Every finding on record at Avir at Giddings

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 set forth at S483.10(c)(2) and S483.10(c)(3), that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #01) whose comprehensive person-centered care plans were reviewed. The facility failed to ensure that Resident #01 was receiving larger portions at lunch and dinner meals. This deficient practice could affect residents by failing to ensure residents received appropriate care for their health conditions.The findings included:An observation of Resident #1's lunch on 05/20/2026 at 12:26 pm revealed a plate of food with 1 chopped beef sandwich, 1 serving of beans, 1 serving of corn, and 1 dessert. Surveyor compared Resident #1's meal ticket with Resident #2's meal ticket. Both tickets had the same amounts of food 3 ounces of beef, 4 ounces of baked beans, 4 ounces of corn, and #8 scoop of key lime mousse. Observation of both plates of food showed the sizes of the food were the same on both plates. I observed the meal card for Resident #1 which stated1 regular serving of the food on his plate with notes saying large portions at lunch and dinner. Resident #2 meal ticket did not have any notes regarding larger portions. Record review of Resident #01's face sheet dated 05/12/2026, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: COPD (a group of disease that cause airflow blockage and breathing- related problems), hypertension (high blood pressure), and Lymphedema (chronic long-term condition of abnormal swelling) Record review of Resident #01's MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Record review of Resident #01's comprehensive care plan dated 03/04/2026, revealed it did not address large portions for lunch and dinner During an interview on 05/12/2026 at 12:30 PM, MDS nurse stated care plans are interdisciplinary. The MDS nurse stated the resident care plan is important to know how to take care of the resident. Surveyor asked if a resident has a doctor order for larger portions at lunch and dinner should that be care planned and the MDS nurse answered yes. Surveyor asked if that order should be care planned and she said yes. During an interview on 05/12/2026 at 12:40 PM, the DON said the care plan should include a doctor's order for larger portions at lunch and dinner. She said the care plan is an individualized plan to let staff know how to care for the resident. During an interview on 05/30/2025 at 12:42 PM, the Administrator stated the care plan should include everything needed to take care of a patient. She said the care plan is interdisciplinary and agreed that an order for larger portions for lunch and dinner should be included in the care plan. Record review of the facility's policy Care Plans, Comprehensive Person- Centered dated 03/2022 revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Record review of the facility's policy Physician Orders: dated 02/2025 revealed: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician's orders to ensure the resident receives the necessary care and services. 5. Physician orders are essential for the comprehensive care of the residents. These orders encompass various aspects, including leave of absence, evaluations, medication and treatment regimen, and therapy for physical therapy, speech therapy, and occupational therapy; consultations with other physicians; dietary plans; activity instructions; x-rays; laboratory work; transfers; discharges; and any other orders as needed.

Based on interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 (Resident #17, Resident #52 and Resident #58) of 8 residents reviewed for activities. The facility failed to provide activities for Resident #17, Resident #52 and Resident #58 to meet their psycho-social and mental needs for the entire month of March and April of 2026. This failure could place residents at risks of boredom, depression, behavior, diminished quality of life and decreased cognitive function. Findings include: Record review of Resident #17's face sheet, dated 04/22/2026, reflected a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses which included senile degeneration of brain, not elsewhere classified ( a progressive decline of memory loss and confusion associated with aging but it is not caused by specific diseases like Alzheimer's- irreversible brain disorder that slowly destroys memory, thinking skill, and eventually the ability to perform daily tasks- or vascular dementia - a decline in thinking, and memory caused by conditions that damage blood vessels in the brain, reducing or blocking blood flow and oxygen), polyneuropathy ( chronic disorder causes widespread of numbness, tingling, burning pain, and muscle weakness, typically staring in the hands and feet before potentially affecting other areas), and major depressive disorder ( a common but serious mental health condition characterized by a persistent feeling of sadness). Record review of Resident #17's admission MDS Assessment, dated 02/14/2026 reflected Resident #17 had a BIMS score of 6 indicated her cognition was severely impaired. She was assessed of feeling down, depressed, or hopeless. Resident #17 activity preferences was the following : Have books, newspaper, and magazines to readListening to favorite musicDo things in with groups of peopleDo favorite activitiesGo outside to get fresh air when the weather was goodParticipate in religious services or practices.Record review of Resident #17's Comprehensive Care Plan, dated 02/23/2026, reflected Resident # 17 did not have an activity care plan related to her activity preferences and abilities to participate in activity programming.Record Review of Activity Participation records reflected Resident #17 did not receive activities on the following days in March 2026:3/1/20263/7/20263/8/20263/12/20263/14/20263/15/20263/18/2026 thru 3/31/2026Record review of the Activity Participation records reflected Resident #17 did not receive activities on the following days in April 2026:4/1/20264/5/20264/9/20264/11/20264/14/2025 thru 4/20/2026Observation on 04/21/2026 at 10:00 a.m. the Activity Assistant was sitting against the wall away from the residents who were sitting at a long table. She had a card table in front of her and was documenting on March 2026 and first week of April 2026 participation records. She did not move from that area to assist residents with their activities they had in front of them. She did not cue the residents or give them the appropriate activity items to complete the activity tasks.Observation and interview on 04/21/2026 at 10:29 a.m. revealed Resident #17 was sitting in the dining room on the secured unit with other residents. She had a plastic activity item sitting in front of her. The activity item had 3 lines across of small holes. Resident #17 stated what is this and she pointed to the activity item. She stated I don't know what to do. What do you think I am to do with it (she pointed to the activity item. There were not any objects to place in the holes, and she was frustrated with not knowing what to do with the activity item. She crossed her hands and stated, I don't know what to do. Resident #17 would sigh and her jaw was clenched. Observation and interview on 04/21/2026 at 10:35 am the Activity Assistant A continued to sit against the wall away from the residents sitting at the long table. Activity Assistant A stated, I did not know the residents needed assistance and or did not have all the items needed to do an activity. She stated I am the one gave the residents the activity items and thought they knew what to do with them. She stated all the residents does receive 1:1 visits every day. She stated she does activities with the residents individually every day. Activity Assistant A stated she worked Monday through Friday and was not at the facility on the weekends. She stated she was working on participation records for March and some for April. Activity Assistant A stated she usually knows what all the residents does every day and knew their routines and could remember what each resident did for the month of March 2026. She stated she was expected to document on participation records when the activity occurs, but she did not always do that due to not having enough time. She stated she did not put on the participation records late entry, and she did not know anything about documenting late entries. Activity Assistant A stated only nurses documents late entries. She stated she did not have participation records every day. Activity Assistant A stated she does not have any proof the residents received activities every day in March 2026 and April 2026. Record review of Resident #52's face sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), major depressive disorder ( a common but serious mental health condition characterized by a persistent feeling of sadness), and anxiety disorder ( a group of treatable mental health conditions characterized by excessive , persistent, and uncontrollable fear, worry, or dread that interferes with daily activities).Record review of Resident #52's Annual MDS Assessment, dated 08/09/2025, reflected Resident #52 had a BIMS score of 3 indicating his cognition was severely impaired. The following activities were very important to Resident #52:Keeping up with the newsDoing things in groups of peopleDoing favorite activitiesParticipating in religious services or practiceListening to favorite music. Record review of Resident #52's Quarterly MDS Assessment, dated 03/02/2026, reflected Resident #52 had a BIMS score of 4 indicating his cognition was severely impaired. Record review of Resident #52's Comprehensive Care Plan, dated 03/10/2026, reflected Resident #52 did not have an activity care plan related to his activity preferences and abilities to participate in activity programming.Record Review of Activity Participation records reflected Resident #52 did not receive activities on the following days in March 2026:3/1/20263/7/20263/8/20263/12/20263/14/20263/15/20263/18/2026 thru 3/31/2026Record review of the Activity Participation records reflected Resident #17 did not receive activities on the following days in April 2026:4/1/20264/5/20264/9/20264/11/20264/14/2025 thru 4/20/2026Observation and interview on 04/21/2026 at 10:19 am revealed Resident # 52 was sitting in the dining room on the secure unit with other residents. He was listening to music. Resident #52 did not answer any questions about his activities. Resident #52 lowered his head looking toward the floor during conversation. He had a sad expression inner eyebrows pulling up and together, and downturned mouth.Record review of Resident #58's face sheet, dated 04/22/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), anxiety disorder ( a group of treatable mental health conditions characterized by excessive , persistent, and uncontrollable fear, worry, or dread that interferes with daily activities), and cognitive- mental processes involved in gaining knowledge and comprehensive, including thinking, knowing, remembering, and problem-solving- communication deficit ( a communication impairment resulting from underlying cognitive issues such as: memory, attention, or execution function deficits- rather than a primary language or speech problem).Record review of Resident #58's Annual MDS Assessment, dated 05/11/2026, reflected resident was rarely/never understood. She had poor short- and long-term memory recall. Resident #58's decision making ability was severely impaired.Record review of Resident #58's Quarterly MDS Assessment, dated 02/11/2026, reflected Resident #58 was rarely/ never understood. She had poor short- and long-term memory recall. Resident #58's decision making ability was severely impaired. Resident #58's favorite activities are the following:Listening to music.Being around animals or petsDoing things in groups of people.Participating in favorite activities.Spending time outdoors.Participating in religious activities or practices.Record review of Resident #58's Comprehensive Care Plan, dated 02/25/2026, reflected Resident #58's activity plan , preferences and abilities to participate in activities was not documented on the comprehensive care plan. Resident #58 was at risk for falls related to confusion, impaired mobility and incontinence. Intervention: Encourage Resident #58 to participate in activities to increase strength and mobility. Observation on 04/21/2026 at 10:40 am revealed Resident # 58 was sitting in the dining room area with other residents. She was not interacting with other residents. Resident #58 had a worried expression on her face. She had facial muscle tension especially on her forehead. Resident #58 was not interview able. Interview on 04/21/2026 at 11:30 am the Activity Director stated Activity Assistant A planned all activities on the secure unit. She stated Activity Assistant A was responsible for the participation records for all residents on the secured unit. The Activity Director stated she expected participation records to be completed immediately after each activity program. She stated she was the Activity Assistant A's supervisor. The Activity Director stated if the activities were not documented on the participation records the activity did not occur with the residents. She stated the only proof to show activities was completed with residents was by the participation document. The Activity Director stated back dating participation records was not allowed. She stated if a resident had a diagnosis of depression, anxiety or any type of dementia and was not receiving activities there was a possibility the resident may become more depressed, anxious, develop behaviors and have a decline in their memory. The Activity Director stated she tried to monitor participation records on the secure unit but sometimes she was so busy it was difficult to complete everything she needed to do in a day. She stated all activities programs was expected to be on each resident's care plans. The Activity Director stated it was very important for the residents Activity preferences to be documented on care plan and if they were not capable of doing certain things in activities, they also needed to be care planned. She stated Activity Assistant A was to relate residents activity preferences and her plan for the resident to the MDS Coordinator to enter the information on the care plans. Surveyor requested activity calendars for the secured unit from the Activity Director for the months of February 2026, March 2026, and April 2026. These calendars were not provided prior to exit.Interview on 04/23/2026 at 9:30 am Activity Assistant A stated she was expected to document on participation records when any activity occurs on the secured unit. She stated if a resident had a diagnosis of depression, anxiety, or dementia and the resident was not receiving activities there was a possibility the resident may have an episode of depression, anxiety and their mental status may decline. She stated it did affect their life if they did not have any activities. Activity Assistant A Stated Resident #17, Resident #52, and Resident #58 needed 1:1 activity every day and they needed to do their favorite activities. She stated she did not have a list of the residents activity preferences. Activity Assistant A stated she knows what they were capable of doing and what they liked to do in activity programs. She stated it would be difficult for other staff to know the residents preferences if it was not documented on the care plan. Activity Assistant A stated she does have her Activity Director Certificate. She stated she had been working at the facility approximately a year as Activity Assistant on the secure unit. She stated when residents were doing an activity she needed to sit with them and assist them with activities. Activity Assistant A stated she also needed to ensure the residents had all the activity items they needed to do any type of activity. She stated she did have a job description. Surveyor requested January 2026, February 2026, March 2026, and April 2026 calendars. They were not provided prior to exit.Interview on 04/23/2026 at 10:14 a.m. the Administrator stated she expected a variety of activities to be provided for all residents. She stated each resident's activity preference needed to be assessed, and each resident's activity was expected to be planned according to their activity preferences. She stated activities such as independent, in-room, and/or group activities were to be documented on participation records. The Administrator stated she expected all residents to be interviewed, and their activity preferences updated and all care plans to be revised to reflect each resident's activity preferences. She stated if a resident was not receiving activities there was potential a resident would have a decline in their cognition, mental status, physical status and quality of life. She stated a resident with a history of depression may become depressed and isolate themselves in their rooms. The Administrator stated the Activity Director and Activity Assistant were responsible for the activity programming and documentation of all activities department including participation records. She stated she was the Activity Director's supervisor. Record review of the Activity Director's personnel file reflected Activity Director had completed Directing Activities in Long Term Care Environment. The certificate does not expire.Record review of Activity Assistant A personnel file reflected she had completed activity training and had received her certificate on 04/29/2025. Record review of Activity Participation, group and in- room activities, dated 12/5/2025, reflected Activity Director received this in-service.Record review of the facility policy on Activity Programming, dated 2011, reflected The Activity Director and staff will provide for ongoing activity programs. Programs will be geared to maintain functional ADLS, provide social interaction and, as the same time, protect residents from environmental over stimulation. Those who cannot participate in group settings are provided with individual programming. Inability to participate could include those who refuse to participate in activities, those who are in isolation or physician ordered bed rest. Record review of the facility's policy on Activity Programs, dated 2001, reflected Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation included:The activities program is provided to support the well-being of residents and to encourage both independence and community interaction.Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.The activities program is ongoing and included facility -organized group activities, independent individual activities and assisted individual activities.Activities are considered any endeavor, other than ADLs, in which the resident participated, that is intended to enhance his or her sense of well-being and to promote physical, cognitive or emotional health.Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs.Activities are scheduled 7 (seven) day a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs.Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident. Activity programs include activities that promote:self-esteem;comfort;pleasure;education;creativity;success; andindependence.All activities are documented in resident's medical record.Activities participation for each residents is approved by the attending physician based on information in the resident's comprehensive assessment.Individualized and group activities are provided that:reflect the schedules, choices and rights of the residents;are offered at hours convenient to the residents, including evenings, holidays and weekends;reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents;appeal to mean and women, as well as those of various age groups residing in the facility and;incorporate family, visitor and resident ideas of desired appropriate activities.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three of eight residents (Resident # 17, Resident #52 and Resident #58) reviewed for ADL care.1. The facility failed to ensure Resident #17's facial hair was removed on 04/21/2026.2. The facility failed to ensure Resident #52 and Resident #58's nails were cleaned on 04/21/2026. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included:1. Record review of Resident #17's face sheet, dated 04/22/2026, reflected a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses which included senile degeneration of brain, not elsewhere classified ( a progressive decline of memory loss and confusion associated with aging but it is not caused by specific diseases like Alzheimer's- irreversible brain disorder that slowly destroys memory, thinking skill, and eventually the ability to perform daily tasks- or vascular dementia - a decline in thinking, and memory caused by conditions that damage blood vessels in the brain, reducing or blocking blood flow and oxygen), polyneuropathy ( chronic disorder causes widespread of numbness, tingling, burning pain, and muscle weakness, typically staring in the hands and feet before potentially affecting other areas), and polyosteoarthritis, unspecified ( a degenerative joint disease characterized by the breakdown of cartilage- a strong, flexible, and resilient connective tissue- in multiple joints, typically affecting three or more joint groups commonly in the hands, knees , and spine simultaneously. Record review of Resident #17's admission MDS Assessment, dated 02/14/2026 reflected Resident #17 had a BIMS score of 6 which indicated her cognition was severely impaired. Resident #17 required supervision or touching assistance with the following ADLS:Personal hygieneToileting hygieneShowersLower and upper body dressingTransfersBed mobility Record review of Resident #17's Comprehensive Care Plan, dated 02/23/2026, reflected Resident # 17 ADL's was not documented on the comprehensive care plan. Observation and interview on 04/21/2026 at 10:29 a.m. revealed Resident #17 was sitting in the dining room on the secured unit with other residents. Resident #17 had facial hair under her chin and on the side of her upper lip. She stated, I do not like hair on my face can you get it off for me. She stated no I did not when she was asked if she knew she had facial hair on her face. She stated if my mother sees it on my face, she will not let me go anywhere. I need to look my best when I go somewhere. 2.Record review of Resident #52's face sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), type 2 diabetes mellitus without complications ( a person has the condition characterized by high blood sugar but has not developed related health issues like nerve, eye, or kidney damage), and muscle weakness ( a feeling or objective observation that reduced effort, such as attempting to lift or move, fails to produce normal muscle contraction).Record review of Resident #52's Quarterly MDS Assessment, dated 03/02/2026, reflected Resident #52 had a BIMS score of 4 indicating his cognition was severely impaired. Resident #52 required supervision or touching assistance with the following ADLS:Personal hygieneToileting hygieneShowersLower and upper body dressingTransfersBed mobility Record review of Resident #52's Comprehensive Care Plan, dated 03/10/2026, reflected Resident #52's ADL's was not documented on the comprehensive care plan.Observation and interview on 04/21/2026 at 10:19 am revealed Resident # 52 was sitting in the dining room on the secure unit with other residents. Resident #52's fingernails on his left and right hand underneath his middle and ring fingernails had a blackish/brownish substance. Resident #52 did not want to answer any questions. Record review of Resident #58's face sheet, dated 04/22/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), muscle weakness ( a feeling or objective observation that reduced effort, such as attempting to lift or move, fails to produce normal muscle contraction), need for assistance with personal care ( requiring hands-on support with activity of daily living due to age, disability, illness, or injury), and lack of coordination (inability to manage precise, smooth, and voluntary muscle movements causing difficulty with daily activities such as : walking, writing, or grasping objects).Record review of Resident #58's Quarterly MDS Assessment, dated 02/11/2026, reflected Resident #58 was rarely/ never understood. She had poor short- and long-term memory recall. Resident #58's decision making ability was severely impaired. She required substantial / maximal assistance ( helper does more than half the effort) with showers. Resident #58 was dependent on staff with the following ADLs:Personal HygieneUpper and lower body dressingToileting HygieneRecord review of Resident #58's Comprehensive Care Plan, dated 02/25/2026, reflected Resident #58's ADLs was not documented on the comprehensive care plan. Observation on 04/21/2026 at 10:40 am revealed Resident # 58 was sitting in the dining room area with other residents. She was not interacting with other residents. Resident #58's fingernails on her right hand underneath her middle and ring fingernails had a blackish/brownish substance. Resident #58 was not interview able. In an interview on 04/23/2026 at 8:10 am, RN J stated the nurses were responsible for all residents with diagnosis of diabetes nail care such as trimming, cleaning, and filing. She stated the CNAs were responsible for all other residents' nail care. She stated nail care was usually completed on Sundays, as needed and during showers. RN J stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as an infection in the stomach. She stated there was a possibility a resident may have nausea and vomiting. RN J stated if a resident refuses showers, nail care or any type of care the nurses document in the nurse's progress notes. She stated if a female had facial hair on their face, there was a possibility the resident may become embarrassed of her appearance and may not want to interact with other residents or leave their room. She stated facial hair on female residents was expected to be removed as needed and during showers. RN J stated she had been in-serviced on ADL care, and all staff was to report any nail issues with the resident to the nurse.In an interview on 04/23/2026 at 8:23 am, CNA D stated the nurses were responsible for diabetic nail care. She stated if a CNA observed any problems with a resident's nails the CNA was to report it to the nurse supervisor with any resident. CNA D stated the CNAs complete all nail care for residents without a diabetes diagnosis. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA D stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated all female residents' facial hair was checked on shower days and as needed. She stated if a female had facial hair the resident may feel humiliated if other people made comments to them about having facial hair. CNA D stated anytime a resident refused any type of care she reported it to the charge nurse and the charge nurse would document it in the resident's medical record. She stated she was not aware of Resident # 58 or Resident #52 refusing nail care. She stated she had been in-service on nail care; however, she did not recall the date.In an interview on 04/10/2026 at 9:45 am, the Director of Nurses stated the CNAs were responsible to clean and trim all residents' nails except for the residents with diabetes. She stated the nurses were responsible for nail care for diabetic residents. RN B stated the residents' nails were usually cleaned during shower days and on Sundays. She stated if a resident ingested blackish/brownish substance there was a potential the resident may experience vomiting or diarrhea. She stated it depended on the type of bacteria. The Director of Nurses stated she expected nail care to be completed as needed and on shower days. She stated anytime there was an issue with nails the staff was to report it to the nurse supervisor. The Director of Nurses stated all female resident was not to have any facial hair unless that was their preference. She stated facial hair on all residents including female residents was to be checked on shower days and as needed. The Director of nurses stated any refusal of care would be documented on the resident's care plan. Record review of the facility's policy on Nail Care, 2001, reflected Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care).

Based on interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 3 of 8 residents (Resident #17, Resident #52 and Resident # 58) reviewed for care plans.1. The facility failed to develop and implement Resident # 17 and Resident #52's care plan to reflect Activity Plans and Interventions.2.The facility failed to develop and implement Resident #52's care plan to reflect ADLs and Activity Plans and interventions.3. The facility failed to develop and implement Resident #58 care plan to reflect ADLs.This failure could place residents at risk of not having their needs met to attain their highest practicable well-being.Findings include: 1.Record review of Resident #17's face sheet, dated 04/22/2026, reflected a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses which included senile degeneration of brain, not elsewhere classified ( a progressive decline of memory loss and confusion associated with aging but it is not caused by specific diseases like Alzheimer's- irreversible brain disorder that slowly destroys memory, thinking skill, and eventually the ability to perform daily tasks- or vascular dementia - a decline in thinking, and memory caused by conditions that damage blood vessels in the brain, reducing or blocking blood flow and oxygen), polyneuropathy ( chronic disorder causes widespread of numbness, tingling, burning pain, and muscle weakness, typically staring in the hands and feet before potentially affecting other areas), and major depressive disorder ( a common but serious mental health condition characterized by a persistent feeling of sadness).Record review of Resident #17's admission MDS Assessment, dated 02/14/2026 reflected Resident #17 had a BIMS score of 6 which indicated her cognition was severely impaired. She was assessed of feeling down, depressed, or hopeless. Resident #17 activity preferences was the following : Have books, newspaper, and magazines to readListening to favorite musicDo things in with groups of peopleDo favorite activitiesGo outside to get fresh air when the weather was goodParticipate in religious services or practices.Record review of Resident #17's Comprehensive Care Plan, dated 02/23/2026, reflected Resident # 17 did not have an activity care plan related to her activity preferences and abilities to participate in activity programming. 2. Record review of Resident #52's face sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), major depressive disorder ( a common but serious mental health condition characterized by a persistent feeling of sadness), and anxiety disorder ( a group of treatable mental health conditions characterized by excessive , persistent, and uncontrollable fear, worry, or dread that interferes with daily activities).Record review of Resident #52's Annual MDS Assessment, dated 08/09/2025, reflected Resident #52 had a BIMS score of 3 indicating his cognition was severely impaired. The following activities were very important to Resident #52:Keeping up with the newsDoing things in groups of peopleDoing favorite activitiesParticipating in religious services or practicesListening to favorite music.Record review of Resident #52's Quarterly MDS Assessment, dated 03/02/2026, reflected Resident #52 had a BIMS score of 4 indicating his cognition was severely impaired. Record review of Resident #52's Comprehensive Care Plan, dated 03/10/2026, reflected Resident #52 did not have an ADL and activity care plan related to his activity preferences and abilities to participate in activity programming3.Record review of Resident #58's face sheet, dated 04/22/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety ( a medical diagnosis indicating that a person has a clear memory loss and the specific cause and severity have not been determined and does not have any behaviors associated with unspecified dementia), muscle weakness ( a feeling or objective observation that reduced effort, such as attempting to lift or move, fails to produce normal muscle contraction), need for assistance with personal care ( requiring hands-on support with activity of daily living due to age, disability, illness, or injury), and lack of coordination (inability to manage precise, smooth, and voluntary muscle movements causing difficulty with daily activities such as : walking, writing, or grasping objects).Record review of Resident #58's Quarterly MDS Assessment, dated 02/11/2026, reflected Resident #58 was rarely/ never understood. She had poor short- and long-term memory recall. Resident #58's decision making ability was severely impaired. She required substantial / maximal assistance (helper does more than half the effort) with showers. Resident #58 was dependent on staff with the following ADLs:Personal HygieneUpper and lower body dressingToileting HygieneRecord review of Resident #58's Comprehensive Care Plan, dated 02/25/2026, reflected Resident #58's ADL's was not documented on the comprehensive care plan.Interview on 04/21/2026 at 11:30 am the Activity Director stated Activity Assistant A planned all activities on the secure unit. She stated all activities programs was expected to be on each resident's care plans. The Activity Director stated it was very important for the residents Activity preferences to be documented on care plan and if they were not capable of doing certain things in activities, they also needed to be care planned. She stated Activity Assistant A was to relate residents activity preferences and her plan for the resident to the MDS Coordinator to enter the information on the care plans. The Activity Director stated she was the Activity Assistant A's supervisor, and she had no explanation of why activity care plans for Resident #12, Resident #52, and Resident #58 were not on their comprehensive care plan. The activity director did not respond to any further questions about the care plan process of how activities were to ensure activity preferences and plan for the next quarter was not on their comprehensive care plan. Interview on 04/23/2026 at 9:15 am the MDS Coordinator LVN stated the Activity Director or Activity Assistant A was expected to discuss the activity plan for each resident with the interdisciplinary team. She stated it was very important for all residents Activity Plans was added to the care plan. She stated the staff would not know what type of interventions to do with a resident if a resident had behaviors, depression or anxiety if there was not an activity care plan. She stated if a resident was required to receive 1:1 activities it was very important for this to be documented on the resident's care plan for staff to know the resident responds more to 1:1 activities instead of group activities. She agreed Resident #17, Resident #52 and Resident #58 did not have an activity care plan. MDS Coordinator LVN stated it was the Activity Department responsibility to ensure they discuss activity plans during care plan meetings and add the activity plan to each resident's plan. She stated if a resident did not have their ADLs documented on the comprehensive care plan it would be difficult for the staff to have the knowledge of what type of care to give the resident. Interview on 04/23/2026 at 9:30 am Activity Assistant A stated she was instructed by the Activity Director to report any activities she planned for the residents to the MDS Coordinator to document on their care plan. Activity Assistant A stated Resident #17, Resident #52, and Resident #58 needed 1:1 activities every day and they needed to do their favorite activities. She stated she did not have a list of the resident's activity preferences. Activity Assistant A stated she knows what they were capable of doing and what they liked to do in activity programs. She stated it would be difficult for other staff to know the resident's preferences if it was not documented on the care plan. Activity Assistant A stated she does have her Activity Director Certificate. She stated she had been working at the facility approximately a year as Activity Assistant on the secure unit. Activity Assistant A stated she would need to review the care plan policy prior to answering any further questions about care plans for resident activities. Activity Assistant A did not answer any further questions about activity care plans prior to exit. Interview on 04/23/2026 at 10:14 am the Administrator stated a resident's activity preferences and interventions to meet a resident's quality of life through the activity programming was expected to be care planned. She stated if a resident needed 1:1 activities the other staff needed to know this information to prevent residents from becoming frustrated when staff may invite him to activity programs. The Administrator stated the Activity Director was responsible for discussing activities for each resident in the care plan with the interdisciplinary team and developing an activity care plan for the next quarter for each resident. She stated she was the Activity Director's supervisor and was responsible for monitoring the activity department. She stated all care was to be documented on the care plan including ADLs. She stated the staff refers to the care plans to know what the resident's physical, mental, and emotional needs. Record review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated 2001, reflected A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan: Includes measurable objectives and timeframes.Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Includes the resident's stated goals upon admission and desired outcomes.Builds on the resident's strengths; andReflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for 2 residents (Resident #10, and Resident #24) of 8 residents observed for infection control practices. The facility failed to ensure RN J followed the hand hygiene policy procedures during wound care on 04/22/2026 for Resident #10 and Resident #24. This failure could place residents at risk for healthcare-associated cross-contamination and infections.Findings included: Review of Resident #10's face sheet dated 04/21/2026 revealed he is a [AGE] year-old male initially admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] with the following diagnoses: Type 2 diabetes mellitus (a chronic condition where the body develops insulin resistance, which is a condition where body cells fail to respond effectively to insulin eventually leading to high blood sugar or type 2 diabetes); Stage 3 pressure ulcer of sacral region (a full thickness skin loss over the tailbone area where subcutaneous fat is visible, but muscle, tendon, or bone is not exposed); end stage renal disease (permanent kidney failure where function falls below 10-15%, requiring dialysis or transplant for survival); and dependence on renal dialysis (chronic, ongoing dependence on dialysis [life-sustaining treatment for kidney failure, filtering water and excess fluid from the blood when kidneys can no longer function]). Review of Resident #10's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 5 which indicated severe cognitive impairment. Review of Resident #10's care plan with an initiation date of 12/18/2025 revealed he is on enhanced barrier precautions. Enhanced barrier precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds). An intervention with a revision date of 01/05/2026 revealed staff must use gown and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. An intervention with an initiation date of 12/18/2025 revealed staff are to wash hands or use alcohol-based gel when entering and exiting the resident room. Observation on 04/22/2026 at 9:41 am reflected RN J failed to clean Resident #10's bedside table prior to placing the wound care supplies onto it. She began wound care on Resident #10's left lateral great toe wound. When she was done, she removed her gloves and gown. She failed to perform hand hygiene. She left the room to get more wound care supplies. When she returned, she failed to perform hand hygiene prior to putting on a new gown and a new pair of gloves. She performed wound care to Resident #10's right medial foot. She changed her gloves and failed to perform hand hygiene. Further observations were made of the complete wound care process for Resident #10, and no other concerns were identified. Review of Resident #24's face sheet dated 4/23/2026 revealed he is a [AGE] year-old male initially admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] with the following diagnoses: peripheral vascular disease (a slow, progressive circulation disorder involving blood vessel blockage or narrowing outside the heart/brain, often causing reduced blood flow to legs, arms, or organs); open wound to his right foot; and non-pressure chronic ulcer (long-lasting skin breaks caused by underlying conditions like poor circulation, diabetes (a chronic condition causing high blood sugar due to insufficient insulin production or ineffective use of insulin), or infection rather than pressure) of other part of left foot [excluding heel/midfoot). Review of Resident #24's annual MDS assessment dated [DATE] revealed he had a BIMS score of 3 which indicated severe cognitive impairment. Review of Resident #24's care plan with an initiation date of 12/18/2025 revealed he is on enhanced barrier precautions. Enhanced barrier precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds). An intervention revealed staff must use gown and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. An intervention with an initiation date of 12/18/2025 revealed staff are to wash hands or use alcohol-based gel when entering and exiting the resident room. Observation on 04/22/2026 at 10:16 am reflected RN J failed to perform hand hygiene after doing wound care on Resident #24s left heel wound and beginning wound care on his right lateral ankle. She failed to perform hand hygiene or change gloves after cleaning Resident #24's right lateral ankle wound. She proceeded to dress Resident #24's right lateral ankle wound. Once wound care was completed for Resident #24, she washed her hands in the sink with soap and water for less than 10 seconds. Further observations were made of the complete wound care process for Resident #10, and no other concerns were identified. In an interview on 04/23/2026 at 2:40 pm, RN J reported she has worked at the facility for about a month. She reported she cleaned the bedside table prior to performing wound care for Resident #10. She stated, once I remove the old dressing, I change dirty gloves to clean gloves, do the wound care, and put the patient back the way they were. She stated, if the old [gloves were contaminated, I would put on new clean gloves. She stated, I try to wash my hands rather than using sanitizer. My hands don't tolerate it. It tears up my skin really bad, and it gets sticky. She agreed that she should perform hand hygiene after removing her gloves prior to moving from cleaning a dirty area to working on a clean area on the resident. She reported residents could get an infection. She reported she received orientation training. She stated, I still have [trainings] due. I don't think I did any. She stated, I followed a nurse for a couple of days.as we ran into things I would ask how they do things around here. She stated, I know what should be there and what should be done. I am learning how the facility does things. In an interview on 04/23/2026 at 6:20 pm, DON reported she was the infection control preventionist. She reported that she was responsible for monitoring infection control. She reported the nurse's and ADONs also monitor it. She reported staff need to take their gloves off and wash their hands or use hand sanitizer prior to putting on new gloves. She stated, cross contamination is possible if they fail to perform hand hygiene between glove changes. Review of infection control and control committee policy with a revision date of 07/2016 revealed the infection prevention and control committee will oversee the infection prevention and control program and report to the infection prevention and control committee. The administrator will be responsible for oversight of the infection prevention and control program. The infection prevention and control committee assist in monitoring and assessing facility-wide environmental infection prevention and control practices. The infection control committee shall oversee training programs for all employees who may have the potential for exposure to blood, or to body fluids containing visible blood, during the course of their workday. Instructions will focus on identifying and using procedures related to the prevention of bloodborne illnesses, including but are not limited to: 1. disease transmission and prevention.3. standard and transmission-based precautions.5. types of personal protective equipment (i.e., gowns, gloves, masks) that are necessary when performing tasks that may involve exposure to blood/ body fluids,8. Procedures to follow when personal protective equipment is used.9. how personal protective equipment in the facility is to be used, decontaminated, and disposed of. Review of the handwashing/hand hygiene policy with a revision update of 01/2025 revealed the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The following are administrative practices to promote hand hygiene: 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility. 4. Personnel are educated regarding ways to prevent contact dermatitis and other skin irritation and provided with supplies that support healthy hand skin. A. Facility-supplied lotions are compatible with antiseptics and gloves. B. ABHRs, soaps and lotions are free of allergenic surfactants, preservatives, fragrances and dyes. Indications for hand hygiene: 1. Hand hygiene is indicated a. immediately before touching a resident; b. before performing an aseptic (techniques and environments free from disease-causing microorganisms); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after the glove removal. 5. The use of gloves does not replace handwashing/hand hygiene. Washing hands: 1. Wet hands first with warm water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.

Based on observation, interviews and record reviews the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (Resident #36) out of 8 residents reviewed for medications. The facility failed to update Resident #36's medication label for hydrocodone-acetaminophen 5-325 mg tablet to reflect a change in the frequency of the administration of the medication. This failure could have placed residents at risk for a medication error such as not receiving adequate pain medication as ordered by the physician.Findings include: Review of Resident #36's face sheet dated 04/23/2026 revealed an [AGE] year-old male initially admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] with the following diagnoses: encephalopathy (brain dysfunction, damage, or disease); cerebellar stroke syndrome (a serious neurological condition caused by interrupted blood flow or bleeding in the cerebellum, which is located at the back of the brain); pain; localized swelling, mass and lump, lower limb, bilateral; and cognitive communication deficit. Review of Resident #36's quarterly MDS dated [DATE] revealed Resident #36 had a BIMS score of 12 which indicated moderate cognitive impairment. Review of Resident #36's comprehensive care plan with an initiation date of 11/19/2025 revealed Resident #36 had acute/chronic pain with the following interventions: administer pain medications per order. Review of physician orders printed on 4/23/2026 revealed an order for HYDROcodone-Acetaminophen Oral Tablet 5-325 mg (Hydrocodone-acetaminophen) *Controlled Drug* Give 1 tablet by mouth three times a day with a start date of 03/29/2026 at 7 pm. Review of discontinued medication orders dated revealed HYDROcodone-Acetaminophen Oral Tablet 5-325 mg Give 1 tablet by mouth every 6 hours as needed for pain was started on 01/20/2026 at 6:15 pm and discontinued on 02/19/2026 at 7:32 pm. Review of the medication administration record dated 02/2026 revealed Hydrocodone-Acetaminophen 5-325 mg Give 1 tablet by mouth three times a day for pain with a start date of 02/20/2026 at 7 am and a discontinue date of 03/29/2026 at 4:43 pm. Observation and interview on 4/21/2026 at 10:18 am reflected Resident #36 was lying in bed and stated, this morning I ordered two pain pills at 7 am and didn't get them until just before you came. My left knee was hurting. Resident #36 rated his pain level at 10 which indicated severe pain on a scale of 1-10. In an interview on 4/23/2026 at 12:50 pm with ADON, she reported when the frequency of administration for a medication had changed, the medication aide and nurse can place a change of direction label on a medication. She stated, ultimately it would be the nurse's responsibility. She reported, the nurses give all prn [as needed] meds. She reported Resident #36 had an order for hydrocodone-acetaminophen 5-325 mg 1 tablet by mouth three times a day. She stated Resident #36 did not have a prn (as needed) order for hydrocodone-acetaminophen 5-325 mg. She reported a change of direction label should have been put on the medication card. She reported the prn order was discontinued. She denied that Resident #36 requests hydrocodone-acetaminophen 5-325 mg pain medication more often than it was ordered. She stated, [Resident #36] hasn't requested [as needed medication] from me since March. In an interview on 04/23/2026 at 12:47 pm with MA/CNA K, she reported ADON told her to put a change of direction label on Resident #36's hydrocodone-acetaminophen 5-325 mg medication which was in MA/CNA K's medication cart. She reported she told ADON to be honest that they were using the tablets from the hydrocodone-acetaminophen 5-325 mg prn medication card to administer Resident #36's scheduled hydrocodone-acetaminophen 5-325 mg medication. She reported she was aware Resident #36 received the medication three times a day, but someone who was not familiar with his medications could make a medication error if a change of direction was not on the label. In an interview on 04/23/2026 at 2:40 pm, RN J reported prn medications were given by the nurses. She reported the medication aides give scheduled medications, but the nurses give the initial doses of the medications. She stated, there should be a card for scheduled and prn medications. She reported when the frequency of the medication is changed, and staff fails to place a change of direction label on the medication, then a medication error could occur. She reported staff may check the medication administration record or look at the computer screen to make sure it is the most current medication order. She stated, they can also go back to the orders and can see if the order had changed. She reported the nurse who received the order to change the frequency of administration for the medication would be responsible for placing a change of direction label is on the medication card. In an interview on 04/23/2026 at 6:20 pm with the DON, she reported the nurse who gets the order was responsible for putting a change of direction label on the medication card. She stated, it will flag the med aides in the electronic medical record.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure the Dietary Manager and Dietary Aide G used proper hand hygiene during food preparation. These failures could place residents who ate food from the kitchen at risk for foodborne illness.Findings included: Observation on 04/22/2026 at 8:15 am the Dietary Manager was wearing gloves in the kitchen. She was serving breakfast from the steam table. She picked up a red crate (used all fingers on both hands) stored near the steam table and moved it to a different area in the kitchen. The Dietary Manager returned to the steam table and did not change her gloves. Her thumb and forefinger on her right hand touched inside a divided plate and placed food on the area where she had touched inside the plate. She exited the steam table area of the kitchen and entered the back of the kitchen to obtain a pitcher. When she placed her hands on the pitcher from the shelf behind the kitchen her forefinger, middle finger and ring finger touched the shelf. The Dietary Manager returned to the steam table and did not change her gloves. She continued to serve food and placed oatmeal in a bowl. When she placed the oatmeal in a bowl her forefinger and middle finger on her right hand touched the oatmeal. The Dietary Manager continued to serve several more plates. She did remove her gloves and washed her hands and placed new gloves on her hands at the end of meal service. Interview on 04/22/2026 at 8:35 am the Dietary Manager stated she did not change her gloves when she was placing food on residents plates and bowls. She stated she did touch the crate, but she did not consider the crate contaminated. The Dietary Manger stated she did not recall if she touched the shelf when she grabbed the pitcher. She stated when she walked away from the steam table to another part of the kitchen to obtain pitcher this was not considered changing tasks in the kitchen. She stated the dietary staff did not sanitize the crates and she did not know how many people had touched the crates without washing their hands. The Dietary Manager stated her gloves were not contaminated and she was not required to change her gloves if she touched a shelf or a crate in the kitchen. She later stated after thinking about what she touched, she was expected to change her gloves and wash her hands prior to continuing serving breakfast. The Dietary Manager stated she did not change her gloves when she touched the crate or the shelf. She stated she had given and received in-services on hand hygiene. She stated she did not remember the date. Interview on 04/23/2026 at 10:14 am the Administrator stated she expected the dietary staff to change their gloves and wash hands in between tasks or whenever they touched any contaminated items. She stated if dietary staff did not change their gloves after touching anything considered contaminated, there was a potential a resident may become ill with an upset stomach such as nausea if a resident ingested any type of bacteria in their food. The Administrator stated the Dietary Manager was responsible to monitor the kitchen. She stated she was the Dietary Managers supervisor. Observation on 04/23/2026 at 10:47 am Dietary Aide G was cutting cheesecake and placing them on dessert plates on the food prep table located to the side of the steam table. She was wearing gloves. Dietary Aide G exited the food prep area and as she was walking to another area of the kitchen she touched her shirt in the left shoulder area with her right hand. Dietary Aide G returned to the food prep area and continued to cut the cheesecake and place the cake on dessert plates. She touched the side of two pieces of cheesecake with her right hand. She also touched inside 4 dessert plates and placed the cheesecake slices on these dessert plates. Interview on 04/23/2026 at 10:55 am Dietary Aide G stated if she touched her clothes it was a habit and did not realize she touched her top. She stated anytime she touched her clothes she was expected to change her gloves, wash her hands and place new gloves on her hands. She stated there was a possibility germs may have been on her gloves. Dietary Aide G stated there was a possibility germs may have transferred from her gloves to the cheesecake or plate. She stated if a resident ate the cheesecake and it had germs on the cheesecake a resident may become sick with upset stomach. Dietary Aide G stated she had been in-service on hand hygiene and changing her gloves. She stated she did not remember the date or time of the in-service. Record review of in-service on Hand Hygiene, dated 04/08/2026 reflected Dietary manager signed hand hygiene in-service record. Record review of in-service on hand washing and hand hygiene, dated 03/16/2026, reflected Dietary Aide G signed in-service record. The in-service was given by the Dietary Manager. Record review of the facility's Handwashing/ Hand Hygiene policy for nursing infection control, dated 01/2023, reflected The facility considers hand hygiene primary means to prevent the spread of infections. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.

Based on observation, interviews, and record review, the facility failed to ensure a resident with dementia received the necessary care and services to support the highest practicable level of physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #2) reviewed for dementia care. The facility did not identify, document, or implement individualized person-centered interventions that were cognitively appropriate for Resident #2. There was no evidence that care planning addressed the resident's specific preferences, abilities, or need for engagement. This failure resulted in lack of dementia-focused care and placed the resident with dementia at risk for increased behavioral symptoms, boredom, and a decreased quality of life.Review of Resident #2's Face Sheet dated 04/21/2026 indicated Resident #2 was a [AGE] year-old female was admitted to the facility initially on 07/17/2025 and last admitted to facility on 03/06/2026 with multiple diagnosis to include hyperosmolality and hypernatremia (large quantity of body fluids are elevated and high sodium levels were in the blood),unspecified dementia(decline in memory and thinking skills), major depressive disorder(sadness loss of interest) anxiety(feelings of panic, fear, irritability) and hypothyroidism(thyroid gland does not produce enough thyroid hormone).Review of Resident #2s Quarterly MDS assessment dated [DATE] revealed that Resident #2 did not a have recorded BIMS score as it noted resident was unable to complete interview as resident was rarely/never understood. Staff Assessment for Mental Status indicated Resident #2 c ognitive skills were severely impaired. Review of Resident #2's comprehensive care plan dated 4/21/2026 included only two focus areas: Resident #2 had a DNR in place and she was at risk for falls related to balance problems.Review of Resident #2's psychiatric evaluation visit note dated 01/12/26, revealed Resident #2 was seen for moderate dementia with behavioral disturbances, delusional disorders, generalized anxiety disorder, major depressive disorder, moderate and primary insomnia. The evaluation further stated, Care Plan Recommendations: The plan of care was discussed with the DON and medication management reviewed.Utilize behavioral interventions to manage episodic behaviors(agitation/aggression), redirect as needed.Provide supportive encouragement to increase interaction to improve socialization.Staff will notify psychiatry services if resident begins to exhibit and signs of worsening mood, anxiety, confusion, or behaviors between visits.Observation and interview conducted 4/21/2026 at 1:09 PM, revealed Resident #2 yelling Oh God while in bed. She was unable to answer questions regarding whether she needed assistance or was she in pain.In an interview conducted 04/23/2026 at 2:10 PM with DON and RNC. They stated the correct care plans were in the miscellaneous section of the electronic health records. It was explained that the facility had been converting documents since October 2025 from their previous system to the current system. RNC provided a printed copy of Resident #2 comprehensive care plan. Resident #2 current care plan was reviewed by the surveyor, and it failed to include dementia as an area of focus and absence of individualized interventions to address resident's cognitive needs.In an interview conducted 04/23/2026 at 4:45 PM, the MDS Coordinator stated she was responsible for care plan entries and reported that the DON inputs information related to wounds. The MDS Coordinator stated she was unsure why dementia was not included on Resident #2's care plan and acknowledged that it should have been care planned, as the resident was followed by psychiatric services. The MDS Coordinator further stated that the potential effect of not including dementia on the care plan was that the resident may not receive appropriate care and services for dementia. She stated the care plan would be updated on the day of the interview.In an interview conducted 04/23/2026 at 4:53 PM, the RNC stated that dementia should be included on a resident's care plan when a diagnosis is present. She stated that it was important for staff to have this information care planned so they can understand how to appropriately care for the resident. The RNC further stated that failure to include dementia on the care plan could result in staff not understanding the residents' needs and abilities. She indicated that this could lead to the resident not receiving appropriate care.In an interview conducted 04/23/2026 at 4:59 PM, the DON stated that care plans were discussed and reviewed during morning meetings and are updated through the MDS process on a quarterly basis. She stated that nursing staff complete a baseline care plan upon admission, and the MDS Coordinator updates the care plan with input from the Interdisciplinary Team. The DON stated that dementia was required to be included on the care plan when a resident has a diagnosis. She reported that the facility provides dementia-related training and in-service education, and that CNAs were trained in dementia care. The DON further stated she did not know why dementia was not included on Resident #2's care plan. She emphasized that it was important for dementia to be reflected on the care plan so staff are aware of appropriate interventions and can provide individualized care. The DON stated that failure to include dementia on the care plan could result in the resident not receiving the best possible individualized care. She further indicated that potential harm could occur if a resident was experiencing pain but was unable to effectively communicate their needs, and staff may not recognize or properly respond due to dementia-specific interventions not placed on the care plan.In an interview conducted 04/23/2026 at 5:22 PM, the Administrator stated that the MDS Coordinator was responsible for updating residents' care plans. She stated that dementia should be included on the care plan when a resident has a diagnosis. The Administrator reported that staff receive training on dementia care. She further stated that failure to include dementia on the care plan could negatively impact the resident's overall care. The Administrator stated her expectation was that the care plan be updated to accurately reflect the resident's diagnosis and care needs.Record review of the facility's policy titled; Dementia -clinical Protocol dated 2001 revised date November 2018 Treatment/Management1. For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life.2. Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually, and in-service education will be based on the results of the reviews.5. The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise.a. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools).Monitoring and Follow-Up1. The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician/physician extender.2. The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors.Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered Policy, dated 2001, revision date March 2022 reflected: A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan:b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observations, interviews and record review, the facility failed to ensure each resident was treated with respect, dignity and care for 1 of 4 residents ( Resident #10) observed for resident rights. RN J failed to ensure Resident # 10's privacy curtain was used or the door to his room was closed when RN J was repositioning Resident #10 in bed and did not ensure his buttocks was not exposed. This failure could place residents at risk of feeling embarrassed and diminish the resident's quality of life. Findings included:Record review of Resident #10's face sheet, dated 04/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of depression ( a common but serious mental health condition characterized by a persistent feeling of sadness), anxiety disorder ( a group of treatable mental health conditions characterized by excessive , persistent, and uncontrollable fear, worry, or dread that interferes with daily activities), and pressure ulcer of sacral region (a damaged area of skin and underlying tissue, ranging from red skin to a deep crater, located on the triangular bone at the base of the spine - sacrum).Record review of Resident #10's Quarterly MDS Assessment, dated 03/03/2026, reflected Resident #10 had a BIMS score of 5 indicating his cognition was severely impaired. He was assessed to have a pressure ulcer. Resident #10 was dependent on staff for the following ADLs:Upper and lower body dressing.Eating.Toileting hygiene.Personal hygieneResident #10 required substantial/maximal assistance (helper does more than half the effort) with the following:Rolling left and right when in bedSit to lying when in bedLying to sitting on side of bed Record review of Resident #10's Comprehensive Care Plan, revised on 03/25/2026, reflected Resident # 10 had a Stage 3 coccyx pressure ulcer. Interventions: follow orders for prevention/treatment of skin breakdown. Notify MD/RP of any worsening of wound. Observation on 04/21/2026 at 10:55 am revealed Resident #10's door was opened, and privacy curtain was not pulled when he was in bed and being repositioned by RN J while he was receiving x-ray. RN J moved Resident #10 toward the window and was holding him while his buttocks was exposed and could see an open area to his sacrum. Interview and observation on 04/21/2026 at 10:57 am CNA E stated Resident #10 was exposed and could see his buttocks and the pressure wound to his buttocks. CNA E stated anytime a resident was receiving care the privacy curtain was expected to be pulled and the door to the resident room to be closed. He stated this was a dignity issue and may humiliate a resident for their buttocks to be shown to anyone passing in the hallway. He stated he had been in-service on resident rights and dignity. He stated he did not remember the date of the in-service. CNA E did not enter the room to ask RN J to pull privacy curtain and did not close the door. CNA E walked toward the end of the hallway (100 hall) where Resident #10 resided. Observation on 04/21/2026 at 11:04 am RN J asked the person from the x-ray company to pull the privacy curtain the surveyor was in the hall. The lady from the x-ray company pulled Resident #10's privacy curtain.Interview on 04/21/2026 at 11:30 am RN J stated anytime care was given to a resident the privacy curtain was expected to be pulled and the door closed to the hallway. She stated Resident #10's buttocks was exposed and anyone passing in the hall would be able to view his buttocks. RN J stated this was a dignity issue and may cause embarrassment or humiliation to Resident #10. She stated she did not know if she would have told the lady from the X-ray department to close the privacy curtain if she had not seen surveyor in the hallway. She stated she did not think about pulling the privacy curtain until she saw the surveyor. RN J stated she had been in-serviced on resident rights and knew this was a resident right to provide privacy during any type of care to a resident. She did not recall the date when she received resident rights in-service or dignity in-services. Interview on 04/21/2026 at 12:05 pm Resident #10 stated he did not want his bottom to be where other people could see it (referring from the hallway). He stated it wasn't nice for people to see him naked in the hall. Resident #10 stated he did not want to talk anymore.Interview with the Administrator on 04/23/2026 at 1:40 p.m., she stated in-services had been given to all staff regarding dignity and resident rights. She stated she did not recall the date of the last in-service. The Administrator stated it was a resident right to preserve the resident's dignity. She stated RN J was expected to pull the privacy curtain and close the door to Resident #10's room prior to repositioning him. The Administrator stated all staff was responsible to ensure Resident Rights are being followed including dignity. She stated if a resident was exposed there was a possibility the resident may become embarrassed, feel humiliated or can become upset by other people in the hall observing their private area. Record Review of the Facility's Policy on Dignity, dated February 2021, reflected Each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Policy Interpretation and Implementation include the following:Residents are treated with dignity and respect at all times.The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interviews, and record reviews the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of two housekeeping carts (Housekeeping Cart #1) reviewed for hazards.The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. This failure could place residents at risk for injuries, illness, and hospitalization. Findings included:Observation on 04/21/2026 at 9:30 am revealed Housekeeping Cart #1 was located in the dining room. The compartment where chemicals were stored was not locked. The compartment had glass cleaner, disinfectant cleaner, tub and tile cleaner, and bio waste degrader. Housekeeper H was not standing near the housekeeping cart, and no other staff was near the unlocked housekeeping cart. Housekeeper H was behind the wall in the dining room and was unable to view the housekeeping cart.During an interview on 04/21/2026 at 9:35 a.m., Housekeeper H stated the housekeeping cart was expected to be locked anytime housekeeper walked away from the cart. Housekeeper H stated she could not see Housekeeping Cart #1 from where she was standing behind the wall in the dining room. She stated there was a possibility that if a resident drank some of the chemicals the resident may become sick with stomach issues or have an allergic reaction. She stated it was possible a resident may need to be evaluated at the hospital. She stated she did have a key to the housekeeping cart, but it was difficult to lock the cart.Interview on 4/23/2026 at 10:14 a.m., the Administrator stated he expected the housekeeping cart to be locked at all times when the housekeeper was not obtaining an item from the housekeeping cart. The Administrator stated all housekeeping staff had been in-serviced on locking the housekeeping carts. The Administrator stated if a resident drank a chemical there was a possibility a resident may become ill with nausea and vomiting. She stated there was a possibility a resident may need to be transported to the emergency room for further evaluation. Interview on 04/23/2026 at 1:30 p.m., the Housekeeping Supervisor stated if a resident swallowed the chemical the nurse would not know what type of care to give the resident without knowing the name of the chemical. She stated all housekeeping carts were expected to be locked anytime the housekeeper was not standing in front of the cart. The Housekeeping Supervisor stated if a resident ingested some chemicals there was a potential for an allergic reaction, such as burning their throat, stomach and may need to be assessed at the hospital. She stated all housekeeping staff were in-serviced on locking housekeeping carts. She stated there was a possibility if a resident spilled chemical on their skin it may cause irritation to the skin. Review of the Facility's Safety and Supervision of Residents dated 2001, Our facility strives to make the environment as free from accident and hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility Oriented Approach to Safety:Our facility -oriented approach to safety addresses risks for groups of residents.Safety risks and environmental hazards are identified on an ongoing basis.Our individualized, resident -centered approach to safety addresses safety and accident hazards for individual needs.Resident Risks and Environmental Hazards1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These are risk factors and environmental hazards include the following: a. poison control.Record request via email on 04/22/2026 at 9:49 am and on 04/23/2026 at 11:29 am of storage of chemicals on housekeeping carts related to accidents and hazards was requested and not provided prior to exit.

Based on observations, interviews, and record reviews, the facility failed to ensure that resident environment remained as free from accident hazards as is possible, by not providing adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for falls. The facility failed to provide adequate supervision to Resident #1, who has frequent falls and severe cognitive impairment, and was allowed to wander outside with no supervision near a busy highway with a speed limit of 45 mph and through restricted construction areas with uneven pavement.This failure resulted in an Immediate Jeopardy (IJ) situation on 11/26/2025. While the IJ was removed on 11/27/2025, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm with an isolated scope and severity. 2. The facility failed to ensure that nursing staff responded to an unwitnessed fall for Resident #1, and when notified by staff member dismissed the fall as a behavior. The fall was not documented by staff, reported to the DON, physician, or resident representative (RP). This failure could place residents at risk for serious injury, fracture, or death. Findings included: Record review of Resident #1's Facesheet dated 11/25/2025 reflected a [AGE] year-old, male admitted to the facility on [DATE]. Diagnoses included: Repeated falls, Impulse disorder, Cerebral Infarction, muscle weakness, unspecified lack of coordination, bipolar disorder, and chronic kidney disease requiring dialysis. Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 7 (severe cognitive impairment), He is partial to moderate assist when moving from sitting to standing and for all transfers. Review of Resident #1 care plan dated 11/25/2025 reflected a Problem area stating as follows: Problem Start Date: 11/15/2023 Category: Falls [Resident #1] has impaired balance during transfers, he is at risk for falls. [Resident #1] likes to self transfer and put himself on the floor at times. [Resident #1] likes to sleep on the floor. [Resident #1] will lean forward to pick up items from floor. [Resident #1] states he likes to lie on the floor 1/12/24 on floor----2/19 fall, 11/17/2024 fall, unwitnessed fall 1-11-2025 no injuries. 3/31/2025 unwitnessed fall x3 no injuries. 4/05/25 unwitnessed fall in restroom no injuries.4/20/25 witnessed fall in room with transfer 7/01/25 Edited: 10/15/2025 Edited By: LVN C. Problem Start Date: 04/25/2024 Category: Behavioral Symptoms [Resident #1] has taken himself outside the front door for fresh air, sunshine exposure and to just sit and watch traffic as well as rolls self around building for exercise Edited: 08/18/2025 Edited By: LVN C. Falls noted on Care Plan are dated 1/12/24, 2/19/24, 11/17/24, 1/11/25, 3/31/2025, 4/05/25, 4/20/25, 7/01/25 and 10/14/2025. Further review revealed there are no interventions related to the type or frequency of staff supervision outside during the day. Record review of Resident #1's progress notes from 9/26/2025 to 11/26/2025 revealed no documentation of a fall or reports of delay in care on 11/13/2025. There was no evidence that notifications were made to the physician, RP, or the Administrative staff. Record review of Resident #1's incident reports from 9/25/2025 to 11/25/2025 revealed no documentation of a fall or reports of delay in care on 11/13/2025. There was no evidence that notifications were made to the physician, RP, or the Administrative staff. Review of Resident #1 Fall risk assessment on 11/7/2025 reflected, History of falls (past 3 months): 3 or more falls in past 3 months . Resident is chairbound / incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 1-2 present. Resident did not have a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. 1. In an interview with CNA A on 11/25/2025 at 4:10PM she stated that Resident #1 was outside the facility doing laps around the building on his own. She stated that he would let himself out of the building. She stated that when he pushed the doors open it would set off the alarm and the staff would know that he was going outside. She led surveyor to the resident and stated that he was allowed to self-propel outside around the building without supervision or assistance. She left the surveyor and resident outside after observing him in that area. Observation of Resident #1 on 11/25/2025 at 4:15PM revealed he was alone outside the facility on the left side of the building, self-propelling in his wheelchair passed a section of broken caution tape. There was a strip of pavement approximately a foot wide, missing with exposed dirt and rocks that was below the level of the pavement. The broken, yellow caution tape was in front of the first strip of missing pavement. In front of Resident #1 was another strip of missing pavement that was below the level of the pavement. He was observed pushing himself over the second area without assistance or supervision from staff. There was caution tape on one side of the breaks in pavement only. The facility was directly adjacent to a busy, 4 lane highway with a paved, uneven driveway leading to the road. In an interview with Resident #1 on 11/25/2025 at 4:15PM, he stated that he was not able to remember how long he had lived at the facility. He stated that he could move himself safely outside alone. He stated that he had previous falls but could not recall when. He stated that he recalled falling on his face twice in the past and one of the times was outside the facility. He stated that he did not remember how long it took for someone to help him. He stated that he did recall falling on a Thursday night a few weeks prior and that it took about 30 minutes for the nurses to arrive. He stated that he fell on his knees while trying to walk and the nurse found him. He denied injuries with any of his falls. Interview with ADMIN and ADON on 11/25/2025 at 4:27PM, both stated that they were aware that Resident #1 was known to let himself out of the facility and self-propel around the building, unsupervised. They stated that he was care planned to be allowed to do so during the day. The ADMIN stated that staff check on him while he was outside every hour or two. She stated there are hazards outside the building from recent plumbing work. She stated the work started a week or two prior to this week. She stated that there was caution tape around the hazard. She stated that he has a history of unwitnessed falls outside. She stated there was no injury to his falls. She stated that to prevent future falls outside the staff told him to stay in the front area away from the caution tape. She stated that she did not know his current BIMS score, but that he was intact enough to follow staff instructions. She stated that the potential risk of allowing him to propel himself outside without supervision or assistance was that he could fall in the areas where the pavement was disturbed. The ADON stated that she was unaware of his last BIMS score. She stated that she did not know if a BIMS of 7 was cognitively intact. She was unable to recall what an intact BIMS score was. In a follow up telephone interview with CNA G on 11/25/2025 at 4:35PM, she stated that Resident #1 was able to go outside alone. She stated that he had fallen from his wheelchair outside the facility in the past to her knowledge. She was not sure when the fall outside occurred. In an interview on 11/25/2025 at 4:52PM with LVN F she stated that she was the nurse assigned to Resident #1 for 11/25/2025. She stated that he was allowed to go outside unsupervised. She stated that anywhere outside was hazardous for residents. She stated that Resident #1 falls frequently inside the building and has fallen outside in the past. She stated that he was not injured in his fall outside to her knowledge. She stated that there is hazard tape near the laundry room outside and he is known to go pass the tape and do loops around the building. She stated that they observe him intermittently through the windows as he goes around the building. She stated that they check on him approximately every 10 minutes. She stated that he should probably be supervised outside with his history of falls and impaired cognition. She stated that he could hurt himself while self-propelling alone, outside and staff might not be aware for ten minutes. In an interview with the ADMIN, DON, and ADON on 11/25/2025 at 5:34PM, they stated that they were not aware of any reports of a fall for Resident #1 on 11/13/2025 or any allegations that nursing did not respond right away to staff reports of an unwitnessed fall. They stated that Resident #1 would not be allowed out of the building, unsupervised at night. They stated that they were all on call and available every night for any reportable incidents or events and should have been informed if there was an allegation of negligence. In an interview with the DON on 11/26/2025 at 7:48AM, she stated that she started an investigation into the fall incident reported by the surveyor on 11/25/2025. She stated that the nurse on duty for Resident #1, LVN C, came into the facility and during an interview with the DON she stated that Resident #1 was found on the floor on 11/13/2025. She stated that LVN C stated that the resident told her that he was transferring from the wheelchair to the bed and went to the floor. She stated that it should have been treated as a fall, but that she thought that LVN C was confused with the context of the difference between Resident #1 placing himself on the floor and what should be considered a fall. She stated that LVN C was written up for the incident. She stated that any resident found on the floor is to be treated as a fall. She stated that it would be considered a, change in plane and should be documented in the resident records. She stated that from her interviews with LVN C and LVN B, it was approximately 2-3 minutes from the time that the fall was first reported by the MAINT DIR to when nurses responded to Resident #1. She stated LVN C stated that she would be right there. She stated that she was told that she needed to secure the medication cart and then responded to the fall. She stated that LVN B stated that the MAINT DIR came down the hallway to report the resident was on the floor, then before the MAINT DIR could get down the hallway to Resident #1's room, the visitor was already walking down the hallway to the nurse's station and the nurses were walking toward Resident #1's room. The DON stated that she was in-servicing staff on the facility policy for abuse, neglect, and exploitation recognition and reporting and the facility policy for falls. She stated that when anyone was found on the floor in the future, staff would need to fill out written statements regarding the incident and submit them to her or place them under her door if she was not present. She stated that she would have the social worker conduct safe surveys with the residents when she arrived on 11/26/2025. She stated that she had not interviewed the MAINT DIR yet, but she planned to speak with her that day. In an interview with the OT on 11/26/2025 at 8:52AM, he stated that Resident #1 is very impulsive. He stated that he self-propelled around the facility in his wheelchair. He stated that he is very difficult to redirect and cursed at staff when they attempted to interrupt him. He stated that the resident has a short frustration tolerance and refuses assistance at times. He stated that the residents did not have good safety awareness at times. He stated that he observed the resident coming in from outside a few days prior with mud covering his wheels. He stated that it was a fall risk to have mud on his wheelchair wheels, and he would not allow the OT to help him remove the mud. He stated that he knew Resident #1 had another fall the previous week, when he was found on the floor. He could not recall the day. He was not aware of a fall on 11/13/2025. He stated that the resident should be reviewed by the therapy department after all falls. He stated that he would consider it a fall if the resident was found on the floor. He stated that he knew that Resident #1 was known to deny falling at times when he was found on the floor. He stated that the therapy department's protocol for residents after a fall is to call the nurse and not to touch them until they are assessed by nursing. He stated that management and staff are all aware that Resident #1 was able to be outside unsupervised. He stated that it is unsafe for him to be alone outside, especially with the construction and areas of digging outside. He stated that the road in front of the facility is very busy. He stated that he had not known Resident #1 to attempt to go into the road. In an interview with the DOR on 11/26/2025 at 9:14AM, she stated that Resident #1 is currently receiving physical therapy three times a week. She stated that he propels himself with his feet in a wheelchair for his mobility. She stated that he is a contact guard assist for ambulating. She stated that he has no safety awareness and is difficult to redirect. She stated that he is known to be impulsive and does not respond to staff education. She stated that he had a history of placing himself on the floor at times. She stated that he had previous falls while propelling in his wheelchair, unsupervised while outside. She stated that he was a high risk for falls. She could not recall when the last fall outside occurred, but stated that was when his wheelchair got stuck on the front wheels and he could not move himself forward on his own and fell. She stated she had educated him on sitting back in the wheelchair and he refused to do so. She stated that his current fall precautions were for staff to try to supervise him and educate him to be aware of his surroundings, especially when he is outside. Staff were not required to be outside with him. She stated there are definitely hazards outside, which included the vehicles in the parking lot, vehicles on the busy road in front of the facility, and the areas of plumbing work going on outside the facility. She stated that she did not believe that, given his history and risk factors, he should be allowed outside, unsupervised. She stated that he knows how to get out of the door and was known to let himself out of the building. She stated that it was dangerous for him to be outside by himself. She stated that there is always a chance he could go into the busy road in front of the building and the parking lot to the facility was known to be busy also. She stated that Resident #1 has been behind her truck more than once while she was attempting to back out of the parking lot, and she only saw him because of the backup camera on her truck. She stated that she educated him regarding not positioning himself behind vehicles in the parking lot and he was not compliant with that education. She stated that the risk to the resident of being alone unsupervised is that they could get run over by a car or severely hurt. She stated that unless the staff happened to witness it, no one would know if he fell or was injured outside. She stated that if it was not time for him to go to an appointment or eat a meal, the staff, really wouldn't know that something had happened to him. In a follow up interview with the RNC on 11/26/2025 at 4:40PM, she stated that she was working to update the fall risk and interventions for residents identified as fall risks in their care plans. She stated that Resident #1 was placed under one to one staff supervision until a new plan is in place to ensure that he will not leave the facility unsupervised. She stated that she had a care conference with Resident #1 and that he was agreeable to the plan for additional supervision. She stated that he told her that he would not go outside without staff, but that she was concerned that he might leave without their knowledge. She stated that there is a possibility that a family member of another resident might know him to be allowed outside unsupervised, and let him out of the doors not knowing there had been a change in his care. On 11/26/2025 at 2:58 PM the surveyor provided an Immediate Jeopardy (IJ) Template notification to the RNC, ADMIN, and DON that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety to the Administrator and a Plan of Removal was requested. 2. Record review of text message from MAINT DIR to SC LVN reflected a text message sent at 10:02PM on 11/13/2025 stated, Hey, I don't know any update but I wanted to let you know that [Resident #1] was on the floor when I walked on [Resident #1's hallway] and the staff took forever to even help him up [Visitor D] walked up to them a second time and snapped on them. The return message from SC LVN on 11/13/2025 at 11:28PM stated, Wow. In an interview with MAINT DIR on 11/25/2025 at 11:10AM, she stated that on 11/13/2025 she observed Resident #1 on the floor in his room. She denied any other witnesses at the scene. She stated that she was unsure how long he had been on the floor. She stated that she informed 2-3 nurses at the nurses station, but they took, too long, about 5 minutes, to respond to the fall. She stated that Resident #1 stated he was on the floor for about an hour, but that she observed him in his wheelchair going down the hallway about ten minutes prior to that. She stated that she informed SC LVN about the fall for Resident #1 and the delay in nursing response. She did not recall which nurses were notified. She stated that was the only phone number that she had for the facility administration. She denied observing any other delays in care or concerning behaviors from nursing before or after this episode. In an interview with the ADON on 11/25/2025 at 10:51AM, she stated that the expectation for resident falls was that nursing assess the resident immediately. She stated that staff should not leave them alone after observing a resident on the floor. She state that nursing should perform vital signs, physical assessment, neurological assessment, and observe for any pain or signs of fracture. She stated that if there was an injury, staff should keep them there and call EMS (emergency medical services). She stated that if nursing was not responding immediately to fall and a resident was injured, they may not receive the medical care they need. She stated that she attends morning meetings and did not recall an incident or grievance of a fall where it was reported that staff did not respond immediately to the fall. Attempted a telephone interview with CNA J on 11/25/2025 at 12:43PM., a voicemail was not able to be left. Text message was sent to request a call back at that time. In a telephone interview with SC LVN on 11/25/2025 at 1:10PM, she stated that she was not in the facility in the evening on 11/13/2025. She denied receiving a call regarding a fall on that night or being found on the ground by staff. She stated that, depending on the circumstances, if a resident was found on the ground that she would consider it a fall and perform a physical assessment of the resident and get x-rays if there was concern for injury. She stated that nursing should report falls to the DON, RP, MD, and complete an incident report. She stated that Resident #1 likes to sleep on the ground. She stated that it was care planned. She stated that she had not observed the behavior, but she knew from conversations with staff that he does get on the ground. She stated that he requires assistance to transfer from the wheelchair, but she believed he could get up on his own from the ground, 9 times out of 10. She stated that if Resident #1 stated that he fell, that staff should treat it as a fall. She stated that when a fall was reported, that nursing should stop what they are doing and attend to the person right away. She stated that if a nurse was in the middle of a treatment or in another emergency situation, they should ask another nurse to assist the resident until they are able to get there. She stated that if nursing was not responding to resident falls right away that the resident could have a lot happen, including blood pressure changes, bleeding or other things that could prolong the healing process if there was an injury. In an interview with LVN B on 12/25/2025 at 12:49PM, she stated that she worked the day shift on 11/13/2025. She denied recalling a fall that day for Resident #1, but then stated that there was a day where the resident, put himself on the floor, and the MAINT DIR and an unknown visitor reported to nursing that Resident #1 was on the floor. She initially stated that one night nurse was passing medications and one was on a hallway. She stated that there was no call light on at the time. She gave multiple accounts of the locations and responses of LVN C and LVN H, who were the two nurses working the night shift on 11/13/2025. In version #1, she stated that the nurse passing medications finished her medication pass and went down the hallway after she was done. In version #2, she stated that the nurse passing medications was already closing her narcotic drawer and walking down the hallway while the second nurse was in the bathroom. She stated that it could not have been a minute after the reported fall, the nurse doing the medications was already walking down the hallway to respond to Resident #1. In version #3, she stated that the second nurse was exiting the bathroom while the nurse was closing the narcotic drawer and they both responded to the fall before she could have responded to the report from the nurses station. She stated that when the MAINT DIR and the visitor reported the resident was on the floor, she told the MAINT DIR that Resident #1 will, sit on the floor, and the other nurse stated that she would be right there. She did not indicate which LVN working that evening was the one passing medications. She stated that Resident #1 was care planned for a, change in plane. She stated that if Resident #1 stated that he put himself on the floor, that she would not treat it as a fall. She stated that he does it often, and she was not sure if she had documented every instance in which he was found on the floor and stated that it was not a fall on her shift. She stated she could not recall how often he exhibits that behavior. She stated that she did not respond to the fall because she had given report and was preparing to leave the facility. She did not report any direct interaction between nursing and the visitor. She stated that the impact to a resident of nursing not responding to a reported fall, is that they could have a fracture or a bleed that may cause more damage during that time or potentially lead to death. In a telephone interview with LVN C on 11/25/2025 at 5:22PM, she stated that she worked with Resident #1 on the evening of 11/13/2025, she denied any recollection of a fall on that evening. She further stated that she did remember Resident #1 having a one to one observation, but denied any falls after or around the time it was completed. In a follow up interview with MAINT DIR on 11/25/2025 at 1:24PM she contradicted her original report that there was a second person with her when she observed the fall. She stated it was because she was walking with Visitor B when she heard Resident #1 calling for help. She stated that Resident #1 was positioned face down with a pillow under his head. She stated that he was asking for help to get back up and denied any injuries. She stated that Resident #1 stated that he fell while he was trying to get into bed from the wheelchair. She stated that the Resident's call light was not in reach. She stated that she and the visitor stayed at the doorway. She stated that she informed the nurses first that the resident had fallen and the nurses, were just standing there talking. She stated she walked back to Resident #1's doorway and approximately 3 minutes later, the visitor went up to the nurse's station and the nurses were still standing at the nurse's station. She stated that the visitor was upset, but she did not hear what was said to the nurses at that time. In a telephone interview with Visitor B on 11/25/2025 at 1:44PM, he stated that it was almost 7:00PM when he was walking down the hallway with the MAINT DIR and heard Resident #1 calling for help. He stated the resident was positioned face down on the floor with a pillow under his head next to the bed. He stated that the resident denied any injuries. He stated there was no visible bleeding and had his pants partially down while he was lying on the ground. He stated that when the MAINT DIR went to the nurse's station there were three nurses at the nurse's station. She stated that when she told them about the fall, they stated that they would, get to it. He stated that 15-20 minutes went by, and when no one came to assist the resident, he stated that he went to the nurse's station while the MAINT DIR stayed with the resident. He stated that when he told the nurses that Resident #1 fell, the nurses chuckled and stated that Resident #1, always falls. He stated that after he informed them of the fall, they responded by coming to assess the resident. Attempted a phone interview with LVN H, who was on staff for the evening shift on 11/13/2025, on 11/25/2025 at 2:49PM. There was no answer. Left a message requesting a call back. Attempted a phone interview with CNA K, who was on staff for the evening shift on 11/13/2025, on 11/25/2025 at 3:52 PM. There was no answer. Left a message requesting a call back. In a follow-up interview with SC LVN on 11/25/2025 at 4:42PM, she received a text message on 11/13/2025 at 10:00PM from MAINT DIR, about a fall for Resident #1 with a delay in nursing response. She stated she did not see it until the following day on 11/14/2025. She stated that she did not tell the ADMIN or any nursing administration about the message. She stated that she believed the MAINT DIR dealt with it. She stated that she was informed by the MAINT DIR that while she was walking down the hallway with a visitor, Resident #1 was found on the floor and nursing took, too long to respond to the fall. She stated that she did not know who was working that night. She stated that she believed the MAINT DIR contacted her because she was the only phone number that she had saved for the staff on her phone, because she was responsible for scheduling. She stated that she was available for call ins and denied being the administrator on call for that time period. She stated that in instances where there was an allegation that staff did not respond to resident needs, it should be investigated by the administrative staff. She stated that the Charge nurse working that night should have written an incident report and reported it to the DON. She stated that she made no attempt to ensure that the DON was made aware of the incident. She stated that she was present for the morning meeting the next day and heard no further mention of the incident with a fall for Resident #1. In an interview with the DON on 11/26/2025 at 7:48AM, she stated that she started an investigation into the fall incident reported by the surveyor on 11/25/2025. She stated that the nurse on duty for Resident #1, LVN C, came into the facility and during an interview with the DON she stated that Resident #1 was found on the floor on 11/13/2025. She stated that LVN C stated that the resident told her that he was transferring from the wheelchair to the bed and went to the floor. She stated that it should have been treated as a fall, but that she thought that LVN C was confused with the context of the difference between Resident #1 placing himself on the floor and what should be considered a fall. She stated that LVN C was written up for the incident. She stated that any resident found on the floor is to be treated as a fall. She stated that it would be considered a, change in plane and should be documented in the resident records. She stated that from her interviews with LVN C and LVN B, it was approximately 2-3 minutes from the time that the fall was first reported by the MAINT DIR to when nurses responded to Resident #1. She stated LVN C stated that she would be right there. She stated that she was told that she needed to secure the medication cart and then responded to the fall. She stated that LVN B stated that the MAINT DIR came down the hallway to report the resident was on the floor, then before the MAINT DIR could get down the hallway to Resident #1's room, the visitor was already walking down the hallway to the nurse's station and the nurses were walking toward Resident #1's room. The DON stated that she was in-servicing staff on the facility policy for abuse, neglect, and exploitation recognition and reporting and the facility policy for falls. She stated that when anyone was found on the floor in the future, staff would need to fill out written statements regarding the incident and submit them to her or place them under her door if she was not present. She stated that she would have the social worker conduct safe surveys with the residents when she arrived on 11/26/2025. She stated that she had not interviewed the MAINT DIR yet, but she planned to speak with her that day. In an interview with the RNC on 11/26/2025 at 10:05AM, she stated that the administration had preformed an Ad Hoc QAPI (when necessary Quality Assurance and Performance Improvement) meeting regarding Resident #1 and an action plan was started for the fall that was not reported to administration. She stated that she did not think there was any evidence of neglect from staff. She stated that the resident was assessed by nursing at the time of the incident, but it was not documented. She stated that it was a documentation error, and they did not feel like it was neglect. She stated that it would not have been something that was brought to the attention of the DON and the ADMIN on the night of 11/13/2025, as there was no injury to the resident. She stated that the investigation revealed that Resident #1 placed himself on the floor as they previously thought. She stated that staff was in-serviced that when a resident is found on the floor that it should be treated and documented as a fall. She stated that when Resident #1 was interviewed by the administrative staff on the night of 11/25/2025, that he stated he slipped from the wheelchair. She stated that an incident report was created with the investigation findings related to the fall on 11/13/2025. She stated that the MAINT DIR was involved and interviewed that on the morning of 11/26/2025. She stated that she was informed that she and person with her found him on the floor in his room but had not witnessed the fall. She stated that she had no knowledge of a report that nursing did not respond when they were notified of the fall. She stated that it was her expectation that nursing should come and assess the resident as soon as they are notified of a fall. She stated that if it is safe to get the resident up after assessing them, then they should assist the resident up. She stated that an incident report should be completed for the fall and the physician and RP should be notified. She stated that because there was no injury involved in Resident #1's fall on 11/13/2025, the notification to the MD and DON do not need to occur right away, as they would be made aware on the risk management report the following morning. She stated that therapy would also be informed of the fall during that meeting also and they would know to screen the resident after the fall. She stated that staff should be implementing interventions after falls to address the root cause to prevent future falls. She stated that she had not read the witness statements at that time. She stated that safe surveys were done with residents that morning with no reports of abuse or neglect. She stated that she questioned Resident #1's ability to be alone outside when she arrived on site. She stated that she was told that staff monitor Resident #1 while he is outside, but she did not know how frequently they were able to monitor him. She stated that because he does not have the code to the door, the staff were aware when he went outside, because he set off the alarm. She stated that she suggested that staff walk with him if he is going outside. She stated that they did new BIMS

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to ensure that nursing staff responded to an unwitnessed fall for Resident #1, and when notified by staff member dismissed the fall as a behavior. The fall was not documented by staff, reported to the DON, physician, or resident representative (RP). This failure could place residents at risk for delays in care that could lead to worsening of a serious injury. Findings included: Record review of Resident #1's Facesheet dated 11/25/2025 reflected a [AGE] year-old, male admitted to the facility on [DATE]. Diagnoses included: Repeated falls, Impulse disorder, Cerebral Infarction, muscle weakness, unspecified lack of coordination, bipolar disorder, and chronic kidney disease requiring dialysis. Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 7 (severe cognitive impairment), He is partial to moderate assist when moving from sitting to standing and for all transfers. Review of Resident #1 care plan dated 11/25/2025 reflected a Problem area stating as follows: Problem Start Date: 11/15/2023 Category: Falls [Resident #1] has impaired balance during transfers, he is at risk for falls. [Resident #1] likes to self transfer and put himself on the floor at times. [Resident #1] likes to sleep on the floor. [Resident #1] will lean forward to pick up items from floor. [Resident #1] states he likes to lie on the floor 1/12/24 on floor----2/19 fall, 11/17/2024 fall, unwitnessed fall 1-11-2025 no injuries. 3/31/2025 unwitnessed fall x3 no injuries. 4/05/25 unwitnessed fall in restroom no injuries.4/20/25 witnessed fall in room with transfer 7/01/25 Edited: 10/15/2025 Edited By: LVN C. Problem Start Date: 04/25/2024 Category: Behavioral Symptoms [Resident #1] has taken himself outside the front door for fresh air, sunshine exposure and to just sit and watch traffic as well as rolls self around building for exercise Edited: 08/18/2025 Edited By: LVN C. Falls noted on Care Plan are dated 1/12/24, 2/19/24, 11/17/24, 1/11/25, 3/31/2025, 4/05/25, 4/20/25, 7/01/25 and 10/14/2025. Further review revealed there are no interventions related to the type or frequency of staff supervision outside during the day. Record review of Resident #1's progress notes from 9/26/2025 to 11/26/2025 revealed no documentation of a fall or reports of delay in care on 11/13/2025. There was no evidence that notifications were made to the physician, RP, or the Administrative staff. Record review of Resident #1's incident reports from 9/25/2025 to 11/25/2025 revealed no documentation of a fall or reports of delay in care on 11/13/2025. There was no evidence that notifications were made to the physician, RP, or the Administrative staff. Review of Resident #1 Fall risk assessment on 11/7/2025 reflected, History of falls (past 3 months): 3 or more falls in past 3 months . Resident is chairbound / incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 1-2 present. Resident did not have a change in condition in the last 14 days. Recent hospitalization history in last 30 days: No. Record review of text message from MAINT DIR to SC LVN reflected a text message sent at 10:02PM on 11/13/2025 stated, Hey, I don't know any update but I wanted to let you know that [Resident #1] was on the floor when I walked on [Resident #1's hallway] and the staff took forever to even help him up [Visitor D] walked up to them a second time and snapped on them. The return message from SC LVN on 11/13/2025 at 11:28PM stated, Wow. In an interview with MAINT DIR on 11/25/2025 at 11:10AM, she stated that on 11/13/2025 she observed Resident #1 on the floor in his room. She denied any other witnesses at the scene. She stated that she was unsure how long he had been on the floor. She stated that she informed 2-3 nurses at the nurses station, but they took, too long, about 5 minutes, to respond to the fall. She stated that Resident #1 stated he was on the floor for about an hour, but that she observed him in his wheelchair going down the hallway about ten minutes prior to that. She stated that she informed SC LVN about the fall for Resident #1 and the delay in nursing response. She did not recall which nurses were notified. She stated that was the only phone number that she had for the facility administration. She denied observing any other delays in care or concerning behaviors from nursing before or after this episode. In an interview with the ADON on 11/25/2025 at 10:51AM, she stated that the expectation for resident falls was that nursing assess the resident immediately. She stated that staff should not leave them alone after observing a resident on the floor. She state that nursing should perform vital signs, physical assessment, neurological assessment, and observe for any pain or signs of fracture. She stated that if there was an injury, staff should keep them there and call EMS (emergency medical services). She stated that if nursing was not responding immediately to fall and a resident was injured, they may not receive the medical care they need. She stated that she attends morning meetings and did not recall an incident or grievance of a fall where it was reported that staff did not respond immediately to the fall. Attempted a telephone interview with CNA J on 11/25/2025 at 12:43PM., a voicemail was not able to be left. Text message was sent to request a call back at that time. In a telephone interview with SC LVN on 11/25/2025 at 1:10PM, she stated that she was not in the facility in the evening on 11/13/2025. She denied receiving a call regarding a fall on that night or being found on the ground by staff. She stated that, depending on the circumstances, if a resident was found on the ground that she would consider it a fall and perform a physical assessment of the resident and get x-rays if there was concern for injury. She stated that nursing should report falls to the DON, RP, MD, and complete an incident report. She stated that Resident #1 likes to sleep on the ground. She stated that it was care planned. She stated that she had not observed the behavior, but she knew from conversations with staff that he does get on the ground. She stated that he requires assistance to transfer from the wheelchair, but she believed he could get up on his own from the ground, 9 times out of 10. She stated that if Resident #1 stated that he fell, that staff should treat it as a fall. She stated that when a fall was reported, that nursing should stop what they are doing and attend to the person right away. She stated that if a nurse was in the middle of a treatment or in another emergency situation, they should ask another nurse to assist the resident until they are able to get there. She stated that if nursing was not responding to resident falls right away that the resident could have a lot happen, including blood pressure changes, bleeding or other things that could prolong the healing process if there was an injury. In an interview with LVN B on 12/25/2025 at 12:49PM, she stated that she worked the day shift on 11/13/2025. She denied recalling a fall that day for Resident #1, but then stated that there was a day where the resident, put himself on the floor, and the MAINT DIR and an unknown visitor reported to nursing that Resident #1 was on the floor. She initially stated that one night nurse was passing medications and one was on a hallway. She stated that there was no call light on at the time. She gave multiple accounts of the locations and responses of LVN C and LVN H, who were the two nurses working the night shift on 11/13/2025. In version #1, she stated that the nurse passing medications finished her medication pass and went down the hallway after she was done. In version #2, she stated that the nurse passing medications was already closing her narcotic drawer and walking down the hallway while the second nurse was in the bathroom. She stated that it could not have been a minute after the reported fall, the nurse doing the medications was already walking down the hallway to respond to Resident #1. In version #3, she stated that the second nurse was exiting the bathroom while the nurse was closing the narcotic drawer and they both responded to the fall before she could have responded to the report from the nurses station. She stated that when the MAINT DIR and the visitor reported the resident was on the floor, she told the MAINT DIR that Resident #1 will, sit on the floor, and the other nurse stated that she would be right there. She did not indicate which LVN working that evening was the one passing medications. She stated that Resident #1 was care planned for a, change in plane. She stated that if Resident #1 stated that he put himself on the floor, that she would not treat it as a fall. She stated that he does it often, and she was not sure if she had documented every instance in which he was found on the floor and stated that it was not a fall on her shift. She stated she could not recall how often he exhibits that behavior. She stated that she did not respond to the fall because she had given report and was preparing to leave the facility. She did not report any direct interaction between nursing and the visitor. She stated that the impact to a resident of nursing not responding to a reported fall, is that they could have a fracture or a bleed that may cause more damage during that time or potentially lead to death. In a telephone interview with LVN C on 11/25/2025 at 5:22PM, she stated that she worked with Resident #1 on the evening of 11/13/2025, she denied any recollection of a fall on that evening. She further stated that she did remember Resident #1 having a one to one observation, but denied any falls after or around the time it was completed. In a follow up interview with MAINT DIR on 11/25/2025 at 1:24PM she contradicted her original report that there was a second person with her when she observed the fall. She stated it was because she was walking with Visitor B when she heard Resident #1 calling for help. She stated that Resident #1 was positioned face down with a pillow under his head. She stated that he was asking for help to get back up and denied any injuries. She stated that Resident #1 stated that he fell while he was trying to get into bed from the wheelchair. She stated that the Resident's call light was not in reach. She stated that she and the visitor stayed at the doorway. She stated that she informed the nurses first that the resident had fallen and the nurses, were just standing there talking. She stated she walked back to Resident #1's doorway and approximately 3 minutes later, the visitor went up to the nurse's station and the nurses were still standing at the nurse's station. She stated that the visitor was upset, but she did not hear what was said to the nurses at that time. In a telephone interview with Visitor B on 11/25/2025 at 1:44PM, he stated that it was almost 7:00PM when he was walking down the hallway with the MAINT DIR and heard Resident #1 calling for help. He stated the resident was positioned face down on the floor with a pillow under his head next to the bed. He stated that the resident denied any injuries. He stated there was no visible bleeding and had his pants partially down while he was lying on the ground. He stated that when the MAINT DIR went to the nurse's station there were three nurses at the nurse's station. She stated that when she told them about the fall, they stated that they would, get to it. He stated that 15-20 minutes went by, and when no one came to assist the resident, he stated that he went to the nurse's station while the MAINT DIR stayed with the resident. He stated that when he told the nurses that Resident #1 fell, the nurses chuckled and stated that Resident #1, always falls. He stated that after he informed them of the fall, they responded by coming to assess the resident. Attempted a phone interview with LVN H, who was on staff for the evening shift on 11/13/2025, on 11/25/2025 at 2:49PM. There was no answer. Left a message requesting a call back. Attempted a phone interview with CNA K, who was on staff for the evening shift on 11/13/2025, on 11/25/2025 at 3:52 PM. There was no answer. Left a message requesting a call back. In a follow-up interview with SC LVN on 11/25/2025 at 4:42PM, she received a text message on 11/13/2025 at 10:00PM from MAINT DIR, about a fall for Resident #1 with a delay in nursing response. She stated she did not see it until the following day on 11/14/2025. She stated that she did not tell the ADMIN or any nursing administration about the message. She stated that she believed the MAINT DIR dealt with it. She stated that she was informed by the MAINT DIR that while she was walking down the hallway with a visitor, Resident #1 was found on the floor and nursing took, too long to respond to the fall. She stated that she did not know who was working that night. She stated that she believed the MAINT DIR contacted her because she was the only phone number that she had saved for the staff on her phone, because she was responsible for scheduling. She stated that she was available for call ins and denied being the administrator on call for that time period. She stated that in instances where there was an allegation that staff did not respond to resident needs, it should be investigated by the administrative staff. She stated that the Charge nurse working that night should have written an incident report and reported it to the DON. She stated that she made no attempt to ensure that the DON was made aware of the incident. She stated that she was present for the morning meeting the next day and heard no further mention of the incident with a fall for Resident #1. In an interview with the DON on 11/26/2025 at 7:48AM, she stated that she started an investigation into the fall incident reported by the surveyor on 11/25/2025. She stated that the nurse on duty for Resident #1, LVN C, came into the facility and during an interview with the DON she stated that Resident #1 was found on the floor on 11/13/2025. She stated that LVN C stated that the resident told her that he was transferring from the wheelchair to the bed and went to the floor. She stated that it should have been treated as a fall, but that she thought that LVN C was confused with the context of the difference between Resident #1 placing himself on the floor and what should be considered a fall. She stated that LVN C was written up for the incident. She stated that any resident found on the floor is to be treated as a fall. She stated that it would be considered a, change in plane and should be documented in the resident records. She stated that from her interviews with LVN C and LVN B, it was approximately 2-3 minutes from the time that the fall was first reported by the MAINT DIR to when nurses responded to Resident #1. She stated LVN C stated that she would be right there. She stated that she was told that she needed to secure the medication cart and then responded to the fall. She stated that LVN B stated that the MAINT DIR came down the hallway to report the resident was on the floor, then before the MAINT DIR could get down the hallway to Resident #1's room, the visitor was already walking down the hallway to the nurse's station and the nurses were walking toward Resident #1's room. The DON stated that she was in-servicing staff on the facility policy for abuse, neglect, and exploitation recognition and reporting and the facility policy for falls. She stated that when anyone was found on the floor in the future, staff would need to fill out written statements regarding the incident and submit them to her or place them under her door if she was not present. She stated that she would have the social worker conduct safe surveys with the residents when she arrived on 11/26/2025. She stated that she had not interviewed the MAINT DIR yet, but she planned to speak with her that day. In an interview with the RNC on 11/26/2025 at 10:05AM, she stated that the administration had preformed an Ad Hoc QAPI (when necessary Quality Assurance and Performance Improvement) meeting regarding Resident #1 and an action plan was started for the fall that was not reported to administration. She stated that she did not think there was any evidence of neglect from staff. She stated that the resident was assessed by nursing at the time of the incident, but it was not documented. She stated that it was a documentation error, and they did not feel like it was neglect. She stated that it would not have been something that was brought to the attention of the DON and the ADMIN on the night of 11/13/2025, as there was no injury to the resident. She stated that the investigation revealed that Resident #1 placed himself on the floor as they previously thought. She stated that staff was in-serviced that when a resident is found on the floor that it should be treated and documented as a fall. She stated that when Resident #1 was interviewed by the administrative staff on the night of 11/25/2025, that he stated he slipped from the wheelchair. She stated that an incident report was created with the investigation findings related to the fall on 11/13/2025. She stated that the MAINT DIR was involved and interviewed that on the morning of 11/26/2025. She stated that she was informed that she and person with her found him on the floor in his room but had not witnessed the fall. She stated that she had no knowledge of a report that nursing did not respond when they were notified of the fall. She stated that it was her expectation that nursing should come and assess the resident as soon as they are notified of a fall. She stated that if it is safe to get the resident up after assessing them, then they should assist the resident up. She stated that an incident report should be completed for the fall and the physician and RP should be notified. She stated that because there was no injury involved in Resident #1's fall on 11/13/2025, the notification to the MD and DON do not need to occur right away, as they would be made aware on the risk management report the following morning. She stated that therapy would also be informed of the fall during that meeting also and they would know to screen the resident after the fall. She stated that staff should be implementing interventions after falls to address the root cause to prevent future falls. She stated that she had not read the witness statements at that time. She stated that safe surveys were done with residents that morning with no reports of abuse or neglect. She stated that she questioned Resident #1's ability to be alone outside when she arrived on site. She stated that she was told that staff monitor Resident #1 while he is outside, but she did not know how frequently they were able to monitor him. She stated that because he does not have the code to the door, the staff were aware when he went outside, because he set off the alarm. She stated that she suggested that staff walk with him if he is going outside. She stated that they did new BIMS (Basic Interview for Mental Status) for Resident #1 and he was scored as a 9 (moderately impaired cognition) on 11/26/2025. She stated that the ADMIN felt like it might be higher but Resident #1 is not answering the questions correctly. Review of facility policy for Falls-Clinical Protocol reflected, Assessment and Recognition1. As part of the initial assessment, the physician will help Identify Individuals with a history of falls and risk factors for subsequent falling.a. Staff will ask the resident and the caregiver or family about a history of falling.b. The staff and physician should document in the medical record a history of one or more recent falls (for example, within 90 days).c. While many falls are isolated individual Incidents, a significant proportion occur among a few residents/patients. Those individuals may have a treatable medical disorder or functional disturbance as the underlying cause.2. In addition, the nurse shall assess and document/report the following:a. Vital signs;b. Recent injury, especially fracture or head Injury;c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.;d. Change in cognition or level of consciousness;e. Neurological status;f. Pain;g. Frequency and number of falls since last physician visit;h. Precipitating factors, details on how fall occurred;i. All current medications, especially those associated with dizziness or lethargy; andj. All active diagnose.3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk.a. Risk factors for subsequent falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, and illnesses affecting the central nervous system and blood pressure.4. The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications associated with Increased falling risk) and the risk for significant complications of falls (for example, increased fracture risk In someone with osteoporosis or Increased risk of bleeding in someone taking an anticoagulant).a. Falls often have medical causes; they are not just a nursing Issue.3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Review of facility policy for Falls and Fall Risk, Managing reflected, Policy heading Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and ImplementationDefinition According to the MDS, a fall is defined as:Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Challenging a resident's balance and training him/her to recover from loss of balance is an intentional therapeutic intervention. The losses of balance that occur during supervised therapeutic interventions are not considered a fall.Resident-Centered Approaches to Managing Falls and Fall Risk1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once).5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.

Based on interviews and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals for 1 of 4 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's Tylenol-codeine 3 were acquired and administered according to physician's orders. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status and decreased quality of life. Findings included: Review of Resident #1's face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of atherosclerotic heart disease (buildup of fats in the artery walls), unspecified dementia (symptoms that negatively affect memory, thinking, and social abilities), pain, other recurrent depressive disorders (repeated periods of significant sadness, loss of interest), and anxiety disorder (excessive worry, fear that interfere with daily life). Review of Resident #1's physician orders reflected Resident #1 had an order for Tylenol-codeine 3 tablet scheduled every 8 hours with a start date of 02/28/2025. Review of Resident #1's MAR reflected Resident #1's Tylenol-codeine 3 was not administered on 05/01/2025 at 12:00 AM and 8:00 AM. Reasons listed on the MAR for 12:00 AM reflected Not Administered: Other and for 8:00 AM Not Administered: Drug/Item Unavailable. Review of Resident #1's care plan dated 03/09/2025 reflected Resident #1 had complaints of acute pain related to having chronic back pain, sciatic nerve pain, and restless leg syndrome. Approach included to administered medications (Tylenol #3) as directed by MD. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 (no cognitive impairment). Further review reflected Resident #1 received a scheduled pain medication regimen. Resident #1's quarterly MDS pain assessment interview revealed Resident #1 had pain frequently. During an interview on 05/02/2025 at 10:59 AM, Resident #1 stated earlier this week she ran out of her Tylenol 3. Resident #1 stated she also received a muscle relaxer, and her pain was okay when she missed her Tylenol 3. Resident #1 stated she had pain and sciatica and that was why she needed her Tylenol-3. During an interview on 05/02/2025 at 2:28 PM, LVN A stated Resident #1's Tylenol 3 was marked as not administered because it was not available or in the facility. LVN A stated narcotics were required to be called in by the NP for refills. LVN A stated she believed Resident #1 had one refill available. LVN A stated she believed the day shift had ordered the refill. She stated Resident #1's pharmacy needed to be called by a certain time for refills. LVN A stated she worked the 6:00 PM to 6:00 AM shift the evening Resident #1's medication was not available as it was scheduled at 12:00 AM during this shift. LVN A stated the medication had been ordered from the pharmacy and it was closed, if it was not ordered by a certain time, it did not get delivered to the facility. LVN A stated the facility had an e-kit but the request for a narcotic had to be called into the pharmacy and the medication needed was in the middle of the night. LVN A stated she believed the DON could call the mediation in. LVN A stated she could not use the e-kit for Resident #1 because it was connected to a different pharmacy than what Resident #1 used. LVN A stated the code for the e-kit was provided by the pharmacy for controlled medications. LVN A stated Resident #1 was asleep when the medication was supposed to be given and did not have any obvious signs or symptoms of pain. LVN A stated Resident #1 also had PRN Tylenol and did not request it. LVN A stated she believed someone went to the pharmacy in the morning and picked up Resident #1's medication. LVN A stated normally she would have notified the NP or the MD for missed medication or refusals. LVN A stated she did not call the NP or on-call and notify them because it was not an emergency, she had been stepped on in the past for calling the NP or MD for non-emergencies . During an interview on 05/02/2025 at 2:51 PM, MA B stated if she saw a medication was out, she would have notified the nurse, and the nurse would handle it from there . During an interview on 05/02/2025 at 2:59 PM, LVN C stated scheduled narcotic medications were refilled by calling the NP or the MD to refill the medication. LVN C stated if she could not get the medication within a few hours or a day, she would see if the resident could get something else while they waited for the medication. LVN C stated it was never okay for a resident to go without their scheduled medication. She stated she would have notified the doctor and asked if they wanted to prescribe something else. LVN C stated the on-call information was posted and there were numbers you could call anytime . During an interview on 05/02/2025 at 3:19 PM, the DON stated scheduled narcotics could be called in by a physician anytime, day or night. The DON stated staff could call the DON and she could have called the pharmacist. The DON stated most every medication was in the e-kit. The DON stated residents should not miss scheduled doses of a narcotic medication. The DON stated if Resident #1 was asleep, staff were able to delay the medication, but it should have been given unless the staff received an order to hold the medication. The DON stated staff did not let her know Resident #1's Tylenol 3 was out and she expected staff to let her know the medication was missed and the staff to notify the NP or the MD because they could have provided a different kind of medication, if needed. The DON stated she expected nurses to document if they ordered a refill and stated they did not always do that. The DON stated medications should have been ordered 5-7 days before the resident ran out of the medication. The DON stated the e-kit was not specific to one pharmacy, it was to any resident in the building. The DON stated Resident #1's Tylenol 3 was available in the e-kit . During an interview on 05/02/2025 at 3:45 PM, the NP stated she was familiar with Resident #1. She stated she was aware the facility ran out of Resident #1's Tylenol 3 and the facility just had to go pick it up but it was difficult logistically and she was unsure if the facility had someone to get it. The NP stated she was notified when she was at the facility the morning of 05/01/2025 that the medication had run out. The NP stated it was zero concern for her and stated Resident #1 was drug seeking. The NP stated that based on her assessment Resident #1 did not have pain. The NP stated Resident #1 had regular Tylenol if she needed it. The NP stated it was not a dire emergency and if it was, the facility could have called the on-call number but that was not an appropriate thing to call on-call for. Review of the facility policy titled Person-Centered Medication Administration (Liberalized Medication Pass), dated February 2025, reflected the facility has a liberalized schedule and if a provider orders that a medication is to be given at a specific time due to specific health benefits to the resident, the medication will be administered as ordered.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure fruit cobbler was covered, dated, or labeled after being in the refrigerator. 2. The facility failed to ensure CK K did not store her shoes on the kitchen utility cart in the kitchen. 3. The facility failed to ensure CK J properly used proper hand hygiene during food preparation. This failure could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: 1. Observation on 02/24/2025 at 9:05 AM in the open front refrigerator located across from the steam table reflected a large pan of fruit cobbler not labeled, covered, or dated. Interview with the Dietary Manager on 02/24/2025 at 9:14 AM stated the fruit cobbler was made on Sunday (02/23/2025) to be served for lunch on 02/24/2025. She stated the fruit cobbler was expected to be covered, labeled, and dated. The Dietary Manager stated there was a possibility if staff were placing items in the refrigerator, their sleeve or anything on their clothes, could touch the cobbler. She stated it was a possibility the fruit cobbler may become contaminated when not covered. She stated a resident had a potential of developing stomach issues if the resident ingested some type of bacteria. 2. Observation on 02/24/2025 at 9:10 AM there was a pair of shoes located on the second shelf of a three-shelf utility cart in the kitchen. The shoes were touching hair nets the staff wore in the kitchen. Interview on 02/24/2025 at 9:14 AM the Dietary Manager stated the shoes belonged to the afternoon shift cook. She stated it was unsanitary for shoes to be stored anywhere in the kitchen area. The Dietary Manager stated there was a potential the hair nets were contaminated. She stated if the utility cart was not sanitized after the shoes were removed there was a possibility clean dishes, food, and/or silverware may become contaminated. She stated her expectations were not to have any staff personal items stored in the kitchen. Interview on 02/25/2025 at 3:05 PM CK K stated the shoes located on the three-shelf utility cart belonged to her. She stated she kept her shoes in the kitchen when she went home for the day. CK K stated she wore another pair of shoes into the kitchen and changed into the tennis shoes she left on the utility cart or other places in the kitchen ( she did not specify the other places she left her shoes). CK K stated she left her shoes in the kitchen after her shift due to not wanting her dogs to chew on her good shoes at her house. She stated she had been in-serviced not to leave personal items in the kitchen. CK K stated the shoes were contaminated and if they touched the utility cart or anything the staff used to prepare residents meals these items would be considered contaminated. Observation on 02/25/2025 at 11:05 AM CK J pureeing residents' lunch meal. CK J removed gloves and placed new gloves on her hands. She did not wash or sanitize her hands prior to replacing new gloves on her hands. CK J touched the fourchette ( area of the glove where the fingers are placed) and palm area of the glove when removing the gloves from the container. She touched her right side of her shirt, touched the handle of the can opener attached to the food preparation table, touched the menu binder, touched the lid, and outside of the thickener can after placed new gloves on her hands. CK J did not change her gloves when she began to place the broccoli into the puree processor. She touched the broccoli with her hands as she placed it in the puree processor. Interview on 02/25/2025 at 11:20 AM CK J stated, I did touch my clothes, the handle of can opener, the recipe binder, and the can of the thickener. She stated all these items were considered contaminated and she was expected to remove the gloves, wash hands, and place new gloves. CK J stated she could have contaminated the broccoli with possible bacteria on her gloves. She stated if the food was contaminated there was a potential a resident may become physically ill such as stomach issues with diarrhea. CK J stated she received an in-service related to hand hygiene. She stated she did not remember the date of the in-service. Interview on 02/26/2025 at 11:45 PM the Administrator stated all dietary staff were expected to wash hands or change gloves in between tasks. She stated if a cook was wearing gloves and touched anything considered contaminated, there was a possibility the cook may contaminate the food. She stated there was a potential a resident may become ill such as diarrhea or vomiting if the resident ingested contaminated food. She stated shoes or any dietary staff personal items were not to be stored in the kitchen. The administrator stated there was an area away from the kitchen, by the bathroom or the dietary manager's office, the staff were permitted to store personal items. The Administrator stated shoes stored on the kitchen utility cart was unacceptable and not sanitary. She stated all foods were expected to be covered, labeled, and dated. The Administrator stated if food was not covered there was a possibility anything type of bacteria may fall on the food and a resident may become ill such as vomiting or diarrhea if they ingested the bacteria. Interview on 02/26/2025 at 10:40 AM with the Dietary Manager requested Label, Dating, Storage of food Policy and it was not provided at time of exit. Review of the Facility Policy on Employee Sanitation , dated 10/01/2018, reflected The Nutrition and Foodservice employees of the facility will practice good sanitation practices to minimize the risk of infection and food borne illness. Gloves are not a substitute for thorough and frequent hand washing. When using, gloves always wash hands before touching or putting on new gloves. Change gloves between each food preparation task. After touching items, utensils or equipment not related to task. After touching hair, face, or any other source of contamination. Review of the FDA Food Code 2022 reflected the following: Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food. Shoes carry contamination onto the floors of food preparation and storage areas. Even trace amounts of refuse or wastes in rooms used as toilets or for dressing, storing garbage or implements, or housing machinery can become sources of food contamination. Moist conditions in storage areas promote microbial growth. . The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code.

Based on observations, interviews, and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of each resident: specifically, expired or opened medical supplies were stored in 1 of 2 (100/200-hall Nurses' medication cart) medication carts. The facility failed to ensure expired or open supplies were removed from the 100/200-hall Nurses' medication cart that included one 5 x 9 Xeroform dressing that expired 01/2025, one sterile cotton tipped applicator that expired 08/01/2024, five 4 x 4 drain sponges that expired 12/05/2024, one 2 x 2 hydrogel saturated dressing that expired 11/15/2024, one 1 x 8 Xeroform dressing that expired 03/2024, three 6 x 7 Silicone Composite Dressings that expired 02/22/2025, and one opened package of rolled gauze bandage. These failures could place residents at risk of contamination causing illness or decreased effectiveness of medication. Findings included: Observation on 02/26/2025 at 11:50 AM of the 100/200 hall Nurses' medication cart with LVN E in attendance revealed one 5 x 9 Xeroform dressing that expired 01/2025, one sterile cotton tipped applicator that expired 08/01/2024, five 4 x 4 drain sponges that expired 12/05/2024, one 2 x 2 hydrogel saturated dressing that expired 11/15/2024, one 1 x 8 Xeroform dressing that expired 03/2024, three 6 x 7 Silicone Composite Dressings that expired 02/22/2025, and one opened package of rolled gauze bandage. During an interview on 02/26/2025 at 11:58 AM, LVN E stated the nurses' including herself were responsible for checking for expiration dates. She stated there used to be a schedule to ensure it was getting done but she hadn't seen that schedule in a long time. She stated open packages should be thrown away and not put back in the cart because it was no longer sterile. LVN E stated if the saturated dressings were used, they may not be as effective. During an interview on 02/26/2025 at 03:57 PM, LVN C stated the nurses were responsible for checking for expired medication and supplies in their carts. She stated if the supplies were used after the expiration date they may not be as effective. During an interview on 02/26/2025 at 04:40 PM, the ADON stated the nurses were responsible for checking expiration dates in their carts. She stated the pharmacist also checked all the carts once a month. She stated if the supplies were used, they may not be as effective. During an interview on 02/26/2025 at 04:57 PM, the DON stated it was a combination of everyone that was responsible for ensuring all expired medications and supplies were removed from the medication carts. She stated the pharmacist checked all the carts once monthly and provided a report each month. She stated she expected her staff to not use an expired supply. She stated the integrity of the product could be affected after the expiration date. During an interview on 02/26/2025 at 05:19 PM, the ADM stated the DON was responsible for ensuring expired medication and supplies were removed from all medication carts. She stated if supplies were used after the expiration date, then it could cause an injury. Record Review of the facility policy and procedure titled Storage of Medications dated 2001 and revised in November 2020 revealed: Policy heading the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and Implementation . 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinues, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of grievances indicated no complaint or concerns from residents about expired medications or supplies being administered.

Based on interviews and record review, the facility failed to provide training on abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, and dementia management and resident abuse prevention to their staff for 4 of 8 staff (RN A, CNA N, CNA O, and CNA P) reviewed for staff training requirements. The facility failed to provide RN A, CNA N, CNA O, and CNA P with orientation, as required by their abuse/neglect prevention policy and procedure prior to scheduling them to work with residents. This failure placed residents at risk of abuse and neglect. Findings included: Review of the personnel file for RN A reflected a hire date of 02/15/24. Her personnel file did not include documentation of the required orientation. Review of the personnel file for CNA N reflected a hire date of 06/24/24. His personnel file did not include documentation of the required orientation. Review of the personnel file for CNA O reflected a hire date of 01/17/23. Her personnel file did not include documentation of the required orientation. Review of the personnel file for CNA P reflected a hire date of 12/03/24. Her personnel file did not include documentation of the required orientation . During an interview on 02/26/25 at 04:24 PM, the HR stated she had been the HR at the facility for years. She stated she was responsible for ensuring orientation was conducted for new hires. She stated the owners had recently implemented a new process for onboarding new staff, and she had stopped doing her old process, which was all on paper. She stated she had discovered that the new process did not have any provision for orientation. She stated she thought the staff had been trained in abuse and neglect, because they had additional computer-based training they completed after they started, but the failure to conduct orientation meant they were not trained in abuse/neglect prevention prior to starting work with residents. The HR stated the potential negative impact to residents was staff would not know how to identify and report abuse or neglect. During an interview on 02/26/25 at 04:58 PM, the DON stated she was familiar with the facility orientation procedure. She stated the HR did a portion of the orientation, and then department heads came in and did the topics that were specific to their departments. She stated required topics were covered during the orientation. She stated not providing orientation to new staff before they started working with residents could impact residents negatively especially if the staff, they hired were not experienced with long term care. The DON stated she monitored for compliance on required trainings and orientation by asking frequently. During an interview on 02/26/25 at 05:19 PM, the ADM stated it was the responsibility of the HR to complete the orientation for new hires. The ADM stated the orientation was very general, and the department heads came in to introduce themselves and speak about what they did in the building. She stated the orientation was required to ensure the required topics were addressed before new staff had contact with residents. She stated staff missing orientation could potentially impact residents because staff might not know the right way to take care of them. Review a sample copy of the facility's New Hire Orientation Checklist reflected the following: MANDATORY IN-SERVICES . Abuse prevention Resident rights . Restraints, restraint reduction Review of undated facility policy titled Abuse and Neglect Policy and Procedure reflected the following: Our facility implements an effective system for the prevention of abuse and neglect The facility during its orientation program and through ongoing training, provides all employees with information regarding abuse and neglect, reporting requirements, prevention, intervention and detection. The facility will train employees, through orientation and ongoing sessions on issues related to abuse/neglect prohibition practices and reporting. 1. a. An orientation leader will be assigned to the new associate. A classroom session will be scheduled for new employee to discuss related to abuse prohibition practices. 2. Documentation of training will be present in the employee file: a. What constitutes abuse, neglect, and misappropriation of resident property. b. Appropriate interventions to deal with aggressive and/or catastrophic reaction of residents. How staff should report their knowledge related to allegations without fear of reprisal. How to recognize signs of burnout, frustration, and stress that may lead to abuse.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 2 of 3 shower rooms (shower rooms A and B), 2 of 24 resident rooms (Residents #18 and 35), and in 2 halls and 1 common area (halls 100 and 600 and the rotunda) reviewed for physical environment. 1. The facility failed to ensure shower rooms A and B were clean from 02/24/25 to 02/26/25. 2. The facility failed to ensure the rooms for Residents #18 and 35 were clean from 02/24/25 to 02/26/25. 3. The facility failed to ensure the 100 and 600 halls and the rotunda were free of unpleasant odors from 02/24/25 to 02/26/25. These failures placed residents at risk of discomfort and diminished quality of life. Findings included: 1. Observation on 02/24/25 at 10:03 AM revealed shower room A (entrance on the 100 hall) had a first aid bandage, hair, and a disposable glove on the floor of the shower. The toilet had a brown substance caked on it in several areas, and the trash can was overflowing. The mirror over the sink was spattered with white specks. The substance on the mirror came off when wiped with a tissue. A gallon jug of body soap was open on a low shelf, and the lid was not visible in the area. Observation on 02/24/25 at 11:40 AM revealed shower room B (entrance on the 500 hall) had brown substance crusted on the seat and the bowl of the toilet, beads of yellow liquid on the toilet seat, dried yellow fluid on the floor, and black/brown tracks on the floor under the sink and toilet. Observation on 2/25/25 at 08:03 AM revealed shower room A still had a first aid bandage, hair, and a disposable glove on the floor of the shower. The toilet still had a brown substance caked on it in several areas, and the trash can was overflowing. The mirror over the sink was still spattered with white specks. Observation on 2/25/25 at 08:07 AM revealed shower room B still had had brown substance crusted on the seat and the bowl of the toilet, beads of yellow liquid on the toilet seat, dried yellow fluid on the floor, and black/brown tracks on the floor under the sink and toilet. Observation on 02/26/25 at 11:02 AM revealed shower room A still had a first aid bandage, hair, and a disposable glove on the floor of the shower. The toilet still had a brown substance caked on it in several areas, and the trash can was overflowing. The mirror over the sink was still spattered with white specks. Observation on 02/26/25 at 11:04 AM revealed shower room B still had had brown substance crusted on the seat and the bowl of the toilet, beads of yellow liquid on the toilet seat, dried yellow fluid on the floor, and black/brown tracks on the floor under the sink and toilet. 2. Review of the undated face sheet for Resident #18 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included intellectual disabilities, depression, and history of urinary tract infection. Review of the quarterly MDS for Resident #18 dated 11/18/24 reflected a BIMS score of 07, indicating severely impaired cognition. It reflected he was occasionally incontinent of bowel and had an indwelling catheter. It reflected he was independent with toileting hygiene. Review of the care plan for Resident #18 dated 12/15/24 reflected the following: [Resident #18] has impaired cognitive abilities related to his diagnosis of Intellectual Disabilities. There was no care plan item related to behaviors of poor hygiene. Review of the undated face sheet for Resident #35 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia with behavioral disturbances and anxiety disorder. Review of the annual MDS for Resident #35 dated 12/19/24 reflected a BIMS score of 03, indicating severely impaired cognition. It reflected he required supervision or touching assistance with toileting hygiene. Review of the care plan for Resident #35 dated 01/23/25 reflected the following: [Resident #35] experience decreased bladder continence. [Resident #35] will attain improved level of bladder continence. There was no care plan item related to behaviors of urinating in wastebaskets or piles of clothing. Observation and interview on 02/24/25 at 10:16 AM revealed Resident #18's bed was unmade, and the sheet had a yellowish moisture stain from the edge of the bed toward the center with a dark brown streak mark in the middle. His toilet had streaks of a thick brown substance on the underside of the seat and within the bowl. There was an unpleasant odor in his room and bathroom. Resident #18 did not respond to questions about the condition of his room, though he did engage in some light conversation. Observation and interview on 02/24/25 at 10:24 AM revealed Resident #35's room had an overwhelming foul odor. His bathroom had white flecks covering the mirror, brown crusted substance on the toilet, and the wastebasket had standing yellow liquid in it. The floor around the base of the toilet was not tiled, and there was a dark brown/black crust both on the toilet base itself and the floor below. Resident #35 stated his room looked good to him and asked if it looked clean enough. Observation on 02/25/25 at 08:20 AM revealed Resident #18's bed and bathroom still unmade, and the sheet still had a yellowish moisture stain from the edge of the bed toward the center with a dark brown streak mark in the middle. His toilet had still streaks of a thick brown substance on the underside of the seat and within the bowl. There was still an unpleasant odor in his room and bathroom. Observation on 02/25/25 at 08:22 AM revealed Resident #35's room and bathroom still had an overwhelming foul odor which was even stronger than on 02/24/25. His bathroom had white flecks covering the mirror, brown crusted substance on the toilet, and the wastebasket had standing yellow liquid in it. The floor around the base of the toilet was not tiled, and there was a dark brown/black crust both on the toilet base itself and the floor below. Observation on 02/26/25 at 03:30 PM revealed Resident #18's bed was still unmade, and the sheet still had a yellowish moisture stain from the edge of the bed toward the center with a dark brown streak mark in the middle. His toilet had still streaks of a thick brown substance on the underside of the seat and within the bowl. There was still an unpleasant odor in his room and bathroom. Observation on 02/26/25 at 03:30 PM revealed Resident #35's bedroom and bathroom still had an overwhelming foul odor which was even stronger than on 02/24/25. His bathroom had white flecks covering the mirror, brown crusted substance on the toilet, and the wastebasket had standing yellow liquid in it. The floor around the base of the toilet was not tiled, and there was a dark brown/black crust both on the toilet base itself and the floor below. 3. Observation from 02/24/25 at 09:00 AM to 04:00 PM, on 02/25/24 from 07:30 AM to 03:30 PM, and 02/26/25 from 08:00 AM to 06:20 PM revealed the facility had a foul odor (urine, among others) that was detectable everywhere in the facility except the secure unit (200 hall) and dining room but became stronger when on the 100 and 600 halls and in the rotunda (center of the wagon wheel-shaped building). During an interview on 02/26/25 at 02:48 PM, HK L stated she had worked at the facility for a few weeks and worked 08:00 AM to 02:00 PM. She stated she was not taught to have a specific procedure or order of cleaning areas of the facility, but most days she was responsible for cleaning 100, 300, and 500 halls as well as the rotunda. She stated she was responsible for cleaning the shower rooms on those halls, but she was not allowed to work any overtime and could not finish her work most days. She stated she had noticed the foul odor in the facility, and the odor came mostly from a few rooms on the 600 hall. She stated the housekeeping staff were instructed to go into those rooms and clean more often, but she did not usually work that hall. She stated none of the residents had complained to her about the odor, but the staff did not like it. During an interview on 02/26/25 at 03:04 PM, the HKS stated she had been in her position since May 2024. She stated they had been shorthanded in the housekeeping department lately, and cleaning the shower rooms did not always happen. She stated she checked the shower rooms as often as she could. She stated the housekeeping staff were paid less than at most facilities and they were not given very many hours. She stated if the housekeepers were to stay longer to finish their cleaning, she had to give up her own hours. She stated she had hired several staff who had quit soon after hiring, because they could not make enough money. She stated she was not aware who was not allowing them to work enough hours, but the staff did not work enough hours to get the facility clean, and they had a resident population who made more mess than average. She stated she had noticed the foul odor in the facility, and the odor was because of Residents #18 and 35. She stated housekeepers were supposed to stop in those rooms more often and make sure they were clean, because both of the residents were incontinent or had the behavior of urinating in inappropriate places such as piles of clothing or waste baskets. She stated the housekeepers did not have time to clean all the areas they had to clean once, let alone enough time to go into certain rooms several times throughout the day. She stated she had reported the concerns about housekeepers having enough time to clean to her management, but nothing had changed. She stated she was responsible for the cleanliness of the facility, but she was not given the resources she needed to do her job. She stated the potential impact on the residents was they could smell bad odors or get sick. During an interview on 02/26/25 at 03:17 PM HK M stated she had worked at the facility since July 2024. She stated the hours they were allowed to work did not give them enough time to clean the whole facility or get into Resident #18 and 35's rooms more than once. She stated Resident #18 and 35's rooms made the whole facility smell bad . During an interview on 02/26/25 at 03:34 PM, CNA F stated she had worked at the facility since September 2024 and one of her duties were giving showers to her residents. She stated she was supposed to sanitize the shower rooms when they were done with each shower, but her management had never given her any sanitizing supplies. She stated the facility could have been cleaner, and it had a bad odor most of the time, but she had not reported the issue to her management. She stated she had not heard residents complain about the odor or the cleanliness of the facility. During an interview on 02/26/25 at 04:58 PM, the DON stated she was familiar with the unpleasant odors in the facility and thought they mostly came from Resident #18 and 35. She stated she thought the residents were care planned for the behaviors related to urine, feces, and poor hygiene. She stated her understanding was housekeeping was to visit those rooms more frequently to make sure there was no urine or feces present. She stated they have had major staffing challenges at the building and the housekeeping had fallen through the gaps. She stated the impact of the facility not being clean was the residents were at risk of infection. During an interview on 02/26/25 at 05:19 PM, the ADM stated she had spoken to the HKS about ensuring the rooms and common areas were clean at the end of each day. She stated the HKS was supposed to clean the common areas so the housekeepers could focus on rooms and shower rooms. The ADM stated the housekeepers only worked six hours a day, and if the census went up, they could work more hours, but she felt it was enough time to get all the housekeeping done. The ADM stated if they were not able to clean thoroughly in all areas in six hours, they could work additional hours. She stated she had not told anyone they could not have additional hours if they needed the time to get the job done. She stated she was aware of the odor in the facility, and it was a new situation that had occurred because they had some turnover in the housekeeping department. She stated a potential negative impact on residents was it could be a dignity issue. Review of the facility policy dated February 2021 and titled Homelike Environment reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment, and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment; e. Clean bed and bath linens that are in good condition; f. Pleasant, neutral scents.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 7 (Resident #6, #49, and #203) residents reviewed for accommodations. The facility failed to ensure that Residents #6, #49, and #203 had their call lights within reach while lying in bed. This failure could place residents at risk of injury, for not receiving timely care, and for not receiving nursing interventions. Findings included: Record review of Resident #6's face sheet, dated 02/26/2025, revealed an [AGE] year-old female, admitted on [DATE], with diagnoses that included cerebral infarction (a condition in which the blood flow to the brain is cut off causing brain damage), hemiplegia (the complete paralysis on one side of the body), and cognitive communication deficit (a condition that affects the ability to communicate effectively). Record review of Resident #6's quarterly MDS, dated [DATE], revealed a BIMS score of 00 which indicated severe cognitive deficits. Record review of Resident #6's care plan, dated 11/15/2024, revealed Problem [Resident #6] is at risk for falls due to: Paralysis to the left side with an approach that included Increased staff supervision with intensity based on resident need. Encourage [Resident #6] to use call light when assistance is needed. Record review of Resident #49's face sheet, dated 02/26/2025, revealed a [AGE] year-old male, admitted on [DATE], with diagnoses that included aphasia (inability to talk), hemiplegia and hemiparesis following a cerebral infarction (one sided paralysis and weakness due to a lack of blood flow to the brain), and lack of coordination. Record review of Resident #49's comprehensive MDS, dated [DATE], revealed Resident #49 was unable to complete a BIMS assessment and had both short- and long-term memory problems. Record review of Resident #49's care plan, dated 01/20/2025 and last revised 02/25/2025, revealed no care plan related to call lights. Record review of Resident #203's face sheet, dated 02/26/2025, revealed a [AGE] year-old male, admitted on [DATE], with diagnoses that included cerebral infarction, respiratory failure (a condition of not enough oxygen or too much carbon dioxide in the blood), and patent foramen ovale (a small opening between the upper heart chambers). Record review of Resident #203's record revealed an admission MDS was in process. Record review of Resident #203's care plan, dated 02/13/2025, revealed no care plan related to call lights. During an observation on 02/24/2025 at 09:50 AM, Resident #49 was lying in bed and his call light was on the floor near the head of the bed next to a fall mat, trash can, and enteral feeding pole. During an observation on 02/24/2025 at 09:55 AM, Resident #203 was lying in bed and his call light was sitting inside of a water basin on top of the nightstand approximately 4 feet from Resident #203. During an observation on 02/25/2025 at 02:46 PM, Resident #6 was lying in bed and her call light was on the floor between the bed and the wall and out of reach. During an interview on 02/26/2025 at 01:23 PM, CNA F stated she had worked at the facility for about 5 months. She stated all staff were responsible for ensuring the call lights were within reach for all residents when in bed. She stated that was something everyone was supposed to look at any time staff go into a resident's room. She stated if the call lights were out of reach it could cause the resident to become scared, increase their fall risk, and it could prevent the residents from getting the help they required. During an interview on 02/26/2025 at 02:48 PM, HK L stated she didn't know what a call light was. She stated she had not been trained to ensure the call light was within resident's reach. During an interview on 02/26/2025 at 03:57 PM, LVN C stated that all staff were responsible for ensuring call lights were within reach. She stated the DON and the ADON did rounds to ensure staff were placing call lights within reach. LVN C stated if the call light was not within reach, then it could be considered neglect because the residents couldn't get what they needed. During an interview on 02/26/2025 at 04:40 PM, the ADON stated she had worked at the facility for about 4 1/2 years. She stated that all staff members were responsible for ensuring the call lights were within reach. She stated she and the DON performed daily rounding and that was one thing that they checked for. The ADON stated if a call light wasn't within reach, then it could be considered neglecting the resident because if they had an emergency it would interfere with their care. During an interview on 02/26/2025 at 04:57 PM, the DON stated she had worked at the facility for 8 to 9 years. She stated the aides, the nurses, and everyone in the building should have ensured call lights were within reach of the residents when in bed. She stated she and the ADON monitored for this during their daily rounds. The DON stated if the call light was not within reach, then the resident would not be able to communicate their needs. During an interview on 02/26/2025 at 05:19 PM, the ADM stated all of us were responsible for ensuring the call lights were within reach of the residents. She stated she expected the staff to make sure the call light was within reach of the resident anytime they were left in their room. The ADM stated the managers performed quality of life checks daily and checking call light placement was part of the checklist. She stated if the call light was not within reach, then it would affect the resident because they wouldn't be able to get the help they needed. Record review of the facility policy titled Answering the call light dated 2001 and revised in March 2021, revealed Purpose The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines 4. Be sure that the call light is plugged in and functioning at all times. 5. 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 grievances revealed no complaints or concerns related to call lights.

Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 8 residents (Residents #45 and 104) reviewed for quality of care. 1. The facility failed to follow up with treatment of a skin tear from a fall for Resident #45 after readmission from the hospital. 2. The facility failed to ensure Resident #104 had compression hose applied to both legs from 02/24/25 to 02/26/25 as ordered. These failures places residents at risk of not receiving necessary medical care, worsened swelling, infection, and hospitalization . Findings included: Record review of Resident #45's face sheet, dated 02/26/25, revealed a [AGE] year-old male, admitted on [DATE], with diagnoses that included cellulitis of left upper limb (an infection in the skin tissue), muscle weakness, unspecified lack of coordination, and other fracture of shaft of left humerus (break in the bone of the upper arm). Review of Resident #45's quarterly MDS, dated [DATE], reflected a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #45's care plan, dated 02/11/25, reflected Problem: Pressure sores/ skin care with approaches including report to charge nurse any redness or skin breakdown immediately. Review of Resident #45's wound management report dated 01/26/25-02/25/25 reflected no wound management records for that time period. Review of Resident #45's nurse's note dated 02/15/25 at 02:15 AM reflected Resident #45 fell and Swelling/redness/abrasions noted to left outer arm, ST to left outer hand .resident transported to ER via EMS. Record review of Resident #45's admission observation form dated 02/17/2025 at 11:29 PM revealed Resident #45 returned from hospital and alterations in skin section revealed s/t to left hand with treatment of application of non-surgical dressing. Review of Resident #45's active and discontinued orders for the month of February 2025 reflected no orders to monitor or treat skin tear to left hand. Review of Resident #45's nurses' notes from 02/18/25-02/25/25 reflected no mention of any skin tears. Observation and interview on 02/24/25 at 11:57 AM revealed Resident #45 had a dressing to the left hand with initials and dated 01/14/25. Resident stated he broke his arm and got a skin tear to his hand when he fell recently. He stated he had just returned from a follow up with the orthopedic doctor. He stated the date on the dressing was wrong, but he didn't know when the dressing had been changed . During an interview on 02/26/25 at 10:46 AM, LVN C stated skin assessments were done weekly, by the nurse for that hall, according to the schedule. She stated she was unaware of the skin tear to Resident #45's left hand. She reviewed the resident's chart and stated the skin tear was documented on the admission assessment, but no orders were written for the skin tear. LVN C stated the resident needed to have the skin tear monitored because he had an infection from a skin tear to the left elbow in January 2025. She stated if it was not monitored then it could get infected and not get the appropriate treatment. During an interview on 02/26/25 at 01:23 PM, CNA F stated if she noticed a new skin issue, then she was expected to report it to the nurse and document it on the shower sheet in the electronic health record. She stated if she noticed an old dressing on a resident then she would tell the nurse and the DON or the ADON. CNA F stated the skin tear could cause increase in pain if not monitored. During an interview on 02/26/25 at 02:33 PM, CNA G stated if she noticed a new skin tear on a resident then she would report it to the nurse. She stated the skin tear could get worse if its wasn't monitored. Review of the undated face sheet for Resident #104 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included persistent atrial fibrillation (irregular heartbeat), hyperlipidemia (high cholesterol), dementia, anxiety disorder, hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery (buildup of hardened fat in the artery restricting circulation), cardiomyopathy (disease that affects the heart muscle), and heart failure. Review of admission MDS assessment for Resident #104 dated 02/12/25 reflected a BIMS score of 02, indicating severely impaired cognition. It reflected she was completely dependent on staff for lower body dressing. It reflected she was taking a diuretic medication (reduces fluid overload in the body when the heart can no longer circulate the fluids adequately). It reflected she had a deep tissue injury (unique form of pressure ulcer that affects the underlying layers of skin, muscle, and other soft tissues. It occurs beneath intact skin and initially appears as a deep bruise. Unlike superficial injuries, deep tissue injuries are not immediately visible, making them challenging to detect and diagnose early.) on both heels and was receiving treatment for pressure injury. Review of the care plan for Resident #104 dated 02/25/25 reflected the following: Resident is on diuretic medication r/t HTN/CAD. Monitor cardiovascular system and fluid status to determine effectiveness of diuretic. Review of a physician's order dated 02/19/25 reflected the following: Apply compression hose to bilateral legs every day as tolerated and remove at HS . Review of the February 2025 MAR for Resident #104 reflected her compression hose were marked as Not administered: Drug/item not available on 02/24/25 and 02/25/25 by LVN D. There was no entry marked for 02/26/25. During an interview on 02/26/25 at 03:57 PM, LVN C stated she was aware Resident #104 had an order for compression hose to be on both legs during the day shift each day. LVN C stated the hose were not applied today, 02/26/25. She stated the hose was not applied, because she got behind in her duties. LVN C stated there had been some days when hose was not applied because she needed a bigger size. The ones they had available were size large, and Resident #104 might have needed a size XL. LVN C stated she did not know if her nurse managers had been notified Resident #104 might have needed a bigger size hose, but the size was not the reason why the hose were not applied today. LVN C stated the hose were helping Resident #104, and the swelling on her legs had gone down since they started applying the hose. LVN C stated she had been trained to follow all physician orders. A telephone attempt was made on 02/26/25 at 04:15 PM to interview LVN D, but contact was not returned as of 03/05/25. During an interview on 02/26/25 at 04:40 PM, the ADON stated a head-to-toe skin assessment was required on all residents when they were [re]admitted . She stated the process was to notify the MD of skin issues and obtain an order for treatment and start the order. She stated skin assessments were done weekly by the nurse that worked the hall on the scheduled day. The ADON stated if the skin tear wasn't monitored then it had the potential to get infected. She stated residents with orders for compression hose should have compression hose applied each day. She stated she did not know Resident #104 very well, as the ADON had been on leave just after Resident #104 admitted to the facility. She stated the nurse management team monitored for compliance with orders by checking the administration report. She stated the report would include any missed treatments no matter what the reason given for the missed administration. She stated she and the DON were responsible for ensuring compliance with quality-of-care issues. She stated the potential negative impacts of compression hose not being applied were increased edema and discomfort. During an interview on 02/26/25 at 04:57 PM, the DON stated she expected the nurse that admitted a resident to do a complete assessment that included a complete skin assessment. She stated if there was an issue with the integrity of the skin, then the nurse needed to document it and contact the MD for treatment orders. She stated the doctor should have been contacted for orders for treatment of a skin tear. The DON stated if the skin tear was not monitored then an infection could have developed. The DON stated she did not know Resident #104 was ordered compression hose daily. She stated the nurse management team had discussions about adding compression hose once Resident #104's initial swelling had gone down on her legs, but when she had first admitted to the facility, the swelling on her feet and legs were so bad, the hose could not have been applied. The DON stated she and the ADON were responsible for making sure the orders were followed, but it was easier to do when she did not have to work the floor as a charge nurse, which she often had to do. The DON stated a potential negative impact of Resident #104 not receiving her compression hose application was her feet would continue to get edematous (swollen) and it could compromise circulation. During an interview on 02/26/25 at 05:19 PM, the ADM stated it was required for skin tears to be reported to the physician and to receive treatment. She stated it was also required for a resident ordered compression hose to receive the compression hose each day unless she refused. The ADM stated the DON and the ADON were responsible for ensuring compliance in these areas, but they had a medication noncompliance report that they pulled each morning and went over in the morning meeting. She stated she did not know why these issues were not reviewed in the morning meeting. The ADM stated the potential negative impact of both failures was the injuries could have worsened. Record review of the facility policy titled Provision of Quality of Care, dated February 2025, revealed the following policy Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The policy explanation and compliance included 1. Each resident will be provided with care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 4. Qualified people will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. 50872

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 24 residents (Residents #35 and 104) reviewed for care plans. The facility failed to include Resident #35's behaviors of urinating in places other than the toilet in his care plan. The facility failed to include Resident #104's bilateral heel injuries in her care plan. These failures placed residents at risk of not having their care needs met. Findings included: Review of the undated face sheet for Resident #35 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia with behavioral disturbances and anxiety disorder. Review of the annual MDS for Resident #35 dated 12/19/24 reflected a BIMS score of 03, indicating severely impaired cognition. It reflected he required supervision or touching assistance with toileting hygiene. Review of the care plan for Resident #35 dated 01/23/25 reflected the following: [Resident #35] experience decreased bladder continence. [Resident #35] will attain improved level of bladder continence. There was no care plan item related to behaviors of urinating in wastebaskets or piles of clothing. Observation and interview on 02/24/25 at 10:24 AM revealed Resident #35's room had an overwhelming foul odor. The wastebasket in his bathroom had standing yellow liquid in it. The floor around the base of the toilet was not tiled, and there was a dark brown/black crust both on the toilet base itself and the floor below. Resident #35 stated he did not notice an odor in his room. Review of the undated face sheet for Resident #104 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included persistent atrial fibrillation (irregular heartbeat), hyperlipidemia (high cholesterol), dementia, anxiety disorder, hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery (buildup of hardened fat in the artery restricting circulation), cardiomyopathy (disease that affects the heart muscle), and heart failure. Review of admission MDS assessment for Resident #104 dated 02/12/25 reflected a BIMS score of 02, indicating severely impaired cognition. It reflected she had a deep tissue injury (unique form of pressure ulcer that affects the underlying layers of skin, muscle, and other soft tissues. It occurs beneath intact skin and initially appears as a deep bruise. Unlike superficial injuries, deep tissue injuries are not immediately visible, making them challenging to detect and diagnose early) on both heels and was receiving treatment for pressure injury. Review of the care plan for Resident #104 reflected no care planning related to pressure injury prevention or treatment. Review of a physician order for Resident #104 reflected the following dated 02/20/25: Wound Treatment Order: Location: Bilateral Heels Clean with normal saline/wound cleanser; apply skin prep; leave OTA Observation on 02/24/25 at 12:14 PM revealed Resident #104 in the dining room with slippers on her feet that had no backs. She had deep tissue injuries (DTIs) visible on both heels. During an interview on 02/25/25 at 03:30 PM, the ADM stated the strong foul odor in Resident #35's room was the result of his behavior of urinating in wastebaskets, piles of clothing, and other inappropriate areas. She stated he had care planning for this behavior, as it was well known throughout the facility. During an interview on 02/26/25 at 04:14 PM, the CCM stated she was responsible for creating care plans. She stated she decided what to add as care plan items by completing the comprehensive MDS assessment and drawing the care areas that triggered on the assessment over to the plan in the facility's EMR . The CCM stated she was aware Resident #104 had DTIs, and there should have been a care plan item for the pressure injuries. She stated DTIs were considered pressure injuries. She stated there should have at least been a care plan item for risk of pressure injuries. The CCM stated the reason the pressure injuries were not placed on the care plan was because she had been working the floor as a charge nurse frequently, and the care plan item had slipped her mind. A potential negative impact on the resident was staff might not know what to do to improve the injuries. The CCM stated Resident #35 had known behaviors of urinating in his wastebasket, on piles of clothes and the floor, and other inappropriate places. She stated she thought he had been care planned for these behaviors, and she did not know he had not. She stated he cleaned his room with his clothes. She stated she had noticed an odor in his room, and it was the result of these behaviors. She stated he should have a care plan for the behaviors. She stated the behaviors placed him at risk for infection and slip hazards. During an interview on 02/26/25 at 04:58 PM, the DON stated Resident #35's behaviors and Resident #104's pressure injuries should have been care planned. She stated she, the ADON, and the CCM were responsible for ensuring care plans were comprehensive. The DON stated she would have expected Resident #35's behaviors related to urination and Resident #104's pressure ulcers to be care planned. She stated she monitored for compliance with comprehensive care plans by discussing all care needs during their morning clinical meetings. She stated a potential negative impact on residents was they might not get their care needs met. During an interview on 02/26/25 at 05:19 PM, the ADM stated she expected Resident #35's behaviors of urinating in places other than the toilet to be in the care plan. She stated she was surprised to learn it was not. She stated Resident #104's pressure injuries should have been care planned, as well. She stated it was the responsibility of the CCM to ensure all needs were in the care plans. She stated she monitored to ensure care needs were in the care plans by discussing it during morning meetings and asking if issues were care planned. She stated the potential negative impact of these issues not being care planned was the residents might not get necessary treatment. Review of the facility policy dated December 2020 and titled Care Plans, Comprehensive and Person-Centered reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally, competent, and trauma informed. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives, and time frames; b. Describe the services that are to be furnished to attain or maintain the resident's highest practical, physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for elopement. The facility failed to ensure Resident #1, who was an elopement risk, was not left outside in the secure unit courtyard by himself on 08/13/24. The noncompliance was identified as PNC IJ. The IJ began on 08/13/24 and ended on 08/18/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving their medications and meals, going missing, or sustaining injuries, dehydration, or death. Findings included: Review of Resident #1's face sheet, dated 09/25/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a group of diseases that cause a loss of cognitive functioning that interferes with daily life), anxiety disorder, and unspecified mood disorder. Review of Resident #1's admission MDS assessment, dated 08/19/24, reflected he had a BIMS of 4, which indicated he had severe cognitive impairment. Review of Resident #1's care plan, dated 08/16/24, reflected he had a diagnosis of dementia and resided in the secure unit due to his known history of wandering and poor safety awareness allowing freedom of mobility. Staff noted on 08/13/24, Resident #1 eloped from secure unit courtyard stating he climbed over the fence. Interventions included refer Resident #1 to behavioral facility for evaluation and treatment, initiate 1:1 monitoring until psychological services discontinues 1:1 monitoring, psychological/psychiatric services evaluation and treatment, initiated medication review with psychologist/MD/Pharmacist as needed, Resident #1 required supervision when he wanted to go outside and encourage extra hydration, encourage to attend group activities daily, have an elopement assessment done on admission, quarterly, and with significant change in condition, provide Resident #1 with activities based on his prior lifestyle/interests if Resident #1 wanders, conduct medical evaluation per MD orders, speech will evaluate and treat for cognition, staff will monitor Resident #1 and report changes in exit seeking behaviors to the ADM, DON, physician and RP, and provide comfort measures for Resident #1's basic needs when he began to wander. Review of Resident #1's elopement risk assessment, dated 08/08/24, reflected he was at risk for elopement with an intervention of being placed in the secure unit. Review of Resident #1's progress notes reflected the following: - LVN A documented on 08/12/24 at 5:48 p.m., Resident day 3/7 admission and resident alert and oriented to self with forgetfulness. Resident noted up pacing all night and as he was pacing proceeded to knock on adjacent doors and required staff redirection. Resident would apologize to staff then continued to pace up and down hall and stated he cannot sleep. Resident will continue to be monitored. - LVN B documented on 08/13/24 at 12:20 a.m., Resident day 6/7 new admit, resident very pleasant, able to make needs known, stated to the nurse he has no pain or discomfort. Nurse noted him wandering from room to room throughout the night, open other residents room doors, he was confused as to what he need and what he was looking for. Staff had to keep directing him back to his room. -LVN B documented on 08/13/24 at 5:22 a.m., Resident did not sleep throughout the night he kept coming out of his room going into other rooms. Staff had to be redirected back into his room. -LVN A documented on 08/13/24 at 6:58 p.m., This staff was alerted by CNA staff that resident was let out to courtyard. This staff walked perimeter of the fence line and alerted other staff as well as DON of missing resident. [PD] was contacted and given description of resident wearing longhorns baseball hat along with grey shirt and khaki shorts. Head count was completed by this staff of 17 accounted for with 1 resident eloping noted 18 before elopement. [PD] then called this staff and alerted resident was found and will be returned per [PD]. Resident returned with no visible sign of injury. Resident ambulated independently back to secured unit without any behaviors and was noted happy and noted with sweaty shirt. Head to toe assessment was noted with no injuries b/p taken and noted 127/68 p74 temp 98.3 spo 97% on rrom air. Resident denies pain or distress, officer stated resident stated he had to walk because his car broke down. Resident sitting in common area water offered and taken well. This staff was then told by don 1 to 1 in place. -DON documented on 08/13/24 at 8:13 p.m., This nurse went to check on resident after returning to facility. Resident was noted to be happy and sitting in recliner in common area drinking water. Resident noted to have sweat on T-shirt. resident ask where he went and he stated for a long walk. Resident denied pain and had no noted visible sign of injury. I ask resident if he could he show me what he did and he said yes, physical therapist and myself walked him outside in courtyard and resident went to fence pointing up to a post and showing us that he just grabbed up and pulled over the fence. resident was easily redirected to inside the building. I ask resident if he would like more water and a snack and he stated yes. Water and pizza was provided to staff and he ate all and drank as he was eating. Resident remains happy and joking. states that he is a little tired now. -DON documented on 08/13/24 at 9:13 p.m., I went to check on resident and he was in bed at this time, I ask if he would like to shower and he declined at this time, I did a head to toe assessment and noted no bruises or scratches to body on anterior or posterior side. Left knee noted to be red in color and resident stated hit it on fence. Resident given glass of water and tolerated well. MD notified of elopement with med review done and stated no lab to be done at this time. Medical director notified as well. Resident remains one on one monitoring at this time. -DON documented on 08/13/24 at 9:31 p.m., I notified resident [family] about elopement and updated on resident overall condition. Resident [family] stated he did this at home all the time. [Family] states they went hiking all the time with me as I am a wildlife photography and he can out do me for sure. [Family] stated he is appreciative for the update and has no concerns at this time. During a group interview on 09/25/24 at 10:31 a.m., the DON and the HRC stated Resident #1 was a new resident. The DON and the HRC stated Resident #1 was in the facility's secure unit courtyard and hopped over the fence. The DON and the HRC stated staff searched for Resident #1, notified the police, and found him. The DON stated her and a physical therapist took Resident #1 out to the secure unit courtyard again and Resident #1 demonstrated how he climbed over the fence. The DON and the HRC stated Resident #1 was in the secure unit courtyard getting fresh air. The DON and the HRC stated they did not know if anyone was outside in the secure unit courtyard with Resident #1. The DON stated CNA C let Resident #1 out into the secure unit courtyard, went to check on another resident, came back to secure unit courtyard, noticed Resident #1 was missing, and notified a night shift nurse. The DON stated she was in the facility when staff notified her that Resident #1 was missing. The DON stated Resident #1 told staff that he wanted to leave, when asked why he climbed over secure unit courtyard fence. The DON stated Resident #1 also told staff he climbed over the secure unit courtyard fence because his car broke down and he was trying to find a phone. The DON stated Resident #1's family told staff that Resident #1 would leave home in the past. The DON stated Resident #1 never eloped at the facility in the past and had been at the facility for one week since admission. The DON stated CNA C told her that Resident #1 did not leave the secure unit courtyard in the past, wanted to go outside, let him out, and did not think he would climb over the fence. The DON stated Resident #1 had no prior exit-seeking behaviors, but Resident #1's family told her that Resident #1 would leave the house in the past prior to his admission, which was why he was considered exit-seeking. The DON stated she believed the secure unit courtyard fence was approximately 8-10 feet and CNA C did not think Resident #1 would climb the fence and leave. The DON stated staff implemented visual observations of Resident #1 and had psychological services visit Resident #1 following the incident. The DON stated Resident #1 was no longer on 1:1 monitoring at the time of the interview because psychological services told staff that they could stop 1:1 monitoring of Resident #1. The DON stated staff documented all 1:1 monitoring performed on Resident #1. The DON stated Resident #1 had short-term memory issues. The DON stated Resident #1's family wanted to place Resident #1 in a facility because he wanted to wander out of the house and would get up and leave the house. The DON stated staff were educated on elopement and other trainings. The DON stated staff did not have orientation training specifically on the topic of elopement prior to beginning employment. The DON stated staff were in-serviced monthly and with elopement being one of the topics reviewed. The DON stated staff were taught to be out in the secure unit courtyard accompanying and supervising residents following Resident #1's incident. The DON stated before Resident #1's incident, residents could walk in the secure unit courtyard, staff could frequently check on residents and were not required to supervise residents in the area. During an interview on 09/25/24 at 10:46 a.m., the DON stated Resident #1 was sent to a behavior hospital on 08/28/24 because of his exhibited aggressive behaviors towards another resident and returned 09/13/24 because he had no behaviors in the hospital. The DON stated Resident #1 did not exhibit any aggressive or exit-seeking behaviors since returning from the hospital. An observation of the secure unit courtyard on 09/25/24 at 11:46 a.m. reflected the courtyard was empty, there were no residents in the area at the time of the observation, there was a fence that stretched the entire landscape with no openings, and approximately 10 feet tall. An observation of the door leading to the secure unit courtyard on 09/25/24 at 11:51 a.m. reflected a sign posted on the door that indicated, Do not let residents out of the facility unassisted. During an interview on 09/25/24 at 11:56 a.m., CNA D stated she could not recall when staff posted the sign on the door leading to the secure unit courtyard, but she believed it was a month or two months ago. During an interview on 09/25/24 at 11:59 a.m., LVN E stated she was given orientation training on elopement and in-serviced by the DON 2-4 times in the last four months on the topic. LVN E stated if a resident asked to go to the secure unit courtyard, she was trained to go out to the courtyard with the resident. LVN E stated she would also bring the resident inside and not leave the resident alone in the secure unit courtyard if another resident needed her help. LVN E stated if a resident was not in the secure unit courtyard, she was trained to initiate the facility's missing resident protocol, start searching the resident, and immediately notify the DON. LVN E stated she never observed a resident climb over the secure unit courtyard fence and did not know how Resident #1 climbed over the secure unit courtyard fence. LVN E stated Resident #1 had no exit seeking behaviors since his incident. LVN E stated Resident #1 was placed on 1:1 monitoring following his incident and taken off 1:1 monitoring after psychological services verified, he was okay. LVN E stated the CNAs and supervising nursing staff initiated Resident #1's 1:1 monitoring. During an interview on 09/25/24 at 12:11 p.m., CNA D stated she was given orientation training on elopement and in-serviced by the DON two weeks ago on the topic. CNA D stated if a resident asked her to go to the secure unit courtyard, she was trained to go out to the secure unit courtyard with them. CNA D stated she would bring the resident back inside the facility and not leave the resident alone in the secure unit courtyard if another resident needed her help. CNA D stated if a resident was not in the secure unit courtyard, she was trained to notify a nurse. CNA D stated there was also a doorbell for assistance in the secure unit courtyard. CNA D stated she helped conduct 1:1 monitoring for Resident #1 every 15 minutes after his incident. CNA D stated Resident #1 had no previous or subsequent elopement incidents. CNA D stated she documented Resident #1's 1:1 monitoring on physical log sheets. CNA D stated she never had a resident climb over the secure unit courtyard fence. CNA D stated she did not know how Resident #1 climbed over the secure unit courtyard fence because Resident #1 did not have any marks, scratches, or scars. CNA D stated Resident #1 had no exit seeking behaviors since the incident. CNA D stated Resident #1 was taken off 1:1 monitoring after psychological services verified, he was okay. During an interview on 09/25/24 at 12:23 p.m., the MR stated she helped supervise residents in the secure unit. An observation of the secure unit and interview on 09/25/24 at 12:24 p.m. reflected Resident #2 wandering to the secure unit entrance doors. CNA D monitored and redirected Resident #2 away from the doors. Resident #2 stated she was doing fine, felt safe, never wanted to leave the facility, and staff checked on her. An observation of the secure unit on 09/25/24 at 12:26 p.m. reflected Resident #3 wandering to the secure unit entrance doors. LVN E monitored and redirected Resident #3 away from the doors. An attempt to interview Resident #3 was made, but he was unable to answer any questions. An observation and interview of Resident #1 on 09/25/24 at 12:28 p.m. reflected he had no scratches, marks, or scars. Resident #1 stated he could not remember how and why he climbed over the secure unit courtyard fence, but he believed it was determination. Resident #1 did not explain why it was determination. Resident #1 stated he also could not remember how long he was away from the facility after he climbed the secure unit courtyard fence. Resident #1 stated he never attempted to climb over the secure unit courtyard fence after his incident. Resident #1 stated he felt safe, staff checked on him often, he had no injuries from his incident, and did not want to leave the facility. An attempt to contact Resident #1's RP was made on 09/25/24 at 12:46 p.m. A voicemail and call back number was left. Resident #1's RP did not return the call prior to exit. During an interview on 09/25/24 at 12:47 p.m. the NP stated staff notified her about Resident #1's elopement episodes. The NP stated Resident #1 tried to leave when he was admitted , which was why he was assigned to reside in the secure unit, because staff had an elopement unit. The NP stated she was notified whenever Resident #1 tried to leave the facility. The NP stated Resident #1 had behavior issues. The NP stated police were called when Resident #1 somehow climbed over the secure unit courtyard fence. The NP stated staff encouraged Resident #1 to come back to the facility. The NP stated to her knowledge, Resident #1 was never out of staff's sight. The NP stated to her understanding, Resident #1 broke through the secure unit courtyard fence and did not climb over the fence. The NP stated Resident #1 was always trying to leave, but he never got that close to leaving the facility. The NP stated Resident #1 medications changed and staff had no problems since he returned from the behavior hospital. The NP stated she heard about Resident #1's incident 1-2x weeks before his transfer to a behavior hospital. The NP stated she last visited Resident #1 at the facility 3 weeks ago. The NP stated she reviewed Resident #1's new medications implemented at the behavior hospital and continued the medications after he returned from the behavior hospital because they were effective. An attempt to contact LVN A was made on 09/26/24 at 9:42 a.m. A voicemail and call back number was left. LVN A did not return the call prior to exit. An attempt to contact CNA F was made on 09/26/24 at 9:43 a.m. An attempt to leave a voicemail and call back number was made, but there was an automatic message that indicated the person the user was trying to reach was not accepting calls at the time and automatically ended the call after the message. An attempt to contact LVN G was made on 09/26/24 at 9:44 p.m. A voicemail and call back number was left. LVN G did not return the call prior to exit. During an interview on 09/26/24 at 11:09 a.m., CNA C stated she was given orientation training on elopement and in-serviced by the DON on the topic. CNA C stated if a resident asked her to go to the secure unit courtyard, she was trained to go with the resident. CNA C stated before the training, she was trained to supervise residents within eyesight from the inside of the facility whenever a resident requested to go out into the secure unit courtyard. CNA C explained she would have another staff member monitor the resident in the secure unit courtyard if another resident asked her for help while another resident was in the secure unit courtyard. CNA C stated she was working in the secure unit when Resident #1 eloped from the facility two months ago. CNA C stated Resident #1 asked her if he could go out to the secure unit courtyard and she allowed Resident #1 to go in the secure unit courtyard. CNA C explained residents could go into the secure into courtyard and be supervised by staff within eyesight at the time of the incident. CNA C explained she went back inside the facility to help lie a resident down into bed, returned 5 minutes later, observed Resident #1 was gone from the secure unit courtyard, and immediately notified the nurse. CNA C stated there was another CNA who was supposed to work on her shift the day of the incident, but the CNA called out sick. CNA C stated the DON, LVN G, and LVN A were working at the time when she notified them that Resident #1 was missing. CNA C stated Resident #1 was placed on 1:1 monitoring after his incident. CNA C stated she participated in monitoring Resident #1 every 15 minutes and documented the monitoring she performed on physical log sheets. Review of Resident #1's elopement risk evaluation, dated 08/13/24, reflected he was at risk for elopement with additional interventions of being placed in secure unit, structural activities, and ensuring room was located close to nursing stations and away from exit doors. Review of Resident #1's orders reflected an order by the MD on 08/13/24 to place Resident #1 on one-on-one monitoring through the night and then monitor every 15 minutes for 72 hours. The order was discharged by the MD on 08/28/24 because Resident #1 was discharged to the behavior hospital on 08/28/24. Review of Resident #1's psychological evaluation note, dated 08/20/24, reflected he was seen by psychological services 1-5 times a month. Session summary indicated, Patient reported that he missed his home and family very much and reported he thought frequently about returning home. When asked, patient reported he did remember trying to make one elopement attempt reporting that he thought he would go to [NAME]. Patient was a poor historian, he initially reported he had zero family in the area and had no children. Later in the interview, he reported that he did have sons and one son was living somewhere in [NAME]. He acknowledged one escape attempt, reporting that he could vaguely remember going over the fence, but could not remember any details about additional attempts. Plan was to see patient one week to assist with identifying coping strategies to assist with reducing anxiety and improving adjustment as well as referring him for psychiatric evaluation to assist with identifying medications that might assist with reducing agitation and improving his adjustment. Review of Resident #1's psychologist progress note, dated 08/27/24, reflected Resident #1 reported that he continued to miss home, but did not think about eloping because he would have nowhere to go. Plan was to consult with Resident #1's staff regarding his psychotropic medications and supervision and the plan was to see him in two days to reevaluate his status and assist with behavior management. Review of Resident #1's 1:1 monitoring sheets, 08/23/24-08/28/24, reflected staff checked on him every 15 minutes and he had no exhibited abnormal behaviors. Review of Resident #1's census report, dated 09/25/24, reflected he discharged on [DATE] and returned 09/13/24. Review of the facility's provider investigation report reflected Resident #1's incident happened on 08/13/24 at 7:41 p.m. in the secure unit and was reported to SA on 08/14/24 at 7:00 p.m. Resident #1 was placed on 1:1 monitoring for 3 days after the incident. There were notices placed on all doors that indicated, No resident should be outside without supervision. Staff were educated on abuse and neglect, wandering, and elopement. Staff also conducted elopement practice drills on 08/13/24. CNA C was interviewed and stated on 08/13/24, she let Resident #1 into the secure unit courtyard at 6:45 p.m. because he asked, she went to change another resident's brief, came back around 7:00 p.m., noticed Resident #1 was not in visible site, and notified the charge nurse on duty. Resident #1 was interviewed and stated he grabbed a bar and climbed over the fence when staff asked him how he got out of the secure unit courtyard. Staff reviewed the facility's missing resident and elopement and wandering policies on 08/13/24. Staff accounted for all residents during their head count except Resident #1 at the time of his incident. Staff also checked all maintenance records on for all doors and gates and ensured they were operable, locked, and secured from 08/12/24 through 08/22/24. Gates and doors passed inspection during the previously mentioned timeframe. All residents were reevaluated for elopement risk observation and had care plans reviewed and revised with new interventions implemented. Staff also verified that all residents' electronic health records included photos of the residents. Staff also updated residents' elopement risk records. Staff were educated on behavior and communication on 08/22/24. Resident #1's progress notes and care plan were updated. Staff were also educated on aggressive behavior on 08/14/24, off-duty call in on 08/13/24, missing resident on 08/13/24, wandering elopement and running away on 08/14/24, abuse and neglect on 08/13/24, and secure unit gates at unknown date. Staff initiated 1:1 monitoring on Resident #1 every 15 minutes from 08/13/24 through 08/18/24. There were no subsequent incidents of elopement. Staff initiated 15 resident safety surveys on 08/14/24, which found residents reported never been harmed by any staff or other residents, never witnessed any form of mistreatment by any staff or other residents, felt safe at facility, staff treated them with respect, and knew who to report mistreatment to. Review of the facility's incident and accident reports reflected Resident #1's elopement incident was documented on 08/13/24 at 8:06 p.m. in which he was placed on 1:1 monitoring every 15 minutes for 72 hours and had a medical work up completed. Review of the facility's admission/discharge report reflected Resident #1 was discharged to a behavior hospital on 08/28/24. Review of the facility's wandering, elopement, and running away policy, undated, reflected the following: Wandering: Random or repetitive locomotion that may be foal directed, non-goal directed, or aimless. Elopement: Occurs when a resident leaves the premises or safe area unplanned. Running Away: Occurs when a resident is in distress about admission to a facility. Review of the facility's emergency policy and procedure for missing resident, revised December 2021, reflected the following: Policy statement: Resident elopement resulting in a missing resident is considered a center emergency. Policy Interpretation and Implementation: 1. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. 2. Staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located. Review of the facility's wandering and elopements policy and procedure, undated, reflected the following: Policy Statement: The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Definitions: 'Wandering' is random or repetitive locomotion that may be goal-directed (e.g., the per on appears to be searching for something such as an exit or person), non-goal directed, or aimless. 'Elopement' occurs when a resident leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The noncompliance was identified as PNC IJ. The IJ began on 08/13/24 and ended on 08/18/24. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review, the facility failed to residents received food prepared in a form designed to meet individual needs for 2 of 2 (Resident #7 and Resident #56) residents reviewed for therapeutic diets. The facility failed to ensure CK K prepared pureed meat for Resident #7 and Resident #56. The facility failed to ensure the Dietary Manager checked the service line for correct consistencies for Resident #7 and Resident #56. The facility failed to ensure CK J did not serve ground meat in place of pureed meat to Resident #7 and Resident #56. The facility failed to ensure DA L checked diet texture against therapeutic orders for Resident #7 and Resident #56. The facility failed to ensure LVN D thoroughly checked Resident #7 and Resident #56's trays for texture-modified diet. The facility failed to ensure CNA F did not feed the wrong texture to Resident #7. An Immediate Jeopardy was identified on 1/17/2024 at 5:13 p.m. While the immediacy was removed on 1/19/2024 at 11:28 a.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm due to the facility's need to continue training and monitoring of the preparation and serving of therapeutic diets as prescribed by the attending physician. These failures placed residents at risk of choking, aspiration (the taking of foreign matter into the lungs with the respiratory current), and death. Findings included: A record review of Resident #7's face sheet dated 1/19/2024 reflected an [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (cognitive impairment), muscle wasting and atrophy (muscle loss), muscle weakness, dysphagia (difficulty swallowing), nausea with vomiting, essential (primary) hypertension (high blood pressure), hyperlipidemia (high cholesterol), and vitamin B12 deficiency anemias. A record review of Resident #7's quarterly MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. This care plan did not reflect Resident #7's need for ADL help while eating. This care plan reflected Resident #7 had coughing or choking during meals or when swallowing medications. This care plan reflected Resident #7 was on a mechanically altered diet. A record review of Resident #7's care plan last revised on 1/18/2024 reflected he was to receive a pureed diet as ordered. A record review of Resident #7's diet order dated 9/13/2023 reflected he was on a pureed diet. A record review of Resident #7's MBSS (Modified Barium Swallow Study) report dated 2/15/2023 reflected the following: RECOMMENDATIONS o Meal Diet: Mechanical soft solids with pureed meats, all solids ground, small bites, slow rate, encourage thorough mastication , effortful swallow, Thin liquids, controlled sips, slow rate, no consecutive swallows, no straws. TREATMENT PLAN Recommendations determined by pathology of swallow function. Tolerance of treatment recommendations to be assessed by facility SLP for appropriateness. Patient will likely benefit from a skilled dysphagia feeding, exercise, and/or management plan directed by a Speech Language Pathologist. A record review of Texas Health and Human Services' document titled Evidence-Based Practices: Managing Aspriation Risk dated December 2023 reflected the following: Overview Aspiration occurs when oropharyngeal (near the esophagus) secretions, food particles, or gastric contents are inhaled into the respiratory tract, often resulting in aspiration pneumonitis or aspiration pneumonia. Aspiration Pneumonitis: Chemical injury to the tracheobronchial tree (lower respiratory tract) and lung caused by acute, often witnessed, inhalation of regurgitated sterile gastric contents (gastric acid). Aspiration Pneumonia: Infection caused by inhaling oral secretions, stomach contents, or both into the lung, leading to colonization by bacteria. Between 1999 and 2017, over 300,000 deaths were reported due to aspiration pneumonia, with people aged 75 or older making up over three-quarters of those deaths. A record review of Resident #56's face sheet dated 1/19/2024 reflected an [AGE] year-old male readmitted on [DATE] with diagnoses of nausea with vomiting, dysphagia (difficulty swallowing), pain, atypical facial pain, essential (primary) hypertension (high blood pressure), and fracture of base of skull. A record review of Resident #56'admission MDS assessment dated [DATE] reflected a BIMS score of 99, which indicated severely impaired cognition. This MDS assessment reflected Resident #56 was dependent on staff for eating. The MDS did not reflect Resident #56 had signs or symptoms of possible swallowing disorder. The MDS reflected Resident #56 was on a mechanically altered diet. A record review of Resident #56's care plan last revised on 1/18/2024 reflected he was to receive a pureed diet as ordered. A record review of Resident #56's diet order dated 12/26/2023 reflected he was on a pureed diet. During an interview on 1/17/2024 at 10:39 a.m., CK J stated lunch that day was cornbread, black-eyed peas, cauliflower and pork. During observations on 1/17/2024 from 10:40 a.m.-11:30 a.m., CK K was observed pureeing sandwich bread, black-eyed peas, and cauliflower. CK K did not puree pork. During an interview on 1/17/2024 at 11:30 a.m. CK K stated it was her second day working in the facility. An observation on 1/17/2024 at 12:00 p.m. revealed CK J asked CK K, where is the pureed food? CK J then served ground meat to Resident #7 and Resident #56. Observed DA L place plates on food cart. An observation of the tray cart on 1/17/2024 at 12:05 p.m. revealed Resident #7 and Resident #56 had ground meat instead of pureed meat on their trays. An observation on 1/17/2024 at 12:09 p.m. revealed LVN D checked the trays on the cart with Resident #7 and Resident #56's trays. LVN D did not send anything back to the kitchen to be fixed and she approved the trays without lifting the lids from the food items on Resident #7's and Resident #56's trays. An observation on 1/17/2024 at 12:25 p.m. revealed CNA F took Resident #56's tray back to the dining room because liquid had spilled all over the tray. When CNA F got a new tray from the kitchen, the ground meat for Resident #56 was left off the tray. An observation on 1/17/2024 at 12:37 p.m. revealed CNA F set Resident #7's tray on his bedside table as Resident #7 sat up in bed. Resident #7 was non-interviewable and did not speak. During an observation and interview on 1/17/2024 at 12:40 p.m., CNA F stated Resident #7 was on a pureed diet. CNA F took the lid off the ground meat, stirred it, and said to Resident #7 do you want to start with the meat? as she raised the utensil up to spoon feed Resident #7. When asked if the meat looked pureed, CNA F said no and it's ground as she stopped herself from spoon feeding Resident #7. CNA F stated it had happened once before where the pureed meat came ground. CNA F said Resident #7 could choke if he got ground meat and said, I'm not gonna feed him that. During an interview on 1/17/2024 at 1:46 p.m., LVN D stated she had checked the trays for lunch that day. LVN D stated she just started working in the facility the day prior (1/16/2024) and her training had not covered checking for diet textures. LVN D stated when checking trays, she checked for choices, diet and texture. LVN D stated she had not lifted the lids off trays and I should have looked more in depth. LVN D stated they could possibly choke if residents on a pureed diet were served ground meat. During an interview on 1/17/2024 at 2:29 p.m., when asked how staff were trained on diet textures, the Dietary Manager stated, we have a binder with different diet textures and when we have a question-if we're unsure about anything we ask our dietitians. The Dietary Manager stated, if there's something we're not doing right, [the dietitians] tell us how to fix it. The Dietary Manager stated CK J was the head cook and she was trained by the previous dietary manager. The Dietary Manager stated she started working in the facility a year and a half ago and she had not done any training with cooks on diet textures because they had been previously trained. The Dietary Manager stated CK K started working there that week and it was her second day working on 1/17/2024. The Dietary Manager stated she monitored staff by checking food consistency but no she had not had a chance to check the service line that day (1/17/2024). The Dietary Manager stated that day (1/17/2024), CK K had been trained by CK J and it was CK K's first hands-on day. The Dietary Manager stated yes the pureed meat could have been missed. The Dietary Manager stated CK J was usually on point, she did not see how it was missed, and maybe she was moving fast. The Dietary Manager stated staff only had so many days of actual training and that she had not yet trained CK K on preparing texture-modified diets. The Dietary Manager stated residents could choke and it's on us if they were served the wrong texture. During an interview on 1/17/2024 at 2:48 p.m., the RD stated he could not remember how long he had been coming to the facility, but he had been there once or twice. The RD stated if residents on a pureed diet received ground meat they could aspirate and get pneumonia, or they could choke and die. The RD stated that month (January) he had not covered the building and he was not sure whether another dietitian had been there that month (January 2024). During an interview on 1/17/2024 at 1:50 p.m., the DOR stated the facility's last speech therapist quit, they were trying to get a new one, and no one was currently providing speech therapy services to residents. The DOR stated new graduates worked there as speech therapists from time to time to get credentialed, but they left after one year and no one wanted to work there due to the geographical location. The DOR stated the facility did not have speech therapy via telehealth services. The DOR stated nurses oversaw food to ensure the right texture was provided by checking trays. The DOR stated she was not aware of any choking incidents in the past year. The DOR stated PTs and OTs were not trained in this practice of food texture and said it was not a scheduled thing for them to oversee dietary. The DOR stated speech, if we had one would oversee dietary for texture modified diets. The DOR stated, residents come in and they need speech and said she thought it affected resident a lot to not receive speech therapy services. The DOR stated if residents received the wrong texture, they could choke. An observation on 1/18/2024 at 8:31 a.m. revealed Resident #56 was lying in bed asleep with his food tray at his bedside table. The consistency of the pureed food was observed to be correct. During an interview on 1/19/2024 at 2:21 p.m., the DON stated nurses were supposed to check trays in the dining room and yes she expected them to lift up the lids to look at the food. The DON stated she monitored during mealtime by walking through the dining room to make sure staff were where they needed to be. The DON stated nursing staff had been trained on checking trays through in-services in the past but I can't tell you the dates. The DON stated residents on a pureed diet were one step away from being tube fed and being served the wrong texture could easily cause them to aspirate a particle or they could choke. During an interview on 1/19/2024 at 4:20 p.m., the Administrator stated therapeutic diets should be prepared and said the Dietary Manager trained dietary staff on texture-modified diets according to their policy. The Administrator stated yeah the Dietary Manager monitored dietary staff because she was there every day. The Administrator stated nurses were responsible for checking trays to ensure food textures matched diet orders and even aides who were passing out trays should monitor. The Administrator stated nursing staff were trained by the ADON and DON. The Administrator stated if residents on a pureed diet received the wrong texture, they could choke and it could cause respiratory problems. A record review of the facility's diet spreadsheet titled Wednesday SLP FW 2023 5wk - Week - 5 reflected residents on a pureed diet were to receive pureed pork with gravy for lunch on 1/17/2024. A record review of the kitchen's recipe for pureed pork with a printed date of January 18, 2024 reflected the following: Place prepared recipe portion(s) into a blender or food processor. Add adequate amount of liquid and/or thickener needed to achieve the consistency as appropriate for resident(s) and puree until smooth. Pureed foods normally are pudding-like consistency. A record review of the facility's incidents and accidents log dated January 2023 to January 2024 reflected no previous choking incidents with residents on a pureed diet. A record review of the facility's in-service trainings from January 2023 to January 15th, 2024 reflected no in-service trainings for nursing staff on texture-modified diets. A record review of the kitchen's in-service titled Diets Offered dated 8/28/2023 reflected the Dietary Manager trained dietary staff on the facility's policy titled Diets Offered by the Facility. A record review of the kitchen's in-service titled Tray Service dated 10/04/[23] reflected the Dietary Manager trained dietary staff on the facility's policy titled Tray Service. A record review of the facility's document titled Mechanically Altered Textures dated 2016 reflected the following: Mechanically altered textures are available for persons having difficulty with chewing or swallowing as prescribed by their physician, speech therapist or registered dietitian. Dysphagia diets Used for residents with swallowing difficulties due to medical conditions such as stroke, degenerative diseases like Huntington's or Parkinson's, cancer and/or radiation therapy DYS L1 - Pureed o This level is for people with moderate to severe swallowing difficulty and have a poor ability to protect their air way o This diet allows pureed food (pudding like consistency) that is smooth and easily stays together o Food should be avoided if they require chewing. Coarse and dry textures, raw fruits and vegetables, breads and nuts should also be avoided. A record review of the facility's policy titled Diets Offered by the Facility dated 2018 reflected the following: Policy: The facility is committed to providing the best nutritional care possible to its residents. All residents will receive diets as ordered by the attending physicians. There are many different names for similar diets. Diet order terminology should be standardized to ensure that the correct diets are served. The following diets are available: Regular No Added Salt LCS Liberal Renal Puree Mechanical Soft Procedure: 1. All diets must be ordered by the attending physician and recorded in the resident's medical record. A record review of the facility's policy titled Tray Service dated 2018 reflected the following: Policy: The facility believes that accurate tray service and adequate portion sizes are essential to the residents' well-being and safety. The facility will ensure that diets are served accurately and in the correct portions and that resident preferences are met. Procedure: 3. For tray line service, Nutrition & Foodservice staff will check each resident's tray card prior to service to ensure that preferences and dislikes are honored, the correct diet is served, portion sizes are accurate and appropriate substitutions provided. 4. For non-tray line service methods, staff will obtain food preferences for the meal from each resident. Serving staff will check each tray against the extensions to ensure that the diet is served accurately and the portion size of each item is correct. A record review of the facility's policy titled Tray Line Service dated 12/01/2011 reflected the following: Policy: The consultant dietitian will monitor the tray line to ensure that diets are served accurately and in the correct portions and that patient/resident preferences are met. See Section 6 for Quality Assurance Monitor forms and schedule. The following guidelines should be followed. Guidelines: 4. Each tray is checked by the tray line personnel to ensure that the diet is served as ordered, the portion size of each item is correct and preferences are met. A record review of the facility's policy titled Food and Nutrition Services dated September 2021 reflected the following: Policy Statement Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 6. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the dietary staff so that a new food tray can be issued. On 1/17/2024 at 5:13 p.m., the Administrator was notified of an Immediate Jeopardy due to above listed failures and an Immediate Jeopardy template was provided. The facility's Plan of Removal was accepted on 1/19/2024 at 11:28 a.m. and included: Plan of Removal: 808: Therapeutic Diet Prescribed by Physician On 1/17/2024 recertification survey was initiated at [the facility]. An Immediate Jeopardy was identified for 808: Therapeutic Diet Prescribed by Physician by the survey team on 1/17/2024. Residents requiring altered diets could be affected by this deficient practice. Action (Immediate Action): Residents #7 and #56 were assessed by the Director of Nursing and/or Designee. No adverse effects were identified through assessment for identified residents. Neither resident Start Date & Completion Date: 1/17/2024 Person(s) Responsible: Director of Nursing and/or Designee Action (Identification): The RD and DON audited all residents' diet textures were audited to identify other residents that could possibly be affected by this alleged deficient practice. The RD reviewed all Diet Orders in Matrix to ensure the Tray Cards matched the current Physician Orders Start Date & Completion Date: 1/17/2024 Person(s) Responsible: Director of Nursing and/or Designee, Registered Dietician Action (Prevention): Residents' diet textures have been printed and are available for staff to review to ensure residents receive the appropriate diet texture. Location of the diet textures are in each dining room and the nurses station. Employees will know the location through education provided by the administrator, Director of Nurses, and/or designee. The DON will review all new physician orders for changes in Diets or New Admission Diet Orders during the Daily Morning meeting and will communicate these changes to the Dietary Manager during this meeting to update the Tray Card system. The DON will update the Diet Roster in the Dining Rooms and the Nursing Stations Start Date: 1/17/2024 & Completion Date: 1/18/2024 Person(s) Responsible: Administrator and/or Designee Action (Prevention): Education: 1. All kitchen staff, including the Dietary Manager, have been educated by a Registered Dietitian to include how to prepare/process the pureed texture meal. The Registered Dietician conducted a Competency Evaluation (return demonstration) for Mechanically Altered Diet Food Preparation on all kitchen staff. All new or temporary (agency) kitchen staff will be educated prior to working their next scheduled shift and a competency Evaluation will be completed by the Dietary Manager. Start Date: 1/17/2024 & Completion Date: 1/18/2024 Person(s) Responsible: Registered Dietitian 2. The Director of Nurses was educated by the Registered Dietitian and the Clinical Company Leader regarding the below information (trained the trainer). Charge Nurses and Nurses Aides have been educated by the Director of Nurses and Clinical Company Leader. A Competency Evaluation (return demonstration) was completed with all staff by the Director of Nurses. All staff not present at the training will be inserviced by the Director of Nurses/designee prior to working the next scheduled shift and a Competency Evaluation will be completed. New staff and temporary staff (agency) will be inserviced by the Director of Nurses/designee prior to working the next scheduled shift and a Competency Evaluation will be completed. a. Description and appearance of Pureed and Mechanical Soft Diet texture. b. Meal Service Guidelines including Diet Rosters in the Dining Rooms: checking the food on the tray prior to delivering the tray to the resident to ensure the food on the tray matches the texture on the resident's tray card and visualizing the food on the tray to ensure it is the right texture. Start Date: 1/17/2024 & Completion Date: 1/18/2024 Person(s) Responsible: Clinical Company Leader alongside the Registered Dietitian, Director of Nursing, and/or Designee Start Date: 1/17/2024 & Completion Date: 1/18/2024 Person(s) Responsible: Director of Nurses and Clinical Company Leader Action (Monitoring): Charge Nurses are responsible for monitoring meals/meal textures at meal times, everyday. They have been educated regarding the diet textures as noted in the action item above by the Director of Nurses. Start Date: 1/17/2024 & Completion Date: 1/18/2024 Person(s) Responsible: Director of Nursing, Administrator, and/or Designee Action (Monitoring): 5x a week, for a minimum of 4 weeks, a meal will be monitored by the Dietary Manager, Director of Nursing, Administrator, and/or Designee to ensure dietary is plating the appropriate diet texture and nursing is checking the diet texture vs the meal cards and serving/assisting with the appropriate diet ordered for the residents. Start Date: 1/18/2024 & Completion Date: 4 weeks or, longer if needed, determined by results of observations and IDT determination. Person(s) Responsible: Dietary Manager, Director of Nursing, Administrator, and/or Designee Action (QAPI ): Medical Director was informed of the Immediate Jeopardy, the contents of the IJ template, and the center's plan to remove the immediacy. Start Date & Completion Date: 1/17/2024 Person(s) Responsible: Administrator Action items listed above will be monitored by [the facility's] Clinical Resource Nurse, Dietitian, Clinical Company Leader (Regional VP of Clinical Services) and Company Leader (Regional Director of Operations) for completion. The Plan of Removal was monitored in the following ways: A record review on 1/18/2024 reflected an ad hoc QAPI meeting was held on 1/17/2024 to review monitoring of meals and food preparation. Attendees included the Medical Director, the DON, the Administrator, the Dietary Manager and the Dietitian. A record review on 1/18/2024 of an in-service dated 1/17/2024 reflected the DON and Dietitian had in-serviced 56% of facility staff on meal service guidelines, altered texture diets, description of pureed texture, and checking diet type against food texture. A record review on 1/18/2024 reflected 29% of nursing staff had been quizzed on mechanically altered diets. A record review on 1/18/2024 reflected the Dietitian in-serviced 100% of the facility's cooks on 1/18/2024 on how to prepare a pureed diet. During an interview on 1/18/2024 at 8:28 p.m., DA L reported she had been in-serviced on what a pureed diet looks like. During an interview on 1/1/8/2024 at 8:31 a.m., CK J reported she had been trained by the Dietitian via in-service and video presentations on how to prepare a pureed diet. An observation of a test tray on 1/18/2024 at 1:00 p.m. revealed the pureed foods were of proper texture and consistency. A record review on 1/19/2024 of the Dietitian's in-service dated 1/18/2024 reflected 85% of dietary staff were in-serviced on pureed foods, dysphagia, and how to prepare pureed foods. A record review on 1/19/2024 reflected 85% of dietary staff received competency trainings on 1/18/2024 on preparing pureed food. During an interview on 1/19/2024 at 3:36 p.m., the DON stated she was in-serviced one-on-one by the Dietitian regarding nursing staff checking all trays prior to trays going out of the kitchen to ensure all trays have the appropriate diets and diet consistency. During an interview on 1/19/24 at 03:30 p.m., LVN D stated she was in-serviced by the Regional Nurse Consultant and the DON regarding checking trays as they come out of the kitchen to ensure they are the right diet orders and the right consistency. LVN D stated for pureed diets the consistency should be pudding like without any lumps. During an interview on 1/19/24 at 03:40 p.m., CNA H stated she was in-serviced regarding checking the residents' trays to make sure the residents received the right diet and the right consistency. CNA H reported an understanding of pureed diet consistency. During an interview on 1/19/24 at 3:45 p.m., CNA G stated she was in-serviced on checking residents' trays before giving to the resident to make sure they have the right diet. CNA G reported an understanding of pureed consistency. During an interview on 1/19/24 at 3:50 p.m., CNA I stated she was in-serviced on checking residents' diets prior to giving residents their trays. CNA I stated pureed diets should be creamy with no lumps and she stated the trays should go through a 3 point inspection-the kitchen, the nurses and the nursing assistants. A record review on 1/19/2024 of Resident #7 and #56 assessments reflected the DON assessed both residents for any signs of injury related to the deficient practice and it was documented in the residents' medical record. A record review on 1/19/2024 reflected 62% of nursing staff had been quizzed on mechanically altered diets. A record review on 1/19/2024 of all residents' diet orders reflected all diet orders were audited to ensure all diet orders were correct. An observation on 1/09/2024 at 3:55 p.m. revealed posting of diet orders and textures were in the kitchen, at the service window and at the nurse's station. A record review on 1/19/2024 of the facility's Competency Evaluation with return demonstration for mechanically altered diets reflected staff were checked for understanding on pureed diet consistency and what to do if they thought the texture or type of diet might be incorrect. Further review reflected 80% of nursing staff had competencies completed. A record review on 1/19/2024 of the facility's diet monitoring checks reflected checks were completed for each meal on 1/17/2024, 1/18/2024, and 1/19/2024. These monitoring checks were signed off by the Dietary Manager and the DON. A record review on 1/19/2024 of all staff in-service training reflected staff were trained on preparing altered texture diets, description of pureed food texture, meal service guidelines and checking diet type and texture to ensure it matched the tray prior to serving residents. The staff in-serviced included 100 % of full-time staff and 84% of PRN staff. The Immediate Jeopardy was removed on 1/19/2024 at 11:28 a.m. and the Administrator was notified. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm due to the facility's need to continue training and monitoring of the preparation and serving of therapeutic diets as prescribed by the attending physician.

Based on observation, interview, and record review the facility failed to ensure residents were free of accidents/hazards for one of twenty residents (Resident #1) reviewed for Quality of Care. The facility failed to ensure LVN A checked the temperature of a cup of hot coffee she had heated in a microwave oven prior to serving it to Resident #1. Resident #1 spilled the coffee on his abdomen and thighs resulting in 2nd and 3rd degree burns. On 05/05/2023 at 4:17 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/08/2023, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed all residents at risk for injuries, pain, and mental anguish. Findings include: Review of Resident #1's undated Face Sheet reflected he was an [AGE] year-old male admitted on [DATE] with diagnoses of Transient Ischemic Attack (brief stroke- like attack that still requires immediate medical attention to distinguish from an actual stroke), muscle weakness, pain in right hand, pain in left hand, age related cognitive decline (overall slowness in thinking and difficulties sustaining attention, multitasking, retaining information and finding words), unspecified lack of coordination and Calcifications and Ossification (calcium deposits as a result of muscles being damaged by burns causing hard areas in the affected muscles, can cause pain in that area) of muscles associated with burns left thigh. Review of Resident #1's Care Plan dated 04/15/2023 reflected Category: Skin (Resident #1) has 1st and 2nd degree burns to R side of abdomen blister measures 1.6 cm X 4.5 cm, L inner posterior thigh with no opening measures 9.5 cm X 10 cm, R upper inner thigh with total area of burn measuring 6.5 cm X 13 cm with 2 open blisters measuring 1.2 cm X 4.5 cm and 6.5 cm X 4.3 cm. R/T spilling coffee on himself causing blister. 4/19/23 Umbilicus [navel] L side 2.8 X 4.2 X 0.1 cm, L upper inner thigh - 8 X 10 X 0.1 cm, R thigh anterior - 2.5 X 3.8 X 0.1 cm, R thigh posterior 6 X 5 - intact skin. Goal: [Resident #1's] burns will heal without complications. Approach: Apply topical antimicrobial medication, Silvadene cream daily. Created by: [DON] Assess the psychosocial impact of burns on [Resident #1's] body. [family member] to bring resident coffee cups with lids in order to prevent future spills. Review of Resident #1's Quarterly MDS dated [DATE] reflected he had a BIMS score of 9 indicating moderate cognitive impairment. Functional status reflected Resident required assistance X 1 staff for adls. Observation and interview on 05/05/2023 at 9:25 AM Resident #1 stated he spilled a whole cup of coffee on his abdomen and right thigh. He stated someone brought hot coffee to his room and there was not a lid on the cup. Resident #1 pulled his short up on his right thigh and pointed to a dressing. Review of a resident progress note dated 04/15/2023 at 4:29 PM by LVN A for Resident #1 reflected Resident spilled a cup of hot coffee on himself causing redness to the area below his navel and on both of his inner thighs. His [family member] and his MD were notified. Review of a Progress Note dated 04/15/2023 at 7:00 PM for Resident #1 and recorded as a late entry on 04/16/2023 at 4:48 AM by the DON reflected I went in to evaluate this resident s/p spilling coffee on himself and noted a blister to the R side of umbilicus that measures 1.6 cm X 4.5 cm. No noted redness or discoloration to peri area. Noted discolored skin to right inner thigh that measures a total of 6.5 cm X 10 cm with two areas with blisters have ruptured within the area, 1st one that is anterior [front] measures 1.2 cm X 4.5 cm and the second to the posterior [back] side measures 6.5 cm X4.3 cm. Both areas with no noted skin coverage. The left inner thigh is discolored with a total area of 9.5 cm X 10 cm with no noted open areas but there are areas that appeared to be very fragile. Resident does complain of pain when areas are touched. Other progress notes regarding the wounds associated with the hot coffee burns were documented on 04/16/2023 and 04/18/2022. A progress note for an assessment for unspecified pain was dated 04/22/2023. Review of a Wound Evaluation and Management Summary dated 05/01/2023 by the wound care MD reflected they performed a wound care evaluation and treatment at the request of the primary care MD for Resident #1. They stated Patient presents with a wound on his abdomen. He has a non-pressure wound on abdomen for at least 15 days duration. There is light serous [clear] exudate [drainage]. Patient spilled coffee on himself. Surgical excision debridement procedure: Remove necrotic [dead] tissue and establish the margins of viable [living] tissue. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise [cut out] 1.06 cm of devitalized [dead tissue from damage] tissue including slough [yellow, stringy, thick tissue adhering to wound bed ], biofilm [formed when certain microorganisms, mostly pathogenic (can cause disease) bacteria adhere to the wound surface] and non-viable (non-living) subcutaneous [layer of tissue that underlies the skin] level tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Hemostasis [stopping of flow of blood] was achieved and a clean dressing was applied. Continue Silver Sulfadiazine [topical cream used to prevent and treat wound infections in patients with 2nd and 3rd degree wounds] once daily for 18 days and use a gauze island dressing with bdr. Observation and Interview on 05/05/2023 at 10:01 AM, Cook C stated the kitchen staff check coffee temperatures after placing it in decanters and prior to placing the decanters in the dining room. Cook C then demonstrated the technique she used for checking the coffee temperature. She stated they keep a temperature log for coffee in the kitchen which she showed the surveyor. She stated some staff say to nuke the coffee (in the microwave oven) to heat it up but she knew that was not correct as it could get too hot. Observation on 05/05/2023 at 10:08 AM of the Resident Nourishment Room which was open to a hallway outside the dining room revealed a microwave oven at countertop height. A sign on a cabinet above the oven stated Please remember that as hot liquids heat up, they release steam or may be spitting. Never cover any container fully. Always leave a gap for steam to release. No instructions were noted to check the temperatures of hot liquids or foods prior to serving them to a resident. There was no thermometer in the room. No coffee cups or lids were observed in the room. Interview on 05/05/2023 at 10:10 AM, MA D stated she normally worked at the corporate office in another city and was assisting at the facility for the day. She stated coffee in the decanters should already be heated and cups should have a lid on them prior to being served to a resident. Interview on 05/05/2023 at 10:14 AM, CNA E stated if a resident wants coffee he goes to the dining room, gets it from the decanter and places a lid on the cup prior to serving it. He stated, I don't microwave it. I've seen the dressings on Resident #1, but I was not here the day he got burned. He stated he could not recall receiving any in-services on serving hot beverages. Interview on 05/05/2023 at 10:17 AM, CNA F stated she had worked at the facility for three months and would never heat coffee in the microwave adding most of the time they [residents] are going to spill it. Interview on 05/05/2023 at 10:21 AM, LVN B stated LVN A told her she had served Resident #1 coffee that she had heated in the microwave. LVN B stated when she observed the burns on Resident #1, they looked like he had been in a fire. Interview on 05/05/2023 at 10:56 AM, a family member of Resident #1 stated he had burns on both legs and his abdomen that blistered. The family member stated he was not sent to the hospital and some kind of ointment was ordered for the burns. Observation on 05/05/2023 at 11:11 AM of Resident #1's abdomen revealed an approximately 3-inch X 1.5-inch oval shaped, scabbed area on his abdomen with slight yellow drainage on the dressing which was pulled back by the DON. He had a scarred, indented area approximately 4 inches X 3 inches on his left inner thigh. A dressing was noted to his right thigh. Interview on 05/05/20223 at 12:06 PM, LVN G stated Resident #1 had spilled hot coffee on himself in his room on 04/15/2023 and she had to go get someone to help her change his brief. She stated she knew not to heat coffee in the microwave and there was no thermometer available to check beverage or food temperatures. Record review of a facility in-service dated 04/15/2023, titled Safety of Hot Liquids given by the DON reflected LVN A and LVN G had not signed the in-service. Record review of a facility in-service dated 04/17/2023, given by the ADON and titled Microwave Heating Safety was signed by twelve out of fifty-five staff members. The Inservice did not include any information regarding how hot liquids could get after microwaving or how to check for a safe serving temperature. LVN A and LVN G who were on duty 04/15/2023 when Resident #1 received hot coffee burns did not sign the in-service. Interview on 05/05/2023 at 1:50 PM, the DON stated she had given LVN A a disciplinary action and a verbal in-service on handling of hot liquids and foods after Resident #1 sustained burns. She stated LVN A had been in the facility working since the incident on 04/15/2023 but had not signed any in-services on microwave heating safety. She stated she thought LVN A had received all the in-services after the incident but had not signed them. The DON stated LVN A gave Resident #1 coffee from the dining room, after she heated it up in the microwave, took it to his room and told him to be careful. She further stated the resident was not responsible for what happened, and he received 2nd degree burns from the hot coffee. She stated she thought they needed to do temperature checks on foods and liquids to validate the temperature was safe prior to serving and they needed to keep a temperature log. The DON stated the ADON was not available for any interviews regarding the in-services she presented to the staff as she was attending RN school that day. Record review of a facility policy and procedure titled Safety of Hot liquids dated 2001 and revised in October 2021 reflected Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. 1. Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal. 2. Residents who prefer hot beverages with meals (i.e., coffee, teas, soups, etc.) will not be restricted form these options. 3. When indicated, appropriate interventions will be implemented and included in the resident's care plan to minimize the risk from burns. This was determined to be an Immediate Jeopardy (IJ) on 05/05/2023 at 4:17 PM. The Acting ADM and DON were notified. The Acting ADM was provided with the IJ template 05/05/2023 at 4:17 PM. The Plan of Removal was accepted on 05/06/2023 at 11:00 AM and included the following: Action: Nurse involved in the incident was provided one on one education with discipline. Start Date: 5/5/2023 Completion Date: 5/5/2023 Responsible: Director of Nursing Who and how will this action be monitored: The Regional Resource team will ensure this action has been completed as of 5/6/2023 via an onsite review of the documentation. Action: Microwave was removed from the nutrition room until all staff are educated on safe temperatures to serve hot liquids and a thermometer and a temperature log has been placed in the room in which employees will know how to utilize through education completed. Start Date: 5/5/2023 Completion Date: 5/6/2023 Responsible: Director of Nursing Who and how will this action be monitored: The regional resource team will ensure this action is completed and will monitor for compliance during onsite visits x 4 weeks and/or until substantial compliance. Action: All staff to be reeducated on accidents, hazards, and supervision, safe temperatures to serve hot liquids, microwave heating safety, taking temperatures (and what appropriate temperatures to serve liquids and food at, and how to document the liquid/food being provided to the resident at a safe temperature with accordance with regulation). Start Date: 5/5/2023. Completion Date: 5/6/2023 Responsible: Administrator/Director of Nursing/Designee Who and how will this action be monitored: The regional resource team will ensure this action has been completed as of 5/6/2023 via an onsite review of the documentation. Action: Regional Resource team reviewed Resident #1's care plan to ensure person centered interventions are in place to avoid resident spilling hot liquids on himself, again. Start Date: 5/6/2023. Completion Date: 5/6/2023 Responsible: Regional Resource Nurse Who and how will this action be monitored: The Clinical Company Leader will review the completion of the care plan review and will additionally review for any necessary changes to ensure resident's safety. Action: Ad Hoc QAPI with IDT to review incident, IJ and POR. Start Date: 5/5/2023. Completion Date: 5/5/2023 Responsible: Director of Nursing Who and how will this action be monitored: Regional Resource and Clinical Company Leader witnessed Ad Hoc QAPI being performed with Medical Director Monitoring for Plan of Removal was completed from 05/06/2023 - 05/07/2023 as follows: Interview on 05/06/2023 at 2:45 PM the DON stated approximately 80% of the staff had been in-serviced regarding use of the microwave to heat liquids and foods. She stated education was provided to all staff regarding monitoring temperatures of food and liquids after microwave use. The DON stated only staff were allowed to use the microwave. Observation and interview on 05/06/2023 at 3:15 PM, Resident #1 was observed with his own coffee cup that was covered. Resident #1 stated he was not in pain and was currently being treated with a cream for his wounds. Interview on 05/07/2023 at 11:30 AM, the DON stated all facility in-services on handling hot liquids, warming up food and checking temperatures were completed in the late afternoon on 05/06/2023. Record review on 05/07/2023 of an in-service regarding food and liquid temperature safety reflected all staff were trained in the safety of hot liquids/food temperatures, supervision of residents and a post-test was completed by all staff. Interview on 05/07/ 2023 at 11:54 AM, LVN A stated she had received verbal training from the DON the day after the hot coffee burns incident with Resident #1. She stated she was educated on coffee temperature, to not heat coffee in the microwave because coffee is served in the dining room and to monitor residents for safe serving of hot liquids. LVN A stated on 05/06/2023 she was re-educated on handling foods and liquids that were hot and checking the temperatures to serve them safely to the residents. The acting ADM and the corporate survey resource person were informed the Immediate Jeopardy was removed on 05/08/2023 at 11:30 AM. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations and interviews the facility failed to serve food in accordance with professional standards for food service safety. The facility failed to ensure that residents used properly sanitized cups and silverware during dining services. This failure placed residents at risk of becoming sick due to the chemicals used to sanitize the silverware and cups not properly sanitized due to dishwasher failure. the facility had been without hot since 12/24/2022. An IJ was identified on 1/5/2023. The IJ template was provided to the facility on [DATE] at 12:30pm. While the IJ was removed on 1/9/2023, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm that is not Immediate Jeopardy because (e.g.) all staff had not been trained on Manual Cleaning and Sanitizing of Utensils and portable equipment . Findings included: Review of Disposable Dishes and Utensils policy dated Sept. 2021 reflected: The facility will use single -service items only in extenuating circumstances, such as dish-machine failure. Disposable dishes, utensils, and other food service items shall be used only once and then shall be discarded. On 1/3/2023 at 12:00pm and 5:00pm observed residents using Styrofoam plates, regular silverware, and cups during each of their meal services. On 1/3/2023 at 12:00pm observed, the water located in the back part of the kitchen was cold and never warmed up to the touch after running for a period. This was source is used to supply hot water to the kitchen dishwasher to sanitize the dishes used by the residents. On 1/3/2023 at 1:47pm observed, the kitchen staff were using the dishwasher to sanitize silverware, cups and trays used after each meal service. On 1/3/2023 at 12:00pm observed, damage to the kitchen ceiling the drywall/sheetrock from ceiling had fallen down the inside wall exposed to see pipes. During an interview on 1/3/2023 at 2:23pm the DM, stated the freeze on 12/24/2022 caused their pipe to bust and they no longer have hot water in the kitchen. She stated they started using the Styrofoam plates but still used the regular silverware, cups, and trays to serve the residents. The DM stated they continued to use the dishwasher even though they didn't have the use of hot water. During an interview on 1/3/2023 at 2:30pm with kitchen staff # 1 stated, they used the dishwasher only to clean the silverware, cups and trays used during lunch service. She stated the pipes busted on12/24/2022 and they have not yet been repaired. She stated she boils her water to clean and sanitize the pots and pans in the three-compartment sink. During an interview on 1/3/2023 at 3:45pm with the ADM, stated she was on vacation during the time of the freeze, she stated the freeze caused the pipe to bust and there is no hot water in the kitchen or on the 300 Hall. She stated the part has been ordered for the repairs to be completed. Observation On 1/4/2023 at 8:30am and 12:00pm observed, kitchen staff using Styrofoam plates, regular silverware, cups, and trays to serve residents meals. On 1/4/2023 at 5:42pm observation of chemical level strip test, reflected a high level of chemical concentration in the water as the color code level was dark purple in the 200 p.p.m (parts per million). The sample chemical level test strip was sent via text to Service Representative for review, he responded the chemical level was too high and could be harmful if ingested. Record review on 1/4/2023 of dishwasher machine sanitizing requirements reflected, once the sanitizing chemicals are in the water the test strip should be dipped in the rinse water solution to test the chemical levels. It stated the levels should be compared with chart on vial which read a minimum of 50-100(parts per million) is required. During a phone interview on 1/5/2023 at 10:27AM with Service Representative for the dishwasher brand used for facility revealed, the Health Department requires the temperature to be at 120F for proper sanitizing. He stated the chemicals are pre-set for the machine for each wash and the water pressure and temperature ensure that all residue and chemicals are off the dishes once the process is complete. The Service Representative stated if the water is not getting hot it's not going to complete the rinse cycle properly and there could be residue from the chemicals still on the dishes. He stated the normal range is between 50 and 100 p.p.m (parts per million). He stated if there is no hot water this will affect the chemical sanitizing process. He stated if the test strip levels read high then this could be harmful if ingested. During an interview on 1/5/2023 at 12:00PM the DM, stated if the dishes are not properly sanitized, she stated it could cause cross contamination and could cause the residents to get sick. DM stated she monitored the kitchen to ensure they had enough disposable ware for each meal service until the dishwasher is repaired. During an interview on 1/5/2023 at 12:15PM the ADM, stated if the residents ingest chemicals from dishes that are not properly sanitized could cause them to get sick. The ADM was notified on 1/5/2023 at 12:30pm that an Immediate Jeopardy had been identified due to the above failure. The IJ template was provided to the ADM on 1/5/2023 at 12:30pm. A Plan of Removal was first submitted by the ADM on 1/5/2023 at 4:29PM. The Plan of removal accepted on 1/8/2023 at 3:30pm. PLAN OF REMOVAL Impact Statement On 01/03/2023 an abbreviated survey was initiated at facility. On 01/05/22 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to all resident's health due to improperly sanitizing cups and silverware. All residents have the potential to be affected by this deficient practice. Summary of Details which lead to outcomes F812-The facility failed to serve food in accordance with professional standards for food service safety. The notification of the immediate jeopardy states as follows: Food Safety: Improperly sanitizing cups and silverware The facility failed to ensure that residents used properly sanitized cups and silverware during dining services. Identify residents who could be affected All residents have the potential to be affected by this deficient practice. Problem 1: Properly sanitizing silverware and cups for resident meal service: facility was observed using dishwasher that did not properly disinfect silverware and cups as the correct water temperature could not be obtained to work appropriately with the chemicals in use. Action Taken: Business Office Manager will ensure Monday thru Friday: Weekend RN Supervisor will ensure Saturday and Sunday that disposable silverware and cups are used during meal service until part is replaced to fix the dishwasher. o Administrator ensured that disposable utensils and plates will be used for resident meals until part is replaced and the facility currently has an adequate supply to last 6 days. If repairs are not completed by Monday as scheduled, then more supplies will be purchased to maintain at a minimum of a 3-day supply. o Administrator to check supply of disposable utensils and plates supply count daily in the AM to ensure there is not a shortage and purchase more if needed. Start Date: 01/05/23 End Date: 1/9/22 or when hot water is restored to kitchen Who will be Responsible: Dietary Manager/Business Office Manager/ Weekend RN Who Will Monitor: Administrator The hot water heater part has been ordered and will be installed on Monday, January 9, 2023. The dishwasher will not be used until the hot water heater part is replaced. A sign will be placed on the dishwasher indicating that it is out of order. The plumber stated on 1/5/2023 that the part for the hot water heater has been ordered and is scheduled to be replaced on Monday, 1/9/2023. Start Date: 01/05/23 End Date: 1/9/23 or when hot water is restored to kitchen Who will be Responsible: Maintenance director Who Will Monitor: Administrator Inservice was conducted by Administrator for the Dietary Manager and dietary staff on Mechanical Cleaning and Sanitizing of pots and pans. Dietary Manager will ensure that the dishwasher will not be used until the hot water heater part is replaced Start Date: 1/5/23 End Date: 1/9 /23 Who will be Responsible: Dietary Manager Who Will Monitor: Administrator Monitoring by the Dietary Manager or the cook on duty in her absence to make sure that pots and pans are being sanitized appropriately and that the automatic dishwasher is not used will be conducted 3 times daily after meal service. This will be continued until the hot water heater is fixed and normal operations resume. A paper monitoring tool has been placed in the kitchen for signature by the dietary manager or the cook on duty. Monitoring form will be signed off on daily until hot water heater has been restored and kitchen resumes normal operations. Start Date: 1/5/23 End Date: 1/9 /23 or when hot water is restored to kitchen Who will be Responsible: Dietary Manager and or Cook on Duty Who Will Monitor: Administrator- will monitor that the dishwasher is not being used Involvement of Medical Director The Medical Director was notified about the Immediate Jeopardy related to sanitary conditions in the kitchen on 1/5/2023. Involvement of QA (Quality Assurance) On 1/5/2023 an Ad Hoc QAPI meeting will be held with facility Administrator, Regional Maintenance Director, Facility Maintenance Director, and Dietary Manager to review plan of removal. The Administrator will be responsible to ensure that disposable products are used until part for the hot water heater is replaced and the dishwasher is properly working. Dietary manager will keep stock of disposable utensils, cups and plates and report to Administrator daily to ensure there is enough for each meal service and snacks. Administrator will purchase if there is a low shortage. This process will begin 1/5/2023. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 1/5/2023. The plan of removal was first submitted on Monitoring completed as follows: 1/7/2023 Observed residents using disposable utensils, disposable cups, and Styrofoam trays during dining room. Observed a sufficient supply of disposable products. Reviewed in-service of Manual Cleaning and Sanitizing of Utensils and portable equipment dated 1/5/2023 Monitoring completed as follows: 1/8/2023 Observation on 1/8/2023 at 5:40pm revealed dietary staff picked up disposable plates, cups and utensils from the dining room. Monitoring completed as follows: 1/9/2023 Action item 1: Business Office Manager will ensure Monday thru Friday: Weekend RN Supervisor will ensure Saturday and Sunday that disposable silverware and cups are used during meal service until part is replaced to fix the dishwasher Observed of kitchen dishwasher had Out of Order sign still posted. Disposable plates, cups, silverware supply. Facility has purchased more to ensure there is enough for each meal service for the next three days. Observed all residents using disposable utensils, cups, Styrofoam plates, and silverware during meal service. Action item 2: The hot water heater part has been ordered and will be installed on Monday, January 9, 2023. The dishwasher will not be used until the hot water heater part is replaced. A sign will be placed on the dishwasher indicating that it is out of order. The plumber stated on 1/5/2023 that the part for the hot water heater has been ordered and is scheduled to be replaced on Monday, 1/9/2023. Hot water heater part was ordered and installed on 1/9/2023- However the part did not work, and they will continue to use the disposable ware. During an interview on 1/9/2023 at 2:10PM DM, stated the contractors had been in the kitchen and on the roof working to make the repairs, but states they have not completed yet. She stated they have continued to use the disposable plates, silverware and cups until their hot water has been restored and they can run the dishwasher again. She stated they have purchased plenty of disposable ware to ensure they had enough to last until repairs have been completed. Observed damage on 1/9/2023 at 5:00pm to hot water heater, exposed wires, motor appeared burnt out. During an interview on 1/9/2023 at 5:00PM with the plumber, stated the hot water would not be able to be repaired today, he stated the parts would not repair the damages. He stated the previous work completed had been done incorrectly bye whoever completed the work. He stated he had given the facility a quote for a new water heater, and he could have it at the facility by tomorrow and installed, he stated the was waiting on approval from the facility. During an interview on 1/9/2023 at 5:10PM with corporate support, stated she would get the approval for the new hot water heater to be ordered and installed for tomorrow 1/10/2023. She provided a letter via email from the corporate office for the repairs to be completed and new hot water [NAME] to be ordered. Action item 3: Inservice was conducted by Administrator for the Dietary Manager and dietary staff on Mechanical Cleaning and Sanitizing of pots and pans. Dietary Manager will ensure that the dishwasher will not be used until the hot water heater part is replaced Reviewed in-service Manual Cleaning and Sanitizing of Utensils and portable Equipment dated 1/5/23 completed by all kitchen staff employed. The staff boiled water on kitchen stove, usedd temp gauge to check temp of water before using in the three compartment sink to sanitize the pots/pans used to prepare the residents meals. Action item 4: Monitoring by the Dietary Manager or the cook on duty in her absence to make sure that pots and pans are being sanitized appropriately and that the automatic dishwasher is not used will be conducted 3 times daily after meal service. This will be continued until the hot water heater is fixed and normal operations resume. A paper monitoring tool has been placed in the kitchen for signature by the dietary manager or the cook on duty. Monitoring form will be signed off on daily until hot water heater has been restored and kitchen resumes normal operations Observed daily monitoring log in binder for pots and pans sanitizing signed off by DM Action item 5: Involvement of Medical Director The Medical Director was notified about the Immediate Jeopardy related to sanitary conditions in the kitchen on 1/5/2023. Reviewed notification letter to MD dated 1/5/2023 Action item 6: Involvement of QA (Quality Assurance) On 1/5/2023 an meeting will be held with facility Administrator, Regional Maintenance Director, Facility Maintenance Director, and Dietary Manager to review plan of removal. Notification of Ad Hoc QAPI letter dated 1/5/2023 Action item 7: The Administrator will be responsible to ensure that disposable products are used until part for the hot water heater is replaced and the dishwasher is properly working. Dietary manager will keep stock of disposable utensils, cups and plates and report to Administrator daily to ensure there is enough for each meal service and snacks. Administrator will purchase if there is a low shortage. This process will begin 1/5/2023. Observed sufficient supply of disposable products in facility on 1/9/2023. The ADM and corporate support were notified on 1/9/2023 at 5:30pm that the IJ had been lowered. While the IJ was lowered on 1/9/2023 at 5:30pm, the facility remained out of compliance at a level of no actual harm/ widespread with potential for more than minimal harm that is not Immediate Jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 1 (Resident #1) of 10 residents reviewed for abuse. The facility failed to ensure Resident # 1 of 10 residents was free from abuse. Resident # 1 was forced to take her medication by staff who forced the medication in Resident # 1 mouth with a spoon that cut her lip and caused her to bleed. This failure could place residents at risk for abuse. An IJ was identified on 1/5/2023. The IJ template was provided to the facility on [DATE] at 12:30pm. While the IJ was removed on 1/9/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy because (e.g.) all staff had not been trained on resident rights, Medication Administration, Notification of Responsible Party and Physician, Documentation of the event of a refusal of medication, Abuse and Neglect Prevention policy and completed the skills competency test regarding abuse and neglect prevention. Findings included: Record review of facility Abuse/Neglect policy dated June 2021stated the following: The Administrator will suspend immediately anyone who is suspected of abuse. The residents have a right to be free from abuse Protect residents during abuse allegations Review of Resident #1 face sheet undated, reflected Resident # 1 was an 85- year- old woman, admitted to the facility on [DATE]. Resident # 1 was diagnosed with an altered mental status, cognitive communication deficit (difficulty with thinking and how someone uses language), unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), psychotic disturbance (when a person lose contact with reality and experience a range of extreme symptoms such as hallucinations, hearing or seeing things that are not real), mood disturbance ( feeling of distress, sadness, or symptoms of depression), and anxiety ( intense, excessive, and persistent worry and fear about everyday situations). Observation on 1/3/2023 at 10:30am, revealed Resident # 1 lying in bed unable to speak. Facility staff assisted and observed Resident # 1's mouth. Resident # 1 observed to have a slight redness to the inside of the bottom lip, no blood observed. Resident # 1's teeth were observed in poor condition. Resident # 1's teeth were decayed with a lot of plaque buildup. Resident # 1's care plan reflected it was last reviewed and revised on 12/15/2022. The care plan reflected the following goal: Resident # 1 would have fewer episodes of yelling/screaming before/during care over the next 90 days. The plan reflected the following interventions: 1. Intervention: Encourage diversional activities 2. Remove from public area when behavior is unacceptable 3. Keep environment calm and relaxed 4. Always ask for help if it becomes abusive/ resistive 5. Convey acceptance during periods of inappropriate behavior 6. Talk to resident during entire procedure of care Quarterly MDS reviewed dated 12/3/2022, reflected Resident # 1 had a BIMS score of 00 (unable to complete assessment). Resident # 1 had a diagnosis of mild depression. The MDS reflected Resident # 1 had significant change in condition on 1/2/2023 and was referred for hospice service. Order for medication reviewed of Resident # 1 medication dated 5/31/2022, reflected an order for Remeron (mirtazapine) tablet; 15mg 1x at bedtime oral and an order for medication to be crushed, open capsules and mix with food or jelly. Record review of Facility event report, dated 12/26/2022 completed by ADM, reflected the incident was witnessed by a staff member of Resident # 1's injury to her lip. The report reflected Resident# 1 had a vertical slit inside the center bottom lip measuring 0.5cm (centimeters) x 0.1cm (centimeters) and a horizontal broken skin to the left side to the left side inside bottom lip measuring 0.4cm (centimeters) x 0.1cm (centimeters) scant (barley sufficient) amount of blood was noted inside the bottom lip and on resident # 1 bottom 2 teeth. The report also reflected Resident # 1 was assessed by LVN C, notified on-call physician with no new orders recommended. Record review of facility progress notes dated, 12/26/2022 reflected Resident # 1 was assessed by LVN C at approximately 8:45pm and noted Resident # 1 had a vertical slit to the inside of her bottom lip measuring 0.5cm(centimeters) and 0.1cm(centimeters) and horizontal broken skin to the left side of the bottom lip measuring 0.4cm(centimeters) and 0.1cm(centimeters). The progress note reflected Resident # 1 had a scant (barley sufficient) amount of dried blood inside the bottom lip and on Resident # 1 two bottom teeth. Record review of the MAR (medication administration record) dated 12/26/2022, reflected Resident #1 was administered Remeron (mirtazapine) (for depression/mood) 15mg (milligram) oral at bedtime. Record review of facility investigation report dated 12/26/2022 reflected, RN administered Resident # 1 medication at 8:00pm. Record review of facility timecards dated 12/26/2022, reflected RN clocked in at 5:52pm and clocked out at 9:58pm. LVN C, clocked in at 9:00pm and clocked out at 3:00am. During a phone interview on 1/3/2023 at 1:46PM, LVN B, stated he arrived to work on 12/26/2022 around 10:00PM to relieve the RN. LVN B stated when he arrived the RN had completed administering medication to all the residents on the 300 Hall, he stated he took over from there and completed the 600 Hall medication pass. LVN B, stated he checked on Resident # 1 when he arrived and noted that Resident # 1 had a little bright red blood in her mouth, and stated Resident #1 still had some of the pudding on her face and in her mouth. LVN B stated he was advised of the abuse to Resident #1 and that he needed to come in to take over RN's shift. During a phone interview on 1/3/2023 at 3:21PM, CNA A, revealed she worked on the evening of 12/26/2022, she stated she visited with Resident # 1 in her room that evening when she witnessed the RN forcing the spoon in Resident # 1 mouth trying to administer her medication after she refused. CNA A stated the RN continued to push the spoon in Resident# 1 mouth and stated Resident # 1 was very upset. CNA A stated even after she asked the RN to stop and she would try to give Resident # 1 her medication, she stated she ignored her and continued to force the spoon in Resident # 1 mouth. CNA A stated after the RN finished, she noticed Resident # 1 had pudding all over her mouth and she offered to clean Resident # 1 mouth and that's when CNA A noticed that Resident # 1 had blood in her mouth and her bottom tooth appeared to be pushed back. CNA A stated she told LVN A about the abuse. During a phone interview on 1/3/2023 at 3:31PM, with RN revealed she attempted to administer Resident #1 her evening medication in some pudding. RN stated Resident #1 did push her hand back however, Resident #1 would always be aggressive and try to resist staff from providing care. RN stated she did not hold Resident # 1 down, she stated she was not mean to Resident # 1. RN stated she understood that Resident # 1 had the right to refuse her medication, but stated she needed to try because it would help Resident # 1 sleep. RN stated she was not aware that anything had happened until LVN C showed up and relieved her of duty. RN stated Resident # 1 was the first resident that she administered medication to the night of 12/26/2022. She stated she administered medication to all the residents on the 300 Hall the night of 12/26/2022. During a phone interview on 1/4/2023 at 11:05am, LVN A, revealed he worked on the secure unit the night of 12/26/2022. LVN A stated he had another situation with another resident at the time CNA A told him of the abuse to Resident # 1. LVN A stated he immediately called the ADM. and advised her of the situation he had and of the abuse to Resident # 1. LVN A stated he never saw Resident # 1 because he was on the secure unit, LVN A stated the ADM. contacted LVN C to come to work. During an interview on 1/5/2023 at 9:10am LVN C, revealed she arrived at the facility at approximately 8:50pm and stated she contacted the ADM after she arrived. LVN C stated the RN was at the nurse's station with the medication cart when she arrived. LVN C stated she was not aware of which residents the RN had administered medication to prior to her arrival. LVN C stated the RN did not administer anymore medication to any residents after she arrived at the facility. LVN C stated the ADM sent her the suspension paperwork via email around 9:13pm and she completed the paperwork with RN. LVN C stated RN did not administer anymore medications after she arrived and remained at the nurse's station until they went into the office to complete the suspension paperwork. During an interview on 1/3/2023 at 4:45PM the ADM, revealed she was on vacation at the time of the incident. The ADM stated once she received the call from LVN A at approximately 8:07PM, she immediately contacted LVN C to come to the facility and relieve RN. The ADM stated LVN C arrived at the facility at 8:30pm. She stated the suspension paperwork was completed with RN at approximately 9:13PM by the ADM via phone, LVN C and RN. The ADM stated RN was suspended pending the investigation. Record review of in-services revealed last education on refusal of medication was held 10/7/2022. Record review of the in-services revealed education on Abuse/ Neglect not dated, the ADM stated it was last given 1/5/2023. The ADM was notified on 1/5/2023 at 12:30pm that an Immediate Jeopardy had been identified due to the above failure. The IJ template was provided to the ADM on 1/5/2023 at 12:30pm. A Plan of Removal was first submitted by the ADM on 1/5/2023 at 4:29PM. The Plan of removal was accepted on 1/8/2023 at 3:30pm. Plan of Removal F600- The facility failed to ensure that the resident was free from abuse. Impact Statement On 01/03/2023 an abbreviated survey was initiated at facility. On 01/05/22 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate threat to resident health due to the failure to protect 58 residents assigned to the charge nurse that day. The resident was forced to take medication that resulted in an injury to her mouth. Action Item: Safe Surveys to be performed on interviewable residents residing in the same Hall as an abused resident and randomly throughout the facility. Weekly skin checks were reviewed all on residents that were under RN's care during the time of the abuse. Start Date: 1/5/23 End Date: 1/6/23 (Completed) Who is Responsible: Social Worker, RNC (Regional Nurse Consultant) DON (Director of Nursing) and LVN C Who will Monitor: Administrator Action Item: Education will be provided on the topic of the Abuse and Neglect Prevention policy now and quarterly. A skills competency test regarding abuse and neglect prevention will be administered to all employees. To ensure 100 percent completion of education of employees has been completed the Administrator will verify with the employee roster that everyone has completed training. All agency employees will be educated before they are allowed to work with facility residents. All new employees will receive this education before they are allowed to start working with residents. Note: No employee will be allowed to work until in-services are completed Start Date: 1/5/23 for education and review End Date: 1/09/23 - New Staff and Agency Staff education will be ongoing as new staff are hired Who will be Responsible: DON/LVN C Who Will Monitor: Administrator ongoing and monthly to ensure the training of new employees and agency staff Action Item: Resident Rights Education including the list below, will be given to all nurses and MA's who administer medications in the facility and will be provided now and quarterly. The DON/LVN C will provide this training every quarter. To verify that 100 percent of the employees complete their education, the Administrator will verify with the employee roster that everyone has completed training. All agency employees will be educated before they are allowed to give medications. All new employees and agency employees will receive this education before they are allowed to give medications. - Resident rights - Medication Administration - Notification of the Responsible Party and Physician - Documentation of the event of a refusal of medications Note: No employee will be allowed to work until in-services are completed Start Date: 1/5/23 for education and review End Date: 1/9/23 for current staff - New Staff ongoing for education and review Who will be Responsible: DON/LVN C -36 Who Will Monitor: Administrator ongoing and monthly to ensure the training of new employees and agency staff Action Item: Medical Director was notified on 1/5/23 of the Abuse IJ related to this event. Start Date: 1/5/23 End Date: 1/5/23 Who was Responsible: DON/Administrator Who Will Monitor: Monitoring is not needed. The action was completed. Information shared. Not an ongoing notification. Action Item: Involvement of Ad hoc QA (Quality assurance) - On 1/5/2023 an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting was held with the facility administrator, Director of Nursing, and Medical Director. The IJ's for abuse and Dietary were discussed and a PIP (Performance Improvement Plan) will be developed for monitoring of action items and future education. The Medical Director will make a final review of the PIP (Performance Improvement Plan) on 1/10/23. Start Date: 1/5/23 End Date: 1/10/23 Who was Responsible: DON/Medical Director Who Will Monitor: Administrator Action Item - Leadership in the facility when the Administrator and the DON are not in the building. When no one at the management level is on-site the charge nurses are considered the managers on duty for the facility. Steps to take regarding abuse and neglect are placed at the nurse's station as a constant reminder of those steps. All charge nurses will be educated on the steps they are to follow in the event of abuse or neglect allegations. All newly hired charge nurses will be trained in this area prior to taking on this role. Note: No employee will be allowed to work until in-services are completed Start Date: 1/6/23 End Date: 1/10/23 and ongoing for new charge nurse employees Who was Responsible: Administrator Who Will Monitor: Regional Director of Operations Action Item - The staff member that failed to stop the abuse was brought to the administrator's office where the staff member was educated on abuse and neglect prevention. She was educated on the fact that even though the abuser left the resident's room that it was her responsibility to make sure that the abuser had no further access to that resident or any other resident while waiting for a management team member or another supervisor to arrive to take control of the situation. Start Date: 1/5/23 End Date: 1/5/23 Who was Responsible: Administrator Who Will Monitor: DON/ LVN C The Surveyor monitored the Plan of Removal on 1/7/2023 as follows: 12:25pm Entered facility 12:55 PM Reviewed in-service for Abuse and Neglect: Charge Nurse Responsibilities for abuse and neglect accusation. Reviewed Abuse and Neglect: Abuse & Neglect Prevention, Resident Rights Reviewed Abuse and Neglect Prevention Reviewed Resident Rights Skills Test Reviewed Inservice for Medication Administration Reviewed Inservice for Events and Grievances Report Reviewed Inservice for Charting and Documentation During an interview on 1/7/2023 at 1:20PM LVN D, revealed she had worked at the facility for 3 months. LVN D stated her job duties were to pass medication, oversee CNAs, and assist residents. LVN D stated she had been in-serviced on the Charge Nurse responsibilities for Abuse and Neglect allegations. LVN D stated the responsibilities were to immediately remove staff from access of to residents, direct another staff member to stay with the affected resident. LVN D stated she would also have the alleged abuser to clock out and leave, contact the administrator, director of nursing, or designee, and notify the director of nursing of any injuries either mental or physical. During an interview on 1/7/2023 at 1:35PM LVN E, revealed she had worked at the facility for 1 year and 6 months. LVN E job duties were to pass medication, ensure residents needs are met, ensure documentation is completed and oversight of CNAs and medication aides. LVN E stated she was in-serviced on the charge nurse responsibilities for abuse and neglect allegations. Record Review on 1/7/2023 reflected, 38 staff members had completed the Skills Test for Abuse and Neglect. Record review also reflected 12/14 staff members that were on duty on 1/7/2023 had completed the skills test for abuse and neglect. ADM and CNA B had not completed the skill test for abuse and neglect. During an interview on 1/7/2023 at 2:10 PM CNA B, revealed she had worked at the facility for [AGE] years and 6 months. CNA B stated her job duties were to provide residents with assistance eating, make beds and assist with ADL's (activities of daily living). CNA B stated she had not witnessed any abuse or neglect and stated she would notify the ADM and DON if she did. CNA B stated she was in-serviced abuse/neglect about a month ago but not in the last few days. CNA B stated she had not taken a skill test for abuse or neglect yet. Record Review reflected; 15 satisfactory resident safe surveys had been completed. During an interview on 1/7/2023 at 2:50PM with Resident # 2 stated the social worker had spoken with him about being safe at the facility and being free of abuse. Resident # 2 stated he felt safe. During an interview on 1/7/2023 at 3:00 PM Resident # 3 stated the social worker conducted a resident safety survey with him. Resident # 3 stated he felt safe in the facility. During an interview on 1/7/2023 at 3:10 PM Resident # 4 stated the social worker conducted a resident safety survey with him. Resident # 4 stated he felt safe in the facility. During an interview on 1/7/2023 at 3:20pm Resident # 5 stated the social worker had not conducted a resident safety survey with her. Resident # 5 stated she had recently moved into the facility last week. Resident # 5 stated she felt safe in the facility. During an interview on 1/7/2023 at 3:20pm with Resident# 6, stated the social worker has not conducted a resident safety survey with her. Resident # 6 stated she had just moved into the facility last week and that she felt safe in the facility. During an interview on 1/7/2023 at 3:45pm the ADM, stated the DON and LVN C were responsible for staff being in-serviced and completing the skills test for abuse and neglect prior to the beginning of the staff members shift. The ADM stated she was the responsible person for today. The ADM stated she will in-service herself and CNA B after this interview. 4:15 PM Investigator exited the facility. The Surveyor monitored the Plan of Removal on 1/8/2023 as follows: In an interview on 1/8/23 at 5:46 CNA B stated she had attended multiple in-services on abuse, abuse reporting and infection control. She stated she understood abuse was to be reported immediately and knew the building abuse coordinator was her ADM. In an interview on 1/8/23 at 5:51 LVN F stated she was an agency nurse but had been in-serviced on abuse prior to starting her shift. She stated she was told the ADM was the abuse coordinator and if she wasn't there any reports of abuse would be given to the DON, LVN C or charge nurse. The Surveyor monitored the Plan of Removal on 1/9/2023 as follows: 1:45PM conducted entrance conference with ADM advised of monitoring visit for POR's (Plan of Removal) in place. ADM was advised of the information needed for review. She reported the census was 57. ADM stated Resident # 1 passed away over the weekend. ADM stated Resident # 1 passing was expected, stated Resident # 1 has been referred to hospice. Reviewed 19 satisfactory resident safe surveys completed. Action Item 2: Education Abuse/Neglect Prevention Policy and Skills Competency test regarding abuse/ neglect prevention. Reviewed Abuse and Neglect Prevention in-service dated 1/5/2023 completed by staff Reviewed Abuse/Neglect Prevention Policy and Skills Competency test regarding abuse/ neglect prevention dated 1/5/2023. All staff except 5 have completed the skills test Action item 3: Education of Resident rights, Medication Administration, Notification Responsible Party /Physician, documentation of the event refusal of medication dated 1/5/2023 Reviewed in-service for Abuse and Neglect: Charge Nurse Responsibilities for abuse and neglect accusation. Reviewed Resident Rights in-service dated 1/5/2023 completed by staff Reviewed Inservice for Medication Administration dated 1/5/2023 completed by staff Reviewed Inservice for Events and Grievances Report dated 1/5/2023 completed by staff Reviewed Inservice for Charting and Documentation dated 1/5/2023 completed by staff All nursing staff have been trained except 5 staff who are out sick or have not returned to work Action item 4: Medical Director notification Reviewed notification for IJ called letter dated 1/5/2023 Action Item 5: ad HOC QAPI notification Reviewed notification letter dated 1/5/2023 Education of Supervisor Staff Reviewed in-service education completed with supervisor staff ADM and DON dated 1/6/2023 Action item 6: Leadership in the facility when the Administrator and DON are not in the building. Reviewed - All nursing staff have been trained except 5 staff who are out sick or have not returned to work. Interview on 1/9/2023 at 1:48PM LVN D, revealed if someone refused their medication she would document refused and let the doctor know. She stated she had been trained on abuse /neglect to contact the ADM immediately if not available then DON, if not available then LVN C, and then the charge nurse. She stated she had never seen or suspected abuse or neglect in the facility. Observed on 1/9/2023 at 1:48pm LVN D, medication administration stated she used the MAR in the matrix system (electronic records system) to verify the dosage, the medication, and the correct resident before administering to resident. During an interview on 1/9/2023 at 2:10pm with CNA B, revealed her job duties were to feed residents, make beds and assist with ADLs (Activities of Daily Living). CNA B stated she had not witnessed any abuse or neglect but stated she would notify the ADM and DON if she did. CNA B stated she had been in-serviced on abuse and neglect and completed the skills test. During interviews on 1/9/2023 at 3:25pm with Resident # 2, Resident # 3, Resident # 5, Resident # 7, Resident # 8, Resident # 9, and Resident # 10, stated they felt safe at the facility. All resident interviewed appeared to be clean and dressed appropriate with no marks or bruises noted. Observed Resident # 11 in the common area with others, resident is not able to speak clearly. Resident appeared to be clean and dressed appropriate. Resident did not appear to be in any pain or distress during this observation Resident # 12 was observed at 3:45 sitting his room fixing his clothes, resident looked when surveyor spoke to him and continued to fix his clothing. Resident appeared to be clean and dressed appropriate, resident did not appear to be in any distress or pain During an interview on 1/9/2023 at 4:00pm the ADM stated the DON and LVN C were responsible for staff in-serviced, and skills test completed for abuse and neglect prior to the beginning of the staff members shift. The ADM stated staff that have not yet been trained were either out with COVID or vacation, she stated when they returned to work, they would be trained. She stated RN was referred to the nursing board, she stated she terminated The ADM and corporate support were notified on 1/9/2023 at 5:30pm that the IJ had been lowered. While the IJ was lowered on 1/9/2023 at 5:30pm, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for 13 of 19 staff (Med-Aide A, Dietary Cook B, CNA C, CNA D, Transportation Aide E, LVN F, CNA G ,Dietary Aide H, LVN I, OT K, CNA K, LVN L and CNA S) reviewed for infection control procedures. A. The facility failed to screen Surveyor, Med- Aide A, Dietary Cook B, CNA C, CNA D, Transportation Aide E, LVN F, Dietary Aide H and LVN I for signs, symptoms and exposure to COVID-19 when they entered the facility and went to residents rooms, kitchen or the nurses desk. B. The facility failed to ensure OT K was wearing N-95 masks covering their noses and mouths per facility protocol while in presence of residents and other facility staff. C. The facility failed to ensure that CNA M wore a gown properly when entering and exiting rooms on the hot zone. CNA M later exited the hot zone and entered the facility front door and began working on the cold zone. OT K failed to practice appropriate hand hygiene/glove change while assisting Resident #1. These failures resulted in an Immediate Jeopardy (IJ) situation on 09/14/2022 at 5:13 PM. While the IJ was removed on 09/16/2022, the facility remained out of compliance at a severity level of actual harm at a scope of widespread due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of acquiring infectious diseases including COVID 19, leading to illness and possible hospitalization . Findings Include: A. Record Review of the Facility Policy of COVID-19 Symptom Screening Card dated 04/29/2022 reflected All who enters the center need to be screened, except EMS. Step 1 Take Temperature 1. If >100.4 then may not enter. Provide a facemask and have them exit the center. 2. If<97 retake temperature. Step 2 Ask if they have any of the following: (if yes to any, provide a facemask and have them exit the center). - Fever - Chills - Cough - Shortness of Breath - Difficulty with Breathing - Fatigue - Muscle or Body Aches - Headache - New loss or taste or smell - Sore Throat - Congestion or runny nose - Nausea, Vomiting or Diarrhea - Has confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Is under investigation for COVID -19 - Is ill with a respiratory illness Step 3 - Staff: If not fully vaccinated, provide N95 respirator to be always worn while in the center. - Ask all to perform hand hygiene and put on a facemask over their nose and mouth before entering. Observation on 09/13/2022 at 9:15 AM revealed Activity Assistant N answered the door when Surveyor was standing outside. She invited Surveyor into the foyer and then into the lobby. There was a laminated COVID-19 Symptom Screening Card on the table in the foyer stating all who entered the center needed to be screened, except EMS. She asked for Surveyor to wait in the lobby until she could find a thermometer. Approximately 15 minutes later she entered the lobby from the facility and took Surveyor's temperature. In an interview on 09/13/2022 at 9:40 AM, Activity Assistant N stated she could not ever find the thermometer when she answered the door. There was never a thermometer in the lobby. She stated she was sorry it was a long time for the wait she could not find a thermometer and had to go down the hall to find one. She stated she did not ask questions anymore about signs and symptoms of COVID-19. She stated she had not asked questions about COVID for approximately 3 months or more. She stated she was told by someone (did not recall the name of the person) the staff who answered the door did not ask any questions about signs / symptoms of COVID-19 to other staff or any visitors. She also stated she did go to the lobby/foyer and opened the door for visitors or staff 1-2 times per day and she usually worked 5 days per week. In an interview on 09/13/2022 at 9:50 PM, Visitor 1 stated she was not asked if she had symptoms of COVID-19 when she entered the facility. She stated her temperature was not taken today (09/13/2022) and she explained to Activity Assistant N she had taken her temperature at home. She stated Activity Assistant N stated that was ok she was not required to have her temperature taken again at the facility. She stated she visited her family member 5-7 days per week and in the past 2 or 3 months she had not been asked if she had any signs or symptoms of COVID. She stated she asked a staff (didn't remember the name of staff or job title) and this person told her the facility did not ask the questions about COVID-19 anymore and this was not a requirement. In an interview on 09/13/2022 at 10:20 AM, Visitor 2 stated she was not asked if she had sumptoms of COVID-19 today (09/13/2022. She stated she did not remember the person who answered the door for her to enter the facility. She stated she was very seldom ever asked questions about anything COVID-19 related. She stated the staff did take her temperature. She stated she visited her family member approximately 3-5 times per week and over the past few months the staff rarely asked any questions regarding COVID-19 symptoms and her temperature was not taken very often. She stated her temperature was taken approximately 2 or 4 times a month. In an interview on 09/13/2022 at 10:45 AM the Administrator stated the facility stopped keeping COVID-19 screening records; however, they continued to ask everyone the signs/symptom questions of COVID-19 and took the temperature of anyone who entered the facility. She stated staff were recently in serviced on the protocol of asking signs/ symptoms of COVID-19. She stated if was herself, DON and ADON/ Infection Control Nurse who were responsible for training the staff who answered the staff who answers the front door. She stated that sometimes if herself, ADON R or DON Q heard the doorbell ring they would enter the lobby and observes staff to ensure they were asking the correct COVID-19 question and taking temperatures of anyone who entered the facility except for EMS. She stated they did not have a schedule of when they made observations and did not document the observations. She stated it was her responsibility to ensure visitors and staff were being screened by the facility protocol and temperatures were taken. She stated she was not aware of anyone who gave instructions to staff to stop any type of screening related to COVID-19. She stated the laminated COVID-19 Symptom Screening Card in the foyer prior to entering the lobby was the example for the staff to follow and this was considered the facility policy for screening. She stated if staff or visitors were not screened according to their policy prior to entering the facility, this failure was potentially the reason the outbreak of COVID-19 which affected residents and staff. She also stated the residents and other staff had the potential to contract the flu or cold if everyone was not being screened when they entered the facility. In an interview on 09/13/2022 at 11:30 AM Visitor # 3 stated she visited her family member approximately 4 times per week. She stated she was not always asked questions about having cough, nausea, temperature, vomiting and all the other symptoms with COVID-19. She stated there were different staff who answered the door to allow her in the facility. She stated they did not take her temperature all the time and she usually walked in the facility without anything being asked of her. She stated one time she forgot to put on her mask and the staff who let her in the facility forgot to remind her and when she was walking down the hall another staff asked her to wear her mask. She stated sometimes she forgot to put on the mask and the staff did not always remind her. She stated she knew the importance of wearing a mask and did not want to spread germs to the staff or residents. She stated she was under her impression by someone working in the Activity Department that it was no longer required to ask questions about signs / symptoms of COVID-19. In an interview and record review on 09/13/2022 at 1:30 PM the ADON/ Infection Control Nurse R stated all staff had been in serviced on screening other staff and visitors for COVID-19 signs and symptoms. She stated it was a nurse's responsibility to screen the morning shift and it was anyone's responsibility to screen staff during the day. She stated whoever was available at the time they heard the doorbell was responsible for screening visitors. She stated it was herself, the Administrator and DON Q's responsibility to make random observations of staff screening anyone coming into the facility. She stated they did not have a schedule and it was not documented when they made observations. She stated the laminated COVID-19 Symptom Screening Card located in the foyer (first area you enter prior to the lobby and facility area) was the facility policy for screening the staff and visitors. She stated this laminated Screening Card had been in the foyer since the facility received it on 04/29/2022. She also stated if staff or visitors were not screened according to their policy, it was a possibility the staff/ visitors could spread the flu, colds and COVID-19. She stated if anyone had an air borne infection it could be spread to other staff and the residents. In an interview and record review on 09/13/2022 at 2:30 PM, the DON Q stated herself, Administrator and the ADON/Infection Control Nurse R were responsible for monitoring the screening process. She stated all three of them would randomly observe staff screening visitors and other staff. She stated they did not have a schedule or a routine to do this on a regular basis and they did not document when they made observations of screening. She stated she was not aware of anyone directing staff to stop asking the signs and symptoms questions about COVID-19. She stated all staff and visitors were expected to be screened before they entered the lobby from the foyer. The DON Q was holding the COVID-19 Symptom Screening Card which read All who enter the center need to be screened, except EMS when she stated this is our facility policy and it is located in the foyer prior to entering the facility for the staff to know what to ask other staff and visitors. She stated they did not have an assigned person to answer the door. She stated it was a possibility that anyone coming into the facility without being screened could have any type of illness such as the flu, colds, COVID and other airborne illnesses which could spread to residents and staff. She stated it was very important for visitors and staff be screened prior to entering the facility. She stated they did not know how the current COVID-19 outbreak began in the facility. She stated if the staff and the visitors were not being screened, there was a possibility that someone had symptoms of COVID, and other staff and residents contracted COVID. Observation on 09/14/2022 between 5:30 AM thru 5:50 AM revealed the following: -Surveyor and Medication Aide A were at the door waiting for staff to open the door to enter the foyer area. Hospitality Aide J came to the door and as soon as she opened the door, she exited the foyer and lobby area and entered the facility. She did not say anything to Surveyor or Medication Aide A. Hospitality Aide J did not ask for temperatures or ask any COVID sign or symptoms questions. -Dietary Cook B, CNA C and CNA D were at the door and Hospitality Aide J came to the door and opened the door for staff to enter the foyer. Hospitality Aide J did not ask the COVID-19 signs or symptom questions or ask to take their temperature. CNA D asked if that was an electronic thermometer on the wall. Hospitality aide J stated she did not know and walked into lobby and then the facility. Dietary Cook B, CNA C and CNA D took their own temperatures with a new electronic thermometer on the wall. - Transportation Aide E, LVN F, Dietary Aide H and LVN I were at the door and Hospitality Aide J came to the door and opened the door for staff to enter the foyer. Hospitality Aide J did not ask any of the staff about any signs or symptoms of COVID-19 or ask them to use the new electronic thermometer to take their temperature. Hospitality Aide J walked in the lobby and entered the facility after she opened the door for the staff. In an interview on 09/14/2022 at 5:55 AM the Hospitality Aide J stated she did not ask the staff if they had signs or symptoms of COVID or ask them to take their temperature. She stated she answered the door frequently, but she did not know she was supposed to ask any questions or ask to use the thermometer to take temperatures. She stated the ADON/Infection Control Nurse had trained her on asking COVID -19 symptom questions when she answered the door and she was in serviced on infection control In an interview on 09/14/2022 at 6:30 AM LVN F stated she was not asked COVID-19 screening questions and her temperature was not taken by another staff when she entered the facility on this date (9/14/2022). She stated she had not been screened or had her temperature taken in a long time. She stated someone answered the door and she entered and continued into the facility for her report. She stated she it had been approximately one month or more since she had been screened by anyone. She stated if staff or visitors were not screened there was a possibility, they could have a temperature or have a symptom of COVID. She stated anyone with a temperature usually had an infection somewhere and it could be contagious. She stated if a resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the staff cannot screen themselvesm, someone else was required to screen them. In an interview on 09/14/2022 at 6:45 AM Medication Aide A stated no one screened her or took her temperature when she entered the facility this AM (09/14/2022). She stated the staff were not being screened or their temperature taken very often. She stated she was screened approximately 5 times in the past 2 or 3 months. She stated she knew they were required to be screened and temperature taken but the staff were not allowed to do their own screening. She stated she was in a hurry and did not remember to ask someone to screen her. She stated it was important to screen staff and visitors. She stated someone may have a temperature and not feel sick or have some symptoms and not really think they are sick. She stated if someone had symptoms and a temperature and came in the facility without being screened it was a possibility others could contract what the person had such as cold, flu or COVID-19. In an interview on 09/14/2022 at 7:15 AM CNA C stated she was not screened today (9/14/2022) for signs or symptoms of COVID-19. She stated no one took her temperature. She stated she did not think anything about it because this was not unusual for staff not to be screened when they came to work in the morning. She stated the night shift was trying to finish their work to leave and the morning shift was trying to hurry in the facility to clock in and get to work. She stated there has been a few times she was screened but not many times in the past month. She stated she was screened approximately 2 times in the past month. She stated if a visitor or staff had fever and didn't realize it, they could be sick and contagious. She stated they could have a cold, flu or even COVID-19. She stated if they were sick and no one took their temperature and or asked questions the other staff and residents could become sick with whatever they may have during their visit. She stated she could not remember if they had an inservice on screening process. She stated they had so many inservices and were asked to sign paper, it was difficult to keep up with all the inservices they had in the past month. She stated she was usually in a hurry and did not think about asking to be screened for COVID symptoms. In an interview on 09/14/2022 at 7:30 AM Transportation AIDE E stated when she entered the lobby, she was not screened by anyone, and her temperature was not taken by anyone. She stated staff were not always screened for COVID-19 or temperature taken when they came to work. She stated the only time she knew when staff temperatures were taken was when someone felt sick. She stated she had not been asked any questions about if she felt sick, had nausea or been around anyone with COVID-19 in a long time. She stated there were more questions to ask staff and visitors, but she did not remember all the questions. She stated she had answered the door several times when visitors were waiting to come into the facility, but she diid not ask the visitors any questions about being sick, signs and symptoms of COVID-19 or take their temperature. She stated she never thought about asking the questions. She stated if someone came in with a temperature, they could be sick with flu or COVID and could cause a resident or staff to have flu or COIVD-19. She stated she had been in serviced on screening visitors and staff and had in services on infection control and signs and symptoms of COVID-19. She stated they had been doing a lot of in services on COVID-19 and infection control over the past month. In an interview on 09/14/2022 at 7:50 AM the Administrator stated she was shocked that the night staff did not screen other staff as they came into work this AM (9/14/2022). She also stated she could not believe they did not screen the surveyor. She stated this was very serious and her expectation was for who entered the facility except EMS to be screened. She stated they had been through an outbreak of COVID and continued to go through an outbreak of COVID-19 with staff and residents. She stated they do not know how this began and why staff and residents continued to test positive for COVID-19. She stated with that many staff not being screened for COVID-19 and their temperature not being taken it was a possibility someone may have come to work with a temperature or other symptoms. She stated a new electronic thermometer was placedin the foyer for staff to use when they entered the foyer area and not everyone used it this morning. In an interview on 09/14/2022 at 8:50 AM the ADON/ Infection Control Nurse stated all staff were expected to be screened prior to entering the facility this AM (09/14/2022). She stated an in-service was completed last night with the night shift on the screening process. She stated she did not understand why the staff were not screened this AM. She stated without staff and visitors being screened it was difficult to determine if anyone had a temperature or any signs or symptoms of COVID or any other contagious illness. She stated a nurse was expected to screen the staff in AM and go to the door whenever the doorbell sounded. She stated there was no one assigned to answer the door during the day. She stated anyone that heard the doorbell and was available was the one who usually went to the door. B. Observation on 09/14/2022 between approximately 8:05- 8:35 AM reveaked Occupational Therapist K repositioned Resident #1 in resident's bed. Occupational Therapist K was wearing gloves. He touched Resident #1's shoulder, hands and legs. He also touched Resident #1's bed, his clothes and overhead rolling table. Occupational Therapist K exited Resident #1's room wearing same gloves and entered the dining room. Occupational Therapist K walked to the kitchen door and was handed Resident #1's breakfast tray. He exited the dining room and walked down 300 hall and entered Resident #1's room. He walked to Resident #1's bed and placed the breakfast tray on the rolling overhead table with dried yellowish and white substance on the overhead bed table. Occupational Therapist K did not sanitize the rolling overhead table. He proceeded to remove the lids covering the plate and the plastic lids covering the liquids. He did not change his gloves. He began to touch Resident #1's shoulder and hospital gown to pull up the hospital gown. He put the tip of his gloves on his right hand inside the cup of juice for Resident #1 to drink. He also picked up the spoon for Resident #1 and touched the area where food is placed on the spoon. He also touched the tines of the fork. Occupational Therapist K never changed his gloves. He also touched inside the plate and touched Resident #1 food that looked like oatmeal. Occupational Therapist K pulled down his mask under his chin and was talking to Resident #1 and was within 1 foot of Resident #1. He turned and began talking to Surveyor and was less than 4 feet from Surveyor. He kept his mask off approximately 5 -10 minutes. He was facing Resident #1 approximately 6 minutes without wearing his face mask. In an interview on 09/14/2022 at 9:40 AM with Occupational Therapist K stated he pulled his face mask down when talking to residents if they could not hear what he was saying. He also stated he pulled his face mask down under his chin when he talked to staff, especially if the staff could not hear what he was saying to them or in a noisey room or area of facility. He stated he had been in serviced on wearing face mask and sometimes he forgot and pulled his face mask under his chin when he provided therapy to residents or talking to staff. Occupational Therapist K stated he cued Resident #1 to eat and gave him therapy on using utensils when eating. He stated he never changed his gloves from the time he repositioned resident in bed and he did wear the same gloves in the hall and in the dining room. He stated he never changed his gloves when he returned to Resident #1's room and began to set up the tray and he stated he didn't realize he touched the silverware in areas where the resident would place it in his mouh; or inside the cup and plate. He stated that was considered cross contamination and could potentially cause Resident #1 to become seriously ill and be hospitalized if Resident #1's food was contaminated or if he had coughed or sneezed on Resident #1, he could become physically ill if there were germs from his cough. He stated he was not screened for COVID-19 and his temperature was not taken when he entered the facility this AM (9/14/2022). He stated he was sometimes screened, and someone would take his temperature but not all the time. In an interview on 09/14/2022 at 12:00 PM the Administrator stated all staff including therapy were always to wear their mask when in the facility. She stated there were no excuses. She stated a resident could become ill with COVD, flu, cold or any other viruses if staff was not wearing face mask less than one feet from a resident. She stated this was unacceptable. She stated all therapy staff did participate in the in-service of demonstrating how to properly wear all PPE including face mask. She stated therapy attended in-services with the other staff in the facility on infection control and he had been in serviced about wearing mask when in the facility, especially when giving therapy to a resident or standing near staff. In an interview on 09/14/2022 at 10:20 AM the ADON/ Infection Control Nurse R stated the Occupational Therapist was to wear a face mask when he was in the facility. She stated he had been in serviced with the other facility staff on how to properly donn and doff PPE. She stated all staff in the facility demonstrated how to properly donn and doff and wear PPE including face mask. She stated it was not acceptable for Occupational Therapist K to be near a resident or another staff member without wearing a face mask. She also stated it was herself and Director of Therapy's responsibility to in-service therapy staff on wearing mask and infection control. She stated it was the Director of Therapy's duty to assist in monitoring her staff to ensure they were properly wearing PPE and following infection control protocol. In an interview on 09/15/2022 at 11:00 AM the Director of Therapy T stated all therapist were to wear mask when in the facility. She stated Occupational Therapist K was required to wear his mask over his nose and mouth when providing therapy to a resident. She stated it did not matter if resident or anyone else could not hear him, that was not an excuse to pull mask down under the chin. She stated a resident had the potential to come in contact with COVID-19 or any type of illness if staff was not wearing their mask over nose or mouth. She stated the Occupational Therapist K was expected to change his gloves and sanitize hands after he assisted resident up in the bed. She stated it was not acceptable for Occupational Therapist K to wear his soiled gloves in the hall and into the dining room. She stated he had a potential to cross contaminate resident food and other areas in the facility wearing soiled gloves. She stated Occupational Therapist K was expected to remove his soiled gloves and sanitize hands and donn new gloves prior to assisting Resident # 1 with setting up his meal tray. She stated the Occupational Therapist K potentially cross contaminated Resident #1's food and silverware if he had touched the silverware, cup, plate and/ or food with his soiled glove. She stated the therapy department attended the facility's in services on infection control and they attended the in-service the facility had first week in September 2022 and she stated Occupational Therapist K did attend the in-service. She stated it was the infection control nurses responsibility to monitor all staff in the facility to ensure they were following PPE guidelines. C. Observation on 09/15/2022 between 12:50- 1:10 PM revealed CNA M was working the 600 hot zone hall. Her gown was not donned appropriately in that the strings to tie the gown were hanging down and the gown was not tied. CNA M was going in and out of the COVID positive residents' rooms on 600 hall with her clothes not completely covered. She was getting residents meal trays and placing them on the tray cart in the hall. CNA M bent over and the side of the bottom to middle of her scrub pants touched the floor. There was a portion of her scrub top and scrub pants on both sides exposed. CNA M doffed at the end of 600 hall and didn't sanitize her hands. She exited the end of 600 hall and entered the front door. She was assigned to the cold zone ( Residents doesn't have any signs or symptoms of COVID-19) on 300 halls and she did not change clothes. There were signs on each resident's door demonstrating how to donn and doff gowns. Observation on 09/15/2022 at 1:10 PM revealed CNA M assist Resident #2 with repositioning in bed on the 300 hall cold zone. In an interview on 09/15/2022 at 1:30 PM CNA M stated she did not tie her gown while working on the 600 hall (hot zone). She stated her clothes did touch the residents with COVID. She stated her clothes did touch the floor and the resident's beds on the hot zone. She stated she had been in serviced on how to properly put on a gown. She stated the facility had an in-service first week of September 2022 and everyone had to demonstrate wearing a gown, gloves, mask, and other things to wear when around COVID residents. She stated she did attend this in-service. She stated she forgot to tie her gown. She stated if someone did not wear their gown properly the person could spread COVID to other residents and staff and she knew she was to tie her gown, but she forgot. In an interview on 09/15/2022 at 1:45 PM the Administrator stated all staff were expected to follow the signs on the door on how to donn and doff gowns and all PPE. She stated the staff had been in serviced approximately 1 week ago on donning and doffing PPE. She also stated each staff was required to demonstrate how to donn and doff all PPE. They were also required to demonstrate proper hand hygiene . She stated if CNA M was not wearing her gown correctly there was a potential of her clothes being in contact with different surfaces in residents' room on the hot zone and be in contact with the positive COVID residents. She stated when the CNA M exited the 600 hot zone hall, she was expected to sanitize her hands. She also stated she did go on the 300 cold zone to work and it was a possibility if her clothes were not completely covered by the gown, she could potentially spread germs and COVID-19 to residents on the 300 hall. Record Review of the Facilities Handwashing/Hand Hygiene Policy dated 2001 reflected hand hygiene is the final step after removing and disposing of personal protective equipment. Record Review of the Facilities Inservice on Competency Validation of Personal Protective Equipment and Hand Hygiene Competency Validation was given to all staff in the facility week of 09/05/2022. All staff demonstrated individually on the Personal Protective Equipment and Hand Hygiene Competency Validation. Requested a copy of the signs on the resident's door on the hot zone from the Administrator on 09/15/2022 at 1:45 PM and on 09/16/2022 at 1:00 PM she stated both times she would make copies. Upon leaving the facility on 09/15/2022 and exiting 09/16/2022, did not receive a copy of the signs of donning and doffing posted on each resident's door on the 600 hot zone hall. Record review of positive COVID residents in the facility on 9/14/2022 reflected 13 residents on the hot zone. There were 19 residents on the warm zone (Resident's with a potential to have COVID-19). In an interview on 09/15/2022 at 1:45 PM the Administrator stated there were 14 staff in September tested positive for COVID and 2 were currently on quarantine and she did state there were 13 COVID positive residents and 19 residents residing on the warm zone. An Immediate Jeopardy (IJ) was identified on 09/14/2022 at 5:13 PM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The final plan of removal was accepted on 09/16/2022 at 1:58 PM and is as follows: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on September 14, 2022 for failing to screen visitors and staff prior to entering the facility. All nursing facility residents have the potential to be affected by this deficient practice. 1. Action: Administrator, Director of Nursing, and Assistant Director of Nursing conducted education with all center staff regarding: 1) Staff and Visitor Screening Prior to Entry into Center; 2) Proper Use of Facemasks; 3) Hand hygiene following glove use; 4) Sanitizing Equipment Surfaces; and 5) Sanitizing Resident Hands. Beginning September 14, 2022, licensed nurses (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Completion Timeline: September 14, 2022 Responsible: Administrator, Director of Nursing, Assistant Director of Nursing 2. Beginning September 14, 2022, Administrator, Director of Nursing, and Assistant Director of Nursing conducted staff and visitor screening education with a staff member to be designated to monitor the front entrance. For the proceeding 30 days, during high traffic staff and visitor entrance times at shift change (5:45-6:25A and 5:45-6:15P) and during normal business hours (9A-5P) this designated staff member will monitor the front entrance. Beginning September 15, 2022, designated front entrance monitors who have not received the above stated education will be educated by Administration prior to monitoring. During non-high traffic visitor times, staff educated to screen prior to entry into center will be designated to screen at front entrance. Completion Timeline: September 14, 2022 Responsible: Administrator, Director of Nursing, Assistant Director of Nursing 3. Action: Beginning [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 7 of 20 residents reviewed for abuse and neglect. (Residents # 1, # 2, # 3, # 4, # 5 # 6 and # 7) The facility failed to ensure Resident #1, who was admitted to the Memory Care Hall on 8/26/2021 from a Psychiatric Hospital, was monitored by staff from 10/31/2021 through 11/22/2021 in order to prevent physical contact with other residents including pushing, slapping, kicking, and choking a resident, and from sustaining injuries to himself from residents he provoked with his behaviors. The facility failed to in-service all staff who worked with Resident #1 on preventing abuse and neglect and preventing aggressive behaviors. These failures resulted in an Immediate Jeopardy (IJ) situation on 11/22/2021. While the IJ was removed on 11/24/2021, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed all residents residing on the Memory Care Hall at risk for mental anguish, injuries and hospitalization s. Findings Include: Review of Resident # 1's Face Sheet reflected he was admitted to the facility Memory Care Hall on 08/26/2021 from a Psychiatric Hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 1's Quarterly MDS dated [DATE] reflected a BIMS interview was not conducted. Review of Resident # 1's Care Plan dated 08/31/2021 reflected Behavioral Symptoms: resists care, pushes others, no concept of personal space for others. Resident will have few episodes of aggression. Approach start date: 10/6/2021 Increase supervision when wandering to monitor movements. Review of Resident # 2's Face Sheet reflected she is a [AGE] year-old female who was admitted to the facility's Memory Care Hall with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 2's Care Plan dated 6/17/2021 reflected Behavioral symptoms: exhibits wandering (moves with no rational purpose, seemingly oblivious to needs or safety) Place Resident # 2 in a secure environment. Remove Resident # 2 from other resident's rooms and unsafe situations. Review of a Nurse Progress Note for Resident #1 dated 10/31/2021 reflected Resident (#1) found inside other residents' (Resident # 2) room. He allegedly grabbed her and was kicked. He is unable to provide statement r/t cognitive impairment. No c/o discomfort noted. No injuries noted at this time Administrator notified and aware. Safety measures in place and will continue to monitor. Review of facility investigation report dated 10/31/2021 reflected (Resident # 2) told aide that (Resident #1) grabbed her arm, so she kicked him, and he kicked her back. (Resident #1) was unable to tell aide what happened or that anything happened. No injury was noted to either resident. Social Services will assess for any emotional needs. Actions and notifications Residents were assessed for injury. In-service on preventing abuse and neglect and preventing aggressive behaviors. Review of a facility investigation report dated 11/01/2021 reflected the Administrator stated, In-service completed on abuse and neglect and aggressive behaviors. Review of an Inservice titled Abuse Prevention, Resident Altercation dated 10/31/21 and instructed by LVN A, reflected only 25 out of 63 staff members listed signed they received the Inservice. Review of Resident # 3's Face Sheet reflected he was a [AGE] year-old-male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 3's Care Plan dated 10/28/2021 reflected he has behavioral symptoms and potential for complications related to [CONDITION(S)] medication use. Review of a Nurse Progress Note dated 11/07/2021, reflected Resident #1 Resident wandered to common area wearing only a brief and tee shirt. When taking him to the bathroom he was noted to have blood on his face. Noted a cut to the center of the upper lip, (Resident # 3) wandered up and stated, I hit him. Asked co-resident why he hit him, and he stated, He was in my room going through my stuff and when I told him to leave, he wanted to be an[OBSCENITY] and push me, so I popped him twice. Review of facility investigation report dated 11/07/2021 reflected (Resident # 1) was seen coming up the hall with blood on his lip. He was unable to tell staff what happened when he was questioned. (Resident # 3) came out of his room and told staff that he clocked him . When asked why, Resident # 3 explained that (Resident # 1) was in his room messing with his stuff and refused to get out so he hit him. Social Services will see both residents' tomorrow. Physical assessment performed on both residents and first aid provided to (Resident # 1). Inservice started on abuse and neglect and monitoring of resident's with known aggressive behaviors. Review of Resident # 4's Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 4's Quarterly MDS dated [DATE] reflected she has a BIMS score of 3 indicating severe cognitive impairment. Review of Resident # 4's Care Plan dated 09/02/2021 reflected she exhibits wandering, is oblivious to needs or safety and has a risk for bruising related to her aspirin therapy. Review of facility Investigation report dated 11/13/2021 reflected Resident #1 walked down the hallway towards Resident #4. When he was face to face with her, he allegedly slapped Resident #4 three times on the left cheek with his right hand. LVN B stated she thought something might happen but was unable to intervene before there was physical contact between the two residents. No injury was noted during physical assessment to either resident. Actions and notifications Residents were separated. skin assessment and pain assessment completed. Medical director, RP, and PCP notified of incident. Inservice on aggression prevention and abuse & neglect. Review of Resident #5's Face Sheet reflected he is an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's quarterly MDS dated [DATE] reflected he has a BIMS score of 3 indicating severe cognitive impairment. Review of Resident #5's Care Plan dated 11/11/2021 reflected he is at risk for fractures related to [CONDITION(S)] and is at risk for skin injuries related to anticoagulant therapy. Review of Resident #6's Face Sheet reflected she was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident # 6's quarterly MDS dated [DATE] reflected she has BIMS score of 3 indicating severe cognitive impairment. Review of facility Investigation Report dated 11/17/2021 reflected Resident # 1 wandered into Resident # 5's room and shoved him in the chest. He was redirected by LVN C and went to TV area and sat down. As LVN C was walking away, Resident #1 got up real fast, walked past her and hit Resident #6 in the back. Physical assessment performed on all individuals. All residents will be seen by social worker. Actions and notifications Residents were separated, and Resident #1 was redirected multiple times. Medical director, RP, PCP notified. No injury noted to residents. Inservice will be done on Abuse and neglect and timely reporting of reportable events. Interview on 11/22/2021 at 11:00 AM, TNA E said The nurse will run back and forth between the units when we take breaks. Resident #1 is violent. He came over this morning when she was sitting doing paperwork and hit TNA E on the back where it's still sore. He tries to grab food off the trays. He went into Resident # 3's room this morning. He hit Resident # 3 and he hit him back. He's hit 3 people this morning, one resident and two aides. We aides are sore and pretty much get hit every day. When we shower him, we both have to deal with him and then the other residents are left on their own. Review of Resident # 7's Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Review of Resident # 7's quarterly MDS dated [DATE] reflected she had a BIMS score of 9 indicating moderate cognitive impairment. Review of Resident # 7's Care Plan dated 05/21/2021 reflected she is at risk for skin injuries related to fragile skin. Interview on 11/22/2021 at 2:30 PM, TNA E on memory care hall said When I was gone on break, Resident # 1 went into Resident # 7's room and she told him to get out and he grabbed her neck. TNA D told me about it. Interview on 11/22/2021 at 2:40 PM, TNA F on the memory care hall stated I've had an 8-hour Nurse Aide training. I think they talked about dealing with aggressive behaviors but I'm not sure. Resident # 1 is aggressive. If I need help, I'll holler at one of the nurses to come help on the floor. Interview on 11/22/2021 at 3:09 PM, the Social Worker said regarding Resident # 7 after Resident # 1 attempted to choke her, I went back there, and she's crying and scared. Observation and interview on 11/22/2021 at 3:20 PM, Resident # 7 was teary-eyed after the incident in which Resident # 1 went into her room. She stated a strange man came in her room. He was choking me. I was scared. He just came in and I told him this is not your room. She grabbed her neck as if in a chokehold to the left side. It doesn't hurt. You never know, he might come back. I'm scared. When he did it, I hollered, and he let loose. The nurse came in later. Interview on 11/22/2021 at 3:42 PM, TNA D said I was alone after about 1:10 p.m. this afternoon sitting in the living area with two residents when I heard Resident # 7 holler, You're not allowed in here. Get out. I went into her room and Resident # 1 said, I think not and he had grabbed her by the neck. Observation and interview on 11/22/2021 at 2:48 PM on memory care hall of Resident # 1 with only one staff, TNA E on the unit with 20 residents. TNA D was on lunch break according to TNA E. Resident # 1 walked into a female resident's room and closed the door; surveyor opened the door to observe him. He drank a coke from the bedside table closest to door. A female resident was lying in second bed with her eyes open but not noticing him. He started to fold clothes on the first bed when LVN C asked him to come out of the room and he complied. She stated, Dr. G was just here. She changed his dose of [MEDICATION(S)] to now. Observation on 11/22/2021 at 2:57 PM, LVN C was leaving the memory care unit and Resident # 1 opened the door to Resident # 4's room. The only aide on the unit was observed at the end of the hall looking after a resident who set off an alarm going out the back door to enclosed patio area. Interview on 11/22/2021 at 3:09 PM with Social Worker regarding Resident # 1, I tried to get him back to (the psychiatric facility he came from) but they won't take him back. He's under the care of a psychiatrist. The psychiatrist saw him on the 18th. They do tele-visits. We got his meds changed and we discussed an alternate placement. We thought he might need a medication holiday. Interview on 11/22/2021 at 4:15 PM, the Administrator stated regarding Resident # 1 I am putting him on 1:1 now. The staffing back there should always be two because of the behaviors. Interview on 11/22/2021 at 4:20 PM, the DON said, What we're going to do is a 1:1 (staff) with Resident # 1. The next group of employees gets here at 6:00 PM. We're going to try to get a 1:1. We may have to rotate others in to help. The 1:1 staff will be dedicated to him. Interview on 11/22/2021 at 4:40 PM, the DON said, Resident # 1 is now on a 1:1 with TNA E. Interview on 11/22/2021 at 2:40 PM, TNA F on the Memory Care Hall stated I've had an 8-hour Nurse Aide training. I think they talked about dealing with aggressive behaviors but that might have been after I left. Resident # 1 is aggressive. If I need help, I'll holler at one of the nurses to come help on the floor. Interview on 11/22/2021 at 2:57 PM, TNA E on the Memory Care Hall, who stated I don't remember having any in-services on how to deal with Resident # 1's aggressive behaviors. I've been back here three months. Interview on 11/30/2021 at 7:50 PM, the Administrator stated she was unable to find any other in-services on ANE, preventing aggressive behaviors or timely reporting of reportable events other than the one dated 10/31/2021, titled Abuse Prevention, Resident Altercation and signed by 25 out of 63 staff members listed. Observation on 11/22/2021 at 9:20 PM on memory care hall, Resident # 1 was standing alone in the darkened living area looking at a staff computer screen. No staff in sight. CNA I showed up from resident hall stating, I had to put someone to bed. It's only been a few minutes. CNA J took trays to the kitchen. CNA J returned and stated, I had to use the restroom. When asked if she or CNA I were supposed to be 1:1 with Resident # 1, she stated Yes ma'am, we're supposed to be with him at all times. Interview on 11/22/202 at 9:55 PM, with Administrator and DON who were informed surveyor observed no staff was 1:1 with Resident #1 on Hall 200 at 9:20 PM. Staff was asked what they will do to ensure staff will be back there with him 1:1 all night and he will not be left by himself. Administrator stated, We will do an in-service right now. The Administrator was notified on 11/22/2021 at 10:50 PM, that an Immediate Jeopardy (IJ) situation was identified due to the above failures. The IJ template was provided to the Administrator. The plan of removal was accepted on 11/24/2021 at 11:50 AM and included the following: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on November 22, 2021, for failing to protect memory care residents by not providing adequate supervisor or intervention to prevent abuse. 1. Action: To ensure awareness of other residents who may be exhibiting behaviors towards other residents all direct care staff, nursing management, IDT team, and administrator will be educated on POC documentation of behaviors, ensure CNA communication (To include walking rounds, and nurse to CNA instruction at the beginning of each shirt to ensure expectations are met and to review implementation and follow through of care plans. This will be monitored through our daily clinical meeting and widgets identifiers. For any identified resident behavior(s) the interdisciplinary team will initiate an intervention care plan update, provide follow-up documentation to include the effectiveness of intervention change. Completion Timeline: November 22, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Responsible: Administrator, Director of Nursing, Social Services, Assistant Director of Nursing, and IDT team. 2. Action: Administration conducted education with all direct care staff regarding: 1) Notification upon identification of resident behaviors; 2) One-to-one resident monitoring procedure in which a staff member will be assigned to a resident. (They are not to leave them and must be close enough to intercede in any instance where a behavior could cause harm to another resident, visitor, or staff member), and 3) Dealing with resident behavior to include behavior management and intervention and documenting resident behaviors in POC. Beginning November 23, 2021, direct care staff (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Completion Timeline: Beginning November 22, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Responsible: Administrator, Director of Nurses, ADON, CCM, Nurse Manager, Charge nurses 3. Action: Residents with aggressive behaviors will be placed on 1:1 monitoring until alternative placement is found or the resident is no longer a danger to other residents or staff as determined by the IDT team. Direct care staff will be educated on what 1:1 monitoring means. No staff will be assigned to provide 1:1 Monitoring until in-service regarding 1:1 monitoring has been done. As a reminder to the expectation 1:1 supervision tool will be placed in sign in book. Completion Timeline: November 23, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Responsible: Administrator, DON, ADON, Charge nurses, Nurse manager 4. Action: Beginning on November 23, 2021, Residents identified of being affected by deficient practice will have a consult by social worker. If follow is needed, with consent social services/nursing will request a referral to the psychological service provider. Completion Timeline: November 23, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN). . Responsible: Administrator, DON, Social Worker 5. Action: Beginning on November 23, 2021, daily during morning clinical meeting, administrative staff will utilize the open events widget located in the resident electronic medical record to review incident reports for intervention care plan update and follow-up documentation to include effectiveness of intervention change. The IDT team will monitor changes to the care plan to ensure effectiveness and follow up. Event will remain open until intervention(s) are effective. The QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. Next QAPI meeting will be held on December 14th, monthly thereafter, and PRN. Completion Timeline: Beginning November 23, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Responsible: Administrator, Director of Nursing 7. Action: Unmanageable Residents will be managed according to policy (please see attached policy). All staff and leadership educated on policies and procedures in identifying at risk residents. All staff in serviced on procedures on policy to promote safety of residents, staff, and visitors. Completion Timeline: November 23, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Responsible: RNM, Administrator, Don, and nurse manager 8. Action: Resident #1 discharged to Oceans Psychiatric Facility in [NAME], Tx. Alternate placement will be sought at one of our more appropriate sister facilities when and if behaviors are controlled and resident is no longer a danger to himself or others. Completion Timeline: November 23, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN). Responsible: Administrator, DON, Social Worker The surveyor monitored the plan of removal as follows: Monitoring was completed on 11/24/2021 from 11:50 AM through 5:00 PM. Interviews on 11/24/2021 with three LVNs and four CNAs reflected they had been in-serviced on how to respond to aggressive residents or residents with behaviors. Staff stated they were to diffuse the situations, so the residents are safe then call for the charge nurse to come. The charge nurse should assess the residents and report the incidents per the facility's policy. Record review of in-services provided to staff on 11/23/2021 and 11/24/2021 reflected staff were in-serviced on Review of Abuse Prevention Program, Matrix POC training, Charting Behaviors, 1:1 Monitoring of Residents, Shift Change Documentation, View Care Plan, and Dealing with Resident Behaviors. The administrator was informed the IJ was removed on 11/24/2021 at 5:00 PM. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring need to evaluate their plan of removal for effectiveness.

Based on observation, interview and record review the facility failed to immediately consult with the resident's physician; and notify the resident representative when there was a deterioration in health with a need to commence a new treatment for one (1) of five (5) residents reviewed for notifications (Resident #1). The facility failed to ensure Resident #1's Physician was notified when his Stage IV (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound.) pressure ulcer declined on 03/26/2020, 04/02/2020 and 04/14/2020. These failures could cause severe pain, and lead to systemic infections causing harm or death for residents that have or are at risk for pressure ulcers. Findings: Review of Resident #1's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Date Set ((MDS) dated [DATE] reflected Resident #1 did not have a BIMS done indicating he had severe cognitive impairment. Resident #1 was assessed to be dependent on staff for all ADLs and was assessed to always be incontinent of bowel and bladder. Resident #1 was assessed to be at risk for developing pressure ulcers and was assessed to have one (1) Stage IV pressure ulcer. Review of Resident #1's Care Plan reflected a problem with a start date of 08/20/2019 Terminal Care (Hospice) for Senile Degeneration of the Brain. Further review of Resident #1's Care plan reflected a problem with a start date 07/08/2019 has an unavoidable, healing Stage IV ulcer to the Coccyx/sacrum. Interventions included: Hospice to manage wound care, treatment as per MD orders, and skin assessment weekly as per facility protocol. Inspection daily with ADL care, with close attention to heels. Review of Resident #1's Wound assessment from 03/5/2020 to 04/14/2020 for his Stage IV sacral pressure ulcer reflected: -03/5/2020 3cm x 5cm x 0.cm with undermining at 2 o'clock 1 cm deep, wound bed with slough at 25 % with serous exudate. (Serous wound drainage looks clear or straw colored. This serous material arises from protein and fluid in the tissue. At times, serous material will leak through swollen skin when a person suffers a critical illness. The serous drainage supports the healing process and contains protein, electrolytes, sugar, white cells and some microorganisms.) -03/26/2020 (22 days later) 5cm x 5cm x 0.1cm with undermining at 3 o'clock 1 cm deep, wound bed non-granulation at 75 % ,no slough was noted on the assessment, serous exudate. (Pressure ulcer larger) -04/02/2020 5cm x 5 x 0.2 with undermining 1 cm deep, wound bed with non-granulation tissue at 75 % (no slough was noted on the assessment with, serous exudate. (Pressure ulcer deeper) -04/14/2020 (11days later) 5cm x 4cm x (stated depth could not be measured) with undermining at 12 o'clock 0.5 cm deep with slough at 25%, exudate [MEDICAL CONDITION] (Thin watery drainage similar to serous but has a milky, coffee-cream color and indicates an infection in the wound.) Review of Resident #1's Physician order [REDACTED]. Apply skin prep to entire peri-wound area pack Medi-honey soaked kerlix to wound bed cover with calcium alginate and secure with [MEDICATION NAME]. Observation on 04/14/2020 at 11:53 AM revealed the ADON outside of Resident #1's room to prepare for wound care. The ADON entered the room and then turned Resident #1 on his left side and removed a [MEDICATION NAME] dressing from his coccyx to reveal a Stage IV pressure ulcer with beveled edges and undermining around the entire diameter of the pressure ulcer with slough from 8 o'clock to 12 o'clock on the left side of pressure ulcer near the undermining. The ADON then sprayed the wound with wound cleanser and cleaned with a gauze. The ADON then measured the wound stating it was 5 cm x 4 cm with undermining at .5 cm. The ADON washed her hands and changed gloves then applied the Medi honey with a Q-tip to the wound bed, she then placed the calcium alginate in the wound bed attempting to pack the calcium alginate into the pressure ulcer. (The calcium alginate was not cut to size and would not go into the pressure ulcer wound bed) and covered the calcium alginate with a [MEDICATION NAME] dressing. (The ADON did not apply skin prep to the peri-wound or use Medi-honey soaked kerlix to the wound bed for packing. Packing a wound is the process of applying a packing material, usually sterile gauze, to a deep wound in order to absorb drainage from it and protect the wound. This allows for faster healing from the inside out. An improperly packed wound may close and appear fine superficially but won't heal inside) In an interview on 04/14/2020 at 1:15 PM the DON stated she looked through the hospice notes and the hospice nurse documented on 03/13/2020 but they did not provide wound measurements or a wound assessment. The DON stated there had been a lack of consistency in the wound assessments for Resident #1 and his pressure ulcer should have been assessed weekly. Interview on 04/14/2020 at 3:13 PM The ADON stated she was responsible for the weekly review of the wound assessments. The ADON stated she could not remember if she notified anyone of changes in Resident #1's pressure ulcer. When asked if she notified anyone today of the slough in his wound she stated she had not. When asked if she preformed Resident #1's pressure ulcer wound care per physician orders [REDACTED]. In an interview on 04/14/2020 at 3:20 PM the Hospice RN stated she looked at Resident #1's wound once a week and felt it was stable. She stated she does not measure the wound herself, that she gets the measurements from the facility. She stated the facility is supposed to call if there is a change in the wounds and then the hospice nurse will contact the doctor. When asked if she had noticed any slough in his wound on previous visits she stated no. She stated that was new and stated she looked in the notes and no one had contacted hospice. She stated she called and checked on the residents wound on 04/08/2020 and the facility stated there were no changes. In an interview on 04/14/2020 at 3:40 PM the DON stated the facility is supposed to measure the wounds weekly and report any changes or decline in the wounds to the doctors or if the resident is hospice to the hospice nurse. The DON stated she expected the nurses to follow physician orders [REDACTED]. Review of Resident #1's Nursing progress dated 04/14/2020 at 4:20 PM I spoke with physician in reference to resident's wound and informed of size increase. Physician stated hospice team will discuss in AM to address and advise me of any changes. Further review of Resident #1's Nursing Progress note dated 04/14/2020 at 6:53 PM reflected Physician in facility to assess Resident #1's sacral pressure ulcer and he discontinued current treatment and to start a new order to Cleanse with wound cleanser, pat dry, apply skin prep to outer wound, apply Santyl to wound bed, lightly pack with gauze and cover with bordered gauze. Review of Resident #1's physician progress notes [REDACTED]. Not appropriate to do any procedures such as [MEDICAL CONDITION] or other revisions. Pt has had severe wound in past with black eschar, now improves and fairly clean. Pt being turned on reg basis and good ulcer care. Actually, looks good in comparison to past information. Currently using med honey no indication for antibiotics. Will change to Santyl to see if helps but probably will go back to med honey later. Will discuss with hospice. Review of the facility's policy Change in a Resident's Condition or Status dated 05/2017 reflected Our facility shall promptly notify the resident, his or her attending Physician .of changes in the resident's medical/ mental condition and/or status .need to alter the resident's medical treatment significantly .

Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (1) five (5) residents reviewed for pressure ulcers. (Resident #1) The facility failed to ensure Resident #1's unavoidable Stage IV (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound.) pressure ulcer was assessed weekly and failed to notify Resident #1's physician when his Stage IV pressure ulcer declined on 03/26/2020, 04/02/2020 and 04/14/2020. The facility further failed to ensure Resident #1's Stage IV pressure ulcer treatment was done per physician orders. These failures could cause severe pain, and lead to systemic infections causing harm or death for residents that have or are at risk for pressure ulcers. Findings: Review of Resident #1's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's MDS dated [DATE] reflected Resident #1 did not have a BIMS done indicating he had severe cognitive impairment. Resident #1 was assessed to be dependent on staff for all ADLs and was assessed to always be incontinent of bowel and bladder. Resident #1 was assessed to be at risk for developing pressure ulcers and was assessed to have one (1) Stage IV pressure ulcer. Review of Resident #1's Care Plan reflected a problem with the start date of 08/20/2019 Terminal Care (Hospice) for Senile Degeneration of the Brain. Further review of Resident #1's Care plan reflected a problem with the start date 07/08/2019 has an unavoidable, healing Stage IV ulcer to the Coccyx/sacrum. Interventions included: Hospice to manage wound care, treatment as per MD orders, and skin assessment weekly as per facility protocol. Inspection daily with ADL care, with close attention to heels. Review of Resident #1's Wound assessment from 03/5/2020 to 04/14/2020 for his Stage IV sacral pressure ulcer reflected: -03/5/2020 3cm x 5cm x 0.cm with undermining at 2 o'clock 1 cm deep, wound bed with slough at 25 % with serous exudate. (Serous wound drainage looks clear or straw colored. This serous material arises from protein and fluid in the tissue. At times, serous material will leak through swollen skin when a person suffers a critical illness. The serous drainage supports the healing process and contains protein, electrolytes, sugar, white cells and some microorganisms.) -03/26/2020 (22 days later) 5cm x 5cm x 0.1cm with undermining at 3 o'clock 1 cm deep, wound bed non-granulation at 75 % ,no slough was noted on the assessment, serous exudate. (Pressure ulcer larger) -04/02/2020 5cm x 5 x 0.2 with undermining 1 cm deep, wound bed with non-granulation tissue at 75 % (no slough was noted on the assessment with, serous exudate. (Pressure ulcer deeper) -04/14/2020 (11days later) 5cm x 4cm x (stated depth could not be measured) with undermining at 12 o'clock 0.5 cm deep with slough at 25%, exudate [MEDICAL CONDITION] (Thin watery drainage similar to serous but has a milky, coffee-cream color and indicates an infection in the wound.) Review of Resident #1's Physician order [REDACTED]. Apply skin prep to entire peri-wound area pack Medi-honey soaked kerlix to wound bed cover with calcium alginate and secure with [MEDICATION NAME]. Observation on 04/14/2020 at 11:53 AM revealed the ADON outside of Resident #1's room to prepare for wound care. The ADON entered the room and then turned Resident #1 on his left side and removed a [MEDICATION NAME] dressing from his coccyx to reveal a Stage IV pressure ulcer with beveled edges and undermining around the entire diameter of the pressure ulcer with slough from 8 o'clock to 12 o'clock on the left side of pressure ulcer near the undermining. The ADON then sprayed the wound with wound cleanser and cleaned with a gauze. The ADON then measured the wound stating it was 5 cm x 4 cm with undermining at .5 cm. The ADON washed her hands and changed gloves then applied the Medi honey with a Q-tip to the wound bed, she then placed the calcium alginate in the wound bed attempting to pack the calcium alginate into the pressure ulcer. (The calcium alginate was not cut to size and would not go into the pressure ulcer wound bed) and covered the calcium alginate with a [MEDICATION NAME] dressing. (The ADON did not apply skin prep to the peri-wound or use Medi-honey soaked kerlix to the wound bed for packing. Packing a wound is the process of applying a packing material, usually sterile gauze, to a deep wound in order to absorb drainage from it and protect the wound. This allows for faster healing from the inside out. An improperly packed wound may close and appear fine superficially but won't heal inside) In an interview on 04/14/2020 at 1:15 PM the DON stated she looked through the hospice notes and the hospice nurse documented on 03/13/2020 but they did not provide wound measurements or a wound assessment. The DON stated there had been a lack of consistency in the wound assessments for Resident #1 and his pressure ulcer should have been assessed weekly. Interview on 04/14/2020 at 3:13 PM The ADON stated she was responsible for the weekly review of the wound assessments. The ADON stated she could not remember if she notified anyone of changes in Resident #1's pressure ulcer. When asked if she notified anyone today of the slough in his wound she stated she had not. When asked if she preformed Resident #1's pressure ulcer wound care per physician orders [REDACTED]. In an interview on 04/14/2020 at 3:20 PM the Hospice RN stated she looked at Resident #1's wound once a week and felt it was stable. She stated she does not measure the wound herself, that she gets the measurements from the facility. She stated the facility is supposed to call if there is a change in the wounds and then the hospice nurse will contact the doctor. When asked if she had noticed any slough in his wound on previous visits she stated no. She stated that was new and stated she looked in the notes and no one had contacted hospice. She stated she called and checked on the residents wound on 04/08/2020 and the facility stated there was no changes. In an interview on 04/14/2020 at 3:40 PM the DON stated the facility is supposed to measure the wounds weekly and report any changes or decline in the wounds to the doctors or if the resident is hospice to the hospice nurse. The DON stated she expected the nurses to follow physician orders [REDACTED]. Review of Resident #1's Nursing progress dated 04/14/2020 at 4:20 PM I spoke with physician in reference to resident's wound and informed of size increase. Physician stated hospice team will discuss in am to address and advise me of any changes. Further review of Resident #1's Nursing Progress note dated 04/14/2020 at 6:53 PM reflected Physician in facility to assess Resident #1's sacral pressure ulcer and he discontinued current treatment and to start a new order to Cleanse with wound cleanser, pat dry, apply skin prep to outer wound, apply Santyl to wound bed, lightly pack with gauze and cover with bordered gauze. Review of Resident #1's physician progress notes [REDACTED]. Not appropriate to do any procedures such as [MEDICAL CONDITION] or other revisions. Pt has had severe wound in past with black eschar, now improves and fairly clean. Pt being turned on reg basis and good ulcer care. Actually, looks good in comparison to past information. Currently using med honey no indication for antibiotics. Will change to Santyl to see if helps but probably will go back to med honey later. Will discuss with hospice. Review of the facility's policy Skin Management Documentation Workflow dated 06/24/2019 reflected Focused observation: Weekly wound assessment and complete pressure and non-pressure surveillance log weekly . Review of the facility's policy Change in a Resident's Condition or Status dated 05/2017 reflected Our facility shall promptly notify the resident, his or her attending Physician .of changes in the resident's medical/ mental condition and/or status .need to alter the resident's medical treatment significantly .

Based on observation, interview, and record review the facility failed to consult with the physician when there was a need to alter treatment significantly for one (1) of five (5) residents reviewed for following physician orders. (Resident #2). Licensed Vocational Nurse (LVN) D failed to properly address Resident #2's Change of Condition and notify the resident's primary care physician (PCP) when the resident complained of indigestion, heartburn, and nausea and vomited continuously from 11/01/15 at 7:30 PM through the end of his shift on 11/02/15 at 6:00 AM. The resident was subsequently transferred on 11/02/15 at 8:30 AM to a local hospital where he spent 12 nights in the Intensive Care Unit being treated for [REDACTED]. Prior to survey, the facility implemented corrective measures. This was determined to be a past non-compliance at an isolated harm level for Resident #2. This deficient practice affected Resident # 2 and placed an additional 52 residents at risk for delayed emergency care resulting in increased injury or death. Findings included: Review of Resident #2's Face Sheet reflected an [AGE] year old male admitted [DATE] and readmitted [DATE]. Diagnoses' included [MEDICAL CONDITION] Hypertension, Chronic [MEDICAL CONDITIONS], Heart Failure, Shortness of Breath, Type 2 Diabetes, [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION]. Review of Resident #2's 30 day Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The Resident's Functional Status scores reflected the need for extensive assistance with two (2) person physical assistance for bed mobility. The MDS further reflected the resident received oxygen therapy. Review of Resident #2's Care Plan dated 03/10/15 reflected a need of Requires 02 (oxygen) for adequate aeration. Observation of Resident #2 on 11/10/15 at 12:07 PM revealed the resident in the hospital Intensive Care Unit (ICU). The resident was receiving oxygen via nasal cannula and had a nasogastric tube in place. The resident used a suctioning wand to remove secretions from his mouth during the interview. In an interview on 11/10/15 at 12:07 PM Resident #2 stated he had been nauseous and had vomited all night long. Resident #2 further stated he had told LVN D You need to do something to help me with this. Resident # 2 stated LVN D had stated Call your doctor. The resident further stated he passed out later in the morning and woke up in an ambulance on his way to the hospital. In an interview on 11/12/15 at 7:00 PM Resident #2 stated he had vomited 15 or 20 times on the night of 11/01/15. He initially vomited in a cup but due to the volume of the vomitus, had to use a bucket. The resident further stated his blood pressure was only checked once during the evening. The residents pulse oximetry (percentage of oxygen in the blood) was not checked. Resident # 2 stated he did not remember anything after he had choked on his vomit on the morning of 11/02/15. In an interview on 11/10/15 at 8:38 AM the Assistant Director of Nursing (ADON) stated on 11/01/15 she was called to Resident #2's room and observed the resident on the bed on his left side. The resident was cyanotic (bluish discoloration of the skin due to the tissues near the skin surface having low oxygen saturation), and gasping. The resident's pulse was low and vomitus was on the resident. The crash cart was brought into the room and the resident was suctioned. An ambo bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) was used to assist the resident to breathe. The resident was suctioned several times and the finger sweep method was used to clear vomitus from the mouth. Emergency Medical Services (EMS) was called per the resident's Primary Care Physician (PCP). EMS personnel added an oral airway and continued use of the ambo bag as they left the facility with the resident. The ADON further stated changes of condition exhibited by Resident #2 should be reported to the resident s Primary Care Physician. Review of Resident #2's nursing notes dated 11/02/15 and signed by LVN E reflected on 11/02/15 LVN E was called to Resident #2's room. The resident was in his bed in the supine position. The facility's ADON was at the head of the bed preparing to bag the resident for 02 (oxygen). The resident was gasping for air, and diaphoretic (excess perspiration or sweating). The resident's pupils were pinpoint. EMS was called. EMS personnel intubated (the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway) the resident and transported the resident to the local emergency room . Review of the facility's Provider Investigation Report dated 11/04/15 reflected on 11/01/15 at 7:30 PM CNA C notified LVN D that Resident #2 was complaining of nausea and heartburn. The CNA further stated Resident #2 called her to his room several times begging for something for heartburn and indigestion. RN B stated Resident #2 had been vomiting for several hours but LVN D did nothing . RN B further stated on two (2) occasions she told LVN D to call the resident's physician but the LVN still did nothing . The investigation report further reflected Resident #2 was being repositioned in his bed when he became unresponsive. A crash cart was brought into the resident's room to assist with breathing and the resident was sent to the local emergency room (ER). The report described the injury as Aspiration Pneumonia. Post investigation actions included in-services for all staff regarding reaction to changes of condition and neglect. The agency that had provided LVN D was notified that the LVN would no longer be allowed to work at the facility. Review of Resident #2's undated Nurse's Notes reflected Resident #2 was noted to have nausea and was vomiting at the beginning of his 7:00 PM to 7:00 AM shift. The note further reflected the resident attributed the nausea and vomiting to a greasy lunch. LVN D checked the resident's chart and determined there were no standing orders for nausea. The note did not reflect any calls to the resident's PCP. The nurse's note further reflected the resident's last episode of nausea occurred at 11:00 PM and that the resident experienced no further symptoms throughout the rest of the shift. The notes did not reflect that vital signs, including pulse oximetry readings, had been taken for the resident. The note further reflected LVN D documented he had reported Resident #2's nausea and vomiting on the written 24 hour report. Review of the facility's 24 hour report covering 11/01/15 and 11/02/15 reflected no entries written by LVN D regarding Resident #2. The only entry regarding the resident's change of condition was written by LVN E on 11/02/15, no time, reporting the resident becoming unresponsive, respiratory distress = transferred to (hospital) admit ICU (Intensive Care Unit) [DIAGNOSES REDACTED]. In an interview on 11/13/15 at 4:26 PM LVN E stated she took over LVN D's shift on 11/02/15 at 6:00 AM. LVN E further stated LVN D had told her during shift report that Resident #2 had thrown up the previous night but was ok. LVN D did not report multiple episodes of vomiting or indigestion. In an interview on 11/10/15 at 2:30 PM CNA C stated Resident #2 had complained to her that he had been vomiting and experiencing chest pain. The CNA further stated she had notified LVN D who told her he would check on the resident. CNA C further stated he was later asked by LVN D Do you think the doctor would be cool with me calling him at night? The CNA further stated she could not recall ever seeing LVN D enter the resident's room. In an interview on 11/16/15 at 7:30 PM LVN D stated CNA C had informed him that Resident #2 had complained of nausea and was vomiting. The LVN further stated he checked Resident #2's chart to see if the resident had a standing PRN (as needed) order for anti-nausea medications. When he saw there were no such orders the LVN asked RN B what to do and was told to just monitor the resident. LVN stated he had been told by Resident #2 he was ill because of a greasy lunch. The LVN further stated the resident fell asleep at 11:00 PM and there were no further episodes of vomiting the rest of the night. LVN D further stated he had not checked the resident's vital signs or oxygen level that evening. The LVN further stated he did not notify the resident's PCP and RP of a change of condition because the resident had stopped vomiting. In an interview on 11/16/15 at 12:42 PM RN B stated LVN D had informed her of Resident #2's condition sometime between 8:30 PM and 9:00 PM. The RN further stated Resident #2 vomited several times through the night and when LVN D asked her opinion, RN B had told him to Call the doctor. RN B stated she later discovered LVN D did not call the resident's PCP during the shift. In an interview on 11/12/15 at 7:20 PM Hospital RN K stated Resident #2, at time of arrival to the hospital, was hypotensive with a blood pressure of 80/40. The resident's pulse oximetry reading was in the 70s . The RN further stated Resident #2 was being treated for [REDACTED]. Review of Resident #2's History and Physical dated 11/02/15 and written by the local emergency room physician reflected Resident #1 was admitted to the hospital on [DATE] with Acute [MEDICAL CONDITION], blood pressure in the 70s - 90s systolic despite several liters of fluid, acute pneumonia, possibly aspiration, and acute septic shock. In an interview on 11/13/15 at 9:15 AM Resident #2's PCP stated the facility's staff was expected to call him whenever a resident exhibits nausea and vomiting whenever there were no preexisting orders for nausea. In an interview on 11/12/15 The Director of Nursing (DON) stated LVN D had not been trained in facility protocols, including reporting changes of condition prior to working a shift at the facility. LVN D was an agency nurse who had only worked one or two shifts prior to the night of 11/01/15 - 11/02/15. Normal procedures were for the DON or ADON to sit with incoming agency staff prior to their first shift and review policy and procedures as well as various protocols including change of condition. In the case of LVN D, the DON and ADON were not on duty to train LVN D at the time of his first shift at the facility. Those personnel that do receive training sign a form stating they had been trained prior to working a shift at the facility. The DON further stated the facility had implemented a new policy in which other administrative level nurses would be responsible for providing the appropriate training for new agency staff. The DON further stated no new agency staff would be allowed to work in the facility without having received the appropriate training. The DON further stated that she would expect any of her staff to immediately notify a resident's PCP when changes of condition to occur including situations in which a resident was exhibiting signs and symptoms of nausea and vomiting if there were no standing orders for anti-nausea medications. Review of the facility's training records reflected no documentation to prove LVN D had ever received any form of training or orientation prior to working at the facility. All other agency staff had received the training. New protocol put into place on 11/04/2015, prior to survey, included: 1. Terminated LVN D and advised the agency he would not be allowed to work in the facility. 2. Developed procedures regarding ensuring agency staff are trained prior to working with residents with regards to accurately addressing a change of condition and notifying the physician. Review of the facility's Policy and Procedure document titled Agency Staffing Usage dated 11/04/15 reflected The Director of Nursing, Assistant Director of Nursing, or Nurse Practice Educator will utilize the Agency Orientation Checklist for Nurses and the Agency Orientation Checklist for CNA's to orient agency staff prior to providing resident care. The policy copy provided was signed by The facility's DON and ADON. 3. Staff was in-serviced regarding the new policy and procedures. Review of the facility's in-service records dated 11/04/15 reflected an in-service on recognizing and reporting changes of condition. The facility's Administrator provided a facility census listing reflecting 53 residents treated at the facility.

Based on observations, interviews, and record reviews the facility failed to develop and implement written policies and procedures that prohibit neglect for one (1) of five (5) residents reviewed for neglect. (Resident #2). Licensed Vocational Nurse (LVN) D failed to properly address Resident #2's Change of Condition and notify the resident's primary care physician (PCP) when the resident complained of indigestion, heartburn, and nausea and vomited continuously from 11/01/15 at 7:30 PM through the end of his shift on 11/02/15 at 6:00 AM. The resident was subsequently transferred on 11/02/15 at 8:30 AM to a local hospital where he spent 12 nights in the Intensive Care Unit being treated for [REDACTED]. Prior to survey, the facility implemented corrective measures. This was determined to be a past non-compliance at an isolated harm level for Resident #2. This deficient practice affected Resident # 2 and placed an additional 52 residents at risk for delayed emergency care resulting in increased injury or death. Findings included: Review of Resident #2's Face Sheet reflected an [AGE] year old male admitted [DATE] and readmitted [DATE]. Diagnoses' included [MEDICAL CONDITION] Hypertension, Chronic [MEDICAL CONDITIONS], Heart Failure, Shortness of Breath, Type 2 Diabetes, [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION]. Review of Resident #2's 30 day Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The Resident's Functional Status scores reflected the need for extensive assistance with two (2) person physical assistance for bed mobility. The MDS further reflected the resident received oxygen therapy. Review of Resident #2's Care Plan dated 03/10/15 reflected a need of Requires 02 (oxygen) for adequate aeration. Observation of Resident #2 on 11/10/15 at 12:07 PM revealed the resident in the hospital Intensive Care Unit (ICU). The resident was receiving oxygen via nasal cannula and had a nasogastric tube in place. The resident used a suctioning wand to remove secretions from his mouth during the interview. In an interview on 11/10/15 at 12:07 PM Resident #2 stated he had been nauseous and had vomited all night long. Resident #2 further stated he had told LVN D You need to do something to help me with this. Resident # 2 stated LVN D had stated Call your doctor. The resident further stated he passed out later in the morning and woke up in an ambulance on his way to the hospital. In an interview on 11/12/15 at 7:00 PM Resident #2 stated he had vomited 15 or 20 times on the night of 11/01/15. He initially vomited in a cup but due to the volume of the vomitus, had to use a bucket. The resident further stated his blood pressure was only checked once during the evening. The residents pulse oximetry (percentage of oxygen in the blood) was not checked. Resident # 2 stated he did not remember anything after he had choked on his vomit on the morning of 11/02/15. In an interview on 11/10/15 at 8:38 AM the Assistant Director of Nursing (ADON) stated on 11/01/15 she was called to Resident #2's room and observed the resident on the bed on his left side. The resident was cyanotic (bluish discoloration of the skin due to the tissues near the skin surface having low oxygen saturation), and gasping. The resident's pulse was low and vomitus was on the resident. The crash cart was brought into the room and the resident was suctioned. An ambo bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) was used to assist the resident to breathe. The resident was suctioned several times and the finger sweep method was used to clear vomitus from the mouth. Emergency Medical Services (EMS) was called per the resident's Primary Care Physician (PCP). EMS personnel added an oral airway and continued use of the ambo bag as they left the facility with the resident. The ADON further stated changes of condition exhibited by Resident #2 should be reported to the resident s Primary Care Physician. Review of Resident #2's nursing notes dated 11/02/15 and signed by LVN E reflected on 11/02/15 LVN E was called to Resident #2's room. The resident was in his bed in the supine position. The facility's ADON was at the head of the bed preparing to bag the resident for 02 (oxygen). The resident was gasping for air, and diaphoretic (excess perspiration or sweating). The resident's pupils were pinpoint. EMS was called. EMS personnel intubated (the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway) the resident and transported the resident to the local emergency room . Review of the facility's Provider Investigation Report dated 11/04/15 reflected on 11/01/15 at 7:30 PM CNA C notified LVN D that Resident #2 was complaining of nausea and heartburn. The CNA further stated Resident #2 called her to his room several times begging for something for heartburn and indigestion. RN B stated Resident #2 had been vomiting for several hours but LVN D did nothing . RN B further stated on two (2) occasions she told LVN D to call the resident's physician but the LVN still did nothing . The investigation report further reflected Resident #2 was being repositioned in his bed when he became unresponsive. A crash cart was brought into the resident's room to assist with breathing and the resident was sent to the local emergency room (ER). The report described the injury as Aspiration Pneumonia. Post investigation actions included in-services for all staff regarding reaction to changes of condition and neglect. The agency that had provided LVN D was notified that the LVN would no longer be allowed to work at the facility. Review of Resident #2's undated Nurse's Notes reflected Resident #2 was noted to have nausea and was vomiting at the beginning of his 7:00 PM to 7:00 AM shift. The note further reflected the resident attributed the nausea and vomiting to a greasy lunch. LVN D checked the resident's chart and determined there were no standing orders for nausea. The note did not reflect any calls to the resident's PCP. The nurse's note further reflected the resident's last episode of nausea occurred at 11:00 PM and that the resident experienced no further symptoms throughout the rest of the shift. The notes did not reflect that vital signs, including pulse oximetry readings, had been taken for the resident. The note further reflected LVN D documented he had reported Resident #2's nausea and vomiting on the written 24 hour report. Review of the facility's 24 hour report covering 11/01/15 and 11/02/15 reflected no entries written by LVN D regarding Resident #2. The only entry regarding the resident's change of condition was written by LVN E on 11/02/15, no time, reporting the resident becoming unresponsive, respiratory distress = transferred to (hospital) admit ICU (Intensive Care Unit) [DIAGNOSES REDACTED]. In an interview on 11/13/15 at 4:26 PM LVN E stated she took over LVN D's shift on 11/02/15 at 6:00 AM. LVN E further stated LVN D had told her during shift report that Resident #2 had thrown up the previous night but was ok. LVN D did not report multiple episodes of vomiting or indigestion. In an interview on 11/10/15 at 2:30 PM CNA C stated Resident #2 had complained to her that he had been vomiting and experiencing chest pain. The CNA further stated she had notified LVN D who told her he would check on the resident. CNA C further stated he was later asked by LVN D Do you think the doctor would be cool with me calling him at night? The CNA further stated she could not recall ever seeing LVN D enter the resident's room. In an interview on 11/16/15 at 7:30 PM LVN D stated CNA C had informed him that Resident #2 had complained of nausea and was vomiting. The LVN further stated he checked Resident #2's chart to see if the resident had a standing PRN (as needed) order for anti-nausea medications. When he saw there were no such orders the LVN asked RN B what to do and was told to just monitor the resident. LVN stated he had been told by Resident #2 he was ill because of a greasy lunch. The LVN further stated the resident fell asleep at 11:00 PM and there were no further episodes of vomiting the rest of the night. LVN D further stated he had not checked the resident's vital signs or oxygen level that evening. The LVN further stated he did not notify the resident's PCP and RP of a change of condition because the resident had stopped vomiting. In an interview on 11/16/15 at 12:42 PM RN B stated LVN D had informed her of Resident #2's condition sometime between 8:30 PM and 9:00 PM. The RN further stated Resident #2 vomited several times through the night and when LVN D asked her opinion, RN B had told him to Call the doctor. RN B stated she later discovered LVN D did not call the resident's PCP during the shift. In an interview on 11/12/15 at 7:20 PM Hospital RN K stated Resident #2, at time of arrival to the hospital, was hypotensive with a blood pressure of 80/40. The resident's pulse oximetry reading was in the 70s . The RN further stated Resident #2 was being treated for [REDACTED]. Review of Resident #2's History and Physical dated 11/02/15 and written by the local emergency room physician reflected Resident #1 was admitted to the hospital on [DATE] with Acute [MEDICAL CONDITION], blood pressure in the 70s - 90s systolic despite several liters of fluid, acute pneumonia, possibly aspiration, and acute septic shock. In an interview on 11/13/15 at 9:15 AM Resident #2's PCP stated the facility's staff was expected to call him whenever a resident exhibits nausea and vomiting whenever there were no preexisting orders for nausea. In an interview on 11/12/15 The Director of Nursing (DON) stated LVN D had not been trained in facility protocols, including reporting changes of condition prior to working a shift at the facility. LVN D was an agency nurse who had only worked one or two shifts prior to the night of 11/01/15 - 11/02/15. Normal procedures were for the DON or ADON to sit with incoming agency staff prior to their first shift and review policy and procedures as well as various protocols including change of condition. In the case of LVN D, the DON and ADON were not on duty to train LVN D at the time of his first shift at the facility. Those personnel that do receive training sign a form stating they had been trained prior to working a shift at the facility. The DON further stated the facility had implemented a new policy in which other administrative level nurses would be responsible for providing the appropriate training for new agency staff. The DON further stated no new agency staff would be allowed to work in the facility without having received the appropriate training. The DON further stated that she would expect any of her staff to immediately notify a resident's PCP when changes of condition to occur including situations in which a resident was exhibiting signs and symptoms of nausea and vomiting if there were no standing orders for anti-nausea medications. Review of the facility's training records reflected no documentation to prove LVN D had ever received any form of training or orientation prior to working at the facility. All other agency staff had received the training. New protocol put into place on 11/04/2015, prior to survey, included: 1. Terminated LVN D and advised the agency he would not be allowed to work in the facility. 2. Developed procedures regarding ensuring agency staff are trained prior to working with residents with regards to accurately addressing a change of condition and notifying the physician. Review of the facility's Policy and Procedure document titled Agency Staffing Usage dated 11/04/15 reflected The Director of Nursing, Assistant Director of Nursing, or Nurse Practice Educator will utilize the Agency Orientation Checklist for Nurses and the Agency Orientation Checklist for CNA's to orient agency staff prior to providing resident care. The policy copy provided was signed by The facility's DON and ADON. 3. Staff was in-serviced regarding the new policy and procedures. Review of the facility's in-service records dated 11/04/15 reflected an in-service on recognizing and reporting changes of condition. The facility's Administrator provided a facility census listing reflecting 53 residents treated at the facility.

Based on observations, interviews, and record reviews the facility failed to develop and implement written policies and procedures that prohibit neglect for one (1) of five (5) residents reviewed for neglect. (Resident #2). Licensed Vocational Nurse (LVN) D failed to properly address Resident #2's Change of Condition and notify the resident's primary care physician (PCP) when the resident complained of indigestion, heartburn, and nausea and vomited continuously from 11/01/15 at 7:30 PM through the end of his shift on 11/02/15 at 6:00 AM. The resident was subsequently transferred on 11/02/15 at 8:30 AM to a local hospital where he spent 12 nights in the Intensive Care Unit being treated for [REDACTED]. Prior to survey, the facility implemented corrective measures. This was determined to be a past non-compliance at an isolated harm level for Resident #2. This deficient practice affected Resident # 2 and placed an additional 52 residents at risk for delayed emergency care resulting in increased injury or death. Findings included: Review of the facility's Policy and Procedures for Abuse and Neglect dated 10/15/15 reflected Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility's Policy and Procedure document titled Agency Staffing Usage dated 11/04/15 reflected The Director of Nursing, Assistant Director of Nursing, or Nurse Practice Educator will utilize the Agency Orientation Checklist for Nurses and the Agency Orientation Checklist for CNA's to orient agency staff prior to providing resident care. The policy copy provided was signed by The facility's DON and ADON. Review of Resident #2's Face Sheet reflected an [AGE] year old male admitted [DATE] and readmitted [DATE]. Diagnoses' included [MEDICAL CONDITION] Hypertension, Chronic [MEDICAL CONDITIONS], Heart Failure, Shortness of Breath, Type 2 Diabetes, [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION]. Review of Resident #2's 30 day Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The Resident's Functional Status scores reflected the need for extensive assistance with two (2) person physical assistance for bed mobility. The MDS further reflected the resident received oxygen therapy. Review of Resident #2's Care Plan dated 03/10/15 reflected a need of Requires 02 (oxygen) for adequate aeration. Observation of Resident #2 on 11/10/15 at 12:07 PM revealed the resident in the hospital Intensive Care Unit (ICU). The resident was receiving oxygen via nasal cannula and had a nasogastric tube in place. The resident used a suctioning wand to remove secretions from his mouth during the interview. In an interview on 11/10/15 at 12:07 PM Resident #2 stated he had been nauseous and had vomited all night long. Resident #2 further stated he had told LVN D You need to do something to help me with this. Resident # 2 stated LVN D had stated Call your doctor. The resident further stated he passed out later in the morning and woke up in an ambulance on his way to the hospital. In an interview on 11/12/15 at 7:00 PM Resident #2 stated he had vomited 15 or 20 times on the night of 11/01/15. He initially vomited in a cup but due to the volume of the vomitus, had to use a bucket. The resident further stated his blood pressure was only checked once during the evening. The residents pulse oximetry (percentage of oxygen in the blood) was not checked. Resident # 2 stated he did not remember anything after he had choked on his vomit on the morning of 11/02/15. In an interview on 11/10/15 at 8:38 AM the Assistant Director of Nursing (ADON) stated on 11/01/15 she was called to Resident #2's room and observed the resident on the bed on his left side. The resident was cyanotic (bluish discoloration of the skin due to the tissues near the skin surface having low oxygen saturation), and gasping. The resident's pulse was low and vomitus was on the resident. The crash cart was brought into the room and the resident was suctioned. An ambo bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) was used to assist the resident to breathe. The resident was suctioned several times and the finger sweep method was used to clear vomitus from the mouth. Emergency Medical Services (EMS) was called per the resident's Primary Care Physician (PCP). EMS personnel added an oral airway and continued use of the ambo bag as they left the facility with the resident. The ADON further stated changes of condition exhibited by Resident #2 should be reported to the resident s Primary Care Physician. Review of Resident #2's nursing notes dated 11/02/15 and signed by LVN E reflected on 11/02/15 LVN E was called to Resident #2's room. The resident was in his bed in the supine position. The facility's ADON was at the head of the bed preparing to bag the resident for 02 (oxygen). The resident was gasping for air, and diaphoretic (excess perspiration or sweating). The resident's pupils were pinpoint. EMS was called. EMS personnel intubated (the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway) the resident and transported the resident to the local emergency room . Review of the facility's Provider Investigation Report dated 11/04/15 reflected on 11/01/15 at 7:30 PM CNA C notified LVN D that Resident #2 was complaining of nausea and heartburn. The CNA further stated Resident #2 called her to his room several times begging for something for heartburn and indigestion. RN B stated Resident #2 had been vomiting for several hours but LVN D did nothing . RN B further stated on two (2) occasions she told LVN D to call the resident's physician but the LVN still did nothing . The investigation report further reflected Resident #2 was being repositioned in his bed when he became unresponsive. A crash cart was brought into the resident's room to assist with breathing and the resident was sent to the local emergency room (ER). The report described the injury as Aspiration Pneumonia. Post investigation actions included in-services for all staff regarding reaction to changes of condition and neglect. The agency that had provided LVN D was notified that the LVN would no longer be allowed to work at the facility. Review of Resident #2's undated Nurse's Notes reflected Resident #2 was noted to have nausea and was vomiting at the beginning of his 7:00 PM to 7:00 AM shift. The note further reflected the resident attributed the nausea and vomiting to a greasy lunch. LVN D checked the resident's chart and determined there were no standing orders for nausea. The note did not reflect any calls to the resident's PCP. The nurse's note further reflected the resident's last episode of nausea occurred at 11:00 PM and that the resident experienced no further symptoms throughout the rest of the shift. The notes did not reflect that vital signs, including pulse oximetry readings, had been taken for the resident. The note further reflected LVN D documented he had reported Resident #2's nausea and vomiting on the written 24 hour report. Review of the facility's 24 hour report covering 11/01/15 and 11/02/15 reflected no entries written by LVN D regarding Resident #2. The only entry regarding the resident's change of condition was written by LVN E on 11/02/15, no time, reporting the resident becoming unresponsive, respiratory distress = transferred to (hospital) admit ICU (Intensive Care Unit) [DIAGNOSES REDACTED]. In an interview on 11/13/15 at 4:26 PM LVN E stated she took over LVN D's shift on 11/02/15 at 6:00 AM. LVN E further stated LVN D had told her during shift report that Resident #2 had thrown up the previous night but was ok. LVN D did not report multiple episodes of vomiting or indigestion. In an interview on 11/10/15 at 2:30 PM CNA C stated Resident #2 had complained to her that he had been vomiting and experiencing chest pain. The CNA further stated she had notified LVN D who told her he would check on the resident. CNA C further stated he was later asked by LVN D Do you think the doctor would be cool with me calling him at night? The CNA further stated she could not recall ever seeing LVN D enter the resident's room. In an interview on 11/16/15 at 7:30 PM LVN D stated CNA C had informed him that Resident #2 had complained of nausea and was vomiting. The LVN further stated he checked Resident #2's chart to see if the resident had a standing PRN (as needed) order for anti-nausea medications. When he saw there were no such orders the LVN asked RN B what to do and was told to just monitor the resident. LVN stated he had been told by Resident #2 he was ill because of a greasy lunch. The LVN further stated the resident fell asleep at 11:00 PM and there were no further episodes of vomiting the rest of the night. LVN D further stated he had not checked the resident's vital signs or oxygen level that evening. The LVN further stated he did not notify the resident's PCP and RP of a change of condition because the resident had stopped vomiting. In an interview on 11/16/15 at 12:42 PM RN B stated LVN D had informed her of Resident #2's condition sometime between 8:30 PM and 9:00 PM. The RN further stated Resident #2 vomited several times through the night and when LVN D asked her opinion, RN B had told him to Call the doctor. RN B stated she later discovered LVN D did not call the resident's PCP during the shift. In an interview on 11/12/15 at 7:20 PM Hospital RN K stated Resident #2, at time of arrival to the hospital, was hypotensive with a blood pressure of 80/40. The resident's pulse oximetry reading was in the 70s . The RN further stated Resident #2 was being treated for [REDACTED]. Review of Resident #2's History and Physical dated 11/02/15 and written by the local emergency room physician reflected Resident #1 was admitted to the hospital on [DATE] with Acute [MEDICAL CONDITION], blood pressure in the 70s - 90s systolic despite several liters of fluid, acute pneumonia, possibly aspiration, and acute septic shock. In an interview on 11/13/15 at 9:15 AM Resident #2's PCP stated the facility's staff was expected to call him whenever a resident exhibits nausea and vomiting whenever there were no preexisting orders for nausea. In an interview on 11/12/15 The Director of Nursing (DON) stated LVN D had not been trained in facility protocols, including reporting changes of condition prior to working a shift at the facility. LVN D was an agency nurse who had only worked one or two shifts prior to the night of 11/01/15 - 11/02/15. Normal procedures were for the DON or ADON to sit with incoming agency staff prior to their first shift and review policy and procedures as well as various protocols including change of condition. In the case of LVN D, the DON and ADON were not on duty to train LVN D at the time of his first shift at the facility. Those personnel that do receive training sign a form stating they had been trained prior to working a shift at the facility. The DON further stated the facility had implemented a new policy in which other administrative level nurses would be responsible for providing the appropriate training for new agency staff. The DON further stated no new agency staff would be allowed to work in the facility without having received the appropriate training. The DON further stated that she would expect any of her staff to immediately notify a resident's PCP when changes of condition to occur including situations in which a resident was exhibiting signs and symptoms of nausea and vomiting if there were no standing orders for anti-nausea medications. Review of the facility's training records reflected no documentation to prove LVN D had ever received any form of training or orientation prior to working at the facility. All other agency staff had received the training. New protocol put into place on 11/04/2015, prior to survey, included: 1. Terminated LVN D and advised the agency he would not be allowed to work in the facility. 2. Developed procedures regarding ensuring agency staff are trained prior to working with residents with regards to accurately addressing a change of condition and notifying the physician. Review of the facility's Policy and Procedure document titled Agency Staffing Usage dated 11/04/15 reflected The Director of Nursing, Assistant Director of Nursing, or Nurse Practice Educator will utilize the Agency Orientation Checklist for Nurses and the Agency Orientation Checklist for CNA's to orient agency staff prior to providing resident care. The policy copy provided was signed by The facility's DON and ADON. 3. Staff was in-serviced regarding the new policy and procedures. Review of the facility's in-service records dated 11/04/15 reflected an in-service on recognizing and reporting changes of condition. The facility's Administrator provided a facility census listing reflecting 53 residents treated at the facility.

Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of five (5) residents reviewed for quality of care. (Resident #2). Licensed Vocational Nurse (LVN) D failed to properly address Resident #2's Change of Condition and notify the resident's primary care physician (PCP) when the resident complained of indigestion, heartburn, and nausea and vomited continuously from 11/01/15 at 7:30 PM through the end of his shift on 11/02/15 at 6:00 AM. The resident was subsequently transferred on 11/02/15 at 8:30 AM to a local hospital where he spent 12 nights in the Intensive Care Unit being treated for [REDACTED]. Prior to survey, the facility implemented corrective measures. This was determined to be a past non-compliance at an isolated harm level for Resident #2. This deficient practice affected Resident # 2 and placed an additional 52 residents at risk for delayed emergency care resulting in increased injury or death. Findings included: Review of Resident #2's Face Sheet reflected an [AGE] year old male admitted [DATE] and readmitted [DATE]. Diagnoses' included [MEDICAL CONDITION] Hypertension, Chronic [MEDICAL CONDITIONS], Heart Failure, Shortness of Breath, Type 2 Diabetes, [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION]. Review of Resident #2's 30 day Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The Resident's Functional Status scores reflected the need for extensive assistance with two (2) person physical assistance for bed mobility. The MDS further reflected the resident received oxygen therapy. Review of Resident #2's Care Plan dated 03/10/15 reflected a need of Requires 02 (oxygen) for adequate aeration. Observation of Resident #2 on 11/10/15 at 12:07 PM revealed the resident in the hospital Intensive Care Unit (ICU). The resident was receiving oxygen via nasal cannula and had a nasogastric tube in place. The resident used a suctioning wand to remove secretions from his mouth during the interview. In an interview on 11/10/15 at 12:07 PM Resident #2 stated he had been nauseous and had vomited all night long. Resident #2 further stated he had told LVN D You need to do something to help me with this. Resident # 2 stated LVN D had stated Call your doctor. The resident further stated he passed out later in the morning and woke up in an ambulance on his way to the hospital. In an interview on 11/12/15 at 7:00 PM Resident #2 stated he had vomited 15 or 20 times on the night of 11/01/15. He initially vomited in a cup but due to the volume of the vomitus, had to use a bucket. The resident further stated his blood pressure was only checked once during the evening. The residents pulse oximetry (percentage of oxygen in the blood) was not checked. Resident # 2 stated he did not remember anything after he had choked on his vomit on the morning of 11/02/15. In an interview on 11/10/15 at 8:38 AM the Assistant Director of Nursing (ADON) stated on 11/01/15 she was called to Resident #2's room and observed the resident on the bed on his left side. The resident was cyanotic (bluish discoloration of the skin due to the tissues near the skin surface having low oxygen saturation), and gasping. The resident's pulse was low and vomitus was on the resident. The crash cart was brought into the room and the resident was suctioned. An ambo bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) was used to assist the resident to breathe. The resident was suctioned several times and the finger sweep method was used to clear vomitus from the mouth. Emergency Medical Services (EMS) was called per the resident's Primary Care Physician (PCP). EMS personnel added an oral airway and continued use of the ambo bag as they left the facility with the resident. The ADON further stated changes of condition exhibited by Resident #2 should be reported to the resident s Primary Care Physician. Review of Resident #2's nursing notes dated 11/02/15 and signed by LVN E reflected on 11/02/15 LVN E was called to Resident #2's room. The resident was in his bed in the supine position. The facility's ADON was at the head of the bed preparing to bag the resident for 02 (oxygen). The resident was gasping for air, and diaphoretic (excess perspiration or sweating). The resident's pupils were pinpoint. EMS was called. EMS personnel intubated (the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway) the resident and transported the resident to the local emergency room . Review of the facility's Provider Investigation Report dated 11/04/15 reflected on 11/01/15 at 7:30 PM CNA C notified LVN D that Resident #2 was complaining of nausea and heartburn. The CNA further stated Resident #2 called her to his room several times begging for something for heartburn and indigestion. RN B stated Resident #2 had been vomiting for several hours but LVN D did nothing . RN B further stated on two (2) occasions she told LVN D to call the resident's physician but the LVN still did nothing . The investigation report further reflected Resident #2 was being repositioned in his bed when he became unresponsive. A crash cart was brought into the resident's room to assist with breathing and the resident was sent to the local emergency room (ER). The report described the injury as Aspiration Pneumonia. Post investigation actions included in-services for all staff regarding reaction to changes of condition and neglect. The agency that had provided LVN D was notified that the LVN would no longer be allowed to work at the facility. Review of Resident #2's undated Nurse's Notes reflected Resident #2 was noted to have nausea and was vomiting at the beginning of his 7:00 PM to 7:00 AM shift. The note further reflected the resident attributed the nausea and vomiting to a greasy lunch. LVN D checked the resident's chart and determined there were no standing orders for nausea. The note did not reflect any calls to the resident's PCP. The nurse's note further reflected the resident's last episode of nausea occurred at 11:00 PM and that the resident experienced no further symptoms throughout the rest of the shift. The notes did not reflect that vital signs, including pulse oximetry readings, had been taken for the resident. The note further reflected LVN D documented he had reported Resident #2's nausea and vomiting on the written 24 hour report. Review of the facility's 24 hour report covering 11/01/15 and 11/02/15 reflected no entries written by LVN D regarding Resident #2. The only entry regarding the resident's change of condition was written by LVN E on 11/02/15, no time, reporting the resident becoming unresponsive, respiratory distress = transferred to (hospital) admit ICU (Intensive Care Unit) [DIAGNOSES REDACTED]. In an interview on 11/13/15 at 4:26 PM LVN E stated she took over LVN D's shift on 11/02/15 at 6:00 AM. LVN E further stated LVN D had told her during shift report that Resident #2 had thrown up the previous night but was ok. LVN D did not report multiple episodes of vomiting or indigestion. In an interview on 11/10/15 at 2:30 PM CNA C stated Resident #2 had complained to her that he had been vomiting and experiencing chest pain. The CNA further stated she had notified LVN D who told her he would check on the resident. CNA C further stated he was later asked by LVN D Do you think the doctor would be cool with me calling him at night? The CNA further stated she could not recall ever seeing LVN D enter the resident's room. In an interview on 11/16/15 at 7:30 PM LVN D stated CNA C had informed him that Resident #2 had complained of nausea and was vomiting. The LVN further stated he checked Resident #2's chart to see if the resident had a standing PRN (as needed) order for anti-nausea medications. When he saw there were no such orders the LVN asked RN B what to do and was told to just monitor the resident. LVN stated he had been told by Resident #2 he was ill because of a greasy lunch. The LVN further stated the resident fell asleep at 11:00 PM and there were no further episodes of vomiting the rest of the night. LVN D further stated he had not checked the resident's vital signs or oxygen level that evening. The LVN further stated he did not notify the resident's PCP and RP of a change of condition because the resident had stopped vomiting. In an interview on 11/16/15 at 12:42 PM RN B stated LVN D had informed her of Resident #2's condition sometime between 8:30 PM and 9:00 PM. The RN further stated Resident #2 vomited several times through the night and when LVN D asked her opinion, RN B had told him to Call the doctor. RN B stated she later discovered LVN D did not call the resident's PCP during the shift. In an interview on 11/12/15 at 7:20 PM Hospital RN K stated Resident #2, at time of arrival to the hospital, was hypotensive with a blood pressure of 80/40. The resident's pulse oximetry reading was in the 70s . The RN further stated Resident #2 was being treated for [REDACTED]. Review of Resident #2's History and Physical dated 11/02/15 and written by the local emergency room physician reflected Resident #1 was admitted to the hospital on [DATE] with Acute [MEDICAL CONDITION], blood pressure in the 70s - 90s systolic despite several liters of fluid, acute pneumonia, possibly aspiration, and acute septic shock. In an interview on 11/13/15 at 9:15 AM Resident #2's PCP stated the facility's staff was expected to call him whenever a resident exhibits nausea and vomiting whenever there were no preexisting orders for nausea. In an interview on 11/12/15 The Director of Nursing (DON) stated LVN D had not been trained in facility protocols, including reporting changes of condition prior to working a shift at the facility. LVN D was an agency nurse who had only worked one or two shifts prior to the night of 11/01/15 - 11/02/15. Normal procedures were for the DON or ADON to sit with incoming agency staff prior to their first shift and review policy and procedures as well as various protocols including change of condition. In the case of LVN D, the DON and ADON were not on duty to train LVN D at the time of his first shift at the facility. Those personnel that do receive training sign a form stating they had been trained prior to working a shift at the facility. The DON further stated the facility had implemented a new policy in which other administrative level nurses would be responsible for providing the appropriate training for new agency staff. The DON further stated no new agency staff would be allowed to work in the facility without having received the appropriate training. The DON further stated that she would expect any of her staff to immediately notify a resident's PCP when changes of condition to occur including situations in which a resident was exhibiting signs and symptoms of nausea and vomiting if there were no standing orders for anti-nausea medications. Review of the facility's training records reflected no documentation to prove LVN D had ever received any form of training or orientation prior to working at the facility. All other agency staff had received the training. New protocol put into place on 11/04/2015, prior to survey, included: 1. Terminated LVN D and advised the agency he would not be allowed to work in the facility. 2. Developed procedures regarding ensuring agency staff are trained prior to working with residents with regards to accurately addressing a change of condition and notifying the physician. Review of the facility's Policy and Procedure document titled Agency Staffing Usage dated 11/04/15 reflected The Director of Nursing, Assistant Director of Nursing, or Nurse Practice Educator will utilize the Agency Orientation Checklist for Nurses and the Agency Orientation Checklist for CNA's to orient agency staff prior to providing resident care. The policy copy provided was signed by The facility's DON and ADON. 3. Staff was in-serviced regarding the new policy and procedures. Review of the facility's in-service records dated 11/04/15 reflected an in-service on recognizing and reporting changes of condition. The facility's Administrator provided a facility census listing reflecting 53 residents treated at the facility.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for one (1) of five (5) residents reviewed for abuse and neglect (Resident#1). The staff failed to follow the instructions of the facility Medical Director when ordered to schedule and facilitate a consult for Resident #1 with an orthopedic surgeon after the resident fell and sustained a fractured clavicle that occurred on 11/24/13 and was identified by x-ray on 11/27/13. The appointment was not scheduled until 12/12/13, which was 18 days after the injury. This deficient practice placed Resident #1 at risk for for pain, decline in Activities of Daily Living skills, infection, and not receiving physician ordered treatment. Findings include: Review of Resident #1's Face Sheet reflected a [AGE] year old male who entered the facility on 10/31/2011. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] reflected no Brief Interview for Mental Status (BIMS) score provided. Severely impaired cognitive skills were noted. One man to extensive assistance for transfers noted. BIMS score of three (severely impaired cognition) recorded on 9/1/13. Review of Resident #1's Care Plan dated 9/26/13 reflected the resident to be on anticoagulant therapy (ASA 81) with care approaches including hourly and PRN (as needed) monitoring and assistance with ADLs. During an interview on 12/12/13 at 8:30 AM the Assistant Director of Nursing (ADON) stated the facility Administrator and Director of Nursing (DON) were out of town. She stated Resident #1 had been sent to a local hospital after sustaining an unobserved fall on 11/24/13. When the resident had been sent to the hospital a request was sent with outgoing paperwork stating a [MEDICAL CONDITION] was suspected. The resident was returned later the same day having only been treated for [REDACTED]. On 11/27/13, the resident appeared to be in pain and the charge nurse requested and received orders for a portable xray to the shoulder. The x-ray results showed a fracture to the clavicle and the Medical Director ordered a consult with an orthopaedic surgeon. Narco was also ordered. Additionally, the resident was moved from the facility's secured unit to an unsecured wing due to the opinion of the staff that the resident was no longer ambulatory and was thus inappropriate for the secure unit. Record review of Resident #1's xray report dated 11/27/13 reflected the following findings: "images of the left shoulder are provided. [MEDICAL CONDITION] clavicle demonstrated with overriding of the fragments." Record review of Resident #1's physician order [REDACTED].T/O Medical Director. An observation of Resident #1 on 12/12/13 at 9:10 AM revealed him to be sleeping in his bed. The bed was set at the lowest possible setting with a mattress lying on the floor adjacent to the bed. The resident was holding his left elbow with his right hand in an attempt to relieve weight bearing pressure on the left arm. During the observation the resident yelled out something the surveyor could not understand but kept his eyes closed. During an interview on 12/12/13 at 10:42 AM the ADON revealed the orthopedic consult was originally attempted on 12/2/13 by the facility transportation worker (driver) but that the surgeon would not schedule an appointment until he had a copy of the x-ray disk to review prior to seeing the resident. The ADON admitted that there was no documentation of this attempt to schedule an appointment. She stated that she contacted the driver and determined that the driver had actually received the disk on 12/4/13, but did not follow up with the orthopedic surgeon to schedule the appointment. The disk was being driven to the surgeon's office at this time. The surgeon had advised, by phone, that he would review the disk as soon as possible. During an interview on 12/12/13 at 9:06 AM Certified Nurse Aide (CNA) A stated Resident #1 had "recently" been moved to an unsecured wing of the facility. He stated the resident "acts out and swats at people." During an interview on 12/12/13 at 12:10 PM LVN A stated Resident #1 had transferred off the secure unit and to her wing "one to two days ago" but was not informed of his injured left shoulder until nine 9:00 AM this day (12/12/13). She stated the ADON approached her to inform her that a Surveyor was in the building and that she needed to know that resident Resident #1 had sustained a fracture after a fall from the 24th of November. She was also told that the resident was supposed to wear an arm sling for the left arm whenever he was up. Additionally, she was told that the resident required a bed alarm. LVN A also stated she had noted Resident #1 to be a fall risk when she first worked with him two days earlier. She had requested a Geri-Chair as the resident tended to slide from his wheelchair. The request was denied as it was felt it would be considered an illegal restraint. LVN A stated she monitored the resident for facial grimacing as a sign of pain. Record review of Resident #1's Medication Administration (MAR) reflected daily administration of PRN pain medications from 11/24/13 (the date of injury) to 11/30 13 and again on 12/7/13. Medications administered included: [MEDICATION NAME] 5-325 and Narco 5-325. During an interview on 12/12/13 at 12:30 LVN B stated she had observed the resident to be "total care." He was declining, not ambulatory and had a history of [REDACTED]. During an interview on 12/12/13 at 12:35 AM CNA B stated she was aware of Resident #1's fall that had occurred 11/24/13. She was aware that the resident had been sent to the hospital and returned without having had an x-ray. At the time of the fall and prior to the resident leaving for the hospital by ambulance she had felt Resident #1 shoulder and stated she felt a protrusion. She stated she notified the charge nurse who, in turn, noted the protrusion in the paperwork to go with the ambulance. She also stated she knew the resident was supposed to wear a sling on the left arm but that he was frequently non-compliant and would take the sling off. Observation of Resident #1 on 12/12/13 at 1:10 PM with CNA A in attendance revealed a bruise to the resident's left shoulder. The bruise was light purple in color and approximately the size of two baseballs. The resident was in bed and his sling was observed to be lying on his bedside table. During an interview on 12/12/13 at 1:47 PM the ADON stated the orthopedic surgeon had called and that an appointment was scheduled for Resident #1 for 12/17/13. During an interview on 12/12/13 at 1:58 PM LVN A stated she was not aware of the resident's left shoulder bruise. She later looked at the bruise and stated she felt the bruise was approximately seven to ten days old and probably was secondary to the fall dated 11/24/13. During an interview with 12/12/13 at 5:20 PM the Administrator stated that following her notification of the fall she had conducted an investigation which involved interviewing staff on scene at the time of the fall, and reviewing Resident #1's medical record. She noted the fall was not witnessed. She stated she saw the orthopedic consult order in the medical record when she reviewed the chart on 11/28/13. She did not follow up on the order to ensure it had been completed. She stated she knew that the consult was held pending receipt of the x-ray disk. She knew it had been delivered to the facility on [DATE] but was not aware until this date that it had not been delivered to the orthopedic surgeon for review. During an interview, by telephone, on 12/12/13 at 6:07 PM the Medical Director stated he felt it would be inappropriate to transfer Resident #1 to the hospital at this time as it was late and an orthopedist would not be available until the next day. The Medical Director stated he would review the x-ray results in the morning and make a determination at the time regarding the best course of action to take. During an interview on 12/13/13 at 11:38 AM the Occupational Therapist stated he had assessed Resident #1 the previous evening and he had recommended working on improving the resident's sitting balance and increasing his range of motion and also increasing his functional Activities of Daily Living (ADL). During an interview on 12/13/13 at 11:42 AM the Physical Therapist stated he had assessed Resident #1 to be resistive to treatment and assessment. He had recommended a Drop Axle Wheelchair configuration which was approved and the wheelchair was reconfigured to lower the center of gravity in the back portion of the chair in order to reduce sliding. During an interview on 12/13/13 at 1:16 PM the Medical Director stated he had reviewed the x-ray and decided against surgical intervention. He stated he felt that after consulting with other physicians and considering the age and current debilitation of the Resident #1 ' s surgery would not be appropriate. Review of Physician orders [REDACTED].#1 were canceled. Additionally, the arm sling was discontinued and pain meds ordered to remain as previously ordered. During an interview on 12/13/13 at 1:23 PM the Administrator stated Resident #1 was transferred off of the secured unit because he was no longer ambulatory which was a requirement of the facility when determining appropriateness of placement. She also stated that communication of resident status and needs was communicated verbally at times of transfer within the facility as well as at shift changes. She stated there were no specific documentation protocols in place. Review of the facility ' s Abuse Prevention Manual dated 07/01/2005 reflected " It is the policy of this Center to maintain the resident ' s right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. " The facility reported 8 residents at risk for falls.

Based on observation, interview and record review the facility failed to implement their written policies and procedures that prohibit neglect for one (1) of five (5) residents reviewed for abuse and neglect (Resident#1). The staff failed to follow the instructions of the facility Medical Director when ordered to schedule and facilitate a consult for Resident #1 with an orthopedic surgeon after the resident sustained [REDACTED]. The appointment was not scheduled until 12/12/13, which was 18 days after the injury. This deficient practice placed Resident #1 at risk for for pain, decline in Activities of Daily Living skills, infection, and not receiving physician ordered treatment. Findings include: Review of the facility ' s Abuse Prevention Manual dated 07/01/2005 reflected " It is the policy of this Center to maintain the resident ' s right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. " Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for one (1) of five (5) residents reviewed for abuse and neglect (Resident#1). The staff failed to follow the instructions of the facility Medical Director when ordered to schedule and facilitate a consult for Resident #1 with an orthopedic surgeon after the resident fell and sustained a fractured clavicle that occurred on 11/24/13 and was identified by x-ray on 11/27/13. The appointment was not scheduled until 12/12/13, which was 18 days after the injury. This deficient practice could place 8 residents of the facility at risk for pain, decline in Activities of Daily Living skills, infection, and not receiving physician ordered treatment. Findings include: Review of Resident #1's Face Sheet reflected a [AGE] year old male who entered the facility on 10/31/2011. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] reflected no Brief Interview for Mental Status (BIMS) score provided. Severely impaired cognitive skills were noted. One man to extensive assistance for transfers noted. BIMS score of three (severely impaired cognition) recorded on 9/1/13. Review of Resident #1's Care Plan dated 9/26/13 reflected the resident to be on anticoagulant therapy (ASA 81) with care approaches including hourly and PRN (as needed) monitoring and assistance with ADLs. During an interview on 12/12/13 at 8:30 AM the Assistant Director of Nursing (ADON) stated the facility Administrator and Director of Nursing (DON) were out of town. She stated Resident #1 had been sent to a local hospital after sustaining an unobserved fall on 11/24/13. When the resident had been sent to the hospital a request was sent with outgoing paperwork stating a [MEDICAL CONDITION] was suspected. The resident was returned later the same day having only been treated for [REDACTED]. On 11/27/13, the resident appeared to be in pain and the charge nurse requested and received orders for a portable xray to the shoulder. The x-ray results showed a fracture to the clavicle and the Medical Director ordered a consult with an orthopaedic surgeon. Narco was also ordered. Additionally, the resident was moved from the facility's secured unit to an unsecured wing due to the opinion of the staff that the resident was no longer ambulatory and was thus inappropriate for the secure unit. Record review of Resident #1's xray report dated 11/27/13 reflected the following findings: "images of the left shoulder are provided. [MEDICAL CONDITION] clavicle demonstrated with overriding of the fragments." Record review of Resident #1's physician order [REDACTED].T/O Medical Director. An observation of Resident #1 on 12/12/13 at 9:10 AM revealed him to be sleeping in his bed. The bed was set at the lowest possible setting with a mattress lying on the floor adjacent to the bed. The resident was holding his left elbow with his right hand in an attempt to relieve weight bearing pressure on the left arm. During the observation the resident yelled out something the surveyor could not understand but kept his eyes closed. During an interview on 12/12/13 at 10:42 AM the ADON revealed the orthopedic consult was originally attempted on 12/2/13 by the facility transportation worker (driver) but that the surgeon would not schedule an appointment until he had a copy of the x-ray disk to review prior to seeing the resident. The ADON admitted that there was no documentation of this attempt to schedule an appointment. She stated that she contacted the driver and determined that the driver had actually received the disk on 12/4/13, but did not follow up with the orthopedic surgeon to schedule the appointment. The disk was being driven to the surgeon's office at this time. The surgeon had advised, by phone, that he would review the disk as soon as possible. During an interview on 12/12/13 at 9:06 AM Certified Nurse Aide (CNA) A stated Resident #1 had "recently" been moved to an unsecured wing of the facility. He stated the resident "acts out and swats at people." During an interview on 12/12/13 at 12:10 PM LVN A stated Resident #1 had transferred off the secure unit and to her wing "one to two days ago" but was not informed of his injured left shoulder until nine 9:00 AM this day (12/12/13). She stated the ADON approached her to inform her that a Surveyor was in the building and that she needed to know that resident Resident #1 had sustained a fracture after a fall from the 24th of November. She was also told that the resident was supposed to wear an arm sling for the left arm whenever he was up. Additionally, she was told that the resident required a bed alarm. LVN A also stated she had noted Resident #1 to be a fall risk when she first worked with him two days earlier. She had requested a Geri-Chair as the resident tended to slide from his wheelchair. The request was denied as it was felt it would be considered an illegal restraint. LVN A stated she monitored the resident for facial grimacing as a sign of pain. Record review of Resident #1's Medication Administration (MAR) reflected daily administration of PRN pain medications from 11/24/13 (the date of injury) to 11/30 13 and again on 12/7/13. Medications administered included: [MEDICATION NAME] 5-325 and Narco 5-325. During an interview on 12/12/13 at 12:30 LVN B stated she had observed the resident to be "total care." He was declining, not ambulatory and had a history of [REDACTED]. During an interview on 12/12/13 at 12:35 AM CNA B stated she was aware of Resident #1's fall that had occurred 11/24/13. She was aware that the resident had been sent to the hospital and returned without having had an x-ray. At the time of the fall and prior to the resident leaving for the hospital by ambulance she had felt Resident #1 shoulder and stated she felt a protrusion. She stated she notified the charge nurse who, in turn, noted the protrusion in the paperwork to go with the ambulance. She also stated she knew the resident was supposed to wear a sling on the left arm but that he was frequently non-compliant and would take the sling off. Observation of Resident #1 on 12/12/13 at 1:10 PM with CNA A in attendance revealed a bruise to the resident's left shoulder. The bruise was light purple in color and approximately the size of two baseballs. The resident was in bed and his sling was observed to be lying on his bedside table. During an interview on 12/12/13 at 1:47 PM the ADON stated the orthopedic surgeon had called and that an appointment was scheduled for Resident #1 for 12/17/13. During an interview on 12/12/13 at 1:58 PM LVN A stated she was not aware of the resident's left shoulder bruise. She later looked at the bruise and stated she felt the bruise was approximately seven to ten days old and probably was secondary to the fall dated 11/24/13. During an interview with 12/12/13 at 5:20 PM the Administrator stated that following her notification of the fall she had conducted an investigation which involved interviewing staff on scene at the time of the fall, and reviewing Resident #1's medical record. She noted the fall was not witnessed. She stated she saw the orthopedic consult order in the medical record when she reviewed the chart on 11/28/13. She did not follow up on the order to ensure it had been completed. She stated she knew that the consult was held pending receipt of the x-ray disk. She knew it had been delivered to the facility on [DATE] but was not aware until this date that it had not been delivered to the orthopedic surgeon for review. During an interview, by telephone, on 12/12/13 at 6:07 PM the Medical Director stated he felt it would be inappropriate to transfer Resident #1 to the hospital at this time as it was late and an orthopedist would not be available until the next day. The Medical Director stated he would review the x-ray results in the morning and make a determination at the time regarding the best course of action to take. During an interview on 12/13/13 at 11:38 AM the Occupational Therapist stated he had assessed Resident #1 the previous evening and he had recommended working on improving the resident's sitting balance and increasing his range of motion and also increasing his functional Activities of Daily Living (ADL). During an interview on 12/13/13 at 11:42 AM the Physical Therapist stated he had assessed Resident #1 to be resistive to treatment and assessment. He had recommended a Drop Axle Wheelchair configuration which was approved and the wheelchair was reconfigured to lower the center of gravity in the back portion of the chair in order to reduce sliding. During an interview on 12/13/13 at 1:16 PM the Medical Director stated he had reviewed the x-ray and decided against surgical intervention. He stated he felt that after consulting with other physicians and considering the age and current debilitation of the Resident #1 ' s surgery would not be appropriate. Review of Physician orders [REDACTED].#1 were canceled. Additionally, the arm sling was discontinued and pain meds ordered to remain as previously ordered. During an interview on 12/13/13 at 1:23 PM the Administrator stated Resident #1 was transferred off of the secured unit because he was no longer ambulatory which was a requirement of the facility when determining appropriateness of placement. She also stated that communication of resident status and needs was communicated verbally at times of transfer within the facility as well as at shift changes. She stated there were no specific documentation protocols in place. The facility reported 8 residents at risk for falls.

Based on observation, interview and record review the facility failed to provide care and services to attain or maintain the highest practicable physical and mental well-being for one (1) of five (5) residents reviewed for abuse and neglect (Resident#1). The staff failed to follow the instructions of the facility Medical Director when ordered to schedule and facilitate a consult for Resident #1 with an orthopedic surgeon after the resident fell and sustained a fractured clavicle that occurred on 11/24/13 and was identified by x-ray on 11/27/13. The appointment was not scheduled until 12/12/13, which was 18 days after the injury. This deficient practice placed Resident #1 at risk for for pain, decline in Activities of Daily Living skills, infection, and not receiving physician ordered treatment. Findings include: Review of Resident #1's Face Sheet reflected a [AGE] year old male who entered the facility on 10/31/2011. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] reflected no Brief Interview for Mental Status (BIMS) score provided. Severely impaired cognitive skills were noted. One man to extensive assistance for transfers noted. BIMS score of three (severely impaired cognition) recorded on 9/1/13. Review of Resident #1's Care Plan dated 9/26/13 reflected the resident to be on anticoagulant therapy (ASA 81) with care approaches including hourly and PRN (as needed) monitoring and assistance with ADLs. During an interview on 12/12/13 at 8:30 AM the Assistant Director of Nursing (ADON) stated the facility Administrator and Director of Nursing (DON) were out of town. She stated Resident #1 had been sent to a local hospital after sustaining an unobserved fall on 11/24/13. When the resident had been sent to the hospital a request was sent with outgoing paperwork stating a [MEDICAL CONDITION] was suspected. The resident was returned later the same day having only been treated for [REDACTED]. On 11/27/13, the resident appeared to be in pain and the charge nurse requested and received orders for a portable xray to the shoulder. The x-ray results showed a fracture to the clavicle and the Medical Director ordered a consult with an orthopaedic surgeon. Narco was also ordered. Additionally, the resident was moved from the facility's secured unit to an unsecured wing due to the opinion of the staff that the resident was no longer ambulatory and was thus inappropriate for the secure unit. Record review of Resident #1's xray report dated 11/27/13 reflected the following findings: "images of the left shoulder are provided. [MEDICAL CONDITION] clavicle demonstrated with overriding of the fragments." Record review of Resident #1's physician order [REDACTED].T/O Medical Director. An observation of Resident #1 on 12/12/13 at 9:10 AM revealed him to be sleeping in his bed. The bed was set at the lowest possible setting with a mattress lying on the floor adjacent to the bed. The resident was holding his left elbow with his right hand in an attempt to relieve weight bearing pressure on the left arm. During the observation the resident yelled out something the surveyor could not understand but kept his eyes closed. During an interview on 12/12/13 at 10:42 AM the ADON revealed the orthopedic consult was originally attempted on 12/2/13 by the facility transportation worker (driver) but that the surgeon would not schedule an appointment until he had a copy of the x-ray disk to review prior to seeing the resident. The ADON admitted that there was no documentation of this attempt to schedule an appointment. She stated that she contacted the driver and determined that the driver had actually received the disk on 12/4/13, but did not follow up with the orthopedic surgeon to schedule the appointment. The disk was being driven to the surgeon's office at this time. The surgeon had advised, by phone, that he would review the disk as soon as possible. During an interview on 12/12/13 at 9:06 AM Certified Nurse Aide (CNA) A stated Resident #1 had "recently" been moved to an unsecured wing of the facility. He stated the resident "acts out and swats at people." During an interview on 12/12/13 at 12:10 PM LVN A stated Resident #1 had transferred off the secure unit and to her wing "one to two days ago" but was not informed of his injured left shoulder until nine 9:00 AM this day (12/12/13). She stated the ADON approached her to inform her that a Surveyor was in the building and that she needed to know that resident Resident #1 had sustained a fracture after a fall from the 24th of November. She was also told that the resident was supposed to wear an arm sling for the left arm whenever he was up. Additionally, she was told that the resident required a bed alarm. LVN A also stated she had noted Resident #1 to be a fall risk when she first worked with him two days earlier. She had requested a Geri-Chair as the resident tended to slide from his wheelchair. The request was denied as it was felt it would be considered an illegal restraint. LVN A stated she monitored the resident for facial grimacing as a sign of pain. Record review of Resident #1's Medication Administration (MAR) reflected daily administration of PRN pain medications from 11/24/13 (the date of injury) to 11/30 13 and again on 12/7/13. Medications administered included: [MEDICATION NAME] 5-325 and Narco 5-325. During an interview on 12/12/13 at 12:30 LVN B stated she had observed the resident to be "total care." He was declining, not ambulatory and had a history of [REDACTED]. During an interview on 12/12/13 at 12:35 AM CNA B stated she was aware of Resident #1's fall that had occurred 11/24/13. She was aware that the resident had been sent to the hospital and returned without having had an x-ray. At the time of the fall and prior to the resident leaving for the hospital by ambulance she had felt Resident #1 shoulder and stated she felt a protrusion. She stated she notified the charge nurse who, in turn, noted the protrusion in the paperwork to go with the ambulance. She also stated she knew the resident was supposed to wear a sling on the left arm but that he was frequently non-compliant and would take the sling off. Observation of Resident #1 on 12/12/13 at 1:10 PM with CNA A in attendance revealed a bruise to the resident's left shoulder. The bruise was light purple in color and approximately the size of two baseballs. The resident was in bed and his sling was observed to be lying on his bedside table. During an interview on 12/12/13 at 1:47 PM the ADON stated the orthopedic surgeon had called and that an appointment was scheduled for Resident #1 for 12/17/13. During an interview on 12/12/13 at 1:58 PM LVN A stated she was not aware of the resident's left shoulder bruise. She later looked at the bruise and stated she felt the bruise was approximately seven to ten days old and probably was secondary to the fall dated 11/24/13. During an interview with 12/12/13 at 5:20 PM the Administrator stated that following her notification of the fall she had conducted an investigation which involved interviewing staff on scene at the time of the fall, and reviewing Resident #1's medical record. She noted the fall was not witnessed. She stated she saw the orthopedic consult order in the medical record when she reviewed the chart on 11/28/13. She did not follow up on the order to ensure it had been completed. She stated she knew that the consult was held pending receipt of the x-ray disk. She knew it had been delivered to the facility on [DATE] but was not aware until this date that it had not been delivered to the orthopedic surgeon for review. During an interview, by telephone, on 12/12/13 at 6:07 PM the Medical Director stated he felt it would be inappropriate to transfer Resident #1 to the hospital at this time as it was late and an orthopedist would not be available until the next day. The Medical Director stated he would review the x-ray results in the morning and make a determination at the time regarding the best course of action to take. During an interview on 12/13/13 at 11:38 AM the Occupational Therapist stated he had assessed Resident #1 the previous evening and he had recommended working on improving the resident's sitting balance and increasing his range of motion and also increasing his functional Activities of Daily Living (ADL). During an interview on 12/13/13 at 11:42 AM the Physical Therapist stated he had assessed Resident #1 to be resistive to treatment and assessment. He had recommended a Drop Axle Wheelchair configuration which was approved and the wheelchair was reconfigured to lower the center of gravity in the back portion of the chair in order to reduce sliding. During an interview on 12/13/13 at 1:16 PM the Medical Director stated he had reviewed the x-ray and decided against surgical intervention. He stated he felt that after consulting with other physicians and considering the age and current debilitation of the Resident #1 ' s surgery would not be appropriate. Review of Physician orders [REDACTED].#1 were canceled. Additionally, the arm sling was discontinued and pain meds ordered to remain as previously ordered. During an interview on 12/13/13 at 1:23 PM the Administrator stated Resident #1 was transferred off of the secured unit because he was no longer ambulatory which was a requirement of the facility when determining appropriateness of placement. She also stated that communication of resident status and needs was communicated verbally at times of transfer within the facility as well as at shift changes. She stated there were no specific documentation protocols in place. Review of the facility ' s Abuse Prevention Manual dated 07/01/2005 reflected " It is the policy of this Center to maintain the resident ' s right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. " The facility reported 8 residents at risk for falls.

Based on observation, interview and record review the facility failed to be administered in a maner that enables it to use its resources effectively and efficiently for one (1) or five (5) residents (Resident #1) when: The Administrator and Assistant Director of Nursing (ADON) failed to monitor staff to ensure appropriate medical care, as ordered by the facility Medical Director, was implement. The Administrator and ADON failed to ensure that an ordered surgical consult was scheduled for Resident #1 after he fractured his clavicle on 11/24/2013. The surgical consult was not scheduled until 12/12/13 which was 18 days after the injury. This deficient practice placed Resident #1 at risk for injury and harm due to a delay in a surgical consult. Findings Include: Review of Resident #1's Face Sheet reflected a [AGE] year old male who entered the facility on 10/31/2011. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] reflected no Brief Interview for Mental Status (BIMS) score provided. Severely impaired cognitive skills were noted. One man to extensive assistance for transfers noted. BIMS score of three (severely impaired cognition) recorded on 9/1/13. Review of Resident #1's Care Plan dated 9/26/13 reflected the resident to be on anticoagulant therapy (ASA 81) with care approaches including hourly and PRN (as needed) monitoring and assistance with ADLs. During an interview on 12/12/13 at 8:30 AM the Assistant Director of Nursing (ADON) stated the facility Administrator and Director of Nursing (DON) were out of town. She stated Resident #1 had been sent to a local hospital after sustaining an unobserved fall on 11/24/13. When the resident had been sent to the hospital a request was sent with outgoing paperwork stating a [MEDICAL CONDITION] was suspected. The resident was returned later the same day having only been treated for [REDACTED]. On 11/27/13, the resident appeared to be in pain and the charge nurse requested and received orders for a portable xray to the shoulder. The x-ray results showed a fracture to the clavicle and the Medical Director ordered a consult with an orthopaedic surgeon. Narco was also ordered. Additionally, the resident was moved from the facility's secured unit to an unsecured wing due to the opinion of the staff that the resident was no longer ambulatory and was thus inappropriate for the secure unit. Record review of Resident #1's xray report dated 11/27/13 reflected the following findings: "images of the left shoulder are provided. [MEDICAL CONDITION] clavicle demonstrated with overriding of the fragments." Record review of Resident #1's physician order [REDACTED].T/O Medical Director. An observation of Resident #1 on 12/12/13 at 9:10 AM revealed him to be sleeping in his bed. The bed was set at the lowest possible setting with a mattress lying on the floor adjacent to the bed. The resident was holding his left elbow with his right hand in an attempt to relieve weight bearing pressure on the left arm. During the observation the resident yelled out something the surveyor could not understand but kept his eyes closed. During an interview on 12/12/13 at 10:42 AM the ADON revealed the orthopedic consult was originally attempted on 12/2/13 by the facility transportation worker (driver) but that the surgeon would not schedule an appointment until he had a copy of the x-ray disk to review prior to seeing the resident. The ADON admitted that there was no documentation of this attempt to schedule an appointment. She stated that she contacted the driver and determined that the driver had actually received the disk on 12/4/13, but did not follow up with the orthopedic surgeon to schedule the appointment. The disk was being driven to the surgeon's office at this time. The surgeon had advised, by phone, that he would review the disk as soon as possible. During an interview on 12/12/13 at 9:06 AM Certified Nurse Aide (CNA) A stated Resident #1 had "recently" been moved to an unsecured wing of the facility. He stated the resident "acts out and swats at people." During an interview on 12/12/13 at 12:10 PM LVN A stated Resident #1 had transferred off the secure unit and to her wing "one to two days ago" but was not informed of his injured left shoulder until nine 9:00 AM this day (12/12/13). She stated the ADON approached her to inform her that a Surveyor was in the building and that she needed to know that resident Resident #1 had sustained a fracture after a fall from the 24th of November. She was also told that the resident was supposed to wear an arm sling for the left arm whenever he was up. Additionally, she was told that the resident required a bed alarm. LVN A also stated she had noted Resident #1 to be a fall risk when she first worked with him two days earlier. She had requested a Geri-Chair as the resident tended to slide from his wheelchair. The request was denied as it was felt it would be considered an illegal restraint. LVN A stated she monitored the resident for facial grimacing as a sign of pain. Record review of Resident #1's Medication Administration (MAR) reflected daily administration of PRN pain medications from 11/24/13 (the date of injury) to 11/30 13 and again on 12/7/13. Medications administered included: [MEDICATION NAME] 5-325 and Narco 5-325. During an interview on 12/12/13 at 12:30 LVN B stated she had observed the resident to be "total care." He was declining, not ambulatory and had a history of [REDACTED]. During an interview on 12/12/13 at 12:35 AM CNA B stated she was aware of Resident #1's fall that had occurred 11/24/13. She was aware that the resident had been sent to the hospital and returned without having had an x-ray. At the time of the fall and prior to the resident leaving for the hospital by ambulance she had felt Resident #1 shoulder and stated she felt a protrusion. She stated she notified the charge nurse who, in turn, noted the protrusion in the paperwork to go with the ambulance. She also stated she knew the resident was supposed to wear a sling on the left arm but that he was frequently non-compliant and would take the sling off. Observation of Resident #1 on 12/12/13 at 1:10 PM with CNA A in attendance revealed a bruise to the resident's left shoulder. The bruise was light purple in color and approximately the size of two baseballs. The resident was in bed and his sling was observed to be lying on his bedside table. During an interview on 12/12/13 at 1:47 PM the ADON stated the orthopedic surgeon had called and that an appointment was scheduled for Resident #1 for 12/17/13. During an interview on 12/12/13 at 1:58 PM LVN A stated she was not aware of the resident's left shoulder bruise. She later looked at the bruise and stated she felt the bruise was approximately seven to ten days old and probably was secondary to the fall dated 11/24/13. During an interview with 12/12/13 at 5:20 PM the Administrator stated that following her notification of the fall she had conducted an investigation which involved interviewing staff on scene at the time of the fall, and reviewing Resident #1's medical record. She noted the fall was not witnessed. She stated she saw the orthopedic consult order in the medical record when she reviewed the chart on 11/28/13. She did not follow up on the order to ensure it had been completed. She stated she knew that the consult was held pending receipt of the x-ray disk. She knew it had been delivered to the facility on [DATE] but was not aware until this date that it had not been delivered to the orthopedic surgeon for review. During an interview, by telephone, on 12/12/13 at 6:07 PM the Medical Director stated he felt it would be inappropriate to transfer Resident #1 to the hospital at this time as it was late and an orthopedist would not be available until the next day. The Medical Director stated he would review the x-ray results in the morning and make a determination at the time regarding the best course of action to take. During an interview on 12/13/13 at 11:38 AM the Occupational Therapist stated he had assessed Resident #1 the previous evening and he had recommended working on improving the resident's sitting balance and increasing his range of motion and also increasing his functional Activities of Daily Living (ADL). During an interview on 12/13/13 at 11:42 AM the Physical Therapist stated he had assessed Resident #1 to be resistive to treatment and assessment. He had recommended a Drop Axle Wheelchair configuration which was approved and the wheelchair was reconfigured to lower the center of gravity in the back portion of the chair in order to reduce sliding. During an interview on 12/13/13 at 1:16 PM the Medical Director stated he had reviewed the x-ray and decided against surgical intervention. He stated he felt that after consulting with other physicians and considering the age and current debilitation of the Resident #1 ' s surgery would not be appropriate. Review of Physician orders [REDACTED].#1 were canceled. Additionally, the arm sling was discontinued and pain meds ordered to remain as previously ordered. During an interview on 12/13/13 at 1:23 PM the Administrator stated Resident #1 was transferred off of the secured unit because he was no longer ambulatory which was a requirement of the facility when determining appropriateness of placement. She also stated that communication of resident status and needs was communicated verbally at times of transfer within the facility as well as at shift changes. She stated there were no specific documentation protocols in place. The facility reported 8 residents at risk for falls.

Based on interview and record review the facility failed to provide necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the plan of care for one (1) of 7 residents (Resident #1) reviewed for end of life decision making. The facility failed to have an in house directive that would give staff direction on end of life wishes. Resident #1 stopped breathing and nursing staff failed to perform Cardio-Pulmonary Resuscitation (CPR). Resident #1's death was pronounced by the facility Director of Nurses (DON) on [DATE] at 10:50 PM. It was determined that this deficient practice was Past Non-Compliance at an Immediate Jeopardy Level on [DATE] thru [DATE] due to the facility having implemented actions that corrected the noncompliance prior to the being of this survey. This failure to provide CPR had the potential to affect any of the 22 residents in the facility who were identified as being "Full Code" status in the event of a cardiac or respiratory event. Findings Included: Review of a hospital History and Physical dated [DATE] reflected Resident #1 who was [AGE] year, was admitted to the hospital on [DATE] with a rapid heartbeat and shortness of breath. The hospital added [DIAGNOSES REDACTED]. Review of nurses' notes dated [DATE] reflected Resident #1 was admitted to the facility from a local hospital at 8:15 AM. Nurses' notes dated [DATE] reflected Resident #1 stopped breathing somewhere between 7:00 PM and 7:30 PM while in bed Resident #1's death was pronounced by the Director of Nurses (DON) at 10:50 PM. Review of a consult with a cardiac specialist dated [DATE] indicated Resident #1 had [DIAGNOSES REDACTED] Fibrillation, and Probably Diastolic [MEDICAL CONDITION]. Review of Resident #1's clinical record contained a red sheet of paper titled DNR in the front of the chart and an In-Hospital Do Not Resuscitate Order, filed directly behind the red paper. There was no In-House DNR in the chart. Review of medication orders continued from the hospital, dated [DATE] indicated no adverse drug reactions, the discontinuation of intra-venous (IV) medications and orders for oxygen therapy, breathing treatments and follow up with a heart specialist. During an interview on [DATE] at 10:00 AM, the Director of Nurses, (DON) stated Resident #1 was admitted to the facility the morning of [DATE] from the hospital with multiple [DIAGNOSES REDACTED]. The DON stated Licensed Vocational Nurse (LVN A) called her the evening of [DATE] at approximately 8:10 PM. to tell her Resident #1 had stopped breathing. The DON stated she left for the facility immediately and lives 45 minutes away. The DON stated she understood from the first call Resident #1 had a DNR, however when the DON called LVN A back, she was informed the DNR was from the hospital. The DON stated she was close to the facility and told LVN A to wait until she arrived (approximately 9:00 PM) to talk to the physcian and make a decision about resusitation. The DON stated upon her arrival at the facility, she had staff call Resident #1's physician for instructions and the physician advised them not to start CPR at that point. The DON stated the police did not respond in person and she pronounced Resident # 1's death at 10:50 PM. During the same interview on [DATE] at 10:00 AM, the DON stated the nurses followed many procedures correctly such as insuring comfort, one nurse fetched the crash cart and one checked the clinical record for a DNR order, one nurse called the DON, the administrator and the doctor however the mistake made was not looking carefully to insure DNR was Out of Hospital until too much time had passed. The DON stated her investigation concluded the facility should have done CPR for Resident #1. The DON stated it was the facility policy to provide resuscitation for all residents during a cardiac/ respiratory episode unless the resident had an Out of Hospital DNR and a doctor ' s order on file. Review of an undated written statement provided by LVN C reflected the following: " I admitted (Resident #1) on [DATE] at 10:15 AM. Upon receiving her she had a DNR paper in the front of her chart. So upon completing her medication List and code status I put no CPR because that ' s what her paperwork stated. DNR paper was on a red sheet of paper with DNR written on it " During an interview on [DATE] at 8:45 AM, LVN C stated she was working as a charge nurse during the day shift on [DATE]. LVN C stated Resident #1 was alert and oriented, and in no distress during the 6:00 AM to 2:00 PM shift. LVN C stated a clinical record was set up for Resident #1 that had blank forms for assessment and information from the hospital. She stated she worked on the record and saw the record had the DNR form in front and a "big red paper " in the front. LVN C stated she had training on facility specific policies and procedures for DNR orders when she was hired. LVN C stated during this new hire orientation the policy for DNRs was reviewed and the facility required an Out-of-Hospital DNR if CPR was not to be performed. . LVN C stated she received additional training after the [DATE] incident regarding proper procedures for DNRs and how to set up a chart during the resident ' s first day. During an interview on [DATE] at 11:30 AM, LVN B stated she was the charge nurse for the 2:00 PM to 10:00 PM shift on [DATE]. LVN B stated she received report at shift change; 2:00 PM at which time she was informed Resident #1 was a new resident with cardiac problems, who was on Oxygen and received breathing treatments. LVN B stated family members were present, some coming and going throughout the afternoon and evening. LVN B stated she provided a breathing treatment for [REDACTED]. LVN B stated she checked Resident #1 a few minutes after the breathing treatment and Resident #1 was asleep. During an interview on [DATE] at 9:10 AM, LVN A stated she was on duty on [DATE] as a charge nurse for the 2:00 PM to 10:00 PM shift. LVN A stated after the evening meal, somewhere around 6:30 to 7:00 PM someone came to the nurses' station and told her Resident #1 had no chest movement (the chest rises and lowers with respiration-air moving in and out of the lungs). LVN A went to Resident #1's room and took her blood pressure. Somewhere around that time she heard a male family member that say Resident #1 had a Do Not Resuscitate and did not want CPR. LVN A stated she checked Resident #1's blood pressure but was unable to get a reading, and then she went back to the nurses' station to look at Resident #1's chart. LVN A stated she saw the DNR in Resident #1's chart along with a red piece of paper with DNR printed on it. The red paper was one used by the facility to warn staff not to perform CPR on residents who had a DNR order. LVN A stated she did not at first realize it was an In-hospital DNR but later in the evening as she was dealing with the incident she realized she was looking at an In-Hospital DNR form and that there was no Out of Hospital DNR for Resident #1. LVN A stated she called the DON (could not remember the time) to let her know the resident had stopped breathing and had a DNR order. LVN A stated she remembers the DON's phone cutting out, she stated she was telling the DON the DNR was In-Hospital. LVN A statedshe did not remeber the time but the DON called her back and told her to wait for her arrival. LVN A stated another nurse went to get a Crash Cart (facility emergency equipment) during the incident, however the family was saying not to give CPR. LVN A stated none of the nurses on duty performed CPR that evening on Resident #1. LVN stated she received training on all agency procedures when she was first hired and stated she attended a lot of training after the incident of [DATE]. Review of LVN A's nurse's notes dated [DATE] reflected the following: "Summoned to room [ROOM NUMBER] per family member who states she didn ' t think Resident #1 was breathing. The notes reflected LVN A observed resident lying supine Skin warm with mottling noted to feet. No chest movement (felt or observed). Unable to palpate carotid pulse (pulse taken at the location of the carotid artery at the side of the neck). Pupils fixed and dilated. Head of bed raised at a 45 degree angle, Oxygen at 4 liters intact. LVN B was sent for crash cart. Asked son if resident DNR or full code, son states "she's a DNR". Went to chart to check DNR, red paper and no signed DNR in chart. (Back) to room unable to obtain resident's oxygen saturation levels, unable to obtain blood pressure. Son states her wishes were not to be resuscitated." During an interview with the Administrator and DON on [DATE] at 10:30 AM, the DON stated, she and the Administrator conducted an investigation in to the incident, called in an incident report to DADS and made immediate changes to the procedures. The Administrator stated training was started the day the incident occurred ([DATE]). The DON stated she did not think the red and green sheets in the resident charts were helpful and that nurses needed to verify the presence of an Out of Hospital DNR that was signed and witnessed as well as a corresponding physician's orders [REDACTED]. The DON stated the facility's internal investigation did not determine who placed the In-Hospital DNR and red paper in the front of the chart; however it has always been the facility policy to look carefully at the DNR document before deciding not to do CPR. The DON stated she provided training after the incident for all nurses and also specific training/counseling for the nurses on duty during the incident of [DATE] as well as LVN C who worked on the clinical record earlier in the day. The DON stated the presence of a red sheet of paper indicating a DNR, the family stating the resident did not want to be resuscitated and their unfamiliarity with the resident were factors but not excuses for not reading the DNR carefully. The DON and Administrator stated they feel they have corrected problems that led to the incident. Review of 7 resident records on [DATE] reflected the presence of all required paperwork related to DNR orders. Records reviewed included: Residents # 1, 2 and 3 (full code) Full Code resident records included quarterly Social Work notes indicating the resident/family wishes to provide CPR. Also reviewed were Residents #4, 5, 6 and 7; residents who did not want to be resuscitated. All 7 residents had signed Out of Hospital (OOH) DNRs and physician orders. All used state approved forms and all were filed at the front of the record. Review of the policy titled Out of Hospital DNR (OOH-DNR), dated [DATE], revised [DATE] reflected a requirement for an Out of Hospital DNR to be completed the first day of admission if that is the wish of the resident or guardian. It was determined that the facility's failure to provide CPR for Resident #1 resulted in an Immediate Jeopardy from [DATE] thru [DATE]. The immediacy was corrected on [DATE]. The facility took the following actions to correct the noncompliance on [DATE]: Review of training records following the incident of [DATE] included the following: Date Training Conducted: [DATE]; Topic: DNR Facility Procedures. Instructor: Staff Training Coordinator. Attendance: Facility Nurses Training Included: Out of Hospital Do Not Resuscitate Orders, Facility Policies and Procedures, Updated requirement from DADS to insure instructions are printed on the back of the DNR form when used by family dated (04./,[DATE]), Copy of the Out-Of-Hospital DNR form, Nursing Manual procedures for DNRs including admission policies (dated ,[DATE]). Date: [DATE]; Topic: Removal of green and red status code sheets. Instructor :staff Training Coordinator; Content: Location of DNR forms, resident charts and discontinued use of red and green sheets to indicate code status. Attendance: All facility nurses Date: [DATE]; Topic: Policies and Procedures for the admission of a resident including nurse duties to determine advance directives the first day of admission. Instructors: DON and Administrator. Content: Nursing operations manual for admission of a resident (,[DATE]). Attendance: all facility nurses Date: [DATE]; Topic: LVN Scope of Practice. Instructor: DON. Content: Scope of practice information from the Board of Nursing (Reviewed ,[DATE]) as related to LVNs and pronouncement of death, presumptive and conclusive signs of death) Attendance: Facility LVNs and RNs. During an interview on [DATE] at 2:45 PM, the Staff Training Training Coordinator stated the training related to the incident was completed on [DATE]. Implementation and effectiveness of training was verified through random interviews conducted on [DATE] between 8:25 and 3:00 PM with four LVNs at the facility. All nurses interviewed correctly described the facility policy and procedures for CPR, DNRs and admission documents. On [DATE] at 12:50 PM, the facility Administrator was notified a Past Non-Compliance at an Immediate Jeopardy Level on [DATE] thru [DATE]. According to the Administrator, 22 residents in the facility were "Full Code" status.

Based on observation, interview, and record review the facility failed to ensure that the residents ' environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents reviewed for accidents during transport. (Resident #1) Resident #1's wheelchair had not been adequately secured while riding in the facility van. Resident #1's wheelchair tipped over, resulting in Resident #1 falling out of the wheelchair and onto the floor of the van. Resident #1 received numerous contusions and a distal shaft right clavicle fracture (collar bone). This deficient practice contributed to Resident #1 falling and sustaining injuries that included contusions and a fracture with pain requiring pain medication and additional therapy. Findings include: Review of Resident #1's Face Sheet 01/23/2012 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 05/17/12 at 1:45PM, Resident #1 was observed seated in her wheelchair. She stated that she was riding on the van in this wheelchair on 04/27/12, coming back from the park. She said that she was buckled in, but couldn ' t really see the straps because she is blind. Resident #1 said that when they were turning a corner, her wheelchair began turning over and she went over with it. She said that the Driver was driving carefully, and this was "just a freak accident. " She stated that she landed on her right arm, near the door, and remembers her shoulder being in a lot of pain. Resident #1 said that the Van Driver stopped the van and came back to help her. The Assistant Activity Director let Resident #1 lay her head on her shoulder until 911 got there, and 911 put the resident on a backboard with a neck collar and took her to the hospital. The doctor at the hospital said that her arm wasn ' t broken, but it kept hurting when she got back to the facility, so the nurse called the doctor on-call and he ordered a new x-ray. The resident said that they came to the facility with a mobile x-ray and it showed that her arm was broken. Resident #1 stated that she is still having problems with pain, and receives therapy for her arm. She stated that this physical therapy causes pain that is unbearable, so she must ask the therapist to quit during the therapy. Resident #1 stated that she has ridden the van with two other drivers and her wheelchair hasn ' t ever tipped over. She stated that they take the van on outings at least once or twice a month, but are using a van from a sister facility right now because the old van was put out of service after her accident. Resident #1 stated that she used to transfer to a seat and use a seatbelt, but has trouble transferring now, so they just buckle in her wheelchair. She said that she has always been buckled in by the drivers. Review of Resident #1's Physician order [REDACTED]. Resident was ordered to " continue current pain meds Vicodin a narcotic pain medication & Naprosyn (NSADI pain medication) as needed for pain." Review of Resident #1 ' s Nursing communication form dated 05/02/12 revealed that Resident #1 was ordered to be scheduled for an orthopedic appointment due to a right fracture of the clavicle. In an interview on 5/17/12 at 2:30 PM, the Van Driver stated she has been a driver for this facility for approximately one month. She stated that she has received training on transporting Residents in the van. She stated that on 04/27/2012, she was transporting residents from the park back to the facility after an outing, and made two trips that day, and transported a total of three residents in wheelchairs, including Resident #1. The Van Driver was unable to remember the names of the residents on the bus with Resident #1 that day, but stated that none of the other wheelchairs tipped that day. She said that she secured Resident #1 ' s wheelchair on the van by locking the wheels and then placing four tie down straps around the frame and demonstrated how she did this. She stated that she always shakes the wheelchair a bit to make sure the straps are tight enough and remembers doing this that day. The Van Driver stated she placed a lap belt across Resident #1 ' s lap, but the shoulder strap would not fit, so she didn ' t use it. The Van Driver stated she stopped at a red light, took a left hand turn and Resident #1's wheelchair tipped half way over, causing her to fall out onto the floor, next to the lift door. The Van Driver stated she was looking in the rear-view mirror as she was turning and saw Resident #1 going over, so she pulled over and stopped the van. The Assistant Activity Director and the Van Driver rushed to assist Resident #1. The Van Driver stated that Resident #1 was crying and saying " oh, oh, my shoulder " and was in obvious pain, so they didn ' t move her, but did move the wheelchair out from under her and drove back to the facility and called 911. She said that 911 got there really quickly, maybe within 10-15 minutes and transported the resident to the hospital. The Van Driver stated she was given a safety course since the incident. During an interview on 05/17/12 at 4:25 PM the Van Driver admitted that she did not place a shoulder restraint across Resident #1 in the van according to policy because it would not fit around the resident. Observation on 5/17/12 at 2:30 PM and again at 4:10 PM, revealed the inside of the facility van was equipped with devices to securely strap in 2 wheelchairs, including seatbelts and shoulder harnesses. The seats of the van were equipped with lap seatbelts but no shoulder harnesses. In an observation/interview on 05/17/12 at 4:10 PM, the Administrator and the Environmental Services Director demonstrated how to strap a wheelchair into the van that was used the day of Resident #1 ' s incident. The shoulder harness was fastened across the wheelchair at the maximum extension of the belt, but was still too tight to allow it to be fastened around a resident. The Administrator acknowledged that Resident #1 is a large woman and the shoulder harness would not fit around her. The Administrator stated that the van has been taken out of commission since the incident and she will have the shoulder straps fixed. In an interview on 05/17/12 at 11:15 AM, the Administrator stated that on 04/27/12, residents were being transported from a nearby park back to the facility after an outing. Resident #1 was in her wheelchair on the van, buckled in, when the van driver went around a corner and the resident ' s wheelchair fell over. Resident #1 was transported to the hospital by EMS and was released with a [DIAGNOSES REDACTED]. The resident continued to complain of pain, and developed swelling, so they called the doctor, who ordered another x-ray and Resident #1 was found to have a fracture of the right shoulder. The Administrator stated that during her investigation she questioned Resident #1, who stated that she was buckled in while on the van, but was unable to say how because Resident #1 is blind. The Administrator stated that according to the Van Driver and Assistant Activity Director, Resident #1 ' s wheelchair was strapped into the van correctly, so they were unable to figure out what caused the wheelchair to tip over, causing the Resident to fall out. The Administrator stated that the van has been taken out of service and the Van Driver will receive additional in-service education. In an interview on 05/17/12 at 12:00 PM, the DON stated that Resident #1 was initially diagnosed with [REDACTED]. The DON said that they called the doctor and obtained an order to have another x-ray performed and that was when they discovered the right distal clavicle fracture. When asked for a list of residents who ride the facility van, the DON stated " that ' s almost everyone in the facility. " In an interview on 05/17/2012 at 1:40 PM, the Assistant Activity Director stated that she was riding on the van on 04/27/12 toward the back, coming back from an outing at the park and this was their last of two transports of residents. She said that Resident #1 was in her wheelchair, strapped in, and there were five other residents on the van sitting on seats, with seatbelts. When asked if she helped buckle the residents in, she stated " I didn ' t buckle the residents in, so the Van Driver must have. " The Assistant Activity Director stated that the Van Driver stopped at a light about half a mile from the facility, and then began to turn to the left. She stated that as the driver turned, Resident #1 ' s wheelchair began tipping over to the right and Resident #1 fell out of the wheel chair, toward the door, landing on her right arm. She stated that the driver was not speeding, and was driving carefully. The Assistant Activity Director said that the Van Driver pulled over immediately and came back to help her " secure the resident and make sure everyone else was ok. " She said that they drove back to the facility and they called an ambulance. The Assistant Activity Director said that Resident #1 was in " visible pain, but was calm and maybe crying a little, but not hollering. " She said that the ambulance got there really fast and Resident #1 was taken off the van by the ambulance crew and transported to the hospital. The Assistant Activity Director stated that she has worked for this facility for eight years and has never heard of an incident of this nature occurring. Review of the Facilty Investigation Reports dated 04/30/12 reflected the following: " Resident had fall on facility van on 04/27/2012 and was transported to a local hospital by Emergency Medical Services (EMS). Resident returned to facility on 04/27/2012 with [DIAGNOSES REDACTED]. On 05/01/2012, the Director of Nursing (DON) reported to the Administrator resident ' s fracture. Per nurses notes, resident continued to have complaints of pain to right shoulder. Physician was notified and new order received to x-ray right clavicle and right shoulder. X-Ray results indicated a distal shaft right clavicle fracture. During interview on 5/1/2012 with Resident #1 and Administrator, the Administrator asked Resident #1 if someone had hurt her and the resident replied no. Resident #1 was also asked if she was buckled in on the van when she had her fall, resident replied yes. Resident #1 stated she did not feel unsafe in the wheelchair while on the van, until she had her fall. " Investigation Summary: Resident #1 was seated in her wheelchair on the van and the wheelchair was secured to the floor with straps, and a lap belt was placed across her lap, but no shoulder harness was used. The Van Driver turned the van to the left at a stop light, and Resident #1 ' s wheelchair tipped partially over, causing the resident to fall to the floor near the door of the van, resting on her right shoulder. There were no other wheelchairs except Resident #1's on the van at this time. The Van Driver looked up in the rear-view mirror and saw Resident #1 falling toward the door. The Van Driver stopped the van and along with the assistance of Assistant Activity Director, secured Resident #1 and then proceeded on to the facility. Once at the facility, the Administrator and DON were notified and called 911 and Resident #1 was transported to a local hospital by EMS. The Van Driver and Assistant Activity Director were both present and witnessed the fall of Resident #1. The Van Driver told the Administrator that all seatbelts were in place. The cause of the wheelchair tipping over was not identified and the van was placed out of service. Review of the Driver/Vehicle Safety Guidelines, appendix, " Ride Safe " dated 2005, revealed the following: " To protect the rider during a crash or sudden braking, and to minimize the likelihood of injury caused by contact with the vehicle, a seatbelt system with both pelvic and upper torso belts must be used. " Review of the Driver/Vehicle Safety Guidelines Training Check List for Patient Transportation Vehicle signed by the Van Driver on 4/12/12 reflected: "1) Transmission is in park, parking brake is set, and flashers on, for all loading and unloading. 2) Vehicle is never left unattended with patient/resident inside. 3) Wheel Chair (W.C.) is in good working condition prior to loading patient/resident onto W.C. lift. 4) Self-releasing seatbelt in W.C. is checked and/or adjusted prior to loading and unloading. 5) Patient ' s/Resident ' s arms and legs are in a safe position during transfers to and from vehicle. 6) Patient/Resident is pulled backward onto W.C. lift. 7) W.C. brakes are locked after W.C. is on lift platform. 8) Ambulatory patients/residents are secured in seat belts before vehicle is put in motion. 9) W.C.s are secured with at least two straps tightly attached to one front and one rear wheel. 10) Always make complete stops at stoplights, stop signs, and railroad tracks. 11) Always observe speed limits and all traffic laws. 12) Ensure a blanket or sweater is available for use on a daily basis. 13) Ensure first aide kit is available on a daily basis. 14) In case of an accident, call for help. Do not move patients/residents except for fire. " This training check list does not address the required use of a shoulder harness, as the facility Driver/Vehicle Safety Guidelines appendix " Ride Safe " states is a requirement. Per Administrator the facility census was 58.

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for 1 of 1 residents reviewed for accidents during transport (Resident #1). Resident #1's wheelchair had not been adequately secured while riding in the facility van. Resident #1's wheelchair tipped over, resulting in Resident #1 falling out of the wheelchair and onto the floor of the van. Resident #1 received numerous contusions and a distal shaft right clavicle fracture (collar bone). This deficient practice contributed to Resident #1 falling and sustaining injuries that included contusions and a fracture with pain requiring pain medication and additional therapy. Findings include: Review of Resident #1's Face Sheet 01/23/2012 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 05/17/12 at 1:45PM, Resident #1 was observed seated in her wheelchair. She stated that she was riding on the van in this wheelchair on 04/27/12, coming back from the park. She said that she was buckled in, but couldn ' t really see the straps because she is blind. Resident #1 said that when they were turning a corner, her wheelchair began turning over and she went over with it. She said that the Driver was driving carefully, and this was "just a freak accident. " She stated that she landed on her right arm, near the door, and remembers her shoulder being in a lot of pain. Resident #1 said that the Van Driver stopped the van and came back to help her. The Assistant Activity Director let Resident #1 lay her head on her shoulder until 911 got there, and 911 put the resident on a backboard with a neck collar and took her to the hospital. The doctor at the hospital said that her arm wasn ' t broken, but it kept hurting when she got back to the facility, so the nurse called the doctor on-call and he ordered a new x-ray. The resident said that they came to the facility with a mobile x-ray and it showed that her arm was broken. Resident #1 stated that she is still having problems with pain, and receives therapy for her arm. She stated that this physical therapy causes pain that is unbearable, so she must ask the therapist to quit during the therapy. Resident #1 stated that she has ridden the van with two other drivers and her wheelchair hasn ' t ever tipped over. She stated that they take the van on outings at least once or twice a month, but are using a van from a sister facility right now because the old van was put out of service after her accident. Resident #1 stated that she used to transfer to a seat and use a seatbelt, but has trouble transferring now, so they just buckle in her wheelchair. She said that she has always been buckled in by the drivers. Review of Resident #1's Physician order [REDACTED]. Resident was ordered to " continue current pain meds [MEDICATION NAME] a narcotic pain medication & [MEDICATION NAME] (NSADI pain medication) as needed for pain." Review of Resident #1 ' s Nursing communication form dated 05/02/12 revealed that Resident #1 was ordered to be scheduled for an orthopedic appointment due to a right [MEDICAL CONDITION]. In an interview on 5/17/12 at 2:30 PM, the Van Driver stated she has been a driver for this facility for approximately one month. She stated that she has received training on transporting Residents in the van. She stated that on 04/27/2012, she was transporting residents from the park back to the facility after an outing, and made two trips that day, and transported a total of three residents in wheelchairs, including Resident #1. The Van Driver was unable to remember the names of the residents on the bus with Resident #1 that day, but stated that none of the other wheelchairs tipped that day. She said that she secured Resident #1 ' s wheelchair on the van by locking the wheels and then placing four tie down straps around the frame and demonstrated how she did this. She stated that she always shakes the wheelchair a bit to make sure the straps are tight enough and remembers doing this that day. The Van Driver stated she placed a lap belt across Resident #1 ' s lap, but the shoulder strap would not fit, so she didn ' t use it. The Van Driver stated she stopped at a red light, took a left hand turn and Resident #1's wheelchair tipped half way over, causing her to fall out onto the floor, next to the lift door. The Van Driver stated she was looking in the rear-view mirror as she was turning and saw Resident #1 going over, so she pulled over and stopped the van. The Assistant Activity Director and the Van Driver rushed to assist Resident #1. The Van Driver stated that Resident #1 was crying and saying " oh, oh, my shoulder " and was in obvious pain, so they didn ' t move her, but did move the wheelchair out from under her and drove back to the facility and called 911. She said that 911 got there really quickly, maybe within 10-15 minutes and transported the resident to the hospital. The Van Driver stated she was given a safety course since the incident. During an interview on 05/17/12 at 4:25 PM the Van Driver admitted that she did not place a shoulder restraint across Resident #1 in the van according to policy because it would not fit around the resident. Observation on 5/17/12 at 2:30 PM and again at 4:10 PM, revealed the inside of the facility van was equipped with devices to securely strap in 2 wheelchairs, including seatbelts and shoulder harnesses. The seats of the van were equipped with lap seatbelts but no shoulder harnesses. In an observation/interview on 05/17/12 at 4:10 PM, the Administrator and the Environmental Services Director demonstrated how to strap a wheelchair into the van that was used the day of Resident #1 ' s incident. The shoulder harness was fastened across the wheelchair at the maximum extension of the belt, but was still too tight to allow it to be fastened around a resident. The Administrator acknowledged that Resident #1 is a large woman and the shoulder harness would not fit around her. The Administrator stated that the van has been taken out of commission since the incident and she will have the shoulder straps fixed. In an interview on 05/17/12 at 11:15 AM, the Administrator stated that on 04/27/12, residents were being transported from a nearby park back to the facility after an outing. Resident #1 was in her wheelchair on the van, buckled in, when the van driver went around a corner and the resident ' s wheelchair fell over. Resident #1 was transported to the hospital by EMS and was released with a [DIAGNOSES REDACTED]. The resident continued to complain of pain, and developed swelling, so they called the doctor, who ordered another x-ray and Resident #1 was found to have a [MEDICAL CONDITION] shoulder. The Administrator stated that during her investigation she questioned Resident #1, who stated that she was buckled in while on the van, but was unable to say how because Resident #1 is blind. The Administrator stated that according to the Van Driver and Assistant Activity Director, Resident #1 ' s wheelchair was strapped into the van correctly, so they were unable to figure out what caused the wheelchair to tip over, causing the Resident to fall out. The Administrator stated that the van has been taken out of service and the Van Driver will receive additional in-service education. In an interview on 05/17/12 at 12:00 PM, the DON stated that Resident #1 was initially diagnosed with [REDACTED]. The DON said that they called the doctor and obtained an order to have another x-ray performed and that was when they discovered the right distal clavicle fracture. When asked for a list of residents who ride the facility van, the DON stated " that ' s almost everyone in the facility. " In an interview on 05/17/2012 at 1:40 PM, the Assistant Activity Director stated that she was riding on the van on 04/27/12 toward the back, coming back from an outing at the park and this was their last of two transports of residents. She said that Resident #1 was in her wheelchair, strapped in, and there were five other residents on the van sitting on seats, with seatbelts. When asked if she helped buckle the residents in, she stated " I didn ' t buckle the residents in, so the Van Driver must have. " The Assistant Activity Director stated that the Van Driver stopped at a light about half a mile from the facility, and then began to turn to the left. She stated that as the driver turned, Resident #1 ' s wheelchair began tipping over to the right and Resident #1 fell out of the wheel chair, toward the door, landing on her right arm. She stated that the driver was not speeding, and was driving carefully. The Assistant Activity Director said that the Van Driver pulled over immediately and came back to help her " secure the resident and make sure everyone else was ok. " She said that they drove back to the facility and they called an ambulance. The Assistant Activity Director said that Resident #1 was in " visible pain, but was calm and maybe crying a little, but not hollering. " She said that the ambulance got there really fast and Resident #1 was taken off the van by the ambulance crew and transported to the hospital. The Assistant Activity Director stated that she has worked for this facility for eight years and has never heard of an incident of this nature occurring. Review of the Facilty Investigation Reports dated 04/30/12 reflected the following: " Resident had fall on facility van on 04/27/2012 and was transported to a local hospital by Emergency Medical Services (EMS). Resident returned to facility on 04/27/2012 with [DIAGNOSES REDACTED]. On 05/01/2012, the Director of Nursing (DON) reported to the Administrator resident ' s fracture. Per nurses notes, resident continued to have complaints of pain to right shoulder. Physician was notified and new order received to x-ray right clavicle and right shoulder. X-Ray results indicated a distal shaft right clavicle fracture. During interview on 5/1/2012 with Resident #1 and Administrator, the Administrator asked Resident #1 if someone had hurt her and the resident replied no. Resident #1 was also asked if she was buckled in on the van when she had her fall, resident replied yes. Resident #1 stated she did not feel unsafe in the wheelchair while on the van, until she had her fall. " Investigation Summary: Resident #1 was seated in her wheelchair on the van and the wheelchair was secured to the floor with straps, and a lap belt was placed across her lap, but no shoulder harness was used. The Van Driver turned the van to the left at a stop light, and Resident #1 ' s wheelchair tipped partially over, causing the resident to fall to the floor near the door of the van, resting on her right shoulder. There were no other wheelchairs except Resident #1's on the van at this time. The Van Driver looked up in the rear-view mirror and saw Resident #1 falling toward the door. The Van Driver stopped the van and along with the assistance of Assistant Activity Director, secured Resident #1 and then proceeded on to the facility. Once at the facility, the Administrator and DON were notified and called 911 and Resident #1 was transported to a local hospital by EMS. The Van Driver and Assistant Activity Director were both present and witnessed the fall of Resident #1. The Van Driver told the Administrator that all seatbelts were in place. The cause of the wheelchair tipping over was not identified and the van was placed out of service. Review of the Driver/Vehicle Safety Guidelines, appendix, " Ride Safe " dated 2005, revealed the following: " To protect the rider during a crash or sudden braking, and to minimize the likelihood of injury caused by contact with the vehicle, a seatbelt system with both pelvic and upper torso belts must be used. " Review of the Driver/Vehicle Safety Guidelines Training Check List for Patient Transportation Vehicle signed by the Van Driver on 4/12/12 reflected: "1) Transmission is in park, parking brake is set, and flashers on, for all loading and unloading. 2) Vehicle is never left unattended with patient/resident inside. 3) Wheel Chair (W.C.) is in good working condition prior to loading patient/resident onto W.C. lift. 4) Self-releasing seatbelt in W.C. is checked and/or adjusted prior to loading and unloading. 5) Patient ' s/Resident ' s arms and legs are in a safe position during transfers to and from vehicle. 6) Patient/Resident is pulled backward onto W.C. lift. 7) W.C. brakes are locked after W.C. is on lift platform. 8) Ambulatory patients/residents are secured in seat belts before vehicle is put in motion. 9) W.C.s are secured with at least two straps tightly attached to one front and one rear wheel. 10) Always make complete stops at stoplights, stop signs, and railroad tracks. 11) Always observe speed limits and all traffic laws. 12) Ensure a blanket or sweater is available for use on a daily basis. 13) Ensure first aide kit is available on a daily basis. 14) In case of an accident, call for help. Do not move patients/residents except for fire. " This training check list does not address the required use of a shoulder harness, as the facility Driver/Vehicle Safety Guidelines appendix " Ride Safe " states is a requirement. Review of the facility's Abuse Prevention policy dated 07/01/05 reflected the following: section II. Training "B. Training of employees upon orientation and on an ongoing basis on issues related to abuse prohibition practices, neglect, and state and federal resident rights. State specific requirements related to frequency and content of training will be incorporated into the training schedule. A change in state and/or federal guidelines related to abuse would constitute need for additional training." and section V.Investigation, "B 7. Review of all events leading up to the incident to attempt to identify causative factors." Per Administrator the facility census was 58.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for 1 of 1 residents reviewed for accidents during transport (Resident #1). Resident #1's wheelchair had not been adequately secured while riding in the facility van. Resident #1's wheelchair tipped over, resulting in Resident #1 falling out of the wheelchair and onto the floor of the van. Resident #1 received numerous contusions and a distal shaft right clavicle fracture (collar bone). This deficient practice contributed to Resident #1 falling and sustaining injuries that included contusions and a fracture with pain requiring pain medication and additional therapy. Findings include: Review of the Driver/Vehicle Safety Guidelines, appendix, " Ride Safe " dated 2005, revealed the following: " To protect the rider during a crash or sudden braking, and to minimize the likelihood of injury caused by contact with the vehicle, a seatbelt system with both pelvic and upper torso belts must be used. " Review of the Driver/Vehicle Safety Guidelines Training Check List for Patient Transportation Vehicle signed by the Van Driver on 4/12/12 reflected: "1) Transmission is in park, parking brake is set, and flashers on, for all loading and unloading. 2) Vehicle is never left unattended with patient/resident inside. 3) Wheel Chair (W.C.) is in good working condition prior to loading patient/resident onto W.C. lift. 4) Self-releasing seatbelt in W.C. is checked and/or adjusted prior to loading and unloading. 5) Patient ' s/Resident ' s arms and legs are in a safe position during transfers to and from vehicle. 6) Patient/Resident is pulled backward onto W.C. lift. 7) W.C. brakes are locked after W.C. is on lift platform. 8) Ambulatory patients/residents are secured in seat belts before vehicle is put in motion. 9) W.C.s are secured with at least two straps tightly attached to one front and one rear wheel. 10) Always make complete stops at stoplights, stop signs, and railroad tracks. 11) Always observe speed limits and all traffic laws. 12) Ensure a blanket or sweater is available for use on a daily basis. 13) Ensure first aide kit is available on a daily basis. 14) In case of an accident, call for help. Do not move patients/residents except for fire. " This training check list does not address the required use of a shoulder harness, as the facility Driver/Vehicle Safety Guidelines appendix " Ride Safe " states is a requirement. Review of the facility's Abuse Prevention policy dated 07/01/05 reflected the following: section II. Training "B. Training of employees upon orientation and on an ongoing basis on issues related to abuse prohibition practices, neglect, and state and federal resident rights. State specific requirements related to frequency and content of training will be incorporated into the training schedule. A change in state and/or federal guidelines related to abuse would constitute need for additional training." and section V.Investigation, "B 7. Review of all events leading up to the incident to attempt to identify causative factors." Review of Resident #1's Face Sheet 01/23/2012 reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 05/17/12 at 1:45PM, Resident #1 was observed seated in her wheelchair. She stated that she was riding on the van in this wheelchair on 04/27/12, coming back from the park. She said that she was buckled in, but couldn ' t really see the straps because she is blind. Resident #1 said that when they were turning a corner, her wheelchair began turning over and she went over with it. She said that the Driver was driving carefully, and this was "just a freak accident. " She stated that she landed on her right arm, near the door, and remembers her shoulder being in a lot of pain. Resident #1 said that the Van Driver stopped the van and came back to help her. The Assistant Activity Director let Resident #1 lay her head on her shoulder until 911 got there, and 911 put the resident on a backboard with a neck collar and took her to the hospital. The doctor at the hospital said that her arm wasn ' t broken, but it kept hurting when she got back to the facility, so the nurse called the doctor on-call and he ordered a new x-ray. The resident said that they came to the facility with a mobile x-ray and it showed that her arm was broken. Resident #1 stated that she is still having problems with pain, and receives therapy for her arm. She stated that this physical therapy causes pain that is unbearable, so she must ask the therapist to quit during the therapy. Resident #1 stated that she has ridden the van with two other drivers and her wheelchair hasn ' t ever tipped over. She stated that they take the van on outings at least once or twice a month, but are using a van from a sister facility right now because the old van was put out of service after her accident. Resident #1 stated that she used to transfer to a seat and use a seatbelt, but has trouble transferring now, so they just buckle in her wheelchair. She said that she has always been buckled in by the drivers. Review of Resident #1's Physician order [REDACTED]. Resident was ordered to " continue current pain meds [MEDICATION NAME] a narcotic pain medication & [MEDICATION NAME] (NSADI pain medication) as needed for pain." Review of Resident #1 ' s Nursing communication form dated 05/02/12 revealed that Resident #1 was ordered to be scheduled for an orthopedic appointment due to a right [MEDICAL CONDITION]. In an interview on 5/17/12 at 2:30 PM, the Van Driver stated she has been a driver for this facility for approximately one month. She stated that she has received training on transporting Residents in the van. She stated that on 04/27/2012, she was transporting residents from the park back to the facility after an outing, and made two trips that day, and transported a total of three residents in wheelchairs, including Resident #1. The Van Driver was unable to remember the names of the residents on the bus with Resident #1 that day, but stated that none of the other wheelchairs tipped that day. She said that she secured Resident #1 ' s wheelchair on the van by locking the wheels and then placing four tie down straps around the frame and demonstrated how she did this. She stated that she always shakes the wheelchair a bit to make sure the straps are tight enough and remembers doing this that day. The Van Driver stated she placed a lap belt across Resident #1 ' s lap, but the shoulder strap would not fit, so she didn ' t use it. The Van Driver stated she stopped at a red light, took a left hand turn and Resident #1's wheelchair tipped half way over, causing her to fall out onto the floor, next to the lift door. The Van Driver stated she was looking in the rear-view mirror as she was turning and saw Resident #1 going over, so she pulled over and stopped the van. The Assistant Activity Director and the Van Driver rushed to assist Resident #1. The Van Driver stated that Resident #1 was crying and saying " oh, oh, my shoulder " and was in obvious pain, so they didn ' t move her, but did move the wheelchair out from under her and drove back to the facility and called 911. She said that 911 got there really quickly, maybe within 10-15 minutes and transported the resident to the hospital. The Van Driver stated she was given a safety course since the incident. During an interview on 05/17/12 at 4:25 PM the Van Driver admitted that she did not place a shoulder restraint across Resident #1 in the van according to policy because it would not fit around the resident. Observation on 5/17/12 at 2:30 PM and again at 4:10 PM, revealed the inside of the facility van was equipped with devices to securely strap in 2 wheelchairs, including seatbelts and shoulder harnesses. The seats of the van were equipped with lap seatbelts but no shoulder harnesses. In an observation/interview on 05/17/12 at 4:10 PM, the Administrator and the Environmental Services Director demonstrated how to strap a wheelchair into the van that was used the day of Resident #1 ' s incident. The shoulder harness was fastened across the wheelchair at the maximum extension of the belt, but was still too tight to allow it to be fastened around a resident. The Administrator acknowledged that Resident #1 is a large woman and the shoulder harness would not fit around her. The Administrator stated that the van has been taken out of commission since the incident and she will have the shoulder straps fixed. In an interview on 05/17/12 at 11:15 AM, the Administrator stated that on 04/27/12, residents were being transported from a nearby park back to the facility after an outing. Resident #1 was in her wheelchair on the van, buckled in, when the van driver went around a corner and the resident ' s wheelchair fell over. Resident #1 was transported to the hospital by EMS and was released with a [DIAGNOSES REDACTED]. The resident continued to complain of pain, and developed swelling, so they called the doctor, who ordered another x-ray and Resident #1 was found to have a [MEDICAL CONDITION] shoulder. The Administrator stated that during her investigation she questioned Resident #1, who stated that she was buckled in while on the van, but was unable to say how because Resident #1 is blind. The Administrator stated that according to the Van Driver and Assistant Activity Director, Resident #1 ' s wheelchair was strapped into the van correctly, so they were unable to figure out what caused the wheelchair to tip over, causing the Resident to fall out. The Administrator stated that the van has been taken out of service and the Van Driver will receive additional in-service education. In an interview on 05/17/12 at 12:00 PM, the DON stated that Resident #1 was initially diagnosed with [REDACTED]. The DON said that they called the doctor and obtained an order to have another x-ray performed and that was when they discovered the right distal clavicle fracture. When asked for a list of residents who ride the facility van, the DON stated " that ' s almost everyone in the facility. " In an interview on 05/17/2012 at 1:40 PM, the Assistant Activity Director stated that she was riding on the van on 04/27/12 toward the back, coming back from an outing at the park and this was their last of two transports of residents. She said that Resident #1 was in her wheelchair, strapped in, and there were five other residents on the van sitting on seats, with seatbelts. When asked if she helped buckle the residents in, she stated " I didn ' t buckle the residents in, so the Van Driver must have. " The Assistant Activity Director stated that the Van Driver stopped at a light about half a mile from the facility, and then began to turn to the left. She stated that as the driver turned, Resident #1 ' s wheelchair began tipping over to the right and Resident #1 fell out of the wheel chair, toward the door, landing on her right arm. She stated that the driver was not speeding, and was driving carefully. The Assistant Activity Director said that the Van Driver pulled over immediately and came back to help her " secure the resident and make sure everyone else was ok. " She said that they drove back to the facility and they called an ambulance. The Assistant Activity Director said that Resident #1 was in " visible pain, but was calm and maybe crying a little, but not hollering. " She said that the ambulance got there really fast and Resident #1 was taken off the van by the ambulance crew and transported to the hospital. The Assistant Activity Director stated that she has worked for this facility for eight years and has never heard of an incident of this nature occurring. Review of the Facilty Investigation Reports dated 04/30/12 reflected the following: " Resident had fall on facility van on 04/27/2012 and was transported to a local hospital by Emergency Medical Services (EMS). Resident returned to facility on 04/27/2012 with [DIAGNOSES REDACTED]. On 05/01/2012, the Director of Nursing (DON) reported to the Administrator resident ' s fracture. Per nurses notes, resident continued to have complaints of pain to right shoulder. Physician was notified and new order received to x-ray right clavicle and right shoulder. X-Ray results indicated a distal shaft right clavicle fracture. During interview on 5/1/2012 with Resident #1 and Administrator, the Administrator asked Resident #1 if someone had hurt her and the resident replied no. Resident #1 was also asked if she was buckled in on the van when she had her fall, resident replied yes. Resident #1 stated she did not feel unsafe in the wheelchair while on the van, until she had her fall. " Investigation Summary: Resident #1 was seated in her wheelchair on the van and the wheelchair was secured to the floor with straps, and a lap belt was placed across her lap, but no shoulder harness was used. The Van Driver turned the van to the left at a stop light, and Resident #1 ' s wheelchair tipped partially over, causing the resident to fall to the floor near the door of the van, resting on her right shoulder. There were no other wheelchairs except Resident #1's on the van at this time. The Van Driver looked up in the rear-view mirror and saw Resident #1 falling toward the door. The Van Driver stopped the van and along with the assistance of Assistant Activity Director, secured Resident #1 and then proceeded on to the facility. Once at the facility, the Administrator and DON were notified and called 911 and Resident #1 was transported to a local hospital by EMS. The Van Driver and Assistant Activity Director were both present and witnessed the fall of Resident #1. The Van Driver told the Administrator that all seatbelts were in place. The cause of the wheelchair tipping over was not identified and the van was placed out of service. Per Administrator the facility census was 58.