Every finding on record at Avir at Carthage

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and ensured the services that were to be furnished attained and maintained the residents' physical, mental, and psychosocial well-being for 1 of 4 residents (Resident#32) reviewed for care plans.The facility failed to implement a person-centered care plan for Resident #32 by monitoring his thyroid function with lab tests as ordered by the physician.This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings include:Record review of Resident #32's, undated, face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #32 had diagnoses which included paralytic syndrome (a serious condition defined by the rapid onset of flaccid muscle weakness or paralysis, often affecting limbs, breathing, and swallowing, commonly triggered by neurotoxins, infections like polio, traumatic brain injury (a disruption in brain function caused by an external physical force, such as a blow to the head, jolt, or penetrating object, often resulting from falls, vehicle crashes, or assaults), and hypothyroidism (the thyroid gland doesn't make enough thyroid hormone). Record review of Resident #32's quarterly MDS assessment, dated 11/03/2025, revealed Resident #32 had a BIMS of 03, which indicated severe cognitive impairment. He required dependent assistance with all ADLS. He had a diagnosis of hypothyroidism. Record review of Resident #32's comprehensive care plan, dated 06/12/2025, revealed Resident #32 had hypothyroidism and an intervention, dated 06/12/2025, stated: Monitor thyroid function test per MD order. Notify MD of abnormal lab values. Record review of Resident #32's physician orders, dated 09/21/2024, revealed an order for a TSH (thyroid stimulating hormone) lab to be drawn every 6 months. Record review of Resident #32's laboratory results revealed the last drawn TSH lab was on 03/17/2025. No laboratory results were noted in the EHR, dated after 03/17/2025. During an interview on 01/29/2026 at 3:20 p.m., the DON stated Resident #32 should have had a TSH lab drawn in September of 2025 and it had not been drawn. She stated the facility changed lab services and the transcription of the order must not have been put in correctly. She stated she called the MD and Resident #32 was scheduled to have a TSH drawn in March of 2026. The DON stated failing to follow the interventions on a care plan could lead to poor care results for the residents. She stated it was her responsibility to ensure the labs were put in correctly.During an interview on 01/29/2026 at 3:30 p.m., MD A stated he was made aware on 01/29/2026 of the missing lab and changed the resident to have yearly TSH labs. He stated that yearly labs are the practice for people like Resident #32 because his medication was managing his thyroid condition.During an interview on 01/29/2026 at 3:45 p.m., the Administrator stated it was her expectation all interventions on care plans be followed as listed on the care plan. She stated not following the care plan could lead to lack of individualized care. She stated she expected the MD to be notified if a lab was missed and the MD was notified.Record review of the facility's, undated, policy titled 'Comprehensive Care Planning revealed The facility will establish, document, and implement the care and services to be provided for each resident to assist in attaining or maintaining his or her highest practical quality of life.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove in the kitchen was in a safe operating condition when on 09/19/25 three of ten burners did not light when turned on and on 09/16/25 two of ten burners did not light. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.Findings included: During an observation and interview on 09/15/25 at 9:44 a.m., [NAME] E turned on the gas stove burners with 3 of 10 burners not lighting. The left front burner did not light but no gas was smelled. The back stove second burner to the left and far right did not light with no gas smell noted. She said she was responsible and had been educated to notify the DM and Maintenance Director if the stove burners did not light. She said the burners lit this morning. [NAME] E said the resident risk of a stove burner not lighting was a resident could smell gas. During an observation and interview on 09/16/25 at 11:37 a.m., the DM turned on the gas stove burners with 2 of 10 burners not lighting. The left front burner did not light but no gas was smelled and the back middle burner (3rd from the left) did not light with no gas smell noted. She said the cooks were responsible for notifying her and the Maintenance Director if the burners did not light and she was responsible for notifying the Maintenance Director if the stove burners did not light. The DM said sometimes the stove burners took a long time to light a minute or so. She said the burners lit this morning. The DM said the resident risk of a stove burner not lighting was that a resident could smell gas. During an interview on 09/16/25 at 3:15 p.m., the Maintenance Director said the dietary staff were responsible for notifying him if the stove burners did not light and he would try to fix the stove if he was unable to fix it a technician would be called to come out and fix the stove. He said the dietary staff did not notify him the burners on the stove did not light, but he would go check on it now. The Maintenance Director said the resident risk of a stove burner not lighting was a resident may smell gas but he said no residents are allowed to go in the kitchen so that would not happen. During an interview on 09/16/25 at 3:23 p.m., the Administrator said the cooks or the Dietary Manager was responsible for notifying the Maintenance Director if the stove burners did not light and the Maintenance Director was responsible for notifying her if he was unable to repair it and she would have a technician come out and repair the stove. She said she was ultimately responsible for ensuring the stove and all equipment in the kitchen was in working order. She said a technician was in the facility and had tried to repair the stove but needed to order a part and it would be repaired as soon as the part came in. The Administrator said the cooks would turn the burner off if it did not light immediately until repaired. She said the dietary staff were educated to notify the Maintenance Director and Administrator with all equipment not functioning properly in the kitchen and the Maintenance Director was educated to repair or notify her if he was unable to repair any equipment in the facility. The Administrator said the resident risk of a stove burner not lighting was a resident could possibly get a headache. She said her expectation was all equipment function properly in the kitchen. Record Review of an undated facility policy titled, Maintenance Policies & Procedures indicated, . Ensuring that all equipment, building, spaces, and fixtures are kept in operable condition. The center shall properly maintain the building, its fixtures, systems, and equipment in good working order to ensure that the entire center is clean, free of environmental pollutants, and in good repair at all times.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 15 residents reviewed for ADLs. (Residents #2) The facility failed to trim and clean under Resident #2's fingernails.This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.Findings included:Record review of Resident #2's face sheet dated 9/16/25 indicated he was [AGE] years old, admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #2 had diagnoses which included heart failure, diabetes (high blood sugar), conduct disorders, lack of coordination, flaccid hemiplegia (unable to move) right dominant side, and cerebral infarction (stroke-disruption of blood flow to the brain causing tissue damage).Record review of Resident #2's quarterly MDS dated [DATE] indicated he usually understood others and was understood. Resident #2 had a BIMS with a score of 6, which indicated he had severe cognitive impairment. The MDS indicated Resident #2 did not have physical, verbal, or other behavioral symptoms and he did not reject care. Resident #2 had impairment of upper lower extremities on one side of his body. Resident #2 was dependent on staff for most ADLs including personal hygiene.Record review of Resident #2's undated care plan indicated the following tasks would be documented in POCareAssist . Nail Care . once a day on Tuesday, Thursday, and Saturday 2:00 PM -10:00 PM.Record review of Resident #2's Point of Care History dated 9/01/25-9/17/25 indicated CNA A documented she performed Nail Care on 9/16/25 at 6:59 AM and CNA B documented she performed Nail Care on 9/16/25 at 5:58 PM.During an observation and interview on 9/15/25 beginning at 11:35 AM, Resident #2 was observed during lunch dining service sitting at the dining table in a geriatric chair. Resident #2's right hand was contracted with hand closed. Resident #2's fingernails were long on both hands and there was a black substance under his fingernails of his left hand. Resident #2 fed himself with his left hand and said the food was good.During an interview on 9/15/25 at 3:00 PM, Resident #2's RP said her only concerns she could think of was his hygiene, clipping and cleaning his dirty nails, and bathing. Resident #2's RP said the facility said he refused at times, and they could not make him bath. During an observation on 9/16/25 at 11:15 AM, Resident #2 was observed sitting in the dining room. Resident #2's fingernails continued to be long on both hands and he had a black substance under his fingernails of his left hand. Resident #2s fingernails on his right contracted hand were very long and were pressing into the palm area of his hand but the skin was not broken.During an observation and interview on 9/17/25 at 7:55 AM, Resident #2 was sitting in his geriatric chair in the dining area waiting to go smoke. Resident #2's fingernails on both of his hands continued to be long and his left hand continued to have a black substance under his nails. Resident #2 said he did not mind his nails being long, but he did not know what was black under his nails. Resident #2 said staff did clean under his fingernails and trimmed them sometimes.On 9/17/25 at 9:56 AM and 11:13 AM, CNA B was called. The call went straight to voicemail, and a detailed voicemail was left. CNA B did not return the call prior to surveyor exiting the facility.During an interview on 9/17/25 at 10:09 AM, CNA A said she had worked at the facility for twenty years. CNA A said nail care consisted of cutting the nails, cleaning under the nails, and handwashing. CNA A said the CNAs were responsible for ensuring nail care was done and the nurses followed up. CNA A said if the nurses noticed the resident's nails were dirty, they would either clean them or notify the CNAs to clean them. CNA A said she did nail care on Resident #2 on 9/16/25 the best she could. CNA A said Resident #2 digs in his private areas and masturbates. CNA A said they could not stop him from doing those things and there was no telling what was under his nails. CNA A said Resident #2 did allow her to do nail care yesterday (9/16/25) on his left hand but not his right hand. CNA A said she did not cut Resident #2's nails and she let the nurse or someone else cut nails because she had cut someone before, so she did not cut nails anymore. CNA A said sometimes, Resident #2 would refuse to have his nails cut and cleaned. CNA A said a resident having long/dirty nails, was not good, and the resident's nails needed to be cleaned, because it was not sanitary. CNA A said Resident #2 fed himself with his left hand. CNA A said Resident #2 usually ate with his hands and did not use utensils. CNA A said anything that would be under Resident #2's nails could go into his mouth. CNA A said Resident #2 would even take the butter and spread on his face at times and he had a lot of behaviors. During an interview on 9/17/25 at 10:23 AM, the DON said the CNAs should be doing the nail care and the nurses follow up to ensure that it was completed. The DON said the nurses looked at the POC (where the CNAs document tasks) to ensure tasks were completed. The DON said the CNAs should be letting the nurse know when a resident refused care. The DON said she put out a list of residents that needed to be looked at to ensure nails, facial hair, and assessed for any needs on Sundays. The DON provided a copy of her list from 9/14/2025 and it included Resident #2. The DON said nail care should consist of staff asking the resident if it was okay to trim their nails, cleaning under the nails, and trimming to an appropriate length. The DON said dirty/long nails could hold bacteria and placed the resident at risk for infection. The DON said the nurses were supposed to supervise the CNAs to ensure the nail task had been completed. The DON said Resident #2 would sometimes refuse care and the refusal should be documented.During an interview on 9/17/25 at 11:00 AM, the ADM said she would expect staff to be ensuring the resident's fingernails were trimmed and cleaned if the resident allowed. The ADM said dirty/long fingernails could be an infection control issue, especially if the resident was feeding themselves. The ADM said the DON and ADONs would be responsible for ensuring nail care was being performed, but ultimately, she (ADM) would be responsible.Record review of the facility's policy titled Activities of Daily Living (ADLs) dated 7/01/25, indicated . The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable . care and services will be provided for the following activities of daily living . 1. Bathing, dressing, grooming, and oral care . Policy Explanation and Compliance Guidelines . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . The facility will maintain individual objectives of the care plan and periodic review and evaluation .Record review of the facility's policy titled Nail Care dated 7/2025, indicated . The purpose of this procedure was to provide guidelines for the provision of care to a resident's nails for good grooming and health . Policy Explanation and Compliance Guidelines . 3. Routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis . 4. Routine nail care, to include trimming and filing, would be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care would be provided between scheduled occasions as the need arises . 5. The resident's plan of care would identify . a. the frequency of nail care to be provided b. The type of nail care provided c. The person(s) responsible for providing nail care (licensed nurse, nurse aide, podiatrist, activity professional) . 6. Principles of nail care . a. Nails should be kept smooth to avoid skin injury b. Only licensed nurses shall trim or file fingernails of residents with diabetes . 7. Procedure . b. fill wash basin with warm water . soak hands/feet in wash basin for 10-20 minutes, unless resident had diabetes or circulation problems c. Gently clean underneath nails with orange stick d. If trimming was allowed, clip nails using nail clippers straight across and even with the tops of the fingers/toes e. Shape nails straight across using nail file, emery board, or the like . i. Document completion of task, any complications, or if the resident refused .

Based on observations, interviews, and record review the facility failed to ensure a resident received adequate supervision using a mechanical lift (assistive device) to prevent accidents for 1 of 18 residents reviewed for accidents (Resident #2). The facility failed to ensure Resident #2 was safely transferred using a mechanical lift with 2-person transfer on 9/16/2025 at 7:55 AM. This failure could place residents at risk for injury or harm. Findings included:Record review of Resident #2's face sheet dated 9/16/2025 indicated he was [AGE] year-old male readmitted to the facility on [DATE]. Some of his diagnoses included chronic diastolic heart failure (a condition in which your heart's main pumping chamber (left ventricle) becomes stiff and does not relax properly between heartbeats), Cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage), Flaccid hemiplegia affecting right dominant side (a condition characterized by flaccid paralysis on one side of the body), hyperlipidemia (a condition that causes high levels of lipids, or fats, in blood), type II diabetes (a chronic condition characterized by high blood sugar levels due to insulin resistance and relative lack of insulin production),schizophrenia(a serious mental health condition that affects the way a person thinks, acts and feels), and morbid obesity (a condition that is characterized by an extremely high body weight that can lead to serious health complications and mobility changes). Record review of Resident #2's MDS dated [DATE] indicated a BIMS score of 6 (severely cognitively impaired). The MDS indicated Resident #2 required a wheelchair in the lookback period of 7 days and was dependent with toileting hygiene, showering/bathing, dressing upper and lower body and personal hygiene. The MDS indicated Resident #2 was dependent with transfers. Record review of Resident #2's care plan dated 5/30/2025 indicated resident had impaired physical mobility related to paralysis and contractures to right extremities. The MDS indicated Resident #2 required a mechanical lift to transfer from chair to bed which puts resident at risk for injury. The MDS goal indicated the resident would not have any injuries due to the mechanical lift over the next 90 day. Interventions included ensure there were no objects in the way during the use of the lift, have 2 people to safely transfer resident from bed to chair using the mechanical lift. During an observation on 9/16/2025 at 7:55 AM, CNA A wheeled the mechanical lift to Resident #2's room. CNA A secured the sling under Resident #2 prior to being placed on the mechanical lift. CNA A used the electronic remote to lift the resident up and CNA G was across the room holding the Geri-chair (a type of clinical recliner to provide comfortable seating and mobility assistance for residents with limited mobility) in place. CNA A spread the legs of the mechanical lift and lowered Resident #2 into the Geri-chair. During an interview on 9/16/2025 at 8:43 AM, CNA G said she had worked at the facility for 15 years. She said Resident #2 was a 2-person transfer with the mechanical lift. CNA G said the second person was supposed to stand behind the resident once he was secured in the lift. She said she was not standing behind him as he was being transferred. She said she should have been right with CNA A and the resident. CNA G said there should always be 2-person. CNA G said she should have been standing right behind him as CNA A was moving the mechanical lift across the room to the Geri-chair (a type of clinical recliner to provide comfortable seating and mobility assistance for residents with limited mobility). CNA G said she was standing behind the Geri chair. She said the resident could have fallen out of the sling (a fabric support used with a mechanical lift to safely transfer individuals with limited mobility from one surface to another). She said there was no excuse. She said she was caught off guard when asked for her to come assist with the transfer. CNA G said both CNAs were responsible for the resident during a mechanical lift transfer. During an interview on 9/17/2025 at 10:03 AM, CNA A said the transfer went well until I talked to CNA G, the other CNA. We have not been doing it that way. CNA A said she had been trained on a mechanical lift. She said the facility wanted to make sure the sling is secure with the straps, and no one was doing the transfer by themselves. CNA A said the facility policy should require 2 persons during the transfers to ensure the straps do not break or someone falls. CNA A thought it was done properly. CNA A said she walked over to the chair, and she should have remained with the resident until he was moved across the room into his Geri chair. CNA A said the strap could have broken or he could have fell. CNA A said she could have assisted if there was an issue. During an interview on 9/17/2025 at 10:13 AM, LVN H said a resident who was non-weight bearing would require a mechanical lift. Resident #2 requires a mechanical lift due to being unable to transfer. The facility policy requires 2 persons for transfer with a mechanical lift. LVN H said the staff should check equipment prior to use. LVN H said the other person should aid and not walk away from the resident. LVN H said for safety there would need to be someone next to the resident. She said the resident would be swinging away if the second person was not there to guide and assist with the transfer. LVN H said the resident could swing and hit head on bar or hit their feet. LVN H said if there was too much weight, the mechanical lift could tip over and a resident could break something or could cause death. LVN H said the nurse or CNAs working the mechanical lift were responsible. During an interview on 9/17/2025 at 10:53 AM, the DON said the second person should remain with resident during the full transfer. She said the resident could fall causing injury by hitting head, it could also result in death. The DON said she expected the staff to have 2-person transfer. Having another person who is trained with a mechanical lift. The DON Said the 2 CNAs have been trained. The charge nurse who is over the floor is responsible for ensuring residents were transferred safely. The DON said she expected the staff to always have a 2 person transfer through the entire process. During an interview on 9/17/2025 at 11:05 AM, the ADM said she expected the 2 persons transfer to be next to the resident during the transfer. If there was an issue with the lift, the resident could fall if the lift and if the second person were not next to the resident to assist. The ADM said the administrative staff was responsible for ensuring the resident were transferred safely. The ADM said the CNAs and nursing staff would also be responsible for transferring the resident safely. The ADM said the resident could have a major injury. Record review of facility's policy dated 7-2025 titled Safe Resident Handling/Transfers indicated Policy.It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Compliance guidelines.3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident needs.6. The staff will inspect the equipment prior to use.10. Two staff members must be utilized when transferring residents with a mechanical lift.11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises.13. Staff members are expected to maintain compliance with safe handling/transfer practices.

Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 18 residents (Resident #14) reviewed for drug storage. The facility failed to securely store a white powder substance in a medication cup for Resident #14 located on bedside table. This failure could place residents at risk for access to medications/biologicals not approved for their health condition. Findings included:Record review of the face sheet dated 9/17/2025 indicated Resident #14 was [AGE] year-old female who was admitted on [DATE] with diagnoses including Chronic inflammatory demyelinating polyneuritis (s a rare neurological condition that causes worsening (progressive) muscle weakness, numbness and other symptoms.), muscle weakness, ataxia (lack of coordination of voluntary muscle movements) and mild intermittent asthma (mild persistent asthma which causes airways to narrow and swell, making it difficult to breath). Record review of the quarterly MDS dated [DATE] indicated Resident #14 was usually understood and usually understood others. The MDS indicated a BIMS score of 10 indicating Resident #14 was moderately cognitively impaired. Record review of a care plan revised on 9/15/2025 indicated Resident #14 had redness under breast related to yeast rash with interventions to avoid positioning resident on a rash, keep clean and dry as possible, minimize skin exposure to moisture, apply nystatin per MD order and monitor effectiveness and report adverse effects to MD.Record review of MAR dated 9/1/2025-9/17/2025 indicated Resident #14 was prescribed Nystatin powder 100,000 Units/gram amount to administer moderate amount topically. The MAR indicated LVN D administered the medication between the scheduled times of 6 AM-10 AM.During an observation and interview on 9/15/2025 at 10:02 AM, Resident # 14 said she could never find her call light. Resident #14 was observed to have 1 medication cup on her bedside with a white powdery substance in the cup. Resident #14 said it was medication that the staff had used to place on her breast for a rash she had developed.During an interview on 9/17/2025 at 10:13 AM, LVN H said medications should be stored on the medication cart or medication room. She said powders are normally stored on the nurse's medication cart. LVN H said a resident should not have nystatin on their bedside table. LVN H said if a nurse took the medication in the room, the nurse should be the one to apply the medication and the medication should be discarded once the nurse leaves the room. She said a medication or powder could be toxic and another person could have a reaction. She said a child could consume it and cause a reaction or death if not used properly. LVN H said the nurse and medication aides were responsible for ensuring the medications were properly stored.During an interview on 9/17/2025 at 10:22 AM, CNA A said the nurses were responsible for ensuring medication was properly stored. CNA A said if she had observed a white powder in a medication cup at the resident's bedside, she would go get a nurse. CNA A said if a resident or visitor took the medication, it could cause them to get sick. During an interview on 9/17/2025 at 10:53 AM, the DON said residents should not have medication on their bedside table. She said she does have some residents who are able to self-administer medication, but Resident #14 was not one of them. The DON said she expected the nurse or staff to dispose of medications in a resident's room. She said another resident could wander in the room and take the medication. She said it may not mix with medication other medications a resident was on. The DON said the charge nurse and the medication aide were responsible for making sure medications were taken and disposed of medication cup. During an interview on 9/17/2025 at 11:05 AM, the Administrator said a resident can have medication at bedside if there was an order, care plan and assessed to see if they can have the medication at bedside or self-administer. The Administrator said the medication would need to be out of sight. She said it could cause harm if a visitor, a resident with dementia wandered in the room. The Administrator said the medication aide, nursing staff, and nursing administration was responsible for ensuring medications were properly stored. Review of a Medication Storage policy titled Medication Storage in the Facility dated 6/1/2022 indicated 1. Storage of medication. Policy.Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. Procedure.a. The provider pharmacy dispenses medications.b. Only licensed nurses, the consultant pharmacist and those authorized to administer medications. c. All medications dispensed by the pharmacy are store in the container with pharmacy label.d. orally administered medications are kept separate from externally used medication and treatments such as suppositories, ointments, creams, vaginal products, etc.I. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity.

Based on observations, interviews, 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 1of 3 residents reviewed for infection control practices (Resident #3). The facility failed to ensure CNA G and CNA M donned a gown when they performed peri care on Resident #3. Resident #3 was on enhancement barrier precautions. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.Findings included: Record review of Resident #3's face sheet, dated 9/16/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included klebsiella pneumoniae (a type of bacteria normally found in human stool (feces) that can cause health-associated infections), personal history of other infectious and parasitic diseases, carrier or suspected carrier of methicillin resistant staphylococcus aureus (a type of staph bacteria that become resistant to many common antibiotics), contact with and (suspected) exposure to other viral communicable diseases. Record review of Resident #3's quarterly MDS assessment, dated 8/1/25, indicated she was usually able to make herself understood and usually understood others. Resident #3's BIMS score was 10, which indicated moderate cognitive impairment. Resident #3 required dependent assistance with ADL's. Resident #3 was always incontinent of bladder and bowel. Record review of Resident #3's care plan dated 7/31/25 indicated resident required enhancement barrier precautions (an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of multidrug-resistant organisms) due to following: I am colonized or infected with multi-drug organism and contact precautions do not apply, feeding tube, and wound. Resident #3's interventions required staff will wear PPE during high-contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing, device care or use (central line, urinary catheter, feeding tube, trach care, colostomy care, etc., dated 5/29/25. Other interventions included for Resident #3 was post a sign on my door that says enhanced barrier precautions dated 5/29/25 and PPE will be available (including gowns/ gloves/ face shield or goggles) will be available right outside my room, in the shower room, dated 5/29/25. Record review of Resident #3's order summary report dated 9/16/25 indicated resident required Enhanced Barrier Precautions in place due to a diagnosis of klebsiella pneumoniae as the cause of diseases classified elsewhere. During observation on 9/16/2025 at 11:36 A.M., CNA G and CNA M provided peri care for Resident #3 and did not apply gowns before providing peri care; the resident was on enhanced barrier precautions. During an interview on 9/16/25 at 1:37 P.M., the ADON said Resident #3 was on enhanced barrier precautions for venous ulcer wound; she should not be on enhanced barrier precautions now, but she would clarify it. During an interview on 9/16/25 at 1:39 P.M., the DON stated Resident #3 should be on enhanced barrier precautions. She said the facility could choose to keep a resident on enhanced barrier precautions. She said Resident #3 had a history of klebsiella pneumoniae (a type of bacteria normally found in human stool (feces) that can cause health-associated infections). She said if staff were doing peri care on Resident #3, they should wear their gowns, because the bacteria could lay dormient in the resident and arrive again. She said the order was still in the computer for Resident #3 to be on enhanced barrier precautions, and the staff should be following the MD orders. She said if the resident was no longer on enhanced barrier precautions, she would have removed the EBP sign outside the resident's door and discontinued the order in the computer for EBP for Resident #3. She said if staff are not wearing the appropriate PPE for residents on EBP they could spread a multi-drug resistant organisms (MDRO) to the next resident. During an interview on 9/16/25 at 1:50 P.M., CNA G said she did not know Resident #3 was supposed to be on EBP. She said there were no boxes in her room or PPE set up outside her door. She said a negative effect of not wearing the appropriate PPE for a resident on EBP was transferring infections to other residents. She said the nurse was not even aware that Resident #3 was still on EBP. During an interview on 9/16/25 at 1:57 P.M., LVN C said she did not know Resident #3 was still EBP, because the boxes to discard used PPE were not in her room and the PPE was not outside her door. She said a negative effect of giving peri care without a gown when a resident was on EBP precautions was staff could give an infection to another resident. During an interview on 9/16/2025 at 2:06 P.M., CNA M said she was not aware Resident #3 was on EBP, because she would have applied her PPE if knew that. She said she knew back in the past she was EBP, and she thought Resident #3 was cleared of everything. She said it was a lack of communication on her still being on EBP with staff. She said a negative effect of not wearing the appropriate PPE was staff could get an infection or staff could transfer the infection to other residents. During an interview on 9/17/25 at 11:10 A.M., the DON stated the staff should know who the residents are that were on EBP by the signs on the resident's door, an orange sticker by the resident's name at the door and the resident should have PPE placed at the door. The DON stated the Infection Preventionist was responsible for ensuring the correct PPE was placed at the resident's door, but she checked to make sure measures were in place. She said those were the 3 indicators for residents on EBP. She said she absolutely expected her staff to follow EBP to prevent infections of the other residents. During an interview on 9/17/25 at 11:19 A.M., the ADM stated there was a list at the nurses' station and it was marked on the resident's door if they were on EBP. She said she expected her staff to follow EBP. She said a negative effect of staff not following EBP was an infection control issue. Record review of the facility's policy, Enhanced Barrier Precautions, revised March 1, 2024, stated: Enhanced barrier precautions (EBPs) are to implement for the prevention of transmission of multidrug organisms.Enhanced barrier precautions (EBPs) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following.ii. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply.3. Implementation of Enhanced Barrier Precautions. a. Make gown and gloves immediately near or outside of the resident's room.b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room.4. High-contact resident care activities include: d. Providing hygiene. f. Changing briefs or assisting with toileting. Record review of the facility's policy, Infection Prevention and Control Program, dated June 2025, stated: This facility has established and maintains 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 as per accepted CDC national standards and guidelines.2. All staff are responsible for following all policies and procedures related to the program.5. Isolation Protocol (Transmission-Based Precautions): .a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.d. When a resident on transmission-based precautions must leave the resident care unit/area, the charge nurse on that unit/area shall communicate to all involved departments the nature of the isolation and shall prepare the resident for transport in accordance with current transmission-based precaution guidelines.

Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 8 residents reviewed for respiratory care. (Resident #47)The facility failed to ensure Resident #47 received continuous oxygen as ordered by the physician when his oxygen tank was empty on 9/16/25. This failure could place residents at risk of respiratory complications. Findings included:Record review of Resident #47's face sheet dated 9/16/25 indicated he was [AGE] years old and admitted to the facility on [DATE] and re-admitted [DATE]. Resident #47 had diagnoses which included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), weakness, and anxiety (mental health condition characterized by excessive worry, fear, nervousness).Record review of Resident #47's quarterly MDS assessment dated [DATE], indicated he had a BIMS score of 8, which indicated he had moderate cognitive impairment. The MDS did not indicate Resident #47 was receiving oxygen therapy.Record review of Resident #47's Care Plan with a problem date of 9/12/25 indicated he had COPD and was at risk of hypoxemic (low oxygen in the blood) hypercarbic (high carbon dioxide in the blood) respiratory failure due to impaired gas exchange, chronic lung disease, and increased oxygen needs. The interventions included monitoring oxygen saturation, maintaining prescribed oxygen therapy. The Care Plan indicated Resident #47 required oxygen at 4 LPM via nasal cannula related to COPD.Record review of Resident #47's Resident Orders dated 9/18/25 revealed an order for nasal cannula continuous oxygen at 4 LPM with a start date of 9/15/25. Record review of Resident #47's Medication Administration Record dated 9/01/25-9/16/25 indicated he received oxygen at 4 LPM by nasal cannula continuously. During an observation and interview on 9/16/25 beginning at 11:18 AM, Resident #47 was sitting up in his wheelchair at a table in the dining room wearing a nasal cannula with the nasal cannula tubing attached to an oxygen tank hanging on the back of his wheelchair set at 4 LPM. The oxygen tank regulator dial showed the arrow was at the bottom of the red area of the dial which indicated the tank was empty. Resident #47 said the staff took good care of him and were real nice. The ADM then brought Resident #47 his lunch and set it up for him, she did not check his oxygen tank.During an observation on 9/16/25 beginning at 1:00 PM, Resident #47 was sitting in his wheelchair in front of the nurse's station and Resident #47 asked this surveyor to fix his oxygen. Resident #47's nasal cannula was in between his hip and chair, and the oxygen tank was set on 4 LPM, however, the oxygen tank regulator dial showed the arrow was at the bottom of the red area of the dial which indicated the tank remained empty. LVN C was sitting behind the desk at the nurse's station and this surveyor asked LVN C if she could look at Resident #47's oxygen. LVN C then took Resident #47 outside of a closet in the hallway and changed out his oxygen tank and tried several different oxygen regulators (attach to oxygen tank to control the rate of delivery) and said they were not working. After multiple failed attempts to set up a full oxygen tank, LVN D told LVN C to take Resident #47 to his room and place him on his oxygen concentrator (medical device that delivered oxygen to resident from drawing oxygen from the air) until they were able to fix Resident #47's oxygen tank.During an interview on 9/16/25 at 2:11 PM, LVN D said she had worked at the facility for one and a half years. LVN D said she was Resident #47's nurse. LVN D said she was responsible for ensuring the oxygen tanks had oxygen in them and the resident was receiving their oxygen as ordered by the physician. LVN D said she had checked Resident #47's oxygen saturation (measurement of oxygen in the blood) level at 12:30 PM and it was 93% (within normal limits). LVN D said Resident #47 was lying in his bed and using his oxygen concentrator and not the oxygen tank at that time. LVN D said she did not check the oxygen tank to ensure it had oxygen at that time, because Resident #47 was not using it at that time. LVN D said at some point between her checking Resident #47's oxygen level and when everyone was gathered around Resident #47 in front of the nurse's station, he must had transferred his self and went up there (nurse's station). LVN D said she normally checked her oxygen tanks every 2-3 hours to ensure the resident did not run out of oxygen, but Resident #47 had just recently returned from the hospital and was new to requiring oxygen continuously. LVN D said at 4 LPM continuously, it appeared to be running out sooner and she was having to figure it out when she needed to check it. LVN D said Resident #47's oxygen tank was empty when he was in front of the nurse's station, and they were having trouble getting the regulator to work on the new oxygen tank and eventually had to take Resident #47 to his room to put him back on his oxygen concentrator. LVN D said if a resident that required continuous oxygen ran out of oxygen, the resident could become hypoxic (not enough oxygen to in the tissues to sustain bodily functions) and get really bad and they could have increased anxiety. LVN D said she was not aware Resident #47's oxygen tank was empty in the dining room before lunch. During an interview on 9/16/25 at 3:30PM, LVN C said she had worked at the facility for about one and half years. LVN C said when this surveyor notified her to look at Resident #47's oxygen, his oxygen tank was empty. LVN C said they replaced Resident #47's empty tank with a new one but did have issues with getting the regulator to work. LVN C said LVN D ended up taking Resident #47 to his room to put him on the oxygen concentrator until they were able to get his oxygen tank fixed. LVN C said if a resident who required continuous oxygen had an empty oxygen tank, the resident could become short of breath, have increased confusion, pass out, or even die if it got bad enough. During an interview on 9/17/25 at 10:23 AM, the DON said the nurses would be responsible for ensuring the oxygen tank was on, was not empty, and their oxygen saturation was staying up. The DON said if the oxygen tank was empty and the oxygen dependent resident was not receiving the ordered amount of oxygen, it could lead to respiratory failure and cause harm to the resident. The DON said the nurse should check the oxygen tank frequently at least every two hours, if the resident was up and using the oxygen tank. During an interview on 9/17/25 at 11:00 AM, the ADM said she would expect the nursing staff to ensure the oxygen dependent residents' oxygen tanks had oxygen in them. The ADM said if the oxygen dependent resident was not receiving their ordered amount of oxygen, then it could cause the resident to have confusion and shortness of breath. Review of the facility's policy titled Oxygen Administration dated February 2025, indicated . Oxygen was administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . Policy Explanation and Compliance Guidelines . 1. Oxygen was administered under orders of a physician . staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy . 11. Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them .

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or others for 1 of 6 residents (Resident #34) reviewed for reasonable accommodations of needs. The facility failed to ensure Resident #34 had a call light within reach. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs.Findings include: Record review of Resident #34's face sheet dated 9/16/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #34 had diagnoses which included: paralytic syndrome (the loss of voluntary muscle movement), hemiplegia (paralysis or severe weakness on one side of the body), weakness, muscle wasting atrophy (wasting or thinning of your muscle mass), alternating exotropia (a type of eye misalignment where the eyes turn outward, alternating between the two eyes) and age- related nuclear cataract (a type of cataract that develops in the central part of the eye's lens as a result of aging). Record review of Resident #34's MDS, dated [DATE], reflected Resident #34 was sometimes understood and sometimes understood others. Resident #34's BIMS score was a 3, which indicated severe impaired cognition. Resident #34 required substantial or maximal assistance with all ADLs. Record review of Resident #34's care plan dated 6/29/25 reflected Resident #34 was at risk for falls related to unspecified lack of coordination and had visual impairment. The interventions included keep call light within reach and orient resident to objects in room. Observations of Resident #34's call light not within reach were made in room: -09/15/25 at 11:00 A.M. -09/15/25 at 1:33 P.M. -09/15/25 at 2:53 P.M. -09/17/25 at 7:45 A.M. -09/17/25 at 8:51 A.M. During an interview on 9/17/2025 at 8:51 A.M., Resident #34 stated if the call light was in reach he could push the button if he needed assistance from staff, but he could not reach the call light in his nightstand. Resident #34 stated he felt like the call light needed to be on his bed, so he could reach it. During an interview on 9/17/2025 at 9:04 A.M., CNA K said everyone was responsible for ensuring Resident #34's call light was within reach. She said Resident #34 was able to use his call light. She said a negative effect of a resident not having a call light within reach was if they needed help, they would not be able to call for help. During an interview on 9/17/2025 10:38 A.M., LVN L said any staff was responsible for ensuring the residents call lights were within reach. She said a negative effect of Resident #34 not having his call light within reach was he might need help and could not ask for it. She said she agreed that Resident #34's call light should be within reach. During an interview on 9/17/2025 at 11:10 A.M., the DON said Resident #34's call light should be within reach, because he was bed bound. She said the CNA should make sure the resident's call light was in reach before she leaves the room, and the nurse should be checking to make sure the call lights were within reach when they are up and down the hallways. She said the negative effects of a resident not having a call light within reach was he could fall from his bed trying to be independent, if he was choking, he could not notify anyone and numerous of other things could happen that he may need to call for help for. During an interview on 9/11/2025 at 11:19 A.M., the ADM said Resident #34's call light should be on his bed. She said all staff were responsible to ensure that the resident's call lights were within reach. She said a negative effect of a resident not having a call light within reach they would not be able to call for help.Record review of facility's Answering the Call Light Policy, revised March 21, 2021, reflected The purpose of this procedure is to ensure timely responses to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Record review of the facility's Accommodation of Needs policy and procedure, revised March 2021, titled, reflected Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom or bathroom, as well the common areas in the facility. a. interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity.

Based on observation, interview and record review the facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 15 residents (Resident #40) reviewed for accuracy of assessments. The facility failed to accurately complete the MDS assessment to indicate Resident #40's wander alarm/ bracelet (wearable safety device that uses door sensors to send real time alerts to care givers when a resident with the bracelet leaves a designated area). This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings include: Record review of Resident #40's face sheet, dated 09/15/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #40 had diagnoses which included schizophrenia (a chronic complex mental health disorder that affects a person's ability to think, feel and behave) and autistic disorder (a complex developmental disability characterized by persistent challenges in social communication and interaction). Record review of Resident #40's care plan, initiated 06/13/25, indicated Resident #40 was at risk of elopement with interventions that included resident will wear a roam alert bracelet at all times and assess roam alert function daily and placement verified every shift. Record review of Resident #40's quarterly MDS assessment, dated 08/09/25, indicated Resident #40 was not marked for wander/ elopement alarm use during the assessment period. The assessment indicated Resident #40 had a BIMS score of 10 of 15, which indicated moderately impaired of cognition with diagnoses of schizophrenia and autistic disorder. Record review of Resident #40's MAR dated 09/16/25 indicated her wander bracelet was assessed every shift for placement and daily for function. During an interview and observation on 09/15/25 at 10:50 a.m., Resident #40 was sitting in her wheelchair with a wander bracelet on her left wrist, Resident #40 said she had a special bracelet she wore all the time, and the staff checked it every day. During an interview on 09/16/25 at 3:33 p.m., LVN C said she was providing care for Resident #40 today (09/16/25) and Resident #40 wore a wander bracelet that was checked daily by staff. She said the MDS Nurse was responsible for all MDSs in the facility and the nurses completed a form related to resident ADLS as needed. During an interview on 09/16/25 at 3:45 p.m., the MDS Nurse said she was responsible for all MDSs in the facility and the Regional Reimbursement Consultant was the back up and double checked random MDSs for accuracy with August 2025 being the most recent reeducation. She said she was educated on completion of MDSs and accuracy. The MDS Nurse said Resident #40 should have been marked for her wander bracelet on her most recent MDS and was not. She said it was overlooked. The MDS Nurse said she would mark it immediately and correct the MDS. She said there was no resident risk to Resident #40's MDS not marked for a wander bracelet. She said Resident #40's wander bracelet had an order, was monitoring every shift and was care planned. The MDS Nurse said it was just an inaccurate MDS. During an interview on 09/16/25 at 3:50 p.m., the Regional Reimbursement Coordinator, said the MDS Nurse was responsible for all MDSs in the facility. She said she was the backup that double checked random MDSs for accuracy. She said the MDS Nurse was in-served on completion and accuracy of MDS with August 2025 the most recent in-service. The Regional Reimbursement Coordinator said Resident #40's wander bracelet should have been marked on the 08/09/25 MDS and was not, she said it was overlooked. She said there was no resident risk of Resident #40's wander bracelet not marked on the MDS, she said there was an order, it was monitored and care planned, it was just human error. During an interview on 09/16/25 at 4:37 p.m., the DON said the MDS Nurse was responsible for all MDSs in the facility and the Regional Reimbursement Director was the back up to double check some MDS. She said the MDS Nurse was educated on completion and accuracy of MDS and attended a conference in the last month for updates. She said there was no resident risk of the wander bracelet not marked on the MDS, she said there was an order, and it was monitored every shift. The DON said it was just an inaccurate MDS. She said her expectation was all MDSs completed accurately and timely. During an interview on 09/16/25 at 4:45 p.m., the Administrator said the MDS Nurse was responsible for all MDSs in the facility and the Regional Reimbursement Director was the back up to double check some random MDSs. She said the MDS Nurse was educated on completion and accuracy of MDSs. The Administrator said there was no resident risk of the wander bracelet not marked on the MDS, she said it was monitored, and care planned, it was just an inaccurate MDS. She said her expectation was all MDSs completed accurately and timely. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, indicated . P0200: Alarms . Code 0, not used: if the device was not used during the 7-day look-back period. Code 1, used less than daily: if the device was used less than daily. Code 2, used daily: if the device was used on a daily basis during the look-back period. Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, cane) or other belongings. Bracelets or devices worn by or attached to the resident and/or their belongings that signal a door to lock when the resident approaches should be coded in P0200E Wander/elopement alarm, whether or not the device activates a sound or alerts the staff.

Based on observations, interviews and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for 1 of 8 residents (Resident #1) reviewed for accident hazards and supervision.The facility failed to supervise and put measures in place to keep Resident #1 from eloping on 6/13/25.The facility failed to complete Resident #1's quarterly elopement risk assessment due after 12/27/25. Resident #1's elopement risk assessment was not completed until 06/13/25, after she had eloped from the facility.The noncompliance was identified as PNC. The IJ began on 06/13/25 and ended on 06/17/25. The facility had corrected the noncompliance before the survey began. These failures could place the residents at risk for serious injury, serious harm, serious impairment, or death. Findings included:Record review of Resident #1's face sheet, undated, indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses including schizophrenia (is a serious mental health condition that affects how people think, feel and behave), bipolar disorder (is a mental health condition that causes extreme shifts in mood, energy, and activity levels, impacting a person's ability to carry out daily tasks), generalized anxiety disorder (is a mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday things), intermittent explosive disorder (is a mental health condition characterized by sudden, impulsive, and disproportionate outbursts of anger or violence), autistic disorder (is a condition related to brain development that affects how people see others and socialize with them), tremor, and right ear hearing loss. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was usually understood and usually had the ability to understand others. Resident #1 had adequate hearing, clear speech, and impaired vision with corrective lenses. Resident #1 had a BIMS score of 09 which indicated moderate cognitive impairment. Resident #1 did not display wandering behaviors. Resident #1 used a walker and wheelchair as mobility devices. Resident #1 required supervision to walk 10 feet and 50 feet with two turns. Resident #1 required substantial assistance to walk 150 feet. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was usually understood and usually had the ability to understand others. Resident #1 had adequate hearing, clear speech, and impaired vision with corrective lenses. Resident #1 had a BIMS score of 11 which indicated moderate cognitive impairment. Resident #1 displayed wandering behaviors 1 to 3 days during the assessment period. Resident #1 used a walker and wheelchair as mobility devices. Resident #1 required supervision to walk 10 feet and 50 feet with two turns. Resident #1 required partial assistance to walk 150 feet. Record review of Resident #1's care plan dated 10/20/24, edited on 06/29/25 indicated:*Resident #1 had intermittent explosive disorder, Schizophrenia, bipolar disorder and anxiety which could affect her mood. Interventions included encourage to report any concerns or needs, assess, monitor, and document mood, and reassure and listen to concerns. *Resident #1 had cognitive deficits and mental disability with childlike responses, poor cognition, delayed response, concentration and attention difficulties, Autism, and speech impediment. Resident #1 had hearing loss in her right ear. Resident #1 had risk for communication deficits. Interventions included allow time when speaking to process thoughts and speck directly to resident in a clear voice facing her. Record review of Resident #1's care plan dated 06/13/25, edited on 06/29/25 indicated:*Resident #1 was at risk for elopement as evidenced by attempt to leave the facility on 06/12/25. Interventions included frequent monitoring and checks throughout the night to ensure safety and roam bracelet will be always worn.*Resident #1 was at risk for wandering due to attempt to exit seek. Resident #1 wore a roam alert bracelet. Intervention included an elopement assessment done on admission, as needed, and with significant change of condition and staff will monitor and report change in exit seeking behaviors. Record review of Resident #1's assessment for risk of elopement dated 12/27/24, completed by LVN A, indicated Resident #1 was not at risk for elopement at this time. Record review of Resident #1's medical records did not reflect an assessment for risk for elopement due 90 days or quarterly from the 12/27/24 assessment for risk of elopement. Record review of Resident #1's assessment for risk of elopement dated 6/13/25, completed by ADON G, indicated Resident #1 was likely at risk for elopement due to resident being ambulatory yet cognitively impaired with poor decision-making skills. Resident #1 was at risk for elopement. Resident #1 had the following intervention implemented of Wander guard ( is bracelet with triggering alarms and locking monitored doors to prevent wander-prone residents from leaving unattended) with informed consent of responsible party and updated care plan on 6/13/25. Record review of Resident #1's Event Report dated 06/13/25 at 12:48 a.m., completed by ADON G, indicated Resident #1 attempted exit seeking approximately 12:18 a.m. Resident #1 was found sitting near a road in the ditch. Resident #1 head to toe assessment did not reveal any injuries. Resident #1 exhibited the following behaviors prior to elopement: resisting redirection from staff, verbalizing statements about leaving, and stated she wanted to go to a group home and social service was working on placement prior to incident. Resident #1 had exhibited a change in mental status of new onset of agitation, resistiveness, and restlessness. Resident #1 stated she could do what she wanted to do. Resident #1 had possible contributing diagnoses to the safety event. Resident #1 had experienced absence of personal contact with family/friends. Resident #1 exhibited depressed, sad or anxious mood but was easily altered. Resident #1 had falls and attention seeking behaviors. Resident #1 had a new medication added at night. Resident #1 had door alarm band applied. Record review of Resident #1's Progress Notes dated 6/13/25, completed by LVN D, indicated .patient [Resident #1] had walked outside down to road and sat down on side of road.a woman came and told us that a lady was sitting on side of road, there was a walker and she was concerned.this sn [LVN D] and CNA K went to get patient [Resident #1], she was agitated and refused to get up and said she would do what she wanted to do.she [Resident #1] finally agreed to get up if she could have her vape.patient [Resident #1] finally got up with minimal assistance and walked back in to n/h with walker and nurse [LVN D] and CNA [K] at side.she [Resident #1] return outside to vape on front porch with supervision.head to toe assessment completed, no apparent injuries. Record review of Resident #1's Progress Notes dated 06/13/25 at 1:03 a.m., revised at 1:22 p.m., completed by ADON G, indicated .Resident [#1] was found attempting to elope from the facility shortly after a reported fall.when approached, resident [Resident #1] states she was upset because she wanted to vape and proceeded to exit the building without staff permission.staff made multiple attempts to redirect resident [Resident #1] back inside approximately 10 minutes, during which time the resident was verbally resistant and refused to comply.after continued encouragement and redirection, the resident [Resident #1] agreed to sit on front porch with CNA J sitting with her at this time.this nurse [ADON G] notified resident's responsible party regarding the incident.RP was in agreement for placement of a Wanderguard for safety and care plan updated to reflect elopement risk.Resident [#1] refused to allow wanderguard placement and stated that if I attempted to place it on her that she would rip it off and that I am not gonna put it on her.RP and MD O notified. Record review of CNA K's witness statement dated 6/13/25 indicated, .at approximately 12:15 a.m., a lady came to the facility and said a resident was walking by the stop sign and was worried about her.LVN D and I [CNA K] went out the door and saw [Resident #1] sitting on the ground at the corner.she [Resident #1] refused to get up and said she ‘was leaving' until the nurse agreed to give let her vape.once LVN D agreed, [Resident #1] got up and quickly walked back to the building and sat on the porch.[ ADON G] got here and after [LVN D] had smoked on her vape, she [Resident #1] agreed to come back in the building but stayed in the lobby the rest of the night.this is the first time I've seen [Resident #1] act like that. Record review of CNA J's witness statement dated 6/13/25 indicated, .about 11:00 p.m. [Resident #1] was going to her room to go to bed.at about 12, she [Resident #1] she had her call light on and I [CNA J] went to answer it and observed [Resident #1] on the floor.she [Resident #1] was crying complaining her hip was hurting.I [CNA J] got the nurse [LVN D] who assessed her [Resident #1], we got her up off the floor and we put her back in bed and she was complaining about the head of her bed being up and was being really pouty.a few minutes later she [Resident #1] came to the nurse's station and asked to vape. the nurse [LVN D] told her she couldn't vape right now, that she had just fallen and said she was hurt.the nurse [LVN D] told her that she needed to go back and lay down.[Resident #1] said, ‘I'm not hurt, I'm a grown woman and I want to vape.' LVN D told her again that she needed to go back to her room.Resident #1 said, ‘Do you want me to come get my vape myself?' and the nurse [LVN D] said no, you need to go back and lay down.[Resident #1] said, ‘I'm leaving' and went outside to sit on the porch.Resident #1 had mentioned earlier in the week that she was moving to a group home so that's what I [CNA J] thought she was talking about when she said, ‘I'm leaving.'.[Resident #1] never tried to leave the building and likes to sit outside on the front porch.approximately 15 minutes later a lady came and said a resident was in the road with her walker.[CNA K] and [LVN D] went outside to see who it was.I [CNA J] stayed in the facility with the other residents, and they came back with [Resident #1] about 5-10 minutes later.I [CNA J] then went outside on the porch with {Resident #1] so she could vape.[ADON G] came after that and got [Resident #1] to come inside and sit in the lobby.I've never seen [Resident #1] act like this before. Record review of ADON G, undated statement indicated, .this nurse [ADON G] received a call around 1218 ish from charge nurse [LVN D] that a lady came to facility and reported a lady was sitting in ditch with walker at roadside and almost hit her and was concerned.she [LVN D] and [CNA K] were at roadside attempting to get resident [Resident #1] to come inside facility and was refusing.this nurse [ ADON G] spoke with resident [Resident #1] and she stated that she did not want to go inside and she did not have to.this nurse [ADON G] discussed with the resident [Resident #1] of the safety issues and concerns and told her that I was on my way to the facility.[LVN D] reported back that resident [Resident #1] agreed to go back if she could vape.stated that she [Resident #1] got up without difficulties, took her walker and walked quickly to facility.upon arriving to facility at 1241am the resident [Resident #1] was sitting on front porch with CNA K vaping.she [Resident #1] was agitated and stated that she wanted to go [local city] to group home. Record review of PIR started on 6/13/25, completed on 6/19/25 by the ADM, indicated a missing resident/individual incident occurred on 6/13/25 at 12:30 a.m. The incident occurred in front of the building and involved Resident #1. Resident #1 was noted to be outside on the corner of two local streets with her walker. Resident #1 had no injuries noted. The investigation summary indicated, .Resident #1 reported fall in room at approximately 11:45 p.m. on 6/12/25.no injuries noted at time nut Resident #1 complained of pain.staff encourage resident [Resident #1] to rest in bed.Resident #1 came to nurses station approximately 5 minutes later wanting to vape and became upset when she was advised she could not vape per the smoking schedule, no one available to monitor her and staff concerned due to recent fall.staff encouraged resident [Resident #1] to rest and monitor condition, however, Resident #1 stated she was leaving and proceeded to exit the building to sit on the front porch, which is a permitted area.approximately 5-10 minutes later, a passerby observed Resident #1 walking with her walker near the end of the building on the corner.passerby alerted staff who directed Resident #1 back to facility.Resident #1 had been verbalizing her plans to move to a group home so when she said she was leaving, they thought she was talking about moving to the group home.staff noted she had been sitting on the front porch 5-10 minutes which was typical behavior for her and other residents and had never attempted to wander off.Resident #1 did not have wanderguard at the time based on her elopement assessment and no history of elopement or wandering behavior.unconfirmed. During an observation on 7/14/25 at 9:15 a.m., the facility's front door was locked. Two residents were outside on the porch and instructed the surveyor to ring a bell. A doorbell was located on the wall and a keypad was also noted. The surveyor was admitted entrance by staff at the front desk. Two keypads were noted on the inside of building near the door. During an observation on 7/14/25 starting at 11:22 a.m., Hall 100-600 doors and side door near the kitchen area had red box alarm lights noted on the keypads. All the doors red box alarms were in the on position. A resident with a wanderguard was near the front door and the alarm sounded. Staff responded to the alarm and redirected the resident. During an observation and interview on 7/14/25 at 1:32 p.m., Resident #1 was sitting in a wheelchair with a wanderguard on her left wrist. Resident #1 had a speech impediment but was understood. Resident #1 was hesitant and appeared nervous when asked about the elopement on 6/13/25. She said she did not remember getting out of the facility last month (June 2025). She said she did not know why she had the bracelet on her wrist. She said the ADM put the bracelet on her wrist. She said the ADM did not want her to go by the front door alone. She said someone was coming on the 27th of July to help her get in a group home. On 7/14/25 at 2:06 p.m., attempted to contact LVN D by phone. Contact was unsuccessful and a message left with callback phone number. On 7/14/25 at 2:11 p.m., attempted to contact CNA J by phone. Contact was unsuccessful and a message left with callback phone number. On 7/14/25 at 2:12 p.m., attempted to contact CNA K by phone. Contact was unsuccessful and a message left with callback phone number. During an interview on 7/14/25 at 2:16 p.m., ADON G said it was reported to her that Resident #1 had a fall then wanted to vape. She said LVN D asked Resident #1 to wait to vape and to stay to be assessed from the earlier fall. She said she did not know if Resident #1 had smoked at the last smoke break at 10 pm. She said the front door was not locked on 6/13/25. She said about a week prior to the elopement, Resident #1 had mentioned leaving. She said when Resident #1 was talking about leaving, it was to a group home in [nearby city]. She said the DON was on vacation and unavailable for an interview. During an interview on 7/14/25 at 2:57 p.m., CNA K said prior to the incident, the residents that vaped could smoke anytime. She said the residents could vape even at 12am and 1am. She said she was in the breakroom on 6/13/25 but overheard the conversation between LVN D and Resident #1. She said Resident #1 wanted to vape but LVN D told her to wait because she just had a fall. She said LVN D told Resident #1 to go to her room and put her feet up. She said Resident #1 refused to lay down. She said the front door was locked so she did not know how Resident #1 got out. She said she did not hear any alarms go off when she was in the breakroom. She said 10-15 minutes later, she heard someone knocking on the facility's front door. She said when she got to the door, a lady said she had almost hit someone. She said when they found Resident #1, she was at the [nearest two streets], in the ditch. She said Resident #1 had refused to get up. She said Resident #1 would only get up after they agreed to let her vape. She said Resident #1 got up by herself. She said she had heard from other employees that Resident #1 had threatened to leave, prior to getting out. She said Resident #1 had never told her she wanted to leave the facility. She said Resident #1 had never misbehaved before the incident on 6/13/25. She said after the incident on 6/13/25, she knew not to take the statements of leaving as a joke. She said if a resident mentioned leaving, she needed to report it to the charge nurse and act. She said if it was not taken seriously, then a resident could get out. During an interview on 7/14/25 at 3:56 p.m., CNA J said she took the smokers to their smoke break at 10 p.m. She said Resident #1 was one of the residents. She said Resident #1 had smoked a cigarette not vaped. She said during the smoke break, Resident #1 said, I'm leaving, She said she replied, Oh, really. Where are you going? She said Resident #1 said, I'm going to [a nearby city]. She said she did not think much of it and brought the residents back in from the smoke break. She said not too long after coming in from the smoke break, she heard Resident #1 ask LVN D for her vape. She said LVN D told Resident #1 she needed to rest her feet. She said LVN D told Resident #1 someone would take her later. She said Resident #1 was not happy and told LVN D, That's why I'm leaving this place!' She said Resident #1 did not go back to her room but went to the lobby in front of the nurses' station and sat down. She said she started answering call lights after that. She said when she last saw Resident #1 in the lobby, LVN D was at the nurses' station. She said she then heard someone beating on the front door. She said a lady told them she was driving by and almost hit Resident #1. She said no one knew when or how Resident #1 got out of the facility. She said the facility's front door was not locked at that time. She said Resident #1 said she left because she wanted to vape. She said she knew not to assume what a resident meant when they said, I'm leaving. She said she knew to report what the resident said to the charge nurse. She said she knew to monitor the resident and not let them leave the building. She said the resident could get hurt if they left the building. During an interview on 7/14/25 at 4:10 p.m., the ADM said before the incident on 6/13/25, the front door only alarmed when the resident with a wanderguard got too close to the door. She said the front door was not locked before the incident on 6/13/25. She said sometimes the staff locked the door after 10pm to the outside but not the inside. She said Resident #1 could have easily got out on 6/13/25 because she did not have on a wanderguard. She said Resident #1 had mentioned going to a group home earlier in the week. She said Resident #1 had made false abuse allegation on a male resident (6/9/25). She said Resident #1 reported she lied because she wanted to go to a group home. She said the facility informed Resident #1's PASRR representative of her request the next day (6/10/25). She said the facility's last smoke break was at 10 pm. She said before the incident, the night shift staff were letting the few residents that vaped, go out anytime. She said that was why Resident #1 felt like she could ask to vape at 12am. She said the resident's elopement assessment were done quarterly and with a change of condition. She said she expected the nursing staff to do the scheduled risk assessments. She said she wished the staff had taken Resident #1's leaving' statements seriously. She said she wished the staff had not let Resident #1 go outside to sit on the porch. She said a staff member had reported seeing Resident #1 sitting on the porch for 10 minutes on 6/13/25. She said Resident #1 was known to sit on the front porch unsupervised prior to the incident. She said a resident sitting on the front porch, unsupervised at 12 am was not a safe idea. Record review of a facility's Wandering and Elopements policy revised 4/22/2025 reflected, .the facility will ensure that residents who exhibit wandering behaviors and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care.residents will be assessed by the IDT for risk of elopement and unsafe wandering on admission, readmission, quarterly, and/or with a change of condition (e.g., increased agitation, changes in mobility, wandering). Record review of a facility's Change in a Resident's Condition or Status policy revised 4/20/23 and reviewed 6/2025 reflected, .our facility promptly notifies the resident, his or her attending physician, healthcare provider and the resident representative of changes in the resident's medical/mental condition and/or status. Record review of a facility conducted in-service, Wandering and Elopement dated 6/13/25 reflected provider and non-provider staff members were provided education on the topic. Record review of a facility conducted in-service, Emergency Procedure-Missing Residents dated 6/13/25 reflected provider and non-provider staff members were provided education on the topic. Record review of a facility conducted in-service, Abuse, Neglect and Exploitation dated 6/13/25 reflected provider and non-provider staff members were provided education on the topic. Record review of facility conducted in-service, Smoking Policy dated 6/13/25 reflected all smoking residents were provided education on the topic. Record review of a facility conducted in-service, Resident Change in Condition dated 6/17/25 reflected provider and non-provider staff members were provided education on the topic. Record review of a facility's smoking policy dated August 2019 indicated .this facility shall establish and maintain safe resident smoking practices .for the purpose of the policy, smoking and smoking materials included but not limited to; cigarettes, cigars, pipes, chewing tobacco, electronic cigarettes and vaporizers .all residents shall have the direct supervision of a staff member while smoking . The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy on (6/17/25) by:- Conducted observation on 7/14/25 at 9:15 a.m., of door lock project completed on 6/17/25. The facility's front door was locked. A doorbell was located on the wall and a keypad was also noted. Two keypads were noted on the inside of building near the door. - Conducted observation on 7/14/25 starting at 11:22 a.m., of all the facility's Halls (100-600 and side door) door alarms were armed. - Conducted observation on 7/14/25 at 1:32 p.m., of Resident #1 with wanderguard on left wrist.- Reviewed completed facility self-reported incident to HHSC for Resident #1 dated 6/13/25. - Reviewed Resident #1's care plan on 7/14/25 which reflected updated care area of elopement risk and incident on 6/13/25.- Reviewed Resident #1's medical record on 7/14/25 which reflected an elopement risk assessment was completed on 6/13/25. Resident #1 was at risk for elopement with intervention in place. - Reviewed resident roster dated 6/13/25 at 1:00 a.m. with validated head count after incident, completed by ADON G. All residents were accounted for.- Reviewed incident reported dated 6/13/25 reflected Resident #1 did not have injuries noted, MD O and Resident #1's RP were notified of the incident. - Reviewed all (7) residents with wanderguards, progress notes dated 6/13/25 which reflected a function test was completed and wander guard functioning properly. Staff members noted location of wanderguards placement.- Reviewed of a facility's Missing Resident Drill-AM shift in-service and sign-in sheet dated 6/13/25 reflected 23 staff members attended the drill. - Reviewed of a facility's Missing Resident Drill-PM shift in-service and sign-in sheet dated 6/13/25 reflected 7 staff members attended the drill. - Record review of a Record of Drills dated 6/13/25 at 12:15 p.m., for 6am-2pm shift reflected adequate response of personnel for missing residents. All departments responded appropriately. Drill conducted by ADM. - Record review of a Record of Drills dated 6/13/25 at 3:38 p.m., for 2pm-10pm shift reflected adequate response of personnel for missing residents. All departments responded appropriately. Drill conducted by DON. - Record review of a Record of Drills dated 6/13/25 at 10:30 p.m., for 10pm-6am shift reflected adequate response of personnel for missing residents. All departments responded appropriately. Drill conducted by DON. - Record review of an Ad Hoc QAPI- Elopement meeting dated 6/13/25 reflected the MD O attended by phone, ADM, DON, ADON P, and ADON G were in attendance. - Record review of a safe survey on resident who sat on the front porch unsupervised dated 6/16/25-6/17/25 reflected 13 residents understood to never leave the facility grounds. - Reviewed in-service and sign in sheet on Wandering and Elopement for all staff which indicated the following:*dated 6/13/25 reflected 51 employees were provided education on the topic. - Reviewed in-service and sign in sheet on Emergency Procedure-Missing Residents for all staff which indicated the following: *dated 6/13/25 reflected 51 employees were provided education on the topic.- Reviewed in-service and sign in sheet on Abuse, Neglect, and Exploitation for all staff which indicated the following:*dated 6/13/25 reflected 51 employees were provided education on the topic.- Reviewed in-service and sign in sheet on Smoking Policy for all smoking residents which indicated the following:*dated 6/13/25 reflected 13 residents were provided education on the topic.- Reviewed in-service and sign in sheet on Resident Change in Condition for all staff which indicated the following:*dated 6/17/25 reflected 46 employees were provided education on the topic.- Reviewed the facility's Change in a Resident's Condition or Status policy was reviewed on 6/2025. - Reviewed all current residents with wander guards and a random sample of other residents' elopement risk assessments on 7/15/25. All residents reviewed had elopement risk assessments completed on 6/13/25.- Reviewed Elopement Binder for accuracy on 7/15/25. All (8) resident's pictures were current with consents noted. - Reviewed logbook documentation for Door, Locks, Gates, and Alarms dated 6/11/25 and 7/9/25 reflected pass for Hall 1-6 exit doors, dining room exit door, entrance door, and service door exit. - Reviewed of a Record of Drills dated 7/10/25 were completed for all three shifts by ADON G. No issue noted.During an interview conducted on 7/14/25 starting at 11:36 a.m., Resident #2, Resident #3, and Resident #4 verbalized understanding of not leaving the facility property without supervision or authorization. On 7/15/25 at 9:59 a.m., attempted to contact Resident #1' RP by phone. Contact was unsuccessful and a message left with callback phone number. No return call received prior or after exit. During interviews conducted on 7/15/25 starting at 11:33 a.m., CNA N (6a-2p), CNA H (6a-2p & 2p-10p), CNA M (6a-2p), LVN A (6a-6p), LVN E (6a-6p), LVN C (6p-6a), CNA L (10pm-6am), CNA K (10pm-6am), HSK/Laundry Manager, Maintenance Supervisor, CNA F (2p-10p), MA B (6a-2p & 2p-10p), LVN D (6p-6a), ADON G, and CNA J (10p-6a) were provided in-service education on abuse, neglect, and exploitation, emergency procedure-missing resident, wandering and elopement, resident's change in condition, and smoking policy. The staff also participated in missing resident drills. The staff were able to give examples of the different types of abuse to include neglect, identify the abuse coordinator, and verbalize abuse or neglect should be reported immediately. The staff were able to verbalize policy and procedure for elopement and identified residents at risk. The staff were able to verbalize interventions that could be used to prevent elopement for residents at risk. The staff verbalize the front door was to be always locked. The staff verbalize understanding of identifying a resident's change in behavior that could place them at risk for elopement. The staff verbalize the smoking policy rules which included adequate supervision and following the smoking schedule. The staff verbalized honoring the resident's rights as much as while keeping them safe. During an interview on 7/15/25 at 12:36 p.m., LVN A said if a resident started talking about leaving the facility, they needed to be monitored. She said if the resident continued talking about it then a consent for a wander guard needed to be obtained. She said it was important to take what the resident said seriously. She said when a resident became agitated, the staff should try to redirect them. She said if the agitation and exit seeking behavior was new, then it needed to be reported immediately. She said when a resident was not taken seriously, they could exit and harm themselves and others. She said elopement was when a resident left the facility unsupervised or without staff knowledge. She said the elopement risk assessments were done on admission, quarterly, and with a change of condition. She said the nurses were responsible for the assessments. She said the assessments should be done on schedule to keep everything updated. She said the resident's condition changed frequently. She said when the elopement risk assessments were not done, a resident could get out without supervision. She said the resident could hurt themselves and others. During an interview on 7/15/25 at 2:07 p.m., LVN E said an elopement was when a resident left the facility unsupervised or without staff knowledge. She said the elopement risk assessments were done on admission, quarterly, and with a change of condition. She said the nurses were responsible for completing the assessments. She said the assessment needed to be done to identify who was most likely to elope. She said when the assessments were not done it increased the risk of a resident slipping through the cracks and missing who was a wander risk. During an interview on 7/15/25 at 3:45 p.m., MA B said an elopement was when a resident left the facility unsupervised or without staff knowledge. She said if a resident started displaying exit seeking behaviors, she would report it to the charge nurse immediately. She said if a resident started making statements of leaving or wanting to go somewhere, she would also report it. She said the statements may or may not be serious. She said the resident needed to be monitored until it was determined how serious the resident was. She said if the resident was not taken seriously, it could be considered neglect and the resident could elope. She said if the resident eloped, they could get hurt. She said when Resident #1 eloped, Resident #1 said she was going to [a nearby city] to get a vape. During an interview on 7/15/25 at 4:09 p.m., LVN D said Resident #1 had a fall late on 6/12/25. She said the staff had to pick Resident #1 off the floor and she was complaining of pain. She said 10-15 minutes after the fall, Resident #1 walked to the nurses' station wanting to vape. She said she told Resident #1 to lay down and rest awhile since she just had a fall. She said Resident #1 got upset and went to the lobby near the nurses' station. She said she did not know when Resident #1 exited the facility. She said she was going back and forth from the nurses

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 01/07/24, 01/13/24, 01/20/24, 1/21/24, 02/03/24, 02/04/24, 02/10/24, 02/24/24, 03/02/24, 03/03/24, 03/16/24, 03/17/24, 03/31/24, and 07/13/24. This failure had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings included: Record review of the facility's PBJ Staffing Data Report for Quarter 2 2024 (January 1-March 31) indicated the facility triggered for No RN Hours. The PBJ reported indicated, No RN Hours for 01/07, 01/13, 01/20, 01/21, 02/03, 02/04, 02/10, 02/24, 03/02, 03/03, 03/16, 03/17, and 03/31. Record review of the facility's January 2024 Staff Schedule provided on 08/18/24 indicated that the facility did not have an RN in the facility or did not work 8 consecutive hours on 01/07/24, 01/13/24, 01/20/24, and 01/21/24. Record review of the facility's February 2024 Staff Schedule provided on 08/18/24 indicated that the facility did not have an RN in the facility or did not work 8 consecutive hours on 02/03/24, 02/04/24, 02/10/24, and 02/24/24. Record review of the facility's March 2024 Staff Schedule provided on 08/18/24 indicated that the facility did not have an RN in the facility or did not work 8 consecutive hours on 03/02/24, 03/03/24, 03/16/24, 03/17/24, and 03/31/24. Record review of the facility's July 2024 Staff Schedule provided on 08/18/24 indicated that the facility did not have an RN in the facility or did not work 8 consecutive hours on 07/13/24. Record review of the facility's Time Punch Sheets provided 08/19/24 indicated: *01/07/24- No punch time for RN noted. *01/13/24- No punch time for RN noted. *01/20/24- No punch time for RN noted. *01/21/24- No punch time for RN noted. *02/03/24- No punch time for RN noted. *02/04/24- No punch time for RN noted. *02/10/24- No punch time for RN noted. *02/24/24- No punch time for RN noted. *03/02/24- No punch time for RN noted. *03/16/24- No punch time for RN noted. *03/17/24- No punch time for RN noted. *03/31/24- No punch time for RN noted. *07/13/24- No punch time for RN noted. During an interview on 08/19/24 at 4:45 p.m., the ADM said at the beginning of the year, the facility had problems getting RN coverage, 7 days a week. She said the facility hired two RNs to cover the weekends. She said unfortunately, one of the RNs, had a family issue and could not work as planned. She said RN M had adjusted her hours to cover weekend shifts not covered. She said there was certain task RNs were trained on. During an interview on 08/20/24 at 2:36 p.m., RN M said the facility had two other RNs rotating RN weekend coverage. She said one of the RNs had to back out. She said now she covered weekend RN coverage when there was a gap in the schedule. She said RN coverage was important for managing, supervising, and educating. She said anything could affect the residents and situation outcome. During an interview on 08/20/24 at 3:56 p.m., the DON said the facility used have an issue for weekend RN coverage. She said the facility hired two RN to cover the weekends. She said when the two other RNs were unable to cover the weekend, RN M worked instead. She said lack of RN coverage at the facility during weekends could affect the resident's care and nursing supervision. Record review of a facility's Staffing policy revised 09/28/23 indicated, .the facility utilizes the services of a registered nurses for at least 8 consecutive hours a day, 7 days a week .

Based on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 3 of 14 residents (Resident #15, Resident #23, and Resident #35) reviewed for care plans. 1. The facility failed to care plan Resident #15's hearing problem and use of hearing aids. 2. The facility failed to care plan Resident #23's hearing problem, impaired vision, on antidepressant (is a type of medicine used to treat clinical depression) and oral antidiabetic (used in the treatment of diabetes mellitus to control glucose levels in the blood) medication, dental issue, and shortness of breath on exertion. 3. The facility failed to care plan Resident #35's impaired vision. These failures could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs. Findings included: 1. Record review of Resident #15's face sheet dated 08/18/24 indicated Resident #15 was a [AGE] year-old, female and admitted on [DATE] and readmitted on [DATE] with diagnoses including acquired stenosis of external ear canal (is a narrow ear canal), acute suppurative otitis media (is defined as an infection of the middle ear space) with spontaneous rupture of right ear drum, bilateral tinnitus (is the perception of sound that does not have an external source, so other people cannot hear it), and impacted cerumen (is the medical term for earwax blockage). Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated Resident #15 was usually understood and usually understood others. Resident #15 had minimal difficulty hearing with hearing aids used, clear speech, and impaired vision with corrective lenses used. Resident #15 had a BIMS score of 10 which indicated moderately impaired cognition. Record review of Resident #15's care dated 06/20/24 did not indicate impaired hearing with hearing aids. During an observation on 08/18/24 at 10:35 a.m., Resident #15 was sitting up in bed. Resident #15's was hard of hearing and had to be spoken loud to. Unable to visualize Resident #15's hearing aids. 2. Record review of Resident #23's face sheet dated 08/18/24 indicated Resident #23 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), abnormal weight loss, and chronic respiratory failure (is a condition where there's not enough oxygen or too much carbon dioxide in your body). Record review of Resident #23's admission MDS assessment dated [DATE] indicated Resident #23 was usually understood and usually understood others. Resident #23 had minimal difficulty hearing, clear speech, impaired vision without corrective lenses. Resident #23's BIMS score was 10 which indicated moderately impaired cognition. The MDS indicated Resident #23 experienced shortness of breath or trouble breathing with exertion. Resident #23 had taken antidepressant and hypoglycemic medication during the last days. Resident #23 had broken or loosely fitting full or partial denture. The MDS assessment, Section V, Care Assessment Area triggered visual function, communication, and dental care to be addressed in Resident #23's care plan. Record review of Resident #23's care plan dated 06/14/24 did not indicate minimal difficulty hearing, impaired vision without corrective lenses, shortness of breath or trouble breathing with exertion, use of antidepressant and hypoglycemic medication, and broken or loosely fitting full or partial denture. Record review of Resident #23's consolidated physician order dated 07/01/24-08/20/24 indicated: *Januvia (is an oral diabetes medicine that helps control blood sugar levels) tablet 50 mg 1 tablet oral, Diagnosis: Type 2 diabetes mellitus, once a day. Start date: 06/14/24-open ended. *Mitrazapine (is an antidepressant used to treat major depressive disorder) tablet 15 mg 1 tablet oral, Diagnosis: abnormal weight loss, once an evening. Start date: 06/14/24-open ended. Record review of Resident #23's MAR dated 07/01/24-07/31/24 indicated: *Januvia (is an oral diabetes medicine that helps control blood sugar levels) tablet 50 mg, Amount to Administer: 1 tablet oral, Diagnosis: Type 2 diabetes mellitus, once a day. Start date: 06/14/24. Resident #23 received 30 doses. *Mitrazapine (is an antidepressant used to treat major depressive disorder) tablet 15 mg, Amount to Administer: 1 tablet oral, Diagnosis: abnormal weight loss, once an evening. Start date: 06/14/24. Resident #23 received 30 doses. During an observation on 08/18/24 at 11:02 a.m., Resident #23 was sitting in his wheelchair. Resident #23 was sitting directly in front of his television on a high volume. 3. Record review of Resident #35's face sheet dated 08/18/24 indicated Resident #35 was a 54-years-old male and admitted on [DATE] and readmitted on [DATE] with a diagnosis including dry eye syndrome (is a common condition that occurs when your tears aren't able to provide adequate lubrication for your eyes) of bilateral lacrimal glands (located above the eye, this structure produces tears). The face sheet indicated Resident #35 was on hospital leave. Record review of Resident #35's significant change MDS assessment dated [DATE] indicated Resident #35 was usually understood and usually understood others. Resident #35 had impaired vision and used corrective lenses. Resident #35's BIMS score was 11 which indicated moderately impaired cognition. The MDS assessment, Section V, Care Assessment Area triggered visual function to be addressed in Resident #35's care plan. Record review of Resident #35's care plan dated 08/10/24 did not indicate impaired vision and corrective lenses. During an interview on 08/20/24 at 2:15 p.m., LVN L said RN M was responsible for care plans. She said it would be important for diagnoses, medication, and vision/hearing problems to be on a resident's care plan. She said care plan were supposed to be individualized and specific to the resident's plan of care. She said the care plan interventions were supposed to provided treatment to address the care plan problem. She said when care plans did not have care areas addressed, staff may not know the resident's plan of care. She said this could hinder the resident's mentally and physically. She said not providing adequate care could limit the resident independence and progress. During an interview on 08/20/24 at 2:36 p.m., RN M said she completed acute care plans. She said care plans were done during MDS assessment periods and changes. She said the MDS Coordinator also did care plans. She said she would expect vision, hearing, and dental problems and diagnoses to be addressed in the resident's care plan. She said the care plan was based off information coded on the MDS assessment. She said the care plan problems was then developed from other information acquired. She said a care plan was developed to accommodate the resident and ensure the resident was independent as possible. She said care plan were important to implement goals and target dates. She said the care plan informed staff who was responsible to work towards the outcomes. During an interview on 08/20/24 at 2:38 p.m., the MDS Coordinator said she was responsible for certain care plans. She said care plans were a shared responsibility with RN M and the DON. She said developing care plans was a team effort. She said she reviewed different type of documents to gather information for a resident's care plan. She said diagnosis and medications should be on Resident #15, Resident #23, and Resident #35's care plans. She said the care plan intervention let you know what monitoring the medication needed. She said care plans were important, so everyone knew how to care and treat the residents. She said she did not know why those care areas were not added to Resident #15, Resident #23, and Resident #35's care plans. She said Resident #35 had poor vision and it should have been on his care plan. During an interview on 08/20/24 at 3:56 p.m., the DON said she, RN M, and the MDS Coordinator completed care plans. She said she expected care area on the MDS to be addressed on the resident's care plan. She said care plans gave a lot of knowledge about the residents and how to care for them. During an interview on 08/20/24 at 4:30 p.m., the ADM said RN M did resident's care plans. She said the DON should ensure the care plan accuracy. She said the care plan was important to know how to care for the residents. She said when a care plan was not accurate then residents' needs could not be met. Record review of a facility's Care Plans, Comprehensive Person-Centered policy revised 12/2020, indicated .to meet the resident's physical, psychosocial and functional needs is developed and implemented for each residents .the care planning process will .include an assessment of the resident's strengths and needs .incorporate identified problem areas .incorporate risk factors associated with identified problems .reflect currently recognized standards of practice for problem areas and conditions .areas of concern that are identified during resident assessment .

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 14 resident reviewed for assessments. (Resident #8 and Resident #15) The facility failed to ensure Resident #8's falls on 05/29/24 and 07/07/24 were coded on her MDS. The facility failed to ensure Resident #15's falls on 05/09/24, 06/26/24, and 07/06/24 were coded on her MDS. The facility failed to ensure Resident #15's diagnosis of dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) was coded on her MDS. The facility failed to ensure Resident #15 was coded for receiving an anticoagulant (medicines that help prevent blood clots) not antiplatelet (medications that prevent platelets from sticking together and forming blood clots). These failures could place residents at risk of not having individual needs met. Findings included: 1. Record review of Resident #8's face sheet dated 08/18/24 indicated Resident #8 was a [AGE] year-old, female and admitted on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left non-dominant and flaccid hemiplegia affecting right dominant side. Record review of Resident #8's quarterly MDS assessment dated [DATE] indicated Resident #8 was usually understood and usually understood others. Resident #8 had minimal difficult hearing, clear speech, and moderately impaired vision. Resident #8 had a BIMS score of 10 which indicated moderately impaired cognition. Resident #8 was dependent for toileting hygiene and chair/bed-to-chair transfer. Resident #8 was always incontinent for urine and bowel. Resident #8 had functional limitation in range of motion impairment for one side of both her upper and lower extremities. Resident #8 used a wheelchair for mobility. The MDS did not reflect Resident #8 had falls during the assessment period. Record review of Resident #8's care plan dated 12/15/20, edited 07/07/24, indicated Resident #8 was at risk for falls related to left side hemiparesis and personal preference to be in high position. Intervention included keep call light in reach of resident. Record review of Resident #8's Safety Events- Fall dated 05/29/24 indicated .05/29/24 at 10:38 a.m.Unwitnessed fall-no visible injury . Record review of Resident #8's Safety Events-Fall dated 07/07/24 indicated .07/07/24 at 1:00 p.m.Fall . 2. Record review of Resident #15's face sheet dated 08/18/24 indicated Resident #15 was a [AGE] year-old, female and admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, history of falling and acute embolism (is an obstruction or blockage in a blood vessel) and thrombosis (occurs when blood clots block your blood vessels). Record review of Resident #15's current ICD-10 Diagnoses provided 08/20/24 indicated dementia in other disease classified elsewhere with behavioral disturbance. Date diagnosed [DATE]. Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated Resident #15 was usually understood and usually understood others. Resident #15 had minimal difficulty hearing with hearing aids used, clear speech, and impaired vision with corrective lenses used. Resident #15 had a BIMS score of 10 which indicated moderately impaired cognition. Resident #15 required partial assistance for toileting hygiene and walk 10 feet and supervision for chair/bed-to-chair transfer, toilet transfer, and sit to stand. The MDS indicated Resident #15 received antiplatelet during last 7 days not anticoagulant. The MDS did not reflect Resident #15's diagnosis of dementia, and falls on 05/09/24, 06/26/24, and 07/06/24. Record review of Resident #15's care plan dated 01/23/20, edited 07/03/24, indicated Resident #15 had a communication deficit. Resident #15 was at risk for further decline as my disease progresses related to dementia. Intervention included encourage me to communicate. Record review of Resident #15's care plan dated 01/23/20, edited 08/05/24, indicated Resident #15 had multiple problems that affected her ability to walk. Resident #15 had a history of falls, the potential to fall and at risk for injury related to falls. Intervention included make sure my call light is within reach and respond quickly. Record review of Resident #15's care plan dated 03/04/24, edited 07/05/24, indicated Resident #15 was at risk for associated complications with use of anticoagulant Eliquis. Intervention included monitor for signs and symptoms of bruising and bleeding. Record review of Resident's 15's consolidated physician orders 07/01/24-08/20/24 indicated Eliquis (an anticoagulant; is used to treat or prevent deep venous thrombosis, a condition in which harmful blood clots form in the blood vessels of the legs) tablet 2.5 mg, 1 tablet oral, Diagnosis: acute embolism and thrombosis, twice a day. Start 03/04/24 and no end date. Record Review of Resident #15's MAR dated 07/01/24-07/31/24 indicated Eliquis tablet 2.5 mg, amount to administer: 1 tablet oral, Diagnosis: acute embolism and thrombosis, twice a day. Start 03/04/24. Resident #15 received 60 doses of Eliquis. Record review of Resident #15's progress noted dated 05/09/24 at 3:54 a.m., indicated post-fall follow up .initial progress note post fall .resident [Resident #15] placed call light on this SN [LVN T] answered and observed resident [Resident #15] on the floor by bed . Record review of Resident #15's Safe Events-Fall dated 07/06/24 indicated .07/06/24 at 11:17 a.m.fall .resident room .witnessed .LVN S . Record review of Resident #15's Safe Events-Fall dated 07/16/24 indicated .07/16/24 at 5:15 a.m. unwitnessed fall without injury .LVN O . During an interview on 08/20/24 at 2:38 p.m., the MDS Coordinator said she was responsible for MDS assessments. She said Resident #15 was on an anticoagulant not antiplatelet. She said coding Resident #8 and Resident #15's falls depended on if it was claimed on the previous MDS assessment. She said if Resident #15's dementia diagnosis was listed on her diagnosis list, then it should be on the MDS. She said she reviewed a lot of different information such as physician notes, orders and progress note to complete the MDS assessment. She said she was human, so sometimes things were missed. She said an accurate MDS assessment was important because the information help make the resident's care plan. She said the corporate MDS coordinator oversaw the MDS assessment she completed. She said the corporate MDS reviewed resident's MDS assessments weekly. During an interview on 08/20/24 at 3:56 p.m., the DON said she was still learning about what was required on MDS assessments. She said the MDS Coordinator was responsible for completing most section on the MDS. She said she checked the MDS assessment, to the best of her ability, before she signed them for submission. She said an accurate MDS assessment was important because it affected the insurance and billing. She said the Regional MDS Coordinator was responsible for helping and reviewing MDS assessment completed by the facility's MDS Coordinator. During an interview on 08/20/24 at 4:30 p.m., the ADM said the MDS coordinator was responsible for MDS assessment accuracy. She said she expected resident's falls, diagnoses, and current medication type to be coded on the MDS assessment. She said the Regional MDS Coordinator should be monitoring the facility's MDS Coordinator. She said accurate MDS assessment were important for billing and insurance. She said the information coded on the MDS assessment helped form the resident's plan of care. Record review of a facility Certifying Accuracy of the Resident Assessment policy dated 11/2019 revealed .the information captured on the assessment reflects the status of the resident during the observation period for that assessment .the Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident

Based on observations, interviews, 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 2 of 2 residents (Resident #19 and Resident #23) reviewed for incontinent care and 3 of 5 (Resident #5, Resident #18, and Resident #22) reviewed for Covid-19 infection control practices. 1.The facility failed to ensure MA A wore an N95 mask when entering Covid positive Resident #19 and #22's room. 2. The facility failed to ensure MA A changed her mask after leaving Covid positive Resident #19 and #22's room and entering another non-isolation room. 3. The facility failed to ensure CNA P and Housekeeper Q wore proper PPE in Resident #5's room on 08/18/24 and 08/19/24. Resident #5 was COVID-19 positive. 4. The facility failed to ensure CNA P changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #18. 5. The facility failed to ensure LVN L changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #23. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1. Record review of Resident #19's face sheet, dated 08/20/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (A lung disease that limits airflow and causes breathing problems), and cough. Record review of Resident #19's progress note, dated 08/15/24, indicated that Resident #19 tested positive for covid-19 on 08/15/24. Record review of Resident #19's progress note, dated 08/16/24, indicated he was placed on isolation precautions related to a positive covid-19 test. 2. Record review of Resident #22's face sheet, dated 08/20/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Record review of Resident #22's progress note, dated 08/15/24, indicated that Resident #19 tested positive for covid-19 on 08/15/24. Record review of Resident #22's progress note, dated 08/16/24, indicated he was placed on isolation precautions related to a positive covid-19 test. During an observation on 08/19/24 at 08:54 AM, MA A donned a gown, gloves, and face shield. She was already wearing a surgical mask. She did not don an N95 Mask. She entered the room of Resident #19 and Resident #22. Both residents in the room were Covid positive. before leaving the room, she doffed her face shield, gown and gloves. She did not remove her surgical mask. After this MA A entered another resident's room that was not covid positive, while wearing the same surgical mask. During an interview on 08/19/24 at 09:40 AM, the DON said the staff should be wearing an N95 mask while in a covid positive resident's room. She said that was what the corporate director said they should be doing. she said she was going to conduct an in-service with the staff. During an interview on 08/19/24 at 09:49 AM, the Director of Clinical Operations said he expected the staff to wear an N95 when entering a Covid positive resident's rom. He said it was not in the policy, but it was a corporate preference. During an interview on 08/20/24 at 01:42 PM, MA A said she should have worn a N95 mask when she went into the covid positive resident's room. She said she also should have changed her mask after she left the covid room before she went into another resident's room. She said the ADON and DON monitors the staff for infection control compliance. During an interview on 08/20/24 at 01:56 PM, the ADON said she expected MA A to wear a N95 mask when going into a covid positive resident's room. She said MA A should have changed masks after being in the covid positive room. During an interview on 08/20/24 at 02:01 PM, the DON said she expected MA A to wear an N95 and change the mask after wearing it in the covid positive resident's room. During an interview on 08/20/24 at 02:09 PM, the Administrator said she expected MA A to follow the facility's policy and change her mask once she had left the room. 44933 3. Record review of Resident #5's face sheet dated 08/20/24 indicated Resident #5 was a [AGE] year-old female admitted on [DATE] with diagnosis including acute respiratory infection (is a serious infection that prevents normal breathing function). Record review of Resident #5's annual MDS assessment dated [DATE] indicated Resident #5 was usually understood and usually understood others. Resident #5 had a BIMS score of 10 which indicated moderate cognitive impairment. Record review of Resident #5's care plan dated 08/14/24 indicated Resident #5 was COVID-19 positive. Interventions included follow principles of infection control and universal/standard precautions and isolation precautions. During an observation and interview on 08/18/24 at 4:25 p.m., Resident #5's door had a posting on instruction for donning and doffing PPE. A sign was posted that stated, full PPE required. Resident #5 asked the surveyor what was on my face. The surveyor asked Resident #5 did staff wear face shield when the entered her room. Resident #5 paused the replied, yes. CNA P entered Resident #5's room to answer her call light. CNA P had on gown, gloves, and regular mask. CNA P did not have on a face shield/googles or N-95 mask. CNA P raised Resident #5's bed and handed Resident #5 her tumbler of water. During an observation on 08/19/24 at 9:17 a.m., Housekeeper Q stood outside of Resident #5's room. Housekeeper Q had on 2 regular face mask, gown, booties, and gloves. Housekeeper Q did not have one face shield/googles or N-95 mask. Housekeeper Q entered Resident #5's room. During an interview on 08/19/24 at 9:40 a.m., the DON said she did not know the facility's policy on which mask had to worn in COVID-19 positive rooms. She said she would look at the policy and let this surveyor know. During an interview on 08/20/24 at 2:30 p.m., Housekeeper Q said she wore a gown, gloves, regular mask, and booties when she went into Resident #5's room on 08/19/24. She said she had on a regular mask when she went into Resident #5's room. She said until today that N-95 masks had to be worn in COVID positive rooms. She said she was also told face shields were optional. She said face shields and N-95 mask were important because COVID can get into body fluids. She said it was important not spread the virus to other residents. 4. Record review of Resident #18's face sheet dated 08/18/24 indicated Resident #18 was a [AGE] year-old, female and admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left non-dominant and urinary tract infection (is an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra). Record review of Resident #18's quarterly MDS assessment dated [DATE] indicated Resident #18 was usually understood and usually understood others. Resident #18 had a BIMS score of 08 which indicated moderate cognitive impairment. The MDS assessment indicated Resident #18 was dependent for toilet hygiene. Resident #18 was always incontinent for urinary and bowel. Record review of Resident #18's care plan dated 07/28/24 indicated Resident #18 experienced bladder incontinence related to cerebral vascular accident (brain attack). Intervention included provide incontinence care after each incontinent episode. During an observation on 08/19/24 at 8:56 a.m., CNA B and CNA P provided Resident #18 incontinent care. During incontinent care, CNA B accidentally knocked over the bottle of hand sanitizer on to the floor. Resident #18 had urine saturated brief, cloth under pad, and bed sheet. CNA P removed Resident #18's soiled linens and placed it in a clear bag. CNA P then attached a clean bed sheet to the top and bottom part of mattress without changing gloves. CNA P then grabbed Resident #18's cloth under pad and moved Resident #18 up in the bed with the same gloves as she removed the soiled linens. 5. Record review of Resident #23's face sheet dated 08/18/24 indicated Resident #23 was a [AGE] year-old male and admitted on [DATE] with diagnoses including pressure ulcer (an injury that breaks down the skin and underlying tissue) of sacral region, stage 4, pressure ulcer and pressure ulcer of other site, stage 3, and cerebral infarction (stroke). Record review of Resident #23's admission MDS assessment dated [DATE] indicated Resident #23 was usually understood and usually understood others. Resident #23 had minimal difficulty hearing, clear speech, impaired vision without corrective lenses. Resident #23's BIMS score was 10 which indicated moderately impaired cognition. Resident #23 used a wheelchair for mobility. Resident #23 required partial assistance for eating, oral hygiene, upper body dressing, substantial assistance for personal hygiene, and dependent for shower/bathe self and lower body dressing on admission performance. Resident #23 urinary continence was not rate and was always incontinent for bowel continence. Record review of Resident 23's care plan dated 07/02/24, edited 07/24/24 indicated Resident #23 was continent of bladder and use a urinal. Resident #23 was at risk for urinary tract infections due to history of UTIs. Intervention included keep perineal area clean and dry. During an observation on 08/19/24 at 3:17 p.m., the ADON, with the assistance of LVN L provided wound and incontinent care on Resident #23. During wound care of Resident #23, the ADON noticed he had formed stool between his buttocks. The ADON cleaned Resident #23, changed gloves and reapplied barrier cream to site. Resident #23 was on his right side facing the wall. LVN L placed a new brief under Resident #23. Resident #23 laid over the new brief. LVN L grabbed peri wipes and cleaned Resident #23's peri area. LVN L, without changing her gloves, closed the tabs on Resident #23 brief. LVN L then turned Resident #23 on his left side with the same gloves to position him for wound care on his stump. During an interview on 08/19/24 at 2:00 p.m., CNA P said she had worked at the facility since February 2023. She said yesterday (08/18/24) when she entered Resident #5's room, she only had on a regular face mask, gown, and gloves. She said she had on a regular face mask because until today, they had not been told N-95 mask had to be worn. She said when the COVID outbreak started, she had been told to use the supplies in the caddies outside of the resident's door. She said in Resident #5's caddie was only a gown, gloves, and regular masks. She said she realized yesterday when she saw the surveyor in Resident #5's room, she needed to wear a face shield. She said it was important to wear face shields and N-95 masks because of the resident's droplet from coughing could be in the air. She said those droplets could get on the face without a face shield and N-95 mask. She said when face shields or N-95 masks were not worn in a COVID positive room, it could be transmitted to yourself and other residents. She said the facility provided an in-service when the outbreak started. She said the in-service was placed on the nurse's station and she signed it. CNA P said during incontinent care on Resident #18, she recalled removing her gloves after placing the soiled linen a bag. She said she placed the gloves in the bag with the soiled linen then grabbed new gloves from the dresser. During an interview on 08/20/24 at 1:40 p.m., CNA B said he could not recall what CNA P did after she removed Resident #18's soiled linen on 08/19/24. He said if she removed her gloves after touching the soiled linens, she was supposed to use hand sanitizer or wash her hands before putting on new gloves. He said it was important to use hand sanitizer or wash her hands after gloves were removed to ensure hands were cleaned after removal. During an interview on 08/20/24 at 2:15 p.m., LVN L said gown, gloves, face mask, and booties were supposed to worn in COVID positive rooms. She said the facility told staff N-95 mask and face shields were optional and personal preference. She said N-95 mask and face shields were important for COVID positive residents because of the droplets. She said if proper PPE was not worn, COVID could be spread to residents and family. She said residents already had poor immune systems and impaired healing process. During an interview on 08/20/24 at 2:40 p.m., the ADON said she was the Infection Control Preventionist. She said the facility interpreted that the type of face mask and to wear a facial shield was optional in the COVID-19 policy. She said after confirming with corporate, N-95 masks and face shields were required to enter a COVID positive room. She said the facility gave 2 in-services on COVID-19 when the outbreak happened on 08/14/24. She said N-95 mask and face shields were important, so the virus was contracted and spread to residents and staff members. She said during incontinent care, staff should place dirty linen in a bag and close it. She said staff should then remove gloves, perform hand hygiene, and place new gloves on before touching clean items. She said hand hygiene was the first defense to stop the spread of infection and viruses. She said LVN L should have removed her gloves, perform hand hygiene and place on new gloves before she touched the resident and attached straps on Resident #23's brief. She said not changing gloves and touching clean items was cross contamination. She said LVN L touched urine and possible feces which could have been transferred to Resident #23's linens and other things. She said LVNs were expected to be competent performing incontinent care. She said LVNs had also had in-services on peri care. During an interview on 08/20/24 at 3:56 p.m., the DON said she expected staff to change gloves after performing a dirty task. She said staff should remove their gloves then perform hand hygiene before place on new gloves. She said when dirty gloves were not changed, or hand hygiene not performed bacteria could spread and germs placed in clean area. She said peri care and hand hygiene competencies were performed upon hire and annually. During an interview on 08/20/24 at 4:25 p.m., LVN L said during wound and incontinent care on Resident #23 she did remember cleaning his peri area then attaching his brief without changing gloves. She said she did not recall touching Resident #23 with dirty gloves. She said she should have removed the dirty gloves, washed her hands then attached his brief. She said not changing her gloves then touching things was cross contamination. During an interview on 08/20/24 at 4:30 p.m., the ADM said she expected staff to perform hand hygiene after touching dirty items. She said staff were trained on hand hygiene and performing proper peri care upon hire and annually. She said it was important for infection control. She said it was the charge nurse, DON and ADON, who was the ICP, to ensure staff were performing hand hygiene and proper peri care. Record review of LVN L's Hand Hygiene Competency Validation by the ADON dated 01/31/24 indicated LVN L was competent for hand hygiene with soap and water and hand hygiene with ABHR. Record review of CNA P's Hand Hygiene Competency Validation by the ADON dated 01/26/24 indicated CNA P was competent for hand hygiene with soap and water and hand hygiene with ABHR. Record review of CNA P's Perineal Care Return Demonstration by the ADON dated 02/01/24 indicated CNA P correctly completed. Record review of CNA P's Personal Protective Equipment (PPE) Competency Validation, Donning and Doffing dated 02/01/24 indicated CNA P was competent for Standard Precautions and Transmission Based Precautions. Staff correctly identifies the appropriate PPE for the following scenarios: standard, contact, droplet, and airborne precaution. Record review of the facility's Perineal Care Return Demonstration date 2022 indicated .used correct technique for peri-care on female vs. male residents .dispose of gloves and perform hand hygiene, don new gloves and roll resident to side .removed gloves and perform hand hygiene before touching clothing, bed rail, cubicle curtain . Record review of a facility's COVID positive resident list provided on 08/18/24 indicated .Resident #5, Resident #19, and Resident #22 . Record review of the facility's undated Covid-19 Infection Prevention policy stated: .In the event of a suspected or confirmed COVID-19 infection, staff will promptly implement appropriate interventions and a management plan based on the Center for Disease Control's (CDC) guidelines, state and federal regulations, and/or guidance from the local health authority to prevent the spread of infection . .3. Implement Source Control (masks) Measures * Source control options for HCP include: * A NIOSH Approved particulate respirator with N95 filters or higher; * A respirator approved under standards used in other counties that are similar to NIOSH Approved N95 filtering facepiece respirators . .*A barrier face covering that meets ASTM F3502-21 requirements including Workplace Performance and Workplace Performance Masks; or *A well-fitting facemask * Any of the above options used solely for source control can be used for an entire shift unless they become soiled, damaged, or hard to breath through. * If using an NIOSH Approved Particulate respirator with N95 filter or higher during the care of a patient with COVID-19 infection, it should be removed and discarded after the patient care encounter and a new one should be donned . Record review of The Center for Disease Control's website, accessed on 08/22/24 at 9:31AM, stated: Infection Control Guidance: SARS-CoV-2 Key Points *This guidance applies to all U.S. settings where healthcare is delivered, including nursing homes and home health. The recommendation in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency . .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection The IPC recommendations described below .also apply to patients with symptoms of COVID-19 . .Personal Protective Equipment *HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection . Record review of a facility's Handwashing/Hand Hygiene policy revised 01/20/23 indicated .the facility considers hand hygiene the primary means to prevent the spread of infections .all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors .hand hygiene must be performed prior to donning and after doffing gloves .hand hygiene is the final step after removing and disposing of personal protective equipment .

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to ensure ice machine was functioning properly and preventing ice from spilling out onto the floor. 2. The facility failed to ensure minimal black carbon buildup on iron gas stovetop and debris cleared from under burner. 3. The facility failed to ensure food was properly labeled, dated, and stored in a resident personal refrigerator. These failures could place residents who received meals from the kitchen at risk for chemical contamination and food-borne illness. The findings were: During an observation on 8/18/2024 at 9:00 AM, the ice machine in the dining hall had a beige/brown blanket absorbing melting ice cubes laying directly in front of ice machine where residents and staff navigate. During an observation on 8/18/2024 at 10:44 AM, Resident #16 had a green, moldy undated, unlabeled sandwich stored in her mini refrigerator. Resident #16 said she needed to throw the sandwich away. During an observation on 8/18/2024 at 9:10 AM, observed black carbon buildup on gas stove in kitchen. During an observation on 8/19/2024 at 8:15 AM, observed iron gas stove with shiny black build up along the edges of the iron stove top. During an interview on 8/20/2024 at 1:21 PM, Dietary Aide F said the cook was responsible for cleaning the stove and oven. Dietary Aide F said a fire could occur if there was grease build up on the stove. Dietary Aide F said the Dietary Manager was the cook for tonight. Dietary Aide F said she does not know who was responsible for cleaning out resident's mini refrigerators and said she was not sure if sandwiches should be dated. During an interview on 8/20/2024 at 1:30 PM, the Dietary Manager said all the kitchen staff were responsible for cleaning the kitchen. The Dietary Manager said the cook was responsible for cleaning the stove and oven and said it was maintained regularly . The Dietary Manager said the ice machine does not have the guard on it causing ice to spill out onto the floor, so the aides put down a blanket to catch the ice. The Dietary Manager said the blanket could be a trip hazard and anyone could fall and hurt themselves. The Dietary Manager said she tries to keep the black grim off the stove and the kitchen has a strapper and brush to clean the stove and oven. The Dietary Manager said they were doing the best they can and use to get hours to help clean them more thoroughly. The Dietary Manager said the staff would stay until 3 AM and they currently do not have enough time during working hours. The Dietary Manager said the staff date the sandwiches leaving the kitchen to resident rooms. The Dietary Manager said she was not for sure but thought the aides and maintenance were responsible for cleaning resident's personal refrigerators. During an interview on 8/20/2024 at 1:44 PM, Hospitality Aide E said staff check and make sure the resident's refrigerators were clean. The Hospitality Aide said she was not sure who was responsible for checking the refrigerators or keeping the temperature logs. She said residents were good about keeping their refrigerators cleaned out. Hospitality Aide E said she does not know the facility policy on in room refrigerators. She said a resident could get sick if they ate something that went bad in their refrigerator. During an interview on 8/20/2024 at 1:47 PM, the Maintenance Supervisor said he was responsible for small appliances and changing air filters. He said he was not responsible for cleaning the oven or stove in the kitchen. The Maintenance Supervisor said he was responsible for thawing the resident's refrigerators if they were frozen up. He said he was not responsible for checking the refrigerator temperatures or removing food. During an interview on 8/20/2024 at 1:51 PM, CNA B said everyone was supposed to clean out the refrigerators in the resident's room. CNA B said housekeeping keeps temperature logs. CNA B said he was not sure who was responsible for the routine cleaning of the resident's refrigerators. During an interview on 8/20/2024 at 1:58 PM, CNA D said she has observed the maintenance person and ADON cleaning out resident's refrigerators. CNA D said there was a schedule and a list with a signature on the side of resident's refrigerator was how they kept up with it. CNA D said the kitchen staff date and label sandwiches in resident's rooms. She said a resident could get sick if they ate something that was out of date. CNA D said if they find something out of date, they take it out and throw it away. During an interview on 8/20/2024 at 2:08 PM, Housekeeper J said the nurse aides were responsible for wiping out the refrigerators. She said maintenance was responsible for monitoring the refrigerator temperatures. Housekeeper J said she was responsible for removing outdated food. She said a resident could get sick if consumed and the food should have a date on it. Housekeeper J said she has a deep clean schedule every 3 weeks, and said she checks the resident's refrigerator and performs a deep clean. During an interview on 8/20/2024 at 2:19 PM, LVN K said she was not sure who was responsible for resident's refrigerators or the ice machine. LVN K said she considers the blanket in front of the ice machine a hazard and was not sure who was responsible for the ice machine. During an interview on 8/20/2024 at 2:24 PM, LVN L said the night nurses check the refrigerators, perform temperature checks, and clean them out. She said a resident could get food poisoning and experience diarrhea or severe food poisoning. She said food opened should have been dated. LVN L said food should have been labeled and dated. LVN L said the blanket on the floor in front of the ice machine was a trip hazard. She said a resident couldor fall and hit their head, get a break, or brain bleed. LVN L said she thought maintenance was responsible for the ice machine. During an interview on 8/20/2024 at 2:33 PM, the ADON said the nurses were to check the refrigerator temperatures nightly and the CNA's and Aides were supposed to clean out the refrigerators. She said the housekeepers would also check the refrigerators. The ADON said there was not a schedule the facility goes by. The ADON said a resident could become sick if they ate something that had spoiled in their refrigerator. The ADON said the residents were not responsible for cleaning out their refrigerator. The ADON said she does not expect the sandwich dates on the refrigerated foods brought from home but if the facility prepared or was provided to the resident, she said it should be labeled and dated. The ADON said she noticed the blanket in front of the ice machine and said the facility recently had someone come out and work on the ice machine. The ADON said the blanket in front of the ice machine could cause a fall resulting in a break or injury. During an interview on 8/20/2024 at 2:49 PM, the DON said Resident #16 does not like you touching her things. The CNA would often go through the resident's refrigerator and take out the outdated items. The DON said housekeeping only takes it out if it needs thawed or deep cleaned. The DON said outdated food could make the resident sick. The DON said she expected the CNAs to go through the refrigerator at least one time weekly to ensure nothing spoiled. The DON said the stove was not her department. She said they have a schedule and maintenance completes certain task. During an interview on 8/20/2024 at 3:06 PM, the ADM said the resident with the green sandwich does not let staff do for her. The ADM said everyone was responsible for ensuring refrigerators are clean. The ADM said the facility does Angel rounds. (Where staff assigned to residents and check on them). The ADM said she thought the policy was for refrigerators to check weekly if residents allow. The ADM said the night nurses check the refrigerator temperature logs. The ADM said the sandwiches would be dated if it came out of the kitchen. She said it had the potential to make a resident sick if a food was outdated or spoiled. The ADM said the blanket in front of the ice machine looked tacky, but it kept water off the floor from the ice machine. She said the ice machine guard was broken. The ADM said the facility was going to reach out to have it serviced to fix the issue. She said the blanket was used to keep water off the floor. The ADM said it was a potential for injury as well as water on the floor could cause injury. She said she expected the ice machine to have the appropriate guard on it. The ADM said the dietary staff were responsible for cleaning the stove. The ADM said she did not think it was grease on the stove and said it was part of the stove. During an observation and interview on 8/20/2024 at 3:30 PM, the ADM and the Dietary Manager revisited kitchen to inspect the iron gas stove black buildup. The Dietary Manager removed the iron stove top and observed a sugar packet under the stove top burner. The ADM removed the sugar packet and threw it in the trash. The ADM said the black buildup on the iron gas stove was part of the stove. The Dietary manager was holding the stove top and around the edges was additional black buildup on the iron top. The Dietary Manager obtained a metal brush with a metal scrapper and started scaping the edges of the stove top and black particles started falling into the sink. The ADM acknowledged the particles but was unsure of the cause of the buildup. During an interview on 8/20/2024 at 3:34 PM, the Clinical Operations brought a small sample of black particles from the stove in the palm of his hand and was informed the black particles were carbon build up on the stove and it would just come back. Record review of FDA Food code dated 2022 Chapter 4 (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The Food-contact surfaces of cooking equipment and pans shall be free of encrusted grease deposits and other coil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Record review of the facility's undated policy titled Kitchen Sanitation and Cleaning Schedules revealed All surfaces, including floors, walls, storage shelves. Prep tables, trash cans, and all food contact surfaces must be routinely cleaned and sanitized. Ceilings, vents, light fixtures, pipes, and any other potentially contaminated surface will be cleaned as needed. All equipment must be thoroughly washed and sanitized between uses, in different food preparation tasks and anytime contamination occurs or was suspected. Cleaning schedules: cleaning schedules are posted at the beginning of each day, week, or month in the kitchen depending on the type of schedule. It was the responsibility of the team member to follow the cleaning schedule and to complete as indicated. Sigh the cleaning schedule once the task was completed. Record review of the facility's policy dated 9/11/2023 titled Personal Resident Refrigerator revealed This facility does not provide a refrigerator in a resident's room. However, it was the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. Policy explanation and compliance guidelines: 1. Dormitory-sized refrigerators are allowed in a resident's room under the following conditions: a. The refrigerator was inspected by maintenance personnel and deemed safe prior to use and upon routine inspection. b. The refrigerator maintains proper temperatures. e. The resident complies with the facility's policy for use of refrigerators. 2. Maintenance staff or designee shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator. 3. Housekeeping and or nursing staff as assigned shall clean the refrigerator weekly and discard any foods that are out of compliance. 4. Residents and staff will comply with safe food handling and storage principals: Perishable foods such as dairy products, meat, and processed foods made with perishable foods or eggs will be stored immediately upon receipt. b. Leftovers shall be dated upon receipt and discarded withing three days. c. Foods with use-by dates shall be discarded accordingly.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 14 residents (Resident #8 and Resident #15) reviewed for reasonable accommodations. The facility failed to ensure Resident #8 and Resident #15's call light was placed within reach. This failure could place residents at risk for unmet needs. Findings included: 1. Record review of Resident #8's face sheet dated 08/18/24 indicated Resident #8 was a [AGE] year-old, female and admitted on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left non-dominant and flaccid hemiplegia affecting right dominant side. Record review of Resident #8's quarterly MDS assessment dated [DATE] indicated Resident #8 was usually understood and usually understood others. Resident #8 had minimal difficult hearing, clear speech, and moderately impaired vision. Resident #8 had a BIMS score of 10 which indicated moderately impaired cognition. Resident #8 was dependent for toileting hygiene and chair/bed-to-chair transfer. Resident #8 was always incontinent for urine and bowel. Resident #8 had functional limitation in range of motion impairment for one side of both her upper and lower extremities. Resident #8 used a wheelchair for mobility. Record review of Resident #8's care plan dated 12/15/20, edited 07/07/24, indicated Resident #8 was at risk for falls related to left side hemiparesis and personal preference to be in high position. Intervention included keep call light in reach of resident. 2. Record review of Resident #15's face sheet dated 08/18/24 indicated Resident #15 was a [AGE] year-old, female and admitted on [DATE] and readmitted on [DATE] with diagnoses including difficulty walking, muscle weakness, unsteadiness on feet, and history of falling. Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated Resident #15 was usually understood and usually understood others. Resident #15 had minimal difficulty hearing with hearing aids used, clear speech, and impaired vision with corrective lenses used. Resident #15 had a BIMS score of 10 which indicated moderately impaired cognition. Resident #15 required partial assistance for toileting hygiene and walk 10 feet and supervision for chair/bed-to-chair transfer, toilet transfer, and sit to stand. Resident #15 was frequently incontinent for urine but always continent for bowel. Resident #15 had functional limitation in range of motion impairment for both side of her lower extremities. Resident #15 used a wheelchair for mobility. Record review of Resident #15's care plan dated 01/23/20, edited 08/05/24, indicated Resident #15 had multiple problems that affected her ability to walk. Resident #15 had a history of falls, the potential to fall and at risk for injury related to falls. Intervention included make sure my call light is within reach and respond quickly. During an observation on 08/18/24 at 10:35 a.m., Resident #15 was sitting up in her bed. Resident #15's call light was on the floor. During an observation and interview on 08/18/24 at 4:35 p.m., Resident #8 was sitting in a wheelchair, in front of her refrigerator. Resident #8 said her call light did not work and she did not know where it was. Both of Resident#8's call lights were behind the foot of her bed, on the floor. She said staff told her they would come in at the right times to assist her, so she did not need her call light. During an observation and interview on 08/19/24 at 8:42 a.m., Resident #15 was sitting up in her bed. Resident #15's call light was on the floor. Resident #15 said she could get herself up if she needed help. Resident #15 said she did not know where her call light was. During an interview on 08/20/24 at 1:40 p.m., CNA B said he was assigned to Resident #15 on 08/19/24. He said he did not recall where Resident #15's call light was that day. He said Resident #15 kept a lot of stuff in her bed and the call light probably fell on the floor. He said it was the CNAs, or whomever entered resident's room to make sure call lights were in reach. He said it was important for call lights to be in reach so the resident could get help. He said when call lights were not in reach, residents could fall and hurt themselves. On 08/20/24 at 2:00 p.m., attempted to contact CNA P regarding Resident #8's call light placement on 08/18/24. CNA P did not answer the call and unable to leave voice message. CNA P did not return call before exit. During an interview on 08/20/24 at 2:36 p.m., RN M said it was everyone responsibility to ensure call light were in reach of residents. She said staff should do frequent rounding to ensure resident's call lights were in reach. She said residents could harm themselves if call light were not within reach. She said Resident #15 could transfer herself but needed supervision. During an interview on 08/20/24 at 3:56 p.m., the DON said when CNAs exited resident's room, they should ensure call light were within reach of the residents. She said before all staff exited resident's rooms, they should ensure call lights were within reach. She said charge nurses should ensure call lights were within reach by doing rounds. She said call lights needed to be within reach so residents could get assistance. She said call lights not being within reach of resident, placed them at risk for falls, not getting needed assistance and needs not being met. During an interview on 08/20/24 at 4:30 p.m., the ADM said she expected call lights to be within reach of the residents and answered timely. She said all staff should make sure call lights were in reach. She said the charge nurses should be ensuring call lights were within reach of residents. She said call lights needed to be within reach always to ensure resident could get the help they needed. She said residents were at risks for falls if their call lights were not within reach. Record review of a facility's Answering the Call light policy revised 03/2021, indicated .when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #44) reviewed for discharge MDS assessments. The facility did not ensure Resident #44's discharge MDS assessment was completed and transmitted within 14 days of completion. This failure could place residents at risk of not having records completed and submitted in a timely manner as required. Findings included: Record review of Resident #44's face sheet dated 08/19/24, indicated Resident #44 was an 85-years-old female, admitted on [DATE] with a diagnosis which included non-ST elevation myocardial infarction (is a type of involving partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle). Resident #44 was discharged home with services on 04/19/24. Record review of Resident #44's discharge assessment-return not anticipated MDS assessment dated [DATE] indicated Resident #44 discharge date was 04/19/24. The MDS indicated Resident #44's observation end date was 04/19/24. The MDS did not indicate submission. During an interview on 08/20/24 at 2:38 p.m., the MDS Coordinator said she was responsible for completing and submitting MDS. She said Resident #44's discharge assessment should have been completed and submitted within 14 days of her discharge. She said the corporate MDS coordinator monitors the MDS assessments she completed. She said it was important to complete and submit discharge assessments because it ensured that proper documentation was collected prior to discharge. She said the facility ran reports on MDS assessments completion and submission. She said she did not know how Resident #44's discharge assessment got missed. During an interview on 08/20/24 at 4:30 p.m., the ADM said she expected the MDS coordinator to follow the MDS Completion and Submission policy. She said the MDS Coordinator was responsible for submitting discharge assessment timely. She said the corporate MDS Coordinator should be ensuring the facility's MDS Coordinator completed and submitted assessment timely. She said timely assessment submission was important ensure the facility was following CMS guidelines. Record review of a facility's MDS Completion and Submission Timeframes policy revised 07/2017 indicated .our facility will conduct and submit resident assessments in accordance with currency federal and state submission timeframes .the assessment coordinator or designee is responsible for ensuring that resident assessment are submitted to CMS QIES assessment submission and processing system in accordance with current federal and state guidelines .timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . Record Review of the CMS RAI Version 3.0 Manual, dated October 2023, indicated, in Chapter 2, page 2-39 09. Discharge Assessment-Return Not Anticipated (A0310F), Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). The RAI Manual further revealed the discharge assessment-return not anticipated must be submitted within 14 days after the MDS completion date (Z0500B +14 calendar days) .

Based on interviews and record review, the facility failed to ensure a registered nurse signed and certified that the MDS assessment was completed for 1 of 1 resident (Resident # 44) reviewed for MDS completion. The facility failed to ensure the RN signed Resident #44's discharge MDS assessment as completed. This failure could place residents at risk for incomplete or inaccurate documentation that does not completely reflect the resident's status. Findings included: Record review of Resident #44's face sheet dated 08/19/24, indicated Resident #44 was an [AGE] year-old female, admitted on [DATE] with a diagnosis which included non-ST elevation myocardial infarction (is a type of involving partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle). Resident #44 was discharged home with services on 04/19/24. Record review of Resident #44's discharge assessment-return not anticipated MDS assessment dated [DATE] indicated Resident #44's discharge date was 04/19/24. The MDS indicated Resident #44's observation end date was 04/19/24. The MDS revealed no RN signature in section Z, which was the signature of RN assessment coordinator verifying assessment completion. During an interview on 08/20/24 at 2:38 p.m., the MDS Coordinator said she was responsible for letting the RN know when a MDS assessment needed to be signed. She said she told either the DON or Regional MDS Coordinator to review the MDS assessment and sign it. She said the RN had to sign the MDS assessment within 14 days of discharge. She said the RN reviewed and signed the MDS assessment to certify the information on the assessment was correct. During an interview in 08/20/24 at 3:56 p.m., the DON said she was still learning about what was required on MDS assessments. She said the MDS Coordinator was responsible for completing most section on the MDS. She said she checked the MDS assessment, to the best of her ability, before she signed them for submission. During an interview on 08/20/2024 at 4:30 p.m., the ADM said she expected the RN/DON to sign when MDS assessments were completed. The ADM said she expected the MDS assessment to be signed with the specified timeframe allowed. The ADM said it was important to ensure timely payment of services. Record review of a facility's MDS Assessment Coordinator revised 12/2019 indicated .a Registered Nurse (RN) shall be responsible for conducting and coordinating the development and completion of the resident assessment (MDS) .the center staff must follow the MDS 3.0 RAI manual current version .the Resident Assessment Coordinator must date and sign each assessment (MDS) to certify that the assessment has been completed . Record review of the MDS 3.0 RAI Manual, dated October 2019, revealed that Federal regulation requires the RN assessment coordinator to sign and thereby certify that the assessment is complete.

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 (Resident #23) residents reviewed for quality of care. The facility failed to ensure Resident #23 had daily blood sugar glucose checks due to being on an antidiabetic (help manage blood sugar (glucose) levels in people who have Type 2 diabetes) medication. This failure could place residents of risk for not receiving appropriate care and treatment for hyperglycemia (when there's too much sugar (glucose) in your blood) or hypoglycemia (when your blood sugar (glucose) level falls too low for bodily functions to continue). Findings included: 1. Record review of Resident #23's face sheet dated 08/18/24 indicated Resident #23 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and abnormal weight loss. Record review of Resident #23's admission MDS assessment dated [DATE] indicated Resident #23 was usually understood and usually understood others. Resident #23 had minimal difficulty hearing, clear speech, impaired vision without corrective lenses. Resident #23's BIMS score was 10 which indicated moderately impaired cognition. Resident #23 had taken a hypoglycemic medication during the last days. Record review of Resident #23's care plan dated 06/14/24 did not indicate, use of hypoglycemic/antidiabetic medication or Type 2 diabetes mellitus diagnosis. Record review of Resident #23's consolidated physician order dated 07/01/24-08/20/24 indicated: *Januvia (is an oral diabetes medicine that helps control blood sugar levels) tablet 50 mg 1 tablet oral, Diagnosis: Type 2 diabetes mellitus, once a day. Start date: 06/14/24-open ended. Record review of Resident #23's prescription order dated 06/13/24 indicated .Januvia tablet; 50 mg; 1 tablet; oral .frequency: once a day .Task (s) to record: Before: Blood Sugar (measures the level of glucose (sugar) in your blood) .physician order . Created by: LVN O .Signed by MD U . Record review of Resident #23's Medication Administration Record dated 07/01/24-07/31/24 indicated Januvia tablet 50 mg 1 tablet oral, other test, Diagnosis: Type 2 diabetes mellitus, once a day. Start date: 06/14/24. Received prescribed dose daily except for 07/19/24. No documented BSGs noted. Record review of Resident #23's Medication Administration Record dated 08/01/24-08/20/24 indicated Januvia tablet 50 mg 1 tablet oral, other test, Diagnosis: Type 2 diabetes mellitus, once a day. Start date: 06/14/24. Received all doses. Documented BSGs on 08/11/24-08/20/24. Record review of Resident #23's Vital Signs: Blood Sugar dated 06/14/24-08/20/24 indicated documented BSGs for 08/12/24, 08/13/24, 08/14/24, 08/15/24, 08/16/24, 08/18/24, and 08/19/24. During an interview on 08/20/24 at 2:15 p.m., LVN L said she thought Resident #23 had BSG checks. She said resident on oral diabetic medication had to get at least weekly BSG checks. She said the resident's TAR informed staff if BSGs were required. She said BSG checks were important to know if the resident was hyperglycemic or hypoglycemic before the medication was administered. She said if BSGs were not checked then staff would not know if the MD needed to be contacted. She said if BSGs were not checked then staff would not know the oral diabetic medications were not working. She said BSGs needed to be checked because the resident could need to be on insulin instead of oral medication. She said if a resident experienced unknown hypo or hyperglycemia then they could suffer brain damage, stroke, or coma. She said resident could also die from untreated hypo or hyperglycemia. During an interview on 08/20/24 at 2:36 p.m., RN M said when a resident was on oral diabetic medication they at least had as needed order for blood sugar checks. She said the blood glucose checks should be on the medication order. She said sometimes adding blood sugar checks to the medication order was missed. She said she thought Resident #23 had blood sugar checks ordered on his medication order. She said sometimes nursing staff missed the order to do a BSG before administration. She said when blood sugars were not checked on a resident taking oral diabetic medication, it placed them at risk for hypo (occurs when your blood glucose (sugar) levels are too low) and hyperglycemic (occurs when the level of blood glucose gets too high) episode. During an interview on 08/20/24 at 3:56 p.m., the DON said a resident on an oral medication should have bsg checks at least daily. She said the nurse who received the oral diabetic medication order should add daily bsg checks to the order. She said bsg checks were important to know if the medication was needed. She said oral diabetic medication was not as known but they could cause hypoglycemia. She said it was important to check bsgs to ensure the tablet form was treating the hyperglycemia. She said the resident could need a stronger diabetic medication. She said the DON was responsible to ensure residents on oral diabetic medication had bsg checks ordered by a nurse. She said RN M and the DON pulled activity reports daily. She said they looked at new orders to see if monitoring was ordered. She said Resident #23 was supposed to get his blood sugar checked before administering his medication. During an interview on 08/20/24 at 4:30 p.m., the ADM said she expected nursing staff to follow the diabetes policy. She said the DON should ensure the diabetic policy was being followed. She said blood sugar checks were important to make sure the medication was needed and effective. Record review of a facility's Nursing Care of the Older Adult with Diabetes Mellitus policy revised 11/2020 indicated .for the resident on oral medication (s) who is well controlled, monitor blood glucose levels at least twice weekly .for the resident receiving oral medication(s) who is poorly controlled .monitor blood glucose levels twice to four times daily as needed .

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents reviewed for urinary and bowel incontinence (Resident #18 and #32). 1. The facility failed to ensure Resident #18 was not found excessively wet on 08/19/24. 2. The facility failed to ensure CNA C performed proper incontinent care by ensuring Resident #32 was completely clean after bowel movement and before placing a new brief on 8/19/2024. These failures placed residents who required assistance with incontinent care at risk for urinary tract infections, skin breakdown, and hospitalization . Findings included: 1. Record review of Resident #18's face sheet dated 08/18/24 indicated Resident #18 was a [AGE] year-old, female and admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left non-dominant and urinary tract infection (is an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra). Record review of Resident #18's quarterly MDS assessment dated [DATE] indicated Resident #18 was usually understood and usually understood others. Resident #18 had a BIMS score of 08 which indicated moderate cognitive impairment. Resident #18 did not reject care. Resident #18's admission performance was dependent for toilet hygiene. Resident #18 was always incontinent of urine and bowel. Record review of Resident #18's care plan dated 07/03/24 indicated Resident #18 had a history of chronic UTIs. Intervention included monitor for signs/symptoms of UTI. Record review of Resident #18's care plan dated 07/28/24 indicated Resident #18 experienced bladder incontinence related to cerebral vascular accident (brain attack). Intervention included provide incontinence care after each incontinent episode. Record review of Resident #18's progress note dated 08/18/24 at 3:29 a.m., indicated .resident continues to require maximum assist with ADL completion by staff .Resident is incontinent of bowel and bladder with incontinent care being provided by facility staff prn .LVN O . Record review of Resident #18's progress note dated 08/20/24 at 10:06 a.m., indicated .during assessment the resident had a large urine output with pink/red tint noted .LVN L . Record review of Resident #18's progress note dated 08/20/24 at 11:38 a.m., indicated .new order of Keflex 500 mg .for possible UTI .ADON . Record review of Resident #18 Bowel/Bladder ADL sheet dated 08/01/24-08/20/24 indicated Resident #18 received incontinent care on 08/18/24 at 3:31 a.m. by CNA R. During an interview and observation on 08/19/24 at 8:42 a.m., Resident #18 was lying in her bed with the call light in her hand. She said last night she had to wait about 25 minutes to be changed. She said she could not remember what time she was lasted changed. She said she needed to be changed right now. Resident #18 pushed her call light and CNA B answered. CNA B told Resident #18 to give him 2 minutes to finish with another resident and he would change her. During an observation on 08/19/24 at 8:56 a.m., CNA B and CNA P performed incontinent care on Resident #18. When CNA B turned Resident #18 on her side, Resident #18's brief, cloth under pad, and sheet were saturated with urine. Resident #18's mattress also had a wet spot on it. During an interview on 08/19/24 at 2:00 p.m., CNA P said she had worked at the facility since February 2023. She said Resident #18 was really wet this morning when she helped CNA B change her. She said she did not work with Resident #18 a lot. She said she did not know if Resident #18 was a heavy wetter or received a diuretic in the morning. During an interview on 08/19/24 at 2:05 p.m., CNA B said RN M told him Resident #18 needed to be changed this morning. He said RN M told him Resident #18 needed to change around 8:40 a.m. He said Resident #18 was excessively wet before he changed her this morning. He said Resident #18 being really wet could cause her to have skin breakdown. He said he had not told the charge nurse Resident #18 was found excessively wet this morning. He said he needed to tell the nurse Resident #18 had pink tinged urine when he changed her, too. During an interview on 08/20/24 at 9:00 a.m., the ADON said CNA R was assigned Resident #18's hall on 08/19/24, 10pm-6am shift. During an interview on 08/20/24 at 2:15 p.m., LVN L said residents were supposed to be changed every 2-3 hours. She said CNAs were responsible for providing incontinent care to residents. She said nurses should also be rounding on residents to ensure they were being changed every 2-3 hours. She said when residents were not provided timely incontinent care, it placed them at risk for skin breakdown and UTIs. On 08/20/24 at 2:25 p.m., called CNA R for interview regarding incontinent care on Resident #18. CNA R did not answer. Messaged left. Return not received before exit. During an interview on 08/20/24 at 3:56 p.m., the DON said CNAs were responsible for providing incontinent care to residents. She said CNAs should make rounds every 2 hours and as needed. She said if a resident was found excessively wet, it could be assumed they had not been changed in a while. She said the LVN charge nurses should be ensuring CNAs were changing residents timely. She said she had never been told Resident #18 was a heavy wetter. She said not changing residents timely placed them at risk for skin breakdown and infections such as UTIs. During an interview on 08/20/24 at 4:30 p.m., the ADM said CNAs were responsible for incontinent care. She said she expected CNAs to perform incontinent care every 2 hours and as needed. She said the charge nurse and the DON should be ensuring the CNAs provided timely incontinent care. She said if a resident was found excessively wet, could indicated Resident #18 was not changed every 2 hours. She said it was important to provide timely incontinent care to prevent skin breakdown and infections. 49019 2. Record review of face sheet dated 8/20/2024, revealed Resident #32 was a [AGE] year-old female, admitted on [DATE] with the diagnoses of Alzheimer's disease (progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), pressure ulcer of sacral region, stage 1 ( non-blanchable redness of a localized area) and depression (a mood disorder that causes persistent sadness and loss of interest). Record review of an annual MDS assessment dated [DATE] revealed Resident #32 BIMS score was blank which indicated resident is rarely or never understood and was severely impaired cognitively. Resident #32 was dependent on staff for majority of activities of daily living. The MDS indicated Resident #32 was incontinent of bowel and bladder. Record review of Resident #32's care plan dated 09/03/2022 indicated Resident #32 had a history of pressure sores and DTI (deep tissue injury). Intervention included follow facility skin care protocol and report to charge nurse any redness or skin breakdown immediately. Record review of Resident #32's care plan dated 9/3/2022 indicated Resident #32 experienced bowel and bladder incontinence and requires assistance with personal care and at risk for breakdown from incontinence. Intervention included check for incontinence frequently throughout the shift, briefs, depends or pantiliners when out of bed and keep call light within reach. During an observation on 8/19/2024 at 9:28 AM, CNA C performed perineum care to Resident # 32 with CNA B assisting. CNA C used proper technique wiping from front to back and disposing of soiled wipe in a separate trash bag. CNA C assisted Resident #32 in positioning on her right side and cleansed her bottom from front to back using appropriate technique. After completing perineum care, CNA C placed a clean brief on Resident #32 and placed a new under pad on her bed. CNA C failed to inspect between Resident #32's legs to ensure she was completely cleaned before placing a new brief. CNA C said she felt she performed proper incontinent care and cleaned Resident #32 correctly. During an observation on 8/19/2024 at 9:51 AM, the DON and RN M came to Resident #32's room to follow-up on perineum care provided by CNA C. The DON was made aware of concerns of Resident #32 perineum care. RN M obtained additional supplies to perform perineum care. The DON rolled Resident #32 on her left side and started wiping from front to back removing moderate amount of feces remaining between Resident #32's perineum area. The DON rolled Resident #32 toward her and RN M assessed skin to sacrum area. RN M said Resident #32 had a blanchable red area to sacrum. During an interview on 8/19/2024 at 10:06 AM, RM M said some residents had issues with loose stools and sometimes staff will clean a resident and they were dirty again. RN M said she expected the residents to be clean prior to placing a new brief. RN M said a resident not receiving proper perineum care could result in an infection, urinary tract infection or skin breakdown if not properly cleaned after a bowel movement. During an interview on 8/19/2024 at 10:11 AM, the DON said she expected CNA's to clean residents from front to back and between the legs as she demonstrated. The DON said the staff has been in-serviced on incontinent care to keep them on their toes. The DON provided CNA C's checklist and provided a copy of perineum policy revised on 1/20/2023. During an interview on 8/20/2024 at 1:51 PM, CNA B said the facility has in-serviced on perineum care. CNA B said it was important to keep environment and workplace sterile. CNA B said you should put a barrier between all supplies and table and keep extra bags. CNA B said he inspects the areas to make sure all fecal matter has been removed from the resident. CNA B said a resident could be at risk for infection, get sick or the resident could get skin irritation or a bed sore. During an interview on 8/20/2024 at 1:58 PM CNA D said the facility had in-serviced on perineum care and the DON checked staff off. CNA D said it was important to inspect skin after cleaning the resident to ensure they are clean. CNA D said a resident could have skin breakdown, pressure sores or urine could saturate the skin and could cause a urinary tract infection. During an interview on 8/20/2024 at 2:19 PM, LVN K said the facility has in-serviced staff on perineum care. LVN K said it was important for residents to have good perineum care to prevent infection and prevent skin breakdown. During an interview on 8/20/2024 at 2:24 PM, LVN L said perineum care was important for men and women residents. LVN L said the resident could get an infection such as a urinary tract infection that could turn into sepsis if not caught early or a resident could get skin breakdown. LVN L said the staff member performing perineum care should inspect skin to ensure all areas are clean. During an interview on 8/20/2024 at 2:33 PM, the ADON said in-services were performed with facility staff every 6 months and performed an annual check off on perineum care. The ADON said perineum care was important to keep residents clean, prevent discomfort, skin breakdown, prevent infections and was a dignity issue. The ADON said she expected the staff to perform proper perineum care and inspect skin following care to ensure resident was clean. During an interview on 8/20/2024 at 2:49 PM, the DON said she expected the CNA's and nurses to perform proper perineum care. The DON said it could be a source for infection and skin breakdown. The DON said she expected the CNA's and nurses to inspect the resident skin after performing care to ensure the residents were clean. The DON said she expected the CNA's performing care if they observe a wound or pressure area, they should notify their charge nurse and the ADON who is also the treatment nurse so she was aware of concern and can stay on top of the issue. During an interview on 8/20/2024 at 3:30 PM, the ADM said she expected the nurses and CNAs to perform proper perineum care to the residents. She said it was important to provide timely incontinent care to prevent skin breakdown and infections. Record review of the facility's check list dated 5/22/2024 titled Perineum care return demonstration checklist revealed CNA C completed demonstration of proper procedure steps performing perineum care on female and male residents. The Procedure steps revealed Use clean section for each wipe or use a new wipe each time. Use correct technique for peri-care on female verse male . Female .Spread labia, maintain serration of labia, clean center, then each groin areas to each side .dirty to clean .wipe one side then the other, and then the middle .wiping toward the rectum .Dispose of gloves and perform hand hygiene .don new gloves and roll resident to side then proceed to clean the rectal and buttock area. Review of a facility policy revised on 1/20/2023 titled Perineal Care revealed Perineal care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition. Steps in the procedure . For female resident: 1. Using the cleansing wipe, clean perineal area, wiping from front to back .2. Separate labia and wash area downward from front to back .3. Continue to clean perineum moving from inside outward to the thighs, cleanse the perineum thoroughly in the same direction .5. Dry the perineum .6. Ask the resident to turn on her side with her top leg slightly bent .7. Using a new cleansing wipe, clean the rectal area thoroughly, wiping from the base of the labia and extending over the buttocks . Reporting .Notify the nurse if the resident refuses the perineum care and/or any concerns identified.

Based on observation, interview, and record review the facility failed to provide basic life support, including CPR to a resident requiring emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the residents advanced directives for 1 of 4 residents reviewed for emergency care ( Resident #1) The facility failed to assess and immediately initiate CPR when Resident #1, who was a full code, was found unresponsive in the dining room on [DATE] at 7:10 a.m. CPR was not initiated until EMS arrived (12 minutes after the resident was found unresponsive). Resident #1 was transported to the hospital, found to have large amounts of solid food in his airway, and pronounced deceased on [DATE] at 9:18 a.m. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:10 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for not receiving immediate emergency services (CPR) and death. Findings included: Review of Resident #1's face sheet with undated indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] and his last readmitted was [DATE]. Some of his diagnoses were stroke, cognitive communication deficit, and seizure disorder. Record review of quarterly MDS dated [DATE] indicated Resident #1's cognitive status was severely impaired with a BIMS score of 5. He required substantial to maximal assist with eating, and oral hygiene. He was dependent for all other ADLs. Record review of Resident #1's care plan dated [DATE] indicated the following care areas: *At risk for choking related to seizure disorder requiring medications problem start date of [DATE] and last edited on [DATE] . The approaches were to monitor the resident frequently throughout the shift following seizure activity. To assess the resident after seizures, the time, length, level of consciousness, activity, and respiratory activity if a seizure occurred. *A mechanical soft diet due to a history of stroke with residual effects and contractors to bilateral hands problem start date of [DATE] . The approaches may have clothes protector during meals if desired, ensure a bedside table was provided in the ding area with meals for easy reach. Report problems to charge nurse such as choking or difficulty chewing. Someone to assist with feeding on days he had difficult feeding himself. *An advance directive problem start date of [DATE] and last edited [DATE]. The approach was full code. Record review of Resident #1's computerized physician orders indicated the following: *dated [DATE] for Full Code Status. *dated [DATE] for regular diet, mechanical soft with thin fluids. Record review of an EMS report dated [DATE] indicated at 7:16 a.m. dispatch received a call. The EMS were in route at 7:17 a.m. and arrived on the scene at 7:20 a.m. The report indicated they were at the patient at 7:22 a.m. and departed the scene at 7:30 a.m. The report indicated they were at the hospital at 7:37 a.m. The report indicated the Resident's primary impression was cardiac arrest with a reported-on set of 7:10 a.m. and a duration of 12 minutes. The report indicated on arrival on the scene they asked for directions to the patient, and the nursing staff pointed to a resident sitting in a wheelchair. The nurse who gave report stated he had breakfast at about 6:30 a.m. and when she approached him at 7:10 a.m. he was not responsive. There was no CPR initiated prior to EMS arrival. At 7:22 a.m. initial contact with the resident showed he was unresponsive, pulseless, and warm to touch. Record review of hospital records dated [DATE] indicated Resident #1 arrived at 7:38 a.m. with a diagnosis of Cardiac arrest with pulseless electrical activity. Resident #1's airway was assessed per guided scope and found to have large amounts of solid food throughout visible airway. The food products were noted in King airway( a tube used for intubation for advanced airway management) as well. Attempts to clear the airway via mechanical and suction removal. EMS stated the patient was sitting in a wheelchair at the nurse's station unresponsive with no CPR in progress when they arrived. The patent had just eaten breakfast. The exact down time is unknown. We were unable to replace the laryngeal mask airway ( LMA a medical device that keeps a patient's air way open while they are unconscious) due to the amount of food in his trachea. (Windpipe ). The patient was pulseless from the time of arrival to the time the MD pronounced him deceased . Compressions were stopped at 8:45 a.m. and he was pronounced by the physician at 9:18 a.m. as deceased . Record review of Resident #1's nursing note dated [DATE] with a time of 7:50 a.m. but was created on [DATE] at 3:41 p.m. indicated, Resident #1 was up in his Geri-chair in the dining room for breakfast between 6:30 a.m. and 7:00 a.m. He was sitting up joking with the other residents in his usual manner. He consumed about 90 percent of his meal which consisted of oatmeal, eggs, and a biscuit. Kitchen Stall D, Kitchen Staff E and LVN B remained in the dining area while this nurse (LVN A) assisted another resident to his room. When nurse returned to the dining area Kitchen Staff D was loudly calling Resident #1's name and tapping him. The nurse performed a sternum rub and he did not respond. He had a significant history of seizures, hypoglycemia, and cardiac arrest. The nurse asked Kitchen Staff D to get LVN B and call 911 for help. LVN B called 911 and came to assist this nurse. The nurse proceeded to check the code status( to determine If he was a do not resuscitate or to perform CPR) and gather items needed to assess the resident while LVN B pushed the resident to the nursing station. Resident #1 was a Full Code( indicated the resident wished for the facility to provide every possible effort to save his life in a medical emergency including CPR). The nurse was unable to get vitals or arose the resident per verbal or tactile stimulation. EMS arrived and initiated CPR. The note indicated the responsible party was notified at 7:19 of the transfer to the hospital. and another entity was notified at 7:18 a.m. The note was written by LVN A. Record review of a nursing note dated [DATE] at 9:20 a.m. indicated the facility contacted the family for a report on Resident #1 and as informed the resident had expired. Record review of a timeline provided by the facility on [DATE] at 3:40 p.m. by the administrator undated indicated on [DATE] between 6:30 a.m. and 7:00 a.m. breakfast was served. LVN A was located in the dining room until 6:50 a.m. when she left to walk a resident back to his room and check on another resident. LVN B was in the dining room until approximately 7:00 a.m. and then gathered smokers to take them out to smoke. At 6:50 a.m. Kitchen Staff D and Kitchen Staff Kitchen Staff were eating their breakfast in the dining room. At 7:10 a.m. smokers came back inside, and Resident #1 appeared to be sleeping. Kitchen staff D went to Resident #1 to take him to the lobby and could not get him to respond. Staff loudly called his name, and LVN A overheard Kitchen Staff D talking to Resident #1 and walked into the dining room. At 7: 14 a.m. LVN A told LVN B to call 911. LVN B dial 911 and handed the phone to CNA C. Then LVN B returned to the dining room with LVN A. LVN A went to the nurse's station to verify Resident #1's code status and get things to check Resident #1's vitals. LVN B then pushed Resident #1 to the nurse's station after she was unable to get vital signs and he did not respond to a sternal rub. EMS arrived at approximately 7:20 a.m. and left the facility at approximately 7:28 a.m. with CPR in progress. Verbal statements from the staff indicated CNA C said she was asked by LVN B to speak with 911 between 7:10 a.m. and 7:14 a.m. During interviews Kitchen Staff D and Kitchen Staff E said between 6:30 a.m. and 7:00 a.m. they served breakfast. They said that LVN A was in the dining room sitting with residents. They said that LVN B took the smokers out to smoke between 7:00 a.m. and 7:10 a.m. Kitchen Staff D said she went over to Resident #1 to push him to the lobby to help nurses out like she always did while Kitchen Staff E went back into the kitchen. Kitchen Staff D said she could not arouse Resident #1. She said she called his name loudly and LVN A came in the dining room. LVN A said she asked Kitchen Staff D to get LVN B and to call 911. LVN A said EMS arrived at approximately 7:15 a.m. to 7:20 a.m. Resident #2 said Resident #1 was sitting up and talking and joking like he always did. She said she went out with the smokers at 7:00 a.m. for smoke break. She said when she returned from smoking Resident #1 appeared to be sleeping. She said Kitchen Staff D was standing with him, calling his name, and shaking him and LVN A came into the dining room. There was no signature on the typed note. During an interview on [DATE] at 4:50 p.m. a concerned citizen said the facility failed to put life saving measures in place to prevent Resident #1 from dying. They said on [DATE] at about 7:30 a.m. EMS arrived, and a full code resident was sitting in a chair, with nurses standing around not performing CPR. They said EMS was informed by a nurse Resident #1 had been unresponsive since 7:10 a.m. They said Resident #1 was still in the chair and facility staff did not perform CPR to try and save the resident's life. During an interview on [DATE] at 7:47 a.m. the Dietary Manager said she worked [DATE] as a CNA. She said she heard Kitchen Staff D calling for LVN A. She said Kitchen Staff D told her Resident #1's lips were blue when she approached him. The Dietary Manager said the two kitchen aides that worked on [DATE] Kitchen Staff D and Kitchen Staff E She said when she walked up front on the morning of [DATE] someone had brought Resident #1 up to the front and CNA C was on the phone with 911. She said LVN B had the Resident #1 in the Geri-chair and LVN A was behind the nurse's station. During an interview on [DATE] at 7:55 a.m. LVN A said Resident #1 was found in the dining room unconscious. She said she was headed back to the dining room when she heard Kitchen Aide D screaming and calling her name. She said when she went into the dining room Resident #1 was unresponsive, she shook him, did a sternal rub, and did not get a response. LVN A said she asked Kitchen Staff D to get LVN B. She said LVN B called 911. LVN A said she did not notice Resident #1's color or take his pulse. When LVN B arrived, she went to check his code status she did not want to initiate CPR if he was a DNR. She said they did not call for the crash cart. While she was at the nurse's station about 2 minutes, LVN B brought Resident #1 up to the nurse's station. She said just about that time EMS walked in the facility. EMS took Resident #1 out of his chair, put him on the gurney, and initiated CPR. LVN A said Resident #1 was a Full Code. She said Resident #1 did not require assistance with eating, but he had a mechanical soft meat. She said he was sitting at the table by himself with a tray table sit up just for him. She said Breakfast stated about 6:30 a.m. and she left about 6:50 a.m. to go and assist another resident to his room. She said Resident #1 had a history of heart attacks. She said he was in a Geri chair, and she checked the status by looking in her book at the nurse's station. She said the crash cart was located on hall 3, but she never sent for it. She said LVN B checked Resident #1's pulse. LVN A said when EMS arrived it was 4 or 5 EMS workers, and they asked when the last time Resident #1 was responsive. She said she told them it was about 7:10 a.m. She said she was behind the nurse's station when EMS arrived and LVN B handed Resident #1 off to EMS. LVN A said she called the ADON/RN on the way to the nurse's station to let her know what was going on. LVN A said she had been a nurse for less than a year, Resident #1 was her first medical emergency. She said ADON/RN had educated them on doing CPR no matter what. LVN A said she was not sure of the exact time frame because everything appeared to go so fast, but it was at least 5 minutes maybe 10 minutes form the time she saw the resident in the dining room until EMS arrived. During an interview on [DATE] at 8:15 a.m. the Administrator said they had completed a timeline regarding Resident #1. They had investigated the incident and taken statements from staff. She said their investigation did not determine any abuse or neglect, so they had not called the incident into the state. She said they had tried to get hospital records but were unable to do so. She said the EMS company was right down the road less than 5 minutes from the facility and they arrived almost immediately after being called. During an interview and observation on [DATE] at 8:17 a.m. LVN B said on [DATE] most residents had finished eating and had left the dining room or been taken to their rooms. She said LVN A left the dining room to take a resident back to his room. She said around 7:00 a.m. there were only two residents left in the ding room, Resident #1, and Resident #2. LVN B said at about 7:00 a.m. someone wanted her to take them out to smoke. She said when she walked outside Resident #1 was drinking his coffee. She said he had a little food on his plate. LVN B said when she came back inside after about 10 minutes, she did not really look at Resident #1. She said she had one resident to push inside, and she had the cigarette box. She said she was at the nurse's station, and she heard Kitchen Staff D yelling for her. LVN B said as she was on her way, she heard LVN A and heard both say come here. She said LVN A called for her, heard her say call 911. LVN B said she called 911 and had CNA C to hold the phone with EMS. She said when she arrived in the dining room Resident # 1 was laid back in his Geri chair, she did see a blue [NAME] to his lips. She said LVN A went to get blood pressure cup and pulse ox. LVN B said she did a sternal rub, she checked Resident #1's pulse at his wrist and neck, and he did not have a pulse. She said she was probably with the resident about 2 minutes after LVN A left. She said LVN A did not return. She said she did not initiate CPR. LVN B said she took Resident #1 to the nurse's station in his Geri chair. LVN B pointed out where the resident was in the dining room which was close to the exit door for the smokers. Observations and interview indicated it was about 100 feet across the dining room to the door and about 5 to 7 feet from the door to the nurse's station. LVN B said the whole process took 5 to 6 minutes. She said no one got the crash cart and she did not request the cart. She said when she got Resident #1 to the nurse's station EMS arrived. LVN B said EMS pulled Resident #1 out of the chair put on gurney and started doing compression right there in the hallway. She said EMS did not ask her any questions, they asked LVN A for a face sheet. LVN B said at school she was taught you did not start CPR until after you verified code status. She said she had been a nurse since [DATE], and this was her first job. She had done CPR but only on a dummy, and Resident #1 was her first code. LVN B said she was in serviced after the incident on [DATE] by ADON/RN who said you start CPR first and then check the code status. During an interview on [DATE] at 8:28 a.m. LVN A said she noted Resident #1's color was off, she did not note anything about his lips being discolored. During an interview on [DATE] at 8:30 a.m., ADON/RN said she came to the facility on [DATE] after the Resident #1 was taken to the hospital. She said she got a call from LVN A on [DATE]. She said her telephone log indicated that call was received at 7:18 a.m. and she was on the phone about two minutes with LVN A. She said when she arrived at the facility, she did in services on emergency procedures and providing CPR. ADON/ RN said she could not say that anyone did anything wrong she just felt that the staff needed education. During an interview on [DATE] at 9:00 a.m. CNA C said she worked at the facility for [AGE] years, and was at the facility on [DATE]. She said she was coming the hall brings something to the dining room. She said she heard Kitchen Staff D yell for LVN A to come to the dining room and run. CNA C said when she made it to the nurse's station LVN B was running to nurse station to call 911. She said LVN B gave the phone to her and told her what to tell dispatch. She said LVN B said they had a resident that was unresponsive, and he was in the dining room. CNA C said while she was still on the phone LVN A came to the Nurses station to see if Resident #1 was full code or DNR. She said LVN A looked on the computer. CNA C said LVN A was on her cell phone talking to ADON/RN. She said she did not know how long LVN A was at the nurse's station, she turned her back while still on the phone with EMS dispatch. She said LVN B brought Resident #1 to the nurse's station still in the Geri chair. CNA C said LVN B asked her to take him to his room while she was still on the phone. CNA C said when Resident #1 was brought to the nurse's station she did not see his color, and no one asked her to get the crash cart. She said after calling EMS they arrived about 5 minutes later. CNA C said it might have been 10 minutes form the time of Kitchen Staff D was screaming to EMS got to the facility. CNA C said LVN A was behind the nurse's station at that point. She said when EMS arrived, LVN B pointed to Resident #1 in the Geri chair. CNA C said EMS asked a few questions, they put Resident #1 on the stretcher, and initiated CPR. She said she did not write a statement; she did not see anyone taking vitals. During an interview and observation on [DATE] at 11:05 a.m. LVN A revealed a book at the nurse's station. Observation of the book showed a couple of pages dated [DATE] with full code residents on the first page and DNR residents on the second page. LVN A said they just updated the list yesterday and that was the book she used to determine if Resident #1 was a full code. She said she did not know how long she remained at the nurse's station after checking but before she could get back to the dining room, LVN B had brought Resident #1 to the nursing station. LVN A said just about that time EMS walked in. She said that she had not taken Resident #1's pulse or checked his mouth to see if there was any food or blockage. During an interview and observation on [DATE] at 11:07 a.m. with the ADON/LVN . The crash cart was located on hall 6 in a storage room. The cart had all the required supplies and on the crash cart was a list of Resident and their code status. The ADON/LVN said the list has always been on the crash cart. The ADON said the AED was located on the wall behind the nurse's station. Observation of the AED showed it was on the wall with the pads right beside it. Also, a battery check of the AED showed it was in working order. During an interview on [DATE] at 11:25 a.m. Resident #2 said she was in the dining room on the morning of [DATE]. She said Resident #1 was his usually joking self. She said they went out to smoke about 7:00 a.m. and he asked for another cup of coffee right before they left. Resident #2 said when they came back inside about ,d+[DATE] minutes later, Resident #1 was sitting in his chair and appeared to be asleep. Resident #2 said she spoke to Resident #1, but he did not speak back. She said it looked like he ate all his food, and sometimes he chokes when he eats, and he made noises in his throat when he ate. She said Kitchen Staff D went over to him and she could not get him to awaken so she started screaming. She said LVN A and LVN B came running. She heard them say something about code status, and they could not find a pulse. She said after a few minutes they took him out of the dining room. During a telephone interview on [DATE] at 11:43 a.m. Kitchen Staff D said that she and Kitchen Staff E were in the kitchen with the door closed. She said around 6:50 a.m. they went out to eat their breakfast in the dining room. She said when they first went into the dining room LVN B was there but had gone to get the smoking box for the residents. Then she took them out to smoke. Resident #1 was sitting at the table, and he looked like he was sleeping. She had gone to take him out of the dining room, she said she normally helped the aides get some of the residents out. She said when she had gone over, she could not get Resident #1 to respond, and his color was off. She called his name several times and she guessed LVN A heard her, she did not remember calling her name. Kitchen Staff D said the nurse came and told her to get LVN B. She said LVN B called 911. She did not know what happened after that she said it was 2 or three minutes and they had him up front and she knew the paramedics came and she went back into the kitchen. During a telephone interview on [DATE] at 11:50 a.m. Kitchen Staff E said she and Kitchen Staff D came out of the kitchen around 6:50 a.m. when they arrived in the dining room LVN A got up to take a resident back to their room. She said LVN B went to take the residents out to smoke. She said the whole time they ate their breakfast Resident # 1 appeared asleep. She said she left to go back in the kitchen at about 7:10 a.m. when she finished eating and Kitchen Staff D went to take Resident #1 out of the dining room. Kitchen Staff E said she did not hear any commotion and was only aware of the situation when Kitchen Staff D came back into the kitchen. During an interview on [DATE] at 2:22 p.m. the Administrator and ADON/RN were informed of the concerns about the resident choking and no CPR being provided prior to EMS arrival. They said that EMS company was right down the street, and it did not take them long to arrive at the facility, about 5 minutes. The Administrator said staff acted appropriately, they called 911. The staff did what they were supposed to do. During an interview on [DATE] at 2:55 p.m. LVN B said she did not look in Resident #1's mouth. She said when they went out to smoke, he had a little food on his plate. She said there was a spoon or two of oatmeal and a small piece of biscuit. She did not look at his plate when they returned, or the plate may have been removed. She said the resident did cough on occasion when he ate but she had never seen him choke. During an interview on [DATE] at 3:00 p.m. CNA C said Resident #1 coughed a lot it did not matter if he was eating or not. Sometimes he did cough when he was eating and cleared his throat quite a bit. She said he had done that for a long time, and it was nothing new. During an interview on [DATE] at 3:05 p.m. p.m. CNA F said Resident #1 had a deep cough that would startle you. She said he did cough when he ate occasionally. During an interview on [DATE] at 3:10 p.m. LVN A said she did not look in Resident #1's mouth on the morning of [DATE]. She had gone to get the supplies to complete his vitals. She had told EMS he had been unresponsive 5 to 10 minutes before they arrived. During a telephone interview on [DATE] at 3:15 p.m. with the DON and ADON/RN, LVN A and the Administrator was present. The DON said the nurses saw Resident #1 unresponsive and tried to arise him. She said LVN A went to the nurse's station to get supplies. She said the resident had a history of seizures and she likely thought he had a seizure. The DON said she stood behind her staff, the resident was unresponsive, and they called 911. She said that was what they were supposed to do, EMS arrived in about 5 minutes, and they did not have time to initiate CPR. The DON asked LVN A what she thought might have happened with Resident #1. LVN A said she did not know what she thought. LVN A said she was going back to the dining room to check Resident #1's blood sugars because she had not had time to do so prior to breakfast. She said when she found Resident #1 unresponsive, she did not check his blood sugar either. LVN A said it was her first code ever, and her first emergency. She said Resident #1 did have a change in the tone of his skin. She said his skin was usually a light brown but was more of a whiter tone. During an interview on [DATE] at 3:40 p.m. the DON and the Administrator said Resident #1 could have had a seizure. The Administrator said they called 911 and EMS at the facility within 6 minutes. The DON said the nurse did a sternal rub, and that was the first part of an assessment, and then they called 911. The Administrator said their timeline correlated with EMS. During an interview on [DATE] at 4:45 p.m. the ADON/RN said the book that contacted the codes had always been at the nurse's station with code status and the code status were always on the crash cart. They update them every Monday and put them in the book and on the cart. During an interview on ,d+[DATE] at 5:31 p.m. ADON/RN said regarding care plan Resident #1 wanted to be more independent and they allowed him to do so by feeding himself. When he first came to the facility he could hardly move or do anything for himself, but he gotten better. She said he did have days when he required assistance with eating. During a telephone interview on [DATE] at 4:05 p.m. an EMS worker said they were notified by dispatch on the morning of [DATE] there was a resident at the facility in cardiac arrest. The worker said the dispatch said Resident #1 was in the dining room. The EMS worker said when they arrived it was four of them that entered the facility at 7:22 a.m. and were directed to a resident sitting beside the nurse's station in a laid-back chair. They were told this was the resident in distress. The EMS worker said an assessment of Resident #1 showed him to be pulseless and they removed him from the chair and began CPR. He said the nurse told him at 7:10 a.m. Resident #1 was unresponsive. The EMS worker said there had never been a time when they had gone to a facility and nurses were just standing around not providing CPR to a resident in need. The worker said there were at least two people behind the nurse's station and one holding on to Resident #1's chair. The EMS worker said it was over 10 minutes and no CPR was being performed. The EMS worker said when they got the resident to the hospital, they found food in his airway. The facility staff said he had just eaten breakfast but gave no indication he could have choked. Record review of in service dated [DATE] was provided to the investigator on [DATE] at 8:30 a.m. indicated staff were educated on Emergency Procedure policy. Record review of facility emergency procedure/cardiopulmonary resuscitation policy last revised, [DATE]. [The policy statement indicated personnel have completed training on the initiation of CPR and basic life support, including defibrillation, for victims of sudden cardiac arrest. The chances of surviving a sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. The delivery of shock with the defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or physicians order not to administer CPR. Emergency procedures indicated if an individual is found unresponsive, briefly check for abnormal or absence of breathing. If sudden cardiac arrest is likely begin CPR. Staff member to activate the emergency response system code and dial 911. Instructed staff member to retrieve the automatic external defibrillator. Verify or instruct the staff member to verify the DNR or code status of the individual. Initiate the basic life support sequence of events, continuous CPR and basic life support until emergency medical personnel arrive.] The Administrator and were notified on [DATE] at 6:10 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on [DATE] at 6:10 p.m. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on [DATE] at 12:40 p.m. and included: [Plan of Removal: 678: Cardio-Pulmonary Resuscitation (CPR) The facility failed to fully monitor the Resident #1 while he was eating to prevent possible choking. The resident was found unresponsive by a dietary staff. The facility failed to immediately assess the resident or check for a pulse, when finding him unresponsive. They failed to initiate CPR within the first 6 to 16 minutes of finding Resident #1 unresponsive. They failed to follow the facility policy on CPR. 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #1 was noted as unresponsive in the dining room, 911 called, EMTs initiated CPR (not the facility), resident left the home with EMTs in the same condition as noted in the dining room (unresponsive). Resident #1 was later pronounced as deceased outside the nursing home. Person(s) Responsible: Charge Nurse Date: [DATE] 2. How the Facility Identified Other Possibly Effected Residents: Action: Completed a DNR and Full Code audit: Reviewed Physician orders, vs the face sheet, vs the care plan, vs the Out of Hospital DNR (if applicable) to ensure all are matching and correct. Person(s) Responsible: Director of Clinical Operations, Clinical Resource Nurse, and/or Designee Date: [DATE] Action: Audit staff CPR cards to ensure proper number of certified employees present each shift. Person(s) Responsible: Human Resources, Administrator, and/or Designee Date: [DATE] 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Ensured the crash cart has an updated list of full code and DNR residents. Person(s) Responsible: Administrator and/or Designee Date: [DATE] Action: The facility will be updating their CPR policy to take out: If the resident's DNR status is unclear, CPR will be initiated per the below procedure until it is determined that there is a DNR or a physician's order not to administer CPR. The facility will be updating their CPR policy to now reflect: If the staff assigned to check the resident's code status is unable to verify if the resident is a Full Code or DNR, CPR will be initiated, per the procedure lined out below, until it is determined that there is a DNR in place, a physician's order to stop CPR, and/or the Emergency Medical Technician/Paramedics take control of the event. Person(s) Responsible: Chief Nursing Officer Date: [DATE] Action: Administrator and Director of Nursing educated regarding the Emergency Management Code Procedure Policy and meal supervision expectations by the Director of Regulatory Compliance and meal service supervision (training the trainer). All Nurses educated regarding Emergency Management Code Procedure Policy (Updated on [DATE]) to include the following, in which would be the response in an emergency situation for a full code resident requiring CPR: 1. If an individual is found unresponsive, the nurse to first arrive to the resident will briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: The first responding nurse will- Instruct a staff member to activate the emergency response system (code) and call 911. The first responding nurse will- Instruct a staff member to retrieve the automatic external defibrillator. The first responding nurse will- Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic lif [TRUNCATED]

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 2 of 10 residents (Resident #1 and Resident #2) reviewed for abuse. 1. The facility failed to ensure [NAME] B, DA C, and MA D immediately reported witnessed abuse towards Resident #1 to the abuse coordinator. 2. The facility failed to ensure Resident #1, and Resident #2 was free from abuse per the policy. 3. The facility failed to ensure the abuse coordinator obtained in writing or electronic format witness statements from [NAME] B, DA C, and MA D. 4. The facility failed to ensure, per their policy, to report alleged allegation of abuse towards Resident #2 to HHSC. The noncompliance was identified as PNC. The IJ began on 12/10/2023 and ended on 12/15/2023. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse. Findings included: Record review of a facility's Abuse Prevention Program policy, revised 01/09/23, indicated .the administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures .our residents have the right to be free from abuse, neglect .our center will not condone any form of resident abuse or neglect .to aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor and to the Abuse Prevention Coordinator immediately .all reports of resident abuse .shall be promptly reported to local, state and federal agencies (as defined by current allegations) and thoroughly investigated by Center management .as part of the resident abuse prevention program, the administration will .develop and implement policies and procedures to aid our Center in preventing abuse, neglect, or mistreatment of our residents .identify and assess all possible incidents of abuse .implement measures to address factors that may lead to abusive situations .investigate and report any abuse within timeframes as required by federal requirements .the administrator will ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented .witness reports will be obtained in writing or in electronic format .the investigator will obtain a statement . Record review of a facility's Reporting Allegations of Abuse, neglect, and Exploitation policy revised 10/2023 indicated .it is the policy of the facility to report to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within all prescribed timeframes all allegations of abuse/neglect/exploitation or mistreatment .the facility will develop and operationalize policies and procedures for screening and training of employees on the topics of protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment .prevention .the facility will identify, correct, and intervene in situations in which abuse, neglect .the facility will identify events, occurrences, patterns, and trends that may constitute .abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can included staff to resident abuse .instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse .verbal abuse means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .mistreatment: inappropriate treatment or exploitation of a resident .alleged violation: a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified , could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse .investigation .the facility will investigate all allegation and type of incidents .reporting/response: the facility will report all alleged violations and all substantiated incidents to the state agency .any owner, operator, manager, agent, or contracture of the facility can report an allegation of abuse/neglect .when suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated .the licensed nurse will .remove the accused employee from resident care areas .notify the Administrator or designee .the Administrator or designee will .notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident .obtain statements from direct care staff . 1. Record review of Resident #1's face sheet, dated 07/08/24, indicated Resident #1 was a [AGE] year-old, male admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), mood affective disorder (is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature), and mild cognitive impairment (is the stage between the expected decline in memory and thinking that happens with age and the more serious decline of dementia). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood and sometimes had the ability to understand others. Resident #1 had minimal difficult hearing, clear speech, and adequate vision. Resident #1 had a BIMS score of 03 which indicated severe cognitive impairment. Resident #1 required supervision for ADL assistance except for shower/bathe self which required maximal assistance. Record review of Resident #1's care plan dated 04/19/23 indicated Resident #1 was at risk for altered psychosocial well-being related to dementia. Intervention included listen carefully and be non-judgmental. Record review of a PIR for Resident #1, dated 12/11/23, indicated .on 12/10/23 at 3:00 p.m.LVN A used foul language and threw ice at a resident .LVN A denied .Cook B and Dietary Aide C reported to me [ADM], that they were standing at the nurses station and witnessed resident [Resident #1] come up to the nurses station and LVN A told him to 'stop fucking looking at me and go on' and threw a piece of ice at him .MA D stated that she heard LVN A say 'stop fucking looking at me and go on' but she did not see her throw ice at him [Resident #1] .LVN A was questioned about it, she denied saying anything to him but stated she and Resident #1 were playing and throwing ice at each other .the administrator visited Resident #1 who did not remember any incident .staff interviews indicated that many staff have witnessed LVN A speak rudely or harshly to the residents and often curse or speaks inappropriately to the staff .Resident safe surveys did not indicate any concerns with LVN A .physician and RP for Resident #1 notified of the incident .investigation findings: unconfirmed .Provider action taken post-investigation: staff reeducated on Abuse and Neglect Prevention and reporting, Professionalism, and Resident Rights .5 random staff interviews and resident safe surveys will be conducted monthly and results will be reviewed by QAPI committee monthly for 3 months . The PIR did not indicate an incident between LVN A and Resident #2. 2. Record review of Resident #2's face sheet, dated 07/08/24, indicated Resident #2 was a [AGE] year-old, male admitted on [DATE] and discharge 06/19/24 with diagnoses including anxiety disorder (persistent and excessive worry that interferes with daily activities), Type 2 diabetes (s a chronic condition that happens when you have persistently high blood sugar levels), nicotine dependence, schizoaffective disorder, bipolar type (is a chronic mental health condition characterized primarily by symptoms of schizophrenia (is a serious mental health condition that affects how people think, feel and behave), such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), and restlessness and agitation. Record review of Resident #2's annual MDS assessment dated [DATE], indicated Resident #2 was usually understood and usually understood others. Resident #2 had moderate difficulty hearing, clear speech, and impaired vision with use of corrective lenses. Resident #2 had a BIMS of 09, which indicated moderate cognitive impairment. Resident #2 required set up assistance for eating, dressing, and personal hygiene, supervision assistance for oral and toilet hygiene and partial assistance for shower/bathe self. Record review of Resident #2's care plan dated 06/12/23, indicated: *Resident #2 was at risk for altered psychosocial well-being related to schizoaffective disorder. Intervention included listen carefully and be non-judgmental. *Resident #2 was at risk for altered mood state related to schizoaffective disorder. Resident #2 pace the halls frequently, visit multiple staff members, frequently in/out of office. Resident #2 am easily agitated, yell loudly, make threatening statements to staff and/or residents. Intervention included be reassuring and listen to concerns. During an interview on 07/09/24 at 9:29 a.m., CNA E said she had worked at the facility for [AGE] years. She said she had witnessed LVN A being loud to resident but had only heard about LVN A using inappropriate language at residents. She said LVN A would escalate situations with Resident #2. She said she heard LVN A had cussed at Resident #1 and Resident #2. She said cussing and throwing things at resident was abuse. She said LVN A talked ugly, and, in a way, she would not want her family members spoken to. She said after LVN A and Resident #2 would get into, Resident #2 would talk aloud to himself and stated he did not like LVN A. She said she thought LVN A had been coached about her conduct with staff and resident before Resident #1's incident. She said if she witnessed or heard abuse toward a resident, she would report it to the ADM immediately. She said she received quarterly abuse prevention training. She said it was important to report abuse to the abuse coordinator immediately so the issue could be taken care of. She said reporting also stopped the abuse from happening. She said not reporting abuse allegations placed resident at risk to getting hurt or harmed. During an interview on 07/09/24 at 10:52 a.m., MA D said she worked for the facility for 2 years. She said she worked the day LVN A cussed at Resident #1. She said Resident #1 said or did something at the nursing station where LVN A was sitting. She said LVN A threw ice at Resident #1 and used the F word towards him. She said Resident #1 liked to touch people and grab drinks so maybe he did something to set her off. She said Resident #1 was walking away from LVN A and she threw ice at him. She said LVN behavior was abusive and inappropriate. She said she did not report the incident between Resident #1 and LVN A. She said she did not have the ADM phone number in her phone, but her number was posted in the sign in book. She said the next day after the incident, the ADM questioned her. She said it was important to report abuse immediately to the ADM so she could report it the state. She said if abuse was not reported immediately, resident could get hurt and situations could escalate. She said Resident #2 was at the nursing station and was asking LVN A to take him out to smoke. She said LVN A and Resident #2 exchanged words because she did not take him out. She said LVN A had made a sign on a posted note that said, get the fuck away or go away, leave me alone and would put it up when Resident #2 came to the nurses' station. She said about the second time Resident #2 came to the nurses' station, LVN A cussed at him and threw the posted note at him. She said Resident #2 walked away and was upset. She said another staff member took him out to smoke. She said this incident happened around the same time of Resident #1's incident. She said LVN A escalate situation especially with Resident #2. She said using foul language at a resident was abusive. She said she immediately reported the incident with Resident #2 and LVN A. She said the situation was getting out of control between LVN A and Resident #2. She said she called the ADM on her phone and told her what was going on. She said the ADM eventually showed up at the facility to handle the situation. During an interview on 07/09/24 at 11:15 a.m., the ADM said LVN A and Resident #1 incident happened on a Sunday. She said on Monday, [NAME] B and DA C told her Resident #1 walked up to the nurses' station and LVN A cussed at him and threw something at him. She said LVN A may have also called him a wierdo. She said [NAME] B and DA C said the situation bothered them, so they reported it. She said LVN A denied the event happened. She said LVN A was suspended pending investigation. She said she interviewed staff and resident about LVN A. She said the staff interviews revealed some concerns about LVN A. She said LVN A was terminated 3-4 days later after completion of the investigation. She said she believed the incident with LVN A and Resident #2 happened the same day as Resident #1's incident with LVN A. She said she recalled being told LVN A held up a sign at Resident #2 but did not remember anything else about foul language being used between them. She said in December 2023, she did not believe it was stated in the facility's policy to obtain witness statements. She said in March 2024, the corporation provided reeducation on self-reports and recommended obtaining witness statements. She said it was important to obtain witness statements to get accurate information. She said witness statements were part of the investigation and made it more thorough. She said witness statements were not obtained stories could change. She said not obtaining witness statements could make the investigation not thorough. She said the incident between LVN A and Resident #1 was the first incident involving LVN A and a resident. She said LVN A had a history bullying staff members but not residents. She said general in-services on professionalism and conduct was provided to LVN A. She said LVN A did have one on one counseling for complaint from staff on her attitude and bullying. She said she expected her staff to report allegation of abuse immediately. She said her information to contact her was posted in the posting cabinet, in the hallway, and at the nurses' station. She said the facility had provided in-person training on abuse prevention and reporting to staff. She said not reporting abuse risked the abuse continuing. During an interview on 07/09/24 at 1:45 p.m., [NAME] B said Resident #1 was at the nurses' station and LVN A told Resident #1 go the fuck away and threw ice at him. She said Resident #1 did say anything because he was not very verbal, but he was visibly upset by his facial expression. She said Resident #1 walked away from the nurses' station away from LVN A. She said she considered what LVN A did to Resident #1 was verbal abuse. She said she did not report the incident between LVN A and Resident #1 until the next day. She said she got busy the day of the incident because she had to do her job and forgot. She said she should have reported the incident between LVN A and Resident #1 immediately and received a verbal coaching for not reporting. She said it was important to report to the ADM immediately, so she could deal with it right then. She said if abuse was not reported, it could keep happening. During an interview on 07/09/24 at 4:15 p.m., DA C said LVN threw ice and said get the fuck away from me to Resident #1. She said Resident #1 looked upset like anyone else would if they got ice thrown at them. She said she did not have the ADM phone number the day of the incident which was why she did not report it immediately. She said she did not know the ADM phone number was at the nurses' station in the sign in book. She said she knew the incident should have been reported to the ADM immediately. She said she did get a verbal corrective coaching for not reporting. During an interview on 07/10/24 at 9:02 a.m., the Housekeeping/Laundry Supervisor F said she had witnessed, on one occasion, LVN A being rude to Resident #2 at the nurses' station. She said LVN was just rude but did not use foul language towards him. She said Resident #2 was mad after the incident and went into his room. She said when she heard how she was talking to Resident #2, she told her to stop being rude. She said she did not tell the DON or ADM about the incident. She said she felt the incident was inappropriate but not abuse. She said she knew to report abuse to the ADM as soon as possible. She said it should be reported because the abuse should not be happening. She said she would not want to be treated the LVN A treated Resident #2. She said abuse could keep happening if not immediately reported. She said she had received training on abuse, neglect, and exploitation. During an interview on 07/10/24 at 11:50 a.m., the ADM said she was the abuse coordinator, and it was her responsibility to investigate and report allegations of abuse to the State. She said she had to report abuse allegation within 2 hours. She said reporting and investigating protected the resident. She said not reporting placed resident at risk for abuse. Record review of LVN A's annual training dated 06/01/23 indicated training on subjects of resident rights and abuse and neglect. Record review of a facility conducted in-service, Abuse Prevention Program dated 12/11/23 reflected all employees were provided education of the topic. Record review of a facility conducted in-service, Reporting Allegations of Abuse, Neglect, and Exploitation dated 12/11/23 reflected all employees were provided education of the topic. Record review of a facility conducted in-service, Resident Rights dated 12/11/23 reflected all employees were provided education of the topic. Record review of 13 resident safe surveys dated 12/12/23-12/14/23 indicated no resident had a staff member curse at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. Record review of 29 staff interviews dated 12/12/23-12/14/23 indicated some staff members witnessed LVN A said or did something inappropriate to a resident, they did know what the resident rights were, knew who was considered a mandated reporter, knew who to report abuse to, and was comfortable reporting abuse. Record review of LVN A's Employee Corrective Action Form dated 12/15/23, indicated .type of action: termination .Category I Offense, inappropriate conduct towards a resident .Code of Conduct, Attitude, and Behavior- Policy Violation .Employees are expected and required to be kind, and considerate of residents, visitors, and other facility personnel. Any behavior that is deemed offensive or unsafe. Using profanity, abusive, or suggestive language, or gestures .date of violation 12/10/23 .incident: on, December 11, 2023, it was reported that LVN A used abusive language towards a resident, in which, led to the throwing of a solid object towards the resident .after speaking with all parties involved, we have confirmed these actions .LVN A has received several in-services regarding abuse and neglect among residents, in which, LVN A understands the appropriate conduct when managing residents .consequences: due to category I offense, LVN A will be subjective to immediate termination of employment .employee's comments: the ADM and DON attempted to call LVN A multiple times on 12/15/23 and left message to return call. LVN A texted and stated, 'if I'm fired just let me know so I can find another job'. This ADM responded with 'after we concluded the investigation and spoke to HR, we've decided to terminate your employment.' LVN A did not respond .DON 12/15/23 .ADM 12/15/23 . Record review of LVN A's Notice of Termination dated 12/18/23, indicated .LVN A .termination date 12/18/23 .reason of termination: abusive language toward resident .is employee eligible for rehire: No . Record review of LVN A's personnel file on 07/09/24 indicated hire date of 10/18/22. The facility had performed background check and employee misconduct search. No concerns were identified. Record review of a facility's Abuse Prevention policy revised 01/09/23 indicated .our residents have the right to be free from abuse, neglect .this includes but is not limited to .verbal, mental, sexual, or physical abuse . Record review of 5 Random Interviews of Staff and Residents, dated 01/23/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. One resident revealed LVN A had cursed at him or another resident. All other resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. Record review of 5 Random Interviews of Staff and Residents, dated 02/22/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. Record review of 5 Random Interviews of Staff and Residents, dated 03/25/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. The administrator was notified of IJ PNC on 07/09/2024 at 4:40 p.m. due to the above failures. The administrator was provided with the IJ template on 07/09/2024 at 4:45 p.m. The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy on 12/15/23 by: - Reviewed completed facility self-reported incident to HHSC for Resident #1 which indicated the following: * dated 12/11/23, indicated .on 12/10/23 at 3:00 p.m .LVN A used foul language and threw ice at a resident .LVN A denied .Cook B and Dietary Aide C reported to me [ADM], that they were standing at the nurses station and witnessed resident [Resident #1] come up to the nurses station and LVN A told him to 'stop fucking looking at me and go on' and threw a piece of ice at him .MA D stated that she heard LVN A say 'stop fucking looking at me and go on' but she did not see her throw ice at him [Resident #1] .LVN A was questioned about it, she denied saying anything to him but stated she and Resident #1 were playing and throwing ice at each other .the administrator visited Resident #1 who did not remember any incident .staff interviews indicated that many staff have witnessed LVN A speak rudely or harshly to the residents and often curse or speaks inappropriately to the staff . - Reviewed paperwork indicating LVN A was suspended until completion of investigation which indicated the following: * dated 12/15/23, indicated .type of action: termination .Category I Offense, inappropriate conduct towards a resident .Code of Conduct, Attitude, and Behavior- Policy Violation .Employees are expected and required to be kind, and considerate of residents, visitors, and other facility personnel. Any behavior that is deemed offensive or unsafe. Using profanity, abusive, or suggestive language, or gestures .date of violation 12/10/23 .incident: on, December 11, 2023, it was reported that LVN A used abusive language towards a resident, in which, led to the throwing of a solid object towards the resident .after speaking with all parties involved, we have confirmed these actions .LVN A has received several in-services regarding abuse and neglect among residents, in which, LVN A understands the appropriate conduct when managing residents .consequences: due to category I offense, LVN A will be subjective to immediate termination of employment .employee's comments: the ADM and DON attempted to call LVN A multiple times on 12/15/23 and left message to return call. LVN A texted and stated, 'if I'm fired just let me know so I can find another job'. This ADM responded with 'after we concluded the investigation and spoke to HR, we've decided to terminate your employment.' LVN A did not respond .DON 12/15/23 .ADM 12/15/23 . - Reviewed termination paperwork for LVN A which indicated the following: *dated 12/18/23, indicated .LVN A .termination date 12/18/23 .reason of termination: abusive language toward resident .is employee eligible for rehire: No . - Reviewed LVN A's time sheet to verify last day worked which indicated the following: * dated 12/01/23-12/31/23, indicated LVN A last day worked was 12/10/23 - Reviewed employee corrective action form for [NAME] B, DA C and MA D which indicated the following: *dated 12/11/23, indicated .Employee Corrective Action Form for [NAME] B C .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur .Cook B .ADM . * dated 12/11/23, indicated .Employee Corrective Action Form for DA C .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur .DA C .ADM . * dated 12/11/23, indicated .Employee Corrective Action Form for MA D .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur . - Reviewed in-service and sign in sheet on Abuse Prevention for all staff which indicated the following: * dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed in-service and sign in sheet on Reporting Abuse Allegation for all staff which indicated the following: *dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed in-service and sign in sheet on Resident Rights for all staff which indicated the following: * dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed completion of notification of RP which indicated the following: *dated 12/15/23, the PIR, reflected responsible party for Resident #1 was notified of incident - Reviewed completion of notifying physician of incident which indicated the following: * dated 12/11/23, the PIR, reflected the physician was notified of the incident involving Resident #1. - Reviewed staff surveys results concerning LVN A which indicated the following: * dated 12/12/23-12/14/23 indicated some staff members witnessed LVN A said or did something inappropriate to a resident, they did know what the resident rights were, knew who was considered a mandated reporter, knew who to report abuse to, and was comfortable reporting abuse. - Reviewed resident safe surveys conducted after incident which indicated the following: * dated 12/12/23-12/14/23 indicated no resident had a staff member curse at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. - Reviewed 5 random staff and resident safe surveys conducted monthly x 3 months for QAPI which indicted the following: dated 01/23/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. One resident revealed LVN A had cursed at him or another resident. All other resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. * dated 02/22/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. * dated 03/25/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. The noncompliance was identified as PNC. The IJ began on 12/10/2023 and ended on 12/15/2023. The facility had corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 10 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to prevent LVN A, on 12/10/23, from verbally and physically abusing Resident #1 when she used foul language and threw ice at Resident #1. The facility failed to prevent LVN A, on or about 12/10/23, from verbally and physically abusing Resident #2 when she used foul language and threw an object at Resident #2. The noncompliance was identified as PNC. The IJ began on 12/10/2023 and ended on 12/15/2023. The facility had corrected the noncompliance before the survey began. These failures could place resident at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: 1.Record review of Resident #1's face sheet, dated 07/08/24, indicated Resident #1 was a [AGE] year-old, male admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), mood affective disorder (is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature), and mild cognitive impairment (is the stage between the expected decline in memory and thinking that happens with age and the more serious decline of dementia). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood and sometimes had the ability to understand others. Resident #1 had minimal difficult hearing, clear speech, and adequate vision. Resident #1 had a BIMS score of 03 which indicated severe cognitive impairment. Resident #1 required supervision for ADL assistance except for shower/bathe self which required maximal assistance. Record review of Resident #1's care plan dated 04/19/23 indicated Resident #1 was at risk for altered psychosocial well-being related to dementia. Intervention included listen carefully and be non-judgmental. Record review of a PIR for Resident #1, dated 12/11/23, indicated .on 12/10/23 at 3:00 p.m .LVN A used foul language and threw ice at a resident .LVN A denied .Cook B and Dietary Aide C reported to me [ADM], that they were standing at the nurses station and witnessed resident [Resident #1] come up to the nurses station and LVN A told him to 'stop fucking looking at me and go on' and threw a piece of ice at him .MA D stated that she heard LVN A say 'stop fucking looking at me and go on' but she did not see her throw ice at him [Resident #1] .LVN A was questioned about it, she denied saying anything to him but stated she and Resident #1 were playing and throwing ice at each other .the administrator visited Resident #1 who did not remember any incident .staff interviews indicated that many staff have witnessed LVN A speak rudely or harshly to the residents and often curse or speaks inappropriately to the staff .Resident safe surveys did not indicate any concerns with LVN A .physician and RP for Resident #1 notified of the incident .investigation findings: unconfirmed .Provider action taken post-investigation: staff reeducated on Abuse and Neglect Prevention and reporting, Professionalism, and Resident Rights .5 random staff interviews and resident safe surveys will be conducted monthly and results will be reviewed by QAPI committee monthly for 3 months . 2. Record review of Resident #2's face sheet, dated 07/08/24, indicated Resident #2 was a [AGE] year-old, male admitted on [DATE] and discharge 06/19/24 with diagnoses including anxiety disorder (persistent and excessive worry that interferes with daily activities), Type 2 diabetes (s a chronic condition that happens when you have persistently high blood sugar levels), nicotine dependence, schizoaffective disorder, bipolar type (is a chronic mental health condition characterized primarily by symptoms of schizophrenia (is a serious mental health condition that affects how people think, feel and behave), such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), and restlessness and agitation. Record review of Resident #2's annual MDS assessment dated [DATE], indicated Resident #2 was usually understood and usually understood others. Resident #2 had moderate difficulty hearing, clear speech, and impaired vision with use of corrective lenses. Resident #2 had a BIMS of 09, which indicated moderate cognitive impairment. Resident #2 required set up assistance for eating, dressing, and personal hygiene, supervision assistance for oral and toilet hygiene and partial assistance for shower/bathe self. Record review of Resident #2's care plan dated 06/12/23, indicated: *Resident #2 was at risk for altered psychosocial well-being related to schizoaffective disorder. Intervention included listen carefully and be non-judgmental. *Resident #2 was at risk for altered mood state related to schizoaffective disorder. Resident #2 pace the halls frequently, visit multiple staff members, frequently in/out of office. Resident #2 am easily agitated, yell loudly, make threatening statements to staff and/or residents. Intervention included be reassuring and listen to concerns. During an interview on 07/09/24 at 9:29 a.m., CNA E said she had worked at the facility for [AGE] years. She said she had witnessed LVN A being loud and heard LVN A used inappropriate language at residents. She said LVN A would escalate situations with Resident #2. She said she heard LVN A had cussed at Resident #1 and Resident #2. She said she did not work the day of LVN A and Resident #1 incident. She said cussing and throwing things at resident was abuse. She said LVN A talked ugly, and, in a way, she would not want her family members spoken to. She said after LVN A and Resident #2 would get into, Resident #2 would talk aloud to himself and stated he did not like LVN A. During an interview on 07/09/24 at 10:52 a.m., MA D said she worked for the facility for 2 years. She said she worked the day LVN A cussed at Resident #1. She said Resident #1 said or did something at the nursing station where LVN A was sitting. She said LVN A threw ice at Resident #1 and used the F word towards him. She said Resident #1 liked to touch people and grab drinks so maybe he did something to set her off. She said Resident #1 was walking away from LVN A and she threw ice at him. She said LVN behavior was abusive and inappropriate. She said Resident #2 was at the nursing station and was asking LVN A to take him out to smoke. She said LVN A and Resident #2 exchanged words because she did not take him out. She said LVN A had made a sign on a posted note that said, get the fuck away or go away, leave me alone and would put it up when Resident #2 came to the nurses' station. She said about the second time Resident #2 came to the nurses' station, LVN A cussed at him and threw the posted note at him. She said Resident #2 walked away and was upset. She said another staff member took him out to smoke. She said this incident happened around the same time of Resident #1's incident. She said LVN A escalate situation especially with Resident #2. She said using foul language at resident was abusive. During an interview on 07/09/24 at 11:15 a.m., the ADM said the incident with LVN A and Resident #1 happened on a Sunday. She said on Monday, [NAME] B and DA C told her Resident #1 walked up to the nurses' station and LVN A cussed at him and threw something at him. She said LVN A may have also called him a wierdo. She said [NAME] B and DA C said the situation bothered them, so they reported it, the next day. She said LVN A denied the event happened. She said she believed the incident with LVN A and Resident #2 happened the same day as Resident #1's incident with LVN A. She said she recalled being told LVN A held up a sign at Resident #2 but did not remember anything else about foul language being used between them. On 07/09/24 at 1:10 p.m., called LVN A and left message. LVN A did not return call before or after exit. During an interview on 07/09/24 at 1:45 p.m., [NAME] B said Resident #1 was at the nurses' station and LVN A told Resident #1 go the fuck away and threw ice at him. She said Resident #1 did say anything because he was not very verbal, but he was visibly upset by his facial expression. She said Resident #1 walked away from the nurses' station away from LVN A. She said she considered what LVN A did to Resident #1 was verbal abuse. During an interview on 07/09/24 at 4:15 p.m., DA C said LVN A threw ice and said get the fuck away from me to Resident #1. She said Resident #1 looked upset like anyone else would if they got ice thrown at them. During an interview on 07/10/24 at 11:50 a.m., the ADM said she recalled MA D telling her LVN A was on a roll that day and LVN A had a sign telling Resident #2 to go away. She said LVN A egged Resident #2 on all the time. She said if LVN A threw something at Resident #2, she was surprised Resident #2 did not attack LVN A. She said maybe she misinterpreted the situation when MA D told her about LVN A and Resident #2. She said maybe she thought MA D was talking about LVN A and Resident #1's incident. She said she was the abuse coordinator, and it was her responsibility to investigate and report allegations of abuse to the State. Record review of LVN A's annual training dated 06/01/23 indicated training on subjects of resident rights and abuse and neglect. Record review of a facility conducted in-service, Abuse Prevention Program dated 12/11/23 reflected all employees were provided education of the topic. Record review of a facility conducted in-service, Reporting Allegations of Abuse, Neglect, and Exploitation dated 12/11/23 reflected all employees were provided education of the topic. Record review of a facility conducted in-service, Resident Rights dated 12/11/23 reflected all employees were provided education of the topic. Record review of 13 resident safe surveys dated 12/12/23-12/14/23 indicated no resident had a staff member curse at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. Record review of 29 staff interviews dated 12/12/23-12/14/23 indicated some staff members witnessed LVN A said or did something inappropriate to a resident, they did know what the resident rights were, knew who was considered a mandated reporter, knew who to report abuse to, and was comfortable reporting abuse. Record review of LVN A's Employee Corrective Action Form dated 12/15/23, indicated .type of action: termination .Category I Offense, inappropriate conduct towards a resident .Code of Conduct, Attitude, and Behavior- Policy Violation .Employees are expected and required to be kind, and considerate of residents, visitors, and other facility personnel. Any behavior that is deemed offensive or unsafe. Using profanity, abusive, or suggestive language, or gestures .date of violation 12/10/23 .incident: on, December 11, 2023, it was reported that LVN A used abusive language towards a resident, in which, led to the throwing of a solid object towards the resident .after speaking with all parties involved, we have confirmed these actions .LVN A has received several in-services regarding abuse and neglect among residents, in which, LVN A understands the appropriate conduct when managing residents .consequences: due to category I offense, LVN A will be subjective to immediate termination of employment .employee's comments: the ADM and DON attempted to call LVN A multiple times on 12/15/23 and left message to return call. LVN A texted and stated, 'if I'm fired just let me know so I can find another job'. This ADM responded with 'after we concluded the investigation and spoke to HR, we've decided to terminate your employment.' LVN A did not respond .DON 12/15/23 .ADM 12/15/23 . Record review of LVN A's Notice of Termination dated 12/18/23, indicated .LVN A .termination date 12/18/23 .reason of termination: abusive language toward resident .is employee eligible for rehire: No . Record review of LVN A's personnel file indicated hire date of 10/18/22. The facility had performed background check and employee misconduct search. No concerns were identified. Record review of a facility's Abuse Prevention policy revised 01/09/23 indicated .our residents have the right to be free from abuse, neglect .this includes but is not limited to .verbal, mental, sexual, or physical abuse . The administrator was notified of PNC IJ on 07/09/2024 at 4:40 p.m. due to the above failures. The administrator was provided with the IJ template on 07/09/2024 at 4:45 p.m. The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy on (12/15/23) by: - Reviewed completed facility self-reported incident to HHSC for Resident #1 which indicated the following: * dated 12/11/23, indicated .on 12/10/23 at 3:00 p.m .LVN A used foul language and threw ice at a resident .LVN A denied .Cook B and Dietary Aide C reported to me [ADM], that they were standing at the nurses station and witnessed resident [Resident #1] come up to the nurses station and LVN A told him to 'stop fucking looking at me and go on' and threw a piece of ice at him .MA D stated that she heard LVN A say 'stop fucking looking at me and go on' but she did not see her throw ice at him [Resident #1] .LVN A was questioned about it, she denied saying anything to him but stated she and Resident #1 were playing and throwing ice at each other .the administrator visited Resident #1 who did not remember any incident .staff interviews indicated that many staff have witnessed LVN A speak rudely or harshly to the residents and often curse or speaks inappropriately to the staff . - Reviewed paperwork indicating LVN A was suspended until completion of investigation which indicated the following: * dated 12/15/23, indicated .type of action: termination .Category I Offense, inappropriate conduct towards a resident .Code of Conduct, Attitude, and Behavior- Policy Violation .Employees are expected and required to be kind, and considerate of residents, visitors, and other facility personnel. Any behavior that is deemed offensive or unsafe. Using profanity, abusive, or suggestive language, or gestures .date of violation 12/10/23 .incident: on, December 11, 2023, it was reported that LVN A used abusive language towards a resident, in which, led to the throwing of a solid object towards the resident .after speaking with all parties involved, we have confirmed these actions .LVN A has received several in-services regarding abuse and neglect among residents, in which, LVN A understands the appropriate conduct when managing residents .consequences: due to category I offense, LVN A will be subjective to immediate termination of employment .employee's comments: the ADM and DON attempted to call LVN A multiple times on 12/15/23 and left message to return call. LVN A texted and stated, 'if I'm fired just let me know so I can find another job'. This ADM responded with 'after we concluded the investigation and spoke to HR, we've decided to terminate your employment.' LVN A did not respond .DON 12/15/23 .ADM 12/15/23 . - Reviewed termination paperwork for LVN A which indicated the following: *dated 12/18/23, indicated .LVN A .termination date 12/18/23 .reason of termination: abusive language toward resident .is employee eligible for rehire: No . - Reviewed LVN A's time sheet to verify last day worked which indicated the following: * dated 12/01/23-12/31/23, indicated LVN A last day worked was 12/10/23 - Reviewed employee corrective action form for [NAME] B, DA C and MA D which indicated the following: *dated 12/11/23, indicated .Employee Corrective Action Form for [NAME] B C .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur .Cook B .ADM . * dated 12/11/23, indicated .Employee Corrective Action Form for DA C .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur .DA C .ADM . * dated 12/11/23, indicated .Employee Corrective Action Form for MA D .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur . - Reviewed in-service and sign in sheet on Abuse Prevention for all staff which indicated the following: * dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed in-service and sign in sheet on Reporting Abuse Allegation for all staff which indicated the following: *dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed in-service and sign in sheet on Resident Rights for all staff which indicated the following: * dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed completion of notification of RP which indicated the following: *dated 12/15/23, the PIR, reflected responsible party for Resident #1 was notified of incident - Reviewed completion of notifying physician of incident which indicated the following: * dated 12/11/23, the PIR, reflected the physician was notified of the incident involving Resident #1. - Reviewed staff surveys results concerning LVN A which indicated the following: * dated 12/12/23-12/14/23 indicated some staff members witnessed LVN A said or did something inappropriate to a resident, they did know what the resident rights were, knew who was considered a mandated reporter, knew who to report abuse to, and was comfortable reporting abuse. - Reviewed resident safe surveys conducted after incident which indicated the following: * dated 12/12/23-12/14/23 indicated no resident had a staff member curse at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. - Reviewed 5 random staff and resident safe surveys conducted monthly x 3 months for QAPI which indicted the following: dated 01/23/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. One resident revealed LVN A had cursed at him or another resident. All other resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. * dated 02/22/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. * dated 03/25/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. The noncompliance was identified as PNC. The IJ began on 12/10/2023 and ended on 12/15/2023. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #160) reviewed for pressure injury. The facility failed to reposition Resident #160. The facility failed to have a low air loss mattress (is a mattress designed to prevent and treat pressure wounds) on admission for Resident #160. The facility failed to follow up on nutritional labs (albumin (is protein in your blood plasma) and total protein (test measures the sum of all types of proteins in the blood. Proteins are fundamental to the functioning of the body)) results for Resident #160. The facility failed to ensure Resident #160 did not have a wound infection. These failures could place residents at risk for deterioration of wound and untreated wound infection. Findings included: Record review of a face sheet dated 06/26/23 indicated Resident #160 was a [AGE] year-old male admitted on [DATE] with diagnoses including pressure ulcer of sacral region, stage 4 (The wound penetrates all three layers of skin, exposing muscles, tendons, and bones in your musculoskeletal system), pain, Type 2 diabetes mellitus (is a disease in which your blood glucose, or blood sugar, levels are too high), nicotine dependence (is an addiction to tobacco products caused by the drug nicotine), congestive heart failure (the heart muscle doesn't pump blood as well as it should), and peripheral vascular disease (is an accumulation of plaque (fats and cholesterol) in the arteries in your legs or arms). The face sheet indicated Resident #160 was admitted from a skilled nursing facility. Record review of the previous facility consolidated physician order dated 06/16/23 indicated Resident #160 had a wound culture lab, once. Record review of the consolidated physician order dated 06/16/23 indicated Resident #160 was admitted to the facility under the care of MD Q with primary admitting diagnosis: Pressure ulcer of sacral region, stage 4. The consolidated physician order dated 06/16/23 indicated pressure reducing mattress (redistribute a patient's weight so as to relieve pressure points) to bed. Record review of the consolidated physician order dated 06/20/23 indicated Resident #160 may have air loss mattress with alternating pressure. Record review of the MDS revealed Resident #160 was admitted to the facility less than 21 days ago. No MDS for Resident #160 was completed prior to exit. Record review of a baseline care plan dated 06/16/23, edited on 06/23/23 indicated Resident #160 had a pressure ulcer of sacral region, stage 4 and was at risk for worsening of wound. Interventions included low air loss mattress with alternating pressure and turn and reposition frequently throughout the shift. Record review of a baseline care plan dated 06/16/23, created on 06/20/23 indicated Resident #160 required dependent assistance for toileting, dressing, and mobility. Record review of a baseline care plan dated 06/16/23, created on 06/20/23 indicated Resident #160 had an infection of the wound. Interventions included receive medications as ordered, be observed or report any worsening signs or symptoms of infection to my caregivers and physician/NP and contact isolation (that everyone coming into a patient's room is asked to wear a gown and gloves) and standard precautions (the basic level of infection control that should be used in the care of all patients all of the time) to prevent transmission as appropriate. Record review of a progress note dated 06/16/23 at 1:55 p.m., by ADON B indicated .Resident #160 admitted with stage 4 pressure ulcer to sacrum 12.5x12xUTD (Length x Width x Depth) . Record review of a progress note dated 06/18/23 at 2:08 p.m., by RN L indicated .Resident #160 being monitored for an active infection .standard precaution and contact precaution .sacral region infection .purulent discharge or drainage from wound . Record review of a progress note dated 06/19/23 at 11:43 a.m., by ADON B indicated .Resident #160 admitted with stage 4 pressure ulcer to sacrum 12.5x12.2xUTD . Record review of a progress note dated 06/19/23 at 12:26 a.m., by LVN R indicated .Resident #160 being monitored for an active infection .standard precaution and contact precaution .sacral region infection .purulent discharge or drainage from wound . Record review of a progress note dated 06/20/23 at 4:13 p.m., by ADON B indicated .sacrum pressure ulcer IV 14.5x9x2cm .low air loss mattress alternating pressure ordered by this nurse to be delivered today . Record review of a progress note dated 06/22/23 at 4:13 p.m., by ADON C indicated .results were communicated to MD Q on 06/22/23 at 4:13 p.m . total protein 5.5 .albumin 1.9 .reported results to MD Q, awaiting orders . No progress note found indicated MD Q returned phone call for new orders. Record review of a wound consultation dated 06/20/23 indicated . new consult . awaiting wound culture results will continue Dakin's (is a broad-spectrum antiseptic, antimicrobial, antibacterial, antifungal, and antiviral wound care solution for acute and chronic wounds) for preventative . stage 4 sacrum pressure .14.5x9x2 .odor .peri wound (is tissue surrounding a wound) no signs/symptoms of infection .recommendations of offload/reposition, optimize nutrition, low air loss mattress . Record review of a wound consultation dated 06/28/23 indicated .pre-admit wound culture has not been received .collected wound culture today .no overt signs/symptoms of infection .will continue Dakin's for preventative until culture results received .will defer starting antibiotics due to no signs/symptoms of infection to wound .stage 4 sacrum pressure .14.5x9x2.3 .odor .peri wound no signs/symptoms of infection . During an observation on 06/26/23 at 11:58 a.m., Resident #160 asleep in the bed with the position wedge on the right side of his body but not underneath him. During an observation on 06/26/23 at 2:10 p.m., Resident #160 asleep in the bed with the position wedge on the right side of his body but not underneath him. During an observation and interview on 06/26/23 at 2:25 p.m., Resident #160 was in bed with the position wedge on the right side of his body but not underneath him. Resident #160 said he had a sore on his bottom and staff turned him sometimes. During an observation on 06/27/23 at 9:00 a.m., Resident #160 was laying on his back with no positioning aides. During an observation and interview on 06/27/23 at 10:30 a.m., Resident #160 was laying on his back with no positioning aides. Dressing change performed by ADON B, the wound care nurse. ADON B said gown and gloves were worn during dressing changes because paperwork from another facility indicated Resident #160 had an infection. She said the facility was waiting on the wound culture results obtained by the transferring facility. ADON B said it was precautionary until they received results. Resident #160 was placed on left side with the wedge underneath him. During an observation on 06/27/23 at 1:22 p.m., Resident #160 was on his left side but had slid partially off the wedge and was partially laying sideways in the bed. During an observation and interview on 06/27/23 at 3:25 p.m., Resident #160 was on his left side but had mostly slid off the wedge and was askew in the bed. A family member of Resident #160 was at the bedside and said when she visited him, he was always flat om his back. The family member of Resident #160 said she visited daily. During an interview on 06/28/23 at 1:53 p.m., CNA A said she worked Hall 1 on Monday (06/26/23) and took care of Resident #160. She said Resident #160 liked to lay flat on his back. CNA A said she did not even notice a positioning wedge in his bed on Monday (06/26/23). She said Hall 1 was a demanding hall, but she felt like she repositioned Resident #160 at least 2-3 times. CNA A said she knew Resident #160 needed to be repositioned frequently to help heal his pressure ulcer. She said not repositioning Resident #160 could cause the wound to get worse. During an interview on 06/28/23 at 2:10 p.m., ADON B, the wound care nurse, said Resident #160 was admitted to the facility on antibiotics and he completed the doses. She said on admission the facility attempted to contact the hospital and transferring facility about his possible wound infection with no luck. ADON B said the wound had an odor, but the facility waited until today to obtain another wound culture. She said another wound culture could have been obtained prior to today. ADON B said she did not know why on the two days it was documented Resident #160 had purulent drainage, an order was not obtained to get another wound culture. She said RN L was no longer employed by the facility to ask about the purulent drainage. ADON B said the facility utilized offloading, low air loss mattresses, wound care, and the dietician to prevent and heal pressure wounds. ADON B said Resident #160 was admitted from a sister facility and the facility was aware on before admission he had a stage 4 sacrum pressure ulcer. She said she did not know why a low air loss mattress was not available on admission. She said the dietician rounded the 1st of every month and made recommendations. ADON B said the dietician was in the facility today and she needed to notify her to see Resident #160. ADON B said Resident #160's lab results should have been followed up by the charge nurse to receive orders from the doctor. She said interventions were placed to prevent wounds from getting worse or cause sepsis which could kill a resident. During an interview on 06/29/23 at 10:50 a.m., ADON C said she was responsible for routine labs and to ensure nurses followed up on other lab results. She said she did notify MD Q about Resident #160 lab results. ADON C said she sent a picture of Resident #160's previous and new lab results, and MD Q said, it dropped. She said I called MD Q on 06/28/23 to address the low total protein and albumin and he order to repeat labs in two weeks. ADON C said she did not document contact with MD Q after her progress note on 06/22/23. She said nursing staff who worked after the progress note on 06/22/23 could have also contact MD Q to get a response. ADON C said Resident #160's lab results needed to be addressed because they could affect his wound healing. On 06/29/23 at 12:00 p.m., the DON was unavailable for interview due to being on leave. During an interview on 06/29/23 at 12:13 p.m., the Registered Dietician said she was not the normal RD who rounded at the facility. She said this was her third time being at the facility. The RD said the regular RD usually rounded earlier in the month, but she came at the end of the month. The RD said some facilities emailed the RD with new admission who needed to be seen as soon as possible but she did not know the facility's procedure. During an interview on 06/29/23 at 12:15 p.m., the Administrator said regarding pressure ulcers she expected the nursing staff to follow physician orders for treatment. She said she expected nursing staff to notify physicians of lab results. The administrator said she expect if the lab results were critical, nursing staff would continue to contact the physician until they received a response. She said she expected any communication regarding the lab results with physician should be documented in the resident chart. The Administrator said the facility communicated lab results with physician by text messages and phone calls. She said the physician needed to be contacted to know if the lab results needed to be addressed. On 06/29/23 at 12:30 p.m., attempted to contact MD Q by phone. No return call prior to exit. Record review of CNA A's proficiency audit checkoff dated 09/29/22 for turns/repositions residents timely/correctly was satisfactory. Record review of a facility Prevention of Pressure Injuries policy dated 05/22 indicated .conduct nutritional screenings for resident at risk .provide optimal hydration, nutrient, protein, and calorie requirement .include nutritional supplements in the resident's diet to increase calories and protein . reposition all residents with or at risk of pressure injuries on an individualized schedule .select appropriate support surfaces based the resident's risk factors . Record review of an undated facility Laboratory Guidelines policy indicated .purpose .to enable prompt communication between the laboratory, facility staff and physician on all laboratory work drawn on residents in the facility and to ensure residents receive appropriate interventions as justified by any abnormal lab values .the lab results will be given to the DON/designee for review .the attending physician will be notified on any abnormal values .there will be follow-up documentation in the medical record . Review of Evaluation of a low-air-loss mattress system in the treatment of patients with pressure ulcers (1995) by M A [NAME], J Oldenbrook, C [NAME], www.pubmed.ncbi.nlm.nih.gov/7612140 was accessed on 07/06/2023 indicated .our observation indicate that use of the low-air-loss mattress system reduces the size and facilitates the healing of previously stable, chronic pressure ulcers . Review of Effects of Albumin Infusion on Serum Levels of Albumin .and Wound Healing (May 20, 2020) by [NAME] Utariani, [NAME] Rahardjo, and [NAME] Perdanakusuma, www.ncbi.nlm.nih.gov/pmc/articles/PMC7256723 was accessed on 07/06/2023 indicated . albumin infusion and dietary proteins play vital roles in accelerating the wound healing process .malnourished patients with protein deficiency have a high risk of infection, impaired wound healing .

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 of 5 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for smoking. The facility failed to ensure Resident #1 was not provided with smoking paraphernalia by Resident #2. Resident #1 had a history of attempting to smoke while in room. On 02/27/2023, Resident #1 was given a cigarette and lighter by Resident #2 and lit the cigarette in her room and set the lit cigarette on the over bed table causing a napkin to catch fire, and minutes later lit a brief on fire catching the residents blanket on fire. On 4/09/2023 Resident #1 was provided with smoking paraphernalia by Resident #2 again. The facility failed to ensure Resident #4 was monitored during a trial of unsupervised smoking. Resident #4 was observed outside smoking unsupervised on 04/11/23. Resident #4 was observed practicing unsafe smoking behaviors. The facility failed to ensure Resident #3 was monitored for safe smoking behaviors. Resident #3 was observed outside in the smoking area on 04/11/23 lighting her pipe while it was resting on her right breast. An Immediate Jeopardy (IJ) was identified on 04/11/2023 at 5:25 PM. While the IJ was removed on 04/12/2023 at 4:35 PM, the facility remained out of compliance at a scope of pattern and severity of no actual harm with a potential for more than minimal harm because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm, severe injury, and possible death to residents who are deemed unsafe smokers. The findings included: 1. Record review of Resident #1's face sheet, dated 04/12/2023, indicated Resident #1 was a [AGE] year-old female, who admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen levels), cognitive communication deficit (difficulty with thinking and how someone uses language), mild cognitive impairment (decline in memory and thinking), and major depressive disorder (persistent feeling of sadness and loss of interest). Record review of Resident #1's comprehensive MDS assessment, dated 10/02/22, indicated that Resident #1 did not have current tobacco use. Record review of the comprehensive care plan, initiated on 11/04/2022, indicated Resident #1 I am a smoker. The interventions included Perform smoking assessment according to facility policy, remind resident frequently that smoking is not allowed in room, use smoking vest when appropriate, keep my smoking materials in a safe and secure place. Provide them to me as per smoking schedule. Record review of Resident #1's quarterly MDS assessment, dated 01/16/2023, did not address current tobacco usage. It indicated Resident #1's BIMS=11, which indicated moderate cognitive impairment. Record review of the smoking risk (acuity), assessment dated [DATE], indicated Resident #1 had a score of 14 which deemed the resident to be an unsafe smoker and to follow facility policy. The care plan indicated Resident #1 had severe problems with smoking in unauthorized areas, she had a severe problem with being careless with smoking materials, and she had a severe problem with the capability to follow the facility's safe smoking policy. Record review of Resident #1's nursing progress note dated 02/27/2023 at 12:45 PM, written by LVN A, indicated CNA reported to this nurse that the resident was smoking in her bedroom. On the way to the resident's room the fire alarm was activated. This nurse observed the resident lighting toilet paper and smoking a cigarette. This nurse removed the cigarette and the lighter in use. This nurse reiterated the smoking policy to the resident, she was upset and used foul language directed at this nurse. The nurse left the room, the fire alarm was again activated. The nurse and CNA again entered the room to find the resident had started a fire. A blanket and a brief were on fire. This nurse put out the fire and educated the resident on fire safety and prohibited items. Record review of the incident report, dated 02/27/2023 at 12:45 PM, indicated Resident #1 was given a cigarette and lighter by Resident #2. Resident #1 then lit the cigarette in her room and was smoking. The report indicated Resident #1 then laid the cigarette down on the over the bed table next to a napkin and the napkin caught fire. The fire alarm activated and LVN A was able to put the fire out and removed the cigarette and lighter in use. LVN A and CNA C returned to the nurse's station when the fire alarm activated a second time. LVN A and CNA C returned to the room and a brief and blanket were on fire. LVN A was able to put the fire out and then searched room and removed 2 additional lighters from Resident #1's room. 2.Record review of Resident #2's face sheet, dated 04/12/2023, indicated Resident #2 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen levels), cognitive communication deficit (difficulty with thinking and how someone uses language), and schizoaffective disorder, bipolar type (mental illness that can affect your thoughts, mood and behavior). Record review of the smoking risk (acuity), assessment dated [DATE], indicated Resident #2 had a score of 05 which deemed resident to be a safe smoker. The assessment indicated Resident #2 had a history of borrowing a lighter, he had a minimal problem with smoking in unauthorized areas, he had a minimal problem with smoking cigarettes/cigar butts from ash trays, and he had a severe problem with general behavior and interpersonal interactions. Record Review of incident report dated 4/09/2023 indicated that Resident #2 was observed by staff giving Resident #1 a cigarette and lighter. Facility staff confiscated the smoking paraphernalia and educated Resident #2 on the smoking policy. During an observation and interview on 4/11/2023 at 9:15 AM, Resident #2 reached into the right pocket of his shorts and retrieved a yellow lighter. He said he did not remember an incident when he gave Resident #1 a cigarette and lighter. Resident #2 said he kept his cigarettes and lighter in his pocket because the administrator said he could, but he was out of cigarettes. Resident #2 said he was going to ask the administrator to get him some more cigarettes. During an interview on 4/11/2023 at 12:45 PM, Resident #1 said she remembered Resident #2 giving her a cigarette and taking her out to smoke a few days ago, but she did not remember if any staff members were with her at the time. Resident #1 said she did not have any smoking materials with her currently because the nurse took it and locked it up. During an interview on 04/12/2023 at 11:06 AM, CNA C said smoking used to always be supervised and then she heard by word of mouth but can not remember who told her, it changed about 4-5 months ago. She said now some residents could go smoke anytime they wanted, and those residents were allowed to keep their smoking materials. CNA C said there were still some residents who must be monitored when smoking and the nurse kept their smoking materials. CNA C said there were 5 residents who were unsupervised smokers and 4 residents who were supervised. CNA C said Resident #2 was an unsupervised smoker and was allowed to keep his smoking materials, she said Resident #2 is a supervised smoker. CNA C said the day in February Resident #1 lit the cigarette in her room, she went to pick up the resident's lunch tray and the resident had a cigarette laying on the table that caught a napkin on fire. CNA C said LVN A came to the resident's room and found the cigarette and a lighter. CNA C said 20-25 minutes later, she went to check on Resident #1 and the resident had a blanket on the bed and a brief on the floor. She said the brief was on fire and had caused the blanket on the bed to catch fire. CNA C said LVN A came down and searched the resident's room again and found 2 more lighters. CNA C said she did not know how Resident #1 had the cigarettes and lighters. CNA C said she was not aware Resident #2 had given Resident #1 a cigarette on 04/09/23. During an interview on 04/11/2023 at 2:28 PM, LVN A said the residents were able to take themselves out to the smoking area and smoke if they were able to smoke unsupervised. LVN A said there were currently no designated smoking times in place and residents could go out whenever. LVN A said the residents were able to keep their cigarettes and lighters. LVN A said there were a few residents who had to be supervised and a list of those residents was kept at the nurse's station. LVN A said supervised smokers were determined by their smoking assessment, but she was not sure who completed that assessment. LVN A said there were 5 unsupervised smokers and 4 supervised smokers. LVN A said Resident #2 was an unsupervised smoker and was allowed to keep his smoking materials. LVN A said Resident #1 lit a cigarette in her room on 02/27/23. LVN A said Resident #1 had laid the cigarette on the over the bed table and caught a napkin on fire. LVN A said she was able to put the fire out and took the cigarette and lighter that was in use. LVN A said a few minutes later the fire alarm activated a second time. LVN A said she returned to the room and Resident #1 had lit a brief on the floor on fire that had caught the blanket on fire. LVN A said she was able to put the fire out and searched the room and found 2 more lighters. During an interview and observation on 04/11/2023 at 12:22 PM, LVN B said some residents were allowed to smoke unsupervised and there was a list of residents who had to be supervised. LVN B said the list was taped to the nurse's station. LVN B provided the initial list titled Monitored Smokers then took the list and added a resident's name at the bottom and returned the updated list. Record Review of Monitored Smokers on 4/11/2023 at 12:22 PM provided by LVN B initially contained 5 residents listed as monitored smokers. LVN B provided the monitored smokers list again and it now contains 6 residents listed as monitored smokers. During an interview on 04/11/2023 at 9:40 AM, the BOM said Attachment K of the Smoking Policy statement (dated 2/22/2022) was provided to residents and families in the admission agreement. Record Review of the facility's Attachment K Smoking policy statement dated 2/22/2022 indicated the facility would supervise all resident smoking for the safety of all residents and employees, and all resident smoking paraphernalia must be checked in with the nurse. Attachment K did not address unsupervised smoking. During an interview on 4/11/2023 at 12:32 PM, the MA said the smoking policy was in the glass case across from the nurse's station. The MA said there was a time to go smoke designated for each hall. She said there were some residents who required to be supervised, but there were some residents who could come and go as they wanted and keep their smoking materials. Record Review of HCC Smoking Policy from the glass case was undated and indicated: In order to protect the lives and safety of all residents, we require that resident smoking be conducted with direct supervision from staff or family/RP at all times. Residents are not allowed to smoke unsupervised. All smoking materials are to be kept by facility staff in a designated secure area. Family members or responsible parties must alert nursing staff when they are accompanying their resident to smoke area during a non-scheduled smoking time. Designated smoking areas: The designated smoking areas are located outside the patio exit int the main dining room; for inclement weather, the covered walkway outside of Hall 4 and Laundry exit; and secured unit residents, outside the end door of Hall 2 or the center court. Smoking is prohibited in all other areas of the facility and the grounds. Designated smoking times: Designated times for staff-supervised smoking for residents are: 8:30am 10:30am 1:00pm 2:30pm 4:30pm 6:30pm 8:30pm designated times for staff-supervised smoking for residents on the secured unit area: 8:00am 11:00am 1:00pm 4:00pm 7:00pm. Record review of the Smoking Policy Independent Smokers In-service, initiated on 02/27/2023, indicated staff were in-serviced on the smoking policy signed by 40 employees with only the sign in sheet provided with no education attached. Record review of Resident #4's face sheet dated 04/11/23 revealed, Resident #4 was admitted on [DATE] with diagnosis of dementia (memory impairment), hemiplegia following cerebral infarction (stroke affecting the left side), and bipolar disorder (affecting mood). Record review of Resident #4's quarterly MDS dated [DATE] revealed, Resident #4 needs extensive assistance with transfers, bed mobility, toilet use, personal hygiene and dressing. Resident #4 also requires supervision with locomotion and eating. Resident #4's BIMS=12 which indicated moderate cognitive impairment. Record review of Resident #4's care plan initiated on 05/16/22, revealed Resident #4 is a smoker. Resident #4's interventions include: I may wear a smoking apron upon my request, I will keep my smoking material in a safe and secure place. Staff will provide smoking materials to me as requested, monitor as needed when smoking so that if something should happen, I have someone to assist and help me at assure my safety. Record review of Resident #4's smoking risk (acuity) assessment dated [DATE] revealed a score of 4, which indicated Resident #4 is a safe smoker. During an interview outside in the smoking area 04/11/2023 at 9:30 AM, Resident #4 said she used to have to have staff take her out to smoke, but she asked the DON to be unsupervised and was granted a trial of being an unsupervised smoker. Resident #4 said when she was ready to smoke, she stopped by the nurse's station and the nurse would give her 2 cigarettes and a lighter. She said she propelled herself outside to smoke unsupervised. Resident #4 said when she went back inside the facility, she would give the lighter back to the nurse. Record review of Resident #3's face sheet dated 04/11/23 revealed, Resident #3 was originally admitted on [DATE] with the most recent admission on 03/23/22. Resident #3's diagnosis includes dementia (memory problem), seizures (stiffness, twitching, or limpness), and schizoaffective disorder (mental health problem where you experience psychosis as well as mood problems). Record review of Resident #3's quarterly MDS dated [DATE] revealed, Resident #3 requires extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Resident #3's BIMS=12 which indicated moderate cognitive impairment. Record review of Resident #3's care plan initiated on 07/23/2019 and revised on 04/11/23 revealed, Resident #3 is a smoker. Care plan interventions include I may use smoking apron upon my request, remind to not share cigarettes with others, report observations of resident having smoking materials in possession at times other than during smoking break and remind to keep in lock box when not smoking, resident may participate independently for smoke break as requested. Record review of Resident #3's smoking risk (acuity) assessment dated [DATE] revealed, Resident #3 score was 1 which indicated resident is a safe smoker. During an interview and observation outside in the smoking area on 04/11/2023 at 9:35 AM, Resident #3 said the residents raised enough ruckus about smoking that the administrator gave in and decided they could smoke anytime they wanted and keep their smoking materials. Resident #3 said Resident #2 came out to the smoking area frequently wanting to borrow cigarettes from other residents. Resident #3 does not have use of her left arm due to hemiplegia following a cerebral infarction affecting the left side. Resident #3 was smoking a pipe. Resident #3 took the pipe and dipped it into a pouch of loose tobacco, put the pipe in her mouth and rested the bottom of the pipe on her right breast, she then took a blue Bic lighter turned it upside down and lit the tobacco in the bottom of the pipe and began to smoke the pipe. After smoking, Resident #3 emptied the contents of the pipe into the ashtray and repeated the process multiple times. During an observation on 04/11/2023 at 10:15 AM, Resident #2 was observed putting in the code to the smoking door and came out to the smoking area. Resident #2 asked Resident #3 if she could pay him back his cigarettes. Resident #3 told Resident #2 that she did not have any money and he would have to wait until she got some. Resident #2 then put the code into the number pad and went back inside the facility. During a continuous observation on 04/11/2023 at 9:30 AM to 10:49 AM, four residents (Resident's #2, #3, #4 and #5) were outside in the smoking courtyard. Residents #2, #3, #4 and #5 had their own cigarettes and lighters and were unsupervised. Resident #4 was wearing a smoking apron that covered the front of her clothing and was not secured in the back. Observed no interaction with staff and smoking residents from 9:30 AM until 10:49 AM. At 10:49 AM, LVN A came to the smoking door and told Resident #4 she needed to come inside. During an interview on 4/11/2023 at 12:05 PM, CNA E said smoking used to always be supervised and then it changed, but she did not know when. CNA E said now some residents could go smoke anytime they wanted, and those residents were allowed to keep their smoking materials. CNA E said there were still some residents who must be monitored when smoking and the nurse kept their smoking materials. CNA E said there were 2 residents who were supervised. CNA E said Resident #2 was an unsupervised smoker and was allowed to keep his smoking materials. During an observation on 4/11/2023 at 12:51pm, two residents (Resident's #2 and #5) were outside in the smoking courtyard. Residents #2 and #5 had their own cigarettes and lighters and were unsupervised. During an interview outside in the smoking area on 04/11/2023 at 12:51 PM, Resident #5 said the staff used to bring him out to smoke, but that had not happened in a while. He said his family member provided his cigarettes, and he had his cigarettes and lighter in his jacket pocket. During an interview on 4/12/2023 at 10:17 AM, CNA D said smoking used to always be supervised and then it was changed but did not know when. CNA D said now some residents can go smoke anytime they want, and those residents are allowed to keep their smoking materials. CNA D said there are still some residents who had to be monitored when smoking and the nurse kept their smoking materials. CNA D said there were 6 residents who were unsupervised smokers and 3 residents who were supervised. CNA D said Resident #2 is an unsupervised smoker and was allowed to keep his smoking materials. CNA D said Resident #1 is a supervised smoker. During an interview on 4/12/2023 at 3:32 PM, CNA E Said that there are 3 residents that must be supervised to smoke, they can't share cigarettes, they must wear their aprons, and they get one every 2 hours. During an interview on 04/11/2023 at 3:23 PM with the Administrator, she said let's go talk to the DON about who completes the smoking risk (acuity) assessments. Upon entering the DON's office, the Administrator left the office. During an interview on 04/11/2023 at 3:25 PM, the DON said they use the smoking assessment in Matrix as a tool for determining what residents are considered safe or unsafe smokers. She said they also will assess the resident for any changes in condition that could cause the resident to become unsafe. Said Resident #4 has come and asked that she be made an unsupervised smoker, she said they are now doing a trial run with the resident to see if she does ok with unsupervised smoking. She Said she is aware Resident #2 gave Resident #1 cigarettes and a lighter on more than one occasion because he is a giver and when he is sweet on someone, he will give that person anything he has. She said he is sweet on Resident #1. The DON said the facility educated Resident #2 on the smoking policy of not giving cigarettes and lighter to a supervised smoker. The DON said Resident #2 is still allowed to keep his smoking paraphernalia and they have no way to ensure that Resident #2 will not do it again. The Administrator was notified on 04/11/2023 at 5:25 PM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy Template on 04/11/2023 at 5:25 PM. The Administrator provided a third smoking policy on 4/11/2023 at 5:30pm, titled, Smoking Policy-Residents 2001 med-pass, INC. (Revised December 2019) and included the following: This facility shall establish and maintain safe resident smoking practices. Policy interpretation and Implementation. 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Otherwise, smoking is not allowed inside the facility under any circumstances. 3. Oxygen use is prohibited in smoking areas. 4. Metal containers, with self-closing cover devices, are available in smoking areas. 5. Ashtrays are emptied only into designated receptacles. 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include A. current level of tobacco consumption; b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipes, etc.); c. Desire to quit smoking, if a current smoker; and d. Ability to smoke safely with or without supervision (per a completed smoke risk (Acuity). 7. The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the safe smoking evaluation. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession, only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. 13. Residents are not permitted to give smoking articles to other residents. 14. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. 15. Staff members and volunteer workers are not permitted to purchase and or provide any smoking articles for residents. 16. This facility maintains the right to confiscate smoking articles found in violation of our smoking policies. 17. Confiscated resident property will be itemized and ultimately returned to the resident, or his or her legal representative. When the property is returned will be determined during a meeting with the resident or representative regarding the circumstances that led to the confiscation. The facility's plan of removal was accepted on 04/12/2023 at 4:35 PM and included the following: The facility's nursing administration will complete smoking acuity assessments on all residents in the facility. The facility's administration will communicate with staff the residents will be deemed to be safe to smoke independently according to our smoking acuity assessment and residents that will be deemed not safe to smoke independently according to our smoking acuity assessment by completing a list and updating the care plans, so staff are aware. The Facility's administration will update the monitored smoking schedule and will ensure residents that will be deemed not safe to smoke independently according to out smoking acuity assessment are monitored while smoking. Nursing administration, Social Services, Administrator, and/or designee will educate all smoking residents regarding having smoking paraphernalia on person, sharing cigarettes and lighters, and ensuring they understand not everyone is capable of self-smoking. Residents will sign or verbally agree with two witnesses to the above educational information (if unable to sign). Violation of this policy will result in supervised smoking. Smoking policy has been reviewed and updated. Ask residents for their smoking paraphernalia while respecting their rights and ensuring residents that will be deemed not safe to smoke independently according to out smoking acuity assessment will not have paraphernalia. The facility will keep residents that will be deemed not safe to smoke independently according to out smoking acuity assessment smoking paraphernalia in a secure location where only staff have access and can distribute as necessary. Resident #2's smoking paraphernalia will be secured where only staff has access and can distribute as necessary. Administrator, Director of Nurses, and /or designee, will in-service all staff on current smoking policy, ensure they understand residents will be deemed to be safe to smoke independently according to our smoking acuity assessment. Vs. residents that will be deemed not safe to smoke independently according to our smoking acuity assessment (those residents will be identified through a list created by nursing administration-post smoking acuity assessment- and can be additionally identified through the residents' care plans). All staff will be trained prior to working their next shift. Administrator, Director of Nurses, and/or designee, will speak with family members of Resident #1 to assist with ensuring that resident does not have smoking paraphernalia and document in medical record. Room search will be conducted as needed. Ad-Hoc QAPI performed with Medical Director, Administrator, and Director of Nursing. The facility smoking policy was revised April 2023 and at that time the DON began in-servicing facility staff on the policy changes. All staff currently on duty were in-serviced on the revised smoking policy 4/12/23 at 3:30 PM. Any staff members not available for in-service will be in-serviced prior to returning to shift. Policy related to supervision during smoking times has been implemented and is in place. The smoking policy implementation explanation started 4/11/23 with all residents who smoke. The smoking policy implementation was completed on 4/12/2023 for all residents who smoke. On 04/12/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation 4/12/2023 at 1:00pm, Resident #2 was observed turning in his lighter to the nurse at the nurse's station. During an observation on 04/03/2023 at 2:25 PM, 4 residents were outside smoking supervised by Administrator in training. During resident interviews on 04/12/2023 between 3:45 PM - 4:15 PM, Resident's #1, #2, #3, #4, #5, #6, #7, #8, and #9 were able to verbalize understanding of the smoking policy, which included supervised smoking for supervised residents and designated smoking times, and verified all cigarettes and lighters were turned into the facility staff. Record review of the comprehensive care plan for Resident's #1, #2, #3, #4, #5, #6, #7, #8, and #9 indicated they had been reviewed and revised as necessary. Record review of the smoking assessments for Resident's #1 #2, #3, #4, #5, #6, #7, #8, and #9 indicated they had been reviewed and revised as necessary. Record review of the smoking policy in-service provided to staff, dated 04/11/2023, indicated 40 staff members had signed and dated the read and understood the smoking policy, which included Resident #2 is required to keep smoking paraphernalia at the nurse's station, supervised smoking residents were required to keep their cigarettes and lighters at the nurse's station, and designated smoking times and supervision. During interview on 04/12/2023 between 3:30 PM and 4:30 PM, the following staff members, 3 charge nurses, 1 CMA, 6 CNA's, 1 housekeeping staff member, and the ADON were interviewed and verbalized understanding that supervised smoking residents were required to keep their cigarettes and lighters at the nurse's station, and Resident #2 must keep his cigarettes and lighter at the nurse's station, and the new digitated smoking times and supervision. On 04/12/2023 at 4:35 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and severity of no actual harm with a potential for more than minimal harm because to the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems.