Every finding on record at Avir at Hillsboro

Based on interviews and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 (CNA A) of 3 CNA's reviewed for proficiency of nurse aides. The facility failed to ensure CNA A had an active CNA license before allowing her to perform CNA tasks, working a total of 83.88 hours between [DATE] and [DATE], with an expired CNA license. This deficient practice had the potential to affect all residents in the facility who CNA A worked with when CNA A failed to maintain a current nurse aide certification. Findings included:Review of an initial EMR check conducted by the facility on [DATE] revealed CNA A was employable and had a nurse aide certification that expired on [DATE]. Review of the Texas HHS TULIP nurse aide search revealed CNA A's nurse aide license was most recently issued on [DATE]. Her initial certification was issued on [DATE].Review of a company-wide staff list provided by the ADM, identified as a staff list provided to the facility by corporate HR, contained names of staff members whose professional licenses were due to expire within the month the list was provided to the facility's electronic mail. CNA A's name, nurse aide license number, and date of expiration ([DATE]) were on this list. A verbal request was made to HR on [DATE] at 8:59pm for all shifts worked by CNA A in the month of [DATE]. Review of an employee timecard report identified as CNA A's timecard dated [DATE]-[DATE] revealed CNA A worked from 6pm-6am on [DATE] for a total of 12 hours. A verbal request was made to the ADM on [DATE] at 9:15pm for all shifts worked by CNA A in the month of [DATE]. Review of an employee timecard report identified as CNA A's timecard dated [DATE]-[DATE] revealed CNA A worked:6pm-6am on [DATE] and [DATE] for a total of 24 hours 6:13pm-6:06am on [DATE] for a total of 11.88 hours.6pm-6am on [DATE], [DATE], [DATE] for a total of 36 hours. In an interview on [DATE] at 8:36 PM with CNA A, she stated that her CNA license had lapsed on [DATE], but she was permitted by the facility to still work on the floor as a CNA, until she got it reinstated on [DATE]. She stated she was working night shift as a CNA giving showers, assisting with ADLs, and performing basic CNA tasks. CNA A made a comment that they (direct care staff) were supposed to document tasks in an electronic system, but she had not been added to the system yet, so she had to chart under other aides logins. She stated that she had received paychecks from this facility for the month of June, during the time her CNA license was lapsed, while working as a CNA, and performing CNA tasks. She stated that her paycheck for the dates of [DATE]-[DATE] she was paid for working 65.88 hours as a CNA. In an interview on [DATE] at 9:39 PM with HR, she stated that she was responsible for ensuring staff with expired licenses were not put on the schedule by informing the nurse (ADON) not to put them in the schedule. She stated she would also alert the DON and ADM about the CNA's license expiring from a list she received from corporate HR. She stated that the CNAs had 2 months prior to their license expiration to get their education modules done and get their license renewed. She stated that CNA A was a 'very different case' because the facility had a customer service issue with CNA A, where a family member was going to remove a resident from the facility because of CNA A's actions. The facility tried to investigate the incident, but CNA A kept showing up for work without management's knowledge due to still being a part of a staff group chat, where HR believed shifts were texted out that needed coverage, and CNA A showed up to cover them without responding to the texts, and after management left the facility for the day. HR made a comment of Maybe that is why the state gives CNAs a 30-day grace period meaning that if all the renewal paperwork was turned in, the CNA would get a 30-day grace period allowing them to work the floor while they awaited the renewal confirmation. She stated this was her understanding since COVID. HR stated that she submitted CNA A's '5506 NAR form' to the State after CNA A completed her required education. HR stated the facility did not have any guidance from HHSC pertaining to CNA licenses having a 30-day grace period to renew, after expiration. In an interview on [DATE] at 10:25 PM with the DON, she stated that she became the DON approximately 3 weeks ago, and prior to that she had been the weekend supervisor. She stated that HR had told her about several staff who could not work until they got their professional licenses renewed, but at the moment, she could not recall which staff it recently was. She stated she was not familiar with a rule that the CNAs could work 30 days while waiting for their license renewal. She stated she had recently heard it from HR as a new rule, but no memorandums from HHSC were provided to her as proof. She stated that she was not aware that CNA A had managed to work 83.88 hours on the floor as a CNA with an expired license. The DON stated she had told CNA A not to come into work because there was a family complaint about her recently, but she was not suspended while her license was getting renewed. In an interview on [DATE] at 10:40 PM with the ADM, she stated that Corporate sent out spreadsheets monthly, identifying employees who had a professional license due to expire within that month. She stated that facility HR was an included recipient on these emails. She stated the facility's process for monitoring CNA certification status and expiration dates was that HR managed that process. She stated that it was the responsibility of the CNAs and HR to verify that their nurse aide license maintained active status on the NAR. She stated that HR ran a check once a month to see whose professional license was expiring, but the facility also got an email from Corporate about whose license was due to expire. She stated the facility's policy and procedure on maintaining professional licensure was located in their employee handbook. She stated that there was a complaint from a FM and the facility addressed it by taking CNA A off the schedule and suspending her login credentials, and she was a PRN staff anyway. She was not on the schedule and just showed up to work. The ADM provided a spreadsheet that listed CNA A, indicated, by Corporate, that her CNA license was expiring.Review of the facility's Employee Handbook dated [DATE] reflected: LicensureThe Company adheres to federal, state, and local regulations and laws that govern all health care facilities and monitors its facilities to ensure ongoing compliance. Employment positions requiring annual certification or licensure are verified and monitored to ensure status, with copies of all current licenses retained in company files. Each licensed or certified employee is expected to maintain his/her ongoing education requirements. The Company will support the employees' efforts in this regard by providing reasonable accommodations flexibility in the work schedule that may be necessary to fulfill these educational obligations.

Based on observation, interviews, and record reviews the facility failed to ensure personal privacy for 1 of 6 residents (Resident #1) reviewed for privacy while receiving care. 1. The facility failed to ensure the privacy of Resident #1 by not closing the door or pulling the privacy curtain during perineal care. This failure could place residents at risk of loss of privacy and dignity.Findings included: Review of Resident #1's face sheet dated 02/18/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (characterized as experiencing significant paranoia and delusions), reduced mobility, abnormalities of gait and mobility, muscle weakness, major depressive disorder (persistent feelings of sadness)- recurrent-severe with psychotic symptoms, and edema (swelling caused by trapped fluid in body tissues). Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 06 indicating severe cognitive impairment. Section GG for functional abilities reflected Resident #1 was completely dependent on staff for toileting hygiene. Section H for bowel and bladder reflected Resident #1 was always incontinent of urinary and bowel continence. Review of Resident #1's care plan last revised 12/05/25 reflected a focus resident is incontinent of bowel and bladder with intervention incontinent: check [Resident #1] frequently and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. During an observation on 02/18/26 at 12:45 PM, while walking down the hall, Resident #1's door was observed opened. From the hallway CNA A was observed on the opposite side of the bed (window side) providing perineal care to Resident #1. Resident #1 could be seen from the hallway fully exposed from the lower body while perineal care was performed as the curtain was not drawn and the door was fully opened. Surveyor knocked on the door and CNA A shouted resident care. Surveyor stepped to the side of the door in the hall waiting for any action from CNA A, however, CNA A continued with incontinent care with no privacy provided. Surveyor once again knocked on the door a second time and CNA A once again only stated resident care and continued to finish perineal care without drawing the curtain or closing the door to the room. CNA A was then observed leaving the room after care was provided to throw out the trash and remove soiled items. During an interview on 02/18/26 at 12:48 PM with CNA A, she stated she was in Resident #1's room providing perineal care. She stated that it is the expectation and procedure to shut the door or ensure the curtain is used to provide privacy to a resident when assisting with incontinent care. CNA A alleged that she initially did close the door but it did not latch and opened back up on its own. CNA A stated a potential negative outcome of failing to provide privacy for residents who are getting perineal care and are exposed would make them feel uncomfortable. During an interview on 02/18/26 at 12:54 PM with Resident #1, she stated CNA A was just in the room providing incontinent care for her and changing her brief. She stated that typically when that is performed the door is closed for her and there is privacy. She stated the lack of privacy that had occurred during this incident did not make me feel good. During an interview on 02/18/26 at 01:13 PM with the DON, she stated it was her expectation that when doing incontinent care the procedure is, knock on the door before entering, ensure the door is shut and say patient care if someone knocks to enter while care is being performed. If there are two residents in the room draw the curtain. She stated that failure to provide privacy for a resident during perineal care is a breach of their dignity. It's a huge dignity issue that can affect them mentally and physically. During an interview on 02/18/26 at 02:28 PM with the ADM, she stated it was her expectation that during incontinent care staff were making sure the door was closed and the curtain was pulled to ensure privacy. She stated failing to ensure there was privacy can affect the residents emotionally and psychologically. She went on to say, it is a resident rights and privacy issue. I wouldn't want someone to see me in that way. It can result in a negative outcome from that experience such as decline in health; they can feel embarrassed and disrespected. Review of the facility Dignity policy last revised in February 2021 reflected: Each resident should be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Residents are treated with dignity and respect at all times.Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of the facility Resident Rights policy last revised in February 2021 reflected: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 residents right toA dignified existenceBe treated with respect, kindness, and dignityPrivacy and confidentiality. Review of the facility Perineal Care policy last revised in February 2018 reflected: The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents skin condition. Steps in the procedure:Provide privacy as appropriate, such as closing doors/ curtains, drape the resident.Cover the resident with a sheet or blanket. Raise cover to expose the perineum

Based on observations, interviews, and record reviews , the facility failed to ensure no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for 61 of 61 residents reviewed for meal frequency . The facility failed to ensure the timing/hours between the supper and breakfast meal was no more than 14 hours. The current schedule was for 14.25 hours between dinner and breakfast the following day. This failure could place all 61 residents who received meals served from the facility's only kitchen at risk of decreased intake and meal dissatisfaction. Findings included: Record review of the facility mealtimes undated and posted outside the facility kitchen revealed: Breakfast at 7:00 AM , Lunch at 11:45 AM, Dinner at 4:45 PM. In a confidential resident group meeting on an undisclosed date and time, it was revealed that residents did not help choose the mealtimes and that the ADM had given (on 12/04/2025) the RCP a piece of paper with new mealtimes to vote on. The residents stated they desired for dinner to be later than the posted time, but they were satisfied with the posted breakfast and lunch times. In an interview on 12/03/2025 at 4:00 a.m., the ADM stated she would get with the RCP to have the council vote on new dinner and breakfast times. She stated the mealtimes were set before she started a few months ago, and she would begin the change by the time the annual survey concluded. She stated there was only a list of residents who received snacks at bedtime, but not every resident who resided in the building. In an interview on 12/04/2025 at 11:02 a.m., the DM stated she was aware there should not be a lapse of more than 14 hours between dinner and breakfast. She stated she had a list of residents who received snacks at bedtime, but it was only the residents on the list, not all residents. She stated she would need to get with the ADM to change the mealtimes. In an interview on 12/05/2025 at 8:51 AM with the RD, she stated the last time she looked at the mealtimes, the facility was at the 14-hour requirement, and that snacks should be offered to residents who had an order for them. Review of the facility's Open Style Dining policy, dated 2023, revealed, Note: Federal nursing home tag F809 requires no more than 14 hours to elapse between a substantial evening meal and breakfast the following day. When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a patient/resident group agrees to this span, and a nourishing snack is served.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. The facility failed to keep a clean veggie/dessert/drink freezer. This failure could place residents at risk of foodborne illness due to unhygienic food storage. Findings included: In an observation of the kitchen on 12/03/2025 at 9:58 a.m., revealed a freezer labeled veggie, dessert, and drinks that contained a yellow sticky residue spilt on the bottom shelf underneath an ice cream tub and surrounding frozen packets of pancakes. In an interview on 12/03/2025 at 10:02 AM, the DM stated she had worked at the facility for two weeks. She stated that they were about to clean up the spill in the dessert freezer and that it must have happened overnight because the spill was not there yesterday. She stated her main goal when she started two weeks ago was to get the kitchen cleaned up. In an interview on 12/05/2025 at 11:00 a.m., the DM stated they used frozen ham to slice and make ham and cheese sandwiches. She stated that if residents did not like the posted menu items, they could choose an item off the alternate menu. She stated that some residents had an order for PB&J with lunch and dinner or as snacks. She confirmed that Resident #39 wanted to receive meat with every meal due to her desire to gain weight, but Resident #39 also made requests for different menu items and was served them upon request, to the DM's knowledge. She stated she was unsure why the resident would receive PB&J sandwiches, unless it was when the DM was not working. In an interview on 12/05/2025 at 12:50 p.m., CNA C stated the nursing staff were responsible for getting alternate food items for residents from the kitchen, but only picking up the items, not preparing them or ensuring it was what the resident wanted. She stated PB&J and ham and cheese sandwiches were go-tos for the kitchen to pass out as alternates. She stated she knew Resident #39 needed double portions for all meals, but the resident did not always get that. In an observation on 12/05/2025 at 11:35 a.m. of the kitchen, revealed a frozen ham in the freezer, canned soup in the pantry, and no alternate menu items (burgers or baked potatoes) prepared on the steam table. In an interview on 12/05/2025 at 4:12p.m.,, the ADM stated that when she started a few months ago, they started ordering bacon and salads, because residents had not been getting those items on a regular basis. The DON stated she had to explain to staff that a few residents needed menus available to them in their rooms so they could submit substitutions prior to the meal being served. The ADM stated that the DM planned to start having the always available menu items prepped in anticipation of residents requesting it.

Based on observation, interview, and record review, the facility failed to establish procedures to ensure that enough water was available in the facility in the event of a loss of normal water supply for 1 of 1 facility. 1. The facility's emergency water supply consisted of 23 gallons (140, 16.9 fl oz water bottles and 1, 5-gallon jug) of water on hand for a census of 61 residents stored in the kitchen's pantry. 2. The facility failed to follow their water supply policy by not having enough water to service the facility's needs in case of a water outage. This failure could place residents at risk of not having water during an outage for bathing, cooking, and drinking. Findings included: In an observation of the kitchen on 12/04/2025 at 8:59 a.m. revealed, four packs of 35-16.9 fl oz water bottles, and 1-5-gallon jug of water. In an interview on 12/04/2025 at 9:05 a.m., the DM stated the water stored in the kitchen pantry was all the emergency supply water they had in the facility for use in case of a water outage. She stated that she could ask the ADM or maintenance if there was additional water stored elsewhere but she was not aware of them. She stated she was unsure how much water was needed per resident, but she did not think they currently had enough to supply all the residents in case of a water emergency. In an interview on 12/05/2025 at 4:12 p.m., the ADM stated the facility received water from [supplier] and that she would put orders in for the required water supply soon. She stated the water in the kitchen pantry was the only emergency supply in the building, and it was not enough to continue daily operations should a water emergency occur. She stated she previously had to get rid of emergency supply water due to it expiring and had not restocked the water yet. Review of a letter dated 01/01/2025, generated by the facility's food procurement servicer, revealed, Please be advised that, while (servicer) warehouses do stock various bottled waters, such inventory is based on regular ongoing customer demand unrelated to an unexpected event or disaster. We do not carry inventory to replace upon an emergency basis a complete loss of, or substantial reduction in, water ordinarily obtained by pipeline, or in truckload or other bulk quantities from municipal entities, utility companies, or other suppliers. We will make available water supply on hand on a pro-rata basis based on inventory not otherwise dedicated to a specific customer until regular water service is restored. For disaster planning purposes, we recommend that you establish disaster water service through a different company capable of fulfilling your particular quantity requirements during a disaster scenario. Review of an undated Emergency Preparedness Guidance policy revealed, We recommend maintaining on hand at least one gallon of bottled water per person per day x 3 days. This includes residents, staff, families of residents and families of staff who will be at the facility.

Based on observations, interviews, and record review, the facility failed to notify residents of how to file a grievance in an anonymous manner, for 6 confidential residents out of 6 residents interviewed for grievances. 1.The facility failed to notify Residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner. 2.The facility failed to ensure residents felt like they could complain about care without worrying someone would get back at them. These failures could affect resident's' ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to request a written decision regarding the resolution of their grievance.Findings Included: Observations on 12/03/2025 and 12/04/2025 throughout the annual survey revealed no blank grievance forms anywhere in the facility where residents or their representatives could obtain a grievance form and/or turn in grievance forms anonymously. No grievance official information was posted, and the only mention of filing complaints was on a posterboard at the beginning of a hall, adjacent from the nurses. In a confidential resident group interview at an undisclosed date and time with six residents revealed that the residents did not know how to file grievances anonymously due to having to obtain grievance forms from the activity director, who would then fill out the grievance form on their behalf. They stated there was not a place to obtain blank grievance forms by themselves or during weekends/holidays when department heads may not be available, and there was not a place to turn in any grievances. The residents stated that they did not know they had the right to file grievances/complaints anonymously. They also stated that in the past, they felt they could not file a grievance without the fear of retaliation due to word getting around about their grievance, they stated this was prior to the current administration. In an interview on 12/04/2025 at 4:09 PM with the AD, she stated that she handled resident grievances. She stated that during resident council she would write the grievance up for the resident. She stated she would also make room rounds in the morning and if a resident had a complaint, she would write the grievance for them. She stated that all department head staff had access to the blank grievance forms. She stated she was not aware of any blank grievance forms being available to residents or their family to make anonymous grievances. In an interview on 12/05/2025 at 4:25PM, the ADM and DON stated that it was an option to file an anonymous grievance, but the forms were not available unless they were requested from staff. The ADM stated that the AD could write up grievances during resident council meetings. The ADM stated that residents should have the right to privacy and confidentiality. The ADM stated that she could post a folder outside the SW office for residents' and their family groups to obtain and submit anonymous grievances. Review of an undated Resident Rights poster revealed, As a resident of a long-term care facility you have the right: to privacy and confidentiality. Review of the facility's policy titled; Grievances/Complaints, filing dated April 2017 revealed that: 2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal.5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously.

Based on observation , interview, and record review, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 (Resident #39) of 24 and multiple confidential residents reviewed that received food from the facility kitchen. 1. The facility failed to provide Resident #39 with a meat sandwich on multiple occasions when she requested them, or an alternative to the posted meal, when her meal tickets had Meat portions for all meals printed on them. 2. The facility failed to have a variety of breakfast meals available to residents. This failure could place residents at risk of weight loss, dissatisfaction with meal service, and interfered with their desire to gain weight. Findings included: Review of Resident #39's comprehensive MDS assessment, dated 10/08/2025, reflected an [AGE] year-old female admitted on [DATE]. Her diagnoses included: atrial fibrillation (irregular and often rapid heart rhythm), high blood pressure, arthritis (bone grinding on bone during movement), osteoporosis (low bone mass, and deterioration of bone tissue), malnutrition, Resident #39 had a BIMS score of 15, which indicated intact cognition. Review of Resident #39's comprehensive care plan, dated 11/18/2025, revealed Resident #39 was not care planned for her dietary preferences or desire to gain weight. Review of Resident #39's medical nutrition therapy assessment conducted by the RD and dated 10/07/2025 revealed Resident #39 was recommended by the RD to receive snacks, supplements, and her food preferences due to being at risk for severe malnutrition. Review of Resident #39's weights revealed she had not experienced weight loss since her admission to the facility on [DATE]. Review of the facility's weeks 2-4 Winter 2025-26 breakfast menus revealed,Week 2 Sunday, Tuesday, Thursday, Saturday: Monday, Wednesday, Friday:Assorted Juice Assorted JuiceCereal of Choice Cereal of ChoiceBacon Sausage PattyScrambled Eggs Scrambled EggsBreakfast bread of choice Breakfast bread of choiceMargarine MargarineJelly JellyMilk MilkBeverage Beverage Week 3Sunday, Tuesday, Thursday, Saturday: Monday, Wednesday, Friday:Assorted Juice Assorted JuiceCereal of Choice Cereal of ChoiceSausage Patty BaconScrambled Eggs Scrambled EggsBreakfast bread of choice Breakfast bread of choiceMargarine MargarineJelly JellyMilk MilkBeverage Beverage Week 4Sunday, Tuesday, Thursday, Saturday: Monday, Wednesday, Friday:Assorted Juice Assorted JuiceCereal of Choice Cereal of ChoiceBacon Sausage PattyScrambled Eggs Scrambled EggsBreakfast bread of choice Breakfast bread of choiceMargarine MargarineJelly JellyMilk MilkBeverage Beverage In an interview and observation on 12/03/2025 at 10:45 a.m., Resident #39 stated if she complained about the meal and took it to the dining room the kitchen staff would offer her a PB&J, but it would be nice if she were given a meat sandwich. She stated sometimes they offered her a hamburger, if they had it. She stated it was usually just a PB&J sandwich they gave her when she asked for different food, and she was not aware of what the always available menu items were or if the facility had that. She stated the facility was aware she wanted/needed to gain weight, and she had previously communicated her preference of receiving meat for every meal. In an interview on 12/04/2025 at 11:02 a.m., the DM stated she told the ADM on 12/03/2025 that she wanted to do something different for breakfast since the menus all said the same options. She stated she wanted to incorporate different meals for the residents but she had only worked at the facility two weeks. In a confidential resident group meeting at an undisclosed time, it was revealed that residents who received meals in their rooms often received cold food, and that the cafe menu (always available) items were not always served when residents requested them. The residents stated they were given PB&J sandwiches if they requested something other than what was served. The residents also stated that they wanted a change in the breakfast menus due to the repetitiveness and some stated they skipped breakfast altogether because they could not stand to look at the same plate over and over again. In an interview on 12/05/2025 at 8:51 a.m., the RD stated she went to the facility once per week, and that she, nor the facility made the menu. The RD stated the menus were created by their food provider. She stated residents had a preference in boiled or scrambled eggs for breakfast, different varieties of bread, hot cereal or cold cereal, which created the variety in food options. She stated she was not invited to resident council to hear concerns. She stated she felt the residents' concerns and choices to skip breakfast due to the menu was disappointing and she would add it to her list of questions to ask residents when she visited with them. She stated she was not told about Resident #39 only getting PB&J sandwiches. She stated the kitchen should always have the always available items available upon resident request. She stated that the kitchen should offer an alternate protein source to Resident #39 since her meal tickets stated she needed meat with all meals. In an observation on 12/04/2025 at 1:47 p.m. of Resident #39's 12/04/25 lunch meal ticket revealed, Regular texture, regular diet, large protein/meat portions for all meals. In an observation of the dining room wall, near the kitchen, on 12/03/2025 at 9:40 AM, a framed paper titled Cafe Menu Available from 7am to 6pm revealed: HamburgerGrilled CheeseCold cerealBaked potatoSoup of the dayDeli SandwichPeanut Butter & Jelly Sandwich. Review of the facility's Food and Nutrition Services policy, dated October 2017 reflected: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization .4. Reasonable efforts will be made to accommodate resident choices and preferences.7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Review of the facility's Open Style Dining policy dated 2023 revealed, 3. Nursing and/or food and nutrition services staff will offer food and beverage choices to the individual at the point of service and report an individual's food and beverage choices to the staff members responsible for serving the food. Food and nutrition services staff will serve food and beverage choices made with consideration given to any dietary restrictions and/or texture modifications.

Based on record review, observations, and interviews, the facility failed to ensure the residents were free from abuse, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 3 of 6 residents (Resident #22, #25 and #45) reviewed for abuse.The facility failed to ensure that Resident #22 and Resident #45 were free from abuse when Resident #73 physically struck the residents on 11/21/2025.The facility failed to ensure Resident #25 and Resident #73 were free from abuse when Resident #25 and Resident #73 were found in Resident #25's room without their clothes on attempting to engage in a sexual act on 12/4/2025.This failure placed the residents at risk of physical harm or injury.Findings included: Review of Resident #22's admission record dated 12/5/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia (condition which can occur suddenly in which the lungs fail to adequately exchange gases), acute conjunctivitis (pink eye), dementia without behavioral disturbance/vascular dementia (reduced blood flow to the brain causing cognitive decline and memory issues), and abnormal posture. The admission record reflected RP 1 to be the resident's responsible party, and medical and financial POA.Review of Resident #22's Quarterly MDS assessment dated [DATE] reflected that the resident rarely or never made herself understood or had the ability to understand others. Therefore, a BIMS was not conducted or scored. Review of Resident #25's admission record dated 12/4/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including unspecified Dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental disorder that affects memory, social abilities, and daily functioning), Alzheimer's Disease (a neurodegenerative condition that leads to the gradual decline of cognitive functions), and Delusional Disorders (serious mental illness characterized by persistent false beliefs that are not based in reality). The admission record reflected RP 2 to be the resident's responsible party.Review of Resident #25's comprehensive annual MDS assessment dated [DATE] reflected the resident's BIMS Summary Score to be 2, indicating severe cognitive impairment.Review of Resident #45's admission record dated 12/5/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Unspecified Dementia, Major Depressive Disorder, Single Episode, and Primary Insomnia (inability to sleep). The record shows the resident to be his own responsible party.Review of Resident #45's Quarterly MDS assessment dated [DATE] reflected the resident sometimes made himself understood and sometimes understood others. The resident's BIMS Summary Score reflected in the record was 0, indicating severe cognitive impairment.Review of Resident #73's admission record dated 12/4/2025 reflected a [AGE] year-old male admitted to the facility on [DATE], with an initial/original admission date of 11/14/2025, with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness, Major Depressive Disorder, Single Episode, Type 2 Diabetes, and Person Injured in Collision Between other Specified Motor Vehicles (Traffic), Subsequent Encounter. The record reflected that Resident #73 was his own responsible party.Review of Resident #73's Comprehensive assessment dated [DATE] reflected a BIMS Summary Score of 5, indicating severe cognitive impairment. The record indicated that Resident #73 experienced delusions and exhibited physical behavioral symptoms 1 to 3 days. The record revealed that the behavioral symptoms exhibited had no significant impact on the resident and did not put other residents at risk of physical injury.Review of Resident #73's Care Plan Report initiated on 11/17/2025 reflected Focus: I have episodes of adverse behavior(s): Verbally Aggressive: cursing, racial slurs, yelling/screaming; Physically Aggressive: hitting, pinching, kicking, throwing objects; Fabricates facts/unreliable historian/manipulates staff. Interventions/Tasks: Administer meds per order, monitor labs-report [abnormals] to MD, Maintain a calm environment. According to information reviewed, the resident's care plan appeared to have been followed.Review of the facility's investigation file and report dated 11/21/2025, for the incident involving Resident #22, Resident #45, and Resident #73, revealed the facility was unaware of any concerning behavior exhibited by Resident #73 prior to this incident. The incident reportedly occurred on 11/21/2025 at approximately 10:24 PM. The report stated that Resident #73 struck Resident #45 in the back several times. It was stated that neither resident suffered any injury. Resident #73 was placed on 1:1, psychological referrals were made for both residents, and no adverse outcomes were observed. The investigation file also indicated that the incident with Resident #45 happened after staff had already intervened in the incident that occurred between Resident #73 and Resident #22. It is stated that Resident #73 grabbed Resident #22 by the face and hair while trying to get her up and out of her wheelchair.Review of Resident #22's Progress Notes dated 11/24/2025 reflected the resident was seen for a Psychiatric Periodic Evaluation after an incident with another resident. The resident was observed to be in a calm state during the encounter. The practitioner noted that the resident was in a safe environment within the facility and had good medical support. The resident's monitoring would continue at her next appointment.Review of Resident #73's Progress Notes dated 11/24/2025 revealed the resident was seen for a Psychiatric Periodic Evaluation. Ongoing recommendations made and directive provided that 1:1 could be discontinued since the resident did not appear to be a danger to himself or others. The practitioner noted that the resident's status could change based on treatment outcomes/worsening medical condition, and psychosocial stressors.Review or Resident #45's Progress Notes dated 11/24/2025 revealed the resident was seen for Psychiatric Periodic Evaluation due to the physical encounter with Resident #73. Resident #45 described as pleasantly confused and unable to provide reliable feedback. The resident's mood was noted to be manageable with no behavioral concerns since the last encounter.Record review of the facility's in-service training reports revealed an in-service was provided to all staff regarding Resident-to-Resident Altercations, Resident Rights, Abuse and Neglect, Reporting and Investigating immediately following this incident.Review of the facility's policy on Resident-to-Resident Altercations revised in September 2022 details the appropriate actions, interventions and notifications that must be made if an incident of this type occurs. Review of Resident #22's Progress Notes dated 11/24/2025 reflected the resident was seen for a Psychiatric Periodic Evaluation after an incident with another resident. The resident was observed to be in a calm state during the encounter. The practitioner noted that the resident was in a safe environment within the facility and had good medical support. The resident's monitoring would continue at her next appointment.Review of the facility's investigation file and report regarding the incident that occurred on 12/4/2025 at 12:15 AM, involving Resident #25 and Resident #73 revealed Resident #73 was found on top of Resident #25 in her bed during the night shift. The residents were separated, and Resident #73 was put on 1:1 monitoring. Neither were sent out to the hospital or emergency room, neither required x-rays, and neither required follow-up medical appointments. The report stated that the physician, guardian and/or family were notified. In-service training was reportedly provided to staff on abuse and neglect and resident rights.Review of Witness Statement provided by CNA C on 12/4/2025, regarding the incident between Resident #25 and Resident #73 stated CNA C was walking a resident into his room to change him and Resident #73 was observed at this time at the end of the hall looking out the door. CNA C stated that she asked CNA D to help change the other resident. CNA C stated Resident #73 was in the same position at that time, looking out the door. CNA C stated when she and CNA D finished changing the other resident and exited that resident's room, she noticed a light on. CNA C said opened the door of Resident #25's room and found both Resident #25 and Resident #73 without their clothes on. Resident #73 was on top of Resident #25 rubbing back and forth. CNA C told Resident #73 to get off of Resident #45 but he became angry. CNA C instructed CNA D to get the nurse. LVN D came and was able to instruct Resident #73 off of Resident #25.Review of Witness Statement provided by CNA D on 12/4/2025, regarding the incident between Resident #25 and Resident #73, stated CNA D was asked to assist with another resident. At that time, she noticed Resident #73 looking out the back door. When they were finished, CNA C noticed a light on and she went to get it. CNA D stated this is when CNA C called to her and asked her to get the nurse.Review of Witness Statement provided by LVN D on 12/4/2025, regarding the incident between Resident #25 and Resident #73, stated a CNA reported observing Resident #73 in Resident #25's room laying on top of her with his pants down and her brief and pants off. The CNA reported that Resident #73 was very uncooperative and agitated when asked to leave the room. LNV D stated the residents were separated and assessed. Neither of the residents' vital signs were concerning, neither resident had any skin issues or signs or symptoms of emotional distress. LVN D stated that Resident #25 stated to her, I love him! The DON was made aware of the occurrence, the ADM was notified, the Primary Care Physician and RP's were notified. Resident #73's RP could not be reached so a message was left.Review of Progress Notes for Resident #25 dated 12/4/2025, reflected at 0236 AM an advanced skin check of Resident #25 was completed by DON that indicated' Complete head to toe assessment completed, vaginal area examined by charge nurse and DON, slight redness noted to outer perineal area, no bruising, scratches, discoloration, or discharge noted. Resident denies any pain or discomfort in vaginal area.Review of Progress Notes for Resident #25 dated 12/4/2025 at 07:46 AM reflected the resident was assessed head to toe and no skin issues were noted. The resident denied pain and vital signs were within normal limits.Review of Resident #25's Care Plan Report on initiated on 12/4/2025, reflected Focus: I reside in the Secure/Memory Care unit and am at risk for injury from wandering in an unsafe environment related to Dementia diagnosis and impaired safety awareness. I am at risk for injury from others while residing in secure/memory unit due to altered cognition. Interventions/Tasks listed do not address monitoring or resident-to-resident altercations.Review of Safe Surveys conducted with residents on the secure unit on 12/4/2025, regarding abuse revealed no responses of concern and residents felt safe and treated with respect and dignity.Review of Staff abuse questionnaires completed on 12/4/2025, indicated staff were aware of reporting requirements regarding abuse.Observation of Resident #45 on 12/3/2025 at 11:18 AM in the secured unit of the facility revealed the resident to be quietly pacing around the parameter of the unit continuously without interaction or regard for others. The resident was non-responsive when interaction attempted. The resident did not appear to be in distress or uncomfortable. The resident's physical appearance was not concerning for abuse or neglect. No injuries or obvious abnormalities noted. During this time, Resident #22 and #73 were all present in the common area of the secured unit in which they all reside. The residents sat fairly close to each other with no disturbances or behaviors observed. None of the residents observed on the unit displayed concerning behaviors or responses during observation period. Staff members were present and nearby monitoring the residents as well. Observation of Resident #73's room on 12/3/2025 at 11:18 AM revealed the resident was assigned the room closest to staff and the first room on the unobstructed hallway. The resident was the only occupant of the room.Observation of Resident #22 on 12/3/2025 at 11:31 AM revealed the resident sitting contently in the open sitting area of the secured unit with other residents around and nearby. Resident #22's daughter was visiting her and sitting with her. An attempt to interview the resident was unsuccessful due to her inability to understand or participate in the conversation. The resident appeared comfortable in the environment and in the presence of other staff. No bruising, injuries or signs of physical harm observed on the resident's face, cheeks, hands, or arms. No distress of signs of discomfort observed.Observation of Resident #73 on 12/3/2025 at 11:43 AM revealed the resident sitting in the open sitting area around or near other residents calmly and quietly. No distress or discontent observed. The resident responded to greetings but did not actively participate in conversation attempts. Resident #73 was observed interacting with staff and complying with staff's request to check his blood sugar. No concerns with the resident's appearance or disposition noted.Observation of Resident #25 on 12/3/2025 at 12:25 PM revealed the resident sitting in and then walking around the dining room of the secure unit with other residents around and nearby. Resident #25 was observed physically interacting with furniture and staff in that the resident was observed pushing a dining room chair around the dining room and then touching staff while trying to braid their hair. The resident was not aware of personal space or boundaries upon observation. The resident appeared content and pleasant with no distress noted.Observation of Resident #73 on 12/3/2025 at 12:25 PM revealed the resident walking the hallway. The resident attempted to push the unit door open, but the alarm sounded so he stopped and turned around.Observation of Resident #25 on 12/4/2025 at 10:26 AM revealed the resident in her bed resting. The resident appeared calm and content with no signs of harm, distress or injury observed. The resident was smiling and mumbled something that sounded as if she were asking to braid my hair.Observation of Resident #73 attempted on 12/4/2025 at 10:26 AM, however, the resident was receiving resident care behind closed doors so no observation conducted. Observation of 1:1 monitoring station outside Resident #73's room was conducted along with additional staff on the unit.In an interview on 12/3/2025 at 11:28 RN A she said she has been employed with the facility strictly on the secured unit for the last 4 months. RN A stated that she typically worked the day shift. She stated that she has not witnessed any incidents of abuse or neglect personally, but she would immediately report any such incidents to ADM if she did. RN A stated that management was supportive of staff and the residents, and she received the necessary orientation, training, education and in-service to do her job and do it well. She stated that staffing is not really a problem on the secure unit. RN A stated that she had no concerns for resident care and safety within the unit. She feels things are managed well. RN A said she has had no problems or issues with any resident on the unit acting out or being aggressive that she has observed. She stated that the residents are typically calm and easy to manage during her shift. RN A stated that she was not present during the incident between Resident #73, #22 and #45. RN A stated that she was surprised to hear that the resident had acted out in such a way. RN A stated that Resident #73 is easily redirected and manageable during her time with him. She stated that Resident #73 showed no signs of discontent or dislike for Resident #22 or Resident #45. RN A said all residents involved were screened and assessed and none were injured or suffered any immediate or ongoing negative effects as a result of the incident. RN A said Resident #73 was placed on 1:1 monitoring around the clock immediately and referred for psychological evaluation and services and to his doctor. The doctor changed the resident's medication and after a day or 2 the resident seemed happier and content. He showed no signs of concerning behavior and it was felt he could be managed without continuing 1:1 monitoring so that was discontinued. RN A stated that she thinks Resident #73 was confused when the incident happened because he was still new to the facility and confused as to where he was and why. RN A stated that she believed Resident #73 moved Resident #45 who was standing in front of the secured unit doors in an attempt to get the door open. RN A stated that the incident with Resident #22 was minor with no injuries or negative impact to either.In an interview on 12/3/2025 at 11:30 AM, CNA A stated that she has not observed any further issues involving Resident #73. She stated there have been no further incidents or occurrences.In an interview on 12/3/2025 at 11:31 AM with RP 1, RP 1 confirmed she is the RP for Resident #22. She stated that the resident is her mother. She stated that the resident has been admitted at this facility for 2 years. RP 1 stated that she is very satisfied with the care and supervision provided by staff at the facility, specifically on the secured unit. She stated that her mother is happy and well cared for. RP 1 stated that she has never had any concerns for abuse or neglect of her mother or any of the residents at the facility. RP 1 stated that she visits often and is able to directly observe the circumstances and environment of the facility. RP 1 stated that she was immediately made aware of the incident involving her mother and Resident #73. She stated that staff are always inclusive and explain her mother's status and care effectively. RP 1 stated that her mother did not suffer any negative outcome as the result of the incident with Resident #73. RP 1 stated that she had concerns or hesitation allowing her mother to remain a resident at the facility as she does not feel her mother is in danger. RP 1 stated that her mother doesn't remember the incident that occurred and could not relay any details. RP 1 said her mother has been happy and no changes in behavior exhibited. In an interview with the ADM on 12/3/2025 at 2:25 PM, ADM stated that since the incident involving Resident #73 occurred, she has been reaching out to the family to discuss seeking placement for Resident #73 at another facility. ADM stated that she just doesn't think the resident is a good fit here. She stated that his injury and condition and circumstances are fairly new and this is likely part of the reason he got agitated. But ADM is concerned that his behaviors will not improve. ADM stated that the resident's family are slow to respond to her calls and messages, even when there is a serious concern or issue. ADM stated that she has actively been seeking alternative placements for the resident that can better service the resident and the family is in agreement but they will not assist. ADM stated that she was already in discussions with the appropriate persons and the family on seeking psychiatric care for the resident that was more intensive than they could provide in a more controlled environment. Family also agreed to this option but made no effort at getting the resident this type of care. ADM stated that they conducted an in-service training on resident-to-resident abuse/altercations, and she arranged for an outside provided to come in next week to give a more detailed presentation on the subject. ADM stated she would request the presenter to come sooner if possible.In an interview on 12/4/2025 at 10:15 AM, ADM revealed an incident occurred between Resident #25 and Resident #73 overnight. ADM stated that a self-report regarding abuse had been submitted and staff have been diligently assessing and monitoring the residents. ADM stated that no injuries occurred and no negative psychosocial impact to either resident detected. ADM stated that the proper notifications and interventions have been initiated and were continuing. ADM stated that Resident #73 will be removed from the facility asap as his family has agreed to provide respite care for the resident at home until another placement for the resident could be secured. ADM stated that it had been difficult to get in contact with Resident #73's family and at that time their responsiveness was inconsistent. ADM stated other measures were being considered including psychiatric commitment. ADM stated that Resident #25's RP and family were supportive and understanding. The family were aware of a similar incident in the past in which Resident #25 took on a romantic friend while residing on the regular unit. That incident was not sexual in nature, but involved the resident being affectionate with another resident. In an interview on 12/4/2025 at 10:15 AM, DON stated Resident #25 and Resident #73 suffered no physical trauma and there was no penetration of Resident #25's sexual organ by Resident #73. DON stated there appeared to be no emotional trauma suffered by either resident as well. She stated that Resident #25's family was not upset or angry and understood the incident would be reported. DON stated both residents were checked and neither sustained injuries.In an interview on 12/4/2025 at 10:52 AM, RN A revealed that Resident #73 had been on 1:1 monitoring since the most recent incident and this would continue indefinitely until an alternate placement for the resident could be obtained. RN A stated that she was surprised Resident #73 had another incident in that his behavior had been stable with no signs of agitation or distress. RN A stated that Resident #73 seemed to act out during the night shift because he was typically stable during the day shift. RN A said Resident #73 was acting fine at that time and that he had been resting and was being closely supervised. RN A said Resident #73 didn't remember the incident it seemed as the resident didn't mention it or ask for the other residentIn an interview on 12/5/2025 at approximately 10:00 A.M., ADM revealed that she was able to secure an emergency order for psychiatric care for Resident #73 on 12/4/2025. ADM stated that Resident #73 had been discharged , and he was transported to the psychiatric facility for intensive treatment and monitoring.In an interview on 12/6/2025 at 12:35 PM, RP 2 stated that he was made aware of the recent incident involving Resident #25. He stated that he was notified right away and the details of the incident were provided. RP 2 stated that he is satisfied with the care and supervision provided to Resident #25 by staff at the facility. RP 2 stated that he does not consider this to be an incident of abuse as neither resident are of sound mind. RP 2 did not believe that a lack of supervision or monitoring contributed to the incident in that it was something that just happened and could not necessarily be planned for. RP 2 stated that he does not feel Resident #25 suffered any ill effects from the incident as her recollection is limited and he has not been made aware of any negative impacts. RP 2 stated that he feels the resident is safe and well cared for and she will remain a resident at the facility.Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, states, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:b. Other residents;2. Develop and implement policies and protocols to prevent and identify:a. Abuse or mistreatment of residents;8. Identify and investigate all possible incidents of abuse.10. Protect residents from any further harm during investigations.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 3 of 6 residents reviewed for infection control (Resident #39, Resident #42, and Resident #57). 1) MA failed to clean the electronic blood pressure cuff after use on Resident #57 and prior to use on Resident #39 in an observation of medication pass at 8:45 a.m. on 12/4/25. 2) LVN A did not wear PPE for enhanced barrier precautions while performing wound care and wash/clean her hands when removing soiled gloves, prior to applying clean gloves on 12/04/2025 at 10:17 a.m. for Resident #42's wound care observation. This deficient practice could place residents at risk for cross contamination and the spread of infection. Findings included: 1. Record review of Resident #39's undated face sheet reflected an admission date of 10/01/2025 with diagnoses of Atrial Fibrillation (an irregular heartbeat), Hypothyroidism (a lack of thyroid hormone), heart disease, and Hypertension (elevated blood pressure). Record review of Resident #39's care plan, dated 10/01/2025, reflected, (Resident #39) have hypertension and is at risk forblurred vision, vertigo (dizziness), headache and nosebleeds. Receives antihypertensive medication and is at risk for side effects. Interventions included, Check blood pressure before administering medication and record on medication administration record. Record review of Resident #39's admission MDS, dated [DATE], reflected a BIMS score of 15 indicating she was cognitively intact. Resident #39 had lower body impairment and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard) assistance with her activities of daily living such as dressing, bathing, and personal hygiene. 2. Record review of Resident #57's undated face sheet reflected an admission date of 08/25/2025 with diagnoses of Alzheimer's disease (an impairment in memory), anemia (a lack of red blood cells), hypertensive chronic kidney disease (elevated blood pressure that had caused kidney disease), and age-related physical debility. Record review of Resident #57's care plan, dated 09/01/2025, reflected, (Resident #57) am at risk for circulatory impairment,chest pain, irregular pulse, impaired skin integrity, skin desensitized to pain, or pressure related to history of heart disease. Interventions included, Administer meds per order, monitor labs, report abnormalities to medical doctor. In an observation at 8:45AM on 12/4/25, the MA checked Resident #57 's blood pressure prior to administration of medications. She did not clean cuff after use on Resident #57 and proceeded to use the blood pressure cuff on Resident #39. In an interview on 12/4/25 at 8:57 a.m., the MA stated she was aware she was supposed to clean the blood pressure cuff between residents. She stated she was nervous and forgot. She stated she was educated by the DON and the pharmacist on policy and procedures for medication pass that included cleaning the blood pressure cuff between residents. The MA stated failing to clean the blood pressure cuff between residents could lead to the spreading of germs causing infections. 3. Record review of Resident #42's undated face sheet reflected an admission date of 11/22/2021 with diagnoses of Atherosclerosis of Native Arteries of Extremities (a narrowing of the arteries in the legs), Type 2 Diabetes Mellitus (elevated blood sugar), Unstable Angina (chest pain), and weakness. Record review of Resident #42's care plan, dated 08/13/2025, reflected, Enhanced Barrier Precautions: Staff must use gown and gloves during high-contact resident care activities that could possibly to result in transfer of multiple drug-resistant organism s to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a multiple drug-resistant organism as well as those who are not confirmed to have a multiple drug-resistant organism (e.g., residents with wounds or indwelling medical devices). Interventions included, Staff must use gown and gloves during high-contact resident care activities that could possibly to result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a multiple drug-resistant organism as well as those who are not confirmed to have a multiple drug-resistant organism. Record review of Resident #42's quarterly MDS, dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Resident #42 was independent with dressing and grooming and was indicated to have a diabetic foot ulcer. Record review of Resident #42's active physicians order summary, dated 12/04/2025, reflected an order for enhanced barrier precautions dated 08/13/2025. In an observation of wound care on 12/04/2025 at 10:17 a.m. for Resident #42, LVN A washed her hands and proceeded to glove and remove soiled dressing. LVN A disposed of the soiled dressing and gloves, not washing hands or cleaning with alcohol-based hand sanitizer, she applied clean gloves and proceeded with completion of wound care. LVN A nurse did not don PPE for enhanced barrier precautions prior to start of wound care. In an interview on 12/04/2025 at 10:47 a.m., LVN A stated she was nervous and forgot to wash/clean her hands in-between changing her gloves. She stated she laid her gown on top of her treatment cart for enhanced barrier precautions and forgot to put it on. She stated the risk to residents for not using PPE and cleaning her hands between gloving was infection due to bacteria spreading from open wound beds from resident to resident. In an interview on 12/06/2025 at 1:03 p.m., the DON stated the nurses and medication assistants were responsible for making sure they used proper hand hygiene, cleaning equipment, and ensured personal protection equipment was worn during care. The DON stated the nursing staff was educated on infection control and were checked off annually in their competency evaluations. She stated risk to the residents would be the spread on infection, Record review of facility policy titled Standard Precautions, dated 2021 and revised September 2022, reflected, Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Hand hygiene a) Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub (ABHR), which does not require access to water. b.) Hand hygiene is performed with ABHR or soap and water: before and after contact with the resident, before performing an aseptic task, before moving from work on a soiled body site to a clean body site on the same resident, after removing gloves. Gowns are worn for direct resident contact if the resident has uncontained secretions or excretions. Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed. Record review of facility policy titled Handwashing/Hand Hygiene, dated 2001 and revised October 2023, reflected hand hygiene was indicated before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. Record review of facility policy titled Enhanced Barrier Precautions, dated March 2024 and revised February 2025 reflected, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: (h.) wound care (any skin opening requiring a dressing).

Based on interview and record review , the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 1 of 6 (Resident #10) residents reviewed for pharmacy services. The facility failed to obtain a stop date for Resident #10's Amoxicillin-Pot Clavulanate (an antibiotic used to treat an acute infection) started on 11/27/2025. This failure could place residents at risk of side effects (gastrointestinal upset, multiple drug-resistant infections) related to long term antibiotic use. Findings included: Record review of Resident #10's undated face sheet reflected an admission date of 08/01/2025 with diagnoses of diverticulosis of the small intestine (inflammation of pouches within the small intestine), diabetes type 2 (elevated blood sugar), chronic kidney disease, and cellulitis (an infection within the skin). Record review of Resident #10's care plan, dated 05/01/2025, reflected, (Resident #10) am at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/ physical impairment/ skin desensitized to pain or pressure, slow healing process related to diagnosis of diabetes mellitus. Interventions included, Monitor skin for changes: redness, circulatory problem, breakdown- report toMedical doctor and responsible party. Record review of Resident #10's annual MDS, dated [DATE], reflected a BIMS score of 10 indicating moderate cognitive impairment. Resident #10 had lower body impairment and was dependent on staff for upper and lower body dressing. Record Review of Resident #10's Hospital Discharge Medication List, dated 11/26/2025, reflected an order for Amoxicillin-Pot Clavulanate 500mg-125mg oral tablet one tablet twice a day for cellulitis. Record review of the progress notes for Resident #10 , dated 12/05/2025, reflected, The patient is on Day 9/10, Augmentin 500-125 for the diagnosis of Cellulitis. Patient remains on Tramadol q6 routine along with Gabapentin 900mg q6 hours routine for pain management. Will monitor for effectiveness., signed by LVN C. Record review of Resident #10's Physicians order summary, dated 12/05/2025, reflected an order for Amoxicillin-Pot Clavulanate Oral Tablet 500-125 MG Give one tablet by mouth two times a day for Cellulitis, dated and started 11/27/2025 . Record review of Resident #10's Medication Administration Record for the months of November 2025 and December 2025 reflected the resident received Amoxicillin-Pot Clavulanate Oral Tablet 500-125 MG (Amoxicillin & Pot Clavulanate) for nine days from dates of 11/27/2025 through 12/05/2025. During an interview on 12/05/2025 at 11:19 a.m., LVN B, charge nurse, stated to the administrator she was not speaking to the surveyor because it disturbed her peace and resigned. In an interview on 12/05/25 at 11:31 a.m., the DON stated all antibiotics should have a stop date. The DON stated the charge nurses were educated on obtaining a stop date for medications that required them. She stated the nurses were responsible for obtaining the stop date. The nurses would do this by contacting the ordering physician and clarifying the order to include a stop date. She stated she was responsible for monitoring the nursing orders for accuracy. She stated the negative effects for the residents taking prolonged antibiotics could include drug resistance and upset stomach. Record review of facility policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, dated 2021, reflected, All resident antibiotic regimens will be documented. The information gathered will include: (i) stop date. (j) total days of therapy.

Based on observations, interviews, and record reviews, 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 1 of 6 Residents (Resident #17) reviewed for respiratory care. The facility failed to place Resident #17's oxygen tubing in a bag when not in use and failed to keep her concentrator filter clean. This failure could place residents at risk of not receiving appropriate air flow resulting in shortness of breath respiratory infections. The findings were: Record review of Resident #17's undated face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Unspecified Dementia (a decline in memory, thinking, daily problem solving), Heart Failure, Hyperlipidemia (elevated cholesterol), and Hypertension (elevated blood pressure). Record review of Resident #17's care plan dated 03/31/2022 reflected Resident requires supplemental oxygento maintain adequate oxygen saturation levels. Date Initiated: 11/10/2025 Interventions included to administer oxygen as ordered. Record review of Resident #17's admission MDS dated [DATE] reflected short term and long-term memory problems indicating she was cognitively impaired. The MDS reflected Resident #17 required Oxygen. Resident #17 was indicated to have shortness of breath both with exertion and when lying flat. Record review of Resident #17's physicians' orders summary dated 12/03/2025 reflected an order to Change oxygen tubing/water every week and PRN (as needed) every night shift every Sun for Oxygen, and Oxygen at 2 liters/minute via nasal cannula every shift. every shift for Oxygen Parameters. In an observation on 12/03/2025 10:35 AM Resident #17 was lying in bed, eyes closed, appeared to be sleeping. She had oxygen in place at 2 lpm through a nasal cannula (a tube that rests on the nostril). The nasal cannula was not dated and the filter on the oxygen concentrator was packed with white lintlike substance, dust, and debris. Resident #17 had portable oxygen tank on a wheelchair with oxygen tubing observed rolled up on armrest, open not bagged. In an observation on 12/05/2025 at 10:54 AM reflected Resident #17 was not in the room. Oxygen tubing was undated and wound up around the dirty concentrator. The Oxygen filter remained dirty with dust and debris. During an attempt to interview LVN D on 12/05/2025 at 11:19 AM she stated to the Administrator she was not speaking to surveyor because it disturbed her peace and resigned. In an interview on 12/05/2025 at 11:31 AM the DON stated the oxygen concentrator and filter in Resident #17's room were dirty. The concentrator and filter should be cleaned routinely. The tubing was to be changed weekly and should have a date on it. The DON stated the tubing should be bagged when not in use. There were no set dates or days for filters to be checked and cleaned. She stated the nurses were responsible for ensuring concentrators, filters, and tubing were changed, dated, and cleaned. She stated the risk to the residents for having dirty filters and tubing on their oxygen concentrators would be respiratory infection or compromised airflow from the concentrator. 4. Record review of facility policy titled Standard Precautions dated 2001 and updated September 2022 reflected: Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. (6) Environmental Controla. Environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces are appropriately cleaned. Surveyor was not provided when requested on 12/4/2025 a policy on Respiratory Equipment / oxygen use.

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 (Residents #4) of 8 residents reviewed for activities. The facility failed to ensure they provided in-room activities for Resident #4 who spent most of or all her time in her room. This failure placed residents at risk of boredom, depression, and diminished quality of life. Review of Resident #4's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included: heart failure, high blood pressure, diabetes mellitus (body's impaired ability to produce or respond to insulin), high cholesterol, anxiety, depression, schizophrenia, morbid obesity, urinary tract infection, constipation (inability to have a bowel movement. Resident #4 had a BIMS score of 07, which indicated severe cognitive impairment. Review of Resident #4's comprehensive care plan dated 11/06/2025 revealed Resident #4 did not like to attend activities, she enjoyed snack cart, reading books, watching television, and she enjoyed one on one visits. The intervention listed for this area was to encourage Resident #4 and assist her in attending and participating in activities. In an interview/observation on 12/04/2025 at 9:42 AM with Resident #4 she was observed lying in bed in a nightgown. She stated that in the past year she had to go to the hospital due to bad constipation and a UTI. She stated she would often get irritated because she resided in the NH, but it helped her mood to watch television and talk to the people at the facility. She stated she did not get out of her room because of her medical condition and that she required a mechanical lift and approximately 5 staff to help her out of bed and into her wheelchair. She stated that the Activity Director did not bring her any books, cards, or puzzles, and that she would enjoy doing puzzles. No puzzles, books, or other activities were observed in her room aside from her television. Review of Resident #4's EHR revealed no recent Resident Preference Assessment to determine what kind of activities she preferred. In an interview on 12/05/2025 at 1:07 PM with the AD, she stated that she started her position a couple months ago. She stated that she conducted Resident Preference Assessments when they came up in the computer as due. She stated that she knew which residents preferred individual activities by talking to the residents and asking them, she stated that she was able to pass out magazines, puzzles, or books when residents requested them. She stated that she ensured residents received individual activities by talking to residents in the mornings to see if there was anything they needed from her. She confirmed that she had not done a Resident Preference Assessment on Resident #4. Review of an undated Resident Rights poster revealed, As a resident of a long-term care facility you have the right: to choose your activities, both inside & outside the facility.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #15) of eight residents reviewed for bathing/showering. 1. The facility failed to provide showers to Resident #15 in compliance with his shower schedule.2. The facility failed to have appropriate interventions in place when Resident #15 refused or was in too much pain to receive a bath. This deficient practice could place residents at risk of decline in skin integrity and overall healthFindings included: Review of Resident #15's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included: high blood pressure, kidney failure, high cholesterol, stroke, hemiplegia (complete paralysis on one side of the body), seizure disorder, depression, unspecified pain, generalized edema (swelling), constipation, and gout (sudden, severe attacks of pain, swelling, redness, and tenderness). Resident #15 was coded as being dependent on staff for shower/bathing. Resident #15 had a BIMS score of 13, which indicated intact cognition. Review of Resident #15's comprehensive care plan dated 11/05/2025 revealed Resident #15 would refuse showers, bed baths, ADL's, he would refuse to let staff perform incontinent and change his soiled linens, he would also curse at staff. The goal listed was for Resident #15 to be free from skin breakdown. The intervention listed for this area was for staff to encourage Resident #15 to take a bed bath or shower. He was also care planned for refusing to get out of bed, which increased the risk for skin breakdown, deconditioning, isolation, and complication of immobility. The goal listed was that Resident #15 would maintain skin integrity and physical function despite refusal behaviors. The intervention listed for this area was for staff to encourage resident to get out of bed. In an interview on 12/03/2025 at 2:11 PM with Resident #15, he stated that he was paralyzed on his left side, and that he was supposed to get showers on Tuesdays, Thursdays, and Saturdays, and the staff would get him into his shower chair and take him to the shower room, but recently they did not adhere to that schedule. He stated they could give him bed baths as well. He stated it had been a few months since he had a bed bath or shower, he stated that once in a great while he would refuse but mostly only if it was an agency staff would he refuse. He stated that the agency staff tended to be the staff he did not care for. Observation on 12/03/2025 at 2:11 PM of Resident #15's face, revealed dead skin flakes all over, his feet were also covered in dark (old) and fresh dead skin flakes, and on the bed, near his feet were large chunks of dead skin that had fallen off. In an interview on 12/05/2025 at 12:25 PM with CNA C, she stated she had been working at the facility for about 4 months. She stated that Resident #15 had a history of refusing brief changes too early in the morning or late at night, and that he had gotten to the point where his muscles could not move so he would not get out of bed anymore. She stated that Resident #15 only got bed baths, and that when she was responsible for bathing him, if he refused, she would offer a bed bath again later, and that she would report it to her charge nurse if he refused altogether. She stated that Resident #15 was vocal and would communicate to staff his needs. She stated she was not recently responsible for giving Resident #15 a bath. In an interview on 12/05/2025 at 1:15 PM with LVN A, she stated that Resident #15 would not allow the staff to touch his feet and legs due to pain. She stated that if they barely touched his legs he would scream out in pain. She stated that they had done x-rays and even gotten an order for fentanyl patches to control his pain, but he just did not like his feet or legs to be touched. She stated that it was very rare that he would request to be put in the shower, and he mostly received bed baths. She stated that the CNA's would report to her when any of their residents' refused showers/baths. She stated Resident #15 was cooperative when she went into his room, but that he would only allow certain staff to care for him. She stated that Resident #15 was given a bed bath on 12/4/25. In an additional observation and interview on 12/05/2025 at 1:25 PM of Resident #15's feet with LVN A, Resident #15's feet were observed to still be peeling and LVN A stated that she would request an order from the MD for sodium lactate to resolve it. She stated that Resident #15 did not have any skin conditions that would contribute to the buildup of skin, and she relied on the CNA's to report skin conditions to her after showers. She stated that a negative outcome of not receiving adequate baths would be the buildup of dead skin, or potential skin breakdown on other areas of the body. In an interview on 12/05/2025 at 4:25 PM, the DON stated that the intervention listed on Resident #15's care plan was not adequate and that she would get with the nurses to update it. She stated that their corporate RN stated that the expectation was to shower/bathe residents 3x/weekly, and if the resident refused the CNAs should report it to the charge RN so the resident could be offered again. She stated that Resident #15 was verbally abusive toward some of her staff and would call them derogatory names. She stated that some staff were able to give him the care he needed. She stated that they would get something incorporated to prevent the dead skin buildup. Review of the facility's policy dated February 2025, titled Activities of Faily Living (ADL), Supporting reflected, 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.2. 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)4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate.7. The resident's response to interventions will be monitored, evaluated and revised as appropriate.

Based on interviews and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 2 of 10 (Resident #52 and Resident #61) reviewed for accuracy of assessments.The facility failed to ensure Resident #52's Quarterly MDS assessment dated [DATE] was accurately coded for the use and indication of high-risk medications, specifically anticoagulant and antiplatelet medication.The facility failed to ensure Resident #61's Quarterly MDS assessment dated [DATE] was accurately coded for the use and indication of high-risk medications, specifically anticoagulant and antiplatelet medication.This failure could place residents at risk of not receiving the appropriate care, treatment, and services due to inaccurate assessments.Review of Resident #52's admission record dated 12/6/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including other viral conjunctivitis (pink eye), repeated falls, weakness, traumatic subdural hemorrhage without loss of consciousness (bleeding between the brain and its protective layers), essential primary hypertension (high blood pressure), and gastro-esophageal reflux disease without bleeding (when stomach acid flows back up into the esophagus and causes heartburn).Review of Resident #52's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 4, indicating severe cognitive impairment. In Section N-Medications, N0415 High-Risk Drug Classes, Anticoagulant use and indication was marked , and Antiplatelet use and indication was not .Review of Resident #52's Care Plan Report revised as recently as 10/3/2025 did not reflect the use or indication of anticoagulants or antiplatelets, or monitoring for anticoagulant or antiplatelet use. Review of Resident #52's Order Summary Report dated 12/6/2025 reflected an order that stated : Anticoagulant Monitoring for Heparin/Lovenox/Coumadin/Plavix/Aggrenox/Xarelto/Pradaza/ASA/Plexal Monitoring: Bruising, nosebleeds, bleeding gums, prolonged bleeding from wound, IV, or surgical sites, blood in urine, feces or vomit; elevated PT/INR (test that measures how fast a blood sample forms a clot), low platelet count, every shift for indications of an adverse drug event. The order status was active upon review with an order date of 9/18/2025. Further review of the order summary reflected no anticoagulant medications ordered within the assessment period or currently. The order summary reflected an active order for Aspirin Oral Capsule 81 MG (Aspirin), an antiplatelet medication, started on 9/18/2025.Review of Resident #61's admission record dated 12/6/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including other Alzheimer's Disease (a type of dementia that affects memory, thinking, and behavior), urinary tract infection, fall, unsteadiness on feet, and Megaloblastic anemia (vitamin deficiency characterized by the production of abnormally large red blood cells).Review of Resident #61's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, indicating severe cognitive impairment. In Section N-Medications, N0415 High-Risk Drug Classes, Anticoagulant use and indication was marked and Antiplatelet use and indication was not.Review of Resident #61's Care Plan Report revised most recently on 9/24/2025 did not reflect the use or indication of anticoagulants or antiplatelets, or monitoring for anticoagulants or antiplatelet use. Review of Resident #61's Order Summary Report dated 12/6/2025 reflected an order that stated: Antiplatelet monitoring: monitor for signs and symptoms of adverse reaction: bruising, interocular hemorrhage, abdominal pain, flatulence, alopecia, rash, pruritus (itching), taste disturbance, tissue necrosis (death of body tissue), headache, lethargy, dizziness, hematuria, anemia, respiratory tract bleeding, hypersensitivity reaction, hemorrhage, bloody urine, fever every shift for antiplatelet medication monitoring. The order status was active upon review with an order date of 8/17/2025. Further review of the order summary reflected an active order for Aspirin 81 MG Chewable Tablet, an antiplatelet medication, started 4/11/2025. The order summary did not reflect any medication that would be classified as an anticoagulant.In an interview with ADM on 12/6/2025 at 12:56 PM, ADM stated that she expected staff to adhere to their assessment and care planning policies and participate in ongoing education, updates and in-service offerings to ensure they are familiar with processes and outcomes. ADM stated that the accuracy of assessments and care plans is up to the entire clinical team.In an interview with the MDS Nurse on 12/6/2025 at 12:56 PM, the MDS Nurse stated that she was told and trained to code aspirin as an anticoagulant and that's why the assessments reflect the residents' use of anticoagulant medications. MDS Nurse said she refers to the RAI manual for coding of assessments. MDS Nurse stated their corporate office personnel monitor assessments for accuracy and will let them know when a correction or change is needed. MDS Nurse stated that she felt she had the experience, knowledge, education and support necessary to do her job and do it well. MDS Nurse stated staff were educated and in-serviced regularly on a variety of care related services, especially if there have been regulation changes. MDS Nurse said the negative effect of a mis-coded assessment would be that it's an inaccurate reflection of resident care and needs and would then create an inaccurate care plan. MDS said if she needs assistance with assessment coding, she refers to the RAI manual or she will contact their corporate office for assistance .Record review on 12/6/2025 of the facility's policy on Quarterly Assessments reflected, Quarterly MDS assessments are conducted to track the resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored.

Based on interview and record review, the facility failed to ensure they did not employ an individual who was found guilty of a criminal offense barring employment by a court of law for 1 of 6 (Maintenance Director) employees reviewed for abuse and neglect. The facility did not disqualify the Maintenance Director from working when a criminal history record indicated a criminal conviction barring employmen t of credit or debit card abuse elderly: 32:31 (D) Felony -3rd degree in a nursing facility. The Maintenance Director had worked in the facility from 09/19/2025 through 12/05/2025. This failure could place residents at risk for possible abuse, neglect, or exploitation. Findings included: Record review of an undated personnel file for the Maintenance Director reflected a hire date of 09/19/2025. Further review revealed a national background check had been conducted on 09/19/2025. The background check reflected the Maintenance Director had an offense date of 09/04/2018 and disposition date of 7/29/2022 charged with credit or debit card abuse elderly: 32:31 (D) Felony -3rd degree (F3) with a final plea of guilty court confinement of 10 years and 5 years' probation sentence dated 09/12/2025 . In an interview on 12/05/2025 at 2:25pm the Maintenance Director stated he had been employed with the facility since October 2025. He stated that he was the Maintenance Director and has served in this role for the duration of his employment with the facility. The Maintenance Director stated that his direct supervisor was the Administrator. The Maintenance Director stated that the previous Administrator had hired him . In an interview on 12/05/2025 at 3:05pm HR A stated that 6 staff including the Maintenance Director on the employee file review list were employable. HR A stated that no staff on the list have any criminal histories that would bar them from employment. She stated that technically anyone that has something more than a misdemeanor on their background the ADM had to sign off on it. She stated that the Maintenance Director was approved by the previous ADM. HR A stated that now the facility had to send the personnel files to the [NAME] President of Operations, the ADM does not just have the authority to approve new hires. HR A stated that with the Maintenance Director, the facility did not want to go back and terminate him. HR A stated that there was an HR policy that outlined what the expectations are for hiring. HR A stated that she would be concerned if someone was hired into a position at a nursing home with a criminal history. In an interview on 12/06/2025 at 11:40 am the ADM stated that the criminal history report for the Maintenance Director was run prior to her employment. The ADM stated some things to her would seem to be automatically an unemployable offence. She stated she was going to get with HR and Cooperate for a full audit of employee files to ensure criminal history checks were reviewed. She stated based on policy and procedure the facility will make the necessary staffing adjustments accordingly. The ADM stated the risk for residents for having employees with conviction for elder abuse would be that it could open the residents up for potential abuse. The ADM stated the Maintenance Director was terminated as of 12/05/2025. Record review of the Employee Handbook dated April 2025 reflected: BACKGROUND AND CRIMINAL HISTORY SCREENS All newly hired employees will undergo a background and/or criminal history screen as required by the State of Texas and in accordance of the Health & Safety Code Section 250,006, Convictions Barring Employment. This will occur on a pre-employment basis. Unsatisfactory reports will result in rescinding the employment offer or termination of employment. Record review of the State of Texas, Health and Safety Code, Chapter 250, Section 250.006 Convictions Barring Employment revealed (Revision 24-1, Effective [DATE]): A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility or may not be employed by an individual employer before the fifth anniversary of the date the person is convicted of: an offense under Section 31, theft, that is punishable as a felony. Record review of the facility's Abuse Prevention Program dated 2001 and revised November 2010 reflected: Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. Screening: The facility will screen employees for a history of abuse, neglect, or mistreating residents by attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries.

Based on record review and interviews, the facility failed to provide advance notice of change in services and charges not covered under Medicare for 1 of 3 residents (Residents #77) reviewed for Medicaid and Medicare Coverage Liability Notices.The facility failed to ensure Resident #77 was provided with a Notice of Medicare Non-coverage (NOMNC) when the resident discharged from Medicare Part A skilled services with benefit days remaining for that episode, or 2 days prior to the resident's planned discharge.This failure could place the residents, or their representatives, at risk of not being fully informed about services covered by Medicaid Part A and unknowingly being charged for skilled nursing services.Record review of Resident #77's admission record dated 12/6/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident's principal diagnosis was heart failure (a long-term condition that prevents the heart from pumping blood effectively throughout the body). The resident's discharge date was listed as 6/17/2025 at 1030 (10:30 AM), with the length of stay being 15 days, and the resident discharged home with home health. Record review of Resident #77's Nursing Home Discharge (ND) MDS, dated [DATE], indicated Resident #77 discharged to Home/Community on this date, The assessment showed Resident #77 had a BIMS Score of 15, which indicated normal cognitive function and intact cognitive response. Record review of the Beneficiary Notice worksheet reflected a list of residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months. The worksheet showed Resident #77 was discharged home from the facility on 6/17/2025. On 12/3/2025, Resident #77 was chosen at random from the list of residents provided for a Beneficiary Notification Review. Record review of Resident #77's SNF Beneficiary Protection Notification Review form on 12/4/2025 revealed Resident #77's Medicare Part A Skilled Services Episode Start Date was 6/2/2025 and the Last Covered day of Part A Services was 6/17/2025. The form revealed that the facility/provider initiated the resident's discharge from Medicare Part A services when benefit days were not exhausted because the resident Decided to go home per family. The form revealed a NOMNC was not provided to the resident. Facility staff did not choose a listed reason as to why the NOMNC was not provided to the resident. Instead, facility staff wrote, discharged to another facility. Record review conducted on 12/4/2025 of Resident #77's progress notes revealed LVN A made a late entry discharge summary note effective 6/17/2025 at 10:34 (10:34 AM). The entry stated Resident #77 discharged to home with personal items and meds. Condition stable at departure. LVN A's nurse's note made on 6/17/2025 at 11:16 (11:16 AM) stated, Patient discharged to home with personal items and medications. Meds reviewed with RP, patient condition stable at departure. Record review of Resident #77's routine physician follow-up visit after hospitalization dated 6/10/2025 indicated, The patient expresses a desire to return home. The visit notes also indicated that PT staff estimated the patient would be ready to return home in 7-10 days. Record review of Resident #77's physician's orders revealed no order for discharge at the time of the resident's departure from the facility; however, a verbal order was obtained on 6/18/2025 that stated, DC HOME WITH HOME HEALTH. In an interview on 12/6/2025 at 12:56 PM , ADM revealed Resident #77 was discharged from the facility with Medicare Part A days remaining. ADM stated that due to an unexpected loss of pertinent staff, she was unable to say for certain the circumstances under which the resident was discharged or locate any notices or forms issued to the resident. ADM stated that Resident #77 was discharged from the facility prior to ADM taking her position at the facility. ADM stated that she was not personally familiar with this resident or her discharge circumstances. ADM speculated that Resident #77 discharged AMA but provided other explanations on the SNF Beneficiary Protection Notification Review form. ADM revealed information regarding the resident's full discharge circumstances was missing and incomplete due to employee and record transitions. ADM stated the former BOM was responsible for issuing those notices and maintaining those records. The former BOM was not able or willing to further discuss facility matters after her termination. ADM stated that a new BOM will assume the position and responsibility soon and ADM will ensure the new BOM and existing staff are educated, training and cross-trained on the process to avoid this type of situation in the future. ADM stated that during the transition from one electronic medical health record system to another, staff were diligently working to ensure completeness of information and record audits will be ongoing. ADM stated that the expectation regarding the NOMNC was that staff would follow the appropriate Medicare guidelines. Record review of Form Instructions for 10123-NOMNC (Notice of Medicare Non-Coverage) revealed the following, in part: - The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. - Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process per Chapter 4, Section 260 of the Medicare Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare Managed Care Manual. - The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Record review of the facility's Medicare Advance Beneficiary and Medicare Non-Coverage Notices revised September 2022, revealed, Residents are informed in advance when changes will occur to their bills.Notice of Medicare Non-Coverage (CMS form 10123) 1. If the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage (CMS form 10123) is issued to the resident at least two calendar days before benefits end.2. The Notice of Medicare Non-Coverage informs the resident of the pending termination of coverage and of his/her right to an expedited review by a Quality Improvement Organization.

Acronyms: HTN COPD MDS DON ADM LVN BIMS Based on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan within 7 days after comprehensive assessment and within 21 days from admission for 1 of 1 resident (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 had a Comprehensive Care Plan that was due within 21 days of admission to reflect the person-centered needs of Resident #1. Resident #1 received only a Baseline Care plan at the time of admission. This failure could place residents at risk of getting insufficient care and having personal needs not met. This could result in diminishing physical and psychosocial well-being. Findings include: Review of Resident #1's undated face sheet reflected that she was a [AGE] year-old female admitted [DATE] with diagnoses of COPD (lung disease), Dementia, Diabetes Type 2, HTN, and Hypothyroidism. Review of Resident #1's 4/17/25 Quarterly MDS reflected her BIMS score was 05, which indicated severe cognitive impairment. Review of Resident #1's care plans reflected only one (1) Baseline Care Plan on 4/8/25, initiated at admission, with a care area initiated for Risk for COPD Complications and a goal to remain free of secondary complications. Review of the facility care plan records reflected that the Comprehensive Care Plan was due on 4/18/25, which was 7 days after the comprehensive assessment and within the 21-day window from admission. In an interview on 5/15/25 at 4:49 PM MDS stated, the 4/8/25 care plan for Resident #1 was a baseline care plan and it was not updated since there were no changes. She stated that she was responsible for maintaining the care plans on residents. She stated the purpose of the care plan is to tell staff how to care for the resident and a negative outcome to the resident if care plans are not done was that the staff would not know what the resident needs or likes. MDS stated that she was unaware that a comprehensive care plan was due within 21 days of admission. In an interview on 5/15/25 at 5:19 PM LVN-A stated that use of oxygen for a resident should be reflected on the care plan. She stated the policy and purpose of care plans is to make sure all staff are on the same page and working towards the same goal for residents. LVN-A stated the negative outcome to residents if care plans are not kept current could be staff confusion or failure to meet the needs of the resident. In an interview on 5/15/25 at 5:35 PM CNA stated the negative outcome to residents if the care plan is not current could be a drop in the health of the resident and the main purpose of the care plan is to make sure they are getting up and living their best life. In an interview on 5/15/25 at 5:47 with the DON who stated the purpose of care plans was to ensure all staff are working on the same goal with residents and to know where they are headed. She stated care plans should be done on admission, a comprehensive care plan within 21 days of admission, quarterly and when a change of condition occurs. She said the negative outcome to residents if the care plan was not kept current was that staff would have no guidance on care for the residents. In an interview on 5/15/25 at 6:05 PM with ADM, who stated the policy and purpose of care plans was to provide individual plans of care to tell staff how to care for and what should be done for residents. She said care plans should be revised as needed and it was a living document-always changing. She said care plans should be done Initial Base Line on admission, then Comprehensive care plan and thereafter Quarterly. She stated the negative outcome to residents if the care plan was not current was the resident would not receive the appropriate care. Record Review of the facility policy titled, Care Plans, Comprehensive Person-Centered and dated March 2022, reflected: The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Acronyms: HTN COPD MDS DON ADM LVN BIMS Based on observations, interviews, and record review the facility failed to ensure that the resident's record reflected an ongoing assessment of the resident's respiratory status, a practitioner's order, and indications for use of oxygen for 1 of 1 resident (Resident #1) reviewed for oxygen therapy. The facility failed to ensure Resident #1's chart reflected a practitioner's order for oxygen indicating the amount and flow type for Resident #1's use of oxygen. There was no oxygen assessments in the chart for Resident #1's diagnosis of COPD. This failure placed residents at risk of developing respiratory distress by receiving too much or too little oxygen . Findings included: Review of Resident #1's undated face sheet reflected that she was a [AGE] year-old female admitted [DATE] with diagnoses of COPD (lung disease), Dementia, Diabetes Type 2, HTN, and Hypothyroidism. Review of Resident #1's Quarterly MDS dated [DATE] reflected her BIMS score was 05, which indicated severe cognitive impairment. Review of Resident #1's Care Plan dated 4/18/25 reflected a care area initiated for Risk for COPD Complications with a goal to remain free of secondary complications. There was not a care area shown for oxygen therapy. Review of all of Resident #1's orders from admission on 4/7/25 to 5/15/25 did not reflect any orders for oxygen therapy. Review of Resident #1's vital signs flow sheet from 4/7/25 to 5/15/25 reflected her oxygen saturation level was charted on 4/8/25, 4/12/25, 4/13/25, 5/5/25, and 5/6/25 with the indicator that she was using oxygen via a nasal canula when the saturation level was checked. All saturation levels were between 90% -100%. Observation on 5/15/25 at 10:49 AM of Resident #1's room revealed an oxygen concentrator machine in the room by the resident's bed with clear, clean nasal canula tubing attached to it. In an interview on 5/15/25 at 4:43 PM Resident #1 stated that she does not know how to use the oxygen concentrator machine and that she does not remember using but she also stated that she has trouble recalling some things. In an interview on 5/15/25 at 4:49 PM MDS-LVN stated she was unaware of the oxygen machine in Resident #1's room and unsure if the resident uses the machine. She stated she was responsible for updating the care plans for residents and the oxygen was not indicated on the care plan. In an interview on 5/15/25 at 5:19 PM the LVN stated that use of oxygen for a resident should be reflected on the care plan and oxygen requires a physician's order. She stated Resident #1 does not keep oxygen on now, but she was wearing oxygen when she was first admitted . She knew there was not a current order for her oxygen. She stated the negative outcome to residents if oxygen was given without an order was that the resident's oxygen could be set too high for a COPD patient. She said the limit was 4 liters per minute for a COPD diagnosis and if it was too high the resident could have trouble breathing. In an interview with the CNA on 5/15/25 at 5:35 PM who stated oxygen should be reflected on the care plan. She stated Resident #1 wore oxygen on her first day here, but not since. She stated the negative outcome if oxygen was not ordered could be death to a resident. In an interview on 5/15/25 at 5:47 PM with the DON who stated, oxygen requires an order and should be indicated on the care plan also. She stated the negative outcome to residents if oxygen was not ordered was that it may not be given when needed or a resident with COPD could get too much oxygen, which could cause harm. In an interview on 5/15/25 at 6:05 PM with ADM who stated that oxygen should have a physician's order and should be indicated on the care plan. She said the negative outcome to residents if there was not an order could be incorrect treatment. She stated oxygen therapy was driven by the physician's order to determine what we are allowed to do with it. She stated determining oxygen therapy was beyond her scope of practice. Record Review of the facility policy titled, Oxygen Administration and dated 2001 with last revision date of October 2010, reflected: Verify that there is a physician's order for this procedure (Oxygen). Before administering oxygen, and while the resident is receiving oxygen therapy, assess for cyanosis (blue skin), hypoxia (low oxygen), or oxygen toxicity (difficulty breathing/shallow rate of breathing). After setting up oxygen, document date, time, name, rate of flow, route, frequency .

Based on observation, interviews and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of six residents reviewed for quality of care. The facility failed to administer triamcinolone acetonide (a medication utilized for pain/itch relief) when Resident #1 was experiencing increased itching from 12/16/24 through 03/17/25. This failure could place residents at risk of not receiving medical care for conditions that cause stress and irritation, and significantly impact quality of life. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including rash and other skin eruption (a general term for any change in the skin's appearance or texture, including redness, bumps, blisters, or dryness, and can be caused by various factors like allergies, irritants, infections, or underlying medical conditions), pruritus (an unpleasant sensation that causes an urge to scratch), acute kidney failure (a sudden and significant decline in kidney function that leads to an accumulation of waste products in the blood), and major depressive disorder (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities that were once enjoyable). Review of Resident #1's quarterly MDS assessment, dated 03/05/25, reflected a BIMS score of 10 suggesting moderate cognitive impairment. Skin and ulcer/treatments reflected applications of ointments/medications other than to feet. Review of Resident #1's care plan, undated, reflected no goal, problem, or approach related to resident's diagnoses of rash and other skin eruption or pruritus. Review of Resident #1's orders revealed an order for triamcinolone acetonide cream 0.1% (used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions. This medicine is a corticosteroid (cortisone-like medicine or steroid) topical (medication or skincare products applied directly to the skin to treat various conditions, including itching and inflammation) every 12 hours apply to areas of itching q12hr prn for DX Pruritus, unspecified start dated 12/16/24 - open ended (prescription that allow for refills or continuation of the medication without a specific end date or number of refills). Review of Resident #1's progress note by LVN A dated 02/10/25 reflected, New order for itching to increase hydroxyzine to 20 mg q6hr prn. Review of Resident #1 progress note by LVN A dated 02/19/25 reflected, Resident states that she is still itching and in pain. PRN tramadol given for the pain and hydroxyzine (used to treat itching caused by allergies) for the itching. hydroxyzine is not helping, PCP notified awaiting response. Review of Resident #1's MD note dated 02/25/25 revealed Resident #1 presented with generalized pruritus. She reported itching in various areas including her throat, tummy, and legs and mentioned having sores on her head which she describes as full of sores and so bad. Review of Resident #1's progress note by AN C dated 03/03/25 reflected, patient is requesting medication for itching, told her she had it ordered 4 times a day. She wanted something between that. Will ask MD in the morning (have AM nurse call MD). Review of Resident #1's progress notes from 3/04/25 through 3/15/25 revealed no progress notes concerning any contact made to the MD regarding additional medication for Resident #1's itching. Attempted to reach AN C on 03/17/25 at 1:16 pm regarding Resident #1's progress note made by AN C dated 03/03/25 by leaving a voice mail and sending a text message, no response was received from AN C. Observation and interview on 03/15/25 of Resident #1's pillowcase at 11:45 am revealed many areas of varying sizes of dried brown spots that appeared to be blood. Resident #1 revealed she said she itched all the time, and it was horrifying. She said she itched on her head, neck, and back and the doctor told her it was her kidneys that caused the itching issues, and he could not do anything else for her. She said she had sores on her head and neck. She said, oh yea, she had told the staff she was uncomfortable, but she did not remember the names of anyone she told. She revealed the dried brown spots on her pillow were from blood from her scratching her head. Interview on 03/16/25 with CNA B at 10:12 am revealed Resident #1 had asked to go to the hospital for itching and had sores from where she was scratching. CNA B revealed there were sores on Resident #1's shoulders and her head where Resident #1 had scratched. CNA B said the nurses were aware of the areas where Resident #1 had scratched. CNA B said Resident #1 was always complaining of itching and it worried CNA B that Resident #1 was always telling them she was, itching and itching and itching. CNA B said they have, done above and beyond for the itching. CNA B said Resident #1 was itching because she had kidney failure. Review of Resident #1's hospital records dated 03/16/25 reflected Resident #1's chief compliant was skin rash and itching. Records reflect that, it started several months and is still present. It is described as itchy. Not painful or burning and has been located on the right and left back. It has been located on the right and left shoulder and neck. No cause has been identified. Observation on 03/17/25 at 1:20 pm with LVN A present revealed Resident #1 left thigh had some red marks, total size about 2 inches in length 3/4 inch width. A couple pin-point areas where skin was broken. No drainage or odor. Wound looked very new. Bilateral trapezius/shoulder area with multiple 0.5cm or less scabs. Surrounding skin not red/inflamed or otherwise irritated. Resident rolled on side, no other skin impairment to back side. Resident complained of whole head itching, no wound visible. Observation and interview on 03/17/25 at 2:45 pm Resident #1 was scratching her head and neck. Resident #1 said she itched a lot all the time and they never put any medicated lotion on her. Interview on 03/17/25 at 12:21 pm LVN A revealed she gave the prn triamcinolone lotion to Resident #1 3-4 times, but did not chart the medication administration and said my bad. Observation and interview on 03/17/25 at 12:30 pm LVN A checked Resident #1's nurse cart, treatment cart, and medication room for Resident #1's triamcinolone prescription. LVN A revealed she could not find Resident #1's prn triamcinolone prescription medication. Interview on 03/16/24 with the ADON at 1:43 pm revealed Resident #1's itching had been an ongoing thing and they have tried different creams, but they could not cure it. She said Resident #1 had a kidney problem and that was the cause of the itching. Resident #1 had complained a lot about the itching, and she scratched herself a lot. She had a scratching tool at one time. The ADON stated her pillowcase had blood on it from areas where she was scratching, and the blood might be from scratching her shoulders. When shown the pictures of Resident #1's pillowcase with the brown areas the ADON said, oh wow she would have to go down there to look and see where it was coming from. She said Resident #1 got little nicks from scratching and Resident #1 did scratch on her shoulders and neck a lot. The ADON said sometimes Resident #1 was smiling and sitting up eating and then sometimes she was itching. The itching had been a problem for a long time. She asked sometimes to go to the hospital because she wanted it to be cured so badly because it was miserable. Interview on 03/17/25 with the ADON at 4:45 pm stated when you are nurse you are going to give residents the ordered medication and then offer them anything prn. She said Resident #1's itching could not be cured but you wanted to give her some relief if possible. She said it does not meet her expectations that Resident #1's prn triamcinolone prescription medication could not be located and was not ever administered to Resident #1. She said it was not good practice that it had not ever been tried as a relief for Resident #1's itching. Interview on 03/17/25 with the DON at 3:12 pm revealed Resident #1 had a complaint of itching, and whether to administer a prn medication was based on the nurse's assessment at that time. She said that because the prn medication had been ordered by the MD on 12/16/24 the nurses should have been applying the prescribed prn triamcinolone acetonide topical medication. The DON said the negative effect of not trying the prn medication was, if you did not apply the medication, you did not know if it worked. The DON stated she did not know that Resident #1's triamcinolone acetonide topical medication could not be located by LVN A and that was a problem because the medication was not available to administer to Resident #1. Interview on 03/17/25 with the Administrator at 4:04 pm revealed Resident #1's itching had been a problem since she has been admitted to the facility. The Administrator felt that someone should have tried to use the ordered prn triamcinolone acetonide topical medication to see if it could have given her some relief from the itching. She stated she did not know if the nurses educated Resident #1 about the prn medication and did not know how, because of Resident #1's itching issues, this medication was never offered to Resident #1. The Administrator said she did not know that the prn triamcinolone acetonide topical medication could not be located when the nurse surveyor asked to see the medication. The negative effect of them not offering her the prn medication was that if given the medication, Resident #1 might have had some relief from the itching. The Administrator stated that not offering medication that could have potentially provide relief from her itching is not good quality of care. Interview on 03/17/25 with Resident #1's MD at 3:47 pm revealed it was ridiculous that Resident #1 was never given her prn prescription for triamcinolone. The MD said the medication had a steroid that helped decrease inflammation and it could have potentially given Resident #1 some relief from the itching. He said Resident #1 had the prescription for several months, it should be available and at the facility for use, and he would not have prescribed it if he did not think it could have given her some relief. Facility Medication Administration policy dated April 2019 reflected medications are to be administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include enhancing optimal therapeutic effect of the medication and honoring resident choices and preferences, consistent with his or her care plan. If a drug is refused, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. Topical medications used in treatments are recorded on the resident's treatment administration record. Facility Medication Labeling and Storage policy dated 2001 reflected medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications for several residents.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for one (Resident #1) of four residents reviewed for accidents hazards, in that: The facility failed to ensure Resident #1 was transferred by mechanical device from her shower chair to her bed without receiving a cut and a bruise on her right toe. This failure could place residents at risk of pain, bruising, or skin tears. The findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life, diastolic (congestive heart failure - a condition where the heart muscle is unable to relax properly between heartbeats, leading to reduced filling of the heart chambers and decreased cardiac output),). Review of Resident #1's care plan reflected no goal, problem, or approach related to resident's ADLs or transfers. Review of Resident #1's quarterly MDS assessment, dated 03/05/25, reflected a BIMS score of 10 suggesting moderate cognitive impairment. Section GG - Functional Abilities of Resident #1's MDS reflected lower extremity (hip, knee, ankle, foot) impairment on both sides, Resident #1 used a wheelchair as a mobility device, Resident #1 was dependent with toileting hygiene, shower/bathing, lower body dressing, and putting on/taking off footwear. Resident #1 requires substantial/maximal assistance with sit to lying, lying to sitting on the side of bed, sit to stand, and chair/bed-to-chair transfer. Review of facility Event Report dated 03/15/25 reflected, Per [CNA B] spoke with [family member] about skin tear to the end of right great toe. The incident occurred when transferring from shower chair to bed via [mechanical lift]. She grabbed chair as they were raising her with [mechanical lift]and it came up and hit the end of her toe. Observation on 03/15/25 at 11:45 am of Resident #1's right toe revealed a closed dark purple colored cut approximately 1 inch in length surrounded by bruising on the top of Resident #1's right toe. Wound surrounded by dry skin and left open to the air. Interview on 03/15/25 with Resident #1 at 11:45 am revealed, that staff (Resident #1 did not know the names of the staff) were giving her a shower and they hit her into something when she was in the mechanical lifting device and she was, screaming blood murder. She said it happened when they took her off the chair and the chair fell over. Interview on 03/16/25 with CNA B at 10:12 am revealed on 03/12/25, between 2:00 pm and 4:00 pm, CNA B and CNA E were transferring Resident #1 from the shower chair to the bed using a mechanical lifting device. The shower chair did not stay on the ground when Resident #1 was being raised by the mechanical lift. The shower chair, which was snug against Resident #1's sides, came up with Resident #1 when she was lifted by the mechanical lifting device. Resident #1 grabbed the arms of the shower chair and the shower chair fell to the floor, bounced and a wheel on the shower chair hit Resident #1's right toe and made a cut to Resident #1's right toe. Resident said, my toe my toe. CNA B said Resident #1's toe was bleeding and CNA B put a wipe around the base of Resident #1's toe away from the tip of the toe which was bleeding to catch the blood. CNA B stated the remainder of the transfer of Resident #1 to her bed was uneventful. CNA B stated she notified AN D. Attempted to reach CNA E on 03/17/25 at 11:51 am no response was received from CNA E. Attempted to reach AN D on 03/17/25 at 9:36 am and 10:10 am no response was received from CNA E. Interview on 03/17/25 with the Administrator at 1:21 pm reflected she was aware of the shower chair incident with Resident #1 and said Resident #1 was injured and the facility needed to check out the chair and talk to the staff and find out if it was an isolated accident. Review of Safety and Supervision of Residents policy dated July 2017 reflected 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. Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk and environments hazards are addressed in dedicated policies and procedures. These risk factors and environments hazards include the following: Safe lifting and movement of residents.

Based on interview, and record review the facility failed to thoroughly investigate the incident of how Resident #1 was left unsupervised and fell from the bed. There was no evidence to show the incident had been investigated at all. The facility failed to investigate a serious injury that occurred when Resident # 1 sustained a wrist fracture and other injuries CNA A left her unsupervised and she fell out the bed on 4/14/2024. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 4/18/2024 at 6:07pm. The IJ Immediate Jeopardy template was provided to the ADM on 4/18/2024 at 6:07pm. While the (IJ) Immediate Jeopardy was removed on 4/19/2024 at 1:26pm, the facility remained out of compliance at a scope of isolated and severity level of actual harm because all staff had not been trained on abuse/neglect, incident/accidents, and reporting. The failure could place residents at risk of accidents and harm. Findings included: Record review of Resident #1's face sheet dated 1/9/2024 reflected, Resident #1 is a [AGE] year-old female who was admitted to the facility on [DATE]. The face sheet reflected Resident #1 had the following diagnoses Other acute osteomyelitis ( bone inflammation that can result in pelvis trauma), left femur, Muscle wasting and atrophy (wasting, thinning or loss of muscle tissue), not elsewhere classified, right upper arm, Muscle wasting and atrophy (muscle that lose their nerve supply), not elsewhere classified, left upper arm, Chronic pain syndrome (other symptoms beyond pain alone), Multiple sclerosis ( a disease in which the immune system eats away at the protective covering of nerves), Functional quadriplegia(Complete Immobility due to sever disability or frailty from another medical condition without injury to the spinal cord). Record review of Resident's #1 admission MDS dated [DATE] BIMS score 15 cognitive intact GG functional section of MDS reflect the resident required substantial /maximal assistance with roll to left or right side. Record review of Resident #1 care plan dated 1/18/2024 reflected Resident # 1 required total staff performs /provides total assistance for all ADL's. The care plan reflected the following interventions: Keep call light within reach and encourage use for assistance. Respond promptly to all request for assistance. Resident # 1 required a bed with side rails on both sides. Record review of physician order dated 3/24/2024 for Resident # 1 reflected Resident #1 required a 2x person assist and hoyer for transfers, mobility, bathing, and a 2x person assist with toileting. During an interview on 4/18/2024 at 11:17 a.m. a FM revealed Resident #1 called her last night 4/17/2024 and stated she fell out the bed on Sunday night 4/14/2024. The FM stated they did not make sure that she was in the center of the bed, she was on the edge and fell out the bed. The FM stated Resident #1 sustained a hairline fracture to her right wrist, she stated she also had a scar on her leg from where she fell and that he was swollen on the right side. The FM stated Resident # 1 was in a lot of pain because usually she did not cry but stated she was crying because of the pain from her injuries. During an interview on 4/18/2024 at 11:46 a.m. Resident #1 revealed on Sunday 4/14/2024 CNA A repositioned her on her left side and pulled her all the way to the edge of the bed and left the room. Resident # 1 stated when she realized she was falling she yelled out help- help. Resident # 1 stated there was another bedside table in the room and when she fell her face hit the table and then the floor, stated her leg also hit the table. Resident #1 stated she tried to brace her fall by putting her hand out and fractured her wrist. Resident #1 stated she was still in pain today and the facility were giving her medication to help with the pain. During an interview on 4/18/2024 at 4:00 p.m. the DON, revealed she was advised of the fall the next day on 4/15/2024. The DON stated nursing staff reported Resident # 1 was turned on left side to have a bowel movement and stated she fell out the bed. She stated Resident # 1 liked to be turned on her side when having a bowel movement. The DON stated the staff were able to look at the resident physician order report to see what their care needs are and to see if they are a one person or two persons assist. During an interview on 4/18/2024 at 4:20 p.m. the Admin. revealed she spoke with Resident #1 after the incident and stated Resident #1 stated the staff positioned her differently in the bed and she fell . She stated this was not reported to HHSC because she did not believe that it was intentional. The Admin. stated after she spoke with Resident # 1 that was the extent of her investigation. The Admin. stated she expected staff to position Resident #1 in the center of the bed while on her side and ensure that she was in a safe position before leaving the room. Record review of facility abuse prevention program dated November 2010 which reflected the following: Our residents have the right to be free from abuse and neglect. Our facility is committed to protecting our residents from abuse by anyone included but not necessarily limited to facility staff. Timely and thorough investigation of all reports and allegations of abuse. An (IJ) Immediate Jeopardy was identified on 4/18/2024 at 6:07pm., due to the above failures. The ADM was notified on 4/18/2023. The ADM was provided with the (IJ) Immediate Jeopardy template on 4/18/2023 at 6:07pm, and a Plan of Removal (POR) was requested. The Plan of removal accepted on 4/19/2024 at 1:26 p.m. and indicated the following: Plan of Removal Date Initiated: 4/18/2024 and accepted on 4/19/2024. Residents #1 was assessed by DON and support was provided as accepted. Resident was informed that she would not be left alone during care. Resident was reminded that call light is available if she is concerned about safety. The physician was notified of the deficiencies cited on 4/18/2024. There were no new orders obtained. The affected resident's responsible party was notified by DON of the cited deficiencies and the plan of removal. CNA A was immediately suspended by DON and Administrator on 4/18/2024. CNA A will be terminated due to not following policy and procedures. On 4/18/2024 the DON (director of nursing) and Administrator interviewed all residents in the facility to determine if any other residents needed any assistive devices or had any concerns regarding staff not supervising during care. There were no concerns identified. The interviews were completed before midnight on 4/18/2024. Ad-Hoc (for this situation) QAPI meeting was held on 4/18/2024, with the Medical Director, NHA (Nursing Home Administrator), COO (Chief Operating Officer) and DON to review the cited deficiencies, policy and procedure, and the plan for removal of immediacy. On 4/18/2024 the COO completed 1:1 in-service on Abuse, Neglect and Incident and Accident Reporting with Administrator, DON, and ADON. The in-service also reviewed the importance of providing adequate supervision to residents during care. Starting on 4/18/24, the facility leadership (Administrator, DON, and ADON) will complete education with nursing staff on incidents and accidents and supervision. The leadership team also in serviced on reporting any incidents and accidents immediately to ensure that each resident receives the services consistent with the professional standards of practice. DON/designee reviewed the resident profiles to include the resident care plan. In servicing from DON and/or designee with direct care staff on how to access profiles in the Point of Care system. The in-services were consistent with nursing staff to be able to identify the type of care each resident needs for ADLs. The training was initiated on 4/18/24 and will be completed on 4/18/24. Nursing staff will give a return demonstration on how to pull profiles in the EMR and Point of Care system. All staff to include PRN, new employees and agency staff will receive training prior to working the floor and giving direct care. All staff to include PRN, new employees and agency staff will receive training prior to working the floor and giving direct care. Staff will not be allowed to work until they receive training. The policy pertaining to Incident, Accidents and supervision were reviewed on 4/18/24 by the DON, NHA (Nursing Home Administrator) and Medical Director. Current policy was reviewed with staff to ensure compliance. Starting on 4/18/24, IDT (Interdisciplinary team), including Administrator, DON, ADON, Activity Director, MDS Coordinator, HR, BOM) will meet with all residents daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any residents have any concerns on supervision during care or if any resident had an incident or accident that was not reported. Any concerns identified will be immediately brought to Administrator for further action, if necessary. All incidents and accidents will be documented in the electronic medical record. On 4/18/24 the COO will start reviewing any incidents or accidents to ensure complete investigation/reporting weekly for four (4) weeks followed by monthly reviews after. The DON/designee will monitor compliance by completing an audit of ten (10) residents per week for four (4) weeks. This was initiated on 4/18/24. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The Administrator will be responsible for ensuring this plan is completed on 4/18/24. The COO will provide oversight of DON and Administrators to ensure that the items on the plan of removal are reviewed and completed. Monitoring of POR on 4/19/2024 included the following: During an observation and interview on 4/19/2024 at 11:20 a.m. Resident #1 was in her room. She stated her mother had just left from visiting with her. She stated she still had pain in her back and wrist. She stated her doctor changed her PRN pain medications to every 12 hours. She stated it does not take staff a long time to answer her call light. She stated CNA J is especially fast. She stated she is not complaining, just mad that the Aide walked out and left her on her side without returning. During an interview on 4/19/2024 at 11:45 a.m. LVN C revealed they were in-serviced over the following at the Nursing Station: Abuse Prevention Program, Incident and Accident Reporting If you suspect or witness anything, inform the ADM and DON. She understands the protocol as she has been a nurse for over [AGE] years. You must make sure the safety of the resident is the main thing and you do whatever is necessary to protect them and keep them safe. If she needed further guidance, she would refer to her DON. During an interview on 4/19/2024 at 12:05 p.m. CNA D provided the following information: Abuse Prevention Program, Incident and Accident Reporting She had been a CNA for [AGE] years and she knows every time someone says they fell , she sees them on the floor, or if report they have been neglected, you are supposed to report it immediately to the Nurse, the DON, and the ADM (ANE Coordinator). She said she had never had to report any abuse or neglect other than a fall. She did not learn anything new, it was more of a refresher. During an interview on 4/19/2024 at 12: 25 p.m. CNA F. She provided the following information: Abuse Prevention Program, Incident and Accident Reporting They were told the signs of abuse and neglect, what to look for and who to report it to. They were told how to protect the resident until it is reported, and they are assessed. She did not learn anything new. It was more of a re-education as she had been in this field since 1999. It was the same information that she remembers. She stated she took away that abuse can also be between two residents, and you must remember what may seem minor to you, the resident can be affected negatively. During an interview on 4/19/2024 at 12:40 p.m. CNA E indicated he was in-serviced on the following information: Abuse Prevention Program, Incident and Accident Reporting He stated they gave everyone their own copy of each in-service. He stated they went over who to contact and what to do if it was an actual incident. He stated he knows any form of abuse and neglect needs to be reported. They have the signs of abuse and neglect posted on the wall by the time clocks and at the beginning of the 200 halls. He stated he did not learn anything new; it was more of a re-education. He stated he oversees the CNAs and conduct in-services with them. During an interview on 4/19/2024 at 12:55 p.m. LVN T. indicated she was in-serviced on the following information: Abuse Prevention Program, Incident and Accident Reporting She stated if you see anything, you must report it to the ADM. You must chart it and fill out an event report. If you see any signs of abuse or neglect you should intervene if you witness it. She learned that locking a resident's wheelchair could be a form of abuse if they are mobile and they cannot unlock the wheelchair themselves. During an interview on 4/19/2024 at 1:20 p.m. CNA K. indicated she was in-serviced on the following information: Abuse Prevention Program, Incident and Accident Reporting She stated if there is a sign of abuse or neglect you must contact the ADM. If you cannot get a hold of her in 10-15 minutes, you must contact the DON because they must report within 2 hours. She stated if you see something you must say something. She stated she has been working in facilities for over 5 years and did not learn anything new. She stated it was more of a reminder. During an interview on 4/19/2024 at 1:40 p.m. the DON provided the following information: Ad Hoc QAPI Meeting She stated they discussed the two Tags and discussed the resident of concern with the PCP. She stated they asked if he wanted anything changed to the policy, and he stated there was nothing at this time. She stated they informed him the CNA was suspended, pending termination. Safe Surveys She stated herself, the MDS Coordinator and the ADON completed the Safe Surveys with each resident. She stated there were no concerns regarding abuse or neglect. She stated one female resident mentioned the Aides talk a lot. She stated one male resident said the Aide of Concern is a little gruff in speaking. She stated to eradicate this, the Aide is being terminated. She stated she will be doing more monitoring over the weekends on the halls and asking random residents about their care. Abuse Prevention Program, Incident and Accident Reporting She stated they went over all parts of the policy and the protection of residents. She stated they went over who to report it to and although they tell the nurse, they must still report it to the DON and the ADM themselves. She provided them a list of signs and symptoms and how the resident may react to being abused. She gave them examples of depression to know what to watch for with a resident. She stated it is not always verbal or physical, but it could be mental abuse, misappropriation, etc. During an interview on 4/19/2024 at 2:00 p.m. the Admin. provided the following information: Ad Hoc QAPI Meeting She stated they went over interviewing all residents for supervision related to incidents and accidents. She stated they discussed in-servicing all staff on Abuse and Neglect, Reporting, Incidents and Accidents. She stated staff not present would be called to provide education over the phone. She stated the IDT team reviewed all residents for abuse, and neglect to include supervision. She stated they discussed policy of ANE, Reporting, Incidents and Accidents. She stated no changes have been made and no new policies were created. She stated they reviewed the Plan of Removal with all attendees. She stated the COO in-serviced her, the DON and the ADON. She stated this morning, the Resident of Concern wanted to be left alone during her bowel movement and they had to re-educate her that it was not safe to do so. She stated the Resident was fine with the decision due to her safety. She stated due to taking a lot of pain medications, it causes the Resident to become constipated. She stated laying on her side, helps it to release. Safe Surveys She stated they completed Safe Survey Audits and spoke with every Resident at the facility. She stated only 2 mentioned that they did not care for the Aide Resident # 3 and Resident #4 stated due to the way she talks. She stated they were never harmed; they just did not care for her demeanor. She stated due to their feedback along with the incident with Resident # 1, they are moving forward with termination. She stated she is currently suspended, and her termination has been approved and will occur this afternoon via phone. Record review of in-service dated 4/18/2024 on Resident Rights completed by 38 staff. Record review of in-service dated 4/18/2024 on Positioning and Re-positioning residents in bed completed by 12 CNA and nursing staff. Record review of progress note dated 4/15/2024 regarding assessment of Resident # 1's hand/wrist, right leg and ankle. On 4/19/2023 at 1:29 p.m., the ADM was informed the (IJ) Immediate Jeopardy was removed. While the (IJ) Immediate Jeopardy was removed on 4/19/2024 at 1:29 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm because all staff had not been trained on abuse/neglect, incident/accidents, and reporting.

Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1(Resident #1) of 6 residents reviewed for accidents and supervision. The facility failed to ensure on 4/14/2024 that Resident # 1 was repositioned in her bed by CNA A, who placed her too close to the edge of the bed. The lack of supervision resulted in that Resident # 1 fell out her bed and sustained a fractured right wrist, swollen right side of her face, and other scratches to her legs from the fall. Resident # 1's right wrist was placed in a brace, and she was prescribed pain medication as needed. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 4/18/2024 at 6:07 p.m. The IJ Immediate Jeopardy template was provided to the ADM on 4/18/2024 at 6:07 p.m. While the (IJ) Immediate Jeopardy was removed on 4/19/2024 at 1:26 p.m., the facility remained out of compliance at a scope of isolated and severity level of actual harm because all staff had not been trained on abuse/neglect, incident/accidents, and reporting. This failure could place residents at risk for accidents and harm. Findings included: Record review of Resident #1's face sheet dated 1/9/2024 reflected, Resident #1 is a [AGE] year-old female who was admitted to the facility on [DATE]. The face sheet reflected Resident #1 had the following diagnoses Other acute osteomyelitis ( bone inflammation that can result in pelvis trauma), left femur, Muscle wasting and atrophy (wasting, thinning or loss of muscle tissue), not elsewhere classified, right upper arm, Muscle wasting and atrophy (muscle that lose their nerve supply), not elsewhere classified, left upper arm, Chronic pain syndrome (other symptoms beyond pain alone), Multiple sclerosis ( a disease in which the immune system eats away at the protective covering of nerves), Functional quadriplegia(Complete Immobility due to sever disability or frailty from another medical condition without injury to the spinal cord). Record review of Resident's #1 admission MDS dated [DATE] BIMS score 15 cognitive intact GG functional section of MDS reflect the resident required substantial /maximal assistance with roll to left or right side. Record review of Resident #1 care plan dated 1/18/2024 reflected Resident # 1 required total staff performs /provides total assistance for all ADL's. The care plan reflected the following interventions: Keep call light within reach and encourage use for assistance. Respond promptly to all request for assistance. Resident # 1 required a bed with side rails on both sides. Record review of physician order dated 3/24/2024 for Resident # 1 reflected Resident #1 required a 2 x person assist and hoyer for transfers, mobility, bathing, and a 2 x person assist with toileting. During an interview on 4/18/2024 at 11:17 a.m. a FM revealed Resident #1 called her last night 4/17/2024 and stated she fell out the bed on Sunday night 4/14/2024. The FM stated they did not make sure that she was in the center of the bed, she was on the edge and fell out the bed. The FM stated Resident #1 sustained a hairline fracture to her right wrist, she stated she also had a scar on her leg from where she fell and that he was swollen on the right side. The FM stated Resident # 1 was in a lot of pain because usually she did not cry but stated she was crying because of the pain from her injuries. During an interview on 4/18/2024 at 11:46 a.m. Resident #1 revealed on Sunday 4/14/2024 CNA A repositioned her on her left side and pulled her all the way to the edge of the bed and left the room. Resident # 1 stated when she realized she was falling she yelled out help- help. Resident # 1 stated there was another bedside table in the room and when she fell her face hit the table and then the floor, stated her leg also hit the table. Resident #1 stated she tried to brace her fall by putting her hand out and fractured her wrist. Resident #1 stated she was still in pain today and the facility was giving her medication to help with the pain. During an interview on 4/18/2024 at 3:45 p.m. CNA B revealed she did work the night of the incident. She stated Resident # 1 told her that CNA A turned her and pulled her too close to edge of the bed and she fell . She stated they do turn Resident #1 to her side when having a bowel movement but stated there is someone in the front and on the other side of the bed and they stay with the resident. During an interview on 4/18/2024 at 4:00 p.m. the DON, revealed she was advised of the fall the next day on 4/15/2024. The DON stated nursing staff reported Resident # 1 was turned on left side to have a bowel movement and stated she fell out the bed. She stated Resident # 1 liked to be turned on her side when having a bowel movement. The DON stated the staff were able to look at the resident physician order report to see what their care needs are and to see if they are a one person or two persons assist. During an interview on 4/18/2024 at 4:20 p.m. with the Admin. revealed she spoke with Resident #1 after the incident and Resident #1 stated the staff positioned her differently in the bed and she fell . She stated this was not reported to HHSC because she did not believe that it was intentional. The Admin. stated that was the extent of their investigation. Record Review of medical record dated 4/15/2024 of X-ray of the right wrist reflected Resident # 1 sustained a Complex intra-articular fracture of the meta-diaphyseal segment of the radius (common orthopedic injuries) Physicians order dated 4/15/2024 reflect portable R wrist XR D/T C/O pain. Physicians order dated 4/16/2024 reflected a brace to right hand /wrist at all times , floor mat to right side of the bed while in bed , check placement q shift Physicians order dated 4/18/2024 reflected hydrocodone -acetaminophen 1 tab every 8 hours. Review of nurse's progress note dated 4/15/2024 reflected the following: 2pm-10pm CNA yelled from hall for a nurse. CNA stated she heard a loud thud from the hall, then upon entering resident's room, found her on the floor. Noted resident lying in a fetal position on right side between bed and wall. Resident moaning in pain, stated I think I broke my wrist. Also states she hit the right side of face on floor as well. Took vitals upon assessment and had her placed back into bed. B/P: 113/80; HR: 106bpm; T: 97.4F; O2 Sat: 98%. States she was placed on left edge of bed to have a BM, then was just left there. States she felt herself falling began to call for help, then fell out of bed, hit right side of face on bedside table, then landed on right wrist as it was hyperextended backwards. Upon assessment, noted redness to right side of face over the cheek bone area without swelling. Resident able to symmetrically move facial muscles. C/o tenderness upon palpation. Denies any dizziness or HA. Noted redness accompanied by swelling to right wrist with limited ROM. Applied ice to injured wrist and administered 1 tablet of Norco 10-325mg PO PRN as ordered for pain. No other injuries noted. States I do not want to go to any hospital. Record review of facility abuse prevention program dated November 2010 which reflected the following: Our residents have the right to be free from abuse and neglect. Our facility is committed to protecting our residents from abuse by anyone included but not necessarily limited to facility staff. Timely and thorough investigation of all reports and allegations of abuse. The Admin. was notified on 4/18/2024 at 6:07 p.m., An (IJ) Immediate Jeopardy was identified due to the above failures. The ADM was provided with the (IJ) Immediate Jeopardy template on 4/18/2023 at 6:07pm, and a Plan of Removal (POR) was requested. The Plan of removal accepted on 4/19/2024 at 1:26 p.m. and indicated the following: Plan of Removal Date Initiated: 4/18/2024 and accepted on 4/19/2024. Residents #1 was assessed by DON and support was provided as accepted. Resident was informed that she would not be left alone during care. Resident was reminded that call light is available if she is concerned about safety. The physician was notified of the deficiencies cited on 4/18/2024. There were no new orders obtained. The affected resident's responsible party was notified by DON of the cited deficiencies and the plan of removal. CNA A was immediately suspended by DON and Administrator on 4/18/2024. CNA A will be terminated due to not following policy and procedures. On 4/18/2024 the DON (director of nursing) and Administrator interviewed all residents in the facility to determine if any other residents needed any assistive devices or had any concerns regarding staff not supervising during care. There were no concerns identified. The interviews were completed before midnight on 4/18/2024. Ad-Hoc (for this situation) QAPI meeting was held on 4/18/2024, with the Medical Director, NHA (Nursing Home Administrator), COO (Chief Operating Officer) and DON to review the cited deficiencies, policy and procedure, and the plan for removal of immediacy. On 4/18/2024 the COO completed 1:1 in-service on Abuse, Neglect and Incident and Accident Reporting with Administrator, DON, and ADON. The in-service also reviewed the importance of providing adequate supervision to residents during care. Starting on 4/18/24, the facility leadership (Administrator, DON, and ADON) will complete education with nursing staff on incidents and accidents and supervision. The leadership team also in serviced on reporting any incidents and accidents immediately to ensure that each resident receives the services consistent with the professional standards of practice. DON/designee reviewed the resident profiles to include the resident care plan. In servicing from DON and/or designee with direct care staff on how to access profiles in the Point of Care system. The in-services were consistent with nursing staff to be able to identify the type of care each resident needs for ADLs. The training was initiated on 4/18/24 and will be completed on 4/18/24. Nursing staff will give a return demonstration on how to pull profiles in the EMR and Point of Care system. All staff to include PRN, new employees and agency staff will receive training prior to working the floor and giving direct care. All staff to include PRN, new employees and agency staff will receive training prior to working the floor and giving direct care. Staff will not be allowed to work until they receive training. The policy pertaining to Incident, Accidents and supervision were reviewed on 4/18/24 by the DON, NHA (Nursing Home Administrator) and Medical Director. Current policy was reviewed with staff to ensure compliance. Starting on 4/18/24, IDT (Interdisciplinary team), including Administrator, DON, ADON, Activity Director, MDS Coordinator, HR, BOM) will meet with all residents daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any residents have any concerns on supervision during care or if any resident had an incident or accident that was not reported. Any concerns identified will be immediately brought to Administrator for further action, if necessary. All incidents and accidents will be documented in the electronic medical record. On 4/18/24 the COO will start reviewing any incidents or accidents to ensure complete investigation/reporting weekly for four (4) weeks followed by monthly reviews after. The DON/designee will monitor compliance by completing an audit of ten (10) residents per week for four (4) weeks. This was initiated on 4/18/24. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The Administrator will be responsible for ensuring this plan is completed on 4/18/24. The COO will provide oversight of DON and Administrators to ensure that the items on the plan of removal are reviewed and completed. Monitoring of POR on 4/19/2024 included the following: During an observation and interview on 4/19/2024 at 11:20 a.m. Resident #1 was in her room. She stated her mother had just left from visiting with her. She stated she still had pain in her back and wrist. She stated her doctor changed her PRN pain medications to every 12 hours. She stated it does not take staff a long time to answer her call light. She stated CNA J is especially fast. She stated she is not complaining, just mad that the Aide walked out and left her on her side without returning. During an interview on 4/19/2024 at 11:45 a.m. LVN C revealed they were in-serviced over the following at the Nursing Station: Abuse Prevention Program, Incident and Accident Reporting If you suspect or witness anything, inform the ADM and DON. She understands the protocol as she has been a nurse for over [AGE] years. You must make sure the safety of the resident is the main thing and you do whatever is necessary to protect them and keep them safe. If she needed further guidance, she would refer to her DON. Residents Rights She stated residents have the right to refuse any services and they cannot force them. She stated it was a re-education for her. She stated they can refuse to eat, not comply with therapy. If they refuse something dealing with a safety concern, she will chart it and inform the DON. She learned today that they can refuse to allow you to go through their personal belongings and if you do so anyway, you would be infringing upon their rights. Residents Profile and Care Plans She stated they went over the POC in Matrix. You go under the resident's name and click on their Care Plan. The Care Plan has everything pertaining to their care. If you have any questions about their care, this is where you would go. She stated the Aides also had access to POC and the Care Plan. She stated she was already aware, and it was more of a re-education. Positioning and Repositioning Residents in Bed She stated you can also find this information in the Care Plan. They should always be positioned in the center of the bed. Some residents reposition themselves even though they are educated on the correct form for safety. She stated if they are not compliant, she would chart the non-compliance in Matrix and inform the DON. During an interview on 4/19/2024 at 12:05 p.m. CNA D provided the following information: Abuse Prevention Program, Incident and Accident Reporting She had been a CNA for [AGE] years and she knows every time someone says they fell , she sees them on the floor, or if report they have been neglected, you are supposed to report it immediately to the Nurse, the DON, and the ADM (ANE Coordinator). She said she had never had to report any abuse or neglect other than a fall. She did not learn anything new, it was more of a refresher. Residents Rights She stated residents have the right to refuse anything. If they refuse care, you are supposed to report it to the nurse. Again, she did not learn anything new, it was more of a re-education. She was in-serviced by the DON. Residents Profile and Care Plans They wanted to make sure they knew how to look up the resident's care. You go under resident task and under their information there is a button for their profile and their Care Plan. She stated it gives you a long list about their daily care, baths, ADLs, how they transfer, their diet, assistance with feeding, etc. She did not learn anything new. Positioning and Repositioning Residents in Bed She stated residents are to be turned every 2 hours. You always make sure the resident is in the center of the bed and not left on their side. You never leave a resident sitting up or laying too close to the edge of the bed, especially if they are not independent. Before leaving the room, you should make sure they have access to their call light. During an interview on 4/19/2024 at 12: 25 p.m. CNA F. She provided the following information: Abuse Prevention Program, Incident and Accident Reporting They were told the signs of abuse and neglect, what to look for and who to report it to. They were told how to protect the resident until it is reported, and they are assessed. She did not learn anything new. It was more of a re-education as she had been in this field since 1999. It was the same information that she remembers. She stated she took away that abuse can also be between two residents, and you must remember what may seem minor to you, the resident can be affected negatively. Residents Rights You must be careful with the resident and treat them with respect and dignity. They have the right to privacy. They can choose what they want to eat. You must respect their decisions. You cannot force them to take their medications or take a shower. You can only document and inform the nurse. Residents Profile and Care Plans She was shown how to go into their Care Plans. She stated she does not have to pull it up often. It is necessary because all their information is listed (ADLs, mobility, showers, etc.). She stated she knew it was there and it was a refresher for her only. Positioning and Repositioning Residents in Bed If a resident is not mobile, you must reposition them every 2 hours. You cannot leave them in one position because they can develop a bedsore. You must always make sure they are comfortable and not just leave them. You should never leave them too close to the side of the bed. She took away that when you are in a hurry, you may not have them in the center of the bed, and you need to be mindful and slow down. During an interview on 4/19/2024 at 12:40 p.m. CNA E indicated he was in-serviced on the following information: Abuse Prevention Program, Incident and Accident Reporting He stated they gave everyone their own copy of each in-service. He stated they went over who to contact and what to do if it was an actual incident. He stated he knows any form of abuse and neglect needs to be reported. They have the signs of abuse and neglect posted on the wall by the time clocks and at the beginning of the 200 halls. He stated he did not learn anything new; it was more of a re-education. He stated he oversees the CNAs and conduct in-services with them. Residents Rights He stated they laid the residents rights out for the staff. They have them posted throughout the facility. They went over the Federal and State laws. If they feel if a resident's rights are not being honored, they would contact the DON and the ADM. Residents Profile and Care Plans He assisted with showing the CNAs how to look in POC. He showed them how to pull up the resident's profile and click on the Care Plan. The Aides enter information under the general comments for any refusals or concerns and inform the Nurse. It is the Nurse's jobs to inform the CNAs when there is anything new or changes made to the Care Plan. Positioning and Repositioning Residents in Bed He stated they went over how to move and reposition residents to keep them from rolling and/or falling out of the bed. He stated you must make sure the resident is secure and positioned in the center of the bed. They were also shown how to keep the sheets pulled over the residents. He stated they had already gone over it 2 weeks ago and again starting yesterday, 4/18. During an interview on 4/19/2024 at 12:55 p.m. LVN T. indicated she was in-serviced on the following information: Abuse Prevention Program, Incident and Accident Reporting She stated if you see anything, you must report it to the ADM. You must chart it and fill out an event report. If you see any signs of abuse or neglect you should intervene if you witness it. She learned that locking a resident's wheelchair could be a form of abuse if they are mobile and they cannot unlock the wheelchair themselves. Residents Rights She stated residents are allowed to deny medications, food, showers, etc. If the resident wants to stay in their rooms, they can. The resident has the right to refuse any treatments, but they can encourage them. When residents refuse, you must chart it and inform the DON and the ADM. Residents Profile and Care Plans She stated she can look in Matrix to see the care required for the Resident. She stated it shows how they transfer, the type of diet, etc. The Care Plan shows it they are full code or DNR status. It also has their observations listed. She stated everything is new to her because she has only been a nurse for a few weeks. Positioning and Repositioning Residents in Bed She stated if a resident is immobile, they must be repositioned every 2 hours. Even if they are not immobile but remains in bed a lot they must still reposition them. She stated you can use pillows to elevevate them and always check for any redness. If a resident slides in bed, you must pull them back up in the bed. She stated she was a CNA before becoming a Nurse and already knew the information. During an interview on 4/19/2024 at 1:20 p.m. CNA K. indicated she was in-serviced on the following information: Abuse Prevention Program, Incident and Accident Reporting She stated if there is a sign of abuse or neglect you must contact the ADM. If you cannot get a hold of her in 10-15 minutes, you must contact the DON because they must report within 2 hours. She stated if you see something you must say something. She stated she has been working in facilities for over 5 years and did not learn anything new. She stated it was more of a reminder. Residents Rights She stated residents have the right to refuse. She stated this has always been the most important to her. She stated you cannot force residents to do anything. She stated residents have the right to refuse showers, food, care, medication, etc. She stated they also have the same rights as they did prior to admitting to the facility. She stated if a resident refuses any care or treatment, she will leave and reattempt 2 more times and then report it to the nurse. Residents Profile and Care Plans She stated she was showed how to pull up residents' Care Plans. She stated she did not know prior to today. She stated the Care Plan tells you about the ADLs, their likes, and dislikes, and what they were accustomed to prior to admitting. She stated you can see their shower days and times, diagnosis, etc. She stated the Care Plan enables her to learn more about her residents and how to care for them properly. Positioning and Repositioning Residents in Bed She stated she was told to make sure the resident is centered in the bed and there is nothing to restrict their movement so they can do whatever they need to do. She stated you must reposition them every 2 hours. She stated she did not know they were supposed to be centered in the bed, she used to just reposition them in whatever spot they would be laying or sitting. During an interview on 4/19/2024 at 1:40 p.m. the DON provided the following information: Ad Hoc QAPI Meeting She stated they discussed the two Tags and discussed the resident of concern with the PCP. She stated they asked if he wanted anything changed to the policy, and he stated there was nothing at this time. She stated they informed him the CNA was suspended, pending termination. Safe Surveys She stated herself, the MDS Coordinator and the ADON completed the Safe Surveys with each resident. She stated there were no concerns regarding abuse or neglect. She stated one female resident mentioned the Aides talk a lot. She stated one male resident said the Aide of Concern is a little gruff in speaking. She stated to eradicate this, the Aide is being terminated. She stated she will be doing more monitoring over the weekends on the halls and asking random residents about their care. Abuse Prevention Program, Incident and Accident Reporting She stated they went over all parts of the policy and the protection of residents. She stated they went over who to report it to and although they tell the nurse, they must still report it to the DON and the ADM themselves. She provided them a list of signs and symptoms and how the resident may react to being abused. She gave them examples of depression to know what to watch for with a resident. She stated it is not always verbal or physical, but it could be mental abuse, misappropriation, etc. Residents Rights She stated they went through the entire list of residents' rights. She stated they explained them all and asked if they had questions. She stated they also posted a list of the rights at the entrance of the hall. Residents Profile and Care Plans She stated she pulled it up and showed them how to access it. She stated she then had them demonstrate it. She stated she showed the Aides how to access the POC, go to the photo area and the second tab shows the profile (ADLS, showers, dietary, etc.). She stated if a resident has a change, she needs to know so that she can update it in Matrix. She stated she also told them to make sure they inform her of any changes they notice right away. Positioning and Repositioning Residents in Bed She stated they are educating both Aids and Nurses when they put a resident on their side to make sure they are centered and not too close to the edge of the bed. She stated if they have a draw sheet, they must still make sure they are still centered in the bed. She stated there was nothing new added to the policy, just more of a re-education for all direct care staff. During an interview on 4/19/2024 at 2:00 p.m. the Admin. provided the following information: Ad Hoc QAPI Meeting She stated they went over interviewing all residents for supervision related to incidents and accidents. She stated they discussed in-servicing all staff on Abuse and Neglect, Reporting, Incidents and Accidents. She stated staff not present would be called to provide education over the phone. She stated the IDT team reviewed all residents for abuse, and neglect to include supervision. She stated they discussed policy of ANE, Reporting, Incidents and Accidents. She stated no changes have been made and no new policies were created. She stated they reviewed the Plan of Removal with all attendees. She stated the COO in-serviced her, the DON and the ADON. She stated this morning, the Resident of Concern wanted to be left alone during her bowel movement and they had to re-educate her that it was not safe to do so. She stated the Resident was fine with the decision due to her safety. She stated due to taking a lot of pain medications, it causes the Resident to become constipated. She stated laying on her side, helps it to release. Safe Surveys She stated they completed Safe Survey Audits and spoke with every Resident at the facility. She stated only 2 mentioned that they did not care for the Aide Resident # 3 and Resident #4 stated due to the way she talks. She stated they were never harmed; they just did not care for her demeanor. She stated due to their feedback along with the incident with Resident # 1, they are moving forward with termination. She stated she is currently suspended, and her termination has been approved and will occur this afternoon via phone. Record review of in-service dated 4/18/2024 on Resident Rights completed by 38 staff. Record review of in-service dated 4/18/2024 on Positioning and Re-positioning residents in bed completed by 12 CNA and nursing staff. Record review of progress note dated 4/15/2024 regarding assessment of Resident # 1's hand/wrist, right leg and ankle. On 4/19/2023 at 1:29 p.m., the ADM was informed the (IJ) Immediate Jeopardy was removed. While the (IJ) Immediate Jeopardy was removed on 4/19/2024 at 1:29 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm because all staff had not been trained on abuse/neglect, incident/accidents, and reporting.

Based on interview, and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse/neglect and investigate such allegations for 1 (Resident # 1) of 6, residents reviewed for accidents and supervision. The facility failed to investigate a serious injury that occurred when Resident # 1 sustained a wrist fracture and other injuries CNA A left her unsupervised and she fell out the bed on 4/14/2024. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 4/18/2024 at 6:07pm. The IJ Immediate Jeopardy template was provided to the ADM on 4/18/2024 at 6:07pm. While the (IJ) Immediate Jeopardy was removed on 4/19/2024 at 1:26pm, the facility remained out of compliance at a scope of isolated and severity level of actual harm because all staff had not been trained on abuse/neglect, incident/accidents, and reporting. The failure could place residents at risk of accidents and harm. Findings included: Record review of Resident #1's face sheet dated 1/9/2024 reflected, Resident #1 is a [AGE] year-old female who was admitted to the facility on [DATE]. The face sheet reflected Resident #1 had the following diagnoses Other acute osteomyelitis ( bone inflammation that can result in pelvis trauma), left femur, Muscle wasting and atrophy (wasting, thinning or loss of muscle tissue), not elsewhere classified, right upper arm, Muscle wasting and atrophy (muscle that lose their nerve supply), not elsewhere classified, left upper arm, Chronic pain syndrome (other symptoms beyond pain alone), Multiple sclerosis ( a disease in which the immune system eats away at the protective covering of nerves), Functional quadriplegia(Complete Immobility due to sever disability or frailty from another medical condition without injury to the spinal cord). Record review of Resident's #1 admission MDS dated [DATE] BIMS score 15 cognitive intact GG functional section of MDS reflect the resident required substantial /maximal assistance with roll to left or right side. Record review of Resident #1 care plan dated 1/18/2024 reflected Resident # 1 required total staff performs /provides total assistance for all ADL's. The care plan reflected the following interventions: Keep call light within reach and encourage use for assistance. Respond promptly to all request for assistance. Resident # 1 required a bed with side rails on both sides. Record review of physician order dated 3/24/2024 for Resident # 1 reflected Resident #1 required a 2x person assist and hoyer for transfers, mobility, bathing, and a 2x person assist with toileting. During an interview on 4/18/2024 at 11:17 a.m. a FM revealed Resident #1 called her last night 4/17/2024 and stated she fell out the bed on Sunday night 4/14/2024. The FM stated they did not make sure that she was in the center of the bed, she was on the edge and fell out the bed. The FM stated Resident #1 sustained a hairline fracture to her right wrist, she stated she also had a scar on her leg from where she fell and that he was swollen on the right side. The FM stated Resident # 1 was in a lot of pain because usually she did not cry but stated she was crying because of the pain from her injuries. During an interview on 4/18/2024 at 11:46 a.m. Resident #1 revealed on Sunday 4/14/2024 CNA A repositioned her on her left side and pulled her all the way to the edge of the bed and left the room. Resident # 1 stated when she realized she was falling she yelled out help- help. Resident # 1 stated there was another bedside table in the room and when she fell her face hit the table and then the floor, stated her leg also hit the table. Resident #1 stated she tried to brace her fall by putting her hand out and fractured her wrist. Resident #1 stated she was still in pain today and the facility were giving her medication to help with the pain. During an interview on 4/18/2024 at 4:00 p.m. the DON, revealed she was advised of the fall the next day on 4/15/2024. The DON stated nursing staff reported Resident # 1 was turned on left side to have a bowel movement and stated she fell out the bed. She stated Resident # 1 liked to be turned on her side when having a bowel movement. The DON stated the staff were able to look at the resident physician order report to see what their care needs are and to see if they are a one person or two persons assist. During an interview on 4/18/2024 at 4:20 p.m. the Admin. revealed she spoke with Resident #1 after the incident and stated Resident #1 stated the staff positioned her differently in the bed and she fell . She stated this was not reported to HHSC because she did not believe that it was intentional. The Admin. stated after she spoke with Resident # 1 that was the extent of her investigation. The Admin. stated she expected staff to position Resident #1 in the center of the bed while on her side and ensure that she was in a safe position before leaving the room. Record review of facility abuse prevention program dated November 2010 which reflected the following: Our residents have the right to be free from abuse and neglect. Our facility is committed to protecting our residents from abuse by anyone included but not necessarily limited to facility staff. Timely and thorough investigation of all reports and allegations of abuse. An (IJ) Immediate Jeopardy was identified on 4/18/2024 at 6:07pm., due to the above failures. The ADM was notified on 4/18/2023. The ADM was provided with the (IJ) Immediate Jeopardy template on 4/18/2023 at 6:07pm, and a Plan of Removal (POR) was requested. The Plan of removal accepted on 4/19/2024 at 1:26 p.m. and indicated the following: Plan of Removal Date Initiated: 4/18/2024 and accepted on 4/19/2024. Residents #1 was assessed by DON and support was provided as accepted. Resident was informed that she would not be left alone during care. Resident was reminded that call light is available if she is concerned about safety. The physician was notified of the deficiencies cited on 4/18/2024. There were no new orders obtained. The affected resident's responsible party was notified by DON of the cited deficiencies and the plan of removal. CNA A was immediately suspended by DON and Administrator on 4/18/2024. CNA A will be terminated due to not following policy and procedures. On 4/18/2024 the DON (director of nursing) and Administrator interviewed all residents in the facility to determine if any other residents needed any assistive devices or had any concerns regarding staff not supervising during care. There were no concerns identified. The interviews were completed before midnight on 4/18/2024. Ad-Hoc (for this situation) QAPI meeting was held on 4/18/2024, with the Medical Director, NHA (Nursing Home Administrator), COO (Chief Operating Officer) and DON to review the cited deficiencies, policy and procedure, and the plan for removal of immediacy. On 4/18/2024 the COO completed 1:1 in-service on Abuse, Neglect and Incident and Accident Reporting with Administrator, DON, and ADON. The in-service also reviewed the importance of providing adequate supervision to residents during care. Starting on 4/18/24, the facility leadership (Administrator, DON, and ADON) will complete education with nursing staff on incidents and accidents and supervision. The leadership team also in serviced on reporting any incidents and accidents immediately to ensure that each resident receives the services consistent with the professional standards of practice. DON/designee reviewed the resident profiles to include the resident care plan. In servicing from DON and/or designee with direct care staff on how to access profiles in the Point of Care system. The in-services were consistent with nursing staff to be able to identify the type of care each resident needs for ADLs. The training was initiated on 4/18/24 and will be completed on 4/18/24. Nursing staff will give a return demonstration on how to pull profiles in the EMR and Point of Care system. All staff to include PRN, new employees and agency staff will receive training prior to working the floor and giving direct care. All staff to include PRN, new employees and agency staff will receive training prior to working the floor and giving direct care. Staff will not be allowed to work until they receive training. The policy pertaining to Incident, Accidents and supervision were reviewed on 4/18/24 by the DON, NHA (Nursing Home Administrator) and Medical Director. Current policy was reviewed with staff to ensure compliance. Starting on 4/18/24, IDT (Interdisciplinary team), including Administrator, DON, ADON, Activity Director, MDS Coordinator, HR, BOM) will meet with all residents daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any residents have any concerns on supervision during care or if any resident had an incident or accident that was not reported. Any concerns identified will be immediately brought to Administrator for further action, if necessary. All incidents and accidents will be documented in the electronic medical record. On 4/18/24 the COO will start reviewing any incidents or accidents to ensure complete investigation/reporting weekly for four (4) weeks followed by monthly reviews after. The DON/designee will monitor compliance by completing an audit of ten (10) residents per week for four (4) weeks. This was initiated on 4/18/24. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The Administrator will be responsible for ensuring this plan is completed on 4/18/24. The COO will provide oversight of DON and Administrators to ensure that the items on the plan of removal are reviewed and completed. Monitoring of POR on 4/19/2024 included the following: During an observation and interview on 4/19/2024 at 11:20 a.m. Resident #1 was in her room. She stated her mother had just left from visiting with her. She stated she still had pain in her back and wrist. She stated her doctor changed her PRN pain medications to every 12 hours. She stated it does not take staff a long time to answer her call light. She stated CNA J is especially fast. She stated she is not complaining, just mad that the Aide walked out and left her on her side without returning. During an interview on 4/19/2024 at 11:45 a.m. LVN C revealed they were in-serviced over the following at the Nursing Station: Abuse Prevention Program, Incident and Accident Reporting If you suspect or witness anything, inform the ADM and DON. She understands the protocol as she has been a nurse for over [AGE] years. You must make sure the safety of the resident is the main thing and you do whatever is necessary to protect them and keep them safe. If she needed further guidance, she would refer to her DON. During an interview on 4/19/2024 at 12:05 p.m. CNA D provided the following information: Abuse Prevention Program, Incident and Accident Reporting She had been a CNA for [AGE] years and she knows every time someone says they fell , she sees them on the floor, or if report they have been neglected, you are supposed to report it immediately to the Nurse, the DON, and the ADM (ANE Coordinator). She said she had never had to report any abuse or neglect other than a fall. She did not learn anything new, it was more of a refresher. During an interview on 4/19/2024 at 12: 25 p.m. CNA F. She provided the following information: Abuse Prevention Program, Incident and Accident Reporting They were told the signs of abuse and neglect, what to look for and who to report it to. They were told how to protect the resident until it is reported, and they are assessed. She did not learn anything new. It was more of a re-education as she had been in this field since 1999. It was the same information that she remembers. She stated she took away that abuse can also be between two residents, and you must remember what may seem minor to you, the resident can be affected negatively. During an interview on 4/19/2024 at 12:40 p.m. CNA E indicated he was in-serviced on the following information: Abuse Prevention Program, Incident and Accident Reporting He stated they gave everyone their own copy of each in-service. He stated they went over who to contact and what to do if it was an actual incident. He stated he knows any form of abuse and neglect needs to be reported. They have the signs of abuse and neglect posted on the wall by the time clocks and at the beginning of the 200 halls. He stated he did not learn anything new; it was more of a re-education. He stated he oversees the CNAs and conduct in-services with them. During an interview on 4/19/2024 at 12:55 p.m. LVN T. indicated she was in-serviced on the following information: Abuse Prevention Program, Incident and Accident Reporting She stated if you see anything, you must report it to the ADM. You must chart it and fill out an event report. If you see any signs of abuse or neglect you should intervene if you witness it. She learned that locking a resident's wheelchair could be a form of abuse if they are mobile and they cannot unlock the wheelchair themselves. During an interview on 4/19/2024 at 1:20 p.m. CNA K. indicated she was in-serviced on the following information: Abuse Prevention Program, Incident and Accident Reporting She stated if there is a sign of abuse or neglect you must contact the ADM. If you cannot get a hold of her in 10-15 minutes, you must contact the DON because they must report within 2 hours. She stated if you see something you must say something. She stated she has been working in facilities for over 5 years and did not learn anything new. She stated it was more of a reminder. During an interview on 4/19/2024 at 1:40 p.m. the DON provided the following information: Ad Hoc QAPI Meeting She stated they discussed the two Tags and discussed the resident of concern with the PCP. She stated they asked if he wanted anything changed to the policy, and he stated there was nothing at this time. She stated they informed him the CNA was suspended, pending termination. Safe Surveys She stated herself, the MDS Coordinator and the ADON completed the Safe Surveys with each resident. She stated there were no concerns regarding abuse or neglect. She stated one female resident mentioned the Aides talk a lot. She stated one male resident said the Aide of Concern is a little gruff in speaking. She stated to eradicate this, the Aide is being terminated. She stated she will be doing more monitoring over the weekends on the halls and asking random residents about their care. Abuse Prevention Program, Incident and Accident Reporting She stated they went over all parts of the policy and the protection of residents. She stated they went over who to report it to and although they tell the nurse, they must still report it to the DON and the ADM themselves. She provided them a list of signs and symptoms and how the resident may react to being abused. She gave them examples of depression to know what to watch for with a resident. She stated it is not always verbal or physical, but it could be mental abuse, misappropriation, etc. During an interview on 4/19/2024 at 2:00 p.m. the Admin. provided the following information: Ad Hoc QAPI Meeting She stated they went over interviewing all residents for supervision related to incidents and accidents. She stated they discussed in-servicing all staff on Abuse and Neglect, Reporting, Incidents and Accidents. She stated staff not present would be called to provide education over the phone. She stated the IDT team reviewed all residents for abuse, and neglect to include supervision. She stated they discussed policy of ANE, Reporting, Incidents and Accidents. She stated no changes have been made and no new policies were created. She stated they reviewed the Plan of Removal with all attendees. She stated the COO in-serviced her, the DON and the ADON. She stated this morning, the Resident of Concern wanted to be left alone during her bowel movement and they had to re-educate her that it was not safe to do so. She stated the Resident was fine with the decision due to her safety. She stated due to taking a lot of pain medications, it causes the Resident to become constipated. She stated laying on her side, helps it to release. Safe Surveys She stated they completed Safe Survey Audits and spoke with every Resident at the facility. She stated only 2 mentioned that they did not care for the Aide Resident # 3 and Resident #4 stated due to the way she talks. She stated they were never harmed; they just did not care for her demeanor. She stated due to their feedback along with the incident with Resident # 1, they are moving forward with termination. She stated she is currently suspended, and her termination has been approved and will occur this afternoon via phone. Record review of in-service dated 4/18/2024 on Resident Rights completed by 38 staff. Record review of in-service dated 4/18/2024 on Positioning and Re-positioning residents in bed completed by 12 CNA and nursing staff. Record review of progress note dated 4/15/2024 regarding assessment of Resident # 1's hand/wrist, right leg and ankle. On 4/19/2023 at 1:29 p.m., the ADM was informed the (IJ) Immediate Jeopardy was removed. While the (IJ) Immediate Jeopardy was removed on 4/19/2024 at 1:29 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm because all staff had not been trained on abuse/neglect, incident/accidents, and reporting.

Based on interview and record review, the facility failed to consult with the resident's physician when the resident had a change in condition and psychosocial needs for 1 of 8 residents (Resident #2) reviewed for behaviors and psychosocial needs. The facility failed to monitor Resident #2 who had a history of [REDACTED]. On [DATE] the resident was found unresponsive with a sandwich in his mouth. He later expired at the hospital. This failure resulted in an identification on [DATE] of an Immediate Jeopardy (IJ) that existed [DATE] to [DATE]. The facility remained out of compliance at a severity level of actual harm with a scope identified as a pattern. This deficient practice placed 33 residents with a psychiatric [DIAGNOSES REDACTED]. Findings include: Review of an undated facility Face Sheet revealed Resident #2 was an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's physician orders [REDACTED]. Review of Resident #2's Plan of Care dated [DATE] revealed the following: Problems Social Services [DATE] Interventions Work with nursing to ensure all psychosocial needs are met. Psychiatric company to evaluate and tx (treat) Review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the following: Section C Cognitive Patterns CO500 Summary Score = 5 on a scale of ,[DATE], (15 being the most cognitive) DO200 Resident Mood Interview Say to resident: Over the last 2 weeks, have you been bothered by any of the following problems? B. Feeling down, depressed, or hopeless Scored Symptom Presence (1) = Yes Scored Symptom Frequency (2) = ,[DATE] days (half or more of the days) Review of LVN C's Nurse's Notes dated [DATE] revealed the following: [DATE] at 2000 (8:00 PM) CNA D stated that when she was relieving down here while the other CNA was taking a break, Resident #2 put half a sandwich in his mouth and attempted to swallow the entire sandwich without chewing it. CNA stated she noticed resident's face very red and that he could not talk, stated she assisted resident in getting the sandwich out of his mouth and that she asked him why he did this, stated he said he was trying to kill himself. This nurse asked resident if he was trying to kill himself resident stated no, 0 acute distress noted. Review of Nurses Notes dated [DATE] did not reflect the physician was notified of the incident. Review of the facility Incident/Accident Reports for [DATE] did not reveal a facility report for Resident #2's [DATE] choking incident. Review of LVN C's Nurse's Notes dated [DATE] at 2100 (9:00 PM) revealed the following: CNA (does not identify which CNA) reported resident has not voiced any wishes about killing himself and no attempts made to kill himself this nurse asked resident if he wants to harm himself he stated no. Review of LVN A's Nurses Notes dated [DATE] at 2140 (9:40 PM) revealed the following: Writer sitting at secure unit desk and Resident #2 pointed to sandwiches - Can I have one of those. Resident #2 was given ,[DATE] sandwich which he began eating - CNA (did not identify) was ,[DATE] ft at unit door when this writer left the unit. Around 2150 (9:50 PM, CNA from secure unit called this writer on East hall to come to secure unit because res. was acting strange and not responsive. Writer went to unit where res. sitting upright in WC (wheelchair) in same area where he was when writer left him. Face red, and mouth open with sandwich in mouth. Writer gave sweep of mouth and retrieved some bread/cheese. Called 911 and assist from house staff, began CPR (Cardiopulmonary Resuscitation) attempted abd (abdominal) thrust. Res. unable to stand at that time, unable to dislodge sandwich. Res. placed on floor and CPR began. Review of the ED (Emergency Department) Physician Documentation revealed the following: Arrival Date: [DATE] Time: 22:24 (10:24 PM) Choked on a sandwich at the nursing home. Found pulseless in his recliner with a sandwich in his mouth. Unknown down time. Differential Diagnosis: [REDACTED]. Disposition: Patient pronounced on [DATE] 22:56 (10:56 AM). Impression: [MEDICAL CONDITION]. During an interview on [DATE] at 9:05 AM, the Director of Nurses (DON) stated that on [DATE], Resident #2 had gone to the nurse's station in his wheelchair to get a snack. She stated, I got called after the 911 call and after they had started CPR, (Cardiopulmonary Resuscitation) because he was a full code. The family was called and the police and EMS came and took him to the hospital. LVN A was walking to the other nurse's station and CNA B paged her that she needed a nurse, that Resident #2 was acting strange and not himself. LVN A came back in did a mouth sweep, [MEDICATION NAME] (maneuver to dislodge food) and called 911. He was pulled to the floor and was given CPR. 911 came. The death report said he had a pulse, he was intubated, so his airway must have been clear. The family wanted to have him a DNR (Do No Resuscitate) and wanted the hospital to stop (trying to revive him). She stated that the cause of death was [MEDICAL CONDITION]. During an interview on [DATE] at 11:50 AM, the Speech Therapist stated the Rehabilitation Manager saw Resident #2 coughing when he was eating on [DATE] and asked her to screen him. She watched Resident #2 eat his breakfast on [DATE] and he knew the appropriate amount of food to put in his mouth. I had not changed his diet order from Regular to Mechanical Soft because I was still in the evaluation process. When asked by the surveyor, Would he have a problem eating a sandwich? She stated, The sandwich is soft texture and he could have eaten it. I was very surprised to learn he had stuffed a whole sandwich in his mouth. I didn't see anything like that. During an interview on [DATE] at 10:00 AM, the DON was informed the surveyor had found nurse's documentation that the resident had a choking incident on [DATE] and that he had stated he was trying to kill himself. The DON stated that when she had taken an interview from CNA D, after the resident had passed away, the CNA stated, You know that he had choked before? The DON stated to CNA D, No, I did not. She stated that she did not ask CNA D any other questions about the choking incident. She stated to the surveyor that the nurse (LVN C) had not reported to her that Resident #2 had previously choked or that he stated he was trying to kill himself. She stated, That is not good, and yes, I would expect the nurse to report this to me or the social worker. I did not investigate it (the [DATE] death incident) because I didn't think it was an incident. I should have investigated it. During an interview on [DATE] at 10:10 AM, the Social Worker stated, No one ever reported to me that Resident #2 wanted to kill himself. I know that he wanted to go home, but his Dementia had increased and he didn't call his wife as much. If they would have reported this to me, I would have had a Counselor come out and put him on a suicide watch. I didn't find out about him choking before ([DATE]), until after he had passed away. I would have expected him to have a speech evaluation after he choked on a sandwich. All the time here, I never thought he was suicidal. I don't really know if his cognition was that good that he knew how to kill himself. During an interview on [DATE] at 12:15 PM, the Attending Physician stated that he had not been notified of the incident on [DATE], nor had he been notified of Resident #2's death on [DATE]. He stated he found out from Resident #2's wife (who also was a patient of his), that Resident #2 died . The wife told him he had died of a [MEDICAL CONDITION]. He stated that when he spoke with the DON about it, she stated that he had been eating a sandwich, choked and went to the ER, and that they had gotten a heart rate back. When the physician was asked, Would you have expected the staff to call you on [DATE] when the resident choked and said, I am trying to kill myself the physician stated, I would think so. During an interview on [DATE] at 12:30 PM, LVN C stated that once CNA D told her that Resident #2 stated he was trying to kill himself she went to his room and asked him, Were you trying to kill yourself? He said, No. I asked him twice and he said no. I asked CNA B, who is back here (on the secure unit) all the time, if Resident #2 had ever told her he was going to try to kill himself and she said, No. The surveyor asked LVN C, Did you believe CNA D? Yes, I did believe her. I put it on the 24 hour shift report and told the night nurse coming on and documented in the chart. I told the Social Worker a couple of days later, she just don't (sic) remember it. I did not tell the DON, but I put it on the 24 hour report. He did not seem depressed and nothing was unusual in his behavior. During an interview on [DATE] at 3:45 PM, the DON gave the surveyor the 24 hour report dated [DATE] that revealed the following: Resident #2 - put half a sandwich in his mouth and attempted to swallow it whole. Stated he was trying to kill himself. When asked by the surveyor, who reads and when is the 24 hour report read, the DON stated that the 24 hour report is read off every morning in the standup meeting. She stated, I always read the 24 hour reports. I didn't see it. During an interview on [DATE] at 12:50 PM, the DON stated she had started in-servicing the nurses to watch residents for choking and coughing while eating. She stated staff was in-serviced on following the facility's policy and calling (physician) to get a psychiatric evaluation on any suicidal residents. We have a new screening tool and have started screening all the residents for suicidal tendencies. During an interview on [DATE] at 2:25 PM, CNA B stated that the nurse was at the nurses station on [DATE] and after she finished her rounds about 9:30 or 9:45 PM she told LVN A she was going to take the dirty barrels out. When I came back in Resident #2 was in his wheelchair at the nurses station with his back to me and when he stood up, I told him to sit down. The nurse was still at the nurse's desk. The nurse was going out to the other nurse's station outside the unit, so I went and washed my hands and noticed his head down and thought he had dozed off. I went over and saw that his lips were blue. I got on the intercom and called STAT for the nurse. LVN A came in and said that she had given him a sandwich and she checked his mouth. We stood him up so she could perform the [MEDICATION NAME] maneuver. Then we put a pillow and blanket on the floor and she did CPR and ,[DATE] nurses came to help and I got out of the way. When asked by the surveyor, Did you ever see him cram food in his mouth? She stated, No, and I did not know of any choking problems. Resident #2 never said anything about harming himself to me, he just wanted to go home. During an interview on [DATE] at 2:30 PM, CNA D stated that on [DATE] she had passed out the evening snacks and Resident #2 stated, Give me a sandwich and a beer. She stated she gave him half of a sandwich and watched him eat it normally, and he asked for another one. After giving him another half sandwich of ham and bread, she went on her rounds while he was sitting up at the nurses' station eating it. She stated, when I looked around, I couldn't see him so I called him and he came out around the nurses station where I could see him. When I noticed his face was red and he could not breathe, I grabbed some gloves and dug the sandwich out of his mouth. It looked like he had broken it up in pieces and then stuffed it in his mouth. When I asked him, Why did you do that? He stated, I was going to try to kill myself because you won't let me go home or give me beer. That was the only time he told me he was going to try to kill himself. I called the nurse and LVN C went into his room. He told her he didn't say that and he wasn't going to do that. When the CNA was asked if she had told the DON about the incident, she stated, No, I figured LVN C would do that. During an interview on [DATE] at 3:55 PM, LVN A stated that Resident #2 had always eaten his snacks without incident. She stated that she had learned, after the fact, that he had choked. She stated, I wished I would have known it happened. He had come to the nurse's desk and wanted a snack and I gave him half of a cheese and meat sandwich. He had his back turned to me, but I could still see him. I heard the CNA tell Resident #2 twice to sit down. I walked to the other nurse's station and had just reached it and she called me to come straight back. When I got there his mouth was open and I could see parts of the sandwich in it. I swept his mouth, patted him, but he was non-responsive and his face was dark. 911 was called and I called STAT and the nurses helped me lay him down to start CPR. He was not left alone, it happened so fast. During an interview on [DATE] at 4:15 PM, the Administrator stated she had not heard about the [DATE] incident of Resident #2 choking and trying to kill himself, and would have expected the DON to tell her, because this was a nursing issue. She stated, It's not like we don't take these things seriously. During a telephone interview on [DATE] at 3:15 PM, the DON stated she was faxing over the sign-in sheets for the in-services she had performed on Suicide Threats, Signs and Symptoms of Depression, Interventions, and all changes in behavior are to be put on the 24 hour report. She stated, I figured out why I didn't see the 24 hour report on [DATE]. I was sick that day. When asked by the surveyor, if you are sick shouldn't someone else read it? She stated, My Assistant Director of Nurses (ADON) was new, so no one read it. Review of a current facility policy dated Revised [DATE] titled, Suicide Threats revealed the following elements: Policy Statement Resident suicide threats shall be taken seriously and addressed appropriately. Policy Interpretation and Implementation 2. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. Review of a current facility policy dated ,[DATE] titled, Abuse revealed the following elements: Policy: 1. The resident has the right to be free from abuse: verbal, mental, physical, or sexual. Procedure: 1. The facility will upon admission and periodically, inform the resident of the definitions of: e. Mental/Psychological abuse is mistreatment that causes or could cause mental injury or harm without physical harm. 2. The facility will, upon admission and periodically, inform the resident of their right be free from abuse/corporal punishment/involuntary seclusion. e. The resident or the resident's representative was involved in the care plan of behaviors or medical condition to the highest practicable extent. f. The facility monitors and modifies the resident's care in an attempt to utilize the least restricted means to manage care. The facility Administrator, DON, and Regional Director of Operations (RDO) were notified on [DATE] at 1:26 PM that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on [DATE] at 3:06 PM. The final Plan of Removal was accepted by the surveyor/investigator on [DATE] at 3:31 PM. The plan of removal included the following: 1. An audit will be completed on [DATE] on every resident in the facility to determine if they have a thought or plan to hurt themselves. Administrator will review the audit to make sure every resident has been assessed. If there is any resident identified, the resident will be immediately assessed by the nurse, the physician will be contacted for further intervention, and the resident will be put on one on one until resident is deemed safe by the physician or sent out to another facility for treatment. DON will verify that these procedures have been followed. 2. All staff will be inserviced on policy and procedures when a resident states that they want to hurt themselves on [DATE]. Staff who are not currently working will be inservice before they take an assignment on the floor but no later than [DATE] at 5 PM. Nursing staff was inserviced on [DATE] to put any changes in behaviors on the 24 hour report for DON/designee. review. 3. DON/designee will review 24 hour report for any change in behaviors daily and PRN. DON/designee will verify that the physician has been notified, family notified, and appropriate intervention is in place. Social Services will review all residents again in 1 month for any [MEDICAL CONDITION] then quarterly thereafter. Administrator will check the Social Services reviews for the following month then prn. These audits will be brought to QA monthly continuously fore the Medical Director and Administrator to review for input or further interventions. The surveyor monitored the current plan of removal as follows: An in-service for the all staff members was conducted on [DATE] concerning signs and symptoms of depression and the facility's policy on Suicide Threats. During an interview on [DATE] at 12:30 PM, LVN C stated she had been in-serviced to contact the DON if there were any reports of resident threats of suicide. During an interview on [DATE] at 2:25 PM and 2:30 PM, CNA's B and D stated they had been in-serviced to not only contact the Charge Nurse, but to tell the DON if they heard any resident wanting to commit suicide. During an interview on [DATE] at 3:43 PM, the RDO stated that during the suicidal tendency interviews/screening with the residents, one resident had triggered for [MEDICAL CONDITION] and that she had a 1 on 1 staff member with her. Two residents had a history of [REDACTED]. She stated that a psychiatrist was on the way and would visit with all three. Review of the facility suicidal tendency interviews/screening dated [DATE] revealed 2 residents with a history of [MEDICAL CONDITION], and one (1) resident currently voicing [MEDICAL CONDITION]. On [DATE] at 4:15 PM, the Administrator, DON, ADON, MDS Coordinator, Social Worker, and RDO were informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as a pattern due to the facility administration and staff requiring time to and monitor their Plan of Removal. Review of the facility completed CMS 672 form identified 33 residents with a psychiatric diagnosis.

Based on observation, interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #2) reviewed for behaviors and psychosocial needs. The facility failed to monitor Resident #2 who had a history of [REDACTED]. On [DATE] the resident was found unresponsive with a sandwich in his mouth. He later expired at the hospital. This failure resulted in an identification on [DATE] of an Immediate Jeopardy (IJ) that existed [DATE] to [DATE]. The facility remained out of compliance at a severity level of actual harm with a scope identified as a pattern. This deficient practice placed 33 residents with a psychiatric [DIAGNOSES REDACTED]. Findings include: Review of an undated facility Face Sheet revealed Resident #2 was an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's physician orders [REDACTED]. Review of Resident #2's Plan of Care dated [DATE] revealed the following: Problems Social Services [DATE] Interventions Work with nursing to ensure all psychosocial needs are met. Psychiatric company to evaluate and tx (treat) Review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the following: Section C Cognitive Patterns CO500 Summary Score = 5 on a scale of ,[DATE], (15 being the most cognitive) DO200 Resident Mood Interview Say to resident: Over the last 2 weeks, have you been bothered by any of the following problems? B. Feeling down, depressed, or hopeless Scored Symptom Presence (1) = Yes Scored Symptom Frequency (2) = ,[DATE] days (half or more of the days) Review of LVN C's Nurse's Notes dated [DATE] revealed the following: [DATE] at 2000 (8:00 PM) CNA D stated that when she was relieving down here while the other CNA was taking a break, Resident #2 put half a sandwich in his mouth and attempted to swallow the entire sandwich without chewing it. CNA stated she noticed resident's face very red and that he could not talk, stated she assisted resident in getting the sandwich out of his mouth and that she asked him why he did this, stated he said he was trying to kill himself. This nurse asked resident if he was trying to kill himself resident stated no, 0 acute distress noted. Review of Nurses Notes dated [DATE] did not reflect the physician was notified of the incident. Review of the facility Incident/Accident Reports for [DATE] did not reveal a facility report for Resident #2's [DATE] choking incident. Review of LVN C's Nurse's Notes dated [DATE] at 2100 (9:00 PM) revealed the following: CNA (does not identify which CNA) reported resident has not voiced any wishes about killing himself and no attempts made to kill himself this nurse asked resident if he wants to harm himself he stated no. Review of LVN A's Nurses Notes dated [DATE] at 2140 (9:40 PM) revealed the following: Writer sitting at secure unit desk and Resident #2 pointed to sandwiches - Can I have one of those. Resident #2 was given ,[DATE] sandwich which he began eating - CNA (did not identify) was ,[DATE] ft at unit door when this writer left the unit. Around 2150 (9:50 PM, CNA from secure unit called this writer on East hall to come to secure unit because res. was acting strange and not responsive. Writer went to unit where res. sitting upright in WC (wheelchair) in same area where he was when writer left him. Face red, and mouth open with sandwich in mouth. Writer gave sweep of mouth and retrieved some bread/cheese. Called 911 and assist from house staff, began CPR (Cardiopulmonary Resuscitation) attempted abd (abdominal) thrust. Res. unable to stand at that time, unable to dislodge sandwich. Res. placed on floor and CPR began. Review of the ED (Emergency Department) Physician Documentation revealed the following: Arrival Date: [DATE] Time: 22:24 (10:24 PM) Choked on a sandwich at the nursing home. Found pulseless in his recliner with a sandwich in his mouth. Unknown down time. Differential Diagnosis: [REDACTED]. Disposition: Patient pronounced on [DATE] 22:56 (10:56 AM). Impression: [MEDICAL CONDITION]. During an interview on [DATE] at 9:05 AM, the Director of Nurses (DON) stated that on [DATE], Resident #2 had gone to the nurse's station in his wheelchair to get a snack. She stated, I got called after the 911 call and after they had started CPR, (Cardiopulmonary Resuscitation) because he was a full code. The family was called and the police and EMS came and took him to the hospital. LVN A was walking to the other nurse's station and CNA B paged her that she needed a nurse, that Resident #2 was acting strange and not himself. LVN A came back in did a mouth sweep, [MEDICATION NAME] (maneuver to dislodge food) and called 911. He was pulled to the floor and was given CPR. 911 came. The death report said he had a pulse, he was intubated, so his airway must have been clear. The family wanted to have him a DNR (Do No Resuscitate) and wanted the hospital to stop (trying to revive him). She stated that the cause of death was [MEDICAL CONDITION]. During an interview on [DATE] at 11:50 AM, the Speech Therapist stated the Rehabilitation Manager saw Resident #2 coughing when he was eatingon [DATE] and asked her to screen him. She watched Resident #2 eat his breakfast on [DATE] and he knew the appropriate amount of food to put in his mouth. I had not changed his diet order from Regular to Mechanical Soft because I was still in the evaluation process. When asked by the surveyor, Would he have a problem eating a sandwich? She stated, The sandwich is soft texture and he could have eaten it. I was very surprised to learn he had stuffed a whole sandwich in his mouth. I didn't see anything like that. During an interview on [DATE] at 10:00 AM, the DON was informed the surveyor had found nurse's documentation that the resident had a choking incident on [DATE] and that he had stated he was trying to kill himself. The DON stated that when she had taken an interview from CNA D, after the resident had passed away, the CNA stated, You know that he had choked before? The DON stated to CNA D, No, I did not. She stated that she did not ask CNA D any other questions about the choking incident. The DON stated to the surveyor that the nurse (LVN C) had not reported to her that Resident #2 had previously choked or that he stated he was trying to kill himself. She stated, That is not good, and yes, I would expect the nurse to report this to me or the social worker. I did not investigate it (the [DATE] death incident) because I didn't think it was an incident. I should have investigated it. During an interview on [DATE] at 10:10 AM, the Social Worker stated, No one ever reported to me that Resident #2 wanted to kill himself. I know that he wanted to go home, but his Dementia had increased and he didn't call his wife as much. If they would have reported this to me, I would have had a Counselor come out and put him on a suicide watch. I didn't find out about him choking before ([DATE]), until after he had passed away. I would have expected him to have a speech evaluation after he choked on a sandwich. All the time here, I never thought he was suicidal. I don't really know if his cognition was that good that he knew how to kill himself. During an interview on [DATE] at 12:15 PM, the Attending Physician stated that he had not been notified of the incident on [DATE], nor had he been notified of Resident #2's death on [DATE]. He stated he found out from Resident #2's wife (who also was a patient of his), that Resident #2 died . The wife told him he had died of a [MEDICAL CONDITION]. He stated that when he spoke with the DON about it, she stated that he had been eating a sandwich, choked and went to the ER, and that they had gotten a heart rate back. When the physician was asked, Would you have expected the staff to call you on [DATE] when the resident choked and said, I am trying to kill myself the physician stated, I would think so. During an interview on [DATE] at 12:30 PM, LVN C stated that once CNA D told her that Resident #2 stated he was trying to kill himself she went to his room and asked him, Were you trying to kill yourself? He said, No. I asked him twice and he said no. I asked CNA B, who is back here (on the secure unit) all the time, if Resident #2 had ever told her he was going to try to kill himself and she said, No. The surveyor asked LVN C, Did you believe CNA D? Yes, I did believe her. I put it on the 24 hour shift report and told the night nurse coming on and documented in the chart. I told the Social Worker a couple of days later, she just don't (sic) remember it. I did not tell the DON, but I put it on the 24 hour report. He did not seem depressed and nothing was unusual in his behavior. During an interview on [DATE] at 3:45 PM, the DON gave the surveyor the 24 hour report dated [DATE] that revealed the following: Resident #2 - put half a sandwich in his mouth and attempted to swallow it whole. Stated he was trying to kill himself. When asked by the surveyor, who reads and when is the 24 hour report read, the DON stated that the 24 hour report is read off every morning in the standup meeting. She stated, I always read the 24 hour reports. I didn't see it. During an interview on [DATE] at 12:50 PM, the DON stated she had started in-servicing the nurses to watch residents for choking and coughing while eating. She stated staff was in-serviced on following the facility's policy and calling (physician) to get a psychiatric evaluation on any suicidal residents. We have a new screening tool and have started screening all the residents for suicidal tendencies. During an interview on [DATE] at 2:25 PM, CNA B stated that the nurse was at the nurses station on [DATE] and after she finished her rounds about 9:30 or 9:45 PM she told LVN A she was going to take the dirty barrels out. When I came back in Resident #2 was in his wheelchair at the nurses station with his back to me and when he stood up, I told him to sit down. The nurse was still at the nurse's desk. The nurse was going out to the other nurse's station outside the unit, so I went and washed my hands and noticed his head down and thought he had dozed off. I went over and saw that his lips were blue. I got on the intercom and called STAT for the nurse. LVN A came in and said that she had given him a sandwich and she checked his mouth. We stood him up so she could perform the [MEDICATION NAME] maneuver. Then we put a pillow and blanket on the floor and she did CPR and ,[DATE] nurses came to help and I got out of the way. When asked by the surveyor, Did you ever see him cram food in his mouth? She stated, No, and I did not know of any choking problems. Resident #2 never said anything about harming himself to me, he just wanted to go home. During an interview on [DATE] at 2:30 PM, CNA D stated that on [DATE] she had passed out the evening snacks and Resident #2 stated, Give me a sandwich and a beer. She stated she gave him half of a sandwich and watched him eat it normally, and he asked for another one. After giving him another half sandwich of ham and bread, she went on her rounds while he was sitting up at the nurses' station eating it. She stated, when I looked around, I couldn't see him so I called him and he came out around the nurses station where I could see him. When I noticed his face was red and he could not breathe, I grabbed some gloves and dug the sandwich out of his mouth. It looked like he had broken it up in pieces and then stuffed it in his mouth. When I asked him, Why did you do that? He stated, I was going to try to kill myself because you won't let me go home or give me beer. That was the only time he told me he was going to try to kill himself. I called the nurse and LVN C went into his room. He told her he didn't say that and he wasn't going to do that. When the CNA was asked if she had told the DON about the incident, she stated, No, I figured LVN C would do that. During an interview on [DATE] at 3:55 PM, LVN A stated that Resident #2 had always eaten his snacks without incident. She stated that she had learned, after the fact, that he had choked. She stated, I wished I would have known it happened. He had come to the nurse's desk and wanted a snack and I gave him half of a cheese and meat sandwich. He had his back turned to me, but I could still see him. I heard the CNA tell Resident #2 twice to sit down. I walked to the other nurse's station and had just reached it and she called me to come straight back. When I got there his mouth was open and I could see parts of the sandwich in it. I swept his mouth, patted him, but he was non-responsive and his face was dark. 911 was called and I called STAT and the nurses helped me lay him down to start CPR. He was not left alone, it happened so fast. During an interview on [DATE] at 4:15 PM, the Administrator stated she had not heard about the [DATE] incident of Resident #2 choking and trying to kill himself, and would have expected the DON to tell her, because this was a nursing issue. She stated, It's not like we don't take these things seriously. During a telephone interview on [DATE] at 3:15 PM, the DON stated she was faxing over the sign-in sheets for the in-services she had performed on Suicide Threats, Signs and Symptoms of Depression, Interventions, and all changes in behavior are to be put on the 24 hour report. She stated, I figured out why I didn't see the 24 hour report on [DATE]. I was sick that day. When asked by the surveyor, if you are sick shouldn't someone else read it? She stated, My Assistant Director of Nurses (ADON) was new, so no one read it. Review of a current facility policy dated Revised [DATE] titled, Suicide Threats revealed the following elements: Policy Statement Resident suicide threats shall be taken seriously and addressed appropriately. Policy Interpretation and Implementation 2. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. The facility Administrator, DON, and Regional Director of Operations (RDO) were notified on [DATE] at 1:26 PM that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on [DATE] at 3:06 PM. The final Plan of Removal was accepted by the surveyor/investigator on [DATE] at 3:31 PM. The plan of removal included the following: 1. An audit will be completed on [DATE] on every resident in the facility to determine if they have a thought or plan to hurt themselves. Administrator will review the audit to make sure every resident has been assessed. If there is any resident identified, the resident will be immediately assessed by the nurse, the physician will be contacted for further intervention, and the resident will be put on one on one until resident is deemed safe by the physician or sent out to another facility for treatment. DON will verify that these procedures have been followed. 2. All staff will be inserviced on policy and procedures when a resident states that they want to hurt themselves on [DATE]. Staff who are not currently working will be inservice before they take an assignment on the floor but no later than [DATE] at 5 PM. Nursing staff was inserviced on [DATE] to put any changes in behaviors on the 24 hour report for DON/designee. review. 3. DON/designee will review 24 hour report for any change in behaviors daily and PRN. DON/designee will verify that the physician has been notified, family notified, and appropriate intervention is in place. Social Services will review all residents again in 1 month for any [MEDICAL CONDITION] then quarterly thereafter. Administrator will check the Social Services reviews for the following month then prn. These audits will be brought to QA monthly continuously fore the Medical Director and Administrator to review for input or further interventions. The surveyor monitored the current plan of removal as follows: An in-service for the all staff members was conducted on [DATE] concerning signs and symptoms of depression and the facility's policy on Suicide Threats. During an interview on [DATE] at 12:30 PM, LVN C stated she had been in-serviced to contact the DON if there were any reports of resident threats of suicide. During an interview on [DATE] at 2:25 PM and 2:30 PM, CNA's B and D stated they had been in-serviced to not only contact the Charge Nurse, but to tell the DON if they heard any resident wanting to commit suicide. During an interview on [DATE] at 3:43 PM, the RDO stated that during the suicidal tendency interviews/screening with the residents, one resident had triggered for [MEDICAL CONDITION] and that she had a 1 on 1 staff member with her. Two residents had a history of [REDACTED]. She stated that a psychiatrist was on the way and would visit with all three. Review of the facility suicidal tendency interviews/screening dated [DATE] revealed 2 residents with a history of [MEDICAL CONDITION], and one (1) resident currently voicing [MEDICAL CONDITION]. On [DATE] at 4:15 PM, the Administrator, DON, ADON, MDS Coordinator, Social Worker, and RDO were informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as a pattern due to the facility administration and staff requiring time to and monitor their Plan of Removal. Review of the facility completed CMS 672 form identified 33 residents with a psychiatric diagnosis.

Based on interview and record review, the facility failed to implement policies and procedures to prohibit neglect for 1 of 8 residents (Resident #2) reviewed for behaviors and psychosocial needs. The facility failed to monitor Resident #2 who had a history of [REDACTED]. On [DATE] the resident was found unresponsive with a sandwich in his mouth. He later expired at the hospital. This failure resulted in an identification on [DATE] of an Immediate Jeopardy (IJ) that existed [DATE] to [DATE]. The facility remained out of compliance at a severity level of actual harm with a scope identified as a pattern. This deficient practice placed 33 residents with a psychiatric [DIAGNOSES REDACTED]. Findings include: Review of an undated facility Face Sheet revealed Resident #2 was an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's physician orders [REDACTED]. Review of Resident #2's Plan of Care dated [DATE] revealed the following: Problems Social Services [DATE] Interventions Work with nursing to ensure all psychosocial needs are met. Psychiatric company to evaluate and tx (treat) Review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the following: Section C Cognitive Patterns CO500 Summary Score = 5 on a scale of ,[DATE], (15 being the most cognitive) DO200 Resident Mood Interview Say to resident: Over the last 2 weeks, have you been bothered by any of the following problems? B. Feeling down, depressed, or hopeless Scored Symptom Presence (1) = Yes Scored Symptom Frequency (2) = ,[DATE] days (half or more of the days) Review of LVN C's Nurse's Notes dated [DATE] revealed the following: [DATE] at 2000 (8:00 PM) CNA D stated that when she was relieving down here while the other CNA was taking a break, Resident #2 put half a sandwich in his mouth and attempted to swallow the entire sandwich without chewing it. CNA stated she noticed resident's face very red and that he could not talk, stated she assisted resident in getting the sandwich out of his mouth and that she asked him why he did this, stated he said he was trying to kill himself. This nurse asked resident if he was trying to kill himself resident stated no, 0 acute distress noted. Review of Nurses Notes dated [DATE] did not reflect the physician was notified of the incident. Review of the facility Incident/Accident Reports for [DATE] did not reveal a facility report for Resident #2's [DATE] choking incident. Review of LVN C's Nurse's Notes dated [DATE] at 2100 (9:00 PM) revealed the following: CNA (does not identify which CNA) reported resident has not voiced any wishes about killing himself and no attempts made to kill himself this nurse asked resident if he wants to harm himself he stated no. Review of LVN A's Nurses Notes dated [DATE] at 2140 (9:40 PM) revealed the following: Writer sitting at secure unit desk and Resident #2 pointed to sandwiches - Can I have one of those. Resident #2 was given ,[DATE] sandwich which he began eating - CNA (did not identify) was ,[DATE] ft at unit door when this writer left the unit. Around 2150 (9:50 PM, CNA from secure unit called this writer on East hall to come to secure unit because res. was acting strange and not responsive. Writer went to unit where res. sitting upright in WC (wheelchair) in same area where he was when writer left him. Face red, and mouth open with sandwich in mouth. Writer gave sweep of mouth and retrieved some bread/cheese. Called 911 and assist from house staff, began CPR (Cardiopulmonary Resuscitation) attempted abd (abdominal) thrust. Res. unable to stand at that time, unable to dislodge sandwich. Res. placed on floor and CPR began. Review of the ED (Emergency Department) Physician Documentation revealed the following: Arrival Date: [DATE] Time: 22:24 (10:24 PM) Choked on a sandwich at the nursing home. Found pulseless in his recliner with a sandwich in his mouth. Unknown down time. Differential Diagnosis: [REDACTED]. Disposition: Patient pronounced on [DATE] 22:56 (10:56 AM). Impression: [MEDICAL CONDITION]. During an interview on [DATE] at 9:05 AM, the Director of Nurses (DON) stated that on [DATE], Resident #2 had gone to the nurse's station in his wheelchair to get a snack. She stated, I got called after the 911 call and after they had started CPR, because he was a full code. The family was called and the police and EMS came and took him to the hospital. LVN A was walking to the other nurse's station and CNA B paged her that she needed a nurse, that Resident #2 was acting strange and not himself. LVN A came back in did a mouth sweep, [MEDICATION NAME] (maneuver to dislodge food) and called 911. He was pulled to the floor and was given CPR. 911 came. The death report said he had a pulse, he was intubated, so his airway must have been clear. The family wanted to have him a DNR (Do No Resuscitate) and wanted the hospital to stop (trying to revive him). She stated that the cause of death was [MEDICAL CONDITION]. During an interview on [DATE] at 11:50 AM, the Speech Therapist stated the Rehabilitation Manager saw Resident #2 coughing when he was eating on [DATE] and asked her to screen him. She watched Resident #2 eat his breakfast on [DATE] and he knew the appropriate amount of food to put in his mouth. I had not changed his diet order from Regular to Mechanical Soft because I was still in the evaluation process. When asked by the surveyor, Would he have a problem eating a sandwich? She stated, The sandwich is soft texture and he could have eaten it. I was very surprised to learn he had stuffed a whole sandwich in his mouth. I didn't see anything like that. During an interview on [DATE] at 10:00 AM, the DON was informed the surveyor had found nurse's documentation that the resident had a choking incident on [DATE] and that he had stated he was trying to kill himself. The DON stated that when she had taken an interview from CNA D, after the resident had passed away, the CNA stated, You know that he had choked before? The DON stated to CNA D, No, I did not. She stated that she did not ask CNA D any other questions about the choking incident. She stated to the surveyor that the nurse (LVN C) had not reported to her that Resident #2 had previously choked or that he stated he was trying to kill himself. She stated, That is not good, and yes, I would expect the nurse to report this to me or the social worker. I did not investigate it (the [DATE] death incident) because I didn't think it was an incident. I should have investigated it. During an interview on [DATE] at 10:10 AM, the Social Worker stated, No one ever reported to me that Resident #2 wanted to kill himself. I know that he wanted to go home, but his Dementia had increased and he didn't call his wife as much. If they would have reported this to me, I would have had a Counselor come out and put him on a suicide watch. I didn't find out about him choking before ([DATE]), until after he had passed away. I would have expected him to have a speech evaluation after he choked on a sandwich. All the time here, I never thought he was suicidal. I don't really know if his cognition was that good that he knew how to kill himself. During an interview on [DATE] at 12:15 PM, the Attending Physician stated that he had not been notified of the incident on [DATE], nor had he been notified of Resident #2's death on [DATE]. He stated he found out from Resident #2's wife (who also was a patient of his), that Resident #2 died . The wife told him he had died of a [MEDICAL CONDITION]. He stated that when he spoke with the DON about it, she stated that he had been eating a sandwich, choked and went to the ER, and that they had gotten a heart rate back. When the physician was asked, Would you have expected the staff to call you on [DATE] when the resident choked and said, I am trying to kill myself the physician stated, I would think so. During an interview on [DATE] at 12:30 PM, LVN C stated that once CNA D told her that Resident #2 stated he was trying to kill himself she went to his room and asked him, Were you trying to kill yourself? He said, No. I asked him twice and he said no. I asked CNA B, who is back here (on the secure unit) all the time, if Resident #2 had ever told her he was going to try to kill himself and she said, No. The surveyor asked LVN C, Did you believe CNA D? Yes, I did believe her. I put it on the 24 hour shift report and told the night nurse coming on and documented in the chart. I told the Social Worker a couple of days later, she just don't (sic) remember it. I did not tell the DON, but I put it on the 24 hour report. He did not seem depressed and nothing was unusual in his behavior. During an interview on [DATE] at 3:45 PM, the DON gave the surveyor the 24 hour report dated [DATE] that revealed the following: Resident #2 - put half a sandwich in his mouth and attempted to swallow it whole. Stated he was trying to kill himself. When asked by the surveyor, who reads and when is the 24 hour report read, the DON stated that the 24 hour report is read off every morning in the standup meeting. She stated, I always read the 24 hour reports. I didn't see it. During an interview on [DATE] at 12:50 PM, the DON stated she had started in-servicing the nurses to watch residents for choking and coughing while eating. She stated staff was in-serviced on following the facility's policy and calling (physician) to get a psychiatric evaluation on any suicidal residents. We have a new screening tool and have started screening all the residents for suicidal tendencies. During an interview on [DATE] at 2:25 PM, CNA B stated that the nurse was at the nurses station on [DATE] and after she finished her rounds about 9:30 or 9:45 PM she told LVN A she was going to take the dirty barrels out. When I came back in Resident #2 was in his wheelchair at the nurses station with his back to me and when he stood up, I told him to sit down. The nurse was still at the nurse's desk. The nurse was going out to the other nurse's station outside the unit, so I went and washed my hands and noticed his head down and thought he had dozed off. I went over and saw that his lips were blue. I got on the intercom and called STAT for the nurse. LVN A came in and said that she had given him a sandwich and she checked his mouth. We stood him up so she could perform the [MEDICATION NAME] maneuver. Then we put a pillow and blanket on the floor and she did CPR and ,[DATE] nurses came to help and I got out of the way. When asked by the surveyor, Did you ever see him cram food in his mouth? She stated, No, and I did not know of any choking problems. Resident #2 never said anything about harming himself to me, he just wanted to go home. During an interview on [DATE] at 2:30 PM, CNA D stated that on [DATE] she had passed out the evening snacks and Resident #2 stated, Give me a sandwich and a beer. She stated she gave him half of a sandwich and watched him eat it normally, and he asked for another one. After giving him another half sandwich of ham and bread, she went on her rounds while he was sitting up at the nurses' station eating it. She stated, when I looked around, I couldn't see him so I called him and he came out around the nurses station where I could see him. When I noticed his face was red and he could not breathe, I grabbed some gloves and dug the sandwich out of his mouth. It looked like he had broken it up in pieces and then stuffed it in his mouth. When I asked him, Why did you do that? He stated, I was going to try to kill myself because you won't let me go home or give me beer. That was the only time he told me he was going to try to kill himself. I called the nurse and LVN C went into his room. He told her he didn't say that and he wasn't going to do that. When the CNA was asked if she had told the DON about the incident, she stated, No, I figured LVN C would do that. During an interview on [DATE] at 3:55 PM, LVN A stated that Resident #2 had always eaten his snacks without incident. She stated that she had learned, after the fact, that he had choked. She stated, I wished I would have known it happened. He had come to the nurse's desk and wanted a snack and I gave him half of a cheese and meat sandwich. He had his back turned to me, but I could still see him. I heard the CNA tell Resident #2 twice to sit down. I walked to the other nurse's station and had just reached it and she called me to come straight back. When I got there his mouth was open and I could see parts of the sandwich in it. I swept his mouth, patted him, but he was non-responsive and his face was dark. 911 was called and I called STAT and the nurses helped me lay him down to start CPR. He was not left alone, it happened so fast. During an interview on [DATE] at 4:15 PM, the Administrator stated she had not heard about the [DATE] incident of Resident #2 choking and trying to kill himself, and would have expected the DON to tell her, because this was a nursing issue. She stated, It's not like we don't take these things seriously. During a telephone interview on [DATE] at 3:15 PM, the DON stated she was faxing over the sign-in sheets for the in-services she had performed on Suicide Threats, Signs and Symptoms of Depression, Interventions, and all changes in behavior are to be put on the 24 hour report. She stated, I figured out why I didn't see the 24 hour report on [DATE]. I was sick that day. When asked by the surveyor, if you are sick shouldn't someone else read it? She stated, My Assistant Director of Nurses (ADON) was new, so no one read it. Review of a current facility policy dated Revised [DATE] titled, Suicide Threats revealed the following elements: Policy Statement Resident suicide threats shall be taken seriously and addressed appropriately. Policy Interpretation and Implementation 2. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. Review of a current facility policy dated ,[DATE] titled, Abuse revealed the following elements: Policy: 1. The resident has the right to be free from abuse: verbal, mental, physical, or sexual. Procedure: 1. The facility will upon admission and periodically, inform the resident of the definitions of: e. Mental/Psychological abuse is mistreatment that causes or could cause mental injury or harm without physical harm. 2. The facility will, upon admission and periodically, inform the resident of their right be free from abuse/corporal punishment/involuntary seclusion. e. The resident or the resident's representative was involved in the care plan of behaviors or medical condition to the highest practicable extent. f. The facility monitors and modifies the resident's care in an attempt to utilize the least restricted means to manage care. The facility Administrator, DON, and Regional Director of Operations (RDO) were notified on [DATE] at 1:26 PM that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on [DATE] at 3:06 PM. The final Plan of Removal was accepted by the surveyor/investigator on [DATE] at 3:31 PM. The plan of removal included the following: 1. An audit will be completed on [DATE] on every resident in the facility to determine if they have a thought or plan to hurt themselves. Administrator will review the audit to make sure every resident has been assessed. If there is any resident identified, the resident will be immediately assessed by the nurse, the physician will be contacted for further intervention, and the resident will be put on one on one until resident is deemed safe by the physician or sent out to another facility for treatment. DON will verify that these procedures have been followed. 2. All staff will be inserviced on policy and procedures when a resident states that they want to hurt themselves on [DATE]. Staff who are not currently working will be inservice before they take an assignment on the floor but no later than [DATE] at 5 PM. Nursing staff was inserviced on [DATE] to put any changes in behaviors on the 24 hour report for DON/designee. review. 3. DON/designee will review 24 hour report for any change in behaviors daily and PRN. DON/designee will verify that the physician has been notified, family notified, and appropriate intervention is in place. Social Services will review all residents again in 1 month for any [MEDICAL CONDITION] then quarterly thereafter. Administrator will check the Social Services reviews for the following month then prn. These audits will be brought to QA monthly continuously fore the Medical Director and Administrator to review for input or further interventions. The surveyor monitored the current plan of removal as follows: An in-service for the all staff members was conducted on [DATE] concerning signs and symptoms of depression and the facility's policy on Suicide Threats. During an interview on [DATE] at 12:30 PM, LVN C stated she had been in-serviced to contact the DON if there were any reports of resident threats of suicide. During an interview on [DATE] at 2:25 PM and 2:30 PM, CNA's B and D stated they had been in-serviced to not only contact the Charge Nurse, but to tell the DON if they heard any resident wanting to commit suicide. During an interview on [DATE] at 3:43 PM, the RDO stated that during the suicidal tendency interviews/screening with the residents, one resident had triggered for [MEDICAL CONDITION] and that she had a 1 on 1 staff member with her. Two residents had a history of [REDACTED]. She stated that a psychiatrist was on the way and would visit with all three. Review of the facility suicidal tendency interviews/screening dated [DATE] revealed 2 residents with a history of [MEDICAL CONDITION], and one (1) resident currently voicing [MEDICAL CONDITION]. On [DATE] at 4:15 PM, the Administrator, DON, ADON, MDS Coordinator, Social Worker, and RDO were informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as a pattern due to the facility administration and staff requiring time to and monitor their Plan of Removal. Review of the facility completed CMS 672 form identified 33 residents with a psychiatric diagnosis.

Based on interview and record review, the facility failed to implement policies and procedures to prohibit neglect for 1 of 8 residents (Resident #2) reviewed for behaviors and psychosocial needs. The facility failed to monitor Resident #2 who had a history of [REDACTED]. On [DATE] the resident was found unresponsive with a sandwich in his mouth. He later expired at the hospital. This failure resulted in an identification on [DATE] of an Immediate Jeopardy (IJ) that existed [DATE] to [DATE]. The facility remained out of compliance at a severity level of actual harm with a scope identified as a pattern. This deficient practice placed 33 residents with a psychiatric [DIAGNOSES REDACTED]. Findings include: Review of an undated facility Face Sheet revealed Resident #2 was an [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's physician orders [REDACTED]. Review of Resident #2's Plan of Care dated [DATE] revealed the following: Problems Social Services [DATE] Interventions Work with nursing to ensure all psychosocial needs are met. Psychiatric company to evaluate and tx (treat) Review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the following: Section C Cognitive Patterns CO500 Summary Score = 5 on a scale of ,[DATE], (15 being the most cognitive) DO200 Resident Mood Interview Say to resident: Over the last 2 weeks, have you been bothered by any of the following problems? B. Feeling down, depressed, or hopeless Scored Symptom Presence (1) = Yes Scored Symptom Frequency (2) = ,[DATE] days (half or more of the days) Review of LVN C's Nurse's Notes dated [DATE] revealed the following: [DATE] at 2000 (8:00 PM) CNA D stated that when she was relieving down here while the other CNA was taking a break, Resident #2 put half a sandwich in his mouth and attempted to swallow the entire sandwich without chewing it. CNA stated she noticed resident's face very red and that he could not talk, stated she assisted resident in getting the sandwich out of his mouth and that she asked him why he did this, stated he said he was trying to kill himself. This nurse asked resident if he was trying to kill himself resident stated no, 0 acute distress noted. Review of Nurses Notes dated [DATE] did not reflect the physician was notified of the incident. Review of the facility Incident/Accident Reports for [DATE] did not reveal a facility report for Resident #2's [DATE] choking incident. Review of LVN C's Nurse's Notes dated [DATE] at 2100 (9:00 PM) revealed the following: CNA (does not identify which CNA) reported resident has not voiced any wishes about killing himself and no attempts made to kill himself this nurse asked resident if he wants to harm himself he stated no. Review of LVN A's Nurses Notes dated [DATE] at 2140 (9:40 PM) revealed the following: Writer sitting at secure unit desk and Resident #2 pointed to sandwiches - Can I have one of those. Resident #2 was given ,[DATE] sandwich which he began eating - CNA (did not identify) was ,[DATE] ft at unit door when this writer left the unit. Around 2150 (9:50 PM, CNA from secure unit called this writer on East hall to come to secure unit because res. was acting strange and not responsive. Writer went to unit where res. sitting upright in WC (wheelchair) in same area where he was when writer left him. Face red, and mouth open with sandwich in mouth. Writer gave sweep of mouth and retrieved some bread/cheese. Called 911 and assist from house staff, began CPR (Cardiopulmonary Resuscitation) attempted abd (abdominal) thrust. Res. unable to stand at that time, unable to dislodge sandwich. Res. placed on floor and CPR began. Review of the ED (Emergency Department) Physician Documentation revealed the following: Arrival Date: [DATE] Time: 22:24 (10:24 PM) Choked on a sandwich at the nursing home. Found pulseless in his recliner with a sandwich in his mouth. Unknown down time. Differential Diagnosis: [REDACTED]. Disposition: Patient pronounced on [DATE] 22:56 (10:56 AM). Impression: [MEDICAL CONDITION]. During an interview on [DATE] at 9:05 AM, the Director of Nurses (DON) stated that on [DATE], Resident #2 had gone to the nurse's station in his wheelchair to get a snack. She stated, I got called after the 911 call and after they had started CPR, because he was a full code. The family was called and the police and EMS came and took him to the hospital. LVN A was walking to the other nurse's station and CNA B paged her that she needed a nurse, that Resident #2 was acting strange and not himself. LVN A came back in did a mouth sweep, [MEDICATION NAME] (maneuver to dislodge food) and called 911. He was pulled to the floor and was given CPR. 911 came. The death report said he had a pulse, he was intubated, so his airway must have been clear. The family wanted to have him a DNR (Do No Resuscitate) and wanted the hospital to stop (trying to revive him). She stated that the cause of death was [MEDICAL CONDITION]. During an interview on [DATE] at 11:50 AM, the Speech Therapist stated the Rehabilitation Manager saw Resident #2 coughing when he was eating on [DATE] and asked her to screen him. She watched Resident #2 eat his breakfast on [DATE] and he knew the appropriate amount of food to put in his mouth. I had not changed his diet order from Regular to Mechanical Soft because I was still in the evaluation process. When asked by the surveyor, Would he have a problem eating a sandwich? She stated, The sandwich is soft texture and he could have eaten it. I was very surprised to learn he had stuffed a whole sandwich in his mouth. I didn't see anything like that. During an interview on [DATE] at 10:00 AM, the DON was informed the surveyor had found nurse's documentation that the resident had a choking incident on [DATE] and that he had stated he was trying to kill himself. The DON stated that when she had taken an interview from CNA D, after the resident had passed away, the CNA stated, You know that he had choked before? The DON stated to CNA D, No, I did not. She stated that she did not ask CNA D any other questions about the choking incident. She stated to the surveyor that the nurse (LVN C) had not reported to her that Resident #2 had previously choked or that he stated he was trying to kill himself. She stated, That is not good, and yes, I would expect the nurse to report this to me or the social worker. I did not investigate it (the [DATE] death incident) because I didn't think it was an incident. I should have investigated it. During an interview on [DATE] at 10:10 AM, the Social Worker stated, No one ever reported to me that Resident #2 wanted to kill himself. I know that he wanted to go home, but his Dementia had increased and he didn't call his wife as much. If they would have reported this to me, I would have had a Counselor come out and put him on a suicide watch. I didn't find out about him choking before ([DATE]), until after he had passed away. I would have expected him to have a speech evaluation after he choked on a sandwich. All the time here, I never thought he was suicidal. I don't really know if his cognition was that good that he knew how to kill himself. During an interview on [DATE] at 12:15 PM, the Attending Physician stated that he had not been notified of the incident on [DATE], nor had he been notified of Resident #2's death on [DATE]. He stated he found out from Resident #2's wife (who also was a patient of his), that Resident #2 died . The wife told him he had died of a [MEDICAL CONDITION]. He stated that when he spoke with the DON about it, she stated that he had been eating a sandwich, choked and went to the ER, and that they had gotten a heart rate back. When the physician was asked, Would you have expected the staff to call you on [DATE] when the resident choked and said, I am trying to kill myself the physician stated, I would think so. During an interview on [DATE] at 12:30 PM, LVN C stated that once CNA D told her that Resident #2 stated he was trying to kill himself she went to his room and asked him, Were you trying to kill yourself? He said, No. I asked him twice and he said no. I asked CNA B, who is back here (on the secure unit) all the time, if Resident #2 had ever told her he was going to try to kill himself and she said, No. The surveyor asked LVN C, Did you believe CNA D? Yes, I did believe her. I put it on the 24 hour shift report and told the night nurse coming on and documented in the chart. I told the Social Worker a couple of days later, she just don't (sic) remember it. I did not tell the DON, but I put it on the 24 hour report. He did not seem depressed and nothing was unusual in his behavior. During an interview on [DATE] at 3:45 PM, the DON gave the surveyor the 24 hour report dated [DATE] that revealed the following: Resident #2 - put half a sandwich in his mouth and attempted to swallow it whole. Stated he was trying to kill himself. When asked by the surveyor, who reads and when is the 24 hour report read, the DON stated that the 24 hour report is read off every morning in the standup meeting. She stated, I always read the 24 hour reports. I didn't see it. During an interview on [DATE] at 12:50 PM, the DON stated she had started in-servicing the nurses to watch residents for choking and coughing while eating. She stated staff was in-serviced on following the facility's policy and calling (physician) to get a psychiatric evaluation on any suicidal residents. We have a new screening tool and have started screening all the residents for suicidal tendencies. During an interview on [DATE] at 2:25 PM, CNA B stated that the nurse was at the nurses station on [DATE] and after she finished her rounds about 9:30 or 9:45 PM she told LVN A she was going to take the dirty barrels out. When I came back in Resident #2 was in his wheelchair at the nurses station with his back to me and when he stood up, I told him to sit down. The nurse was still at the nurse's desk. The nurse was going out to the other nurse's station outside the unit, so I went and washed my hands and noticed his head down and thought he had dozed off. I went over and saw that his lips were blue. I got on the intercom and called STAT for the nurse. LVN A came in and said that she had given him a sandwich and she checked his mouth. We stood him up so she could perform the [MEDICATION NAME] maneuver. Then we put a pillow and blanket on the floor and she did CPR and ,[DATE] nurses came to help and I got out of the way. When asked by the surveyor, Did you ever see him cram food in his mouth? She stated, No, and I did not know of any choking problems. Resident #2 never said anything about harming himself to me, he just wanted to go home. During an interview on [DATE] at 2:30 PM, CNA D stated that on [DATE] she had passed out the evening snacks and Resident #2 stated, Give me a sandwich and a beer. She stated she gave him half of a sandwich and watched him eat it normally, and he asked for another one. After giving him another half sandwich of ham and bread, she went on her rounds while he was sitting up at the nurses' station eating it. She stated, when I looked around, I couldn't see him so I called him and he came out around the nurses station where I could see him. When I noticed his face was red and he could not breathe, I grabbed some gloves and dug the sandwich out of his mouth. It looked like he had broken it up in pieces and then stuffed it in his mouth. When I asked him, Why did you do that? He stated, I was going to try to kill myself because you won't let me go home or give me beer. That was the only time he told me he was going to try to kill himself. I called the nurse and LVN C went into his room. He told her he didn't say that and he wasn't going to do that. When the CNA was asked if she had told the DON about the incident, she stated, No, I figured LVN C would do that. During an interview on [DATE] at 3:55 PM, LVN A stated that Resident #2 had always eaten his snacks without incident. She stated that she had learned, after the fact, that he had choked. She stated, I wished I would have known it happened. He had come to the nurse's desk and wanted a snack and I gave him half of a cheese and meat sandwich. He had his back turned to me, but I could still see him. I heard the CNA tell Resident #2 twice to sit down. I walked to the other nurse's station and had just reached it and she called me to come straight back. When I got there his mouth was open and I could see parts of the sandwich in it. I swept his mouth, patted him, but he was non-responsive and his face was dark. 911 was called and I called STAT and the nurses helped me lay him down to start CPR. He was not left alone, it happened so fast. During an interview on [DATE] at 4:15 PM, the Administrator stated she had not heard about the [DATE] incident of Resident #2 choking and trying to kill himself, and would have expected the DON to tell her, because this was a nursing issue. She stated, It's not like we don't take these things seriously. During a telephone interview on [DATE] at 3:15 PM, the DON stated she was faxing over the sign-in sheets for the in-services she had performed on Suicide Threats, Signs and Symptoms of Depression, Interventions, and all changes in behavior are to be put on the 24 hour report. She stated, I figured out why I didn't see the 24 hour report on [DATE]. I was sick that day. When asked by the surveyor, if you are sick shouldn't someone else read it? She stated, My Assistant Director of Nurses (ADON) was new, so no one read it. Review of a current facility policy dated Revised [DATE] titled, Suicide Threats revealed the following elements: Policy Statement Resident suicide threats shall be taken seriously and addressed appropriately. Policy Interpretation and Implementation 2. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. Review of a current facility policy dated ,[DATE] titled, Abuse revealed the following elements: Policy: 1. The resident has the right to be free from abuse: verbal, mental, physical, or sexual. Procedure: 1. The facility will upon admission and periodically, inform the resident of the definitions of: e. Mental/Psychological abuse is mistreatment that causes or could cause mental injury or harm without physical harm. 2. The facility will, upon admission and periodically, inform the resident of their right be free from abuse/corporal punishment/involuntary seclusion. e. The resident or the resident's representative was involved in the care plan of behaviors or medical condition to the highest practicable extent. f. The facility monitors and modifies the resident's care in an attempt to utilize the least restricted means to manage care. The facility Administrator, DON, and Regional Director of Operations (RDO) were notified on [DATE] at 1:26 PM that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on [DATE] at 3:06 PM. The final Plan of Removal was accepted by the surveyor/investigator on [DATE] at 3:31 PM. The plan of removal included the following: 1. An audit will be completed on [DATE] on every resident in the facility to determine if they have a thought or plan to hurt themselves. Administrator will review the audit to make sure every resident has been assessed. If there is any resident identified, the resident will be immediately assessed by the nurse, the physician will be contacted for further intervention, and the resident will be put on one on one until resident is deemed safe by the physician or sent out to another facility for treatment. DON will verify that these procedures have been followed. 2. All staff will be inserviced on policy and procedures when a resident states that they want to hurt themselves on [DATE]. Staff who are not currently working will be inservice before they take an assignment on the floor but no later than [DATE] at 5 PM. Nursing staff was inserviced on [DATE] to put any changes in behaviors on the 24 hour report for DON/designee. review. 3. DON/designee will review 24 hour report for any change in behaviors daily and PRN. DON/designee will verify that the physician has been notified, family notified, and appropriate intervention is in place. Social Services will review all residents again in 1 month for any [MEDICAL CONDITION] then quarterly thereafter. Administrator will check the Social Services reviews for the following month then prn. These audits will be brought to QA monthly continuously fore the Medical Director and Administrator to review for input or further interventions. The surveyor monitored the current plan of removal as follows: An in-service for the all staff members was conducted on [DATE] concerning signs and symptoms of depression and the facility's policy on Suicide Threats. During an interview on [DATE] at 12:30 PM, LVN C stated she had been in-serviced to contact the DON if there were any reports of resident threats of suicide. During an interview on [DATE] at 2:25 PM and 2:30 PM, CNA's B and D stated they had been in-serviced to not only contact the Charge Nurse, but to tell the DON if they heard any resident wanting to commit suicide. During an interview on [DATE] at 3:43 PM, the RDO stated that during the suicidal tendency interviews/screening with the residents, one resident had triggered for [MEDICAL CONDITION] and that she had a 1 on 1 staff member with her. Two residents had a history of [REDACTED]. She stated that a psychiatrist was on the way and would visit with all three. Review of the facility suicidal tendency interviews/screening dated [DATE] revealed 2 residents with a history of [MEDICAL CONDITION], and one (1) resident currently voicing [MEDICAL CONDITION]. On [DATE] at 4:15 PM, the Administrator, DON, ADON, MDS Coordinator, Social Worker, and RDO were informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as a pattern due to the facility administration and staff requiring time to and monitor their Plan of Removal. Review of the facility completed CMS 672 form identified 33 residents with a psychiatric diagnosis.