C\O (complains of) pain on touch." The note reflected the NP was notified and an X-ray was ordered to rule out a fracture. A treatment of [REDACTED]. The note reflected the next shift was told to "just keep leg elevated and immobilize the extremity." The note reflected Resident #1 was on scheduled pain management. The entry was signed by RN D. 7:30 a.m. "Call made to stat x-ray. X-ray ordered...." Signed by RN D. 12:10 p.m. "Stat X-Ray here to take x-ray to R LE (lower extremity) @ this time, will monitor and leg elevated immobilize @ this time." Signed by LVN E. 2:50 p.m. "X-ray result @ (right) leg obtained @ this time which impression written: proximal lower leg fractures of unknown age, NP notified and said that will assess resident by self when she will be here, because resident is bed bound and fx of unknown age, will monitor." Signed by LVN E. Nurse's Notes: 10/27/10 1:03 a.m. "Resident in room complain of pain [MEDICATION NAME] 5/500 prn administered for pain." The note reflected Resident #1's right leg was swollen and immobilized. The note reflected the NP was paged and orders were received for the resident to be sent to the emergency room . Signed by RN D. Review of the Skin Condition Report for Non-Pressure Sore Skin Conditions revealed an entry dated 10/21/10. Under "Appearance (include color/Odor/Drainage, As Appropriate)" was written: "Skin tear R lower leg." Treatment included NS (normal saline), TAO dressing BID and PRN. Signed by LVN A. Review of Resident #1's entire clinical record revealed no other documentation of the resident's skin tear between the dates of 10/21/10 and 10/26/10. An interview with LVN E on 11/04/10 at 3:30 p.m. revealed on 10/26/10, the night shift reported Resident #1 had bruises, they had called the NP and obtained orders for X-rays. LVN E stated she cleaned the area during the day with normal saline, and Resident #1 needed additional pain medication due to pain in her leg. (Note: Resident #1 was already receiving scheduled pain medications). LVN E stated toward the end of her shift. she called the X-ray company for a report, because one had not been received yet. Upon hearing there was a fracture, LVN E stated she requested a faxed copy and called the result to NP. When queried how the NP responded, LVN E stated, "She said, 'Okay. I'll assess her tomorrow.' I said, 'Should I send her to the hospital?' She said, 'No. I'll assess her tomorrow.' " LVN E stated, "I called the (X-ray) result to ADON (M), told her results. She told me to chart it and write an incident report." LVN E explained an incident report had already been written by the night shift nurse. When queried whether she called the family, LVN E replied, " ____ (RN D) said she called the family." During an interview with LVN F on 11/04/10 at 3:41 p.m., regarding the events on 10/26/10, the LVN stated, "When I came to work, I got report that she had a fracture. I was dismayed. She was fine. I never heard she had a problem the night before. I was told the NP would come the next day." LVN F added when Resident #1 was in pain, they could hear her from the nurses' station, and she had been "okay" the evening before. During an interview on 11/05/10 at 8:25 a.m., the Administrator was queried whether there was any investigation as to how Resident #1 fractured her leg. The Administrator explained staff believed it was related to the incident on 10/21/10 when Resident #1 received a skin tear during the transfer. The Administrator further explained the staff had been in-serviced on proper Hoyer lift transfer techniques. When queried why the bruising and swelling were not mentioned on the earlier incident report, the Administrator stated she felt it may have started as a small fracture and then became worse. During an interview on 11/05/10 at 9:55 a.m., LVN A was queried regarding the events of 10/21/10 and how the resident obtained the skin tear. LVN A stated, "They got her up on the Hoyer. They hit her leg. I did the assessment and told the family." When queried about the injury, LVN A stated it was just a tear, no bruising at the end of the shift. She added Resident #1 wanted to remain in her chair. LVN A further stated Resident #1 had no complaints the next day, and no bruises were observed the next day. Interview with CNA H on 11/05/10 at 11:45 a.m. revealed she worked with Resident #1 on 10/23/10. CNA H stated when she went to bathe Resident #1, she noticed her leg was very bruised. CNA H stated at that point she stopped and reported it to the weekend nurse, LVN I, and asked her to check and see if something had happened. She stated LVN I told her she "didn't see nothing in the book and would write an incident report." When asked to describe the bruising, CNA H pointed to an area approximately two inches above the knee to two inches below the knee and stated it was red and purple and had two little blister spots. She added Resident #1 was not complaining other than her usual complaints. CNA H also stated she had seen Resident #1 up in a chair on the day before (Friday, 10/22/10) and did not see any bruising on her then. An interview with CNA J on 11/05/10 at 2:00 p.m., revealed she assisted with transferring Resident #1 on 10/21/10. CNA J stated she did not recall Resident #1 bumping anything and denied Resident #1 complained of anything during the transfer. She stated she and the other CNAs noticed the skin tear after the transfer and reported it to her nurse. When queried whether she provided a statement, CNA J replied, "No. They said they were going to fill out an incident report but no one ever asked me for anything." Interview with CNA C on 11/05/10 at 5:57 p.m. revealed she assisted with Resident #1's transfer on 10/21/10. CNA C stated a Hoyer lift was never used to transfer Resident #1. CNA C stated she, CNA B and CNA J physically lifted Resident #1 and moved her from her bed to a Geri-chair. She denied seeing the resident hit her leg or any indication of injury during the transfer. CNA C stated they noticed the skin tear after the resident was moved and settled in the Geri-chair. CNA C added Resident #1 never complained of pain and told them she wanted to stay in the chair. "I guess her leg scraped something when we lifted her legs on the chair." CNA C stated the skin tear was reported to LVN A. On 11/07/10 at 9:20 a.m., an interview with CNA B revealed she assisted with transferring Resident #1 on 10/21/10. She described how she and two other CNAs "man-lifted" Resident #1 from her bed to a chair. She stated after the lift, CNA C pointed out a small skin tear near the resident's ankle. CNA B denied seeing Resident #1 hit her leg during the transfer. She stated Resident #1 did not cry out. When asked if that was how they typically transferred Resident #1, CNA B replied, "We usually don't get her up. This was my first time to get her up. It was my understanding she wasn't care-planned to be a Hoyer lift, so we man-lifted her." When queried whether she knew about the bruise, CNA B stated she had not seen the bruise and added, "I can't see that what we did could have done that." On 11/07/10 at 9:40 a.m. CNA C was interviewed again regarding Resident #1. CNA C pointed out the type of Geri-chair used. She added the next day (10/22/10) they got Resident #1 up again, and there was no bruising, and the resident made no complaint. CNA C stated when she worked on Saturday (10/23/10), CNA H asked for her assistance with Resident #1. When they pulled back the sheet, the bruise was there. "We told ____ (LVN I) and asked if there was an incident report. There wasn't. ____ (LVN I) said she was going to write an incident report." On 11/08/10 at 10:10 a.m., the Administrator was queried regarding the incident report dated 10/21/10, which reflected Resident #1 was transferred via a Hoyer lift when, in fact, she was not. The Administrator stated LVN A had initially been told by the CNAs a Hoyer lift was used. Later, when physical therapy went to conduct an in-service with the CNAs, they found out she was physically lifted. The Administrator added LVN A was supposed to re-do the incident report. The Administrator stated she would attempt to reach staff and obtain written statements. Telephone interview with LVN I on 11/08/10 at 12:42 p.m. revealed she could not recall a large bruise on Resident #1. When queried whether anything had been reported to her by the CNAs, she stated, "I think they might have said something, but I checked, and there was a treatment ordered for her skin. ...she always has skin tears. I noticed she had a treatment, so I thought it (the skin tear) reopened. ...if there had been a big bruise, I would have done something." A written statement received from the ADON M on 11/08/10 and dated 11/08/10 reflected: "Sunday (10/24/10) afternoon I walked in to ____ (Resident #1's) room spoke to her and checked her for b/b (bowel and bladder) incontinence she was clean before checking her I seen her leg R (right) knee area was very bruised and blue black. I put the leg on a pillow and reported it to the charge nurse." The statement was signed by CNA K and dated 11/08/10. During an interview on 11/08/10 at 1:45 p.m., the Administrator identified herself as the facility's designated Abuse Coordinator. When queried whether she reported Resident #1's fractures, the Administrator replied, "No, because when I asked about it, I was told the skin tear and the bruise were in the same location. I still thought it was related to the Hoyer." When queried regarding who told her about the incident, the Administrator replied, "During our stand up meeting ____ (ADON M) said it was the same location, area. So I thought it was a known origin. This was after the second incident. I remembered the first incident with the skin tear. I got (physical therapy) to do a Hoyer in-service right away. Afterward (physical therapy) came and told me it (Resident #1's transfer) was a manual lift. I really felt that was how the fracture occurred. They hit her leg. She got a hairline fracture and during the week, it worsened." When queried whether any further investigation was done, the Administrator replied, "No. I thought and still think it was related to the first incident, same leg, same area." Resident #1's MAR indicated [REDACTED]. The October 2010 MAR indicated [REDACTED]. Review of Resident #1's Pain Management Flowsheet dated 05/18/10 through 10/27/10 revealed Resident #1 required PRN pain medication more frequently in October 2010 as PRN [MEDICATION NAME] 5/500 mg was administered on: 05/18/10 for back pain 06/23/10 for back pain 08/30/10 for back pain 09/18/10 for leg pain 10/14/10 for headache 10 (no day or year identified) for (unspecified) pain 10/18/10 for leg pain 10/26/10 for leg pain 10/27/10 for right leg pain The hospital H and P dated 10/27/10 reflected extensive ecchymoses (bruising) over the knee and upper leg. The H and P reflected, "The etiology of the extensive ecchymoses over the right lower extremity is uncertain." A hospital consultation report dated 10/28/10 revealed, "On the ankle x-ray, there is a suggestion of a medial malleolus fracture and it is difficult to determine the age of this fracture. There is no gross displacement of the ankle mortise. On evaluation of the tibia fibula x-rays, there may be evidence of impacted [MEDICAL CONDITION] plateau, but there is no clear displacement." Review of the facility's current policy Acute Condition Changes - Clinical Protocol dated revised April 2009 revealed, in part, "...The nursing staff and physician will discuss possible causes based on resident history, current symptoms, medication regimen, and existing test results. a. If necessary, the Physician will order diagnostic tests or evaluate the resident directly. 2. As needed, the Physician will discuss with the staff and resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization . ...The physician will help identify and authorize appropriate treatments...." Taber's Cyclopedic Medical Dictionary, 20th Edition, F.A.Davis Company, Copyright 2005, pages 683-684 reflected: A fat embolism is "...caused by globules of fat obstructing blood vessels. It frequently occurs after fracture of long and pelvic bones. ...Long bone fractures are immobilized immediately. Limited movement and gentle handling of any fractures prior to fixation may help to prevent fat globule release...." The form CMS 672 (Resident Census and Conditions of Residents) signed by the Administrator and dated 11/08/10 reflected a total census of 148.