Every finding on record at Avir at Keller

Based on observation, interview, and record review, the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 5 shower rooms (Halls 300, 400 and 500) reviewed for environmental conditions.The facility failed to ensure the shower rooms on Halls 300, 400, and 500 were maintained in a clean, safe, and orderly manner. The failure placed residents at risk of decreased quality of life. Findings included: During an observation of the Hall 300 shower room on 08/25/2026 at 10:29 AM, the following were observed: - one wire hanger;- one black plastic hanger on the shower bench;- one can red can of aerosol deodorant on the floor;- a brown disposable paper towel on the floor;- one yellow plastic bed pan containing a gait belt, body wash, white bottle of liquid and a green face towel stacked on a grey plastic square container positioned on top of the vinyl gloves box;- two gray bins stacked with the top containing 1 blue sock, 1 empty bottle, and a smaller white container;- one roll of white wrapping tape on the sink;- no soap dispenser for handwashing;- one 6-ounce bottle of blue body wash 1/4 full of blue liquid on the shower bench;- one 8-ounce bottle of used shampoo body wash lying on the shower bench; - one plastic package open and used pack of personal cleansing wipes on the shower bench;- one large white box labeled (vinyl gloves) 150 per box on the shower bench; and- one empty body wash bottle left on the sink. During an observation of the Hall 400 shower room on 08/25/2026 at 10:35 AM, the following were observed:- one 6-ounce bottle of pink used baby lotion left on the sink;- one 8-ounce bottle of used shampoo body wash left on the sink;- one box of medium-sized vinyl gloves left on the shower bench;- one empty box of large-sized gloves was left on top of the yellow trash can in the shower room; and- one resident pull-up brief on the top shelf of cabinet (used or new). During an observation of the Hall 500 shower room on 08/25/2026 at 10:48 AM, the following were observed: - five 8-ounce body washes left on the bariatric shower chair,- one large container of brand name shampoo left on the shower rail;- one can of shaving cream on the sink;- one empty box of medium-sized vinyl gloves on the shower bench;- one box of medium-sized vinyl gloves left open on the yellow trash can;- one box of large-sized vinyl gloves left open on the shower bench;- one small container of skin treatment lotion with pharmacy label that was not legible;- one metal L-shaped device with a black rubber cover approximately 5-inches long on the shower bench; and- one pair of silver and pink rain boots on the floor.During an interview on 08/25/2026 at 10:30 AM, CNA A stated that she was trained on environmental sanitation and infection control while working at the facility. She was not sure which staff used the shower room this morning because she had not showered residents. She denied that staff previously left the shower room with trash, resident property, care supplies, and hygiene solutions. She stated the protocol for environment sanitation and safety included hand washing, using disposable gloves during care and discarding in the trash, to prevent cross-contamination. had not used the shower room that morning. She said all staff were supposed to clean and disinfect the shower rooms before entering with the resident and supplies, then after returning the resident to their room. She said failing to follow protocol to maintain a safe and sanitized environment was important to prevent residents from exposure to germs and obtain infections from cross-contamination. important to clean and disinfect the shower room prior to bringing their clothing She stated she had not reported the condition of the shower to leadership that day. n as this could result in resident's being exposed to germs and infections. She stated that disposable gloves should be stored in an area to prevent cross. During an interview on 08/25/2026 at 11:30 AM, the Housekeeping Supervisor state that housekeeping was responsible for cleaning the showers rooms and restrooms in the facility. She stated that shower rooms were cleaned several times throughout the day. She stated it was the responsibility of her staff to report to her when the shower room was left with resident personal items and trash. She stated that when the shower room was left with these items, the administrator should be notified. She denied notifying the administrator or DON regarding the unsanitary conditions of the shower rooms. She stated it was the responsibility of the facility staff to ensure the shower rooms were cleaned and free of personal supplies after each task. She observed the items in the shower room with the surveyor and stated that those items should not be left behind. The Housekeeping Supervisor stated she expected her staff to report to her any repairs and conditions that were not in keeping with facility sanitation. During an interview on 08/25/2026 at 11:45 AM, CNA T stated that nurses and nursing aides were responsible for removing bottles, boxes, and resident personal items from the shower room after the task was completed. She said all staff were trained and expected to disinfect the shower rooms before bringing the resident and supplies for hygiene task. She said upon completion of the task, all PPE trash should be discarded to prevent use by other staff providing care. She said resident personal hygiene products should be returned to the residents room. She said failing to follow the protocol for sanitation can result in resident infections. She said the residents had the right to be showered and cleaned in an environment that was safe and clean. She stated she had not observed staff leaving the shower room unsanitary, however if observed, she would report to the Administrator. During an interview on 08/25/2026 at 11:55 AM, the ADON stated that staff being educated frequently on environment sanitation and safety. The ADON said it was her expectation that staff sanitize all the equipment prior to entering with the resident and their supplies. She was not aware that staff were leaving resident personal items, hangers, used hygiene bottles, incontinent supplies, and other items in the shower room. She stated this was unsanitary, and could result in residents experiencing infections, or feeling no one cared if the facility was not maintained appropriately. The ADON said it was the responsibility of the charge nurses and ADONs to monitor for cleanliness and sanitation. She said all personal items and supplies should be discarded or removed. During an interview on 08/25/2026 at 3:48 PM, the DON stated that she expected the care staff to clean and sanitize the shower room prior to providing resident care. She said failing to follow sanitation and infection control protocol could result in residents being exposed to germs, and infections. The DON was not aware that shower rooms were left in unsanitary and unsafe conditions for residents. DON stated it was her responsibility along with ADONs to monitor, audit, and ensure the staff were following sanitation protocols for environment sanitation and resident showers. During an interview on 08/25/2026 at 3:55 PM, the Administrator stated that it was her expectation for the staff to follow infection control protocol and sanitation of the environments where the residents received care. She said failing to maintain a safe and clean environments for the residents could result in exposure to germs, cross contamination, and infections. Record review of the facility's Bath, Shower/Tub policy, dated February 2018, reflected: Purpose The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Equipment and Supplies.The following equipment and supplies will be necessary when performing this procedure: Face cloth and bath towels. Disinfectant solution.Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Steps in the Procedure: Wash and dry your hands thoroughly.Be sure the tub or shower is clean. Clean the bathtub with a disinfectant solution. Pick up all towels, bath cloths, soiled clothing, etc. Discard in the soiled laundry container inside the bath.Pick up all towels, bath cloths, soiled clothing, etc. Discard in the soiled laundry container inside the bath area. Clean the bathtub with a disinfectant solution. Record review of the facility's Resident Rights policy, dated 02/20/2021, reflected: . Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interview and record review the facility failed to develop the comprehensive care plan within seven days of the completion of the comprehensive assessment and review and revise the care plan after each assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #1's care plan, dated 02/15/2026, was revised to address his behaviors of care refusal, verbal, and physical aggression. This failure placed residents at risk of not receiving timely and appropriate individualized care to prevent harm. Findings included: Record review of Resident #1's Quarterly MDS dated [DATE], reflected he was a [AGE] year-old male that was admitted on [DATE]. Resident #1 had a BIMS score of 09, indicating he was moderately impaired cognitively. Mood feeling down and depressed every 2-6 days and having trouble concentrating.Behaviors of verbal behavioral symptoms directed toward others (every 1 to 3 days). Resident #1's ADL functional abilities reflected that he required substantial assistance from staff. Resident #1 used a wheelchair for mobility.DX Anemia (condition where your blood lacks enough healthy red blood cells or hemoglobin to carry sufficient oxygen to your body's tissues), Renal insufficiency (it means your kidneys do not work well. They fail to clean waste from your blood, control body water, or balance minerals.), Pneumonia (an infection that makes the small air sacs in one or both of your lungs swell.). Record review of Resident #1's care plan dated 02/15/2026 reflected he was at risk of ADL performance deficits and required staff assistance for care task. Resident #1's behaviors of refusing showers, incontinent care, MD treatments, verbal, and physical aggression toward staff was not addressed in his care plan. Record review of Resident #1's progress note dated 03/10/2026 at 10:27 AM, by LVN-M, reflected resident's [family member] present in SW for care plan meeting, discussed wound care orders and treatment, informed again of patient not always allowing staff to complete wound care as ordered requiring multiple attempts & extensive redirection for incontinence care & wound care. Resident was refusing to get in bed for off-load per doctor's recommendation, multiple attempts to take ordered medications & supplement, at times very verbally abusive to staff attempting to provide care, [family member] verbalizes awareness due to staff notifying her via phone & at times witnessed behavior at bedside. Record review of Resident #1's psychiatric assessment dated [DATE] reflected the facility staff submitted a referral for psychiatric assessment for Resident #1. Resident #1 was experiencing changes including depression (feeling down) and Anxiety (excessive worrying), due to adjustment issues and mood reactivity s/s. The staff reported Resident #1 was observed to have loss of interest, fatigue (tiredness), psychomotor slowing (reduction in speed and thought) and decreased concentration. Resident #1 had HX of depression/Anxiety. Resident #1's most recent changes included recent Delirium, Cognitive Losses, Includes: Anxiety (worrying); Dementia (loss of memory). Record review of Resident #1's physician orders dated 02/14/2026 reflected: Thiamine 1-100 mg tablet daily monitor closely for +/- effects as SNF placement proceeds; Remeron, 1- 15 mg tablet at bedtime adjustment disorder, unspecified dementia, alcohol dependence. Psych in place; MD order dated 02/14/2026 reflected an order for Melatonin 13 mg tablet QHS for Delirium due to a known physiological condition (fluctuating change in mental state, attention and awareness caused by underlying medical issues). unspecified dementia, and alcohol dependence. Resident #1 was not observed or interviewed, due to being discharged from the facility on 03/12/2026.An attempted phone interview with Resident #1's RP on 08/10/2026 at 9:30 AM and requested a return call.An attempted phone interview with Resident #1's RP on 08/11/2026 at 11:19 AM and 4:51 PM was initiated and the voicemail was full.During an interview on 08/12/2026 at 1:23 PM, DON stated it was the MDSC's responsibility to develop, change, and revise care plans. DON said it was not DON or ADON's responsibility to ensure revisions were made regarding behaviors. DON said failing to document resident behaviors could result in Resident #1's behaviors and care not being addressed, and delayed interventions. DON said it was her expectation for resident care plans to be revised immediately within 24 hours of IDT discussion. During an interview on 08/12/2026 at 1:41 PM, the MDSC stated that care plan development, changes and revisions were the responsibility of everyone on the IDT meeting. She stated it was the assigned RN's responsibility to review and sign that it was completed and accurately reflected the resident's individual care needs and treatments. MDSC said the resident was at risk of not receiving individualized task and treatment when the care plan fails to communicate his goal and needs. MDSC said the expectation for care plan changes and revisions was they were expected to be completed within 24 hours of the IDT meeting. During an interview on 08/12/2026 at 1:46 PM, LVN-M stated Resident #1 would refuse care, showers, incontinent care. He would become physically and verbally aggressive toward MDs, nurisng staff, and aides when attempting to provide care and treatment. Behaviors included: cursing, throwing items, using catheter device and fist to hit them. LVN-M stated that he was the wound care nurse, and it was his expectation for the careplan to address his behaviors to inform clinical staff of his specific trends and needs to provide point of care and treatments. He said care plan changes and revisions should be completed by the designated department head. Failing to ensure the care plan addressed resident beahviors and mood, posed risk to resident missing care over a period of time. During an interview on 08/12/2026 at 1:55 PM with the ADM, she said it was every departments' responsibility to ensure the care plan was revised to address resident's current status. She was aware that Resident #1 had behaviors and refused care. ADM stated all staff in the IDT were responsible for ensuring resident care plans reflect most recent care needs, behaviors, and interventions. ADM expected care plan revisions to be completed immediately or within 24 hours. ADM said failing to update the resident care plan could result in worsening behaviors and harm to resident, as well as missed interventions. ADON was not interviewed on 08/12/2026, due to being out of the office on leave. Record review of facility staff in-service reflected no trainings recently on care plans. The facility policy for care plans was requested at the entrance on 08/11/26 at 9:30 AM and was not provided at the time of exit. On 08/16/2026 the Administrator provided a new protocol for monitoring care plans for timeliness and accuracy. The document dated 08/16/2026 reflected: A designated staff member will be responsible for maintaining oversight of care-plan completion and identifying any outstanding care plans. Care Plan Tracking.follow-up.Staff transition process.assigning a staff to the task and ADON and DON follow up.

Based on interview 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 1 of 6 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1's biliary drain (thin plastic tube used to clear blocked bile ducts) was flushed per the physician's order for seven days. This failure could place residents at risk for worsening of condition which could lead to serious harm.Findings included:Record review of Resident #1's Discharge MDS Assessment, dated 07/15/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 07/15/26. Section C-Cognitive Patterns reflected Resident #1's BIMS score was a 15, which indicated his cognition was intact. Section GG-Functional Abilities reflected Resident #1 required moderate assistance with most self-care ADLs. Resident #1 was dependent on staff for most mobility functions and used a manual wheelchair. Section I-Active Diagnoses reflected Resident #1's active diagnoses included: cerebral infarction (stroke), secondary malignant neoplasm of liver and intrahepatic bile duct (liver cancer), reduced mobility, and ileostomy status (surgical procedure that allows waste to bypass the colon and empty through an opening in the stomach). Record review of Resident #1's Baseline Care Plan, dated 07/02/26, reflected the document did not indicate Resident #1 required any special treatments or procedures. Record review of Resident #1's discharge hospital records, dated 07/02/26, reflected in part the following: .A biliary drain catheter is placed to drain bile from your liver. Your doctor who requested this procedure will discuss with you how long it will be placed and/or when you need exchanged of this catheter if necessary.Physician discharge instructions-Flush the tube with sterile saline daily as directed given by the Interventional Radiology team. Record review of Resident #1's progress notes, dated 07/02/26 at 10:46 p.m., by LVN E, reflected in part the following: .Other Observations:[Resident #1] arrived via [transportation company] at 3:30 pm. Accompanied by [Resident #1's family]. [Resident #1] is on skilled services for colon cancer. [Resident #1] has a colostomy. Empty the colostomy (surgical procedure that allows waste to bypass the colon and empty through an opening in the stomach) x 2. Has a drain to left side of abdominal area. Has med port to left upper chest. Redness to coccyx. Has a skin tear to left elbow. Very thin gentleman. Skin is very dry due to chemo. Has psoriasis (chronic autoimmune disease that causes rashes and scaly patches on skin) of scalp, face and neck. Can turn from side to side with assist. Can feed self in room. Fair appetite. [MD] is aware of new resident. [Resident #1] Denies any pain or discomfort noted at this time. Record review of Resident #1's progress notes, dated 07/04/26 at 3:57 p.m., by RN C, reflected in part the following: . Other observations:[Resident #1] on skilled services for weakness r/t colon cancer. [Resident #1] no s/s of distress, PRN Norco (prescription pain relief drug) given for back pain, effective. Tx to skin issues provided. Emptied colostomy x2. A drain tube to left side of abdominal area not used. Med port to left upper chest intact. Scheduled meds taken, tolerated. Fair appetite. Participated PT/OT. Keep monitoring. Record review of Resident #1's progress notes, dated 07/04/26 at 8:50 p.m., by the NP, reflected in part the following: . [Resident #1] is a [AGE] year-old male who is seen in the skilled nursing facility for a new admission, day two follow-up evaluation. [Resident #1] was recently hospitalized at [local hospital] history is significant for stage IV colon adenocarcinoma (colon cancer) with hepatic (relating to liver) and bilateral adrenal metastases (cancer spread from one part of body to adrenal glands), status post subtotal colectomy (surgical procedure to remove part of the colon) with ileostomy. Additional medical history includes hypercholesterolemia (high blood cholesterol), hypertension (high blood pressure), and cerebrovascular accident (CVA/stroke). [Resident #1] is currently clinically stable. Continue current treatment plan, monitor chronic conditions, andprovide supportive care. Record review of Resident #1's consolidated physician orders, dated 07/29/26, reflected in part the following:-Flush IR drain to LUQ with 10 ml normal saline once daily. Start date: 07/09/26. Discontinued. In an interview on 07/29/26 at 9:25 a.m., Resident #1's family stated upon the resident's admission to the facility, there was a care plan meeting held with the DON and other clinical staff. Resident #1's family stated during the meeting she notified the facility that Resident #1 had a biliary drain that had to be flushed daily. She stated the facility claimed not to have instructions or orders to do so. Resident #1's family stated the biliary drain was newly placed while Resident #1 was at the hospital and the doctor informed them that it was important to flush it daily. Resident #1's family stated the resident was at the facility for about a week without getting his biliary drain flushed, and the facility did not start flushing it until she brought in an order to prove that it was required. Resident #1's family stated there were no obvious issues from the delay in care, but she filed a grievance with the facility and discharged Resident #1 before any harm could occur. In an interview on 07/29/26 at 12:58 p.m., the DON stated Resident #1 was admitted to the facility for almost two weeks, and the resident admitted after a stay in the hospital. The DON stated Resident #1 had an ileostomy and biliary drain, and his care needs were discussed during the care plan meeting with family. The DON could not recall if care for the biliary drain was addressed or if Resident #1 admitted with a physician order for biliary care. The DON stated a biliary drain was uncommon for residents at the nursing facility; however, the nurses would be educated on appropriate care if needed. The DON stated the biliary drain was used to drain and fluid leaving the body and not providing appropriate care could place the resident at risk of complications and infection. The DON stated she would check Resident #1's hospital records to see if he was admitted with an order for biliary care. In an interview on 07/29/26 at 1:17 p.m., RN C stated she worked weekends at the facility and worked with Resident #1. RN C stated Resident #1 required ileostomy care, and he also had a biliary drain that was not used. RN C stated the biliary drain was capped with no drainage or signs of infection, and she would only ensure the site was clean. RN C stated there were no orders in the medical chart for her to flush the biliary drain or provide any additional care. RN C stated Resident #1's family had concerns about the biliary drain not being flushed and she explained to them she could not do anything without an order. RN C stated as a nurse, if there were any concerns raised by the resident or family it was her responsibility to notify the MD for clarity. RN C stated she did not notify the MD that Resident #1's family had concerns regarding the resident's biliary drain as she should have. In an interview on 07/29/26 at 2:15 p.m., RN D stated she worked weekdays at the facility and worked with Resident #1. RN D stated Resident #1 had a lot of co-morbidities and was a high maintenance resident who required a lot of assistance. RN D stated Resident #1's family was very involved in his care and seemed to have different expectations than Resident #1. RN D described Resident #1 as pleasant and easygoing but Resident #1's family had concerns regarding care for the biliary drain. RN D stated Resident #1's family stated she wanted the resident's biliary drain flushed; however, there were no orders to do so. RN D stated the biliary drain was capped off with no drainage. RN D stated Resident #1's family provided an order the following day that was clarified with the MD and implemented. RN D stated when a resident was admitted to the facility from a hospital, the admitting nurse was responsible for assessing the resident and reviewing the discharge report to check for any orders and instructions. RN D stated she was not the nurse when Resident #1 was admitted ; however, ADON B was assigned to Resident #1 and would have confirmed the resident's orders. In an interview on 07/29/26 at 2:45 p.m., Interim ADON A stated ADON B was on vacation, and she was covering for her. Interim ADON A stated she did not review Resident #1's orders because he had already been admitted when she took over the caseload. Interim ADON A stated when a resident was admitted to the facility, the ADONs were responsible for double checking all documents from the discharging facility or hospital to ensure all medication orders, procedures, upcoming appointments, or other care needs were confirmed and entered into the system for clinical staff to be aware. In an interview on 07/29/26 at 3:28 p.m., the MD stated when a resident admitted to the facility, his expectation was for the nurses to notify him to clarify all orders and carry them out accordingly. The MD stated a biliary drain was placed to drain fluid and prevent bile ducts from being blocked. The MD stated it was important to flush the drain to prevent any clogs, although flushing could also introduce bacteria to the abdomen. The MD stated there were no reported issues with Resident #1's biliary drain; however, the facility was still expected to follow any physician orders for care. In an interview on 07/29/26 at 4:25 p.m. with the Administrator and DON, the DON stated it was her expectation for the charge nurses to review and confirm all orders with the MD. The DON stated the ADONs were responsible for reviewing the orders after the charge nurses to ensure no orders were missed. The DON stated an order for Resident #1's biliary drain was in the discharge hospital records and should have been acknowledged and implemented by the facility when the resident admitted . The DON stated Resident #1's discharge documents were extensive which was probably how it was missed; however, the nurses were still expected to look at each document. The DON stated not following all physician orders could place the residents at risk of not receiving all care needs. Record review of the facility's policy titled Physician Orders, revised February 2025, reflected in part the following: PurposeThe purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services. Supervision by a Physician.Physician orders are essential for the comprehensive care of the residents. These orders encompass various aspects, including leave of absence, evaluations, medication and treatment regimen, and therapy for physical therapy (PT), speech therapy (ST), and occupational therapy (OT); consultations with other physicians; dietary plans; activity instructions; X-rays; laboratory work; transfers; discharges; and any other orders as needed. Therapy orders must be renewed every 30 days and can be documented in the therapy notes.

Based on interviews and reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 3 residents (Resident #1) reviewed for accuracy of assessments. The facility staff failed to ensure Resident #1's quarterly MDS dated [DATE] addressed resident Safety and Quality of Performance: Eating; Oral hygiene; C. Toileting hygiene; E. Shower/bathe self; F. Upper body dressing; G. Lower body dressing; H. Putting on/taking off footwear; Personal hygiene.Indicate the type of wheelchair or scooter used. This failure could result in residents missing essential treatments and interventions for care. Findings included: Record review of Resident #1's Quarterly MDS dated [DATE] completed by LVN-D reflected the resident was a [AGE] year-old female that was admitted on [DATE]. Resident #1 had a BIMS score of 03, indicating she was severely impaired cognitively. MDS dated [DATE] addressed resident Safety and Quality of Performance: Eating; Oral hygiene; C. Toileting hygiene; E. Shower/bathe self; F. Upper body dressing; G. Lower body dressing; H. Putting on/taking off footwear; Personal hygiene.Indicate the type of wheelchair or scooter used.Record review of Resident #1's quarterly care plan dated 03/24/2026 reflected the resident had an ADL Self Care Performance Deficit and was at risk for not having their needs met in a timely manner. The care plan reflected she was at risk for emotional distress . will have express feeling of safety in facility and show no s/s of emotional distress r/t improve current level of function in Bed Mobility, Transfers, Eating, Dressing, allegation.Administer medications as ordered. Monitor/document for side effects and effectiveness. The Care plan further stated the resident required Assist x1 Personal Hygiene: Assist x1 Bathing: Assist x1.Provide shower, shave, oral care, hair care, and nail care per schedule and when needed.Encourage to participate to the fullest extent possible with each interaction and praise when attempts are made.Encourage to use call light to call for assistance before attempting any activities of daily living (ADLs) that resident cannot do independently. Record review of Resident #1's physician orders dated 02/24/2026 reflected: 08/28/24, Geri sleeves to BUE (Bilateral Upper Extremities,) q shift, .During an observation and interview on 03/27/2026 at 12:10 PM, Resident #1 was in the dining area watching television. She was well groomed, sitting in a chair with a doll. She was alert to her name; however, she was not interviewable due to severe cognitive impairment. During an interview on 03/28/2026 at 4:00 PM, the ADON stated that she was not aware that Resident #1's MDS did not address her functional abilities and had incomplete sections, or that Resident #3's MDS was not updated according to guidelines. She stated that the MDS staff were not here today. She stated that it was important for the MDS to be completed timely as it reflected the daily care and needs of the resident for them to maintain highest level of care. During an interview on 03/28/2026 at 4:15 PM, with the DON she stated that it was her expectation that the MDS conducts a timely comprehensive quarterly assessment to address the resident current status of care and prevent decline. She stated that it was the DON and MDS staff responsibility to ensure MDS were completed comprehensively. The facility Administrator was not interviewed, as she resigned a week prior to the investigation, and the MDS Coordinator was not interviewed, because she was not working on the weekend. Record review of the facility's Clinical Practice Guidelines MDS Completion policy, dated 11/05/2024, reflected in part: resident are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Quarterly assessments completed using ARD no >92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD).

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication refrigerators reviewed for pharmacy services. The facility failed to ensure insulin vials were dated after they were opened in the medication refrigerator. This failure had the potential to result in decreased therapeutic efficacy which could lead to uncontrolled blood sugars. Findings included:Observation on 09/24/2025 at 1:41 PM with LVN A of the medication room refrigerators for Halls 100, 200, and 300 revealed one vial of Lantus insulin 100 unit/ml (used to improve blood sugar control) which was opened, partially used, and not labeled with the open date. Interview on 09/24/2025 at 1:45 PM, LVN A revealed she knew insulin pens/vials were supposed to be dated once they were opened or after they were removed from the refrigerator. She stated all nurses were responsible for putting date and labelling the insulin vials once they were opened because short acting insulin was good for 28 days. She also stated failure to label and date insulin with opened dates could result in staff not noticing when the insulin had expired, and they could continue to administer the expired medications, which would result in blood sugar levels not being controlled. She stated she had been trained regarding labeling of medications, storage of medications, and putting the open date on insulin; however, she did not remember when she had been trained.Interview on 09/24/2025 at 2:14 PM, the DON revealed she expected the nursing staff to date the insulin pens once they were opened. She stated it was all nurses' responsibility to check the carts and refrigerator to ensure insulin was dated and labeled. She stated it was the responsibility of ADON to monitor and ensure the nurses were labelling medications, but she did not specify how often. She stated if the staff was not putting the open dates on the insulin pens and vials, it would place residents at risk of having reactions like the medication being ineffective since they could not tell of the potency. She provided documentation on training courses which included dating insulin once it was opened. The training was dated 08/16/25, and LVN C was not in attendance.Interview on 09/25/2025 at 1:27 PM, ADON B revealed her expectation was for nurses to check their cart for medication labelling every week. She stated she expected the nurses to date insulin when opened. She stated she was responsible for checking the refrigerators to ensure insulins were dated and labeled. She stated she missed the vial that was opened, not dated, and was returned to the refrigerator. She stated once the vial was opened and used it should be placed on the cart. She stated she last checked the carts and the refrigerators at the end of August. She stated the risk of not putting the opening date on insulin vials/pens was that they could not tell when they expired. If administered, they might not meet the therapeutic effects as expected. She stated the short acting insulins were good for only 28 days. She stated she had done in-service training on medication labelling and storage, in August.Record review of the facility's training record, dated 08/16/25, reflected that once insulin was opened it should be dated. The ADON was in attendance. Record review of facility's Medication Storage policy. dated 01/20/21 reflected: .iii. Expiration dating (beyond -use dating) .3.Certain medications or package types, such as intravenous solutions, multiple dose injectables vials. require an expiration date shorter than the manufactures expiration date once opened to ensure medication purity and potency.8.Medication carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts (Halls 300 nurse medication cart) reviewed for labeling of drugs and biologicals. The facility failed to ensure expired medications was removed from the Hall 300 medication cart. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction. Findings included:Observation on 09/24/2025 at 1:27 PM of the Hall 300 nurse medication cart with LVN A revealed one bottle of Nitroglycerin 0.4 mg (used to treat or prevent attacks of chest pain) with an expiry date of July 2025 and 12 tablets of Oxycodone 10 mg (Schedule II opioid pain medication) with a use by date of 09/04/25. Interview on 09/24/2025 at 1:45 PM, LVN A revealed she was responsible for checking the cart for expired medications. She stated she checked the cart once a month for expired medications, and she last checked her cart two weeks ago. She stated failing to remove the expired medication could result in the medications being administered which could cause reactions, and the residents would not get the required therapy. She stated she had done training on checking the carts for expired medications, but she could not recall when she had completed the training. She stated she had been trained regarding labeling of medications, storage of medications, and putting the open date on insulin; however, she did not remember when she had been trained.Interview on 09/24/2025 at 2:14 PM, the DON revealed it was all nurses' responsibility to check the carts and refrigerator to ensure expired medications were removed for destruction. She stated it was the responsibility of the ADON to monitor and ensure the nurses was labelling and discarding the expired medications, but she did not specify how often. She stated if the staff was not checking carts for expired medications, it would place residents at risk of having reactions like the medication being ineffective since they could not tell of the potency. She provided documentation on training courses which included dating insulin once it was opened. The training was dated 08/16/25 and LVN C was not in attendance.Interview on 09/25/2025 at 1:27 PM, ADON B revealed her expectation was for nurses to check their cart for medication labelling and to look for expired medications every week. She stated she last checked the carts and the refrigerators at the end of August. She stated the risk of having expired medications on the cart was that if they were administered, they would not be effective. She stated she had done in-service training on medication labelling and storage, in August. Record review of facility's Medication Storage dated 01/20/21 reflected: .iii. Expiration dating (beyond-use dating) .3.Certain medications or package types, such as intravenous solutions, multiple dose injectables vials. require an expiration date shorter than the manufactures expiration date once opened to ensure medication purity and potency.8.Medication carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy.

Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team determined if it was clinically appropriate to self-administer medications for 1 of 5 residents (Resident #7) reviewed for medication administration. The facility's interdisciplinary team failed to ensure Resident #7 was clinically appropriate to self-administer antihistamine eyedrops that was at the resident's bedside. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction. Findings included:Record review of Resident #7's quarterly MDS dated [DATE] reflected Resident #7 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #7's BIMS score of 15 indicated his cognition was intact. Resident #7's diagnoses included amputation (removal of body limbs), high blood pressure (when the force of blood flowing through the blood vessels is consistently too high), renal insufficiency (characterized by reduced kidney function), diabetes (high blood sugar), lack of coordination, with adequate vision with no use of corrective lenses. Observation and interview on 09/23/25 at 11:30 AM, revealed Resident #7 had a bottle of Olopatadine Hydrochloride Ophthalmic Solution (antihistamine eye drops) at his bedside table. Resident #7 said his family member might have brought him the eye drops because his eyes had been itching, especially his right eye. Resident #7 stated he used the eye drops once in the morning and then again in the evening hours, and he did this daily.Record review of Resident #7's order summary reflected orders for eye drops had been started on 09/23/25 and 09/24/25 with no prior orders, and the orders reflected the following: - Ketotifen Fumarate Ophthalmic Solution 0.035 % Instill 1 drop in right eye two times a day for Itch Relief Active with order date 09/23/25 Start date 09/23/25.- Blink Tears Ophthalmic Solution 0.25 % Instill 1 drop in both eyes one time a day for dry eyes unsupervised self-administration. Active with order date 09/23/25 Start date 09/24/25.Interview with RN C on 09/23/25 at 12:36 PM, who was the charge nurse for Hall 100, revealed he was not aware Resident #7 had eye drops at his bedside to administer to himself. RN C stated he was not aware of any concerns with Resident #7's eye irritation. RN C stated someone from Resident #7's family may have brought him the eye drops, however there was supposed to be a prescription for the eye drops and they should be stored in our mediation cart. I will let the physician know so I can get an order so he can have it at his bedside. According to RN C, a physician's order was required to administer all medications whether it was for nursing staff to administer or residents to self-administer. RN C was observed removing the eyedrops from the bedside table. RN C stated all staff was responsible for removing medications from bedside and alerting the nursing staff, ADONs, or the DON. RN C stated allowing residents to have medications at the bedside without a physician's order placed residents at risk of over-using medication, forgetting how and when to use them. Interview on 09/25/25 at 2:00 PM, ADON B revealed residents should not have any medications in the room with them. ADON B stated residents would have to pass an assessment which would indicate they are capable of administering medications on their own. ADON B stated nursing staff was responsible for ensuring residents did not have any type of medications whether over the counter or prescribed in their rooms. ADON B stated Resident #7 should not have eye drops in his room because it could place him at risk of overdose, overusing the medication. Interview on 09/25/25 at 2:16 PM, the DON revealed residents are not supposed to have medication of any kind in their rooms. The DON stated she expected all staff to be more vigilant while making rounds in resident rooms. The DON stated in order for residents to have medication at their bedside, a safe survey, care plan updated, and an order for the medication. The DON stated it was the responsibility of the nursing staff to remove any pills, prescriptions, or over the counter medications from resident rooms. The DON stated residents having medications in their rooms put them at risk of overmedicating, staff not knowing what they are taking, or other residents getting the medications. Record review of facility's policy titled Medication storage dated 1/20/2021 revealed It is the policy of this facility to ensure that all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. A. All drugs and biologicals will be stored in locked compartments.B. Only authorized personnel will have access to the keys to locked compartmentsC. During a medication pass, mediations must be under direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for transfers. CNA failed to safely transfer Resident #1 on 11/09/25, when she did not use a gait-belt to assist the resident on or off the toilet. As a result, Resident #1 fell when being transferred from the toilet to the wheelchair, and the resident sustained a 10th rib fracture and a right tibia spiral fracture (break that twists around the right shin bone) as well as a proximal (where the limb begins) and distal (where the limb ends) right fibula (bone on the outside of your lower leg) fracture to Resident #1's right leg. The noncompliance was identified as past noncompliance. The IJ began on 11/09/2025 and ended on 11/14/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of serious injury or death.Findings included: Record review of Resident #1's Face Sheet, dated 11/19/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE].Record review of Resident #1's Quarterly MDS Assessment, dated 10/02/25, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her MDS indicated she required substantial/maximal assistance with transfers. Her MDS also indicated she exhibited no behaviors related to rejection of care. Her active diagnoses included Unspecified Sequelae of Cerebral Infarction (long term effects of a stroke with non-specific symptoms), Hemiplegia affecting right dominant side (paralysis on right side of body), Generalized Muscle Weakness, Long Term (current) use of Anticoagulants, and Insomnia (trouble falling asleep or staying asleep). Record review of Resident #1's Care Plan, dated 11/19/25, reflected the following: Focus: ADLs: [Resident #1] has an ADL Self Care Performance Deficit. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: use gait belt for safety for transfers. Focus: Falls: [Resident #1] has the potential for falls related to Gait/balance problems, history of falls with major injury. right side weakness. Goal: The resident will be free of falls through the next review date. Resident will not sustain additional fall related injury by utilizing fall precautions through next review date. Interventions: Allow [Resident #1] time to communicate how she prefers to be transferred. Which includes staff using a gait belt with all transfers. Allow time for [Resident #1] to position her right leg in the most comfortable position to be able to stand or transfer. Assess pt for weakness prior to transfers.Record review of Resident #1's Fall Risk Assessment, dated 09/01/25, reflected that she was a moderate fall risk with a score of 09. Record review of an Incident Note, dated 11/09/25 at 11:08 PM, written by RN B reflected the following: CNA called help. [sic] Upon entering room resident sitting on the floor in the front of toilet, W/c at side, non-slide socks to feet, resident alert, oriented, c/o severe pain to RLE. The CNA stated that after she helped resident using toilet, helped resident to stand up and put a new diaper on, then helped resident to turn to sit on w/c, suddenly resident fell down to floor, right leg twisted, resident c/o severe, another nurse held resident and checked VS: [Blood pressure] 171/62, [Heart rate] 100, [Temperature] 97.0, [Respirations] 18, [Oxygen Saturation] SpO2 96% RA. This nurse called 911, resident left to [the hospital] via 911 at 6:18 PM with documents. Notified DON, [family member] and [Company Name] MD. Called ER to give report to the ER nurse.Record review of Resident #1's hospital records reflected she was admitted on [DATE]. The hospital records reflected the following, This a [AGE] year-old female with a very extensive medical history with known history of essential hypertension history of stroke with weakness and wheelchair-bound, and below other extensive medical history who presents to the emergency room after sustaining a ground-level fall and complaining of right sided rib cage pain as well as pain in the right foot. Patient is non-ambulatory and wheelchair-bound and upon evaluation in the ED patient is noted to have a 10th rib fracture as well as a right tibia and spiral fracture extending to the IM nail as well as proximal and distal right fibular fracture. Orthopedic surgeon has been consulted, and this is felt to be nonoperative mostly admitted for pain management and other supportive treatment. Record review of the Provider Investigation Report, dated 11/10/25 reflected the following, [Resident #1] fell after using the toilet during transfer from toilet to wheelchair and sustained a fracture to 10th rib, right tibia/fibula. Family made an allegation of neglect. Visual assessment and vital signs: Excruciating pain to right lower extremity, 911 called, resident sent to ER for further evaluation: Nondisplaced, nonoperative fracture of right 10th rib and right tibia/fibula. Nonoperative treatment and support, pain management and cast.Interview on 11/19/25 at 9:22 AM with Resident #1 revealed that CNA A was assisting her off the toilet on 11/09/25. She stated CNA A pulled up her brief and pajama bottoms and had her hand resting on the back of her arm. Resident #1 stated to CNA A, Help me, don't let me fall. Resident #1 stated after she said that the next thing she remembered was landing on the floor and screaming due to the excruciating pain in her leg. Resident #1 stated she hit the toilet paper holder, the toilet, and wheelchair before hitting the ground. She stated she did not have a gait belt on. Resident #1 stated the nurse [RN B] came into the room after hearing her screaming and immediately called 911. Resident #1 stated at the hospital they told her she broke her leg in 3 places and broke her ribs. She stated she now had a full leg cast on her right leg and could only use the bathroom in her brief. Resident #1 stated she was feeling better after leaving the hospital, but she did feel upset with having to stay in bed instead of her recliner. Resident #1 stated she understood why she needed to stay in bed for care and agreed to it, but prior to the incident, for the past 12 years, she slept exclusively in her recliner. Resident #1 stated the fall has caused her to have a lot of changes and she felt like the CNA did not know what she was doing. Interview on 11/19/25 at 1:10 PM with Resident #1's RP revealed that he was very upset with the fall and how it happened. Resident #1's RP stated the CNA did not have a gait belt and he felt that no staff should have operated without a gait belt. He stated Resident #1 was wheelchair bound, and staff should have used the gait belt. He said since the fall, staff have been very attentive and have had training. Resident #1's RP stated Resident #1 was now in a lot of pain and tried to keep a positive attitude, but he knew it was affecting her. He stated she was forced to sleep in the bed, and she had never done that. He stated she had tailbone surgery and had slept in the recliner for the last 10-12 years. Resident #1's RP stated Resident #1 did not sleep good in a bed. He stated the facility was doing a good job now and he was very pleased with therapy.Interview on 11/19/25 at 11:27 AM with CNA A revealed on 11/09/25 she answered Resident #1's call light and Resident #1 requested to use the bathroom. CNA A stated Resident #1 did not seem like her normal self. CNA A stated Resident #1 was sleeping more that day and assumed the resident was tired. CNA A stated she assisted Resident #1 to the toilet with no issues. CNA A stated when the resident finished, Resident #1 pushed the call light, and she went to assist. CNA A stated she assisted Resident #1 to stand and pulled her pants up. CNA A stated when she went to pivot, Resident #1 asked her not to touch her right there . CNA A stated it confused her because it was on the back of Resident #1's arm to steady her. CNA A stated the resident started to fall and stated, Don't let me fall. CNA A stated she started to try and help and did everything she could to get the resident into the wheelchair. CNA A stated the resident may have hit the trash can on the way down. CNA A said Resident #1 was in immediate pain after she fell. CNA A stated RN B came into the room, checked her vital signs, and called 911 since Resident #1 was in a lot of pain. CNA A stated she would use the gait belt sometimes with Resident #1, but that day, she forgot to use one. CNA A stated she should have used the gait belt because it may have prevented the fall. CNA A stated the risk of not using a gait belt was the resident could fall. CNA A stated she had been in-serviced on abuse/neglect, gait belt usage, safe transfers, fall prevention, and checking Kardex (CNAs charting system) to see what level of assistance the residents require. Interview on 11/19/25 at 12:54 PM with CNA C revealed she had worked at the facility for 6 years. She stated she was familiar with and cared for Resident #1. CNA C stated Resident #1 always needed assistance with standing. She stated she always used the gait belt because the resident was unsteady. She stated she was not at the facility when Resident #1 fell. She stated Resident #1 was now bedbound and needed total assistance. CNA C stated she knew what level of assistance the residents were based on the Kardex. She stated she would always clarify and ask her nurses if she was ever unsure. She stated she had been in-serviced on transfers, falls, and when to use the gait belt. CNA C stated a gait belt should be used with any transferring or resident walking. She stated gait belts were kept behind each door and were mandatory to use. She stated the risk of not using the gait belt was that the resident could fall and get hurt. Interview on 11/19/25 at 1:22 PM with CNA D revealed she has worked at the facility for 4 years. CNA D stated she worked with Resident #1 before she fell. She stated Resident #1 needed extensive 1-person assist when using the bathroom. CNA D stated she would use the gait belt on her. CNA D stated she was very familiar with Resident #1 and automatically knew how to use the gait belt with her. She stated she had been in-serviced on falls, transfers, and using gait belts. CNA D stated the aides were to check the chart with any new residents and at least once a day. She stated the nurses were also good at educating her with new residents or if they have a change in condition. CNA D stated gait belts should be used for any transfers. She stated the risk of not using a gait belt was the resident could fall. Interview on 11/19/25 at 1:36 PM with CNA E revealed she has worked at the facility since July 2025. She stated she worked with Resident #1 prior to her fall. CNA E stated she always used the gait belt on Resident #1 and used it to assist her with standing. She stated Resident #1 was an extensive 1-person assist. CNA E stated she had been in-serviced on transfers, gait belts, and preventing falls. She stated she knew what assistance a resident needed based on the Kardex. She stated that all transfers needed gait belts. CNA E stated there were gait belts in each room and they were always to be used. CNA E stated the risk of not using a gait belt was injury to the residents. Interview on 11/19/25 at 2:15 PM with RN F revealed he has worked at the facility since 2018. He stated he had worked with Resident #1 but was not present the day she had fallen. He stated that Resident #1 always needed a gait belt and was a 1-person assist before her fall. RN F stated she had one sided weakness and needed extensive assistance. He stated Resident #1 did have previous falls, but not frequently. He stated Resident #1 was now bedbound due to her injuries and physical therapy were the only ones that could get her up. RN F stated he was in-serviced on falls, transfers, and gait belts. He stated all weight bearing transfers should use gait belts. He stated CNAs knew what assistance level a resident was based on their charting, and they could always ask him. He stated he always checked the resident rooms to ensure there was a gait belt and would observe transfers. He stated the risk of not using a gait belt was the resident could get fractures from getting dropped or staff could grab them incorrectly and cause injuries. Interview on 11/19/25 at 2:34 PM with LVN G revealed she had worked at the facility for 3 years. She stated she had not worked with Resident #1 and was not aware of the fall. She stated she had been in-serviced on transfers, falls and gait belts. She stated all residents who were transferred without a mechanical lift and needed staff assistance needed a gait belt. She stated that when a resident was admitted to the facility, the nurses and therapists did an assessment to determine what assistance level was needed for transfers. LVN G stated they always let the CNAs know and it was documented in Kardex so they could see. She stated the CNAs should check Kardex daily and talk to the nurses if they had any questions. She stated she was always educating and reminding the aides to use gait belts. LVN G also revealed she would make rounds to check if gait belts were present and being used. She stated the risk of not using gait belts was that the residents could lose their balance and fall. She stated it was a huge safety risk to not use gait belts. Interview on 11/19/25 at 3:25 PM with the Administrator revealed after Resident #1's fall she provided education and in-serviced all staff to follow the care plan regarding fall precautions, safe transfers, and therapy did education and demonstration with staff on transferring. She stated the ADONs did check-offs for gait belts and transfers as well. The Administrator stated she had done audits to make sure each room had a gait belt present. She stated they in-serviced on abuse, neglect, exploitation, updating care plans after each fall and with any changes. The Administrator stated she suspended the perpetrator after finding out a gait belt was not used. She said before suspending they did education and in-service. The Administrator stated she brought CNA A back on 11/13/25 to monitor her gait belt usage and reinstated the education. She stated CNA A did follow the care plans and used gait belts correctly that day, but she still had not officially brought her back. The Administrator stated she was waiting to discuss it with Resident #1 and the resident's RP to decide if she would continue working on that hall or be moved to a different one. Interview on 11/19/25 at 3:36 PM with LVN H revealed she had worked at the facility for 5 years. She stated she had worked with Resident #1 but was not present the day she had fallen. LVN H stated Resident #1 did need a gait belt with all transfers because she needed staff assistance. LVN H stated Resident #1 has more pain, was now bedbound and sleeps most of the day. She stated she had been in-serviced on falls and transfers. She stated the CNAs go to the plan of care and Kardex to review the residents and their needs. She stated the CNAs could always go to the nurses as well. LVN H stated every room had a gait belt and she would round to make sure gait belts were used during transfers. She stated if any rooms did not have a gait belt, the nurses could get one. LVN H stated all transfers required a gait belt. She stated the risk of not using a gait belt was the resident could fall. Interview on 11/19/25 at 4:26 PM with RN B revealed she was present on 11/09/25 when Resident #1 had a fall. She stated she went to the room when she heard screaming, and the emergency call light was on. RN B stated when she went into the bathroom, she found the resident right in front of the toilet with her back against the wall and facing the toilet. She stated her wheelchair was present as well. RN B stated Resident #1 was screaming and had severe pain in her right leg. She stated she did not observe the gait belt on Resident #1. RN B stated Resident #1 normally did wear a gait belt. RN B stated she only worked the weekends, so she was not as familiar with Resident #1, but she checked her vital signs at the start of her shift, as well as blood sugar with no concerns. She stated Resident #1 appeared her normal self. She stated she could not recall if there were any other staff present during the incident. RN B stated she immediately called 911 due to Resident #1's pain and the paramedics were there within a couple minutes. RN B stated she checked her vital signs and did not see any wounds or open areas. RN B stated she had been in-serviced on transfers, gait belts, and fall prevention. She stated all transfers should have a gait belt. She stated the gait belts were in every room, and she was monitoring the transfers to ensure they were used. RN B stated it was a safety risk if a gait belt was not used and puts the residents at a high risk of falling. Interview on 11/19/25 at 5:33 PM with ADON I revealed she had worked at the facility for 2 years. She stated she was not at the facility the day Resident #1 fell and went to the hospital. She stated it was a weekend, and the DON was made aware immediately after it happened. ADON I stated CNA A should have used a gait belt when transferring Resident #1. She stated Resident #1 had one sided weakness but would sometimes refused the gait belt. ADON I stated on the date of the incident Resident #1 did not refuse the gait belt, so it should have been used. ADON I stated any residents that needed assistance and was weight bearing with transfers should have a gait belt. ADON I stated Resident #1 did always sleep in her recliner. She stated when Resident #1 came back from the hospital, she really wanted to be back in the recliner. ADON I stated the staff could not change her in the recliner so Resident #1 finally agreed, but she did not like to use the bed. ADON I stated staff were in-serviced on everything regarding abuse/neglect, falls, transfers, and using the gait belts. She stated she did spot checks and audits to ensure staff were using the gait belts. She stated the risk of not using a gait belt was a fall and injuries. Interview on 11/19/25 at 5:51 PM with the Administrator revealed she expected all her staff to use gait belts during transfers. She stated that was why the gait belts were kept in the room, so they were easily accessible. The Administrator stated she reinforced that education and has ensured that the gait belts were all present. The Administrator stated there had been no other recent falls related to gait belt usage. The Administrator stated the risk when not using the gait belt was an increased risk of falls and injury to both the residents and staff. Record review of the facility's undated CNA onboarding training revealed it included Using a Gait/Transfer Belt, which reflected the following, . There are several advantages to using a gait/transfer belt: 1. It reduces the chance of injury to either the resident or nursing assistance. 2. It helps minimize fall related injuries. 3. As you have the belt to hold on to, you will feel more in control of the situation. 4. This provides a feeling of security and helps maintain the resident's strength. The gait belt is used with residents who require assistance in moving. This includes those who are weak, unsteady, or prone to falling.Record review of the facility's Transfer: Bed-chair/wheelchair policy, dated 02/05/15, reflected the following, Purpose: To move safely from bed to chair or wheelchair and back again. Equipment: Wheelchair with locks or sturdy chair, Shoes or slipper with nonskid soles, Gait belt, if necessary, Pillows, if necessary, Slide board, if necessary. Procedure . ONE PERSON - STAND-PIVOT: .4. Assist to sitting position on side of bed - refer to Dangling procedure for specific instructions 5. Apply gait belt to resident, if necessary. 12. Align in chair/wheelchair using pillows to support proper positioning. 13. Remove gait belt. The facility implemented the following corrective measures prior to the HHSC investigation:Record review of a facility in-service completed on 11/10/25 revealed the following, Transfers: 1. Gait belts must be used for ALL transfers. 2. When a resident is a standby assist, staff must use gait belt for resident safety. 3. Staff must ensure that each resident has a gait belt in their room behind the door. 41 staff signatures were present, all from the nursing department. Record review of the facility Gait Belt Check off, dated 11/11/25 reflected the ADONs completed gait belt checkoffs with 26 staff members, who were able to demonstrate correct use of gait belts. Record review of the facility's gait belt transfer audit completed between the dates of 11/10/25 - 11/14/25 reflected that the ADONs audited 23 gait belt gate belt transfers. Staff were able to demonstrate and perform safe gait belt transfers. Record review of a facility in-service, Preventing, recognizing, and reporting abuse, neglect, exploitation/misappropriation, completed on 11/10/25 revealed the following, 1. When suspecting abuse, neglect, exploitation/misappropriation, you must report to the abuse coordinator immediately. 2. The abuse coordinator is [The Administrator]. 45 staff signatures were present from various departments.Record review of a facility in-service record, dated 11/10/25, reflected 24 staff members from the nursing department attended the in-service which covered the following: In the event when a resident falls, a CNA may NOT move the resident or any part of the resident's body until the resident is evaluated by the nurse. When a resident had an incident that requires medical care (fall, code blue, etc), the first responder may NOT leave the resident alone. The first responder calls (shouts) for help and stays with the resident until help arrives. Record review of a facility in-service record, dated 11/10/25, reflected 26 staff members from the nursing department received training on the facility's Fall Management System Policy.Record review of an individual in-service completed on 11/10/25 with CNA A reflected the following: Safe Transfer. CNA must use gait belt for all transfers. CNA must ensure that they are familiar with each resident's Kardex to learn how to care for them. If resident declines use of gait belt or declines assistance, change nurse must be notified immediately. Record review of an individual in-service completed on 11/10/25 with CNA A revealed the following, Falls and Safety. CNA may not move any part of the resident's body after a fall unless instructed by the nurse after assessment. CNA must remain with the resident until the nurse arrives to assess the resident.Record review of a Quality Assurance Agreement Patient Questionnaire with 6 residents on 11/10/25 revealed none of the 6 residents had concerns.Observation on 11/19/25 at 10:56 AM with CNA C and Resident #2 revealed the resident being transferred from her wheelchair to the bathroom. A gait belt was noted to have been stored on the back of the bedroom door and another in the bathroom. The gait belt was used appropriately throughout the observation, and no concerns were noted with the transfer. Observation on 11/19/25 at 11:10 AM with CNA J and Resident #3 revealed the resident being transferred from his wheelchair to the toilet. A gait belt was stored on the back of the bedroom door and used throughout the transfer. No concerns were noted with the transfer, and the gait belt was properly used. Observation on 11/19/25 at 11:52 AM with CNA K and Resident #4 revealed the resident being transferred from her wheelchair to the bathroom. The gait belt was stored on the back of the door, and another was present in the bathroom. Resident #4 was safely transferred by CNA K using the gait belt. No issues were noted with the transfer. Observation on 11/19/25 at 4:47 PM with CNA L and Resident #5 revealed the resident being transferred from her bed to the wheelchair. The gait belt was used properly, and no concerns were noted with the transfer. Another gait belt was noted in bathroom.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 7 residents (Resident #1) reviewed for infection control. CNA B failed to wear a gown for Enhanced Barrier Precautions while assisting LVN A with wound care for Resident #1. These failures could place residents at risk of infectious disease. The finding included: Review of Resident #1's admission record dated 02/20/25 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were acquired absence of left leg above the knee, orthopedic after care following surgical amputation, pressure ulcers (bed sore), and infection following a procedure. Review of Resident #1's admission MDS dated [DATE] was not completed and did not reflect a Brief Inventory of Mental Status (a standardized assessment to measure long and short-term memory), indwelling medical devices, wounds, wound vac (this is a medical device that helps to heal the wound from the inside using a suction motion) or infection. Review of Resident #1's physician orders for February reflected: -Cleanse pressure wound with cleanser, pat dry, apply collagen particles and calcium alginate to wound bed and cover with silicone foam dressing everyday shift for Right Posterior Thigh Wound. -Cleanse pressure wound with cleanser, pat dry, apply collagen particles and calcium alginate to wound bed and cover with silicone foam dressing everyday shift for Sacrum (tail bone) Wound. Review of Resident #1's care plan initiated 02/12/25 revealed Resident#1 had multiple pressure ulcers to sacrum & thigh and was at increased risk for infection, pain, and a decline in functional abilities. The goal was Resident #1's pressure ulcer would show signs of healing through next review date. Resident#1's pressure ulcer would be free from infection and the risk for infection would be minimized through the next review date. The intervention was to provide pain management prior to dressing changes and repositioning as needed, provide wound care per physician's order, Keep dressing clean, dry, and intact, replace the dressing as needed for soiling. Monitor dressing to ensure it is intact and adhering. Report loose or soiled dressings to treatment or charge nurse. Routinely evaluate and document the wound dimensions, drainage, and condition of surrounding tissue. Notify the physician as needed for changes. Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Low air loss mattress. Provide incontinent care as needed. The care plan did not reflect EBP for Resident #1with wounds or wound vac. Observation and interview on 02/20/25 at 1:30 PM, revealed a door signage that read STOP Enhanced Barrier Precautions. Everyone must clean their hands before entering the room and when leaving the room. Providers and staff must wear gloves and gown for the following: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use such as central lines, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring dressing. LVN A put on his gown and gloves to perform wound care for Resident #1. CNA B stated she was there to assist LVN A. CNA wore gloves. She did not wear a gown. Resident #1 was in the bed with family at bedside. Family stated Resident #1 moved from another facility due to worsening infection. Family stated resident had a wound vac on her amputated leg and that she admitted with wounds. CNA B helped to hold Resident #1 onto the left side by the amputated leg without a gown on. In an interview with LVN A on 02/20/25 at 1:48 PM, he stated he did not remind CNA B to put on a gown because he thought only the person completing the actual wound care needed to wear a gown. LVN A stated following EBP was important to prevent infection. In an interview with CNA B on 02/20/25 at 1:51 PM, she stated she forgot to put on her gown for EBP. She stated she had been in serviced for EBP which was used to prevent infection. She stated she was not thinking and forgot to wear a gown. In an interview with DON on 02/20/25 at 4:47 PM, DON stated CNA B should have worn a gown for PPE during wound care assistance. She stated the expectation was to follow precautions of EBP when touching bed, resident, or any high contact activities. She said EBP was put in place for infection control, and everyone should wear PPE, as necessary. In an interview the administrator on 02/20/25 at 5:15 PM revealed that all staff were expected to wear their PPE for EBP. She stated this was part of the infection control and all staff were responsible for following the infection control policy. Review of the facility's in-service dated 12/10/24, titled skin assessment during shower: Head to toe, Weekly skin assessment, abnormal findings must be reported, wound care revealed, LVN A, LVN C and CNA B had completed training. Review of policy Infection Prevention and Control Program, revised 11/06/24, revealed, .Enhanced Barrier Precautions EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: a. Infection or colonization with an MDRO when Contact Precautions do not otherwise apply. b. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status During high-contact resident care activities: o Dressing o Bathing/showering o Transferring o Providing hygiene o Changing linens o Changing briefs or assisting with toileting o Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator o Wound care: any skin opening requiring a dressing Gloves and gowns prior to the high-contact care activity (Change PPE before caring for another resident) (Face protection may also be needed if performing activity with risk of splash or spray) .

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for one of one (Resident #1) reviewed for intravenous fluids. The facility failed to change Resident #1's PICC (this is a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing before 02/20/25. This failure could affect residents by placing them at risk for infection and IV complications. Findings included: Review of Resident #1's admission record dated 02/20/25 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were acquired absence of left leg above the knee, orthopedic after care following surgical amputation, pressure ulcers (bed sore), and infection following a procedure. Review of Resident #1's physician's orders for February 2025 reflected: -Change transparent dressing to the Midline (a type of IV line) site one time a day every 7 day(s) for PICC IV ACCESS. Measure upper arm circumference and exterior catheter length with each dressing change. - Observe IV access site for erythema (redness), drainage, and edema (swelling) every shift for IV access Record any abnormal findings in the progress notes and notify the physician. Review of Resident #1's care plan initiated 02/12/25 revealed Resident#1 had multiple pressure ulcers to sacrum & thigh and was at increased risk for infection, pain, and a decline in functional abilities. The goal was Resident #1's pressure ulcer would show signs of healing through next review date. Resident#1's pressure ulcer would be free from infection and the risk for infection would be minimized through the next review date. The intervention was to provide pain management prior to dressing changes and repositioning as needed, provide wound care per physician's order, Keep dressing clean, dry, and intact, replace the dressing as needed for soiling. Monitor dressing to ensure it is intact and adhering. Report loose or soiled dressings to treatment or charge nurse. Routinely evaluate and document the wound dimensions, drainage, and condition of surrounding tissue. Notify the physician as needed for changes. Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Low air loss mattress. Provide incontinent care as needed. The care plan did not reflect Resident #1 a PICC line. Review of Resident #1's MAR/TAR for February 2025 reflected Change transparent dressing to the Midline site one time a day every 7 day(s) for PICC IV ACCESS Measure upper arm circumference and exterior catheter length with each dressing change. Start Date- 02/14/2025 0900, the MAR/TAR was marked that the dressing change was completed by LVN D on 02/14/25 at 09:00 AM. During wound care observation and interview with LVN A on 02/20/25 at 1:30 PM, it was revealed that Resident #1 had an IV on her right upper arm with a single lumen (access port of the IV line) . LVN A stated it was a PICC line. The PICC line dressing was dated 02/10/25. In an interview with LVN A on 02/20/25 at 1:48 PM, LVN A stated the PICC dressing was supposed to be changed every 7 days. He stated Resident #1's PICC dressing should have been changed 3 days ago [02/17/25]. He stated the nurse taking care of Resident #1 was responsible for changing the IV dressing unless the floor nurse had asked him to do so, he would have changed it. He stated if he had noticed the IV dressing beforehand, he would have informed the nurse (LVN C) taking care of Resident #1. He stated he was training on PICC line dressings. He stated he would inform the floor nurse, LVN C, right away. LVN A stated IV dressing changes was important to prevent infection. In an interview with LVN C on 02/20/25 at 1:54 PM, she stated she did not check the date on Resident #1's IV dressing. She stated, To be honest I only focused on the assessment of the IV site for redness and swelling. She stated she had used the PICC line to infuse an antibiotic this morning. She stated the PICC line dressing was changed every 7 days or as needed. She stated the risk to the resident was infection. She stated she would change the dressing immediately. In an interview with the DON on 02/20/25 at 4:47 PM, she stated they had a batch order for a PICC line, and the task had popped up on the EMR 3 days ago and one of the nurses might have marked the task as done . She stated nurses were responsible for completing the tasks and not just marking it as completed. She stated LVN C was responsible for accessing the PICC before and after use and she should have noticed the date. She stated the expectation was that PICC dressing change was completed every 7 days on the night shift. She stated all nursing was responsible for accessing the IV's. She stated the dressing change was necessary for infection control. LVN D was not available for interview on 02/20/25 by 5:15 PM. In an interview with the Administrator on 02/20/25 at 5:15 PM revealed that nurses were responsible for assessing the PICC line dressings and completing dressing changes as ordered, weekly. She said all dressing changes should be documented by the nurses. She stated if the IV dressing was not changed as ordered, then there was a potential for infection. Review of the facility's PICC line Transparent Dressing Change policy, revised 07/06/2018, revealed, Policy to prevent external infection of the peripheral or central venous catheter .Upon initial insertion of PICC Line monitor the dressing in the first 24 hours for accumulation of blood fluid or moisture beneath the dressing . Transparent membrane dressings (no gauze over site) are changed every 7 days and PRN . Document the procedure in the Nurses Notes or initial Treatment Administration Record. Chart for any signs, symptoms of complications related to the vascular access device, arm circumference measurement and external exposed PICC line catheter measurement .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. CNA A failed to use a gait-belt to transfer Resident #1 from her bed to the shower chair on 09/03/24 causing a 1.0 cm x 1.5 cm skin tear on Resident #1's right arm. This failure could place residents at risk of injury. Findings included: Record review of Resident #1's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included psychotic disturbance (loss of touch with reality and having abnormal thoughts, precerptions and behaviors), muscle wasting, history of falls, and unsteadiness on her feet. Record review of Resident #1's admission MDS assessment, dated 05/04/22, and her discharge MDS assessment, dated 10/07/24, reflected she had a BIMS score of 5, indicating she had severe cognitive impairment. Her Functional Status assessment indicated she required total assistance with all ADLs, to include transfers. Record review of Resident #1's care plan, dated 10/07/24, indicated she had an ADL self-care deficit with an intervention of extensive assistance of one for transfers. Record review of an x-ray report, dated 09/04/24, reflected Resident #1 had an x-ray done of her right tibia and fibula (lower leg) and right ankle, and there was no fracture indicated. Record review of the NP's Progress Notes, dated 09/05/24, reflected Resident #1 seen and noted to have no injury, redness, bruising or edema to her right leg. The Progress Note reflected Resident #1 was seen after the resident had complained of pain following a transfer. The NP noted an x-ray was done of the resident's right leg, and there was no fracture noted. The NP also noted the resident had a superficial left arm skin tear during this transfer which is being treated. Record review of LVN B's written statement, dated 09/05/24, reflected she was notified of Resident #1 having a skin tear by CNA A. When LVN B assessed the resident, she noted a skin tear measuring 1.0 cm x 1.5 cm. She noted no other injury and treated the skin tear with steri-strips. LVN B made the appropriate notifications. LVN B was later notified by Resident #1' s family the resident was complaining of right leg and ankle pain. The NP was notified, and an x-ray was ordered. The x-ray revealed no fractures. Interview on 11/13/24 at 11:30 AM with LVN B revealed when she assessed Resident #1, the resident had been showered and put back in bed. She stated CNA A did not know how the skin tear had occurred. She stated CNA A did not notice it until she was putting the resident back to bed. LVN B stated the injury did not require a dressing because there was no bleeding. Record review of the Social Worker's written statement, dated 09/05/24 reflected she was contacted on 09/03/24 by Resident #1's family complaining the resident had been handled roughly during a transfer to the shower chair, resulting in a skin tear to her arm. The Social Worker initiated a grievance for Resident #1. The resident's family visited the Social Worker on 09/05/24 and informed her that after viewing video footage from Resident #1's room the resident had refused a shower, but the CNA had proceeded with the transfer and shower. Interview on 11/13/24 at 11:49 AM with the Social Worker revealed she had not been shown the video footage the family referenced, and her notes and the grievance report were from her communication with Resident #1's family. Record review of the facility's Provider Investigation Report, signed and dated by the DON on 09/12/24, reflected on 09/03/24 Resident #1 sustained a skin tear to her right arm, measuring 1 cm x 1.5 cm, when she was transferred from her bed to a shower chair by CNA A. The family reported the occurrence to the facility after seeing the incident on video recorded in the resident's room. The Provider Investigation Report reflected after the facility learned of the incident, they suspended CNA A on 09/03/24 and then terminated her employment. Observation of the video, dated 09/03/24 at 11:40 AM, provided by Resident #1's family, included audio. The video revealed Resident #1 in bed and CNA A attempting to transfer the resident from bed to a shower chair that was on the left side of the bed. CNA A had Resident #1 sitting up in bed with her legs off the side of the bed, with Resident #1 holding onto CNA A's shirt. Without using a gait-belt, CNA A held Resident #1 up with her hand on the back of the resident's neck. Resident #1 fell back on to the bed. CNA A then lifted Resident #1 up with her hands under the resident's left arm and by the right arm. CNA A counted to three and then put the resident into a shower chair. The resident complained of pain to her leg after being put into the shower chair. The video clip did not show the resident being combative or verbally/physically resisting care. Interview on 11/13/24 at 2:26 PM with the Administrator and the DON revealed the family had not provided them with the video of the transfer. During this interview, they were shown the video, and the Administrator stated he did not know the transfer was that bad. He added that was why CNA A was terminated. The DON stated she did not see CNA A use a gait-belt, which was against policy, as was lifting the resident by their arms. The DON stated she had done a one-on-one in-service with CNA A on resident rights and customer service immediately and before CNA A was suspended, but not on transfers or accident prevention. Telephone interview was attempted on 11/13/24 at 1:10 PM and 2:35 PM with CNA A, but the attempts were unsuccessful. Record review of the facility's Transfers of Residents policy, dated 09/02/24, reflected: The goal is to ensure the safety of the resident when moving from one place to another, to prevent injuries to the resident .Use a gait belt around the resident to protect both the resident and yourself, unless contraindicated and as applicable.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three residents (Resident #1) reviewed. The facility failed to ensure the Wound Care Nurse used proper body mechanics while providing incontinence care to Resident #1 on 07/11/24. This failure could place residents at risk of injury, change in condition, and not receiving proper treatment and care in a timely manner. Findings included: Record review of Resident #1's face sheet, dated 10/22/24, reflected the resident was an [AGE] year-old female, with an initial admitted [DATE] and a readmitted [DATE]. Resident #1 had diagnoses of cerebral infarction (brain tissue death due to blood blockage), irritant contact dermatitis due to fecal, urinary, or dual incontinence (skin rash), chronic pain syndrome (persistent pain), muscle wasting atrophy (loss or thinning of muscle tissue), cognitive communication deficit (difficulty with communication), muscle weakness (lack of muscle strength), abnormal posture (chronic or rigid body position), edema (fluid buildup in body tissue), and acute pain due to trauma. Record review of Resident #1's MDS assessment dated [DATE], reflected Resident #1's had a BIMS score of 15, which meant the resident had intact cognition. Record review of Resident #1's care plan dated 08/07/24, reflected the following: [Resident #1] has recurrent chronic rash and recurrent cellulitis. Provide gentle peri-care after each incontinence episode. Communication (Impaired): Resident has a communication problem related to history of aphasia (language disorder). Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express. Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Observation of a video, dated 07/11/24, reflected the Wound Care Nurse and Caregiver A as they provided perineal and incontinent care to Resident #1. In the video the Wound Care Nurse was seen lifting Resident #1's right leg straight in the air as he instructed Caregiver A on how to apply the white cream to the resident's under thigh area. The Wound Care Nurse was then seen putting Resident #1's leg back down straight on the bed, and the two staff members secured Resident #1's brief. The video had sound and it did not appear Resident #1 mentioned or appeared to have any pain. Record review of the Resident #1's hospital record dated 07/26/24, reflected Resident #1 admitted to the emergency department due to an altered mental status. The hospital record noted Resident #1' Family Member stated Resident #1 had complained of right hip pain for 1 and half weeks. It noted Resident #1 had tenderness around the right hip and pain with range of motion. The hospital document noted Resident #1 had an acute sub-capital right femoral neck fracture (neck of thighbone) without dislocation at the right hip joint. It also noted mild right hip joint osteoarthritis (joint breakdown). Record review of Resident #1 Medical Record from the Attending Surgeon at the hospital dated 07/26/2024 noted, Resident #1 was able to verbally tell her about the right hip pain. The Attending Surgeon noted upon starting the surgery the fracture site was not mobile and appeared subacute to chronic (bone fracture that started to heal). The Attending Surgeon noted the following: Addendum The fracture appeared subacute to chronic in nature, given the amount of fibrous tissue at the fracture site and small hematoma. It is my professional opinion that the EMS team that transported the patient to the hospital just prior to this admission was not at fault. In an interview on 10/22/24 at 12:08 PM, Resident #1's Family Member stated the family thought Resident #1's fracture resulted from the leg lift seen in the video. Resident #1's Family Member stated Resident #1 went to the hospital for something unrelated and asked the hospital to check her leg, because Resident #1 had complained about pain in the area. Resident #1's Family Member stated Resident #1 was diagnosed with a fracture while at the hospital. Resident #1's Family Member stated the resident had not fallen or had any accidents recently. The Family Member stated the facility did not report any incidents to the family which could have resulted in an injury. In an interview on 10/22/24 at 1:50 PM, Resident #1's Primary Care Physician stated he had no concerns with the care of Resident #1 while she was at the facility. The Primary Care Physician stated he stayed on top of Resident #1's care, especially since the resident's family member was very involved and liked to be updated frequently. He stated Resident #1 passed away recently, but it was not due to the care from the facility. He stated the resident had a lot of health issues. The Primary Care Physician stated he did not think lifting the resident's leg about 60-65 degrees could have caused the hip fracture. The Primary Care Physician stated he had not received any reports from the facility regarding Resident #1 and pain, or an increased amount of pain. He stated there was no change of condition reported to him regarding pain. He stated he did not receive a report of acute pain until Resident #1 was transported to the hospital on 07/26/24. He stated the facility management was convinced the fracture occurred during transport to the hospital. The Primary Care Physician stated he assessed the resident a couple of days before she went to the hospital, and Resident #1 did not complain of pain. In an interview on 10/24/24 at 11:41 AM, the Wound Care Nurse stated he knew Resident #1 well, and she did not complain at all. He stated he never received any complaints from the family. He stated Resident #1 was vocal and would tell you how she liked staff to provide care at times. The Wound Care Nurse stated Resident #1's legs were kind of forced inward, and it was easier at times to elevate her leg instead of turning her on her side when providing care. He stated he would generally turn the resident instead of lifting the leg, but it would depend on the limitations of whichever resident. The Wound Care Nurse stated in this instance he thought she asked him to lift her leg, because it felt better for her due to the wounds on her right leg. He stated he did not document her request. The Wound Care Nurse stated there was never a time when he lifted her leg and she complained of pain. The Wound Care Nurse stated there was no risk when he lifted Resident #1's leg, because the leg was not straight up, but just lifted, and he stated the resident was not in any pain. In an interview on 10/24/24 at 2:44 PM, the DON stated Resident #1 had a strong side and a weak side of her body. She stated Resident #1 would tell you if she wanted her care a certain way or if she was in pain. The DON stated the Wound Care Nurse would not have done Resident #1's care differently unless it was requested. The DON stated there was no documentation or any changes to the resident's care plan because it was probably a one-time request or a request in the moment. She stated if Resident #1 requested it more than once then it would have been care planned. The DON stated generally it was safer to turn a resident on their side instead of lifting the resident's leg. The DON stated the risk was the quality of care given to the resident if the resident did not request the leg lift. In an interview on 10/24/24 at 3:19 PM, the Administrator stated Resident #1's family would communicate with him and his staff often and never mentioned any concerns with the resident's leg being lifted. The Administrator stated the residents should be repositioned instead of lifting their legs in most instances. He stated he did not recall her being injured and she did not complain of pain, so he did not see the risk of the leg lift. The Administrator stated there was a care plan meeting after the resident returned from the hospital, in which Resident #1's family told the staff the resident's hip was fractured. He stated they believe the fracture occurred during the transport to the hospital, because he nor the DON received any report of any incidents with the resident prior to her transport to the hospital. The Administrator stated the staff should follow their policy and reposition the resident unless the resident requests otherwise. The Administrator stated he was not aware of the video or Resident #1's leg being lifted. The Administrator stated he did not see the risk, because the staff would be handled and re-trained. Record review of the facility's Incontinence Care policy, last revised 02/14/20, reflected the following: .Procedure Position on side turned away from caregiver. Position on back with knees flexed and feet flat on the bed

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #1) reviewed for infection control. 1. The facility failed to ensure Caregiver A provided incontinence care using the proper technique when she wiped Resident #1's perineal area from back to front on 07/11/24. 2. The facility failed to ensure Caregiver A changed her gloves after she wiped Resident #1's perineal area on 07/11/24. These deficient practices could place residents at-risk for infections. Findings included: Record review of Resident #1's face sheet, dated 10/22/24, reflected the resident was an [AGE] year-old female, with an initial admitted [DATE] and a readmitted [DATE]. Resident #1 had a diagnosis of cerebral infarction (brain tissue death due to blood blockage), irritant contact dermatitis due to fecal, urinary or dual incontinence (skin rash), chronic pain syndrome (persistent pain), muscle wasting atrophy (loss or thinning of muscle tissue), cognitive communication deficit (difficulty with communication), muscle weakness (lack of muscle strength), abnormal posture (chronic or rigid body position), edema (fluid buildup in body tissue), and acute pain due to trauma. Record review of Resident #1's MDS assessment dated [DATE], reflected Resident #1's had a BIMS score of 15, which meant the resident had intact cognition. Record review of Resident #1's care plan dated 08/07/24, reflected the following: (Resident Name) has recurrent chronic rash and recurrent cellulitis. Provide gentle peri-care after each incontinence episode. Observation of a video, dated 07/11/24, reflected the Wound Care Nurse and Caregiver A as they provided perineal and incontinence care to Resident #1. In the video Caregiver A was seen as she wiped Resident #1's vaginal area from bottom to top. Caregiver A was seen putting a white cream on Resident #1's vaginal area, and then put the same white cream on the under-thigh area of Resident #1's right leg without changing her gloves before she went to a different area of Resident #1's body. In an interview on 10/24/24 at 12:24 PM, Caregiver A stated staff should wipe from front to back when perineal care was provided to a resident. She stated gloves should be changed after each task or area. Caregiver A stated Resident #1's legs were pretty close to each other, and stated Resident #1 was not flexible. Caregiver A stated it was hard to wipe the resident a certain way, because she was not flexible. Caregiver A stated not wiping Resident #1 correctly could have caused an infection, and not changing her gloves could have caused contamination. In an interview on 10/24/24 at 2:44 PM, the DON stated staff should wipe a female resident from front to back when providing care. She stated the staff should not wipe back and forth, because that would cause infection. The DON stated when cleansing or putting cream on different areas of the body, the staff should remove gloves, sanitize, then put on a new pair of gloves before tending to another area of the resident's body to prevent cross-contamination. The DON stated all staff were trained on infection control and perineal care. In an interview on 10/24/24 at 3:19 PM, the Administrator stated the staff had been trained on infection control and perineal care. He stated staff should know when to change their gloves and how to provide perineal care. He stated residents should be wiped from front to back when staff provide perineal care. The Administrator stated getting a citation for infection control would be a learning experience for his staff, as he has tried to train and re-train them on important subjects like infection control. The Administrator stated the risk of not changing gloves between areas of the body and wiping incorrectly was infection. Record review of the facility's Incontinent Care policy, last revised on 02/14/20, reflected the following: .Procedure .11. Cleanse per-area and buttocks with cleansing agent wiping from front of the perineum toward rectum. 12. Dry peri-area and buttocks from front to back 13. Apply skin protectant products, if needed and, or as ordered, per manufacturer's instructions . 15. Remove and discard gloves . Record review of an in-service titled, Covid-19 and Infection Control, dated 08/10/24, reflected the following: When to Perform Hand Hygiene Clean your hands: If hands will be moving from a contaminated body site to a clean body site during patient care . A general policy on infection control was requested on 10/22/24 and not received.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three (Residents #36, #107, and #69) of eight residents reviewed for ADL care. 1. The facility failed to provide two female residents, Residents #36 and #107, with grooming to ensure their facial hair was shaved. 2. The facility failed to provide Resident #69 assistance with timely incontinence care. These failures could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection. Findings included: 1. Record review of Resident #107's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, ulcer, and communication deficit. Record review of Resident #107's Quarterly MDS Assessment, dated 06/02/24, reflected a BIMS score of 4 indicating severe cognitive impairment. Her Functional Status evaluation indicated she required assistance with her personal hygiene. Record review of Resident #107's care plan, dated 07/03/24, reflected she had an ADL self-care deficit, with interventions including Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Her care plan did not reflect she refused ADL care. Observation and interview on 08/27/24 at 2:30 PM revealed Resident #107 was noted to have white facial hair on her chin, consisting of 6 hairs approximately an inch long. Resident #107 stated she was not aware of the hair on her chin, but she did not like the idea of having any facial hair. Resident #107 stated she thought her last shower was on the previous day (08/26/24) but could not recall her last shave. Observation and interview on 08/28/24 at 12:24 PM revealed Resident #107 remained unshaved and stated she had not asked the CNA to shave her. Record review of Resident #36's undated Admission Record reflected she was admitted to the facility on [DATE] with diagnoses which included right ankle injury, morbid obesity, sleep apnea, and high blood pressure. Record review of Resident #36's admission MDS, dated [DATE], reflected a BIMS score of 12 indicating she was cognitively intact. Her Functional Status evaluation indicated she required partial assistance with her personal hygiene. Record review of Resident #36's care plan, dated 07/17/24 reflected she had an ADL self-care deficit, with interventions including Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Her care plan did not reflect any refusal of personal hygiene. Observation and interview on 08/27/24 at 2:34 PM revealed Resident #36 was noted to have white facial hair consisting of four hairs on her chin that were approximately 1/2 inch long. Resident #36 stated she did not like having facial hair of any kind, it was embarrassing. Her last bed bath was on 08/26/24 but the CNA did no mention the facial hair. Observation on 08/28/24 at 12:24 PM revealed Resident #36 was still unshaven. Interview on 08/28/24 at 2:25 PM CNA A stated she had bathed both Resident #36 and #107 on 08/26/24. She stated she did not notice their facial hair at the time because she was in a hurry because she was too busy with her patient load. Interview on 08/29/24 at 3:02 PM the DON stated the facility had plenty of staff to care for the residents, and any CNA could call for help any time they needed. The DON stated they did not have a policy that addressed shaving residents. She stated it should be done as part of the bathing process. 2. Record review of Resident #69's face sheet, dated 08/27/24, indicated Resident #69 was a [AGE] year-old male, admitted to the facility on [DATE], 09/04/19 and readmitted on [DATE]. Resident #69's diagnosis included Cerebral Infarction (stroke, poor blood flow to the brain), Contracture of Muscle (shortening of muscles causes joints to become stiff), Urinary Tract Infection (infection that affects part of the urinary tract), Acute Kidney failure (sudden decrease in kidney function), Type 2 Diabetes Mellitus (high blood sugar), Major Depressive Disorder (pervasive low mood, low self-esteem), absence of right leg above knee. Record review of Resident #69's admission MDS assessment, dated 07/18/2024, indicated Resident #69 had the ability to make himself understood and understood others. The assessment indicated Resident #69's BIMS score was not indicated, because he was rarely understood. Resident #69 was dependent on staff with toileting. Resident #69 required substantial/maximal assistance with shower/bathing and personal hygiene. Record review of Resident #69's care plan, undated, indicated Resident #69 was incontinent of bowel and bladder due to disease process and Resident #69 has potential for development for pressure ulcer related to immobility impairment. Goal: Resident will remain free from skin breakdown due to incontinence and brief use. Resident # 69 will be free of preventable breakdown. Interventions included: Check frequently for wetness and soiling, every two hours and change as needed. Briefs or incontinent products as needed for protection. Apply barrier cream after each incontinent episode. Weekly skin checks to monitor for redness, circulatory problems, breakdown, report any new skin conditions to the physician. Record review of Resident #69's task for toileting care revealed Resident #69 had received incontinent care last at 03:17 (3:17 AM) on 08/27/24. Interview and observation on 08/27/24 at 2:57 PM of Resident #69 revealed him in bed, Resident #69 stated lunch was great, and he had no concerns with his care at this time. Observation revealed Resident # 69's cloth bed pad was discolored with dark colored rings that indicated the resident may have been incontinent several times throughout the day. When Resident #69 was asked if he was soiled, he responded no. Surveyor did not observe any strong urine smells, however observation of the pad revealed his bedding had been wet at some point throughout the day. When Resident #69 was asked if he had any burning or irritation in his groin area he responded no. When Resident #69 was asked when the last time was, he had been changed he stated, I don't know. Observation and interview on 08/27/24 at 3:22 PM revealed CNA C exiting the room emptying contents in the dirty laundry barrel. During interview with Resident #69 revealed he had his bedding changed, clothing changed, and was wearing a new brief. Resident #69 stated staff came in and changed him and bedding, he was not having any issues or concerns in his groin area. Interview on 08/28/24 at 2:44 PM with CNA C revealed she arrived late to work on 08/27/24, and CNA D had to remain on shift to cover for her until she arrived. CNA C stated she entered the facility around 3:00 PM to begin her shift. CNA C stated she worked the 200 hall, CNA C stated she found Resident #69 heavily soiled. CNA C stated Resident #69 drank lots of fluid and was a heavy wetter. CNA C stated she had to change Resident#69 and his bedding and because she observed different colored rings on his bed pad indicating he soiled himself through the brief onto his bed. CNA C stated it was unknown when the last time Resident #69 had been changed, and the aide on previous shift did not report any concerns for Resident #69. According to CNA C the previous aide was responsible to ensure residents were clean and dry prior to end of their shift and she should report any concerns if she noted otherwise. CNA C stated if Resident #69 was changed around 2:00 PM, when she entered at 3:00 PM, Resident #69 would not have soiled to his bedding. CNA C stated since she was late to arrive to her shift, she felt it was necessary to jump in and get him changed. CNA C stated she had not reported this to the nurse because she had to ensure all residents had been cleaned and changed. CNA C stated having residents waiting too long to receive incontinent care could result in skin breakdown, infection, and irritation to the skin. Interview on 08/28/24 at 3:24 PM with CNA D revealed she worked hall 200 and cared for Resident #69 on 08/27/24. According to CNA D she usually completed incontinent care for Resident #69 twice during her shift, once in the morning and again prior to end of her shift. According to CNA D she was really busy on 08/27/24, towels were late which made her late for completing showers. CNA D stated she was aware she did not change the resident for a second time. CNA D stated she observed the surveyor going into Resident #69's room. CNA D stated she was upset when she returned to resident at the end of her shift to find him soiled down to his bed sheets. CNA D stated she then completed care, changed his bedding, and cleaned up Resident #69. CNA D revealed she could not recall the last time she was inserviced on activities of daily living care. CNA D stated not changing a resident in a timely manner could result in skin breakdown. CNA D stated she was responsible to ensure residents were changed in timely manner. CNA D stated she did not report her findings to her nurse or the oncoming aide. Interview on 08/29/24 at 10:56 AM with LVN E revealed she was notified of the incident with Resident #69 had not received proper incontinent care. LVN E stated CNA D was very good and works very hard at her job duties. LVN E stated it was reported to her that Resident #69 was a heavy wetter. LVN E stated aides that worked the floor were responsible to ensure residents were changed, clean and dry in a timely manner. LVN E stated she expected aides to notify her if they needed help with providing care so she could get adequate help or provide help herself. LVN E stated she noticed the linen closet was short on bed sheets and towels however it was not an excuse to prevent residents from having adequate care when it came to being changed. According to LVN E not changing residents in a timely manner could result in redness in their private areas and skin breakdown or infection. Interview on 08/29/24 at 1:20 PM with the DON revealed she was alerted to incident with staff not changing Resident #69 in a timely manner. The DON stated Resident #69 was a heavy wetter so she did not understand how CNA D could have gone all day without changing him. The DON stated there was plenty of staff in the building that could have assisted on the hall to ensure residents had adequate care. The DON stated her expectations included nursing staff to alert the nurses on the floor if they were running behind or off schedule. According to The DON not changing Resident #69 placed him at risk of skin breakdown, infection, emotional abuse, dignity concerns and re-igniting previous pressure sores. Review of the facility's policy Resident Showers , updated on 2/11/22, reflected: 3. The CNA will assess the skin for any changes while performing bathing and inform the nurse of any changes. 11. Assist the resident with showering as needed. The policy did not address personal hygiene, specifically shaving of female residents. Review of the facility's Provision of Quality of Life policy, revised 01/10/22, reflected: based on comprehensive assessments, the facility will ensure that each resident will receive the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well being, consistent with resident's comprehensive assessment and plan of care In order to achieve a culture and environment that supports quality of life the facility leadership will validate that all staff, across all shifts and departments receives training that provides understanding on the principles of quality of life. Review of the facility's Incontinence Care policy, revised 02/14/20, reflected an outlined procedure for cleaning the perineum and buttocks after an incontinence episode. The policy did not address timeliness of incontinent care. 44937

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (Resident #57) of three residents reviewed for respiratory care. The facility failed to ensure Resident #57's had a physician's order for oxygen treatment. This deficient practice could affect residents who received oxygen therapy from receiving inadequate oxygen support and a decline in health. Findings included: Record review of Resident #57's significant change MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease , non-Alzheimer's dementia, respiratory failure, hypertension (high blood pressure), atrial fibrillation (an irregular often rapid heart rate). The MDS further reflected the resident was on hospice services. Record review of Resident #57's progress notes dated 06/11/24 reflected the resident was on oxygen via nasal cannula. Observation and interview on 08/27/24 at 11:40 AM of Resident #57 revealed she in bed watching TV. The resident was on continuous oxygen via nasal cannula, and it was running at 2 liters per minute. Resident #57 was asked if her oxygen was working well for her and she stated it was. The resident did not appear to be in any distress. Record review of Resident #57's clinical record revealed there was no physician's order for the oxygen. Interview on 08/29/24 at 12:08 PM with LVN B revealed Resident #57 had been put on continuous oxygen a while back, possibly two months prior, because her oxygen saturations were not staying above 90% on room air. LVN B did not realize there was not a physician's order for the oxygen when she checked the clinical record. LVN B said the nurse that received the order should have put the order into the system but she did know who the nurse was that got the initial order. LVN B further stated it was important to have an oxygen order so staff would know what care was needed for the residents. Interview on 08/29/24 at 1:46 PM with the DON revealed she was not aware Resident #57 was on continuous oxygen and thought it was only as needed. The DON said all residents with oxygen should have a physician's order so that all staff knew what care was needed for the residents. Review of the facility's Oxygen Administration policy, dated September 2014, reflected the following: Policy To describe methods for delivering oxygen to improve tissue oxygenation. Procedure 1. Verify Physician Order 2. Order should have when to call the physician parameters

Based on interview and record review, the facility failed to coordinate assessments with the PASARR program for 1 (Resident #1) of 4 residents reviewed for PASRR coordination. The facility failed to meet deadlines for submitting a NFSS for specialized services and customized manual wheelchair for Resident #1. This failure could place residents at risk of not receiving qualified specialized services. Findings included: Review of Resident #1's undated Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included seizures, Alzheimer's disease, and Parkinson's disease. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate cognitive impairment. The assessment revealed she required assistance with all of her ADLs, and she required the use of a wheelchair for mobility. Review of Resident #1's care plan, dated 03/06/24, revealed she had the potential for falls related to gait and balance problems. She was PASRR positive for Intellectual Disability placing the resident at risk of not having the ordered specialized services provided with interventions of specialized services determined to be necessary by the IDT will be initiated and request submitted to DADS [HHSC] within 20 business days after date of IDT. Services will be delivered within 3 days after approval. Dated 08/08/23 Interview on 03/18/24 at 3:38 PM with the PASRR Unit Program Specialist revealed on 02/01/24 the Administrator was notified via phone and email his facility had to submit a NFSS for Specialized Services for OT and PT by 02/05/24 and by 02/07/24 for Customized Manual Wheelchair, based on the IDT meeting in August 2023. As of 02/22/24, the facility was considered delinquent. Interview on 03/19/24 at 11:00 AM with the MDS Coordinator revealed the request for Specialized Services was handled by the Rehabilitation Department, so she did not know about the issues. Interview on 03/19/24 at 11:10 AM with the Director of Rehabilitation Services revealed began working in her position on 03/04/24, and she did not know what the previous director had done or not done. She stated the previous director left around 02/14/24. She called the Regional Director of Rehabilitation Services for assistance. The Regional Director was able to reveal the NFSS had been submitted on 03/01/24. Resident #1 had been on Skilled Nursing Services, following an admission to the hospital, until 03/16/24, so the NFSS was denied. On 03/19/24, the Regional Director re-submitted the request. The Regional Director and the Director of Rehabilitation Services understood the re-submission was considered a late submission. Interview on 03/19/24 at 3:00 PM with the Administrator revealed he recalled speaking to someone from HHSC about Resident #1's MDS, but the caller did not explain the issue very well. He stated he was confused about what she was talking about. The Administrator stated the caller had been so rude and he ended the call. The Administrator asked the MDS Coordinator to check Resident #1 to insure everything had been submitted. The Administrator stated he had not been aware that Rehab Services handled anything with the MDS so he did not think to follow up with them. Review of the facility's undated MDS Coordination policy revealed it did not address Specialized Services.

Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for two (Residents #1 and#2) of four residents reviewed for elopement. 1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 09/25/23. 2. The facility failed to ensure Resident #2 was provided with adequate supervision to prevent him from eloping from the facility on 09/28/23. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 09/25/23 and ended on 09/30/23. The facility corrected the non-compliance before surveyor's entrance. This failure placed residents at risk of harm and/or serious injury. Findings included: 1. Review of Resident #1's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, non-Alzheimer's dementia, and cognitive communication deficit. Resident #1 had long and short-term memory impairment and a BIMS could not be completed due to his impaired cognition. Review of Resident #1's care plan initiated on 08/04/23 revealed the resident wandered related to cognitive impairment and was at risk for elopement. Interventions included putting the resident on 1:1 (one-on-one supervision) while behaviors like seeking exit were noted. The care plan further reflected Resident #1 was able to self propel his wheelchair. Review of Resident #1's elopement assessment dated [DATE] reflected the resident was at a high risk to elope and a care plan for elopement was indicated. Review of the facility's Provider Investigation Report dated 09/25/23 reflected the following: At 5:02am [on 09/25/23], when returning to the desk from down the 100 hall, [LVN A] heard the alarm sounding from the dining room door. She looked outside and around the door and didn't see anyone, so she immediately called for a code silver and staff completed a head count. At 5:06am, it was noted that [Resident #1] was not able to be located and a search ensued, including the interior and exterior of the facility, parking lots, bushes, etc. At 5:25am, the search was expanded by car to include the area directly surrounding the facility. [Resident #1] was noted at the gas station about half a block from the facility at approximately 5:30am, with 2 police officers, by [LVN A]. Resident was returned to the facility, and released to the nurse assigned to him, [LVN A] who completed a head to toe assessment and placed the resident on 1:1 staff supervision Review of Resident #1's progress notes dated 09/25/23 completed by LVN B reflected the following: At 5:00 [AM] code silver was initiated. Census was printed and a complete head count was done on all the resident [sic]. At 5:10 we noted that [Resident #1] was missing, CNA's along side with nurses searched the outside grounds. Resident was located at 5:36 am. Resident was returned to the inside of the facility at 5:40 am. A completed head to toe assessment was done, not noted skin abnormalities was seen Resident was placed on a one to one observation for acute monitoring Review of a [NAME] map on 10/24/23 revealed the location where Resident #1 was located on 09/25/23 was 0.3 miles from the facility. Attempts to interview LVN A and LVN B on 10/24/23 were unsuccessful. Interview on 10/24/23 at 11:29 AM with the Receptionist revealed Resident #1 always sat at the front lobby and looked outside and let her know when visitors were coming to the door and greeted all who entered the facility. She stated Resident #1 was confused but had never made any attempts to elope nor expressed wanting to leave to her. Interview on 10/24/23 at 12:29 PM with CNA C revealed Resident #1 had confusion but he was not exit seeking and self-propelled his wheelchair through the facility. Interview on 10/24/23 at 2:42 PM with LVN D revealed Resident #1 was confused and sat in the front lobby greeting all the visitors that entered the facility. Resident #1 was very calm and was never known to be exit seeking. Interview on 10/24/23 at 9:50 AM with the Maintenance Director revealed he was on his way to work the morning Resident #1 eloped from the facility, 09/25/23. When he arrived at the facility, he checked all the exit doors to ensure they were all operating and there were no concerns. The Maintenance Director further stated Resident #1 was confused but he had never known the resident to be exit seeking. Interview on 10/24/23 at 10:56 AM with the ADON revealed Resident #1 used a wheelchair to get around and he was alert and oriented to himself only. She stated the resident did not wander or was exit seeking to her knowledge nor had he ever expressed wanting to leave the facility. Interview on 10/24/23 at 9:00 AM with the Administrator and DON revealed they were immediately made aware of Resident #1's elopement and he was put on 1:1 supervision until he was transferred to a facility with a secure unit to prevent another incident. 2. Review of Resident #2's MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included cerebrovascular accident (stroke) and non-Alzheimer's dementia. The MDS further reflected Resident #2 had a BIMS of 3 (cognition severely impaired). Review of Resident #2's undated care plan revealed he had impaired cognition and was at risk for a further decline in cognitive and functional decline abilities. Interventions included to monitor/document/report to physician any changes in cognitive function. Review of Resident #2's Elopement assessment dated [DATE] revealed he was low risk. Review of the facility's Provider Investigation Report dated 09/29/23 reflected the following: The resident was noted to be missing from his room at 4:05 PM [on 09/28/23] by his nurse [LVN E]. As she was going to the front to call a code silver, a visitor was informing the receptionist that there was a resident in the parking lot. The resident was returned to the facility at 4:07 PM and a head to toe assessment was completed with no injuries noted. During door alarm checks, it was noted that the 200 hall door lock was malfunctioning. A sentry was placed at the door until the maintenance supervisor repaired the door, then q 4 hour door checks were performed until the alarm company came to inspect all the doors. Door checks continue daily. Interview on 10/24/23 at 3:04 PM with LVN E revealed she arrived to work the day of Resident #2's elopement, 09/28/23 at 2:00 PM, and during her initial rounds, she saw the resident in his room. Around 3:30 PM, she noticed Resident #2 was not in his room or the bathroom and asked nearby staff if they had seen the resident. At that time, they began to look for the resident and they had called a code silver as the same time an employee from a nearby business was in the front lobby saying Resident #2 was at their business and the resident was taken back to the facility. LVN said Resident #2 had not been at the facility long but during that short time, the resident had not been exit-seeking. The LVN further stated the resident was ambulatory without assistance. Resident #2 was put on 1:1 supervision until he was discharged from the facility. Interview on 10/24/23 at 12:29 PM with CNA C revealed the day of Resident #2's elopement, 09/28/23, the resident had been seen at the nurse's station around 3:35 PM, and around 4:00 PM LVN E was looking for the resident and decided to call a code silver. At that same time, they got word that Resident #2 had been found outside next door at a nearby establishment and they had the resident. Facility staff went to the establishment and brought Resident #2 back to the facility. CNA C further stated that during the short time the resident was at the facility, he had never been exit seeking nor had he ever made the comment about wanting to leave. Interview on 10/24/23 at 9:50 AM with the Maintenance Director revealed when he was made aware of Resident #2's elopement, he was called to check the exit doors and he found the exit door on 200 hall was not working. It appeared the exit door had come out of adjustment but once he fixed it, it began to work again. The Maintenance Director stated all the exit doors were checked weekly and all the doors had just been checked a few day prior, when Resident #1 eloped on 09/25/23 and they had all been in good and operating correctly. After Resident #2's incident, the mag lock on the 200 hall door was replaced and all facility exit doors were being checked and the codes were being changed every morning as well. Interview on 10/24/23 at 10:56 AM with the ADON revealed on the day of Resident #2's elopement, 09/28/23, she was in her office on the 500 hall when she heard LVN E asked if anyone had seen Resident #2. At that time, they activated a code silver when they saw an employee of a nearby business in the front lobby saying they had one of their residents. Resident #2 was brought back to the facility and the nurse did a head-to-toe assessment and there were no injuries noted. After the resident was brought back to the facility, he was asked why he had left and the resident stated because this is a free country. Resident #2 was put on 1:1 supervision until he was discharged from the facility with family. The ADON further stated the resident had only been at the facility for a short time and he had never shown exit seeking behaviors. Observation from the 200 exit door of the facility on 10/24/23 at 2:23 PM revealed the establishment where Resident #2 was found was about 100 yards from the facility premises. The establishment and facility shared a paved parking lot with some landscaped grass. Interview on 10/24/23 at 5:27 PM with the Regional Nurse Consultant revealed Residents #1 and #2 were discharged from the facility to a secure unit. All staff were re-educated on code silver and live drills were done every shift for a week and a half, then daily, then transitioned weekly and now are being done monthly so all staff knew what to do in case a resident went missing. Exit door checks were being done daily by the Maintenance Director and the mag lock was changed on the hall 200 exit door. She further stated there was an elopement assessment done on all the residents after the incidents and there were two additional residents identified and measures were put in place to prevent any further incidents. Observation on 10/24/23 from 9:34 AM to 9:50 AM revealed all 13 facility exit doors were checked with the Maintenance Director and all of the doors were functioning properly. Each door was equipped with a 15 second egress release followed by an alarm after it was opened. There were 3 dining room doors and there was an additional louder alarm added so they could be heard throughout the facility. Review of the facility's policy titled Missing Resident Policy revised on 08/15/23 reflected the following: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk This was determined to be a Past Non-Compliance Immediate Jeopardy on 10/24/23 at 5:15 PM. The Administrator, DON, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 10/24/23 at 5:26 PM. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of the following in-services, dated 09/25/23 and 09/28/23, reflected the in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM: - Missing resident guidelines; - Missing resident protocol-Elopement binder; - Code Silver; - Exit seeking behavior; and - Head count procedural guidelines. Interviews on 10/24/23 from 9:34 AM to 3:59 PM with the Receptionist, HR Director, Restorative Aide, Maintenance Director, ADON, LVN A, LVN B, CNA C, LVN D, and LVN E who worked all three shifts revealed they were able to conduct a code silver drill for a missing resident, perform a head count check, what to do when they heard a door alarm and monitor any changes in condition that could indicate a resident was a high elopement risk. Record review of the facility's Code Silver drills revealed they were conducted daily on each shift beginning on 09/25/23 and they were currently being done monthly with no end date. Record review of exit door checks on 09/25/23, after Resident #1 eloped, revealed all exit doors were functioning properly. Record review dated 09/28/23 revealed staff were doing 15 minute checks on the 200 hall door from 4:20 PM until the Maintenance Director arrived and it was fixed at 6:47 PM. Record review of the fire and security invoice revealed that on 09/30/23 a delayed egress lock was replaced on the 200 hall. Record review of the door alarm checks dated 09/29/23 to 10/23/23 revealed they were being checked daily by the Maintenance Director. Record review revealed an elopement assessment was completed on all the residents on 09/29/23 to identify any additional high risk residents. Two additional residents were identified as being at high risk for elopement. One of the resident was transferred out to a more secure facility and the other resident was monitored until he was deemed safe to remain at the facility.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. -The facility failed to ensure food items and clean dishes were kept away from airborne contaminants and an unsanitary environment. -The facility failed to ensure that two ice machines were clean and sanitary. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: An observation of the kitchen on 07/18/2023 at 09:20 AM revealed that all four vents just above where the clean pots and pans were stored had debris and fluttering lint. Observation also revealed that the kitchen had two ice machines, and both had a brown, slimy buildup on the inside lining of the lids where ice was touching. Interview on 07/18/2023 at 10:05 AM with Dietary Aide F, revealed she had worked at the facility for 2 years. She stated all kitchen staff were trained and in-serviced on kitchen sanitation at least once a month. She stated it was the responsibility of all kitchen staff to maintain the cleanliness and sanitation of the kitchen. She stated general cleaning of the kitchen such as sweeping, mopping, washing dishes and wiping down the counters and equipment was done daily. She stated that deep cleaning was done at least once a month and basically included the same tasks but more thorough and included equipment like the oven and ice machines. She denied that it was the kitchen staff's responsibility to clean the vents. Dietary Aide F stated that maintenance was responsible for cleaning the vents. She was unsure how often the vents were cleaned or when the last time it was done. She stated the risk of having debris and lint being in the vents could be cross-contamination if anything fell inside of the pots and pans where food would be prepared, which could lead to food-borne illness for the residents. Interview and observation on 07/19/2023 at 10:15 AM, the Area Dietary Manager stated she was standing in because the assigned dietary manager was on vacation. She stated the expectation was for all kitchen staff to maintain cleanliness and sanitation of the kitchen daily. The Area Dietary Manager stated there was a weekly and monthly cleaning schedule for staff to follow and sign off on as the tasks were completed. She stated that all kitchen staff were trained on kitchen sanitation; however, she could not state how often the trainings were done. She was not able to provide copies of previous trainings and in-services for kitchen sanitation. Observation revealed that all four vents still had debris and lint. The Area Dietary Manager acknowledged that the vents above the clean pots and pans were covered in debris and lint and that both ice machines had a brown, slimy substance on the inside lining of the lids. She stated maintenance was responsible for cleaning the vents, but she did not know how often this was done. She stated the kitchen staff were responsible for keeping the ice machines clean and that they should be checked at least weekly. The Area Dietary Manager stated having dirty vents above the pots and pans and unsanitary ice machines could cause cross-contamination and place the residents at risk for food-borne and water-borne illness. Interview and observation on 07/20/2023 at 1:30 PM, the Maintenance Director revealed that it was his responsibility to take down all vent covers in the kitchen for the kitchen staff to clean. He stated this was done every 6 months. He stated there was not a log of when the vents were cleaned, he just knew that it was done every 6 months. The Maintenance Director stated there were not any filters in the vents that needed to be changed and that was why the vents were only taken down every 6 months. Observation with the Maintenance Director revealed that all four vents still had debris and lint in them. The Maintenance Director stated the vents needed to be cleaned and that he would take them down for a cleaning as soon as possible. He stated the kitchen staff were responsible for cleaning the ice machines. The Maintenance Director stated the ice machines should be dumped and cleaned weekly because the facility's water had high calcium, which could cause buildup in the ice machines. Record review of the facility's Monthly Cleaning Schedule, dated for July 2023, revealed the task of cleaning the ice machines. There were staff initials next to the task, indicating that it had been completed for the month. Record review of the facility's Monthly Sanitation Audit, dated 06/28/2023, revealed all areas of the kitchen were satisfactory, except the vents. A note indicated that a maintenance request had been submitted for the vents to be cleaned. Record review of the facility's policy titled Equipment Cleaning Procedures, revised 01/2013, revealed the following: Policy: It is the policy of this facility that all dietary equipment and the environment are cleaned and sanitized in a manner that meets local (if applicable), state, and federal regulations. Cleaning Frequency: . Weekly: .Clean refrigerator and freezer weekly. Monthly: Wash walls, ceilings, and vents monthly or as needed. Maintaining Kitchen and Storage Area: .Lighting, ventilation, temperature, and humidity must be properly maintained and controlled to prevent condensation and the growth of molds Record review of the facility's policy titled Food Safety and Sanitation Plan, revised 11/2017, revealed the following: Policy: It is the policy of the facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur Procedures: . -Ice-Appropriate ice and water handling practices prevent contamination and the potential for water-borne illness Keeping the ice machine clean and sanitary will help prevent contamination of the ice. Contamination risks associated with ice and water handling practices may include, but are not limited to: . -Unclean equipment, including the internal components of ice machines that are not drained, cleaned and sanitized as needed to manufacturer's specifications. Record review of the Federal Drug Administration Food Code dated 2017 section titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils revealed (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observations, interviews, and record review the facility failed to ensure total privacy for residents in 4 of 28 rooms (Rooms 401 A bed, 401 B bed, 405 A bed, and 405 B bed) reviewed for privacy. The facility failed to provide privacy curtains to ensure residents' privacy in Rooms 401 A bed, 401 B bed, 405 A bed, and 405 B bed. Each of these rooms only had one curtain. This failure could place residents at risk of decreased self-worth by being exposed during resident care. Findings included: Observation of room [ROOM NUMBER] revealed that there was only one curtain in the room that went between both A and B beds. For residents in room [ROOM NUMBER] (A bed) and room [ROOM NUMBER] (B bed) each to be provided privacy, a second curtain would be required to be hung in the room. Also, observation of room [ROOM NUMBER] revealed that there was only one curtain in the room that went between both A and B beds. For residents in room [ROOM NUMBER] (A bed) and room [ROOM NUMBER] (B bed) each to be provided privacy, a second curtain would be required to be hung in the room. Interview and observation on 07/19/23 at 12:30 PM with Resident #59 (405 A bed) revealed the resident, who resided in this room, was receiving a bed bath. Further observation revealed there was not a privacy curtain available to surround the bed to ensure privacy when the door was opened. The hospice CNA G was giving a bed bath to the Resident #59 in her room. Staff was observed entering and exiting the room and leaving the door open during the resident's bed bath. When interviewed, the hospice CNA G stated that she felt the dignity and the privacy of the resident was not taken seriously because there was not a curtain. She stated she had not told her supervisor because she did not think about it. She stated she would try to close the door during care, but every time staff entered the room, they left the door open. Observations on 7/19/2023 at 12:45 PM of rooms 401 (A bed) and 401 (B bed) revealed that neither rooms had privacy curtains. Interview on 07/19/23 at 1:15 PM with the Housekeeping Supervisor revealed that each room should have two curtains for privacy. The Surveyor and the Housekeeping Supervisor went to room [ROOM NUMBER] (A bed). The Surveyor pointed out that room [ROOM NUMBER] (A bed) only had one curtain and asked the Housekeeping Supervisor why there was no second curtain. The Housekeeping Supervisor replied that The Maintenance Supervisor would have taken the curtain down. She also stated that the curtains were for privacy for patient care. Interview on 07/19/23 at 3:04 PM with the Maintenance Supervisor revealed he had not taken down curtains in a while. He said the rooms should have two curtains in them. He also stated that the privacy curtains were used for privacy for the residents. Interview on 07/19/23 at 3:18 PM with the ADON, again confirmed two curtains should have been up in all rooms with two patients. However, only one curtain was up. The ADON stated staff should keep the door closed and keep Resident #59 covered. She was uncertain when they took the curtain down. The ADON stated she did not know if curtains were not up in any other rooms. She stated they had the curtains for privacy. If the curtain was not there, there was no privacy to the resident. The ADON stated they have completed in-services on dignity and privacy. Interview on 07/20/23 at 8:37 AM with Resident #79 room [ROOM NUMBER] (A bed) revealed the night shift had installed the missing privacy curtain the previous night (7/19/2023). She stated that one time they took her toenail off during a procedure and did not shut the door. She stated, That bothered me. Interview on 07/20/23 at 8:41 AM with Resident #72 room [ROOM NUMBER] (B bed) revealed that at no time previous to the night before (7/19/23) had a second curtain ever been hung in her room. Interview on 07/20/23 at 10:54 AM with the DON determined that two curtains were supposed to be in rooms with two residents for privacy. She noticed rooms did not have two curtains up on 7/19/2023. She called the housekeeper and maintenance to put the curtains up. She did not know the time that she instructed them to hang the curtains. The nurses taking care of the residents were supposed to let housekeeping know if they were taken down for any reason like washing needs. Record review of facility policy Resident Rights, dated February 2021, states the following: The resident has a right to be treated with respect and dignity.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures for investigating and reporting allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, for 1 (Resident #35) of 18 residents reviewed for abuse. The facility failed to follow their policy and report to the State Survey Agency when Resident #35 alleged he had been cursed at by CNA C. The failure could place residents at risk of repeated injuries, abuse and/or neglect. Findings included: Review of Resident #35's MDS revealed the resident was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, anxiety disorder, depression, and contracture of muscle. Resident #35 had a BIMS of 15 (cognition intact). Observation and interview on 07/18/23 at 10:15 AM revealed Resident #35 was in his room in bed watching TV The resident stated CNA C did not like him and had called him an asshole three times about three to four weeks ago. The resident said he reported the incident to his family and stated he was not afraid of the CNA and felt safe at the facility. Interview on 07/18/23 at 11:54 AM with Resident #35's family revealed the resident had called them a few weeks back (did not recall he date) and told them CNA C had called him an asshole three times. Resident #35's family said they reported the allegation to the Social Worker and they had a care plan meeting and they were told CNA C had been spoken to about the matter. The family further stated the facility had offered to move the resident to another hall but the resident did not want to leave the room he was in. Interview on 07/18/23 at 1:53 PM with the Social Worker revealed Resident #35's family had gone to her a while back (did not recall the date) and stated Resident #35 had complained about CNA C giving him a cold shower and they also mentioned the aide had called the resident an asshole. The Social Worker said she reported the incident to the ADON and an investigation had been done. Review of the grievance report dated 05/25/23 completed by the Social Worker revealed family stated Resident #35 said CNA C called him an asshole and would not turn on the heater in the shower room. Further review of the grievance report revealed they had spoken with CNA C and she had not been in the building on the day the resident made the allegation. The CNA also said there was always a staff member present when she gave Resident #35 a shower. Interview on 07/19/23 at 2:57 PM with the ADON revealed CNA B reported Resident #35 said CNA C had called him an asshole earlier that day. The ADON did not recall the date of the incident but recalled CNA C had not worked the day the resident alleged the incident occurred. The ADON said she spoke to the DON about the incident but had not been able to speak to the resident that day because he was asleep. Interview on 07/19/23 at 12:19 PM with CNA B revealed she was feeding Resident #35 when he asked her if CNA C had been fired because she (CNA C) had called him an asshole three times. CNA B did not recall the date of the incident but thought it was some time in May (2023). CNA B reported the incident to the ADON because the Administrator and DON were not at the facility. Interview on 07/19/23 at 12:19 PM with the DON revealed sometime in May (2023) Resident #35's family had called the Social Worker to report the resident said CNA C had given him a cold shower and called him an asshole. The DON did not recall the date but that it had been a Monday. Resident #35 had also reported the incident to CNA B and they had investigated the incident and gotten statements of the incident. Attempts to contact CNA C on 07/18/23 were unsuccessful. Interview on 07/18/23 at 11:45 AM with the DON revealed the incident between Resident #35 and CNA C was not reported to the Survey Agency because CNA C was not working the day Resident #35 said the incident occurred but they had gone ahead and completed an investigation. Interview with the Administrator, working at the time of the incident, was not possible because he was on leave at the time of the investigation. Review of the facility's policy titled Abuse, Neglect and Exploitation implemented 10/24/22 reflected the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .VII. Reporting/Response .2. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes: a. Immediately, but not later than 2 hours after the allegation after the allegation is made

Based on observations, interviews and record reviews, it was determined the facility failed to immediately consult with a resident's physician when there was a significant change in the resident's physical status for one (Resident #2) of one resident reviewed for change of condition. RN B failed to immediately consult with Resident #2's physician, when the resident's oxygen saturation level dropped to a critical level of 46%. RN B called the physician one hour later, when the resident's oxygen saturation level dropped again. Resident #2 was admitted to the hospital with [REDACTED]. She was later discharged from the hospital to inpatient hospice services. An Immediate Jeopardy (IJ) was identified on 06/20/13. While the IJ was removed on 06/26/13, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. This failure could affect the 11 residents, who received oxygen, by placing them at risk for [MEDICAL CONDITION] and/or death. Findings included: http://www.mayoclinic.com/health/hypoxemia/MY /METHOD=print reflected, "Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low...." Resident #2's History and Physical, dated 03/30/13, reflected the resident was a [AGE] year-old female with [DIAGNOSES REDACTED]. Resident #2's March 2013 physician's orders [REDACTED]. The Orders also reflected to check her oxygen saturation level as needed when short of breath or when there was [MEDICAL CONDITION] in her lower legs. The Orders also reflected [MEDICATION NAME](2.5 mg/3 ml) 0.083% Nebulization Solution Inhalation one unit dose via nebulizer four times a day as needed for shortness of breath. Resident #2's MDS assessment, dated 04/30/13, reflected she was admitted to the facility on [DATE]; she was not oriented to the day, month or year; she required assistance with activities of daily living; and she had a [DIAGNOSES REDACTED].e., asthma, [MEDICAL CONDITION] or [MEDICAL CONDITION]). The MDS assessment further reflected she had no issues with shortness of breath or trouble breathing with exertion, when sitting at rest or when lying flat. Further review of the MDS assessment did not reveal she received oxygen therapy. Resident #2's Plan of Care, dated 05/07/13, reflected she had episodes of shortness of breath and was at risk of respiratory distress/failure, and she had a [DIAGNOSES REDACTED]. The Care Plan's approaches included applying oxygen as ordered, encouraging slow, deep breaths and assessing respiratory status such as breath sounds, respiratory rate, skin color, and notifying the physician of abnormalities. Resident #2's Nurse's Notes dated 07/14/12 through 05/19/13 did not reflect problems with Resident #2's oxygen saturation levels dropping. Resident #2's Nurse's Notes, dated 05/27/13 (no time), reflected she was "breathing heavily" and her oxygen saturation level was at 46%. The Notes also reflected she was given an as needed nebulizer treatment and her oxygen saturation level increased to 86%. Further review of Resident #2's Nurse's Notes revealed her oxygen saturation level was checked later (no time indicated), and it had decreased to 66%. The Notes reflected the physician was notified and the resident was transferred to a local hospital. (Note: There was no documented evidence the physician was immediately consulted when her oxygen saturation level dropped to a critical level of 46% as her Plan of Care indicated should occur.) During an interview with RN B, Resident #2's Charge Nurse, on 06/20/13 at 1:45 p.m., he stated Resident #2's critical low oxygen saturation level occurred while he was passing the 9:00 a.m. medications. He said he checked her oxygen saturation level (which was 46% and did not call 911) and then checked with LVN Y, who was also an ADON, who suggested giving Resident #2 a breathing treatment. RN B added Resident #2 had never had her oxygen saturation level drop before. RN B revealed Resident #2's oxygen saturation level went up to 80% then dropped again. He stated it was after her oxygen saturation level went down again (to 60%) that he called Resident #2's physician and she was then transferred to a hospital. During an interview with LVN Y on 06/20/13 at 2:10 p.m., she stated she thought RN B gave Resident #2 the breathing treatment due to her [MEDICAL CONDITION]. She stated she was unaware Resident #2's oxygen saturation level had dropped. During an interview with the DON on 06/20/13 at 2:30 p.m., she stated the incident should have involved two staff: one to administer Resident #2's breathing treatment while another one called the physician and 911. During an interview with Resident #2's physician on 06/20/13 at 2:40 p.m., the surveyor reviewed with the physician the following: --RN B finding Resident #2 with an oxygen saturation level of 46%; --Leaving the resident to speak with LVN Y; --LVN Y told RN B to give the resident a nebulizer treatment; -- LVN Y denied being told Resident #2's oxygen level had dropped and thought the resident's [MEDICAL CONDITION] was the problem; --RN B gave Resident #2 a nebulizer treatment; --Resident #2's oxygen level rose to 80% and then started dropping again; --RN B left the resident again and called the physician; --RN B received orders to send her to the hospital and 911 was called; and --This occurred over approximately 60 minutes. When the physician was asked about the care Resident #2 received, the physician responded, "They did the right thing." Resident #2's Physician Telephone Order, dated 05/27/13 reflected to send the resident to the ER for evaluation of low oxygen saturation level. Resident #2's hospital ED Nurse Notes, dated 05/27/13 and timed at 11:41 AM, reflected, "Presenting complaint: EMS states SOB...Oxygen via [MEDICAL CONDITION] (machine to help someone breathe)...Triage Assessment...Appears uncomfortable...Respiratory effort is with [MEDICAL CONDITION] sounds are course bilaterally. Reports shortness of breath at rest...the patient has severe shortness of breath... 11:44 Pulse ox (oximetry) 92% on 15% [MEDICAL CONDITION] (machine to help someone breathe)...." Resident #2's hospital ED Physician Notes, dated 05/27/13 at 11:49 AM, reflected, "The patient has shortness of breath at rest, that woke him/her from sleep...The symptoms/episode began/occurred acutely, this morning at 02:00 (2:00 AM)...pt had very elevated blood pressure and responded to nitro, [MEDICATION NAME], and [MEDICAL CONDITION]. Also received nebs (nebulizer treatments)...14:35 (2:35 PM)...moderate respiratory distress is noted...14:40 (2:40 PM)...Pulse oximetry: on 95% oxygen by non-rebreather, is 98%...Pt stable on [MEDICAL CONDITION] in ED...." Resident #2's hospital Discharge Summary, dated 05/30/13, reflected, "FINAL Diagnoses: [REDACTED]. Dyspnea (air hunger resulting in labored or difficult breathing). 3. [MEDICAL CONDITION]...8. [MEDICAL CONDITION] infiltrates. 9. [MEDICAL CONDITIONS], volume overload, hypercarbia (elevated levels of carbon [MEDICATION NAME] in the blood)...presents to the hospital with complaints of shortness of breath and [MEDICAL CONDITION] (oxygen deficiency in body tissues)...patient was this morning was noted to be hypoxic with saturations in the 70s...The patient was seen in the emergency room and has (sic) been placed on [MEDICAL CONDITION] morning on examination patient remained to be (sic) somnolent. The patient was also having hypercapnia...The patient was has been evaluated by hospice and is being transferred to inpatient hospice unit...." On 06/20/13 an IJ was identified. On 06/20/13 at 5:17 p.m., the Administrator and Regional Administrator were notified of the IJ and a Plan of Removal was requested at that time. On 06/24/13, the facility's Plan of Removal was accepted and reflected: (1) An in-service was conducted with all charge nurses regarding a) Recognition of changes of condition/physician notification; b) Physician notification parameters and related care areas such as oxygen saturation levels. The in-services were conducted by the DON, ADON, RNC and LVN/CMM with a start date of 06/17/13 and a conclusion date of 6/21/13. One charge nurse was unavailable and would not work until she received the in-service training. (2) CNAs received in-service training regarding reporting changes of condition to their charge nurses. The in-services initiated on 06/24/13 and were presented by the DON, LVN Y, LVN Z and RNC. (3) A QAA Audit was conducted of all incidents reports and charts of residents on oxygen therapy from 05/01/13 through 6/18/12 by the RNC. The RNC completed the audit on 06/21/13. (4) The RNC audited the 24 Hour Reports from 06/15/13 through 06/18/13 to identify changes of condition and follow-up and found no issues. (5) The RNC, DON, LVN Y and LVN Z audited charts to validate physician notification parameters for care areas such as oxygen saturation levels. None of the residents' physicians' orders included parameters. The physicians were contacted to request physician notification parameters. One of four physicians requested to be contacted if the level was below 85% and three of the four physicians requested to be contacted if the oxygen saturation level fell below 90%. (6) The RNC and DON completed a one-on-one in-service to re-educate both RN B and LVN Y on parameters now set forth by the physician prior to returning to work. The DON would monitor through daily start up process and quarterly evaluations for the first six months and then every six months for one year and annually thereafter. (7) The DON, LVN Y and LVN Z would complete daily walking rounds Monday through Friday. On Saturday and Sunday, one of the three staff would conduct rounds to identify residents with a change in status. (8) The DON, LVN Y and LVN Z would conduct weekly Standard of Care Meetings with the Interdisciplinary Team (DON, Social Worker, Dietary Service Manager, Activities Director, Rehab Director and ADON) to discuss resident issues such as residents on oxygen. (9) The Medical Director was notified of the IJ on 06/20/13 at approximately 9:00 p.m. A QAA Audit Tool would be utilized by the DON, LVN Y and LVN Z five days per week for 30 days to validate sustained compliance with oxygen saturation orders including physician notification parameters and nurse follow-up if parameters were exceeded. (10) The findings of the QAA Audits submitted by the DON and reviewed by the Standards of Care Ad Hoc QAA team who would make the recommendations for additional staff in-service and monitoring. This review/evaluation would occur weekly for 30 days, then twice a month for an additional 30 days. Interviews conducted with LVN D, LVN E, LVN F, LVN G, LVN H, LVN I, LVN J, LVN K, RN L, LVN M, and LVN N, who represented each shift, on 06/21/13, 06/22/13, and 06/24/13, revealed they had received the required in-service education and they comprehended the information provided. The interviews did not reveal any problems. Interviews conducted with CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V and CNA W, who represented each shift, on 06/26/13 from 10:25 a.m. through 11:22 a.m. revealed they had received the required in-service education and they comprehended the information provided. The interviews did not reveal any problems. Interview conducted with MA A on 06/26/13 at 11:09 a.m. revealed she had received the required in-service education and comprehended the information provided. The interview did not reveal any problems. On 06/26/13 at 11:15 a.m., the Administrator was notified the IJ was removed. While the IJ was removed on 06/26/13, the facility remained out of compliance at scope of "isolated" and severity level of "actual harm that is not immediate jeopardy," because the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. The facility's list of residents, who used oxygen, dated 06/26/13, reflected 11 residents.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect of residents for one (Resident #1) of one resident reviewed for oxygen therapy. RN B failed to call 911 for emergency medical services and to notify Resident #2's physician, when the resident's oxygen saturation level dropped to a critical level of 46%. RN B called the physician one hour later, when the resident's oxygen saturation level dropped again. Resident #2 was admitted to the hospital with [REDACTED]. She was later discharged from the hospital to inpatient hospice services. An Immediate Jeopardy (IJ) was identified on 06/20/13. While the IJ was removed on 06/26/13, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. This failure could affect the 11 residents, who received oxygen, by placing them at risk for [MEDICAL CONDITION] and/or death. Findings included: http://www.mayoclinic.com/health/hypoxemia/MY /METHOD=print reflected, "Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low...." Resident #2's History and Physical, dated 03/30/13, reflected the resident was a [AGE] year-old female with [DIAGNOSES REDACTED]. Resident #2's March 2013 physician's orders [REDACTED]. The Orders also reflected to check her oxygen saturation level as needed when short of breath or when there was [MEDICAL CONDITION] in her lower legs. The Orders also reflected [MEDICATION NAME](2.5 mg/3 ml) 0.083% Nebulization Solution Inhalation one unit dose via nebulizer four times a day as needed for shortness of breath. Resident #2's MDS assessment, dated 04/30/13, reflected she was admitted to the facility on [DATE]; she was not oriented to the day, month or year; she required assistance with activities of daily living; and she had a [DIAGNOSES REDACTED].e., asthma, [MEDICAL CONDITION] or [MEDICAL CONDITION]). The MDS assessment further reflected she had no issues with shortness of breath or trouble breathing with exertion, when sitting at rest or when lying flat. Further review of the MDS assessment did not reveal she received oxygen therapy. Resident #2's Plan of Care, dated 05/07/13, reflected she had episodes of shortness of breath and was at risk of respiratory distress/failure, and she had a [DIAGNOSES REDACTED]. The Care Plan's approaches included applying oxygen as ordered, encouraging slow, deep breaths and assessing respiratory status such as breath sounds, respiratory rate, skin color, and notifying the physician of abnormalities. Resident #2's Nurse's Notes dated 07/14/12 through 05/19/13 did not reflect problems with Resident #2's oxygen saturation levels dropping. Resident #2's Nurse's Notes, dated 05/27/13 (no time), reflected she was "breathing heavily" and her oxygen saturation level was at 46%. The Notes also reflected she was given an as needed nebulizer treatment and her oxygen saturation level increased to 86%. Further review of Resident #2's Nurse's Notes revealed her oxygen saturation level was checked later (no time indicated), and it had decreased to 66%. The Notes reflected the physician was notified and the resident was transferred to a local hospital. (Note: There was no documented evidence the physician was immediately consulted when her oxygen saturation level dropped to a critical level of 46% as her Plan of Care indicated should occur.) During an interview with RN B, Resident #2's Charge Nurse, on 06/20/13 at 1:45 p.m., he stated Resident #2's critical low oxygen saturation level occurred while he was passing the 9:00 a.m. medications. He said he checked her oxygen saturation level (which was 46% and did not call 911) and then checked with LVN Y, who was also an ADON, who suggested giving Resident #2 a breathing treatment. RN B added Resident #2 had never had her oxygen saturation level drop before. RN B revealed Resident #2's oxygen saturation level went up to 80% then dropped again. He stated it was after her oxygen saturation level went down again (to 60%) that he called Resident #2's physician and she was then transferred to a hospital. During an interview with LVN Y on 06/20/13 at 2:10 p.m., she stated she thought RN B gave Resident #2 the breathing treatment due to her [MEDICAL CONDITION]. She stated she was unaware Resident #2's oxygen saturation level had dropped. During an interview with the DON on 06/20/13 at 2:30 p.m., she stated the incident should have involved two staff: one to administer Resident #2's breathing treatment while another one called the physician and 911. During an interview with Resident #2's physician on 06/20/13 at 2:40 p.m., the surveyor reviewed with the physician the following: --RN B finding Resident #2 with an oxygen saturation level of 46%; --Leaving the resident to speak with LVN Y; --LVN Y told RN B to give the resident a nebulizer treatment; -- LVN Y denied being told Resident #2's oxygen level had dropped and thought the resident's [MEDICAL CONDITION] was the problem; --RN B gave Resident #2 a nebulizer treatment; --Resident #2's oxygen level rose to 80% and then started dropping again; --RN B left the resident again and called the physician; --RN B received orders to send her to the hospital and 911 was called; and --This occurred over approximately 60 minutes. When the physician was asked about the care Resident #2 received, the physician responded, "They did the right thing." Resident #2's Physician Telephone Order, dated 05/27/13 reflected to send the resident to the ER for evaluation of low oxygen saturation level. Resident #2's hospital ED Nurse Notes, dated 05/27/13 and timed at 11:41 AM, reflected, "Presenting complaint: EMS states SOB...Oxygen via [MEDICAL CONDITION] (machine to help someone breathe)...Triage Assessment...Appears uncomfortable...Respiratory effort is with [MEDICAL CONDITION] sounds are course bilaterally. Reports shortness of breath at rest...the patient has severe shortness of breath... 11:44 Pulse ox (oximetry) 92% on 15% [MEDICAL CONDITION] (machine to help someone breathe)...." Resident #2's hospital ED Physician Notes, dated 05/27/13 at 11:49 AM, reflected, "The patient has shortness of breath at rest, that woke him/her from sleep...The symptoms/episode began/occurred acutely, this morning at 02:00 (2:00 AM)...pt had very elevated blood pressure and responded to nitro, [MEDICATION NAME], and [MEDICAL CONDITION]. Also received nebs (nebulizer treatments)...14:35 (2:35 PM)...moderate respiratory distress is noted...14:40 (2:40 PM)...Pulse oximetry: on 95% oxygen by non-rebreather, is 98%...Pt stable on [MEDICAL CONDITION] in ED...." Resident #2's hospital Discharge Summary, dated 05/30/13, reflected, "FINAL Diagnoses: [REDACTED]. Dyspnea (air hunger resulting in labored or difficult breathing). 3. [MEDICAL CONDITION]...8. [MEDICAL CONDITION] infiltrates. 9. [MEDICAL CONDITIONS], volume overload, hypercarbia (elevated levels of carbon [MEDICATION NAME] in the blood)...presents to the hospital with complaints of shortness of breath and [MEDICAL CONDITION] (oxygen deficiency in body tissues)...patient was this morning was noted to be hypoxic with saturations in the 70s...The patient was seen in the emergency room and has (sic) been placed on [MEDICAL CONDITION] morning on examination patient remained to be (sic) somnolent. The patient was also having hypercapnia...The patient was has been evaluated by hospice and is being transferred to inpatient hospice unit...." On 06/20/13 an IJ was identified. On 06/20/13 at 5:17 p.m., the Administrator and Regional Administrator were notified of the IJ and a Plan of Removal was requested at that time. On 06/24/13, the facility's Plan of Removal was accepted and reflected: (1) An in-service was conducted with all charge nurses regarding a) Recognition of changes of condition/physician notification; b) Physician notification parameters and related care areas such as oxygen saturation levels. The in-services were conducted by the DON, ADON, RNC and LVN/CMM with a start date of 06/17/13 and a conclusion date of 6/21/13. One charge nurse was unavailable and would not work until she received the in-service training. (2) CNAs received in-service training regarding reporting changes of condition to their charge nurses. The in-services initiated on 06/24/13 and were presented by the DON, LVN Y, LVN Z and RNC. (3) A QAA Audit was conducted of all incidents reports and charts of residents on oxygen therapy from 05/01/13 through 6/18/12 by the RNC. The RNC completed the audit on 06/21/13. (4) The RNC audited the 24 Hour Reports from 06/15/13 through 06/18/13 to identify changes of condition and follow-up and found no issues. (5) The RNC, DON, LVN Y and LVN Z audited charts to validate physician notification parameters for care areas such as oxygen saturation levels. None of the residents' physicians' orders included parameters. The physicians were contacted to request physician notification parameters. One of four physicians requested to be contacted if the level was below 85% and three of the four physicians requested to be contacted if the oxygen saturation level fell below 90%. (6) The RNC and DON completed a one-on-one in-service to re-educate both RN B and LVN Y on parameters now set forth by the physician prior to returning to work. The DON would monitor through daily start up process and quarterly evaluations for the first six months and then every six months for one year and annually thereafter. (7) The DON, LVN Y and LVN Z would complete daily walking rounds Monday through Friday. On Saturday and Sunday, one of the three staff would conduct rounds to identify residents with a change in status. (8) The DON, LVN Y and LVN Z would conduct weekly Standard of Care Meetings with the Interdisciplinary Team (DON, Social Worker, Dietary Service Manager, Activities Director, Rehab Director and ADON) to discuss resident issues such as residents on oxygen. (9) The Medical Director was notified of the IJ on 06/20/13 at approximately 9:00 p.m. A QAA Audit Tool would be utilized by the DON, LVN Y and LVN Z five days per week for 30 days to validate sustained compliance with oxygen saturation orders including physician notification parameters and nurse follow-up if parameters were exceeded. (10) The findings of the QAA Audits submitted by the DON and reviewed by the Standards of Care Ad Hoc QAA team who would make the recommendations for additional staff in-service and monitoring. This review/evaluation would occur weekly for 30 days, then twice a month for an additional 30 days. Interviews conducted with LVN D, LVN E, LVN F, LVN G, LVN H, LVN I, LVN J, LVN K, RN L, LVN M, and LVN N, who represented each shift, on 06/21/13, 06/22/13, and 06/24/13, revealed they had received the required in-service education and they comprehended the information provided. The interviews did not reveal any problems. Interviews conducted with CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V and CNA W, who represented each shift, on 06/26/13 from 10:25 a.m. through 11:22 a.m. revealed they had received the required in-service education and they comprehended the information provided. The interviews did not reveal any problems. Interview conducted with MA A on 06/26/13 at 11:09 a.m. revealed she had received the required in-service education and comprehended the information provided. The interview did not reveal any problems. On 06/26/13 at 11:15 a.m., the Administrator was notified the IJ was removed. While the IJ was removed on 06/26/13, the facility remained out of compliance at scope of "isolated" and severity level of "actual harm that is not immediate jeopardy," because the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. The facility's list of residents, who used oxygen, dated 06/26/13, reflected 11 residents.

Based on observation, interview and record reviews, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one (Resident #2) of one resident reviewed for change in condition. RN B failed to call 911 for emergency medical services and to notify Resident #2's physician, when the resident's oxygen saturation level dropped to a critical level of 46%. RN B called the physician one hour later, when the resident's oxygen saturation level dropped again. Resident #2 was admitted to the hospital with [REDACTED]. She was later discharged from the hospital to inpatient hospice services. An Immediate Jeopardy (IJ) was identified on 06/20/13. While the IJ was removed on 06/26/13, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. This failure could affect the 11 residents, who received oxygen, by placing them at risk for [MEDICAL CONDITION] and/or death. Findings included: http://www.mayoclinic.com/health/hypoxemia/MY /METHOD=print reflected, "Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low...." Resident #2's History and Physical, dated 03/30/13, reflected the resident was a [AGE] year-old female with [DIAGNOSES REDACTED]. Resident #2's March 2013 physician's orders [REDACTED]. The Orders also reflected to check her oxygen saturation level as needed when short of breath or when there was [MEDICAL CONDITION] in her lower legs. The Orders also reflected [MEDICATION NAME](2.5 mg/3 ml) 0.083% Nebulization Solution Inhalation one unit dose via nebulizer four times a day as needed for shortness of breath. Resident #2's MDS assessment, dated 04/30/13, reflected she was admitted to the facility on [DATE]; she was not oriented to the day, month or year; she required assistance with activities of daily living; and she had a [DIAGNOSES REDACTED].e., asthma, [MEDICAL CONDITION] or [MEDICAL CONDITION]). The MDS assessment further reflected she had no issues with shortness of breath or trouble breathing with exertion, when sitting at rest or when lying flat. Further review of the MDS assessment did not reveal she received oxygen therapy. Resident #2's Plan of Care, dated 05/07/13, reflected she had episodes of shortness of breath and was at risk of respiratory distress/failure, and she had a [DIAGNOSES REDACTED]. The Care Plan's approaches included applying oxygen as ordered, encouraging slow, deep breaths and assessing respiratory status such as breath sounds, respiratory rate, skin color, and notifying the physician of abnormalities. Resident #2's Nurse's Notes dated 07/14/12 through 05/19/13 did not reflect problems with Resident #2's oxygen saturation levels dropping. Resident #2's Nurse's Notes, dated 05/27/13 (no time), reflected she was "breathing heavily" and her oxygen saturation level was at 46%. The Notes also reflected she was given an as needed nebulizer treatment and her oxygen saturation level increased to 86%. Further review of Resident #2's Nurse's Notes revealed her oxygen saturation level was checked later (no time indicated), and it had decreased to 66%. The Notes reflected the physician was notified and the resident was transferred to a local hospital. (Note: There was no documented evidence the physician was immediately consulted when her oxygen saturation level dropped to a critical level of 46% as her Plan of Care indicated should occur.) During an interview with RN B, Resident #2's Charge Nurse, on 06/20/13 at 1:45 p.m., he stated Resident #2's critical low oxygen saturation level occurred while he was passing the 9:00 a.m. medications. He said he checked her oxygen saturation level (which was 46% and did not call 911) and then checked with LVN Y, who was also an ADON, who suggested giving Resident #2 a breathing treatment. RN B added Resident #2 had never had her oxygen saturation level drop before. RN B revealed Resident #2's oxygen saturation level went up to 80% then dropped again. He stated it was after her oxygen saturation level went down again (to 60%) that he called Resident #2's physician and she was then transferred to a hospital. During an interview with LVN Y on 06/20/13 at 2:10 p.m., she stated she thought RN B gave Resident #2 the breathing treatment due to her [MEDICAL CONDITION]. She stated she was unaware Resident #2's oxygen saturation level had dropped. During an interview with the DON on 06/20/13 at 2:30 p.m., she stated the incident should have involved two staff: one to administer Resident #2's breathing treatment while another one called the physician and 911. During an interview with Resident #2's physician on 06/20/13 at 2:40 p.m., the surveyor reviewed with the physician the following: --RN B finding Resident #2 with an oxygen saturation level of 46%; --Leaving the resident to speak with LVN Y; --LVN Y told RN B to give the resident a nebulizer treatment; -- LVN Y denied being told Resident #2's oxygen level had dropped and thought the resident's [MEDICAL CONDITION] was the problem; --RN B gave Resident #2 a nebulizer treatment; --Resident #2's oxygen level rose to 80% and then started dropping again; --RN B left the resident again and called the physician; --RN B received orders to send her to the hospital and 911 was called; and --This occurred over approximately 60 minutes. When the physician was asked about the care Resident #2 received, the physician responded, "They did the right thing." Resident #2's Physician Telephone Order, dated 05/27/13 reflected to send the resident to the ER for evaluation of low oxygen saturation level. Resident #2's hospital ED Nurse Notes, dated 05/27/13 and timed at 11:41 AM, reflected, "Presenting complaint: EMS states SOB...Oxygen via [MEDICAL CONDITION] (machine to help someone breathe)...Triage Assessment...Appears uncomfortable...Respiratory effort is with [MEDICAL CONDITION] sounds are course bilaterally. Reports shortness of breath at rest...the patient has severe shortness of breath... 11:44 Pulse ox (oximetry) 92% on 15% [MEDICAL CONDITION] (machine to help someone breathe)...." Resident #2's hospital ED Physician Notes, dated 05/27/13 at 11:49 AM, reflected, "The patient has shortness of breath at rest, that woke him/her from sleep...The symptoms/episode began/occurred acutely, this morning at 02:00 (2:00 AM)...pt had very elevated blood pressure and responded to nitro, [MEDICATION NAME], and [MEDICAL CONDITION]. Also received nebs (nebulizer treatments)...14:35 (2:35 PM)...moderate respiratory distress is noted...14:40 (2:40 PM)...Pulse oximetry: on 95% oxygen by non-rebreather, is 98%...Pt stable on [MEDICAL CONDITION] in ED...." Resident #2's hospital Discharge Summary, dated 05/30/13, reflected, "FINAL Diagnoses: [REDACTED]. Dypsnea (air hunger resulting in labored or difficult breathing). 3. [MEDICAL CONDITION]...8. [MEDICAL CONDITION] infiltrates. 9. [MEDICAL CONDITIONS], volume overload, hypercarbia (elevated levels of carbon [MEDICATION NAME] in the blood)...presents to the hospital with complaints of shortness of breath and [MEDICAL CONDITION] (oxygen deficiency in body tissues)...patient was this morning was noted to be hypoxic with saturations in the 70s...The patient was seen in the emergency room and has (sic) been placed on [MEDICAL CONDITION] morning on examination patient remained to be (sic) somnolent. The patient was also having hypercapnia...The patient was has been evaluated by hospice and is being transferred to inpatient hospice unit...." On 06/20/13 an IJ was identified. On 06/20/13 at 5:17 p.m., the Administrator and Regional Administrator were notified of the IJ and a Plan of Removal was requested at that time. On 06/24/13, the facility's Plan of Removal was accepted and reflected: (1) An in-service was conducted with all charge nurses regarding a) Recognition of changes of condition/physician notification; b) Physician notification parameters and related care areas such as oxygen saturation levels. The in-services were conducted by the DON, ADON, RNC and LVN/CMM with a start date of 06/17/13 and a conclusion date of 6/21/13. One charge nurse was unavailable and would not work until she received the in-service training. (2) CNAs received in-service training regarding reporting changes of condition to their charge nurses. The in-services initiated on 06/24/13 and were presented by the DON, LVN Y, LVN Z and RNC. (3) A QAA Audit was conducted of all incidents reports and charts of residents on oxygen therapy from 05/01/13 through 6/18/12 by the RNC. The RNC completed the audit on 06/21/13. (4) The RNC audited the 24 Hour Reports from 06/15/13 through 06/18/13 to identify changes of condition and follow-up and found no issues. (5) The RNC, DON, LVN Y and LVN Z audited charts to validate physician notification parameters for care areas such as oxygen saturation levels. None of the residents' physicians' orders included parameters. The physicians were contacted to request physician notification parameters. One of four physicians requested to be contacted if the level was below 85% and three of the four physicians requested to be contacted if the oxygen saturation level fell below 90%. (6) The RNC and DON completed a one-on-one in-service to re-educate both RN B and LVN Y on parameters now set forth by the physician prior to returning to work. The DON would monitor through daily start up process and quarterly evaluations for the first six months and then every six months for one year and annually thereafter. (7) The DON, LVN Y and LVN Z would complete daily walking rounds Monday through Friday. On Saturday and Sunday, one of the three staff would conduct rounds to identify residents with a change in status. (8) The DON, LVN Y and LVN Z would conduct weekly Standard of Care Meetings with the Interdisciplinary Team (DON, Social Worker, Dietary Service Manager, Activities Director, Rehab Director and ADON) to discuss resident issues such as residents on oxygen. (9) The Medical Director was notified of the IJ on 06/20/13 at approximately 9:00 p.m. A QAA Audit Tool would be utilized by the DON, LVN Y and LVN Z five days per week for 30 days to validate sustained compliance with oxygen saturation orders including physician notification parameters and nurse follow-up if parameters were exceeded. (10) The findings of the QAA Audits submitted by the DON and reviewed by the Standards of Care Ad Hoc QAA team who would make the recommendations for additional staff in-service and monitoring. This review/evaluation would occur weekly for 30 days, then twice a month for an additional 30 days. Interviews conducted with LVN D, LVN E, LVN F, LVN G, LVN H, LVN I, LVN J, LVN K, RN L, LVN M, and LVN N, who represented each shift, on 06/21/13, 06/22/13, and 06/24/13, revealed they had received the required in-service education and they comprehended the information provided. The interviews did not reveal any problems. Interviews conducted with CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V and CNA W, who represented each shift, on 06/26/13 from 10:25 a.m. through 11:22 a.m. revealed they had received the required in-service education and they comprehended the information provided. The interviews did not reveal any problems. Interview conducted with MA A on 06/26/13 at 11:09 a.m. revealed she had received the required in-service education and comprehended the information provided. The interview did not reveal any problems. On 06/26/13 at 11:15 a.m., the Administrator was notified the IJ was removed. While the IJ was removed on 06/26/13, the facility remained out of compliance at scope of "isolated" and severity level of "actual harm that is not immediate jeopardy," because the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. The facility's list of residents, who used oxygen, dated 06/26/13, reflected 11 residents.