Every finding on record at Avir at Gonzales

Based on observation, interview, and record review, the facility failed to post the current nurse staffing data for 1 of 1 facility, in that: The nurse staffing data upon entrance on 6/16/26 was dated 6/9/26. This deficient practice could place residents at risk by not providing adequate staffing information for the residents, staff, and visitors to ensure that resident care needs are met. Based on observation, interview, and record review, the facility failed to post the current nurse staffing data for 1 of 1 facility, in that: The nurse staffing data upon entrance on 6/16/26 was dated 6/9/26. This deficient practice could place residents at risk of not receiving appropriate care by not providing adequate staffing information for the residents, staff, and visitors to ensure that resident care needs are met. Findings included: Observation on 6/16/26 at 11:04 am, revealed a posting detailing nurse staffing information for 6/16/26 was not available in the facility lobby. Further observation revealed that the Daily Nurse Staffing Report was dated 6/9/26. During an interview on 6/16/26 at 5:28 pm, the DON said staffing should be posted every day. The DON further stated there was no reason why the daily posting was not current. The DON said she should have checked the posting every day, as she was responsible for ensuring the Daily Nurse Staffing Report was current. The DON further stated it was important to ensure the posting was current because the facility needed to ensure they had enough staff to care for the residents and if anyone came in, they could see that the facility had enough staff to care for loved ones. Record review of the facility's policy titled Posting Direct Care Staffing Numbers, revised August 2022, revealed: .Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents .

Based on interviews and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 3 residents (Resident #1 and Resident #4) reviewed for dental services. The facility did not ensure Resident #1's physician was contacted for an order to withhold blood thinners prior to dental extractions on 5/19/26. The facility did not ensure Resident #4's physician was contacted for an order to withhold blood thinners prior to dental extractions on 5/19/26. This failure could place residents at risk of bleeding and diminished quality of life.Findings included: 1. Record review of Resident #1's Face Sheet, dated 6/16/26, revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included: Cerebral Infarction (stroke - disrupted blood flow to the brain). Record review of Resident #1's Dental Treatment Note, dated 5/19/26, revealed: .tooth #4,28,29 extracted. Record review of Resident #1's quarterly MDS assessment, dated 6/8/26, revealed the resident had a BIMS score of 15, suggesting intact cognition. Record review of Resident #1's Order Summary Report, dated 6/16/26 revealed an order for Aspirin 81 MG, 1 tablet by mouth once a day, dated 4/7/25. Record review of Resident #1's May MAR revealed Aspirin 81 MG, 1 tablet by mouth once a day was administered on 5/19/26. During an interview on 6/16/26 at 1:15 pm, Resident #1 nodded yes when asked if he saw the dentist last month (May) and if he had teeth extracted. 2. Record review of Resident #4's Face Sheet, dated 6/16/26, revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included: Cerebral Infarction (stroke - disrupted blood flow to the brain). Record review of Resident #4's quarterly MDS assessment, dated 5/13/26, revealed the resident had a BIMS score of 14, suggesting intact cognition. Record review of Resident #4's Dental Treatment Note, dated 5/19/26, revealed: .tooth #21,22,23,24 extracted. Record review of Resident #4's Order Summary Report, dated 6/16/26 revealed orders for Aspirin 81 MG, 1 tablet by mouth once a day, dated 6/12/25 and Xarelto 10 MG (used to prevent clotting) orally once a day, dated 3/31/25. Record review of Resident #4's May MAR revealed Aspirin 81 MG, 1 tablet by mouth once a day and Xarelto 10 MG orally once a day were administered on 5/19/26. Record review of the mobile dental services communication revealed: .List as of 4/27/2026.Date of Visit: 5/19/26.[Resident #1] Due For: Extraction(s) TX Planned.Begin full mouth extractions.blood thinners to be withheld is requested. [Resident #4] Due For: X-Rays Extractions(s).request physician withhold blood thinners. During an interview on 6/16/26 at 1:39 pm, Resident #4 said he saw the dentist about a month ago. Resident #4 further stated his doctor was supposed to be contacted about stopping his blood thinners. During a telephone interview on 6/16/26 at 1:49 pm, the Dental Services Rep said the mobile dental services did not give orders to hold blood thinners. The Dental Services Rep further stated they sent out a communication informing the facility they were going to be performing dental extractions, and the facility was responsible for contacting the residents' physician to see if he wanted to hold any medications. During an interview on 6/16/26 at 2:07 pm, CNA A confirmed Resident #1 and Resident #4 saw the dentist in May and had teeth extracted. CNA A further stated Resident #4 had continuous bleeding. CNA A said the day following Resident #4's extractions the bleeding had stopped. CNA A said Resident #1 had minimal bleeding after the extractions. Attempt to interview the MD on 6/16/26 at 2:49 pm was unsuccessful. Attempt to interview the NP on 6/16/26 at 2:52 pm was unsuccessful. During an interview on 6/16/26 at 3:01 pm, the ADON said the facility received email communications from the mobile dental services prior to appointments, but she did not pay close attention to them. The ADON further stated that she did not review or respond to emails from the mobile dental services. The ADON said that she did not know if there was a designated person that was responsible for responding to the emails. The ADON said that she remembered Resident #1 and Resident #4 had tooth extractions but did not remember when. During an interview on 6/16/26 at 3:13 pm, the DON said the facility's process, when communication was received from the mobile dental service, was to review the list of residents and confirm the appointments. The DON further stated if medication changes were required, like holding blood thinners, the provider was contacted to decide how to proceed and the nurses were notified of what needed to be done prior to the appointment. The DON said she or the ADON were responsible for contacting the physician and documenting the communication in the residents' progress notes. The DON said Resident #4 saw the dentist on 5/19/26 and had teeth extracted. The DON said Resident #4 bled more than normal on the day of the extractions because he was on blood thinners. The DON said Resident #1 also had teeth extracted on 5/19/26 but he did not have excessive bleeding. The DON said the physician was not contacted for orders to withhold the blood thinners due to a systemic breakdown. Record review of the facility's policy titled Dental Services, revised December 2016, revealed: . Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADLs. The facility failed to provide Resident #1 with assistance with the bathroom for more than 40 minutes following his second verbal request to CNA A on 1/02/2026. This failure could affect and diminish the resident's quality of life by potentially placing the resident at risk of infections, skin breakdown and/or it can make the resident feel neglected affecting their mental health and overall psychosocial well-being. The findings include: Record review of Resident #1's admission record dated 1/03/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cerebral infarction (also known as an ischemic stroke, occurs when a blood vessel in the brain becomes blocked, cutting off oxygen supply to brain tissue) quadriplegia (a form of paralysis that affects all four limbs and the torso), and muscle wasting and atrophy (is the loss of muscle mass and strength). Record review of Resident #1's quarterly Minimum Data Set, dated [DATE] reflected a BIMS score 14, which indicated cognition to be intact. Section GG - Functional Abilities reflected Resident #1 required Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. The assistance of 2 or more helpers to provide total care is required for the resident to complete chair/bed-to-chair transfer, toilet transfer, shower transfer, sit to stand. Self-Care reflected Resident #1 required Dependent - Helper does All of the effort for activities of eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene. Resident #1 uses a wheelchair for mobility. Resident's urinary continence is always incontinent, and bowel continence is frequently incontinent. Record review of Resident #1's care plan dated 6/19/2025 and last revised 12/12/2025, reflected the following, Impaired Physical Mobility. Goal Resident Will Be Free of Complications of Immobility and Resident's Skin Will Remain Intact. Interventions Assist Resident in performing movements / tasks. Resident is at risk for pressure ulcer due to moisture. Goal Intact skin without evidence of redness, irritation, maceration, or open areas. Resident #1 is at Risk for Impaired Skin Integrity. Goal Resident's Skin Will Remain Intact and Identify Resident's Risk for Impaired Skin Integrity. Interventions Educate Resident / Representative about proper skin care to prevent skin breakdown. Further review of Resident #1's care plan dated 7/02/2025 and last revised on 12/12/2025, reflected the following, The resident has an ADL self-care performance deficit r/t. Goal The resident will maintain current level of function. Interventions TOILET USE: The resident is totally dependent on (X) staff for toilet use and TRANSFER: The resident requires Mechanical Lift (SPECIFY) with (X) staff assistance for transfers. Record review of Resident #1's progress note, dated 12/11/2025 and created by the ADON, Functional Limitations and Range of Motion: reflected the following: ADON documented, Significant Correction. Dates for 3-day window: 12/09-12/11 IDT Collaboration.Upper extremity (shoulder, elbow, wrist, hand): Impairment on one side. Lower extremity (hip, knee, ankle, foot): Impairment on one side. Wheelchair (manual or electric). Self-Care: Eating: Interim: Dependent. Oral hygiene: Interim: Dependent. Toileting hygiene: Interim: Dependent. Shower / bathe self: Interim: Dependent. Upper body dressing: Interim: Dependent. Lower body dressing: Interim: Dependent. Putting on/taking off footwear: Interim: Dependent. Personal hygiene: Interim: Dependent. Record review of Resident #1's quarterly Bowel and Bladder Program Screener dated 12/09/2025 reflected the following: a. Voids appropriately without incontinence3. Alwaysb. Incontinent of Stool3. Neverc. Ability to Get to the BR/transfer to toilet/commode/urinal, adjust to clothing and wipe etc0. Immobile, or 2 person assistd. Mental Status3. Alert and orientede. Mentally aware of need to toilet3. Always aware of need to toilet In an observation and interview on 1/02/2026 at 12:48 PM, Resident #1 was observed sitting in his wheelchair, he was dressed appropriately for the weather. He was observed to lower and raise his head numerous times. He was holding the call light. Resident #1 stated he was not having a good day, he was angry. He stated he has been wet for an hour now; CNA A doesn't want to change or bathe him. He stated he needs 2 staff to transfer him and all he wants was to be changed. He was observed pressing the call light for assistance. In an observation on 1/02/2026 at 12:50 PM, CNA A entered Resident #1's room to respond to his call light being on. CNA A turned off the call light and informed Resident #1 she was still waiting for additional nursing staff to help her change his brief and she will return once she has another staff. She walked out of resident's room rushed and didn't allow Resident #1 to explain why he pressed the call light. In an observation and interview on 1/02/2026 at 1:06 PM, Resident #1 stated he was still waiting for the nursing staff, and he had yet to be changed. CNA A entered Resident #1's room and put down wipes, gloves, and changing pads on his bed near him and walked out quickly saying she would return and state, resident is so impatient, I'm trying to help him, but I need another staff to help me. In an observation on 1/02/2026 at 1:19 PM, CNA A was observed asking Med Tech if she would be able to assist her with a 2-person brief change and she responded she would help her. In an observation on 1/02/2026 at 1:21 PM, Med Tech and CNA A were observed entering Resident #1's room to provide resident with incontinent care. The two staff exited the room quickly. In an observation and interview on 1/02/2026 at 1:24 PM, CNA A was observed entering Resident #1's room and wheeling Resident #1 to the shower area. She passed surveyor and stated for the second time, Resident #1 is so impatient, and I keep explaining to him that I need another staff to help me clean and change him or bathe him. In an observation on 1/02/2026 at 1:28 PM, Med Tech was observed entering the shower area to assist CNA A with toileting hygiene and showering Resident #1. In an interview on 1/02/2026 at 5:35 PM, CNA B stated she has received training in ANE and resident rights during onboarding to full-time staff on 12/09/2025. CNA B was knowledgeable of ANE and resident rights and provided examples. She stated call lights responses are within 5-10 minutes. She stated the residents can wait up to 30 minutes at most for care as there was one charge nurse and one CNA for each hallway. She stated the wait time can be longer for residents that require 2-person assistance. She stated residents waiting more than 30 minutes for toileting hygiene was outside of facility protocol and can be seen as neglectful and could affect a resident in that they can distrust staff and think that all staff were the same. In an interview on 1/03/2026 at 11:20 AM, CNA A stated she received in-service on ANE and resident rights during monthly meetings. She was knowledgeable of ANE and resident rights and provided examples. She stated call light responses are within 5 minutes, but no more than 10 minutes. She stated anything after 15 minutes was not okay but sometimes it can go past 30 minutes if staff were too busy or cannot find a 2nd staff member to help with 2-person transfer. She stated rounds for brief change should be made every 2 hours. She stated Resident #1 was a 2-person transfer, she asked other nursing staff for help, and she was not getting it. She stated she was able to get help from Med Tech after more than 30 minutes waiting for toileting hygiene. She stated she believes several staff members do not care for her and refuse to help her. She stated that a waiting time of 40 minutes was excessive and can make a resident feel like they were not important and make them feel bad and feel like they were not getting proper hygiene. CNA A stated 100 hallway had heavy male residents who were heavy wetters and require frequent changes with 2-person and hoyer lift. She stated it was difficult to transfer residents as she has carpal tunnel, she was too stressed, very tired, and frustrated she doesn't get help quickly. CNA A was unable to recall when she informed management of these concerns, and she would not provide information as to which management staff she approached directly with these concerns. CNA A stated she couldn't recall what time Resident #1 requested assistance with brief change and that she was doing her best to assist him. In an interview on 1/03/2026 at 12:02 PM, CNA C stated she received in-service on ANE and resident rights during mandatory monthly meetings. She was knowledgeable of ANE and resident rights and provided examples. She stated effects of ANE on a resident would be loss of trust in staff and would not want staff to work or provide them with care. She stated call lights responses were within 5 minutes, but no more than 10 minutes and rounding every two hours. She stated there were challenges with meeting the call light response and rounding expectation of the facility and sometimes can go a little longer than 5-10 minutes. She stated assisting a resident was everybody's job. She stated providing brief change for a resident can exceed the 5-10 minutes wait time, but more than 30 minutes for call light response for brief change would be considered excessive and can make a resident upset to stay soiled for long periods of time. She was not familiar with Resident #1's care other than he requires 2-person assistance with hoyer lift. In an interview on 1/03/2026 at 12:25 PM, LVN stated she was agency staff, and this was her 2nd shift at this facility. She stated there were enough staff to meet the needs of the residents. She stated call lights were expected to be answered ASAP, and rounding was expected every 2 hours. She stated she believes more than 30-minute wait time for brief change would be excessive for a resident and could cause them to become upset and would not be happy about it and would feel helpless. She stated she was not familiar with Resident #1's care. In an interview on 1/03/2026 at 1:00 PM, the Regional Nurse Consultant stated that she received ANE and resident rights training 2 weeks back at a sister facility of the company. She stated the facility has annual training on procedures and policies that were conducted by the DON at the other facility. She stated the response of call lights was in a timely manner and this was within 5 minutes. She stated nursing staff may not be able to provide care for the residents immediately but were required to communicate with the residents during the waiting time. She stated she wouldn't want a resident to wait more than 10 minutes for brief changes. She stated that rounding and call light response in-service was conducted about 3 weeks back. The Regional Nurse Consultant stated it was a team at this facility, and everyone should help. She stated it would be excessive for a resident to wait more than 30 minutes for a brief change. She stated if a resident was soiled and in brief for more than 30 minutes it could make the residents angry, especially if alerted. She stated Resident #1 was total care and he was alert. She stated more than 35-minute wait time to have his brief changed was unacceptable and that staff not helping each other after asking one another was not acceptable and will look into this incident. In an interview on 1/03/2026 at 3:31 PM, the Administrator stated she completed ANE and resident rights training online in the last week. She was knowledgeable of ANE and resident rights and provided examples. She stated she was the abuse coordinator for the facility. She stated that the call light response time follows the Texas Administration code and rounding of 2 hours. She stated all staff can answer a call light and if something out of the scope of practice would need to notify the nurse aid or charge nurse. She stated a recent in-service on call lights was conducted and it conveyed to staff check on call lights quickly when it is seen. She stated if an aide needs additional staff for a 2-person transfer, let the resident know that they were going to go get help. The Administrator stated residents were not aware of time or believe they have been waiting longer if staff are not communicating or feel they have been neglected if not responded to. She stated if staff were not rounding or responding to call lights in a timely manner, the resident may want to go to the restroom, and they could get up on their own and hurt themselves. She stated rounding protocol was every 2 hours to ensure residents are cared for, clean, safe, and not neglected. The Administrator stated residents who are total care would require 2-person assistance for toileting hygiene. She stated if the aide was working with another resident the aide can then request help from a charge nurse. She stated that residents should not wait longer than 30 minutes for brief change. She stated Resident #1 was total care and he was alert. She stated more than 35-minute wait time to have his brief changed was unacceptable and that staff not helping each other after asking one another was not acceptable and will look into this incident. Record review of facility In-Service Training Report, dated 11/07/2025 revealed: Content: Respect & dignity, communication, compassion & patience, teamwork & attitude, service recovery. Record review of the facility's policy, Resident Rights, dated 02/2021 revealed: Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity Record review of the facility's policy, Activities of Daily Living (ADL), Supporting, dated 2001 revealed: 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 the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a. hygiene (bathing, dressing, grooming, and oral care);b. mobility (transfer and ambulation, including walking);c. elimination (toileting);5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the assessment reference date (ARD) and the following MDS definitions:f. Dependent: If the helper does ALL of the effort. Resident does none of the effort to complete the activity; or the assistance of two or more helpers is required for the resident to complete the activity. Record review of the facility's policy, Call System, Residents, dated 01/2025 revealed: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station.6. Calls for assistance are answered timely.

Based on observation, interview, and record review, the facility failed to ensure RN coverage of eight (8) hrs daily and a full time DON for eight days (11/1/25, 11/2/25,11/6/25,11/9/25,11/12/25, 11/13/25,11/17/25, and 11/18/25) in November 2025 for 1 of 1 facility. The facility failed to ensure RN 8 hour daily coverage and a full time DON in the facility for eight days in November 2025. This deficient practice could place residents at-risk of not having their care needs assessed by a licensed RN on a daily basis.The findings included: Record review of the facility's daily nursing staffing for the time period of 10/31/25 through 11/24/25 revealed there were eight days in the month of November 2025 in which there was not an RN or DON working at the facility during the 24 hour time period for the following days (11/1/25,11/2/25,11/6/25, 11/9/25, 11/12/25,11/13/25, 11/17/25, and 11/18/25). During an interview on 11/26/25 at 9:00 a.m. with the Corporate RN-A she advised that she had visited the facility as much as possible since the DON position became vacant in order to provide the required RN coverage. The RN Corporate Nurse stated that her visits to the facility were not made on a daily basis. During an interview on 11/26/25 at 9:20am with the Human Resources (HR) Director she advised that the previous DON who provided the daily 8 hours of RN coverage at the facility was last employed at the facility on 10/31/25.The HR Director stated that there was not an RN or DON working at the facility during the 24 hour time period on the following days (11/1/25, 11/2/25, 11/6/25, 11/9/25, 11/12/25. 11/13/25. 11/17/25, and 11/18/25). During an interview on 11/26/25 at 11:00am with the Administrator and ADON-B they advised that having a DON/RN at the facility was necessary to provide a licensed nursing assessment of resident care needs and behaviors on a daily basis. Record review of the facility policy titled Staffing, Sufficient and Competent Nursing revealed A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on observation, interview, and record review, the facility failed to ensure an adequate communication system to allow residents to call for staff assistance for 3 of 9 rooms (Rooms# 108,109, and 206) reviewed on the three resident hallways for an operating call light system. The facility failed to ensure Resident rooms # 108, 109, and 206 had a fully functional call light notification system. This deficient practice could place residents at-risk of not being able to call for staff assistance to meet care needs.The findings included: Record review of the facility floor plan revealed there were three resident hallways (hallway #'s 100, 200, and 300). Record review of the facility's maintenance repair log from 01/25 through 10/25 revealed maintenance repairs on all of the three resident hallways included call light notification repairs which had been completed. Observation rounds on 11/25/25 from 2:55 p.m. through 3:15 p.m with the Maintenance Director and Activity Director., revealed that the room dome lights outside the entrance to rooms #108 and 109 did not come on when the call light was engaged inside the room and the room dome light apparatus outside of room [ROOM NUMBER] was missing from the room's door entrance. During an interview on 11/25/25 at 3:20 p.m., with the Maintenance Director and Activity Director , the Maintenance Director stated that he was not aware of how long the dome lights in the rooms [ROOM NUMBER] had been in need of repair. The Maintenance Director stated that he had been in the Maintenance Director position for approximately one month. The Maintenance Director stated he had checked the hallway call lights as needed but had not kept a written log of the room call light checks which were completed. The Maintenance Director and Activity Director stated that having an operating dome light would have assisted staff by providing visual notification that the resident had care needs. During an interview on 11/26/25 at 8:30am with the Administrator she stated that all of the resident hallway room call lights had been re-checked and were functioning properly. The Administrator stated that the Residents had to have a complete functional alarm notification system to ensure notification of their care needs. Record review of the facility's policy titled Call System Residents dated 2001 revealed The resident call system remains functional at all times.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility failed to use the services of an RN as required for 13 days during the period between 3/1/2025 through 7/20/2025. This could result in residents not receiving the needed care and services to meet their needs and could result in illness, a decline in health, and in quality of care.The findings were: Review of the facility's RN hours revealed there were no RN coverage hours on the following dates: 4/13/2025; 4/26/2025; 5/10/2025; 5/11/2025; 5/24/2025; 5/25/2025; 6/15/2025; 6/21/2025; 6/28/2025; 6/29/2025; 7/4/2025; 7/5/2025; 7/6/2025. During an interview on 07/24/2025 at 3:17 p.m., the Administrator reviewed the time sheets for RN hours and confirmed there was no RN coverage on the listed dates. The Administrator stated they didn't have enough RNs to cover all the weekend slots, and stated it was very tough hiring enough RNs in rural settings. During an interview with the DON on 07/25/2025 at 3:30 p.m., the DON stated they did not have a nursing policy which addressed RN coverage for 8 hours per day as that was a CMS standard.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 2 (Residents #1 and #11) of 4 residents reviewed for medication errors, in that: 1. Medication aide-B (MA-B) administered Resident #11 his medication Omeprazole (a medication used to reduce the amount of acid produced by the stomach and recommended to be taken on a empty stomach before a meal) late by 1 hour and 48 minutes. 2. MA-B administered Resident #1's Refresh Optive Mega-3 eyedrops (a medication to relieve eye dryness), late by 4.5 hours. 3. MA-B administered Resident #1's Refresh Optive Mega-3 eyedrops, one drop to each eye on 07/24/2025 at 12:28 p.m., but the physician order indicated REFRESH OPTIVE ADVANCED DROPS Instill 1 drop in both eyes one time a day related to LEGAL BLINDNESS. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications or not receiving them as prescribed, per physician orders. Findings include: 1.Record review of Resident #11's admission Record, dated 07/25/2025 revealed he was a [AGE] year-old man admitted on [DATE] with readmission on [DATE], and with diagnoses which included: Gastro-esophageal Reflux Disease (a digestive disease in which stomach acid irritates the esophagus lining, causing heartburn). Record review of Resident #11's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated the resident's cognition was intact. Record review of Resident #11's Order Summary, dated 07/25/2025, revealed the resident had a Physician Order for OMEPRAZOLE DR 20MG TABLET Give 1 tablet orally one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS. Record review of Resident #11's MAR for July 2025 reflected an administration time of 7:00 a.m. for the Omeprazole. Record review of website for Drugs.com at https://www.drugs.com revealed it is usually best to take Omeprazole 1 hour before meals and When omeprazole is taken with food, it reduces the amount of omeprazole that reaches the bloodstream. Observation and interview with MA-B on 07/24/2025 at 8:48 a.m., revealed MA-B preparing medications to administer to Resident #11. MA-B's computer electronic medical record display showed a display of Resident's #11 medications, all of which were highlighted in yellow, except for one, which was highlighted in red. The medication highlighted in red was his Omeprazole. MA-B stated the red highlighted medication meant the medication was late in being administered. MA-B administered 10 medications to Resident #11, all of which were on time, except for the Omeprazole which was administered 1 hour and 48 minutes late. During further interview with MA-B on 07/24/2025 at 12:30 p.m., she stated she was late giving Resident #11 his medications that morning, because she arrived late to work, and arrived too late to administer Resident #11's Omeprazole on time. She stated she was supposed to start work at 7:00a.m., but that does not give her enough time to give everyone scheduled for 7:00 a.m. their medications within the hour window (a one-hour medication administration window, created by giving healthcare professionals 30 minutes before and after a medication is scheduled to be given to administer the medication). Medication Aide-B stated she thought medications likes Omeprazole should be given at 6:00 a.m. by the night shift. 2. Record review of Resident #1's admission Record dated 07/22/2025 revealed he was a [AGE] year-old man initially admitted on [DATE] with re-admission on [DATE] and with diagnoses which included: Legal Blindness (visual acuity of 20/200 meaning a person can see at 20 feet what a person with normal vision can see at 200 feet) and Dry Eye Syndrome (condition where tears produced aren't able to provide adequate lubrication for the eyes). Record review of Resident #1's annual MDS assessment dated [DATE] revealed he had a BIMS score of 11, indicating moderate cognitive impairment and had an active diagnosis of legal blindness. Record review of Resident #1's Order Summary dated 07/24/2024 revealed a physician order for REFRESH OPTIVE ADVANCED DROPS Instill 1 drop in both eyes one time a day related to LEGAL BLINDNESS. Record review of Resident #1's July Medication Administration Record (MAR) revealed an administration time of 0700 for Resident #1's Refresh Optive Advanced Drops. During an observation on 07/24/2025 at 12:28 p.m. of medication administration of an antibiotic oral pill for Resident #1 by MA-B, Resident #1 told MA-B that she did not give him his eye drops that morning. MA-B told him she had not given him his eyedrops this morning because she had been running late, but she would give him his eyedrops now. Further observation revealed MA-B then prepared and administered Resident #1's Refresh Optive eye drops, one drop in each eye. During an interview on 07/24/2025 at 12:30 p.m., MA-B stated that because she was running late that morning, she was trying to hurry and was going to give Resident #1's eye drops later in the day. MA-B stated that when medications are not given at the time listed on the MAR, it could result in medications being given too close together. 3. Observation of medication administration on 07/24/2024 at 12:28 p.m., for Resident #1 by MA-B, revealed MA-B administered one drop of Refresh Optive Mega-3 eye drops, one drop into each eye, but the physician order indicated REFRESH OPTIVE ADVANCED DROPS Instill 1 drop in both eyes one time a day related to LEGAL BLINDNESS. During an interview on 07/24/2025 at 12:30 p.m., MA-B stated she was aware the eyedrops she administered to Resident #1 did not exactly match the name of the medication on the MAR, but stated this is what the pharmacy delivered so she assumed it was just a substitute for the ordered medication and okay to give. During a joint interview on 07/24/2025 at 12:45 p.m. with the Administrator and DON, the DON stated medications administered to the Residents needed to be administered within the one-hour window for medication administration, and that if it was not given at the correct time, it could affect how medications are absorbed, noting some medications such as Omeprazole should be taken on an empty stomach. The DON further stated that the right medication needed to be given and that meant it matched what was listed on the MAR. The DON stated that if the wrong type of eyedrop was given it could result in possible adverse reaction or decreased therapeutic effect. Record review of facility policy titled Administering Medications revised April 2019 revealed Medications are administered in accordance with prescriber orders, including any required time frame. Further review revealed Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment, for 3of 8 residents (Residents #1, #6, and #3) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #1 had a care plan accessible in his current active record. 2. The facility failed to ensure that Resident #6's diagnoses of anxiety and depression, including a past history of self-harm, were focus areas on the resident's comprehensive care plan. 3. The facility failed to develop and implement a care plan to reflect Resident #3's surgical removal of his kidneys. These deficient practices could place residents at risk for having their medical, nursing and psychosocial needs not being met and staff who provide direct care to the residents not having information needed The findings were: 1.Record review of Resident #1's admission Record revealed he was a [AGE] year-old man admitted [DATE], and re-admitted on [DATE], with diagnoses which included: Legal Blindness (visual acuity of 20/200 meaning a person can see at 20 feet what a person with normal vision can see at 200 feet), Borderline Intellectual Functioning (cognitive abilities that are below average, but not enough to be classified as intellectual disability), Major Depressive Disorder (mental health disorder characterized by persistent depressed mood or loss of interest causing impairment in life), and Anxiety Disorder (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #1's annual MDS assessment dated [DATE] revealed he had a BIMS score of 11, indicating moderate cognitive impairment and had an active diagnosis of legal blindness. Record review of Resident #1's EHR revealed there was no care plan available in Resident #1's Electronic Health Record (EHR). During an interview on [DATE] at 3:35 p.m., the DON checked Resident #1's EHR and confirmed that there was no care plan available in his record. The DON stated the care plan screen showed his care plan was last revised on [DATE] by the Regional Nurse Consultant (RNC) and stated it might have been deleted and she would check with the RNC. The DON stated it was important for staff to have access to the Resident's Care Plans so they could have all the information needed to provide individualized care to the Residents. During an interview with the MDS Nurse on [DATE] at 3:51 p.m., she stated that she also was unable to access Resident #1's Care Plan in the EHR, but knows he had one, and stated the facility switched EHR programs in late April, and Resident #1's Care Plan may not have transferred over yet. The MDS Nurse stated she still had access to the previous EHR system and accessed Resident #1's Care Plan from it, which showed an initiation date of [DATE]. The MDS Nurse stated that only she and a few other staff still had access to the old EHR system. Interview on [DATE] at 08:30 am. with the Regional Nurse Consultant (RNC) revealed she stated the former electronic medical record was not able to transfer everything over to the current EHR system, so they had to manually enter the Care Plans. She stated there were so many Care Plans to enter that she instructed her staff to manually enter the Care Plans at their quarterly reviews and stated that was most likely why Resident #1's Care Plan was not in the new EHR system yet. The Regional Training Nurse checked Resident #1's Care Plan schedule and stated his quarterly should have been done [DATE]. The RNC stated that staff could contact any of the Nursing or Administrative staff 24/7 if they had questions regarding Resident #1's care, but also stated that his Care Plan should have been available and accessible to staff who work with him in the current EHR system, so they had access to all needed care information for Resident #1. 2. Record review of Resident #6's admission Record dated [DATE] revealed an [AGE] year-old woman admitted on [DATE] with diagnoses which included: Psychotic Disorder with delusions due to known physiological condition (mental disorder which consists of a belief or altered reality that is persistently held despite evidence to the contrary); Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities); and Anxiety Disorder (condition with intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #6's 5-day MDS assessment dated [DATE] revealed she had a BIMS score of 12, indicating moderate cognitive impairment. She was assessed with having active diagnoses of Anxiety Disorder, Depression and Psychotic Disorder and was taking antipsychotic, antianxiety and antidepressant medications. Under section D0150 - Resident Mood Interview (PHQ-2 to 9), Resident #6 was assessed as having no symptoms for feeling bad about yourself and having thoughts that you would be better off dead or of hurting yourself in some way. Record review of Resident #6's Order Summary dated [DATE] revealed physician's orders which included:- Buspirone HCL oral tablet 7.5 mg - Give one tablet by mouth two times a day related to anxiety disorder.- Depakote oral tablet delayed release 125 mg (Divalproex Sodium) -Give 1 table by mouth two times a day related to psychotic disorder with delusions due to known physiological condition.- Quetiapine Fumarate [Seroquel] oral tablet 25 mg - Give 1 tablet by mouth at bedtime related to Psychotic Disorder with Delusions due to known physiological condition.- Sertraline HCL [Zoloft] oral tablet 100mg - Give 1 tablet by mouth one time a day for depression.- Trazodone HCL oral tablet 50 mg - Give 1 tablet by mouth at bedtime related Major Depressive Disorder, Single Episode. During an interview on [DATE] at 11:22 a.m., Resident #6 stated she shot herself several months ago, because her husband had died and she did not want to live after that. Resident #6 appeared calm and did not make any statements regarding wanting to harm herself or expressing feelings of depression or hopelessness. She stated the staff had been helping her and she felt safe. Record review of Resident #6's Progress Notes by the Nurse Practitioner (NP) on [DATE] revealed Resident #6's mental and emotional status was assessed and the NP found No indication she would harm herself at this time in the facility. Record review of Resident #6's EHR revealed her husband was alive and was a resident in the same facility but resided in a different room. Further review revealed Resident #6 had initial consult with the mental health counselor on [DATE] and had been receiving both psychiatric and psychotherapy counseling services since her admission. Record review of Resident #6's Care Plan initiated [DATE] revealed focus areas which included Resident is on antipsychotic R/T delusional thinking initiated [DATE]. The interventions for this focus area included: Mental Health to follow resident with counseling: Psychiatric NP to follow resident.; Pharmacy Consultant to follow and make recommendations for GDR/Changes; and Notify MD/RP of any concerns with resident being on antipsychotic. There were no care plan focus areas addressing her past history of or risk of self-harm, or her health diagnoses of anxiety disorder, major depressive disorder, and the medications she took as treatment for her mental health conditions. During a joint interview with the DON and MDS Nurse on [DATE] at 1:34 p.m., the MDS Nurse stated that Resident #6's family member #1, requested that the facility not mention Resident #6's attempted suicide in her documentation, as the family wished to keep it private, and therefore she did not put it explicitly in the care plan. The DON stated that the psychiatrist and mental health counselor and nursing staff assessed and monitored Resident #6's mental health status closely, and noted she has shown improvement since treatment has started. The DON stated that although the family requested her past attempt at self-harm not be included in her record, Resident #6's care plan should have included focus areas addressing her psychiatric diagnoses of Anxiety and Depression, monitoring for side effects of the psychoactive medications she takes to treat her Anxiety and Depression, including the past history of self-harm, so that staff could be aware of what signs/symptoms of ineffective coping, that needed to be monitored for and reported, as well as any other interventions the team has put into place to meet her psychiatric needs into her care plan. 3. Record review of Resident #3's admission Record dated [DATE] revealed he was admitted on [DATE] with re-admit on [DATE] and had diagnoses which included: Dementia (general term for loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) , acquired absence of kidney (surgical removal of kidney) and nicotine dependence. Record review of Resident #3's 5-day MDS assessment dated [DATE] revealed he had a BIMS score of 3, indicating severe cognitive impairment and was assessed as having an active diagnosis of acquired absence of kidney. Review of Resident #3's Nursing Progress Note dated [DATE] revealed Resident arrived to facility via EMS.s/p RT radical nephrectomy [removal of kidney] for right adrenal mass [growth found on adrenal gland located on top of right kidney]. Mass diagnosed as adenocarcinoma [type of cancer that grows in glandular cells]. Record review of Resident #3's Comprehensive Care Plan initiated [DATE] revealed the resident's surgical removal of a kidney on [DATE] was not included in his care plan. During an interview with Resident #3 and his friend on [DATE] at 1:37 p.m., his friend stated that Resident #3 had a bad kidney and had it surgically removed recently. She stated that the doctors told him that if he did not stop smoking, he could severely damage his one remaining kidney, so he made the choice to stop smoking. She stated it was important to him to protect his remaining kidney. During a joint interview with the DON and MDS Nurse on [DATE] at 1:34 p.m. the DON stated that the surgical removal of Resident #3's right kidney should have been included in his care plan, as it would have been important to include interventions such as educational needs, and health monitoring into his plan. The DON stated the care plan provided information to the staff on the personalized care needs of each resident, and not having information regarding his acquired absence of a kidney in his care plan could result in Resident #3 not receiving the individualized care he needs. The DON stated she only recently started working at the facility, after he had already had the surgery, so she did not know why it was not included in his plan. The MDS Nurse noted that revision and updating of care plans was a group effort between herself and the DON and noted Resident #3's surgical removal of his kidney occurred when the previous DON was leaving and before the new DON started work, and believes that was the reason they missed updating his care plan to reflect the surgical removal of his kidney. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered revised [DATE] revealed in part, .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 care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . and 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 that all drugs and biologicals used in the facility, were labeled and stored in accordance with professional standards for 1 (Hall 300 Nurse's medication cart) of 3 medication carts reviewed for medication storage. The facility failed to ensure one controlled medication Morphine Sulfate 20mg/5ml oral suspension for Resident #8 was removed from the medication cart when it had expired on 12/28/2024. This failure could place residents at risk of not receiving the therapeutic benefit of medications.Findings included: Record review of Resident #8's admission Record dated 07/22/2025 revealed she was an [AGE] year-old woman admitted [DATE] with re-admission on [DATE] and with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that blocks air flow and makes it difficult to breathe). Record review of Resident #8's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 2, indicating severe cognitive impairment. Record review of Resident #8's Order Summary dated 07/22/2025 revealed a physician order for Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate) Give 1 ml by mouth every 4 hours as needed for pain or shortness of breath. During an observation of the Hall 300 Nurse's medication cart with LVN-A present on 7/24/2025 at 8:00 a.m., a box of Morphine Sulphate 20mg/5ml oral suspension prescribed for Resident #8 with an expiration date of 12/28/2024 was found in the back of the locked controlled medication storage inside the Hall 300 Nurse's medication cart. Interview on 07/24/2025 at 8:04 a.m. with LVN-A revealed she had only been working at the facility for 3 weeks. LVN-A stated that the date on the pharmacy label for the Morphine Sulfate showed that the medication was expired. LVN-A stated she did not know whose responsibility it was to check the medication carts and remove expired medications, but she would ask her supervisor. During an interview on 07/24/2025 at 08:10 a.m., the DON reviewed the pharmacy label on the Morphine Sulfate for Resident #8 and confirmed that it was expired and should not be stored in the medication cart. The DON stated that it was the responsibility of the Nurse using the medication cart to remove any expired medications. She stated expired medications may lose some of their therapeutic effect, and not removing expired medications from the medication cart may result in expired medications being administered to residents. Record review of Competency Checklist for LVN-A dated 7/10/2025, revealed LVN-A had been checked as showing competency in pharmacy to include: expiration of medications, ordering medications, House stock and Documentation. Record review of the facility policy titled Medication Labeling and Storage revised February 2023 revealed If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 1 resident (Resident #6) reviewed for PASRR assessments. The facility did not refer Resident #6 to the appropriate state-designated mental health authority for review when she was admitted with diagnoses including: Psychotic Disorder with delusions due to known physiological condition (mental disorder which consists of a belief or altered reality that is persistently held despite evidence to the contrary); Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities); and Anxiety Disorder (condition with intense, excessive, and persistent worry and fear about everyday situations). This failure could place residents at risk of not being evaluated and receiving needed PASRR services. Findings included: Record review of Resident #6's admission Record dated 07/23/2025 revealed an [AGE] year-old woman admitted on [DATE] with diagnoses which included: Psychotic Disorder with delusions due to known physiological condition (mental disorder which consists of a belief or altered reality that is persistently held despite evidence to the contrary); Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities); and Anxiety Disorder (condition with intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #6's 5-day MDS assessment dated [DATE] revealed she had a BIMS score of 12, indicating moderate cognitive impairment. She was assessed with having active diagnoses of Anxiety Disorder, Depression and Psychotic Disorder and was taking antipsychotic, antianxiety and antidepressant medications. Record review of Resident #6's Care Plan initiated 6/17/2025 revealed a Focus area for Resident is on antipsychotic R/T delusional thinking, initiated 6/19/2025. Record review of Resident #6's PASRR Level 1 screening dated 6/16/2025 reflected she did not have a primary diagnosis of dementia and did not have a mental illness. During an interview on 07/25/2025 at 10:09 a.m., the MDS Nurse stated she was responsible for the PASRR reviews and stated Resident #6 was admitted from the hospital on a weekend, and she completed Resident #6's PASSR that following Monday, 6/16/2025. She stated she relied primarily on the hospital records when she completed the PASSR review for Resident #6, and the PASRR review from the hospital did not indicate any dementia or mental illness. After reviewing Resident #6's admission record and diagnoses, the MDS Nurse confirmed Resident #6 was admitted with diagnoses of Psychotic Disorder with Delusions, Major Depressive Disorder and Generalized Anxiety Disorder, and stated she used poor judgement when she did not revise the PASSR to reflect that Resident #6 had mental illness without a diagnosis of dementia as that would have prompted the Local Mental Health Authority to come to facility for a Level 2 PASSR screening to determine her eligibility for PASSR services. The MDS Nurse stated that Resident #6 was currently receiving mental health counseling and psychiatric services. Record review of Resident #6's EHR revealed she was seen by the mental health counselor on 6/18/2025, and by the psychiatric provider on 6/24/2025 for initial consult, and continued to be seen regularly by both. Interview with the DON on 07/25/2025 at 10:13 a.m. revealed she stated that Resident #6 did have diagnoses of mental illness and her PASRR should have reflected this upon her admission from the hospital. The DON stated that Resident #6 was seen by the mental health counselor within days after her admission and continues to receive regular mental health counseling and psychiatric services, but the result of not referring her for Level 2 PASRR screening was that these services were not coordinated through the local authority. The DON further stated they did not have a policy regarding PASRR services as they use the state guidelines.

Based on interview and record review the facility failed to ensure the resident had the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option preferred for 1 of 8 Residents (Resident #6) whose records were reviewed for informed consent. The facility failed to ensure psychoactive medication consents for Resident #6 were signed and dated by her POA (Power of Attorney) for the use of: Seroquel (antipsychotic medication); Buspar (anti-anxiety); Zoloft (anti-depressant); Trazodone (anti-depressant); and Depakote (anti-convulsant also used to treat mood disorder) This failure could place residents at risk for receiving psychoactive medications without consent and knowledge of side effects.The findings were: Record review of Resident #6's admission Record dated 07/23/2025 revealed an [AGE] year-old woman admitted on [DATE] with diagnoses which included: Psychotic Disorder with delusions due to known physiological condition (mental disorder which consists of a belief or altered reality that is persistently held despite evidence to the contrary); Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities); and Anxiety Disorder (condition with intense, excessive, and persistent worry and fear about everyday situations). Further review revealed Resident #6 had a family member who had Power of Attorney for medical and financial. Record review of Resident #6's 5-day MDS assessment dated [DATE] revealed she had a BIMS score of 12, indicating moderate cognitive impairment. She was assessed with having active diagnoses of Anxiety Disorder, Depression and Psychotic Disorder and was taking antipsychotic, antianxiety and antidepressant medications. Record review of Resident #6's Order Summary dated 07/25/2025 revealed physician orders which included:- Buspirone HCL oral tablet 7.5 mg - Give one tablet by mouth two times a day related to anxiety disorder.- Depakote oral tablet delayed release 125 mg (Divalproex Sodium) -Give 1 table by mouth two times a day related to psychotic disorder with delusions due to known physiological condition.- Quetiapine Fumarate [Seroquel] oral tablet 25 mg - Give 1 tablet by mouth at bedtime related to Psychotic Disorder with Delusions due to known physiological condition.- Sertraline HCL [Zoloft] oral tablet 100mg - Give 1 tablet by mouth one time a day for depression.- Trazodone HCL oral tablet 50 mg - Give 1 tablet by mouth at bedtime related Major Depressive Disorder, Single Episode. Record review of Resident #6's Care Plan initiated 6/17/2025 revealed a Focus area for Resident is on antipsychotic R/T delusional thinking, initiated 6/19/2025. There were no Care Plan focus areas for other medications. During an interview on 07/22/2025 at 11:22 a.m., Resident #6 stated she was experiencing a lot of back pain and the pain medication the Nurses gave her really helped. However, Resident #6 was not aware of any other medications that she takes. Record review of the Resident #6's EHR did not reveal any consents for psychoactive medications. During an interview on 07/25/2025 at 1:23 p.m., the DON stated there were no consents for psychoactive medications for Resident #6 in the EHR, so she completed a hard copy record search and was able to find a consent for Seroquel for Resident #6, but the consent for Seroquel was not dated or signed by the POA. She stated she was not able to find any other consents for psychoactive medications for Resident #6. She stated she had only been here at the facility for 2 weeks, so she checked with other staff who have been here longer, and their search resulted in no consents for Resident #6 being found. Further interview with DON revealed the DON or his/her designee were ultimately responsible for ensuring medication consents were obtained prior to giving the medications and did not know why the consents were not obtained and documented in the EHR. The DON stated that not obtaining a consent prior to the start of a medication may result in the medication being given without the resident or their representative party being aware of the risks, side effects and benefits of the medication being given. Record review of facility policy titled Antipsychotic Medication use revised July 2022 provided by DON when policy regarding need for obtaining consent for psychoactive medications was requested, revealed there was no information included in the policy regarding need to obtain consent for psychoactive medications.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 6 residents (Residents #4 and #24) reviewed for infection control: 1.The facility failed to maintain proper infection control procedures when LVN-A place Resident #4's open left heel wound directly onto the Resident's bedspread to during wound care treatment. 2.The facility failed to ensure MA-B sanitized the blood pressure cuff per facility protocol before and after checking Resident #24's blood pressure. These failures could place residents at-risk for infection due to improper care practices. The findings included: 1.Record review of Resident #4's admission Record dated 07/25/2025 revealed she was an [AGE] year-old woman admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included: Venous insufficiency-peripheral (condition where veins in leg become damaged and struggle to send blood back up to the heart), and hemiplegia and hemiparesis following cerebral infarction (partial paralysis on one side of body resulting from a stroke) affecting left non-dominant side. Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment and was assessed as having a pressure ulcer/injury over bony prominence requiring application of dressings to feet. Record review of Resident #4's Order Summary dated 07/25/2025 revealed an order for Left heel wound: Cleanse with wound cleanser, apply betadine, wrap with kerlix every day shift for wound care related to VENOUS INSUFFICIENCY (CHRONIC) (PERIPHERAL). Record review of Resident #4's Care Plan revealed a focus area for Pressure ulcer to left heel-stage 3 initiated 06/19/2025, with interventions which included treatments as ordered. Observation on 07/24/2025 at 2:09 p.m. of wound care for Resident #4 by LVN-A revealed that after removing the old dressing from Resident #4's left heel, LVN-A placed Resident #4's heel/foot on top of the bedspread on her bed to rest while LVN-A sanitized her hands and changed her gloves. After sanitizing her hands and changing her gloves, LVN-A picked up Resident #4's left foot and proceeded to clean and change the dressing per physician orders. During an interview on 07/24/2025 at 2:28 p.m. - LVN-A stated she was having trouble holding up Resident #4's foot and trying to clean/dress the wound at the same time. LVN-A stated she should not have placed Resident #4's heel down on the bedspread as it was not a sanitized surface, which could result in transfer of germs into the heel wound, and the transfer of germs onto the bedspread. LVN-A stated she had only been working at the facility a few weeks but had received training in infection control and wound care. Interview on 07/25/2025 at 9:50 a.m. with the DON revealed the DON stated that LVN-A should not have placed Resident #4's heel wound directly onto a surface that was not clean, as this could result in spread of infection. The DON stated LVN-A had received training in wound care and infection control, but they will educate and re-do her competency checklist for infection control. 2.Record review of Resident #24's admission Record dated 07/25/2025 revealed he was a [AGE] year-old man admitted [DATE] with diagnoses which included Essential Hypertension (high-blood pressure). Record review of Resident #24's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment and had an active diagnosis of hypertension. Record review of Resident #24's Medication Administration Record (MAR) for July 2025 revealed an order for AMLODIPINE BESYLATE 10MG TAB Give 1 tablet orally one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION with space on the MAR to document Resident #24's blood pressure. During an observation of medication administration for Resident #24 on 07/24/2025 at 8:16 a.m., MA-B was observed to clean the blood pressure cuff before and after checking Resident #24's blood pressure by taking a tissue, pumping 1-2 pumps of gel from the hand sanitizer dispenser onto the tissue, and cleaning the blood pressure cuff with the tissue. During an interview with MA-B on 07/24/2025 at 12:30 p.m., MA-B stated that cleaning the blood pressure cuff with a tissue that had hand sanitizer gel on it was not the proper way to sanitize the cuff. She opened one of the drawers on the medication cart to reveal a blue top disinfecting wipes container labeled Micro-Kill Bleach and stated that is what they are supposed to use to sanitize the blood pressure cuffs in between uses, however she is allergic to bleach so she cannot use it. She further stated she had seen other staff clean the blood pressure cuffs using tissue and hand-sanitizing gel, so thought it would be okay, noting if it could sanitize hands it should be enough to sanitize the blood pressure cuffs. During an interview with the ADM and DON on 07/24/2025 at 12:45 p.m., the DON stated that using a tissue with hand sanitizer gel on it was not an acceptable method to sanitize a blood pressure cuff and could result in the spread of infection. The DON stated that Medication Aides and Nurses are taught to sanitize blood pressure cuffs using the purple top disinfecting wipes (Super Sani-Cloth) which do not contain bleach, and to wear gloves when they were disinfecting the blood pressure cuffs, and that they will be in-servicing MA-B regarding infection control and device sanitation. Interview on 07/25/2025 at 9:50 a.m. with the DON revealed the DON stated that they do not have a policy which specifically addresses how to sanitize blood pressure cuffs. Record review of facility policy titled Standard Precautions revised September 2022, revealed under policy statement Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. and Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed.

Based on interviews and record review the facility failed in accordance with accepted professional standards and practices, to maintain medical records on each resident that are complete and accurately documented, for 1 of 8 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's application of TED hose was accurately documented on his Medication Administration Record (MAR) for 23 of 23 daily entries in July 2025. This failure could place the residents at risk of not receiving the care and services needed due to inaccessible and inaccurate clinical records. Findings included: Record review of Resident #1's admission Record revealed he was a [AGE] year-old man admitted [DATE], and re-admitted on [DATE], with diagnoses which included: Legal Blindness (visual acuity of 20/200 meaning a person an see at 20 feet what a person with normal vision can see at 200 feet), Borderline Intellectual Functioning (cognitive abilities that are below average, but not enough to be classified as intellectual disability), Major Depressive Disorder (mental health disorder characterized by persistent depressed mood or loss of interest causing impairment in life), and Anxiety Disorder (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #1's annual MDS assessment dated [DATE] revealed he had a BIMS score of 11, indicating moderate cognitive impairment and had an active diagnosis of legal blindness. Record review of Resident #1's Order Summary dated 07/24/2025 revealed an order for TED Hose -On in AM, off at HS at bedtime for edema (swelling). Record review of Resident #1's July 2025 MAR revealed every daily entry at 0700 from 07/01/2025 through 07/23/2025 was checked and initialed for TED Hose - On in AM. indicating that TED hose were placed on Resident #1 every morning. Further review revealed 20 of 22 daily entries at 1900 (7:00p.m.) were documented with a 9 indicating see progress note. The two remaining daily entries at 1900 were documented as off and N/A (non-applicable). Observation and Interview with Resident #1 and family member #1 on 07/23/2025 at 2:53 p.m. revealed Resident #1 was sitting on the edge of his bed, wearing black compression knee-hi socks on his feet. Resident #1 stated staff have never put TED hose on him, and he always wears the type of socks he was currently wearing, and he puts them on himself every day. Resident #1's family member stated she has never seen staff put TED hose on Resident #1, and he always puts on the black knee-high compression socks he was wearing currently. Interview on 07/23/2025 at 6:36 p.m. with LVN C revealed she has never seen Resident #9 wear TED hose, so she documents 9 on his MAR, which she stated meant to check the progress record, and stated she usually writes in note that Resident #1 was not wearing TED hose at 7:00p.m. LVN-C stated she thought his primary doctor was going to discontinue the TED hose order, because he does not experience leg swelling anymore and does not need them. During an observation of Resident #1, and interview with the Unit Manager on 07/24/2025 at 8:03 a.m. the Unit Manager stated that Resident #1 wears his black compression socks every day, and stated that the day Nurse's were documenting the use of the compression socks in place of the TED hose on his MAR. The Unit Manager noted Resident #1's ankle/feet/legs were not swollen at this time. Observation of Resident #1 during this interview revealed Resident #1's ankle/feet/legs were not swollen. During an interview on 07/24/2025 at 4:50 p.m., the DON stated that compression socks and TED Hose were not the same thing and should not be substituted one for the other. TED hose are used to treat edema and are used primarily for bed bound residents, and compression stockings are used for residents who are more ambulatory. The DON stated she will contact Resident #1's primary physician for clarification of the TED hose order, and also stated the discrepancy on Resident #1's (day shift documenting TED hose were placed on in mornings and night shift documenting the TED hose were not on at 7:00p.m.) was inaccurate documentation and she would address. Record review of facility policy titled Charting and Documentation undated revealed The following information is to be documented in the resident medical record:.treatments or services performed. and Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

Based on observation, interview, and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 2 of 3 residents (Residents #4 and #15) reviewed for personal food policy, in that: 1.Resident # 4's personal refrigerator located in her room revealed food item of a glass jar of Picante Sauce which had been opened with a Best Use By Date of February 9,2025. There was no label or date of when the jar had been opened. 2.Resident # 15's personal refrigerator located in his room revealed food item of a Styrofoam cup covered with clear plastic wrap with white liquid inside it. There was no label or date identifying the name or date. These failures could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included:Record review of Resident #4's face sheet, dated 07/24/2025, reflected the resident was an [AGE] year old female and was initially admitted to the facility on [DATE] with diagnoses that included: Fracture of the Left Femur (Broken leg), Hemiplegia and Hemiparesis affecting Left non-dominant side (Unable to move left side of body) Unspecified Dementia (group of symptoms that affect memory, thinking, and other cognitive functions, significantly impacting daily life) Record review of Resident #4's quarterly MDS assessment, dated 07/07/2025, reflected the resident's BIMS score was 4 out of 15 which indicated the resident had severe cognitive impairment. Record review of Resident # 15's face sheet, dated 07/24/2025, reflected the resident was an [AGE] year-old male and was initially admitted to the facility on [DATE] with diagnoses that included: Muscle Wasting and Atrophy (loss of muscle tissue and strength), Chronic Kidney Disease Stage 3 (kidneys are not filtering correctly), Type 2 Diabetes (body does not produce enough insulin). Record review of Resident #15's quarterly MDS assessment, dated 05/01/2025, reflected the resident's BIMS score was 13 out of 15 which indicated the resident had mild cognitive impairment. Observation on 07/22/2025 at 11:00 a.m. revealed Resident #4 was not in her room. There was a personal refrigerator in the room, and inside the refrigerator was a glass jar of Picante Sauce which had been opened with a Best Use by Date of February 9,2025. There was no label or date of when the jar had been opened. Observation on 07/22/2025 at 11:30 a.m. revealed Resident #15 was not in his room. There was a personal refrigerator in the room, and inside the refrigerator was a Styrofoam cup covered with clear plastic wrap with white liquid inside it. There was no label or date identifying the name or date. Interview and observation on 07/24/2025 beginning at 11:00 a.m. the DON and the Administrator went to both residents' room and showed them the food items. I asked what the white liquid was in the Styrofoam cup. They thought it might be milk. I asked them how long it had been in the refrigerator. The DON and Administrator were unable to answer since there was no date on the cup I talked to them about the expired picante sauce jar. I asked the DON and Administrator what could happen if food or drink that is consumed that is outdated, and both replied that the residents could become ill. The DON and Administrator confirmed that outdated food should be thrown away. I asked who is responsible for checking items in refrigerator. The Administrator told me it is the nursing staff, and the housekeeping keeps track of the temperature logs. Record review of the facility policy titled Foods Brought by Family/Visitors, revised March 2022, revealed .5. Food brought by family/visitors that is left with the resident to consume later will labeled and stored in a manner that is clearly distinguishable from facility-prepped food. 6. The nursing staff will discard perishable foods on or before the use by or expiration date.

Based on observation, interview, and record review the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 1 of 5 Residents (Resident #1) whose assessment records were reviewed. The facility failed when nursing staff did not code on Section GG of MDS Comprehensive assessment dated [DATE] that Resident #1 had functional limitation in range of motion to her upper extremity. This deficient practice could affect residents and contribute to residents not receiving care and services as needed. The findings included: Review of Resident #1's face sheet, printed 04/29/25, revealed the resident was admitted to the facility on [DATE]/24 with a primary diagnoses of myopathy (a disease of the muscle in which muscle fibers do not function properly), Rheumatoid Arthritis (an autoimmune disorder where the immune system attacks to joints, causing inflammation, pain and potential joint damage), Osteoarthritis (a degenerative joint disease characterized by the breakdown of joint tissues over time), Osteoporosis a condition that causes bone loss and increases the risk of fractures), Osteopenia (a condition characterized by lower than normal bone density which makes bones weaker and more susceptible to fractures), contractures of multiple sites (structural changes to soft and connective tissues that cause them to stiffen, tighten and contract that causes tissues to lose their former elasticity and range of motion), chronic pain, hypermetropia (far sightedness), Hypertension, anxiety, insomnia, and muscle atrophy (wasting or thinning of muscle mass). Record review of Resident #1's MDS, dated [DATE], revealed it was noted that the resident had no impairment to upper extremity (should, elbow, wrist, hand). Interview and observation on 04/29/2025 at 11:20 AM with Resident #1 revealed she had suffered with hand contractures from Rheumatoid Arthritis for many years. Resident #1 presented with left hand contractures and no assistive device was in place. Interview on 04/29/2025 at 1:08 PM with MDS Coordinator LVN A revealed Resident #1's MDS Comprehensive assessment, dated 02/13/2025, did not capture that Resident #1 has limited range of motion secondary to contractures. LVN A stated it was important to accurately reflect Resident #1's status so staff would provide the necessary care and services needed. Record review of Resident #1's Care Plan problem, dated 2/14/24, revealed Resident #1 required assistance of staff to transfer and that resident has contractures. Record review of Resident #1's physician's progress note, dated 09/18/2024, revealed the resident had definite decreased range of motion and contractures to distal extremities. Interview on 04/30/25 11:30 AM with the DON revealed DON stated accuracy of MDS records was important to ensure correct information was submitted to Centers for Medicare & Medicaid Services. Interview on 04/30/25 at 11:30 AM with the Administrator revealed the Administrator stated expectations were for accurate information to be reflected on the MDS. Record review of the facility policy, Comprehensive Assessments, revised February 2025, read Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User manual.

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 3 of 8 residents (Residents # 2, #3 and #7) reviewed for respiratory therapy. 1. The facility failed to ensure Resident #2 had a physician order, was care planned or had an oxygen safety sign on the resident's room door. 2. The facility failed to ensure Resident #3 had a physician order, was care plan or had an oxygen safety sign on the resident's room door. 3. The facility failed to ensure Resident #7 had a care plan or oxygen safety sign on the door. These deficient practices could place residents at risk of receiving incorrect or inadequate oxygen support which could result in a decline in health. Findings include: 1) Record review of Resident #2's, undated, face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Hypertensive Heart Disease (heart problems caused by high blood pressure) and Dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #2's admission MDS assessment, dated 02/06/2025, revealed Resident #2 had a BIMS score of 7, which indicated severe cognitive impairment. Section GG - Functional Abilities revealed Resident #2 used a wheelchair for mobility and required moderate assistance with mobility in the wheelchair. Resident #2 required supervision with chair to bed transfers and bed mobility. Section O - Special Treatments, Procedures, and Programs revealed Resident #2 was not receiving oxygen therapy. Record review of Resident #2's March 2025 consolidated physician orders revealed Resident #2 did not have an order for oxygen administration. Record review of Resident #2's comprehensive care plan revealed a care plan, dated 02/12/2025, which stated Resident #2 was on hospice services related to a terminal condition. Resident #2 did not have a care plan for oxygen administration. During an observation on 03/25/2025 at 9:30 a.m., an oxygen concentrator and oxygen cylinder were observed in Resident #2's room and there was not a no smoking/oxygen in use sign on the door. The concentrator and cylinder were not in use. During an interview with LVN A on 03/25/2025 at 1:48 p.m., LVN A stated Resident #2 was on hospice and had oxygen in his room as needed. LVN A said she thought Resident #2 had an order for oxygen and residents on oxygen were identified by having a sign on the resident's door which indicated oxygen was in use. 2) Record review of Resident #3's, undated, face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included Alzheimer's Disease (a progressive disease that affects memory and other important mental functions) and Congestive Heart Failure (a condition in which the heart doesn't pump blood as well as it should). Record review of Resident #3's quarterly MDS assessment, dated 01/08/2025, revealed Resident #3 had a BIMS score of 06, which indicated severe cognitive impairment. Section GG- Functional Abilities revealed Resident #3 used a wheelchair for mobility and was dependent on staff for transfers and bed mobility. Section O - Special Treatments, Procedures, and Programs revealed Resident #3 was not receiving oxygen therapy. Record review of Resident #2's March 2025 consolidated physician orders revealed Resident #2 did not have an order for oxygen administration. Record review of Resident #3's comprehensive care plan revealed a care plan, dated 10/11/2024, which stated Resident #3 was on hospice services related to a terminal condition. Resident #3 did not have a care plan for oxygen administration. During an observation on 03/25/2025 at 9:40 a.m., an oxygen cylinder was observed in Resident #3's room and there was not a no smoking/oxygen in use sign on the door. The oxygen cylinder was not in use. 3) Record review of Resident #7's, undated, face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included End Stage Renal Disease (progressive loss of kidney function), Hemiplegia (paralysis of one side of the body), Type II Diabetes (a condition that results in too much sugar circulating in the body) and Depression (a mood disorder that causes persistent feelings of sadness and loss of interest). Record review of Resident #7's admission MDS assessment, dated 03/19/2025, revealed Resident #7 had a BIMS score of 1, which indicated severe cognitive impairment. Section GG- Functional Abilities required partial to moderate assistance with ADL's, transfers, and bed mobility. Section O - Special Treatments, Procedures, and Programs revealed Resident #7 was not coded as receiving oxygen therapy. Record review of Resident #7's March 2025 consolidated physician orders revealed Resident #7 had an order, dated 03/07/2025, for oxygen at 2-5 liters per minute for shortness of breath as needed. The MAR revealed oxygen had not been administered since admission. Record review of Resident #7's comprehensive care plan, dated 03/20/2025, revealed a care plan, which stated Resident #7 was on hospice services related to a terminal condition. Resident #7 had a care plan that revealed Resident #7 was at risk for edema (swelling), shortness of breath and fluid volume overload related to renal failure. Resident #7 had a care plan that revealed Resident #7 was had the potential for a safety hazard or injury related to Resident #7 being a smoker. Resident #7 did not have a care plan for oxygen administration. During an observation on 03/25/2025 at 2:03 p.m., an oxygen cylinder was observed in Resident #7's room and there was not a no smoking/oxygen in use sign on the door. The oxygen cylinder was not in use. During an interview with CNA B on 03/25/2025 at 2:08 p.m., CNA B stated Resident #7 did not use the oxygen in her room and hospice brought the tank just in case it was needed. CNA B stated there should have been an oxygen in use sign on Resident #7's door and the Charge Nurse or DON were responsible for placing the signs on the door. During an interview with LVN D on 03/26/2024 at 10:57 a.m., LVN D stated residents on oxygen were identified by having a sign on their door and most of the hospice patients had oxygen in their rooms and should have oxygen orders. LVN D stated the nursing staff was responsible for managing the oxygen and getting oxygen orders. During an interview with the Administrator on 03/26/2025 at 12:56 p.m., the Administrator stated residents on oxygen or residents with oxygen equipment in their room were supposed to have signs for oxygen on their room door. The Administrator stated it was important to have the oxygen in use signs so we can make sure we are changing out the tubing and have the oxygen on the resident but also to remind people to not smoke, or if there is an issue with fire, to get them to safety. The Administrator stated it was important to have oxygen orders so we know if and what amount of oxygen we should be giving to the resident. The Administrator stated oxygen administration should be part of a resident's comprehensive care plan so we know what level of care we are supposed to be providing to the resident and stated it was the responsibility of nursing to place the place the oxygen signs, obtain the orders and update the resident care plan. The Administrator stated staff received education on the oxygen administration system on 3/25/2025 but was unsure when educated was offered prior to that date. During an interview with the DON on 02/26/2025 at 1:46 p.m., the DON stated residents on oxygen should have a sign on their door and an order for oxygen administration. The DON stated she was unsure if these measures should be in place for a resident not actively using the oxygen but had oxygen equipment in their room. The DON stated it was important for a resident with oxygen equipment to have an order so the nurses know what to administer with the order if the resident needs it. The DON stated residents on oxygen should have a care plan so the nurses know how much oxygen to give them and what interventions to use. The DON stated Residents #2, #3 and #7 had not used their oxygen equipment and hospice placed oxygen equipment in rooms of hospice patients so it was available if needed. The DON stated oxygen should not have been placed in resident rooms without an order. Record review of the facility's policy titled Oxygen Administration, Copyrighted 2001 MED-PASS, Inc. (Revised October 2010), revealed the purpose of the policy was to provide guidelines for safe oxygen administration. Under Preparation it stated, 1. Verify that there is a physician's order for this procedure . 2. Review the resident's care plan to assess any special needs of this resident. 3. Assemble the equipment and supplies needed .The following equipment will be necessary when performing this procedure .4. 'No Smoking/Oxygen in Use' signs.

Based on observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 8 residents (Resident #2 and Resident #6) reviewed for reasonable accommodation of resident needs. 1. The facility failed to ensure Resident #2 had access to his call light which was draped over his nightstand outside of the resident's reach. 2. The facility failed to ensure Resident #6 had access to her call light which was wrapped around the call light plug on the wall, behind Resident #6 and outside of her reach. These deficient practices could place residents at risk of not maintaining and/or achieving independent functioning, dignity, and well-being. Findings include: 1) Record review of Resident #2's, undated, face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Hypertensive Heart Disease (heart problems caused by high blood pressure) and Dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #2's admission MDS assessment, dated 02/06/2025, revealed Resident #2 had a BIMS score of 7, which indicated severe cognitive impairment. Section GG - Functional Abilities revealed Resident #2 used a wheelchair for mobility and required moderate assistance with mobility in the wheelchair. Resident #2 required supervision with chair to bed transfers and bed mobility. Record review of Resident #2's comprehensive care plan revealed a care plan, dated 02/12/2025, which stated Resident #2 was at risk for falls related to Resident #2 requiring assistance, unsteady gait, confusion, medications, and behavioral symptoms. The care plan included an intervention which stated, call bell in reach, educate and encourage use, answer all requests for assistance. Resident #2 had a care plan, dated 02/21/2025, which stated Resident #2 was a fall risk related to self-transfers, unsteady gait and confusion and included an intervention, call bell in reach, explain/encourage use and answer promptly. Resident #2 had a care plan dated, 02/12/2025, which stated Resident #2 had a self-care deficit and required assistance with ADLs. The care plan intervention stated, keep call light within reach and encourage to use it for assistance. Respond to all requests for assistance. Record review of Resident #2 Fall Risk Assessment, dated 01/27/2025, completed by the DON revealed Resident #2 scored a 14. The risk assessment stated a score of 10 or higher represented a high risk for falls. During an observation on 03/25/2025 at 9:30 a.m., revealed Resident #2 was observed asleep in his recliner with leg rest halfway up. The resident was leaning to his far-right side and had a single serving size of chips in his lap that had spilled on his recliner and on his legs. Resident #2 had a push button call light and a soft touch call light that were both draped across a nightstand which was not within Resident #2's reach. During an observation on 03/25/2025 at 1:47 p.m., Resident #2 was observed sleeping upright in his recliner with his legs fully extended and the call light was draped across a nightstand which was not within Resident #2's reach. During an observation on 03/25/2025 at 2:00 p.m., Resident #2 was observed sitting in his recliner with his call light on the nightstand which was not within his reach. Resident #2 woke up when the state surveyor entered the room and immediately began trying to scoot out of the recliner and said, get me up. Resident #2 was not able to answer questions about his call light related to his cognition. During an interview with LVN A on 03/25/2025 at 1:48 p.m., LVN A stated all resident call lights should be within reach of the resident when the resident was in their room. LVN A stated she received education on keeping call lights in reach and the placement of call lights was the responsibility of the nurses and CNA's. LVN A observed Resident #2's call light placement and stated Resident #2's call light was out of reach of Resident #2. LVN A stated it was important call lights were in reach on residents in case the resident needs assistance and to prevent falls. 2) Record review of Resident #6's, undated, face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included Alzheimer's Disease (a progressive disease that affects memory and other important mental functions) and Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #6's quarterly MDS assessment, dated 01/30/2025, revealed Resident #6 had a BIMS score of 3, which indicated severe cognitive impairment. Section GG -Functional Abilities revealed Resident #6 required supervision with chair to bed transfers and was ambulatory with supervision. Record review of Resident #6's comprehensive care plan revealed a care plan, dated 07/21/204, which stated Resident #6 was at risk for falls due to requiring assistance, unsteady gait/balance, and cognitive impairment. An intervention for falls stated, call bell in reach, educate and encourage use and answer. A care plan, dated 07/31/2024, revealed Resident #6 required assistance for ADL's and the intervention stated, keep call light within reach and instruct resident on use as needed. During an observation on 03/25/2025 at 1:40 p.m. revealed Resident #6 was observed asleep in her bed with her call light cord wrapped around the call light plug on the wall behind Resident #6's bed, placing the call light outside of Resident #6's reach. During an interview with CNA B on 03/25/2025 at 2:08 p.m., CNA B stated resident call lights should be clipped to a resident sitting in a wheelchair in their room or laid across their chest when in bed so the resident could reach the call light. CNA B stated everyone was responsible for making sure call lights were within reach for residents in their rooms which included herself, housekeeping and the Administrator. CNA B stated Resident #6 used her call light faithfully to call for assistance when Resident #6 needed anything. CNA B observed Resident #6's call light placement wrapped around the call light plug on the wall behind Resident #6 and stated, maybe the resident placed it there and removed the call light cord from the wall and placed the call light next to Resident #6. During an interview with Resident #6 on 02/25/2025 at 3:30 p.m., Resident #6 stated she did not wrap her call cord after the call cord plug in on the wall and stated, why would I do that, I would have had to crawl up my bed and wrap it up, no I did not do that. Resident #6 stated staff usually kept her call light within reach and stated she used the call light to call for staff assistance with things she needed in her room. During an interview with the Administrator on 03/26/2025 at 12:56 p.m., the Administrator stated call lights should be located within reach of residents and she could not recall if an in-service had been conducted on call light placement within the last 12 months. The Administrator stated the CNA's and all staff were responsible for ensuring call lights were within reach of residents and a resident could get up on their own and hurt themselves if they did not have a way to reach anyone for help. During an interview with the DON on 03/26/2025 at 1:46 p.m., the DON stated call lights should be within reach of the residents in their rooms. The DON stated she trained staff to place the call lights across the laps or chest of residents but stated a lot of our clips are not working that are used to attached call light cords to clothing or sheets. The DON stated she would change out the call cords if a broken clip was identified. The DON stated she was not sure when the last training or call light placement education was conducted but she would be adding it to training in the near future for staff. The DON stated everyone was responsible for ensuring call lights were within reach for residents and a resident who did not have a call light in reach could fall and be injured. Record review of the facility policy titled Answering the Call Light, Nursing Services Policy and Procedure Manual, Copyrighted 2001 MED-PASS, Inc and revised October 2010, stated the purpose was to respond to the resident's requests and needs. Under the general guidelines .5. When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 8 residents (Residents #1 and #4) reviewed for care plans. 1. The facility failed to ensure a care plan was developed to address Resident #1's enhanced barrier precautions which required staff to utilize gowns and gloves when direct care was provided. 2. The facility failed to ensure a care plan was developed to address Resident #4's enhanced barrier precautions which required staff to utilize gowns and gloves when providing direct care. These deficient practices could place residents at risk of an infection. The findings include: 1) Record review of Resident #1's, undated, face sheet revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases causing constriction of the airways and difficulty breathing) and Restlessness and Agitation. Record review of Resident #1's quarterly MDS assessment, dated 01/22/2025, revealed Resident #1 had a BIMS score of 3, which indicated a severe cognitive impairment. Section E -Behavioral Symptoms revealed Resident #1 had verbal behavioral symptoms directed toward others 1-3 days during the look back period. Resident also displayed other behavioral symptoms that were not directed toward others on 1-3 days during the look back period. Section GG- Functional Abilities revealed Resident #1 was ambulatory with a walker and was able to walk up to 150 feet with staff supervision. Resident #1 was independent with bed mobility and required supervision with sit to stand. Record review of Resident #1's comprehensive care plan revealed Resident #1 had a care plan, dated 03/21/2025, which revealed Resident #1 had a wound of a laceration to her eyebrow related to a fall. Resident #1 did not have a care plan for enhanced barrier precautions. Record review of Resident #1's emergency room physician note, dated 03/21/2025, revealed Resident #1 received 5 sutures to her left eyebrow and a dressing was placed over the wound. During an observation on 03/25/2025 at 9:45 a.m., revealed Resident #1 had an orange sign outside the resident's room door which had a stop sign on it and said, Enhanced Barrier Precautions and indicated providers and staff should wear gloves and a gown when providing high contact direct care activities like dressing, bathing, transferring, changing linens, providing hygiene or toileting/brief changes. The sign also included a gown and glove must be worn for device care or use for central lines, urinary catheters, feeding tubes, tracheostomy and any wound care with a skin opening that required a dressing. 2) Record review of Resident #4's, undated, face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Chronic Venous Hypertension (a condition characterized by high blood pressure in the veins of the legs), Colostomy (surgical procedure that creates an opening in the large intestine) and Dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #4's quarterly MDS assessment, dated 01/20/2025, revealed a BIMS score of 14, which indicated no cognitive impairment. Section GG - Functional Abilities revealed Resident #1 was dependent on staff for transfers, dressing, showers, and wheelchair mobility. Record review of Resident #4 care plan on 03/25/2025 at 1:26 p.m., revealed no care plan for enhanced barrier precautions. Record review of Resident #4's care plan on 03/26/2025 at 3:20 p.m., revealed a care plan, dated 03/26/2025, which stated Resident #4 was at risk for infection and listed the approach to prevent infection as utilize enhanced barrier precautions as ordered every shift. This care plan was added after survey intervention. Record review of Resident #4's March 2025 administration orders revealed an order, start date 03/03/2025 and end date 03/24/2025, which stated, top right foot: cleanse with wound cleaner, pat dry, apply calcium alginate to wound bed, cover with dry dressing. Resident #4 had an order, start date 03/24/2025 and no end date, which stated, right shin cleanse with wound cleaner, pat dry, apply Xeroform to wound bed, cover with dry dressing. Resident #4 had an order, dated 06/13/2023, which stated, change colostomy bag and wafer every three days. Monitor stoma for irritation, signs, and symptoms of infection. During an observation on 03/25/2025 at 10:55 a.m., revealed Resident #4 had an orange sign outside of the resident's room door had a stop sign on it and said, Enhanced Barrier Precautions and indicated providers and staff should wear gloves and a gown when providing high contact direct care activities like dressing, bathing, transferring, changing linens, providing hygiene or toileting/brief changes. The sign also included that a gown and gloves must be worn for device care or use for central lines, urinary catheters, feeding tubes, tracheostomy and any wound care with a skin opening which required a dressing. During an interview with LVN D on 03/26/2025 at 10:57 a.m., LVN D stated residents on enhanced barrier precautions should have a sign on their door and a care plan which stated the resident was on enhanced barrier precautions. LVN D stated she was aware of the level of care each resident needed when she arrived for her shift because she had access to the resident care plan and the staff completed a shift change report with the staff leaving their shift. During an interview with Agency CNA E on 03/26/2025 at 11:11 a.m., Agency CNA E stated she knew what level of care each resident needed when she arrived for her shift by looking at the resident profile and care plan in the electronic medical record. During an interview with the Administrator on 03/26/2025 at 12:56 p.m., the Administrator stated residents on enhanced barrier precautions should have a care plan so staff know what the plan of care is and staff can provide the proper protection. The Administrator stated the DON was responsible for updating the resident care plans. During an interview with the DON on 03/26/2025 at 1:46 p.m., the DON stated she was responsible for updating resident care plans and residents on enhanced barrier precautions should have a care plan that addressed enhanced barrier precautions, so the staff had access to the information and interventions in place. The DON stated staff received training on enhanced barrier precautions and Resident #1 was on enhanced barrier precautions related to a wound from her fall and Resident #4 was on enhanced barrier precautions related to a wound on her foot and a colostomy. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, Copyrighted 2001 MED-PASS, Inc., and revised March 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 .7. 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 . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to promote the residents' right to receive mail, for 1 of 1 facility review for residents' right to receive mail, in that: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. The findings were: During a confidential group meeting on 06/05/2024 at 11:00 AM, members of the resident group stated they did not receive mail on Saturdays, they did not understand why it was not distributed on Saturdays, and stated they felt this practice was disrespectful. During an interview on 06/07/2024 at 11:22 AM with the BOM she stated she was the only one who distributed mail to the residents and did so Monday through Friday. Mail that came in on Saturdays remained in the mailbox until Monday. This had been the practice at the facility since she was hired in 2018. Department heads rotated serving as the manager on duty every weekend, but did not distribute the mail even though they had access to the mailbox as it was unlocked. Even when she worked as the manager on duty, approximately every two months, she did not distribute mail to the residents on Saturdays. During an interview on 06/07/2024 at 11:30 AM the Administrator stated residents did not receive mail on Saturdays, and this practice should change. Record review of facility policy Resident Rights, 2001, revealed, Employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: h. Privacy in sending and receiving mail. 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility failed to use the services of an RN as required, for 10 days, during the period between 3/1/2024 through 5/31/2024. This could result in resident's not receiving the needed care and services to meet their needs and could result in illness, a decline in health, and in quality of care. The findings were: Review of the facility's RN hours record revealed there were no RN coverage hours on 3/9/2024, 3/10/2024, 3/31/2024, 4/6/2024, 4/7/2024, 4/20/2024, 5/4/2024, 5/5/2024, 5/18/2024 and, 5/19/2024. All of these dates are on weekends. During an interview with the DON, on 6/6/2024 at 3:27 p.m., the DON stated the facility had two RN's, one full-time and one part-time, who worked different shifts, and confirmed there was no RN coverage on 3/9/2024, 3/10/2024, 3/31/2024, 4/6/2024, 4/7/2024, 4/20/2024, 5/4/2024, 5/5/2024, 5/18/2024 and, 5/19/2024. During an interview with the Regional Nursing Consultant, on 6/6/2024 at 4:50 p.m., the Regional Nursing Consultant confirmed they did not have any agency RN's working on 3/9/2024, 3/10/2024, 3/31/2024, 4/6/2024, 4/7/2024, 4/20/2024, 5/4/2024, 5/5/2024, 5/18/2024 and, 5/19/2024. During an Interview with the Regional Nursing Consultant on 6/7/2024 at 10:55 a.m., The Regional Nursing Consultant revealed they did not have a Nursing policy which addressed RN coverage for 8 hours per day as that was a CMS standard.

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 4 residents (Resident #1) whose records were reviewed for quality of care, in that: 1. Nursing staff failed to assess and identify when Resident #1 initially had a change of condition. 2. Nursing staff failed to follow protocol for a change of condition including sending Resident #1 to the emergency room for medical treatment when she initially had a change of condition. These deficient practices could place residents at-risk of a delay of necessary medical treatment. The findings were: Record review of Resident #1's admission record, undated, revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had moderate cognitive impairment; required extensive to total assistance by one person for all ADLs; was always incontinent of bowel and bladder, and had a [DIAGNOSES REDACTED]. Record review of Resident #1's Care Plan, revised 02/26/2019, revealed the care plan addressed the resident's history of Hypertension with the goal that the resident's blood pressure would remain within acceptable limits set by MD. Further review revealed some of the approaches included: instruct resident and or staff to report headache, dizziness, blurred vision. Check BP and report if exceeds acceptable range. Notify MD of any suspected signs of a stroke and seek emergency treatment for [REDACTED]. Record review of Resident #1's progress note, dated 03/14/2019, read: PCP here, made aware of res ongoing behaviors of wandering, exit seeking, pulling Nursing fire alarms, taking others belongings, [MEDICAL CONDITION] at night time, sleeping throughout day shift, etc. New orders rec'd (received) to start weaning [MEDICATION NAME], will decrease to 1 mg PO HS x 3 days, then decrease to 0.5 mg PO HS x 4 days; DC [MEDICATION NAME] & [MEDICATION NAME]. Record review of Resident #1's consolidated physician orders [REDACTED]. Record review revealed it was noted that Resident #1's blood pressure and heart rate were not recorded on 04/21/2019 at 12:00 PM and 8:00 PM and then on 04/22/2019 at 8:00 AM. Further review revealed it was noted Resident #1's BP vacillated from as high as 189/95 (on 04/07/2019) to 118/80 (on 04/18/2019); it was also noted Resident #1's BP would decrease as the day went on. Record review of a telephone order, dated 04/17/2019, for Resident #1 read, Start [MEDICATION NAME] (an antipsychotic) 5 mg. p.o. QHS. Record review of Resident #1's MAR for (MONTH) 2019 revealed the resident did not receive the three scheduled doses of [MEDICATION NAME] on 04/21/2019. Further review revealed the resident did not receive any medications scheduled for the entire day of 04/21/2019, and the resident did not receive any scheduled medications on 04/22/2019 at 8:00 AM. Record review revealed it was noted the resident received a new medication, [MEDICATION NAME] 5 mg, on 04/20/2019 during evening medication pass, but the resident did not receive the medication on 04/21/2019. Record review of Resident #1's nurse's notes revealed the following: - note dated 04/21/2019 at 5:15 PM, revealed: CNA states res too sleepy to get up for meal. States res sat up on beside, but did not want to stay up. Res is 2nd group, cna instructed to get res up for 2nd meal group, per usual. O2 sat=94% RA BP=139/86, P=79. Further review revealed this was written as a late entry on 04/25/2019 at 9:19 PM. - note dated 04/22/2019 at 11:20 AM, revealed: @1115 summoned to residents room by CNA stating can you take a look at resident she isn't wanting to wake up. Resident noted to be lethargic, eyes open but will not respond to verbal/painful stimuli. 02 sat 82-87% RA, O2 placed @ 2 L per NC, sats up to 92%, Vitals: 100.2 axillary, Pulse 128 apical, BP 160/102, Respirations 21. Rubs not anterior and posterior lobes (lungs). @1120 called (nurse) @ SMC re: above, she is going to call back with orders. - note dated 04/22/2019 at 11:27 AM revealed: @1123 (nurse) called back order per (Physician) to send to ER for eval. @1127 911 called. Further review of Resident #1's nurse's notes revealed these were the only nurses notes documented for the weekend of 04/20/2019 to 04/22/2019. Review of local hospital Emergency Department Report dated 4/22/19 at 11:59 AM read in part: Chief Complaint: DECREASED MENTAL STATUS, CHANGED MENTAL STATUS AND FEVER. The patient is described as having decreased responsiveness. This started just prior to arrival, unknown when patient was last known well and is still present. The patient was found unresponsive. Record review of Resident #1's Imaging Department Report, dated 04/22/2019 at 12:08 PM, revealed in part: Findings: There is a large amount of intraventricular hemorrhage with associated [DIAGNOSES REDACTED]. This appears to be arising from the right basal ganglia. Most of the acute blood products are visualized in the right lateral ventricle, but there is extension into the left lateral ventricle, third ventricle, and fourth ventricle. There is bowing of the intraventricular septum to the left, but otherwise no significant evidence of herniation. Impression: Large amount of intraventricular hemorrhage with associated [DIAGNOSES REDACTED], likely from a right basal ganglia hemorrhage. Record review of Resident #1's transfer form from the local hospital, dated 04/22/2019, revealed the resident was transferred (air lifted by helicopter) to a hospital in another nearby larger city. Further review revealed it was noted the benefits related to services or consultation not available at this facility. Observation on 04/26/2019 at 7:10 AM, while at the hospital, revealed Resident #1 was lying in bed with eyes closed; leaning to her right side. There were two nurse's at bedside providing report during shift change. The hospital night nurse, RN A reported the resident had a fever but subsided. The on-coming day nurse attempted to arouse Resident #1 but she was not responding. During an interview with hospital RN A on 04/26/2019 at 7:20 AM, hospital RN A stated Resident #1 was admitted yesterday, 04/25/2019, at about 3:00 PM from the ICU. RN A stated the resident had a history of [REDACTED]. RN A stated Resident #1's status upon admission was fever, cough and congestion (pneumonia), and increased confusion. RN A stated stated Resident #1 had a CT scan which revealed a brain bleed, and further stated, (Resident #1) had a stroke. RN A stated Resident #1 had history of Hypertension but not [MEDICAL CONDITION]. Observation on 04/26/2019 at 7:45 AM revealed nursing staff gathered in Resident #1's room; called RR (Rapid Response Team). During an interview with hospital RN B on 04/26/2019 at 7:45 AM,at this same time as observation, hospital RN B stated Resident #1 was having difficulties breathing and was unresponsive. Nursing staff noted to be assessing Resident #1. During an interview with the Administrator on 04/26/2019 at 10:35 AM, the Administrator stated Resident #1 had lived in the facility for five years. The Administrator stated Resident #1 had Dementia and would sun down. She stated the physician had recently made some medication adjustments. The Administrator stated Resident #1 wandered and had a wander guard bracelet and stated every now and then would try to leave. The Administrator stated on Monday, 04/22/2019, Resident #1's BP was high and then suffered a stroke prior to staff sending her out to the hospital. The Administrator stated the aide had noted the resident was more lethargic than usual and alerted the nurse who took the resident's vitals and noted her BP was high. The Administrator stated Resident #1 would sleep late during the day and then was more active during the evening. The Administrator stated the late hours were the resident's normal routine related to her history of working as a bartender. The Administrator stated she had looked at the resident's BP for two days prior to the resident's change of condition and noted it was within normal limits. The Administrator stated she had talked with the resident's PCP who told her he was not surprised when it was reported the resident had a stroke due to history of [MEDICAL CONDITION], Diabetes and HTN. The Administrator stated the resident's PCP had told her the resident was very sick and they had helped her the best they could. During an interview with the DON on 04/26/2019 at 1:29 PM, the DON revealed a change of condition was any acute change in behaviors, signs or symptoms outside the normal for aresident. The DON stated the standard normal BP reading was 140/90. The DON stated that every resident had their own standard or baseline BP reading that could variate from the standard BP reading of 140/90, however, an alarming reading, much higher or lower than usual, would be considered a change of condition and a nurse would want to let the resident's doctor know about the change. The DON stated she was very new to the facility and had been training when Resident #1 was discharged to the hospital. The DON stated she understood Resident #1's BP was high and was transferred to a local hospital and then air lifted to a nearby city hospital. During an interview with the Administrator on 04/26/2019 at 2:00 PM, the Administrator revealed several changes and adjustments were made to Resident #1's medications. The Administrator stated Resident #1 was receiving psychiatric services and any changes would go through the resident's PCP who determined whether changes were appropriate. The Administrator clarified that Resident #1 was not being treated for [REDACTED]. During an interview with CNA C on 04/26/2019 at 3:14 PM, CNA C stated she had worked from 2:00 PM to 10:00 PM on Sunday, 04/21/2019. CNA C stated the CNA she relieved reported Resident #1 did not wake during her shift from 6:00 AM to 2:00 PM that same date. CNA C stated the CNA had reported Resident #1 was dead weight and almost hurt the CNA's back because of it. CNA C stated Resident #1 slept during her entire shift (from 2:00 PM to 10:00 PM), and was lethargic and did not eat dinner. CNA C stated she reported the resident's condition to LVNs D and E. CNA C stated LVN D left the facility at 6:00 PM on 04/21/2019, and LVN [NAME] had reported to work early to fill-in for another nurse. CNA C stated she had tried to sit Resident #1 up on the side of the bed, and the resident had one eye open and was drooling. CNA C stated she did not report that the resident was drooling to the nurses. CNA C stated the nurses believed that what she reported was the resident's norm, however, CNA C stated she worked with the Resident regularly and stated the resident was normally very active during the 2:00 to 10:00 PM shift so she noted a change. CNA C stated typically Resident #1 would wander around the halls in her wheelchair; would try to get up, would set off the fire alarms; the resident was constantly moving. CNA C further stated that most recently Resident #1 started napping after lunch, but once she woke up between 3:00 PM and 3:30 PM then she was up all night and through the early morning hours. CNA C stated she was not sure if the nurses went in to check the resident during her shift; she did not notice. CNA C stated LVN D reported to her that Resident #1 had slept the day before, 04/20/2019) as well. During an interview with LVN D on 04/26/2019 at 3:37 PM, LVN D confirmed she had worked from 6:00 PM to 6:00 AM on 04/20/2019 and 04/21/2019. LVN D stated on 04/21/2019 CNA C reported to her that Resident #1 was not waking up for dinner. LVN D stated she checked in on Resident #1 and she would not wake up and further stated, (Resident #1) just moaned, but did not wake up. LVN D further stated the resident would not open her eyes. LVN D confirmed Resident #1 slept during her shift the day before as well (6:00 AM to 6:00 PM). LVN D confirmed this change in Resident #1's normal routine was as a change of condition for the resident, and stated she had talked with the other floor nurses on duty. LVN D stated the other nurses told her this was normal for Resident #1 as a result of the resident's medication changes. LVN D confirmed that as the charge nurse she should complete an assessment (at minimum take a resident's vitals), talk to the manager on duty, call the physician and follow instructions when a resident had a change of condition. LVN D confirmed she did not follow this process, and again stated because the other nurses told her the resident was okay. LVN D stated that she was a new nurse and understood the other nurses knew the resident better. LVN D stated she had worked at the facility for about four months. LVN D confirmed she did not check what medication changes were made or added for Resident #1 to determine the side affects. LVN D confirmed she did not talk with the manager on duty because, she was busy. LVN D further stated she was not sure if she took Resident #1's vitals, but stated she would have documented it in a nurse's note. During an interview with Resident #1's PCP on 04/26/2019 at 5:17 PM, Resident #1's PCP confirmed Resident #1 had a history of [REDACTED]. The PCP stated he was not surprised Resident #1 had a stroke and stated the resident had been declining over the last several years. The PCP confirmed the Psychiatric NP had recommended a new order for [MEDICATION NAME], and stated a common side-affect of [MEDICATION NAME] was sleepiness. The PCP stated Resident #1 did not have history of low blood pressure so he could not be certain if it could cause lethargy. The PCP confirmed he was alerted to Resident #1's change of condition on 04/22/2019 via voice mail, and that he was informed Resident #1 was lethargic and her BP was 160/102. The PCP stated this was high for the resident. The PCP stated he had the facility send him Resident #1's BP readings once a month and did not note varied fluctuation as noted on the resident's MAR for (MONTH) 2019. The PCP stated he did not review the BP readings on the MAR indicated [REDACTED]. The PCP stated another physician was on-call during the weekend and he would have to check with the on-call doctor to ask if staff left him a message. The PCP confirmed Resident #1 would sleep during day and would be up late at night; was usually be up and active during the evening into the night. The PCP confirmed the resident had sundowning behaviors. During an interview with the Administrator on 04/29/2019 at 9:30 AM, the Administrator revealed Resident #1 had passed on Friday, 04/26/2019, per hospital staff and family members. During an interview with LVN [NAME] on 04/29/2019 at 10:45 AM, LVN [NAME] confirmed she had worked on 04/20/2019 from 2:00 AM to 2:00 PM, and on 04/21/2019 from 3:00 PM to 6:30 PM. LVN [NAME] confirmed she was the charge nurse for Resident #1, and stated that on 04/20/2019 she had checked on Resident #1 during her shift every 2-hour rounds. LVN [NAME] stated on 04/20/2019 it was reported Resident #1 did not want to get up for breakfast but then the resident was up for lunch. LVN [NAME] stated Resident #1 had eaten a sandwich because she did not want the meal that was served. LVN [NAME] stated Resident #1 would usually stay up in her wheelchair after lunch at the nurses station sometimes falling asleep, but stated she was not certain if that was what happened on 04/20/2019. LVN [NAME] stated Resident #1's baseline was: she was alert and oriented to self; would try to get up on her own without assistance; would would try to climb out of wheelchair. LVN [NAME] stated staff would assist times one to two persons for transfers. LVN [NAME] stated Resident #1 wore a wander guard because she would try to elope related to confusion. LVN [NAME] stated that she did not note anything out of the normal on her scheduled work days, however, she stated Resident #1 typically slept most of the day. LVN [NAME] stated that on Sunday, 04/21/2019, Resident #1 was already in bed when she arrived at 3:00 PM. LVN [NAME] stated that CNA C had alerted her that Resident #1 was not waking up for dinner at about 5:00 PM with the first group. LVN [NAME] stated she checked on Resident #1 at about 6:30 PM to check to see if the resident was getting up for dinner, and further stated the resident was lethargic so she took the resident's vitals which were within WNL. LVN [NAME] stated she was not more lethargic, but confirmed Resident #1 was usually up and around at that time. LVN [NAME] stated she did not know if Resident #1 got up for dinner. LVN [NAME] further stated that she usually worked from 6:00 AM to 6:00 PM, and stated that normally Resident #1 would get up by lunch time; would go down at 2:00 PM and would get back up at 3:00 PM and then she would stay up. LVN [NAME] stated, she (Resident #1) was always ready to go back to bed (or) would ask to go to bed. LVN [NAME] stated that once Resident #1 was up after 5:00 PM or 6:00 PM she would stay up until 4:00 AM or 5:00 AM. LVN [NAME] stated Resident #1 had started receiving [MEDICATION NAME] and upon reviewing the start date (04/20/2019) stated she thought the resident had been receiving it prior to 04/20/2019. LVN [NAME] stated in responding to a change in condition would include the following process: obtain vital signs, complete assessment, call the doctor and call the RP. LVN [NAME] stated again that she took the resident's vitals and they were within normal limits so she did not do anything else. During an interview with RN F on 04/29/2019 at 1:24 PM, RN F stated she had provided RN weekend coverage at the facility since (MONTH) (YEAR). RN F confirmed she worked on 04/20/2019 from 7:00 AM to 3:00 PM, and on 04/21/2019 from 2:00 PM to 10:00 AM. RN F stated typically she would start making rounds when she first reported to work and throughout the day. RN F stated on 04/20/2019 Resident #1 did not get up for breakfast but was up and eating in the dining room for lunch. RN F stated she had dining room duty and sat with Resident #1 who she believed ate the meal for the day because if she had eaten a sandwich she would asked for a PBJ sandwich but stated she did not remember Resident #1 eating a sandwich. RN F further stated Resident #1 was up and talking; was her normal self. RN F stated she did not see Resident #1 again before leaving on 04/20/2019 at the end of her shift. RN F stated she worked on Sunday during the night shift and stated that Resident #1 was usually up at night; was active throughout the night. RN F stated Resident #1 was not up on Sunday during her shift. RN F stated while making rounds, Resident #1 did not appear to be in distress; normal sleep pattern and the resident's respirations were not labored. RN F confirmed it was different for the resident to be sleeping but stated she understood there had been some medication changes for the resident and had started a new medication. RN F stated she was not sure what changes were made and that she did not pull Resident #1's chart/MAR to determine the side effects for the new medication. RN F confirmed the charge nurse, LVN E, did not report any changes in condition for to her on Sunday regarding Resident #1. During an interview with MA G on 04/29/2019 at 1:33 PM, MA G revealed he worked part-time hours on Sunday and Monday from 5:00 AM to 2:00 PM. MA G confirmed he had worked on 04/21/2019 and 04/22/2019. MA G stated Resident #1 was usually sleeping during the 8:00 AM med pass because she would routinely stay up until 3:00 AM or 4:00 AM. MA G stated Resident #1 would wake for the med pass; would open her eyes to look at him and would take her medications. MA G stated he remembered one morning Resident #1 was not waking up at all. MA G stated he reported to the nurse that Resident #1 did not receive her AM medications because the resident was, out of it. MA G initially stated he could not remember what day it was but knew it was before the resident was hospitalized last week. MA G reviewed Resident #1' MAR for 04/21/2019 and 04/22/2019 and he stated he forgot to circle that the resident did not receive the medications maybe because he was distracted. MA G confirmed he did not take Resident #1's BP reading or heart rate. During an interview with the Administrator on 4/29/19 at 4:39 PM, the Administrator stated nursing staff had not recorded Resident #1's food intake for the weekend of 04/20/2019 to 04/21/2019 therefore could not confirm if she had eaten over the weekend. During an interview with LVN H on 04/29/2019 at 5:29 PM, LVN H confirmed she had worked on 04/21/2019 from 6:00 AM to 1:00 PM. LVN H stated LVN D had reported to her that Resident #1 had not been up during her shift from 6:00 PM to 6:00 AM on 04/20/2019. During this interview with LVN H, RN F interjected at this same time and stated Resident #1 had been up for lunch on Saturday, 04/20/2019. LVN H stated Resident #1 did not wake up for lunch on Sunday per the CNA on duty that date. LVN H stated when she started her rounds she checked in on Resident #1 first thing. LVN H stated she touched Resident #1's hand. Resident #1 was sleeping (did not wake up to stimuli), her respirations were even and unlabored and did not appear to be in distress. LVN H stated she did not see the resident get up prior to her leaving at the end of her shift. LVN H stated therefore, Resident #1 had not been up since at least 6:00 PM on 04/20/2019 which was unusual for Resident #1. LVN H stated protocol for change of condition included discussing the resident's status with other nurses because she was a new nurse. LVN H stated she did not note a change because there had been times when Resident #1 slept through lunch, however, stated typically Resident #1 would be up by lunch, the resident would lay down afterwards, but by 2:00 PM to 3:00 PM the resident would be up roaming the halls; Resident #1 was very active. LVN H confirmed she did not talk with other nurses, the manager on duty or call the physician regarding the Resident's status. During an interview with MA G on 04/29/2019 at 6:14 PM, MA G confirmed he had worked on 04/22/2019, and stated Resident #1 did not receive her 8:00 AM and 12:00 PM medications because the resident was, out of it. MA G stated he did not take the resident's BP reading or heart rate. MA G stated he could not remember if he let the nurse know. MA G stated he could not remember what nurses were working that day and upon reviewing the schedule stated could not be certain who he might have told. During an interview with LVN I on 04/29/2019 at 6:24 PM, LVN I revealed she had worked at the facility for almost 3 years on a PRN basis. LVN I confirmed she had worked on 04/22/2019, and stated she had reported to work at the facility at about 10:45 AM. LVN I stated the CNA was the first staff who talked with her about Resident #1. LVN I stated the CNA had reported Resident #1 was not waking up. LVN I stated she did not talk with MA G. LVN I stated she assessed Resident #1 shortly after talking with the CN[NAME] LVN I stated when she called Resident #1's name and took her arm it was flaccid. LVN I stated Resident #1 did not respond when usually she would moan or open eyes. LVN I stated she did a sternal rub and the resident still did not wake so she called 911 and followed the change of condition protocol. LVN I stated Resident #1 was discharged to the local hospital. Record review of a facility policy, Acute Conditions Changes-Clinical Protocol, revised 12/2012, revealed: 1. During the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay. 2. In addition, the Nurse shall assess and document/report the following baseline information. a. Vital signs; b. Neurological status; c. Current level of pain, and any recent changes in pain level; d. Level of consciousness; e. Cognitive and emotional status; f. Resident's age and sex; g. Onset, duration, severity; h. Recent labs; i. History of psychiatric disturbances, mental illness, depression, etc.; j. All active diagnoses; and k. All current medications.

Based on observation, interview and record review, the facility failed to provide services that meet professional standards of quality as outlined by the comprehensive care plan for 1 of 4 residents (Resident #1) whose records were reviewed, in that: 1. Nursing staff failed to assess and identify when Resident #1 initially had a change of condition. 2. Nursing staff failed to follow protocol for a change of condition including sending Resident #1 to the emergency room for medical treatment when she initially had a change of condition. These deficient practices could place residents at-risk of a delay of necessary medical treatment. The findings were: Record review of the Texas Board of Nursing Standards of Nursing Practice Title 22 Part 11 Chapter 217 Rule §217.11(1)(K)(iv), revised 11/15/2007, revealed: Standards Applicable to All Nurses. All vocational nurses, registered nurse and registered nurses with advanced practice authorization shall: Comply with mandatory reporting requirements of Texas Occupations Code Chapter 301 (Nurse Practice Act), Subchapter I, which include reporting a nurse: whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior. Record review of Resident #1's admission record, undated, revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had moderate cognitive impairment; required extensive to total assistance by one person for all ADLs; was always incontinent of bowel and bladder, and had a [DIAGNOSES REDACTED]. Record review of Resident #1's Care Plan, revised 02/26/2019, revealed the care plan addressed the resident's history of Hypertension with the goal that the resident's blood pressure would remain within acceptable limits set by MD. Further review revealed some of the approaches included: instruct resident and or staff to report headache, dizziness, blurred vision. Check BP and report if exceeds acceptable range. Notify MD of any suspected signs of a stroke and seek emergency treatment for [REDACTED]. Record review of Resident #1's progress note, dated 03/14/2019, read: PCP here, made aware of res ongoing behaviors of wandering, exit seeking, pulling Nursing fire alarms, taking others belongings, [MEDICAL CONDITION] at night time, sleeping throughout day shift, etc. New orders rec'd (received) to start weaning [MEDICATION NAME] (sedative), will decrease to 1 mg PO HS x 3 days, then decrease to 0.5 mg PO HS x 4 days; DC [MEDICATION NAME] (antidepressant) & [MEDICATION NAME] (hormone that helps regulate sleep-wake cycles). Record review of Resident #1's consolidated physician orders [REDACTED]. Record review revealed it was noted that Resident #1's blood pressure and heart rate were not recorded on 04/21/2019 at 12:00 PM and 8:00 PM and then on 04/22/2019 at 8:00 AM. Further review revealed it was noted Resident #1's BP vacillated from as high as 189/95 (on 04/07/2019) to 118/80 (on 04/18/2019); it was also noted Resident #1's BP would decrease as the day went on. Record review of a telephone order, dated 04/17/2019, for Resident #1 read, Start [MEDICATION NAME] (an antipsychotic) 5 mg. p.o. QHS. Record review of Resident #1's MAR for (MONTH) 2019 revealed the resident did not receive the three scheduled doses of [MEDICATION NAME] on 04/21/2019. Further review revealed the resident did not receive any medications scheduled for the entire day of 04/21/2019, and the resident did not receive any scheduled medications on 04/22/2019 at 8:00 AM. Record review revealed it was noted the resident received a new medication, [MEDICATION NAME] 5 mg, on 04/20/2019 during evening medication pass, but the resident did not receive the medication on 04/21/2019. Record review of Resident #1's nurse's notes revealed the following: - note dated 04/21/2019 at 5:15 PM, revealed: CNA states res too sleepy to get up for meal. States res sat up on beside, but did not want to stay up. Res is 2nd group, cna instructed to get res up for 2nd meal group, per usual. O2 sat=94% RA BP=139/86, P=79. Further review revealed this was written as a late entry on 04/25/2019 at 9:19 PM. - note dated 04/22/2019 at 11:20 AM, revealed: @1115 summoned to residents room by CNA stating can you take a look at resident she isn't wanting to wake up. Resident noted to be lethargic, eyes open but will not respond to verbal/painful stimuli. O2 sat 82-87% RA, O2 placed @ 2 L per NC, sats up to 92%, Vitals: 100.2 axillary, Pulse 128 apical, BP 160/102, Respirations 21. Rubs not anterior and posterior lobes (lungs). @1120 called (nurse) @ SMC re: above, she is going to call back with orders. - note dated 04/22/2019 at 11:27 AM revealed: @1123 (nurse) called back order per (Physician) to send to ER for eval. @1127 911 called. Further review of Resident #1's nurse's notes revealed these were the only nurses notes documented for the weekend of 04/20/2019 to 04/22/2019. Record review of local hospital Emergency Department Report, dated 04/22/2019 at 11:59 AM, revealed: Chief Complaint: DECREASED MENTAL STATUS, CHANGED MENTAL STATUS AND FEVER. The patient is described as having decreased responsiveness. This started just prior to arrival, unknown when patient was last known well and is still present. The patient was found unresponsive. Record review of Resident #1's Imaging Department Report, dated 04/22/2019 at 12:08 PM, revealed: Findings: There is a large amount of intraventricular hemorrhage with associated [DIAGNOSES REDACTED]. This appears to be arising from the right basal ganglia. Most of the acute blood products are visualized in the right lateral ventricle, but there is extension into the left lateral ventricle, third ventricle, and fourth ventricle. There is bowing of the intraventricular septum to the left, but otherwise no significant evidence of herniation. Impression: Large amount of intraventricular hemorrhage with associated [DIAGNOSES REDACTED], likely from a right basal ganglia hemorrhage. Record review of Resident #1's transfer form from the local hospital, dated 04/22/2019, revealed the resident was transferred (air lifted by helicopter) to a hospital in another nearby larger city. Further review revealed it was noted the benefits related to services or consultation not available at this facility. Observation on 04/26/2019 at 7:10 AM, while at the hospital, revealed Resident #1 was lying in bed with eyes closed; leaning to her right side. There were two nurse's at bedside providing report during shift change. The hospital night nurse, RN A reported the resident had a fever but subsided. The on-coming day nurse attempted to arouse Resident #1 but she was not responding. During an interview with hospital RN A on 04/26/2019 at 7:20 AM, hospital RN A stated Resident #1 was admitted yesterday, 04/25/2019, at about 3:00 PM from the ICU. RN A stated the resident had a history of [REDACTED]. RN A stated Resident #1's status upon admission was fever, cough and congestion (pneumonia), and increased confusion. RN A stated stated Resident #1 had a CT scan which revealed a brain bleed, and further stated, (Resident #1) had a stroke. RN A stated Resident #1 had history of Hypertension but not [MEDICAL CONDITION]. Observation on 04/26/2019 at 7:45 AM revealed nursing staff gathered in Resident #1's room; called RR (Rapid Response Team). During an interview with hospital RN B on 04/26/2019 at 7:45 AM,at this same time as observation, hospital RN B stated Resident #1 was having difficulties breathing and was unresponsive. Nursing staff noted to be assessing Resident #1. During an interview with the Administrator on 04/26/2019 at 10:35 AM, the Administrator stated Resident #1 had lived in the facility for five years. The Administrator stated Resident #1 had Dementia and would sun down. She stated the physician had recently made some medication adjustments. The Administrator stated Resident #1 wandered and had a wander guard bracelet and stated every now and then would try to leave. The Administrator stated on Monday, 04/22/2019, Resident #1's BP was high and then suffered a stroke prior to staff sending her out to the hospital. The Administrator stated the aide had noted the resident was more lethargic than usual and alerted the nurse who took the resident's vitals and noted her BP was high. The Administrator stated Resident #1 would sleep late during the day and then was more active during the evening. The Administrator stated the late hours were the resident's normal routine related to her history of working as a bartender. The Administrator stated she had looked at the resident's BP for two days prior to the resident's change of condition and noted it was within normal limits. The Administrator stated she had talked with the resident's PCP who told her he was not surprised when it was reported the resident had a stroke due to history of [MEDICAL CONDITION], Diabetes and HTN. The Administrator stated the resident's PCP had told her the resident was very sick and they had helped her the best they could. During an interview with the DON on 04/26/2019 at 1:29 PM, the DON revealed a change of condition was any acute change in behaviors, signs or symptoms outside the normal for a resident. The DON stated the standard normal BP reading was 140/90. The DON stated that every resident had their own standard or baseline BP reading that could variate from the standard BP reading of 140/90, however, an alarming reading, much higher or lower than usual, would be considered a change of condition and a nurse would want to let the Resident's doctor know about the change. The DON stated she was very new to the facility and had been training when Resident #1 was discharged to the hospital. The DON stated she understood Resident #1's BP was high and Resident #1 was transferred to a local hospital and then air lifted to a nearby city hospital. During an interview with the Administrator on 04/26/2019 at 2:00 PM, the Administrator revealed several changes and adjustments were made to Resident #1's medications. The Administrator stated Resident #1 was receiving psychiatric services and any changes would go through the resident's PCP who determined whether changes were appropriate. The Administrator clarified that Resident was not being treated for [REDACTED]. During an interview with CNA C on 04/26/2019 at 3:14 PM, CNA C stated she had worked from 2:00 PM to 10:00 PM on Sunday, 04/21/2019. CNA C stated the CNA she relieved reported Resident #1 did not wake during her shift from 6:00 AM to 2:00 PM that same date. CNA C stated the CNA had reported Resident #1 was dead weight and almost hurt the CNA's back because of it. CNA C stated Resident #1 slept during her entire shift (from 2:00 PM to 10:00 PM), and was lethargic and did not eat dinner. CNA C stated she reported the resident's condition to LVNs D and E. CNA C stated LVN D left the facility at 6:00 PM on 04/21/2019, and LVN [NAME] had reported to work early to fill-in for another nurse. CNA C stated she had tried to sit Resident #1 up on the side of the bed, and the resident had one eye open and was drooling. CNA C stated she did not report that the resident was drooling to the nurses. CNA C stated the nurses believed that what she reported was the resident's norm, however, CNA C stated she worked with the Resident regularly and stated the resident was normally very active during the 2:00 to 10:00 PM shift so she noted a change. CNA C stated typically Resident #1 would wander around the halls in her wheelchair; would try to get up, would set off the fire alarms; the resident was constantly moving. CNA C further stated that most recently Resident #1 started napping after lunch, but once she woke up between 3:00 PM and 3:30 PM then she was up all night and through the early morning hours. CNA C stated she was not sure if the nurses went in to check the resident during her shift; she did not notice. CNA C stated LVN D reported to her that Resident #1 had slept the day before, 04/20/2019) as well. During an interview with LVN D on 04/26/2019 at 3:37 PM, LVN D confirmed she had worked from 6:00 PM to 6:00 AM on 04/20/2019 and 04/21/2019. LVN D stated on 04/21/2019 CNA C reported to her that Resident #1 was not waking up for dinner. LVN D stated she checked in on Resident #1 and she would not wake up and further stated, (Resident #1) just moaned, but did not wake up. LVN D further stated the resident would not open her eyes. LVN D confirmed Resident #1 slept during her shift the day before as well (6:00 AM to 6:00 PM). LVN D confirmed this change in Resident #1's normal routine was as a change of condition for the resident, and stated she had talked with the other floor nurses on duty. LVN D stated the other nurses told her this was normal for Resident #1 as a result of the resident's medication changes. LVN D confirmed that as the charge nurse she should complete an assessment (at minimum take a resident's vitals), talk to the manager on duty, call the physician and follow instructions when a resident had a change of condition. LVN D confirmed she did not follow this process, and again stated because the other nurses told her the resident was okay. LVN D stated that she was a new nurse and understood the other nurses knew the resident better. LVN D stated she had worked at the facility for about four months. LVN D confirmed she did not check what medication changes were made or added for Resident #1 to determine the side effects. LVN D confirmed she did not talk with the manager on duty because, she was busy. LVN D further stated she was not sure if she took Resident #1's vitals, but stated she would have documented it in a nurse's note. During an interview with Resident #1's PCP on 04/26/2019 at 5:17 PM, Resident #1's PCP confirmed Resident #1 had a history of [REDACTED]. The PCP stated he was not surprised Resident #1 had a stroke and stated the resident had been declining over the last several years. The PCP confirmed the Psychiatric NP had recommended a new order for [MEDICATION NAME], and stated a common side-affect of [MEDICATION NAME] was sleepiness. The PCP stated Resident #1 did not have history of low blood pressure so he could not be certain if it could cause lethargy. The PCP confirmed he was alerted to Resident #1's change of condition on 04/22/2019 via voice mail, and that he was informed Resident #1 was lethargic and her BP was 160/102. The PCP stated this was high for the resident. The PCP stated he had the facility send him Resident #1's BP readings once a month and did not note varied fluctuation as noted on the resident's MAR for (MONTH) 2019. The PCP stated he did not review the BP readings on the MAR indicated [REDACTED]. The PCP stated another physician was on-call during the weekend and he would have to check with the on-call doctor to ask if staff left him a message. The PCP confirmed Resident #1 would sleep during day and would be up late at night; was usually be up and active during the evening into the night. The PCP confirmed the resident had sundowning behaviors. During an interview with the Administrator on 04/29/2019 at 9:30 AM, the Administrator revealed Resident #1 had passed on Friday, 04/26/2019, per hospital staff and family members. During an interview with LVN [NAME] on 04/29/2019 at 10:45 AM, LVN [NAME] confirmed she had worked on 04/20/2019 from 2:00 AM to 2:00 PM, and on 04/21/2019 from 3:00 PM to 6:30 PM. LVN [NAME] confirmed she was the charge nurse for Resident #1, and stated that on 04/20/2019 she had checked on Resident #1 during her shift every 2-hour rounds. LVN [NAME] stated on 04/20/2019 it was reported Resident #1 did not want to get up for breakfast but then the resident was up for lunch. LVN [NAME] stated Resident #1 had eaten a sandwich because she did not want the meal that was served. LVN [NAME] stated Resident #1 would usually stay up in her wheelchair after lunch at the nurses station sometimes falling asleep, but stated she was not certain if that was what happened on 04/20/2019. LVN [NAME] stated Resident #1's baseline was: she was alert and oriented to self; would try to get up on her own without assistance; would would try to climb out of wheelchair. LVN [NAME] stated staff would assist times one to two persons for transfers. LVN [NAME] stated Resident #1 wore a wander guard because she would try to elope related to confusion. LVN [NAME] stated that she did not note anything out of the normal on her scheduled work days, however, she stated Resident #1 typically slept most of the day. LVN [NAME] stated that on Sunday, 04/21/2019, Resident #1 was already in bed when she arrived at 3:00 PM. LVN [NAME] stated that CNA C had alerted her that Resident #1 was not waking up for dinner at about 5:00 PM with the first group. LVN [NAME] stated she checked on Resident #1 at about 6:30 PM to check to see if the resident was getting up for dinner, and further stated the resident was lethargic so she took the resident's vitals which were within WNL. LVN [NAME] stated she was not more lethargic, but confirmed Resident #1 was usually up and around at that time. LVN [NAME] stated she did not know if Resident #1 got up for dinner. LVN [NAME] further stated that she usually worked from 6:00 AM to 6:00 PM, and stated that normally Resident #1 would get up by lunch time; would go down at 2:00 PM and would get back up at 3:00 PM and then she would stay up. LVN [NAME] stated, she (Resident #1) was always ready to go back to bed (or) would ask to go to bed. LVN [NAME] stated that once Resident #1 was up after 5:00 PM or 6:00 PM she would stay up until 4:00 AM or 5:00 AM. LVN [NAME] stated Resident #1 had started receiving [MEDICATION NAME] and upon reviewing the start date (04/20/2019) stated she thought the resident had been receiving it prior to 04/20/2019. LVN [NAME] stated in responding to a change in condition would include the following process: obtain vital signs, complete assessment, call the doctor and call the RP. LVN [NAME] stated again that she took the resident's vitals and they were within normal limits so she did not do anything else. During an interview with RN F on 04/29/2019 at 1:24 PM, RN F stated she had provided RN weekend coverage at the facility since (MONTH) (YEAR). RN F confirmed she worked on 04/20/2019 from 7:00 AM to 3:00 PM, and on 04/21/2019 from 2:00 PM to 10:00 AM. RN F stated typically she would start making rounds when she first reported to work and throughout the day. RN F stated on 04/20/2019 Resident #1 did not get up for breakfast but was up and eating in the dining room for lunch. RN F stated she had dining room duty and sat with Resident #1 who she believed ate the meal for the day because if she had eaten a sandwich she would asked for a PBJ sandwich but stated she did not remember Resident #1 eating a sandwich. RN F further stated Resident #1 was up and talking; was her normal self. RN F stated she did not see Resident #1 again before leaving on 04/20/2019 at the end of her shift. RN F stated she worked on Sunday during the night shift and stated that Resident #1 was usually up at night; was active throughout the night. RN F stated Resident #1 was not up on Sunday during her shift. RN F stated while making rounds, Resident #1 did not appear to be in distress; normal sleep pattern and the resident's respirations were not labored. RN F confirmed it was different for the resident to be sleeping but stated she understood there had been some medication changes for the resident and had started a new medication. RN F stated she was not sure what changes were made and that she did not pull Resident #1's chart/MAR to determine the side effects for the new medication. RN F confirmed the charge nurse, LVN E, did not report any changes in condition for to her on Sunday regarding Resident #1. During an interview with MA G on 04/29/2019 at 1:33 PM, MA G revealed he worked part-time hours on Sunday and Monday from 5:00 AM to 2:00 PM. MA G confirmed he had worked on 04/21/2019 and 04/22/2019. MA G stated Resident #1 was usually sleeping during the 8:00 AM med pass because she would routinely stay up until 3:00 AM or 4:00 AM. MA G stated Resident #1 would wake for the med pass; would open her eyes to look at him and would take her medications. MA G stated he remembered one morning Resident #1 was not waking up at all. MA G stated he reported to the nurse that Resident #1 did not receive her AM medications because the resident was, out of it. MA G initially stated he could not remember what day it was but knew it was before the resident was hospitalized last week. MA G reviewed Resident #1' MAR for 04/21/2019 and 04/22/2019 and he stated he forgot to circle that the resident did not receive the medications maybe because he was distracted. MA G confirmed he did not take Resident #1's BP reading or heart rate. During an interview with the Administrator on 4/29/19 at 4:39 PM, the Administrator stated nursing staff had not recorded Resident #1's food intake for the weekend of 04/20/2019 to 04/21/2019 therefore could not confirm if she had eaten over the weekend. During an interview with LVN H on 04/29/2019 at 5:29 PM, LVN H confirmed she had worked on 04/21/2019 from 6:00 AM to 1:00 PM. LVN H stated LVN D had reported to her that Resident #1 had not been up during her shift from 6:00 PM to 6:00 AM on 04/20/2019. During this interview with LVN H, RN F interjected at this same time and stated Resident #1 had been up for lunch on Saturday, 04/20/2019. LVN H stated Resident #1 did not wake up for lunch on Sunday per the CNA on duty that date. LVN H stated when she started her rounds she checked in on Resident #1 first thing. LVN H stated she touched Resident #1's hand. Resident #1 was sleeping (did not wake up to stimuli), her respirations were even and unlabored and did not appear to be in distress. LVN H stated she did not see the resident get up prior to her leaving at the end of her shift. LVN H stated therefore, Resident #1 had not been up since at least 6:00 PM on 04/20/2019 which was unusual for Resident #1. LVN H stated protocol for change of condition included discussing the resident's status with other nurses because she was a new nurse. LVN H stated she did not note a change because there had been times when Resident #1 slept through lunch, however, stated typically Resident #1 would be up by lunch, the resident would lay down afterwards, but by 2:00 PM to 3:00 PM the resident would be up roaming the halls; Resident #1 was very active. LVN H confirmed she did not talk with other nurses, the manager on duty or call the physician regarding the Resident's status. During an interview with MA G on 04/29/2019 at 6:14 PM, MA G confirmed he had worked on 04/22/2019, and stated Resident #1 did not receive her 8:00 AM and 12:00 PM medications because the resident was, out of it. MA G stated he did not take the resident's BP reading or heart rate. MA G stated he could not remember if he let the nurse know. MA G stated he could not remember what nurses were working that day and upon reviewing the schedule stated could not be certain who he might have told. During an interview with LVN I on 04/29/2019 at 6:24 PM, LVN I revealed she had worked at the facility for almost 3 years on a PRN basis. LVN I confirmed she had worked on 04/22/2019, and stated she had reported to work at the facility at about 10:45 AM. LVN I stated the CNA was the first staff who talked with her about Resident #1. LVN I stated the CNA had reported Resident #1 was not waking up. LVN I stated she did not talk with MA G. LVN I stated she assessed Resident #1 shortly after talking with the CN[NAME] LVN I stated when she called Resident #1's name and took her arm it was flaccid. LVN I stated Resident #1 did not respond when usually she would moan or open eyes. LVN I stated she did a sternal rub and the resident still did not wake so she called 911 and followed the change of condition protocol. LVN I stated Resident #1 was discharged to the local hospital. Record review of a facility policy, Acute Conditions Changes-Clinical Protocol, revised 12/2012, revealed: 1. During the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay. 2. In addition, the Nurse shall assess and document/report the following baseline information. a. Vital signs; b. Neurological status; c. Current level of pain, and any recent changes in pain level; d. Level of consciousness; e. Cognitive and emotional status; f. Resident's age and sex; g. Onset, duration, severity; h. Recent labs; i. History of psychiatric disturbances, mental illness, depression, etc.; j. All active diagnoses; and k. All current medications.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical and mental status for 1 of 4 residents (Resident #1) whose records were reviewed for a change of condition, in that: Nursing staff did not notify Resident #1's physician as soon as the resident had a change of condition for three shifts after experiencing a change of condition. This deficient practice could place residents at-risk of a delay of necessary medical treatment. The findings were: Review of Resident #1's admission record, undated, revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had moderate cognitive impairment; required extensive to total assistance by one person for all ADLs; was always incontinent of bowel and bladder, and had a [DIAGNOSES REDACTED]. Record review of Resident #1's Care Plan, revised 02/26/2019, revealed the care plan addressed the resident's history of Hypertension with the goal that the resident's blood pressure would remain within acceptable limits set by MD. Further review revealed some of the approaches included: instruct resident and or staff to report headache, dizziness, blurred vision. Check BP and report if exceeds acceptable range. Notify MD of any suspected signs of a stroke and seek emergency treatment for [REDACTED]. Record review of Resident #1's progress note, dated 03/14/2019, read: PCP here, made aware of res ongoing behaviors of wandering, exit seeking, pulling Nursing fire alarms, taking others belongings, [MEDICAL CONDITION] at night time, sleeping throughout day shift, etc. New orders rec'd (received) to start weaning [MEDICATION NAME] (sedative), will decrease to 1 mg PO HS x 3 days, then decrease to 0.5 mg PO HS x 4 days; DC [MEDICATION NAME] (antidepressant) & [MEDICATION NAME] (hormone that helps regulate sleep-wake cycles). Record review of Resident #1's consolidated physician orders [REDACTED]. Record review revealed it was noted that Resident #1's blood pressure and heart rate were not recorded on 04/21/2019 at 12:00 PM and 8:00 PM and then on 04/22/2019 at 8:00 AM. Further review revealed it was noted Resident #1's BP vacillated from as high as 189/95 (on 04/07/2019) to 118/80 (on 04/18/2019); it was also noted Resident #1's BP would decrease as the day went on. Record review of a telephone order, dated 04/17/2019, for Resident #1 read, Start [MEDICATION NAME] (an antipsychotic) 5 mg. p.o. QHS. Record review of Resident #1's MAR for (MONTH) 2019 revealed the resident did not receive the three scheduled doses of [MEDICATION NAME] on 04/21/2019. Further review revealed the resident did not receive any medications scheduled for the entire day of 04/21/2019, and the resident did not receive any scheduled medications on 04/22/2019 at 8:00 AM. Record review revealed it was noted the resident received a new medication, [MEDICATION NAME] 5 mg, on 04/20/2019 during evening medication pass, but the resident did not receive the medication on 04/21/2019. Record review of Resident #1's nurse's notes revealed the following: - note dated 04/21/2019 at 5:15 PM, revealed: CNA states res too sleepy to get up for meal. States res sat up on beside, but did not want to stay up. Res is 2nd group, cna instructed to get res up for 2nd meal group, per usual. O2 sat=94% RA BP=139/86, P=79. Further review revealed this was written as a late entry on 04/25/2019 at 9:19 PM. - note dated 04/22/2019 at 11:20 AM, revealed: @1115 summoned to residents room by CNA stating can you take a look at resident she isn't wanting to wake up. Resident noted to be lethargic, eyes open but will not respond to verbal/painful stimuli. O2 sat 82-87% RA, O2 placed @ 2 L per NC, sats up to 92%, Vitals: 100.2 axillary, Pulse 128 apical, BP 160/102, Respirations 21. Rubs not anterior and posterior lobes (lungs). @1120 called (nurse) @ SMC re: above, she is going to call back with orders. - note dated 04/22/2019 at 11:27 AM revealed: @1123 (nurse) called back order per (Physician) to send to ER for eval. @1127 911 called. Further review of Resident #1's nurse's notes revealed these were the only nurses notes documented for the weekend of 04/20/2019 to 04/22/2019. Review of local hospital Emergency Department Report, dated 04/22/2019 at 11:59 AM, revealed: Chief Complaint: DECREASED MENTAL STATUS, CHANGED MENTAL STATUS AND FEVER. The patient is described as having decreased responsiveness. This started just prior to arrival, unknown when patient was last known well and is still present. The patient was found unresponsive. Record review of Resident #1's Imaging Department Report, dated 04/22/2019 at 12:08 PM, revealed: Findings: There is a large amount of intraventricular hemorrhage with associated [DIAGNOSES REDACTED]. This appears to be arising from the right basal ganglia. Most of the acute blood products are visualized in the right lateral ventricle, but there is extension into the left lateral ventricle, third ventricle, and fourth ventricle. There is bowing of the intraventricular septum to the left, but otherwise no significant evidence of herniation. Impression: Large amount of intraventricular hemorrhage with associated [DIAGNOSES REDACTED], likely from a right basal ganglia hemorrhage. Record review of Resident #1's transfer form from the local hospital, dated 04/22/2019, revealed the resident was transferred (air lifted by helicopter) to a hospital in another nearby larger city. Further review revealed it was noted the benefits related to services or consultation not available at this facility. Observation on 04/26/2019 at 7:10 AM, while at the hospital, revealed Resident #1 was lying in bed with eyes closed; leaning to her right side. There were two nurse's at bedside providing report during shift change. The hospital night nurse, RN A reported the resident had a fever but subsided. The on-coming day nurse attempted to arouse Resident #1 but she was not responding. During an interview with hospital RN A on 04/26/2019 at 7:20 AM, hospital RN A stated Resident #1 was admitted yesterday, 04/25/2019, at about 3:00 PM from the ICU. RN A stated the resident had a history of [REDACTED]. RN A stated Resident #1's status upon admission was fever, cough and congestion (pneumonia), and increased confusion. RN A stated stated Resident #1 had a CT scan which revealed a brain bleed, and further stated, (Resident #1) had a stroke. RN A stated Resident #1 had history of Hypertension but not [MEDICAL CONDITION]. Observation on 04/26/2019 at 7:45 AM revealed nursing staff gathered in Resident #1's room; called RR (Rapid Response Team). During an interview with hospital RN B on 04/26/2019 at 7:45 AM,at this same time as observation, hospital RN B stated Resident #1 was having difficulties breathing and was unresponsive. Nursing staff noted to be assessing Resident #1. During an interview with the Administrator on 04/26/2019 at 10:35 AM, the Administrator stated Resident #1 had lived in the facility for five years. The Administrator stated Resident #1 had Dementia and would sun down. the Administrato stated the physician had recently made some medication adjustments. The Administrator stated Resident #1 wandered and had a wander guard bracelet and stated every now and then would try to leave. The Administrator stated on Monday, 04/22/2019, Resident #1's BP was high and then suffered a stroke prior to staff sending her out to the hospital. The Administrator stated the aide had noted the resident was more lethargic than usual and alerted the nurse who took the resident's vitals and noted her BP was high. The Administrator stated Resident #1 would sleep late during the day and then was more active during the evening. The Administrator stated the late hours were the resident's normal routine related to her history of working as a bartender. The Administrator stated she had looked at the resident's BP for two days prior to the resident's change of condition and noted it was within normal limits. The Administrator stated she had talked with the resident's PCP who told her he was not surprised when it was reported the resident had a stroke due to history of [MEDICAL CONDITION], Diabetes and HTN. The Administrator stated the resident's PCP had told her the resident was very sick and they had helped her the best they could. During an interview with the DON on 04/26/2019 at 1:29 PM, the DON revealed a change of condition was any acute change in behaviors, signs or symptoms outside the normal for a resident. The DON stated the standard normal BP reading was 140/90. The DON stated that every resident had their own standard or baseline BP reading that could variate from the standard BP reading of 140/90, however, an alarming reading, much higher or lower than usual, would be considered a change of condition and a nurse would want to let the Resident's doctor know about the change. The DON stated she was very new to the facility and had been training when Resident #1 was discharged to the hospital. The DON stated she understood Resident #1's BP was high and Resident #1 was transferred to a local hospital and then air lifted to a nearby city hospital. During an interview with the Administrator on 04/26/2019 at 2:00 PM, the Administrator revealed several changes and adjustments were made to Resident #1's medications. The Administrator stated Resident #1 was receiving psychiatric services and any changes would go through the resident's PCP who determined whether changes were appropriate. The Administrator clarified that Resident was not being treated for [REDACTED]. During an interview with CNA C on 04/26/2019 at 3:14 PM, CNA C stated she had worked from 2:00 PM to 10:00 PM on Sunday, 04/21/2019. CNA C stated the CNA she relieved reported Resident #1 did not wake during her shift from 6:00 AM to 2:00 PM that same date. CNA C stated the CNA had reported Resident #1 was dead weight and almost hurt the CNA's back because of it. CNA C stated Resident #1 slept during her entire shift (from 2:00 PM to 10:00 PM), and was lethargic and did not eat dinner. CNA C stated she reported the resident's condition to LVNs D and E. CNA C stated LVN D left the facility at 6:00 PM on 04/21/2019, and LVN [NAME] had reported to work early to fill-in for another nurse. CNA C stated she had tried to sit Resident #1 up on the side of the bed, and the resident had one eye open and was drooling. CNA C stated she did not report that the resident was drooling to the nurses. CNA C stated the nurses believed that what she reported was the resident's norm, however, CNA C stated she worked with the Resident regularly and stated the resident was normally very active during the 2:00 to 10:00 PM shift so she noted a change. CNA C stated typically Resident #1 would wander around the halls in her wheelchair; would try to get up, would set off the fire alarms; the resident was constantly moving. CNA C further stated that most recently Resident #1 started napping after lunch, but once she woke up between 3:00 PM and 3:30 PM then she was up all night and through the early morning hours. CNA C stated she was not sure if the nurses went in to check the resident during her shift; she did not notice. CNA C stated LVN D reported to her that Resident #1 had slept the day before, 04/20/2019) as well. During an interview with LVN D on 04/26/2019 at 3:37 PM, LVN D confirmed she had worked from 6:00 PM to 6:00 AM on 04/20/2019 and 04/21/2019. LVN D stated on 04/21/2019 CNA C reported to her that Resident #1 was not waking up for dinner. LVN D stated she checked in on Resident #1 and she would not wake up and further stated, (Resident #1) just moaned, but did not wake up. LVN D further stated the resident would not open her eyes. LVN D confirmed Resident #1 slept during her shift the day before as well (6:00 AM to 6:00 PM). LVN D confirmed this change in Resident #1's normal routine was as a change of condition for the resident, and stated she had talked with the other floor nurses on duty. LVN D stated the other nurses told her this was normal for Resident #1 as a result of the resident's medication changes. LVN D confirmed that as the charge nurse she should complete an assessment (at minimum take a resident's vitals), talk to the manager on duty, call the physician and follow instructions when a resident had a change of condition. LVN D confirmed she did not follow this process, and again stated because the other nurses told her the resident was okay. LVN D stated that she was a new nurse and understood the other nurses knew the resident better. LVN D stated she had worked at the facility for about four months. LVN D confirmed she did not check what medication changes were made or added for Resident #1 to determine the side effects. LVN D confirmed she did not talk with the manager on duty because, she was busy. LVN D further stated she was not sure if she took Resident #1's vitals, but stated she would have documented it in a nurse's note. During an interview with Resident #1's PCP on 04/26/2019 at 5:17 PM, Resident #1's PCP confirmed Resident #1 had a history of [REDACTED]. The PCP stated he was not surprised Resident #1 had a stroke and stated the resident had been declining over the last several years. The PCP confirmed the Psychiatric NP had recommended a new order for [MEDICATION NAME], and stated a common side-affect of [MEDICATION NAME] was sleepiness. The PCP stated Resident #1 did not have history of low blood pressure so he could not be certain if it could cause lethargy. The PCP confirmed he was alerted to Resident #1's change of condition on 04/22/2019 via voice mail, and that he was informed Resident #1 was lethargic and her BP was 160/102. The PCP stated this was high for the resident. The PCP stated he had the facility send him Resident #1's BP readings once a month and did not note varied fluctuation as noted on the resident's MAR for (MONTH) 2019. The PCP stated he did not review the BP readings on the MAR indicated [REDACTED]. The PCP stated another physician was on-call during the weekend and he would have to check with the on-call doctor to ask if staff left him a message. The PCP confirmed Resident #1 would sleep during day and would be up late at night; was usually be up and active during the evening into the night. The PCP confirmed the resident had sundowning behaviors. During an interview with the Administrator on 04/29/2019 at 9:30 AM, the Administrator revealed Resident #1 had passed on Friday, 04/26/2019, per hospital staff and family members. During an interview with LVN [NAME] on 04/29/2019 at 10:45 AM, LVN [NAME] confirmed she had worked on 04/20/2019 from 2:00 AM to 2:00 PM, and on 04/21/2019 from 3:00 PM to 6:30 PM. LVN [NAME] confirmed she was the charge nurse for Resident #1, and stated that on 04/20/2019 she had checked on Resident #1 during her shift every 2-hour rounds. LVN [NAME] stated on 04/20/2019 it was reported Resident #1 did not want to get up for breakfast but then the resident was up for lunch. LVN [NAME] stated Resident #1 had eaten a sandwich because she did not want the meal that was served. LVN [NAME] stated Resident #1 would usually stay up in her wheelchair after lunch at the nurses station sometimes falling asleep, but stated she was not certain if that was what happened on 04/20/2019. LVN [NAME] stated Resident #1's baseline was: she was alert and oriented to self; would try to get up on her own without assistance; would would try to climb out of wheelchair. LVN [NAME] stated staff would assist times one to two persons for transfers. LVN [NAME] stated Resident #1 wore a wander guard because she would try to elope related to confusion. LVN [NAME] stated that she did not note anything out of the normal on her scheduled work days, however, she stated Resident #1 typically slept most of the day. LVN [NAME] stated that on Sunday, 04/21/2019, Resident #1 was already in bed when she arrived at 3:00 PM. LVN [NAME] stated that CNA C had alerted her that Resident #1 was not waking up for dinner at about 5:00 PM with the first group. LVN [NAME] stated she checked on Resident #1 at about 6:30 PM to check to see if the resident was getting up for dinner, and further stated the resident was lethargic so she took the resident's vitals which were within WNL. LVN [NAME] stated she was not more lethargic, but confirmed Resident #1 was usually up and around at that time. LVN [NAME] stated she did not know if Resident #1 got up for dinner. LVN [NAME] further stated that she usually worked from 6:00 AM to 6:00 PM, and stated that normally Resident #1 would get up by lunch time; would go down at 2:00 PM and would get back up at 3:00 PM and then she would stay up. LVN [NAME] stated, she (Resident #1) was always ready to go back to bed (or) would ask to go to bed. LVN [NAME] stated that once Resident #1 was up after 5:00 PM or 6:00 PM she would stay up until 4:00 AM or 5:00 AM. LVN [NAME] stated Resident #1 had started receiving [MEDICATION NAME] and upon reviewing the start date (04/20/2019) stated she thought the resident had been receiving it prior to 04/20/2019. LVN [NAME] stated in responding to a change in condition would include the following process: obtain vital signs, complete assessment, call the doctor and call the RP. LVN [NAME] stated again that she took the resident's vitals and they were within normal limits so she did not do anything else. During an interview with RN F on 04/29/2019 at 1:24 PM, RN F stated she had provided RN weekend coverage at the facility since (MONTH) (YEAR). RN F confirmed she worked on 04/20/2019 from 7:00 AM to 3:00 PM, and on 04/21/2019 from 2:00 PM to 10:00 AM. RN F stated typically she would start making rounds when she first reported to work and throughout the day. RN F stated on 04/20/2019 Resident #1 did not get up for breakfast but was up and eating in the dining room for lunch. RN F stated she had dining room duty and sat with Resident #1 who she believed ate the meal for the day because if she had eaten a sandwich she would asked for a PBJ sandwich but stated she did not remember Resident #1 eating a sandwich. RN F further stated Resident #1 was up and talking; was her normal self. RN F stated she did not see Resident #1 again before leaving on 04/20/2019 at the end of her shift. RN F stated she worked on Sunday during the night shift and stated that Resident #1 was usually up at night; was active throughout the night. RN F stated Resident #1 was not up on Sunday during her shift. RN F stated while making rounds, Resident #1 did not appear to be in distress; normal sleep pattern and the resident's respirations were not labored. RN F confirmed it was different for the resident to be sleeping but stated she understood there had been some medication changes for the resident and had started a new medication. RN F stated she was not sure what changes were made and that she did not pull Resident #1's chart/MAR to determine the side effects for the new medication. RN F confirmed the charge nurse, LVN E, did not report any changes in condition for to her on Sunday regarding Resident #1. During an interview with MA G on 04/29/2019 at 1:33 PM, MA G revealed he worked part-time hours on Sunday and Monday from 5:00 AM to 2:00 PM. MA G confirmed he had worked on 04/21/2019 and 04/22/2019. MA G stated Resident #1 was usually sleeping during the 8:00 AM med pass because she would routinely stay up until 3:00 AM or 4:00 AM. MA G stated Resident #1 would wake for the med pass; would open her eyes to look at him and would take her medications. MA G stated he remembered one morning Resident #1 was not waking up at all. MA G stated he reported to the nurse that Resident #1 did not receive her AM meds because the resident was, out of it. MA G initially stated he could not remember what day it was but knew it was before the resident was hospitalized last week. MA G reviewed Resident #1' MAR for 04/21/2019 and 04/22/2019 and he stated he forgot to circle that the resident did not receive the medications maybe because he was distracted. MA G confirmed he did not take Resident #1's BP reading or heart rate. During an interview with the Administrator on 4/29/19 at 4:39 PM, the Administrator stated nursing staff had not recorded Resident #1's food intake for the weekend of 04/20/2019 to 04/21/2019 therefore could not confirm if she had eaten over the weekend. During an interview with LVN H on 04/29/2019 at 5:29 PM, LVN H confirmed she had worked on 04/21/2019 from 6:00 AM to 1:00 PM. LVN H stated LVN D had reported to her that Resident #1 had not been up during her shift from 6:00 PM to 6:00 AM on 04/20/2019. During this interview with LVN H, RN F interjected at this same time and stated Resident #1 had been up for lunch on Saturday, 04/20/2019. LVN H stated Resident #1 did not wake up for lunch on Sunday per the CNA on duty that date. LVN H stated when she started her rounds she checked in on Resident #1 first thing. LVN H stated she touched Resident #1's hand. Resident #1 was sleeping (did not wake up to stimuli), her respirations were even and unlabored and did not appear to be in distress. LVN H stated she did not see the resident get up prior to her leaving at the end of her shift. LVN H stated therefore, Resident #1 had not been up since at least 6:00 PM on 04/20/2019 which was unusual for Resident #1. LVN H stated protocol for change of condition included discussing the resident's status with other nurses because she was a new nurse. LVN H stated she did not note a change because there had been times when Resident #1 slept through lunch, however, stated typically Resident #1 would be up by lunch, the resident would lay down afterwards, but by 2:00 PM to 3:00 PM the resident would be up roaming the halls; Resident #1 was very active. LVN H confirmed she did not talk with other nurses, the manager on duty or call the physician regarding the Resident's status. During an interview with MA G on 04/29/2019 at 6:14 PM, MA G confirmed he had worked on 04/22/2019, and stated Resident #1 did not receive her 8:00 AM and 12:00 PM medications because the resident was, out of it. MA G stated he did not take the resident's BP reading or heart rate. MA G stated he could not remember if he let the nurse know. MA G stated he could not remember what nurses were working that day and upon reviewing the schedule stated could not be certain who he might have told. During an interview with LVN I on 04/29/2019 at 6:24 PM, LVN I revealed she had worked at the facility for almost three years on a PRN basis. LVN I confirmed she had worked on 04/22/2019, and stated she had reported to work at the facility at about 10:45 AM. LVN I stated the CNA was the first staff who talked with her about Resident #1. LVN I stated the CNA had reported Resident #1 was not waking up. LVN I stated she did not talk with MA G. LVN I stated she assessed Resident #1 shortly after talking with the CN[NAME] LVN I stated when she called Resident #1's name and took her arm it was flaccid. LVN I stated Resident #1 did not respond when usually she would moan or open eyes. LVN I stated she did a sternal rub and the resident still did not wake so she called 911 and followed the change of condition protocol. LVN I stated Resident #1 was discharged to the local hospital.

Based on interviews, observation and record reviews, the facility failed to ensure adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) whose care was reviewed for accidents in that: 1. RN H left uncertified NA D to continue providing care to Resident #1; 2. NA D did not check the Point of Contact Matrix to determine the number of persons required to assist Resident #1 with bed mobility. The resident required 2 persons for both bed mobility and transfers; 3. NA D failed to wait for a second person to assist with bed mobility to sit Resident #1 on the side of the bed. As a result, Resident #1 lost her balance and slid off the bed and sustained a displaced spiral fracture of the left femur. An immediate jeopardy was identified that existed from 12/24/16 to 12/30/16 at a scope of isolation at actual harm. This was determined to be past non-compliance. The facility implemented actions that corrected the non-compliance prior to the beginning of the investigation survey. This deficient practice could affect 16 residents at the facility who were assessed by the facility as needing 2 staff persons to assist the residents with bed mobility and transfers and could result in declines and injuries. The findings were: Record review of Resident #1's undated admission face sheet revealed that Resident # 1 was admitted on [DATE] with a history of senile dementia with delusions, [DIAGNOSES REDACTED], osteoporosis, hypertension, [DIAGNOSES REDACTED] (collection of fluid that causes swelling in the arms and legs) and venous embolism (deep vein thrombosis). Review of a care plan dated 11/18/16 revealed that Resident #1 required 2 persons to be transferred by Hoyer lift when the resident sustained [REDACTED]. Review of a quarterly MDS dated [DATE] revealed in Section G, Functional Status, that the resident's bed mobility required 2 persons for physical assistance. The MD documented that the resident weighed 181 pounds. Review of the current consolidated physician orders [REDACTED]. Review of the facility's provider investigation report for Resident #1's 12/24/16 fall revealed that RN H had just left NA D in Resident #1's room after assisting NA D with incontinent care. NA D was finishing up putting the resident's sweater on and another aide was going to come in and assist with the Hoyer transfer. RN H had been summoned to another room. The resident leaned forward while sitting on the side of the bed and NA D caught her and attempted to ease her fall to the floor. The charge nurse, LVN E, came in and noted the resident's left leg was rotated inward and that the resident was complaining of pain to the left leg. The resident was kept as comfortable as possible and emotional support was provided while the on-call physician and EMS were notified and the resident was transferred to a local hospital. The facility was later informed that an x-ray of the left leg confirmed that the leg was fractured. Review of a hospital's history and physical dated 12/24/16 revealed the resident had been brought into the hospital after a fall in the nursing home with a fractured femur and low blood pressure of 80/63 and was immediately transferred to ICU. The history and physical also documented that the resident's fractured was inoperable and both legs were bound together with ace wraps with a pillow between the legs. Due to the patient's worsening condition, the resident was transferred to in-patient hospice service on 12/26/16. Review of NA D's personnel file revealed the Nurse Aide had completed a certified nurse aide program on May 2016 and was hired by the facility on 10/18/16 pending the certification test. During an entrance conference at 3:00 p.m. on 1/3/16, the Administrator stated that the facility had reported Resident #1 ' s incident to Consumer Services on 12/24/16 and immediately began conducting an investigation regarding the circumstances of the fall. Staff education was immediately begun on 12/26/16 at 3:00 p.m. on identifying the coding in the Point of Contact Matrix used by the direct care staff (CNAs), when documenting care to residents. The staff was also instructed on how to access the resident's profile to obtain information on the number of staff required to provide direct care to each resident. A DVD was used to conduct the hour long in-services also on 12/29/16 and 12/30/16. The class also included education on the facility's abuse/neglect policies and procedures and on falls/interventions. During an interview on 1/3/17 at 3:23 p.m., a family member reported that Resident #1 was [AGE] years old and up to the date of the fall was able to feed herself and propel in the hallways in her wheelchair. The family member reported that ever since the resident's admission, the resident had required 2 persons for transfers and 2 persons when providing ADLs due to the resident's spunkiness. During an interview on 1/3/17 at 5:20 p.m., NA D reported that she had sat the resident up on the edge of the bed to untangle her sweater. NA D stated that the resident was wearing plain slippers (not non-skid) and both feet were touching the floor when the resident began to lose her balance and started to slide off the bed. NA D stated that she attempted to stop the resident from falling by placing her knee between the resident's legs. However, the resident continued to fall to the floor and immediately complained of pain to the left leg. This interview confirmed a written statement dated 12/24/16 that was included in the facility's investigation. NA D stated that the resident had been lying flat and that she lifted Resident #1 up in bed and swung her legs over the side of the scoop mattress (both sides of mattress are raised to prevent rolling on to the floor) on the bed. During an interview at the hospital on [DATE] at 10:46 a.m., Resident #1's Responsible Party reported that the last time the resident fell was after her initial admission to the nursing facility in 2008 when another resident pushed her and she fell and broke her hip. The resident was operated on and as a result could no longer walked and bear weight and depended on a wheelchair to get around the facility. During an observation on 1/5/17 at 10:46 a.m., Resident #1 was observed lying in a hospital bed with both legs bound together with ace wraps and a pillow between the legs. Two large blisters the size of a tennis ball had developed on the lateral side of the left leg. The resident's urine output collected by an indwelling urinary tube was scant in the collection bag. The resident was receiving oxygen via nasal cannula and was unresponsive. During an interview on 1/5/17 at 12:15 p.m., LVN E, Charge Nurse, reported that she worked on 12/24/16 and was called into Resident #1's room by NA D to assess the resident after the fall. She stated that the left leg was turned inward and the resident was sitting on the floor with her back to the bedframe. Because the resident was complaining of pain to the left leg, LVN E stated that she instructed LVN F and NA D not to move the resident until EMS arrived. During an interview on 1/5/17 at 12:45 p.m., CNA G reported that she worked on 12/24/16 and was coming off break when Resident #1 fell . She stated that she entered the room to assist and found Resident #1 on the floor. CNA G stated that when providing ADLs such as incontinent care was provided to Resident #1, 2 persons were required because the resident could become feisty and combative. During a later interview on 1/5/17 at approximately 2:00 p.m., NA D reported that she had assumed that Resident #1's bed mobility only required 1 person. She stated that she was instructed by the Administrator on how to document direct care accurately in accordance with the resident's profile (plan of care) on the matrix and that the documentation should correspond with the profile. NA D stated that she did not bother to check the POC Matrix prior to the fall. Review of an excerpt of the facility's Safety and Supervision of Residents Policy and Procedure Manual dated 2001 revealed that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Further review of the manual describes Resident-Oriented Approach to Safety as Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and MDS. and Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. insuring that interventions are implemented; and e. documenting interventions. On 1/5/17, the Administrator was notified that an immediate jeopardy at past non-compliance had been identified. The immediate jeopardy occurred 12/24/16 to 12/30/16 at a scope of isolated. The facility began corrective action on 12/26/16. This was verified by reviewing the earliest in-services conducted for 5 CNAs, who were counseled regarding coding and checking profiles for following resident plans of care. On 1/5/17 confirmed, the Administrator reported that she had given a one-on-one verbal counseling on 12/24/16 to NA D regarding her documentation and following resident profiles. (This was verified during interview of NA D on 1/5/17). By 12/30/16, in-service log confirmed that 12 CNAs had been educated on checking matrix profiles and accurate documentation. During the investigation, the DON provided the names of 16 residents at the facility who were assessed by the facility as needing 2 staff persons to assist the residents with bed mobility and transfers.

Based on interviews, observations and record reviews, the facility failed to ensure each resident was free of neglect for 1 of 4 residents (Resident #1) whose care was reviewed in that the facility failed to provide goods and services necessary to avoid physical harm in that: 1. RN H left uncertified NA D to continue providing care to Resident #1; 2. NA D did not check the Point of Contact Matrix to determine the number of persons required to assist Resident #1 with bed mobility. The resident required 2 persons for both bed mobility and transfers; 3. NA D failed to wait for a second person to assist with bed mobility to sit Resident #1 on the side of the bed. As a result, Resident #1 lost her balance and slid off the bed and sustained a displaced spiral [MEDICAL CONDITION] femur. An immediate jeopardy was identified that existed from 12/24/16 to 12/30/16 at a scope of isolation at actual harm. This was determined to be past non-compliance. The facility implemented actions that corrected the non-compliance prior to the beginning of the investigation survey. This deficient practice could affect 16 residents at the facility who were assessed by the facility as needing 2 staff persons to assist the residents with bed mobility and transfers and could result in declines and injuries. The findings were: Record review of Resident #1's undated admission face sheet revealed that Resident # 1 was admitted on [DATE] with a history of senile dementia with delusions, [DIAGNOSES REDACTED], [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] (collection of fluid that causes swelling in the arms and legs) and venous embolism ([MEDICAL CONDITION]. Review of a care plan dated 11/18/16 revealed that Resident #1 required 2 persons to be transferred by Hoyer lift when the resident sustained [REDACTED]. Review of a quarterly MDS dated [DATE] revealed in Section G, Functional Status, that the resident's bed mobility required 2 persons for physical assistance. The MD documented that the resident weighed 181 pounds. Review of the current consolidated physician orders [REDACTED]. Review of the facility's provider investigation report for Resident #1's 12/24/16 fall revealed that RN H had just left NA D in Resident #1's room after assisting NA D with incontinent care. NA D was finishing up putting the resident's sweater on and another aide was going to come in and assist with the Hoyer transfer. RN H had been summoned to another room. The resident leaned forward while sitting on the side of the bed and NA D caught her and attempted to ease her fall to the floor. The charge nurse, LVN E, came in and noted the resident's left leg was rotated inward and that the resident was complaining of pain to the left leg. The resident was kept as comfortable as possible and emotional support was provided while the on-call physician and EMS were notified and the resident was transferred to a local hospital. The facility was later informed that an x-ray of the left leg confirmed that the leg was fractured. Review of a hospital's history and physical dated 12/24/16 revealed the resident had been brought into the hospital after a fall in the nursing home with a fractured femur and low blood pressure of 80/63 and was immediately transferred to ICU. The history and physical also documented that the resident's fractured was inoperable and both legs were bound together with ace wraps with a pillow between the legs. Due to the patient's worsening condition, the resident was transferred to in-patient hospice service on 12/26/16. Review of NA D's personnel file revealed the Nurse Aide had completed a certified nurse aide program on May 2016 and was hired by the facility on 10/18/16 pending the certification test. During an entrance conference at 3:00 p.m. on 1/3/16, the Administrator stated that the facility had reported Resident #1 ' s incident to Consumer Services on 12/24/16 and immediately began conducting an investigation regarding the circumstances of the fall. Staff education was immediately begun on 12/26/16 at 3:00 p.m. on identifying the coding in the Point of Contact Matrix used by the direct care staff (CNAs), when documenting care to residents. The staff was also instructed on how to access the resident's profile to obtain information on the number of staff required to provide direct care to each resident. A DVD was used to conduct the hour long in-services also on 12/29/16 and 12/30/16. The class also included education on the facility's abuse/neglect policies and procedures and on falls/interventions. During an interview on 1/3/17 at 3:23 p.m., a family member reported that Resident #1 was [AGE] years old and up to the date of the fall was able to feed herself and propel in the hallways in her wheelchair. The family member reported that ever since the resident's admission, the resident had required 2 persons for transfers and 2 persons when providing ADLs due to the resident's spunkiness. During an interview on 1/3/17 at 5:20 p.m., NA D reported that she had sat the resident up on the edge of the bed to untangle her sweater. NA D stated that the resident was wearing plain slippers (not non-skid) and both feet were touching the floor when the resident began to lose her balance and started to slide off the bed. NA D stated that she attempted to stop the resident from falling by placing her knee between the resident's legs. However, the resident continued to fall to the floor and immediately complained of pain to the left leg. This interview confirmed a written statement dated 12/24/16 that was included in the facility's investigation. NA D stated that the resident had been lying flat and that she lifted Resident #1 up in bed and swung her legs over the side of the scoop mattress (both sides of mattress are raised to prevent rolling on to the floor) on the bed. During an interview at the hospital on [DATE] at 10:46 a.m., Resident #1's Responsible Party reported that the last time the resident fell was after her initial admission to the nursing facility in 2008 when another resident pushed her and she fell and broke her hip. The resident was operated on and as a result could no longer walked and bear weight and depended on a wheelchair to get around the facility. During an observation on 1/5/17 at 10:46 a.m., Resident #1 was observed lying in a hospital bed with both legs bound together with ace wraps and a pillow between the legs. Two large blisters the size of a tennis ball had developed on the lateral side of the left leg. The resident's urine output collected by an indwelling urinary tube was scant in the collection bag. The resident was receiving oxygen via nasal cannula and was unresponsive. During an interview on 1/5/17 at 12:15 p.m., LVN E, Charge Nurse, reported that she worked on 12/24/16 and was called into Resident #1's room by NA D to assess the resident after the fall. She stated that the left leg was turned inward and the resident was sitting on the floor with her back to the bedframe. Because the resident was complaining of pain to the left leg, LVN E stated that she instructed LVN F and NA D not to move the resident until EMS arrived. During an interview on 1/5/17 at 12:45 p.m., CNA G reported that she worked on 12/24/16 and was coming off break when Resident #1 fell . She stated that she entered the room to assist and found Resident #1 on the floor. CNA G stated that when providing ADLs such as incontinent care was provided to Resident #1, 2 persons were required because the resident could become feisty and combative. During a later interview on 1/5/17 at approximately 2:00 p.m., NA D reported that she had assumed that Resident #1's bed mobility only required 1 person. She stated that she was instructed by the Administrator on how to document direct care accurately in accordance with the resident's profile (plan of care) on the matrix and that the documentation should correspond with the profile. NA D stated that she did not bother to check the POC Matrix prior to the fall. Review of an excerpt of the facility's Safety and Supervision of Residents Policy and Procedure Manual dated 2001 revealed that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Further review of the manual describes Resident-Oriented Approach to Safety as Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and MDS. and Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. insuring that interventions are implemented; and e. documenting interventions. On 1/5/17, the Administrator was notified that an immediate jeopardy at past non-compliance had been identified. The immediate jeopardy occurred 12/24/16 to 12/30/16 at a scope of isolated. The facility began corrective action on 12/26/16. This was verified by reviewing the earliest in-services conducted for 5 CNAs, who were counseled regarding coding and checking profiles for following resident plans of care. On 1/5/17 confirmed, the Administrator reported that she had given a one-on-one verbal counseling on 12/24/16 to NA D regarding her documentation and following resident profiles. (This was verified during interview of NA D on 1/5/17). By 12/30/16, in-service log confirmed that 12 CNAs had been educated on checking matrix profiles and accurate documentation. During the investigation, the DON provided the names of 16 residents at the facility who were assessed by the facility as needing 2 staff persons to assist the residents with bed mobility and transfers.

Based on interviews, observations and record reviews, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 1 of 4 residents (Resident #1) whose care was reviewed in that the facility failed to provide goods and services necessary to avoid physical harm in that: 1. RN H left uncertified NA D to continue providing care to Resident #1; 2. NA D did not check the Point of Contact Matrix to determine the number of persons required to assist Resident #1 with bed mobility. The resident required 2 persons for both bed mobility and transfers; 3. NA D failed to wait for a second person to assist with bed mobility to sit Resident #1 on the side of the bed. As a result, Resident #1 lost her balance and slid off the bed and sustained a displaced spiral [MEDICAL CONDITION] femur. An immediate jeopardy was identified that existed from 12/24/16 to 12/30/16 at a scope of isolation at actual harm. This was determined to be past non-compliance. The facility implemented actions that corrected the non-compliance prior to the beginning of the investigation survey. This deficient practice could affect 16 residents at the facility who were assessed by the facility as needing 2 staff persons to assist the residents with bed mobility and transfers and could result in declines and injuries. The findings were: Review of an excerpt of the facility's Safety and Supervision of Residents Policy and Procedure Manual dated 2001 revealed that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Further review of the manual describes Resident-Oriented Approach to Safety as Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and MDS. and Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. insuring that interventions are implemented; and e. documenting interventions. Review of the facility's (undated) Abuse, Neglect and Exploitation Statement revealed that neglect was defined as: the failure of a caretaker of the resident themselves to provide the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services. Record review of Resident #1's undated admission face sheet revealed that Resident # 1 was admitted on [DATE] with a history of senile dementia with delusions, [DIAGNOSES REDACTED], [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] (collection of fluid that causes swelling in the arms and legs) and venous embolism ([MEDICAL CONDITION]. Review of a care plan dated 11/18/16 revealed that Resident #1 required 2 persons to be transferred by Hoyer lift when the resident sustained [REDACTED]. Review of a quarterly MDS dated [DATE] revealed in Section G, Functional Status, that the resident's bed mobility required 2 persons for physical assistance. The MD documented that the resident weighed 181 pounds. Review of the current consolidated physician orders [REDACTED]. Review of the facility's provider investigation report for Resident #1's 12/24/16 fall revealed that RN H had just left NA D in Resident #1's room after assisting NA D with incontinent care. NA D was finishing up putting the resident's sweater on and another aide was going to come in and assist with the Hoyer transfer. RN H had been summoned to another room. The resident leaned forward while sitting on the side of the bed and NA D caught her and attempted to ease her fall to the floor. The charge nurse, LVN E, came in and noted the resident's left leg was rotated inward and that the resident was complaining of pain to the left leg. The resident was kept as comfortable as possible and emotional support was provided while the on-call physician and EMS were notified and the resident was transferred to a local hospital. The facility was later informed that an x-ray of the left leg confirmed that the leg was fractured. Review of a hospital's history and physical dated 12/24/16 revealed the resident had been brought into the hospital after a fall in the nursing home with a fractured femur and low blood pressure of 80/63 and was immediately transferred to ICU. The history and physical also documented that the resident's fractured was inoperable and both legs were bound together with ace wraps with a pillow between the legs. Due to the patient's worsening condition, the resident was transferred to in-patient hospice service on 12/26/16. Review of NA D's personnel file revealed the Nurse Aide had completed a certified nurse aide program on May 2016 and was hired by the facility on 10/18/16 pending the certification test. During an entrance conference at 3:00 p.m. on 1/3/16, the Administrator stated that the facility had reported Resident #1 ' s incident to Consumer Services on 12/24/16 and immediately began conducting an investigation regarding the circumstances of the fall. Staff education was immediately begun on 12/26/16 at 3:00 p.m. on identifying the coding in the Point of Contact Matrix used by the direct care staff (CNAs), when documenting care to residents. The staff was also instructed on how to access the resident's profile to obtain information on the number of staff required to provide direct care to each resident. A DVD was used to conduct the hour long in-services also on 12/29/16 and 12/30/16. The class also included education on the facility's abuse/neglect policies and procedures and on falls/interventions. During an interview on 1/3/17 at 3:23 p.m., a family member reported that Resident #1 was [AGE] years old and up to the date of the fall was able to feed herself and propel in the hallways in her wheelchair. The family member reported that ever since the resident's admission, the resident had required 2 persons for transfers and 2 persons when providing ADLs due to the resident's spunkiness. During an interview on 1/3/17 at 5:20 p.m., NA D reported that she had sat the resident up on the edge of the bed to untangle her sweater. NA D stated that the resident was wearing plain slippers (not non-skid) and both feet were touching the floor when the resident began to lose her balance and started to slide off the bed. NA D stated that she attempted to stop the resident from falling by placing her knee between the resident's legs. However, the resident continued to fall to the floor and immediately complained of pain to the left leg. This interview confirmed a written statement dated 12/24/16 that was included in the facility's investigation. NA D stated that the resident had been lying flat and that she lifted Resident #1 up in bed and swung her legs over the side of the scoop mattress (both sides of mattress are raised to prevent rolling on to the floor) on the bed. During an interview at the hospital on [DATE] at 10:46 a.m., Resident #1's Responsible Party reported that the last time the resident fell was after her initial admission to the nursing facility in 2008 when another resident pushed her and she fell and broke her hip. The resident was operated on and as a result could no longer walked and bear weight and depended on a wheelchair to get around the facility. During an observation on 1/5/17 at 10:46 a.m., Resident #1 was observed lying in a hospital bed with both legs bound together with ace wraps and a pillow between the legs. Two large blisters the size of a tennis ball had developed on the lateral side of the left leg. The resident's urine output collected by an indwelling urinary tube was scant in the collection bag. The resident was receiving oxygen via nasal cannula and was unresponsive. During an interview on 1/5/17 at 12:15 p.m., LVN E, Charge Nurse, reported that she worked on 12/24/16 and was called into Resident #1's room by NA D to assess the resident after the fall. She stated that the left leg was turned inward and the resident was sitting on the floor with her back to the bedframe. Because the resident was complaining of pain to the left leg, LVN E stated that she instructed LVN F and NA D not to move the resident until EMS arrived. During an interview on 1/5/17 at 12:45 p.m., CNA G reported that she worked on 12/24/16 and was coming off break when Resident #1 fell . She stated that she entered the room to assist and found Resident #1 on the floor. CNA G stated that when providing ADLs such as incontinent care was provided to Resident #1, 2 persons were required because the resident could become feisty and combative. During a later interview on 1/5/17 at approximately 2:00 p.m., NA D reported that she had assumed that Resident #1's bed mobility only required 1 person. She stated that she was instructed by the Administrator on how to document direct care accurately in accordance with the resident's profile (plan of care) on the matrix and that the documentation should correspond with the profile. NA D stated that she did not bother to check the POC Matrix prior to the fall. Review of an excerpt of the facility's Safety and Supervision of Residents Policy and Procedure Manual dated 2001 revealed that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Further review of the manual describes Resident-Oriented Approach to Safety as Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and MDS. and Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. insuring that interventions are implemented; and e. documenting interventions. On 1/5/17, the Administrator was notified that an immediate jeopardy at past non-compliance had been identified. The immediate jeopardy occurred 12/24/16 to 12/30/16 at a scope of isolated. The facility began corrective action on 12/26/16. This was verified by reviewing the earliest in-services conducted for 5 CNAs, who were counseled regarding coding and checking profiles for following resident plans of care. On 1/5/17 confirmed, the Administrator reported that she had given a one-on-one verbal counseling on 12/24/16 to NA D regarding her documentation and following resident profiles. (This was verified during interview of NA D on 1/5/17). By 12/30/16, in-service log confirmed that 12 CNAs had been educated on checking matrix profiles and accurate documentation. During the investigation, the DON provided the names of 16 residents at the facility who were assessed by the facility as needing 2 staff persons to assist the residents with bed mobility and transfers.