Every finding on record at Avir at Knox City

Based on observation and interview, the facility failed to respect the resident's right to personal privacy in 1 of 3 common hallways reviewed for privacy in that: A list of residents that received incontinence care services was posted on the wall in a hallway at a nurse charting station which was visible to potential passersby. This failure could place residents at risk of having medical information personal, or care instructions exposed to others and misuse of personal information. During an observation on 12/16/25 at 4:05 PM revealed a list of 14 residents names that received incontinence care services was posted on the wall in a hallway on the secured unit at the nurse charting station which was located across from the doorway of a dining room. During an interview on 12/18/25 at 11:30 AM, the ADON stated she posted the incontinence care list on the wall in the hallway at the charting station. She stated she posted it on the wall but did not think about how it affected resident's privacy when she did that. She stated she did not remember when she posted it there. She stated she now realized that may have caused residents to feel embarrassed. She stated she had received training about a month ago on privacy. She stated the DON also provided training to staff on privacy periodically. She stated everyone was responsible for ensuring residents had privacy. She stated privacy was important to residents because this was their home and they wanted to ensure residents felt safe and comfortable. She stated a potential negative outcome was embarrassment, that it could cause residents to feel unhappy and not want to live here, or it could cause others to make fun of residents. During an interview on 12/18/25 at 12:55 PM, the DON stated residents should feel protected and in a safe environment and not feel exposed. She stated residents had the right to have their personal care needs private. She stated she was not aware of the incontinence care list posted on the wall in a hallway. The DON stated the list was not appropriate because it gave information that residents may not want to be known because it was a dignity issue. She stated staff were also trained on privacy when they were hired. She stated herself and their Human Resources department provided ongoing training to staff regarding privacy. She stated she expected staff to ensure residents have their rights to privacy. She stated a potential negative outcome was that it could cause depression. During an interview on 12/18/25 at 2:15 PM, the ADM stated residents have a right to privacy. The ADM stated she was not aware of the incontinence list posted in the hallway. She stated this was a privacy and dignity issue. She stated she trained all staff in the residents' privacy, and she also provided ongoing in-services to staff. She stated she expected residents' privacy to be respected so they felt safe and comfortable. She stated a potential negative outcome was that residents would not feel safe and comfortable and not feel like they were at home. Record review of the facility policy, Resident Rights, revised February 2021, revealed the following in part: Policy Statement Employees should treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:a. a dignified existence.b. be treated with respect, kindness, and dignity.t. privacy and confidentiality.dd. communicates in person and by mail, email, and telephone with privacy.4. Unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA compliance officer.

Based on observation and interview, the facility failed to provide information to residents and their representatives on their rights related to filing grievances or concerns for 4 of 4 confidential residents. The facility failed to ensure 4 of 4 confidential residents were provided, per the facility policy through postings in prominent locations: the grievance procedure, access to grievance forms, information regarding who the facility grievance officer was with their contact information, and accommodations to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Observation of prominent posting on 12/17/2025 at 9:44 AM revealed the facility did not have instructions regarding the grievance procedure with any of their prominent postings. Grievance forms were not readily available to residents in the facility, and there was no accommodation to submit grievance anonymously. During a confidential interview on 12/17/2025 at 10:00 AM with the resident council, 4 confidential residents stated they did not know how to file a formal grievance. The residents attending Resident Council stated they did not have access to grievance forms, and they did not know where grievance forms were kept. Additionally, residents in the Resident Council were not aware of who their grievance officer was, nor the process to resolve grievances. The residents stated they had not seen a posting in the facility pertaining to grievances. The residents in the Resident Council also stated they did not know how to file anonymous grievances, and they were not aware they had the option to file a formal complaint anonymously. During an interview on 12/18/2025 at 12:55 PM the DON stated there were grievances forms on her door. She stated everyone was responsible for taking grievances from residents. She stated residents could tell any staff member of their grievance and the staff member would fill out the grievance form for the resident. She stated she was not sure if information on grievances was posted on the bulletin board. She stated the grievance process should be posted for residents to see. She stated she would be involved in any grievance that involved the nursing department and then either she or the ADM would provide the resident with the outcome. She stated she had received training on the grievance policy. She stated supervisors, including herself, were responsible for ensuring their staff were trained in grievances. She stated they also discussed grievances that needed to be addressed during morning meetings. She stated she was not aware residents did not know who the grievance officer was and that residents did not know how to file a grievance. She stated residents could complain to anyone or call her as well. She stated she did not consider the grievance forms on her door to be accessible to residents because there was no prominent sign that indicated the forms were there. She was not aware residents could not access forms without staff assistance. She stated she was not aware residents must have the option to file an anonymous grievance. She stated anonymous grievances were important so residents could report their concerns without fear of retaliation. She stated it was possible there were grievances not filed due to lack of access to the forms. She stated she expected grievance postings to be in prominent areas so residents would not be afraid of retaliation and so they had easy access to file grievances. She stated a potential negative outcome was that residents could feel discontent and not file grievances due to feeling things would not get done or not feel comfortable complaining, which could cause them to be introverted. During an interview on 12/18/2025 at 2:15 PM the ADM stated she was the Grievance Officer for the facility. The ADM stated there were grievance forms on DON's door and residents could let staff know about grievance and staff could fill out the grievance form for them. The ADM stated the grievance policy was that she was to investigate grievances and ensure they were resolved. The ADM stated the grievance process information was posted on the bulletin board by the nurse station. She stated she was not aware residents did not know how to file a grievance or who the grievance officer was. The ADM stated she did not consider the grievance forms on the DON's door to be readily accessible to residents because of the height they were located at and because the forms were not prominent and blended in with other items on the door. The ADM stated there was no procedure in place currently that allowed residents to obtain a grievance form on their own or to submit it anonymously. The ADM stated it was important that residents had a way to submit an anonymous grievance and not be afraid of retaliation. She stated it was possible she may not be aware of some grievances. She stated she was concerned about this because there could have been issues that she was not aware of that were reportable to the State. The ADM stated she had been trained in grievances. She stated staff have also been trained in grievances. The ADM stated the grievance posting was important for residents so they could know where to get the form and know how to file a grievance. She stated she expected residents to feel comfortable with filing a grievance. She stated she believed residents should have a way to file an anonymous. She stated she expected grievances to be resolved as soon as possible. She stated a potential negative outcome of not having a grievance posting was that was that residents would not know to file a grievance so, then grievances would not be corrected. She stated a negative outcome of not having a way to submit an anonymous grievance could cause residents to not feel safe. The ADM stated the grievance posting was no longer on the bulletin board after she observed the bulletin board. Record review of the facility policy, Grievances/Complaints, Filing, revised April 2017, revealed the following in part: Policy Statement Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the residents and/or representatives. Policy Interpretation and Implementation2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal.3. All grievances, complaints or recommendations stemming from residents or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response.4. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board.5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously.6. The contact information for the individual(s) with whom a grievance may be filed is provided to the residents and/or representative upon admission.7. The administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer who is __________ and can be contacted by __________.13. If the grievance is filed anonymously, the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance(s) and report the findings. The grievance officer will reiterate to the resident that it is against facility policy and federal regulations to discriminate or sanction a resident who has filed or verbalized a complaint against the facility, and that his or her rights to be free of discrimination or reprisal will be protected.

Based on observation, interviews, and record review, the facility failed to ensure that the menu met the nutritional needs of residents and was followed for the lunch meal on 12/16/25 reviewed for nutritional adequacy. The facility failed to: 1) Ensure lunch item served on 12/16/2025 reflected what was on the DM's menu. 2) Ensure residents on special diet (pureed bread) receive pureed bread for the 12/16/2025 lunch meal. These failures could affect all residents who ate food from the kitchen by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. The findings included: Review of the weekly menu week 3 Tuesday lunch revealed Beef goulash, Squash medley, tossed salad, Cornbread, Margarine, Dressing of choice, Fresh baked cookie and a Beverage. During an observation on 12/16/25 from 12:15 PM to 12:30 PM revealed a message written on a white board hanging on a wall in the secured unit dining room said that reflected, Lunch: goulash, green beans, bread slice, fruit. Three items of pureed food were observed to be included on four pureed meals that were served which included: pureed goulash, pureed green beans, and pureed mixed fruit. The pureed bread was not observed to be included with any of the four meals. In an interview on 12/18/2025 at 9:53 AM with the DM, he stated that I am responsible for making the pureed bread and residents on that meal type were supposed to get it. The DM further stated that he made the pureed bread and forgot it in the refrigerator. He stated, Sometimes I forget stuffs. The DM stated he did inform the ADM, RD and all the other residents that the menu was being substituted. [BR1] The DM stated he did inform the ADM, RD, and all the other residents that the menu was being substituted. He stated that it would cause residents' dissatisfaction resulting in weight loss. In an interview on 12/18/2025 at 10:39 AM with the RD, she stated that she was not aware that pureed bread was not served to some of the residents. The RD stated the DM was responsible to follow that, and such be documented. The RD stated that the potential negative outcome on such residents could be less calories. In an interview on 12/18/2025 at 11:47 AM with LVN A, she stated I was not here on that day, 12/16/2025; the dietary staff were responsible to serve resident with the correct meal. LVN A stated that residents would not get all the calories and nutrients needed which could result in malnutrition and breakdown. LVN A further stated, The facility doesn't provide nutritive meals for the residents, and I told my DON about it. She responded that she would take care of it. In an interview on 12/18/2025 at 12:18 PM with the DON, she stated I was not aware that pureed bread was not served on 12/16/2025; the DM was responsible for making sure that pureed bread was served to the resident for lunch on Tuesday, 12/16/2025. When asked about the menu not being followed, the Director of Nurses stated, It must have come up in one of our meetings. Usually, the Dietary Manager and Administrator will figure it out. She stated, within the nursing department, none of the staff members had complained about dietary services not following the menus. DON stated that residents could have less nutrition resulting in weight loss. In[BR2] an interview on 12/18/25 at 12:47 PM with the ADM, she stated I was not aware that pureed bread was not served on 12/16/2025. The DM [BR3] was responsible for making sure that pureed bread was served to the resident for lunch on Tuesday, 12/16/2025. She stated she had been notified before that menus were not followed by the DM and nursing staff. The ADM stated the potential negative outcomes to the residents without the pureed bread was, The residents are not getting enough portions leading to possible weight loss. Record review of the facility's undated policy and procedure manual titled, Menu Planning, reflected the following: Policy: Nutritional needs of individuals be provided in accordance with the established national standards adjusted for age, gender, activity level and disability, through nourishing, well balanced diets, unless contradicted by medical needs. Based on a facility's reasonable efforts, menu should reflect the religious, cultural, and ethnic needs of the population served, as well as input received from individuals and group. Procedure: 1. Menu planning will be completed by the facility at least two weeks in advance of service and menu kept on file for a reasonable period (check individual state regulations to see if there are specific guidelines). All current menus will be posted in the kitchen area during the appropriate time. a. Regular and therapeutic menus will be written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances. If menus are written in circles, they are rotated. 4. Regular and therapeutic menus will be written by the facility's food and nutrition professionals in accordance with the facility's approved diet manual or purchased from an approved vendor. The registered dietitian nutritionist (RDN) or designee will approve all menus. 5. Menus will be posted in areas that are accessible to patients/residents at heights where all individuals can easily view them. 6. Temporary changes in the menu will be noted on the menu substitution sheet [BR4] and posted so that facility staff are aware of changes. (See Sample Menu Substitution Sheet later in this chapter.) The RDN or designee will approve all permanent menu changes.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1) The facility failed to ensure food items in the freezers (4), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to protect foods from potential contamination. These failures could place residents at risk for food-borne illness and cross contamination.The findings included: The following observations were made during a kitchen tour on 12/16/25 that began at 11:01 AM and concluded at 11:38 AM: The facility failed to have vent hood located directly above the cooktop on the right side of the kitchen free from dust and cobwebs. Walk-in Freezer #1 revealed the following: What appeared to be chicken breasts, ground beef, and chicken wings in three different clear plastic bags with no label, no date on bag. Walk-in Freezer #2 revealed the following: What appeared to be sausage in a clear plastic bag with no label, no date on bag. Walk-in Freezer #3 revealed the following: What appeared to be Chinese rice, French fries, mixed vegetables, and okra in four different clear plastic bags with no label, no date on bag. Walk-in Freezer #4 revealed the following:What appeared to be chicken drumsticks, and egg rolls in two different clear plastic bags with no label, no date on bag. In an interview on 12/18/2025 at 9:53 AM with the DM, he stated I am responsible for dating and labeling of all food items in the freezers. The DM further stated that he was not sure why the food items were not labeled or dated, and that he must have forgotten. The DM stated he was trained and had seen the policy on food storage/labeling and dating. When asked about the unclean vent hood with cobwebs, the DM stated, I have spoken to the maintenance guy about it, but he is so busy, though promised to take care of it. The DM stated it was important for food items to be labeled and dated to ensure outdated food was not being served as that could cause residents to get sick. In an interview on 12/18/2025 at 10:39 AM with the RD, she stated that the dietary staff was responsible for dating and labelling of all food items in the freezers. She added that the DM should have the log of all in-services done on dating and labeling of all food items. The RD stated that food items not labeled or dated would potentially cause food borne illness to the residents. In interview on 12/18/2025 at 11:47 AM with the LVN A, she stated I don't know why the food items were not labeled or dated; that everything was supposed to be labeled and dated. She added that the DM was responsible for ensuring that food items were dated properly. LVN A stated that residents could get an infection from food items not labelled properly. In an interview on 12/18/25 at 12:47 PM with the ADM, she stated that the DM was responsible for dating and labelling all food items in the freezers and it was the facility's policy that all food items be properly labeled/dated and monitored. The ADM stated food items should be labeled and dated, but the kitchen staff must have forgotten to do that when the food items were received. The ADM stated the potential negative outcomes to the residents with unlabeled/undated food, was it could make the residents sick because we do not know how long the food items were in the freezers. The ADM stated she did not notice the dusty vent hood with cobwebs inside the kitchen. Record review of the facility policy and procedure titled, Food receiving and storage, revised date November 2022, reflected the following: Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation:Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen, or discarded. Record review of the facility policy and procedure titled, Sanitation, revised date November 2022, reflected the following: Policy Statement: The Food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.

Based on observation and interview, the facility failed to respect the resident's right to personal privacy in 10 of 33 resident rooms (24, 25, 26, 28, 30, 31, 32, 33, 34, and 35) reviewed for privacy in that: 1. Resident rooms [ROOM NUMBERS], beds B, didn't have privacy curtains that were designed or equipped to allow for full visual privacy. 2. Resident rooms 24, 25, 26, 28, 30, 31, 32, 33, 34, and 35 had slats missing from the window vertical blinds, which allowed potential passersby to see inside the rooms. These failures could also cause residents to feel uncomfortable, disrespected, and possible exposure to anyone passing by. Findings included: During an observation on 12/16/25 at 11:42 AM in room [ROOM NUMBER] revealed, the vertical blinds on the bedroom window were missing 1 slat which left an opening of approximately 3 inches wide of the window from top to bottom to be uncovered when the blinds were closed. During an observation on 12/16/25 at 12:14 PM in room [ROOM NUMBER] revealed the vertical blinds on the bedroom window missing 1 slat which left an opening of approximately 3 inches wide of the window from top to bottom to be uncovered when the blinds were closed. During an observation on 12/16/25 at 2:38 PM room [ROOM NUMBER] revealed the vertical blinds on the bedroom window missing 1 slat which left an opening of approximately 3 inches wide of the window from top to bottom to be uncovered when the blinds were closed. During an observation on 12/16/25 at 2:43 PM in room [ROOM NUMBER] revealed the vertical blinds on the bedroom window were missing 1 slat which left an opening of approximately 3 inches wide of the window from top to bottom to be uncovered when the blinds were closed. Additionally, there was no privacy curtain that allowed B to have full visual privacy. There was a privacy curtain hanging between bed A and bed B however, the curtain did not extend all the way to the wall, which left approximately a 4-foot gap between that privacy curtain and the wall. During an observation on 12/16/25 at 2:49 PM room [ROOM NUMBER] revealed the vertical blinds on the bedroom window missing 1 slat which left an opening of approximately 3 inches wide of the window from top to bottom to be uncovered when the blinds were closed. During an observation and interview on 12/16/25 at 3:01 PM resident # 3 room [ROOM NUMBER], bed B, said he changed clothes in the restroom in his bedroom because there was a surveillance camera in the hallway directly outside his bedroom door that was watching him. The resident said he did not have a privacy curtain on his side of the room to close for privacy from the surveillance camera or from his roommate. Observation of the room revealed the vertical blinds on the bedroom window were missing 2 slats which left an opening of approximately 3 inches wide of the window from top to bottom to be uncovered for each missing slat when the blinds were closed. There was a surveillance camera dome installed in the hallway ceiling outside of the bedroom. This camera was visible from bed B. Additionally, there was no private curtain between bed B and the restroom in the room. There was a privacy curtain hanging between bed A and bed B however, the curtain did not extend all the way to the wall, which left approximately a 4-foot gap between that privacy curtain and the wall. During an observation on 12/16/25 at 3:30 PM in room [ROOM NUMBER] revealed the vertical blinds on the bedroom window was missing 1 slat which left an opening of approximately 3 inches wide of the window from top to bottom to be uncovered when the blinds were closed. During an observation on 12/16/25 at 4:03 PM in room [ROOM NUMBER] it revealed the vertical blinds on the bedroom window were missing 10 slats which left an opening of approximately 3 inches wide of the window from top to bottom to be uncovered for each missing slat when the blinds were closed. During an observation on 12/17/25 at 12:47 PM in room [ROOM NUMBER] the vertical blinds on the bedroom window was missing slats which left an opening of approximately 3 inches wide of the window from top to bottom to be uncovered for each missing slat when the blinds were closed. During an observation on 12/17/25 at 1:05 PM, room [ROOM NUMBER] revealed the vertical blinds on the bedroom window missing 3 slats which left an opening of approximately 3 inches wide of the window from top to bottom to be uncovered for each missing slat when the blinds were closed. During an interview on 12/18/25 at 11:30 AM, the MS stated he walked the building several times daily to identify issues that needed repairs; he did not solely depend on residents and staff to submit work orders for repairs. He stated repairs needed were documented in an electronic system called Tels. He stated he could access the Tels system through an application on his cellular phone and it organized the maintenance work orders. He stated he was responsible for ensuring repairs were completed timely. He stated high priority repairs were completed immediately, and other repairs were completed when he could get to them. He stated housekeeping installed privacy curtains, but he did not know who was responsible for installing the privacy curtain tracks on the ceiling. He stated he was aware there were several rooms that were missing slats on the window vertical blinds. He stated the facility just switched owners a couple of months ago and there was an issue with the funding. He stated he had not followed up recently to check on the status of the funding since the switch. He stated he had been busy trying to get his classes, new training, and learning new ways of doing things that were required from the new owners. He stated there was no funding at the time to purchase materials needed and they also had no access to petty cash. He stated the new owners monitored the work orders in the Tels system. He stated he had not received training on maintenance or the importance of residents having a comfortable homelike environment. He stated he did not know how missing slats from the blinds negatively affected the residents. During an interview on 12/18/25 at 11:30 AM, the ADON stated she was aware that the broken blinds had been like that for several months and had been reported to the corporate office as well as submitted in the Tels system. ADON stated she had been trained in the environmental requirements of the facility. She stated she was responsible for training staff in reporting maintenance needs. She stated it was important that residents lived in a homelike environment so they could be comfortable, just like she preferred at her home, because this was their home. The ADON stated missing slats on the blinds did not allow residents to have privacy. She stated she was not aware of residents not having privacy curtains in their rooms that allowed them to have full visual privacy. She stated she was not aware there was a surveillance camera outside one of these rooms but realized how uncomfortable the resident felt. She stated residents should be able to be hidden from everyone except for others who were inside the privacy curtains with them. She stated she had received training about a month ago about privacy. She stated the DON also provided training to staff on privacy periodically. She stated everyone was responsible for ensuring residents had privacy. She stated privacy was important to residents because this was their home and they wanted to ensure residents felt safe and comfortable. She stated a potential negative outcome was embarrassment, that it could cause residents to feel unhappy and not want to live here, or it could cause others to make fun of residents. During an interview on 12/18/25 at 12:55 PM, the DON stated the MS and ADM were responsible to ensure needed repairs were completed. She stated all staff were responsible for reporting repairs needed. She stated they had a rounding system every week with staff where they could report repairs needed directly to the MS and they could also enter repairs needed in the Tels system. She stated the broken blinds had been reported and were ordered but they were the wrong size and were sent back. She stated the facility was bought by a new company afterwards and there had been a delay with having access to money. She stated the Tels system was documentation to make the MS accountable to ensure repairs were completed. She stated she had received training on importance of maintenance with the previous company as well as this new company. The DON stated residents should feel protected and in a safe environment and not feel exposed. She stated residents had the right to have their personal care needs private. She stated she was not aware of the bedrooms that did not allow residents to have full visual privacy. She believed privacy curtains should be able to provide a separation so residents would not be able to see their roommate. She stated another privacy curtain may be needed in rooms that have a bathroom to provide privacy to the residents whose room was in front of the restroom. She stated she was not aware residents should be able to have full visual privacy in rooms that did or did not have a restroom. She stated she was concerned residents did not have total privacy when changing or receiving care. She stated the systems in place to monitor privacy were the in-services and rounding's they provided to staff on resident rights and HIPAA rights. She stated staff were also trained on privacy when they were hired. She stated herself and their Human Resources department provided ongoing training to staff regarding privacy. She stated she expected staff to ensure residents have their rights to privacy. She stated a potential negative outcome was that it could cause depression. During an interview on 12/18/25 at 2:15 PM, the ADM stated the MS was responsible for assessing the building for repairs. She stated all staff were responsible for reporting repairs needed. She stated the Tels system was the main system used to submit and monitor repairs needed but serious things should have been directly reported to the MS. The ADM stated she was aware of the vertical blinds that were broken in several rooms. She stated the blinds had been broken for a while and they had been replacing them little by little. She stated the broken blinds were a privacy issue. She stated she had received training on maintenance and environment. She stated herself and the MS were responsible for training staff. She stated staff had been trained in how to document repairs in the Tels system. She stated the Tels system was for tracking repairs, and it was important for the repairs to be documented there. She stated she expected a simple repair to be completed on the same day; however, she would have allowed 2-3 more days if additional materials were needed. She stated staff should shut the door and have the privacy curtain drawn when changing residents in their rooms. She stated residents have a right to privacy. The ADM stated she was not aware residents did not have full privacy in their bedrooms due to lack of privacy curtains. She stated it was important for them to have privacy, so they felt comfortable when changing and during peri-care. She stated she trained all staff in the residents' privacy, and she also provided ongoing in-services to staff. She stated she expected residents' privacy to be respected so they felt safe and comfortable. She stated a potential negative outcome was that residents would not feel safe and comfortable and not feel like they were at home. The ADM stated a potential negative outcome of not addressing repairs needed in the facility would not allow the facility to provide a homelike environment for residents and this was important because it was their home. Record review of the facility policy, Resident Rights, revised February 2021, revealed the following in part: Policy Statement Employees should treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:a. a dignified existence.b. be treated with respect, kindness, and dignity.t. privacy and confidentiality.dd. communicates in person and by mail, email, and telephone with privacy.4. Unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA compliance officer.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 1 of 2 medication carts (Medication Cart A) reviewed for medication storage. LVN B left Medication Cart A unlocked and unattended in the hallway by the nurse's station. The facility failed to ensure Medication Cart A's medications were stored separately by route. These failures could place residents at risk for drug diversion and an increased risk for medication errors. The findings included: During an observation on 12/16/25 at 11:31 AM, Medication Cart A was observed unlocked and unattended in the hallway by the nurse's station. No staff members or residents were observed in the area around Medication Cart A.During an interview on 12/16/25 at 11:33 AM, LVN B stated she knew she was supposed to lock the medication cart when she walked away from it. LVN B stated she forgot to lock it when she went to check on a resident. LVN B stated a potential negative outcome to the residents was they could get into it [the medication cart]. During an observation on 12/17/25 at 4:15 PM of Medication Cart A with LVN A and the DON revealed the following:-Fluticasone/Salmeterol inhaler for Resident #1 was stored next to Calcitonin Nasal Spray for Resident #12 in the same sectioned area in the third drawer, -Nitroglycerin sublingual tablets for Resident #41, Ondansetron injections for Resident #7, Cosopt eye drops for Resident #7, and Rhopressa eye drops for Resident #7 were stored next to each other in the same sectioned area in the first drawer, and-Latanoprost eye drops for Resident #7, Lantus flexpen for Resident #10, and Insulin Aspart flexpen for Resident #10 were stored next to each other in the same sectioned area in the first drawer. During an interview on 12/17/25 at 4:25 PM, LVN A stated she was not aware of the medications needing to be separated by route and the pharmacy consultant had never said anything when they had done their checks. LVN A stated a potential negative outcome to the residents was the staff could give the wrong med or wrong patient and there was also a risk for cross contamination. Attempted phone interview on 12/18/25 at 9:34 AM with the Pharmacist revealed no answer. The Surveyor left a voice mail with call back number. During an interview on 12/18/25 at 9:47 AM, the DON stated she expected the medications carts to be locked at all times. The DON stated she trained the nurses by doing in-services and watching to see if the carts were locked. The DON stated LVN B was checking on residents down the hall the other day and she just forgot to lock the medication cart. The DON stated a potential negative outcome with the medication cart being unlocked and unattended was someone could get into it who was not authorized. The DON stated she expected medications to be separated in the medication cart. The DON stated the pharmacy consultant went in and checked their medication carts and had not mentioned the storage of medications being an issue. The DON stated there used to be a divider in the medication cart to keep the medications separated but she did not know what happened to the dividers. The DON stated a risk to the residents was a nurse not looking at the label and a medication error occurring. During an interview on 12/18/25 at 11:03 AM, the ADM stated she expected the medication carts to be locked at all times. The ADM stated she did not know why LVN B did not lock the medication cart when she walked away from it. The ADM stated the nurses were trained in medication storage, but it was unknown when. The ADM stated the DON and herself were responsible for ensuring the nurses kept the medication carts locked at all times. The ADM stated a potential negative outcome was that a resident could get in [the medication cart] or an employee could also get in [the medication cart]. The ADM stated the medications stored in the medication carts should be separated and easily accessible. The ADM stated the DON was responsible for monitoring the storage of medications in the medication carts. The ADM stated the nurses were trained on medication storage, but she would have to go back and look at in-services for exact dates. The ADM stated a potential negative outcome was that the nurses could get the medications mixed up or give the wrong medication. Record review of the facility's document titled, Consultant Pharmacist Summary dated 11/17/2025, reflected the following: .4. Medication Carts:.All medications stored/labeled properly: No.The following suggestions are best practice guidelines: -always keep inhalers, eye drops, ear drops, oral liquids and topical labeled patient specific items and stored separately to help reduce the possibility of med [medication] errors. Record review of the facility's policy titled, Medication Labeling and Storage, dated 2001, reflected the following: Policy Statement - The facility stores al medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.Policy Interpretation and Implementation:Medication Storage: .4. Compartments (including, but not limited to, drawers.carts .) containing medications and biologicals are locked when not in use.5. Medications are stored in an orderly manner in cabinets, drawers, carts. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview, and record review, the facility failed to ensure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 1 of 2 common dining rooms and 10 of 33 resident rooms (24, 25, 26, 28, 30, 31, 32, 33, 34, and 35) reviewed for environment. The facility failed to ensure residents that used common areas and rooms were clean, safe, and did not need repair. These failures could place residents at risk of living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings included: During an observation on 12/16/25 at 11:42 AM in room [ROOM NUMBER] revealed, the vertical blinds in the bedroom window were missing 1 slat. During an observation on 12/16/25 at 12:14 PM room [ROOM NUMBER] revealed 2 broken and/or cracked planks on the flooring in the room. The planks were also bowing upward and sticking up from the floor. Additionally, the window was broken and covered with two doubled up pieces of cardboard and duct taped to the framing. Also, the vertical blinds on the bedroom window were missing 1 slat. During an observation on 12/16/25 at 2:38 PM, room [ROOM NUMBER] revealed the vertical blinds on the bedroom window missing 1 slat. During an observation on 12/16/25 at 2:43 PM room [ROOM NUMBER] revealed the vertical blinds on the bedroom window missing 1 slat. During an observation on 12/16/25 at 2:49 PM in room [ROOM NUMBER] revealed, the vertical blinds on the bedroom window were missing 1 slat. During an observation on 12/16/25 at 3:01 PM in room [ROOM NUMBER] it was revealed the vertical blinds on the bedroom window were missing 2 slats. During an observation on 12/16/25 at 3:30 PM in room [ROOM NUMBER] it was revealed the vertical blinds on the bedroom window were missing 1 slat. During an observation on 12/16/25 at 4:03 PM room [ROOM NUMBER] revealed 22 broken and/or cracked flooring tiles in the room. Additionally, the vertical blinds on the bedroom window were missing 10 slats. During an observation on 12/17/25 at 12:11 PM in the dining room [ROOM NUMBER] broken and/or cracked tiles that went all the way across the middle of the dining room floor. The vertical blinds on a dining room window were missing 7 slats. Additionally, a white blanket was used as a window covering on that window. During an observation on 12/17/25 at 12:47 PM in room [ROOM NUMBER] it was revealed the vertical blinds on the bedroom window were missing 2 slats. During an observation on 12/17/25 at 1:05 PM in room [ROOM NUMBER] it revealed the vertical blinds on the bedroom window was missing 3 slats. Record review of a document titled, Work Orders for [facility name], undated, revealed an open work order for blinds torn that was not dated. There were no open or closed work orders for broken or cracked floor tiles or planks, or a broken window documented on the list of work orders. During an interview on 12/18/25 at 11:30 AM, the MS stated he walked the building several times daily to identify issues that needed repairs; he did not solely depend on residents and staff to submit work orders for repairs. He stated repairs needed were documented in an electronic system called Tels. He stated he could access the Tels system through an application on his cellular phone and it organized the maintenance work orders. He stated he was responsible for ensuring repairs were completed timely. He stated high priority repairs were completed immediately, and other repairs were completed when he could get to them. He stated he considered a broken window a high priority repair. He stated he was aware there were several rooms that were missing slats on the window vertical blinds. He stated the facility just switched owners a couple of months ago and there was an issue with the funding. He stated he had not followed up recently to check on the status of the funding since the switch. He stated he had been busy trying to get his classes, new training, and learning new ways of doing things that were required by the new owners. He stated he was aware of rooms with cracked and broken tiles and planks, and he changed them 2 years ago, but the building floor was pier and beam which caused flooring to move and break. He stated he was not aware of plank flooring that was broken in the resident's room. He stated he did not know why there was no work order for broken tiles and planks listed in the Tels system as they should have been submitted on the list of work orders. He stated he was aware of the room with the broken window, but there was no funding at the time to purchase materials needed to repair it and they also had no access to petty cash. He stated he cleaned out the broken pieces of glass and installed two layers of cardboard and duct taped it. He stated he did not know why there was no work order for broken window listed in the Tels system, however it should have been submitted as a work order. He stated the new owners monitored the work orders in the Tels system. He stated he had not received training on maintenance or the importance of residents having a comfortable homelike environment. He stated he did not know how missing slats from the blinds negatively affected the residents. He stated cracked and broken tiles, and broken plank flooring could be a tripping hazard for residents. The MS stated he could not determine a possible negative outcome of not repairing a window. During an interview on 12/18/25 at 11:30 AM, the ADON stated she was aware that the broken blinds and flooring had been like that for several months and had been reported to the corporate office as well as submitted in the Tels system. She stated she was aware of the broken window in room [ROOM NUMBER]. She stated she did not enter a work order for the broken window in the Tels system because she knew the MS was aware of the broken window. ADON stated she had been trained in the environmental requirements of the facility. She stated she was responsible for training staff in reporting maintenance needs. She stated it was important that residents lived in a homelike environment so they could be comfortable, just like she preferred at her home, because this was their home. She stated broken and cracked flooring was a potential trip hazard. She stated broken windows could have allowed animals to enter the building as well as not protect residents from weather conditions. The ADON stated missing slats on the blinds had not allowed residents to have privacy. She stated not making needed repairs could cause residents to have depression when they saw things that were broken. During an interview on 12/18/25 at 12:55 PM, the DON stated the MS and ADM were responsible to ensure needed repairs were completed. She stated all staff were responsible for reporting repairs needed. She stated they had a rounding system every week with staff where they could report repairs needed directly to the MS and they could also enter repairs needed in the Tels system. She stated the importance of reporting repairs was to prevent accidents or complications in the facility. She stated the broken blinds had been reported and were ordered but they were the wrong size and were sent back. She stated the facility was bought by a new company afterwards and there had been a delay with having access to money. She stated she was aware of broken tiles and plank flooring. She stated she was concerned because it could be an accident risk and could cause issues when staff tried to clean the floors. The DON stated she was not aware of the broken window in the resident's room. She stated the Tels system was documentation that someone reported to make the MS accountable to ensure repairs were completed. She stated she expected staff to document issues such as broken windows in the Tels system as well as verbally tell the MS. She stated she considered a broken window to be a priority. She stated she had received training on importance of maintenance with the previous company as well as the new company. She stated a potential negative outcome of a broken window was elopement or injury. She stated broken and cracked flooring could cause residents to trip or they cut could themselves on it.During an interview on 12/18/25 at 2:15 PM, the ADM stated the MS was responsible for assessing the building for repairs. She stated all staff were responsible for reporting repairs needed. She stated the Tels system was the main system used to submit and monitor repairs needed but serious things should have been directly reported to the MS. The ADM stated she was aware of the vertical blinds that were broken in several rooms. She stated the blinds had been broken for a while and they had been replacing them little by little. The ADM stated she had been aware of broken tiles and cracked tiles, and broken plank flooring in resident's rooms for a couple of months. She stated those issues should have been documented in the Tels system. She stated she was aware the broken and cracked tile flooring in the dining room had been reported to the corporate office of the previous company that owned the facility, but they had to restart that process with the new company. She stated she was not aware if the broken flooring in the resident's room having been reported. She stated that it was a fall hazard. The ADM stated she was not aware of the broken window in the resident's room. She stated that there was an elopement risk and shard glass could've possibly caused injury and she considered that a serious repair that needed to be addressed. She stated the broken window should have been documented in the Tels system so they could track it and ensure it had been fixed. She stated she had received training on maintenance and environment. She stated herself and the MS were responsible for training staff. She stated staff had been trained in how to document repairs in the Tels system. She stated the Tels system was for tracking repairs, and it was important for the repairs to be documented there. She stated she expected a simple repair to be completed on the same day; however, she would have allowed 2-3 more days if additional materials were needed. She stated she expected a broken window to be repaired on the same day. The ADM stated a potential negative outcome of not addressing repairs needed in the facility would not allow the facility to provide a homelike environment for residents and this was important because it was their home. Record review of the facility policy, Maintenance Service, revised December 2009, revealed the following in part: Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 2. Functions of maintenance personnel include, but are not limited to:a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.b. maintaining the building in good repair and free from hazards.f. establishing priorities in providing repair service. Record review of the facility policy, Homelike Environment, revised February 2021, revealed the following in part: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. clean, sanitary and orderly environment.

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 2 of 3 residents (Resident #5 and Resident #6) reviewed for infection control.-CNA A did not perform hand hygiene after touching a trash can, before touching wipes, and did not perform hand hygiene between all glove changes when providing incontinence care to Resident #6.-LVN A did not perform hand hygiene between all glove changes when providing wound care to Resident #5. These failures could place residents at risk for cross contamination and infection. The findings include: Resident #6 Record review of the admission record for Resident #6, dated 12/18/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: atherosclerotic heart disease (plaque buildup up in arterial walls), abnormal weight loss, and urinary incontinence. Record review of the quarterly MDS assessment for Resident #6, dated 11/12/25 revealed Resident #6 was dependent for toileting hygiene - the helper does all of the effort and the resident does none of the effort to complete the activity, or the assistance of 2 or more helpers was required for the resident to complete the activity. Record review of the current care plan for Resident #6, last care conference dated 08/22/25, revealed there was a problem area: Urinary Incontinence: I am incontinent of bowel and bladder due to my cognitive status. I am at risk for skin breakdown if I am not cleaned properly and regularly. During an observation on 12/17/25 at 1:10 PM revealed CNA A provided incontinence care for Resident #6 with the help of CNA B. CNA A washed her hands with soap and water and then moved the trash can that was next to Resident #6's head of bed with her bare hands and her thumb went inside the trash can to pick it up. CNA A then began pulling out the wipes for Resident #6 and opened up the clean brief and set it aside. CNA A then used ABHR and put on clean gloves. CNA A then unfastened the brief and began wiping the groin area. CNA A then removed her gloves, used ABHR and put on clean gloves. CNA A then turned Resident #6 on her side and removed the old brief, placed a towel for a barrier and then wiped Resident #6's buttocks. CNA A then removed her gloves and put on clean gloves with no hand hygiene in between the glove change. CNA A then placed a clean brief under Resident #6 and turned her on her back and fastened the brief. CNA A then removed her gloves and used ABHR. During an interview on 12/17/25 at 1:21 PM, CNA A stated she had been trained on hand hygiene between all glove changes and to perform hand hygiene after touching a trash can. CNA A stated she thought it was ok to touch the trash can because it was clean from any other trash. CNA A stated she got nervous and that was why she messed up. CNA A stated she did not remember when she was last trained on hand hygiene during incontinence care. CNA A stated the risk to the residents was they could get infected. Resident #5 Record review of the admission record for Resident #5, dated 12/16/25 revealed an [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: metabolic encephalopathy (when your brain doesn't work right because of chemical imbalance or problem in your body), pressure ulcer of buttocks Stage 2 (wound from pressure) and depression (mood disorder). Record review of the comprehensive MDS assessment for Resident #5, dated 03/11/25, revealed Resident #5 was at risk for developing pressure ulcers/injuries. Record review of the order summary report for Resident #5, dated 12/16/25, revealed the following order: Clean area with Normal Saline or wound cleanser to right gluteus (buttock). Apply collagen dressing to manage exudate (drainage), cover with foam dressing, change every day and PRN with a start date of 11/11/25. Record review of the current care plan for Resident #5, last care conference 10/28/25, revealed there was a problem area: Resident has a pressure ulcer r/t right gluteus (buttock). During an observation on 12/17/25 at 3:34 PM, LVN A provided wound care to the pressure wound on Resident #5's right gluteus. LVN A put on a clean gown outside the room. LVN A washed her hands with soap and water and put on clean gloves. LVN A then cleansed Resident #5's wound with normal saline and 4x4 gauze. LVN A then removed her gloves and put on clean gloves and did not perform hand hygiene between the glove changes. LVN A then applied collagen to the wound bed and covered with a silicone border foam dressing. LVN A then removed her gloves and washed her hands with soap and water. During an interview on 12/17/25 at 4:32 PM, LVN A stated she had been trained to perform hand hygiene between glove changes but could not remember when. LVN A stated it just slipped her mind. LVN A stated the risk to the residents was possible infection. During an interview on 12/18/25 at 9:28 AM, the ADM stated she was unable to find a basic Infection Prevention and Control Program Policy for the facility and the policy provided was the most relevant. During an interview on 12/18/25 at 9:47 AM, the DON stated she expected staff to sanitize their hands between glove changes. The DON stated she expected the staff to sanitize their hands after touching a trash can. The DON stated CNA A and LVN A may have been rattled when providing care in front of a surveyor. The DON stated CNA A and LVN A made honest mistakes. The DON stated the staff were recently trained in hand hygiene and she would have to look up exactly when they were trained. The DON stated she was responsible for ensuring staff were following infection control policies. The DON stated the residents had a risk of infection. During an interview on 12/18/25 at 11:03 AM, the ADM stated she expected staff to hand sanitize between glove changes. The ADM stated she expected the staff to hand sanitize after touching a trash can. The ADM stated the staff have been trained on hand hygiene and the DON was responsible to monitoring. The ADM stated she did not know why CNA A or LVN A did not sanitize their hands between all glove changes. The ADM stated a possible negative outcome was it could lead to infections. Record review of the Relias training transcript for CNA A, undated, revealed Hand Hygiene Basics was completed on 12/09/25. Record review of the Relias training transcript for LVN A, undated, revealed Hand Hygiene Basics was completed on 11/22/25. Record review of the facility policy titled, Handwashing/Hand Hygiene, with a revised date of 01/2025 reflected the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare - associated infections. Administrative Practices to Promote Hand Hygiene:2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiene:1. Hand hygiene is indicated:.c. after contact with blood, body fluids, or contaminated surfaces;e. after touching the resident's environment;g. immediately after glove removal.5. The use of gloves does not replace hand washing/ hand hygiene.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that facility was free of pests and rodents for the facility's only kitchen. The facility did not maintain an effective pest control program to ensure the facility was free of flies in the kitchen. These findings could place residents at risk for an unsanitary environment and a decreased quality of life.The findings included: Record review of the facility's pest control binder 2025 pest control visited the facility bi-weekly to treat pests and insects. The kitchen was last treated for rats on 06/11/2025 and there was no mention of flies. Observation of the facility's kitchen on 12/16/2025 at 11:16 AM, revealed approximately four flies flying around DM as he prepared meal before lunch was served. The flies were observed landing on food preparation stations that were not in use, on top of the plate warming station and on cooking utensils. No fly trap tapes observed. In an interview on 12/18/2025 at 9:53 AM with the DM, he stated It is the maintenance personnel that is responsible for pest control. The DM stated pest control was at the facility last month and had no reasons why the flies were there. When asked if anyone was notified regarding the flies in the kitchen, the DM stated, I have spoken to the maintenance guy, and he promised to get in touch with pest control. The DM stated having flies in the kitchen could get residents sick, but there is nothing I could do about it. In an interview on 12/18/2025 at 11:11 AM with the MS, he stated I am responsible for making sure that flies are controlled in the kitchen and environs. The MS stated that pest control was at the facility a week ago and had nothing written down on the pest control log. The MS stated flies in the kitchen were due to going in and out of the kitchen door all day. The MS further stated, I know what the policy on pest control is but haven't looked at it for a long time. The MS stated having flies in the kitchen could result in flies getting in food, which could spread diseases on food prepared in the kitchen. In an interview on 12/18/2025 at 11:47 AM with the LVN A, she stated No, I don't know if the facility sent any pest control to the kitchen for the flies, it is mild now because it is winter, you should come see it during summer. She further stated that I have reported to the MS, and he always says, am doing what I can. LVN A stated the flies could spread diseases on the food and then transferred to the residents, making them sick. In an interview on 12/18/25 at 12:47 PM with the ADM, she stated that she believed the opened back door was the reason flies kept getting into the kitchen, as they used the door to exit the kitchen to discard trash and accept deliveries. The ADM stated they had pest control out once a month and as needed for flies. She further stated, It is the responsibility of the MS to get pest control to the kitchen. The ADM stated having flies in the kitchen could be bad, as residents could get sick due to infections. The ADM stated she would continue to work with pest control to solve the problem in the kitchen and had ordered air curtains. Record review of the facility policy and procedure titled, Pest Control, revised date May 2008, reflected the following: Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on interviews and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 34 (4/1, 4/3, 4/6, 4/7, 4/8, 4/10, 4/11, 4/12, 4/13, 4/14, 4/20, 4/21, 4/27, 4/28, 5/7, 5/10, 5/11, 5/12, 5/24, 5/25, 5/28, 5/29, 5/30, 5/31, 6/1, 6/2, 6/7, 6/8, 6/14, 6/15, 6/21, 6/22, 6/25, and 6/29/2024) of 91 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours a day for 34 days. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Record review of the facility's employee survey roster dated 10/2/24 revealed there were no RNs employed at the facility. Record review of Schedule Sheet dated April 2024 revealed there was not an RN scheduled to work on (4/1, 4/3, 4/6, 4/7, 4/8, 4/10, 4/11, 4/12, 4/13, 4/14, 4/20, 4/21, 4/27, and 4/28/2024). Record review of Schedule Sheet dated May 2024 revealed there was not an RN scheduled to work on (5/7, 5/10, 5/11, 5/12, 5/24, 5/25, 5/28, 5/29, 5/30, and 5/31/2024). Record review of Schedule Sheet dated June 2024 revealed there was not an RN scheduled to work on (6/1, 6/2, 6/7, 6/8, 6/14, 6/15, 6/21, 6/22, 6/25, and 6/29/2024). During an interview on 9/26/24 at 3:45 PM, the DON stated the facility did not have any RN coverage in April 2024 and that she covered some days in May and June 2024. She stated there were no other RNs employed at the facility in April, May, and June 2024 besides herself. During an interview on 9/26/24 at 4:25 PM, the DON stated she was not able to print out the RN time detail to show that No RN's were covering on the dates in question. She stated she did not punch in on a timesheet because she was a salaried employee. During an interview on 9/26/24 at 4:47 PM, the contracted staffing agency employee stated she was contacted by the facility about needing RNs to work at the facility. She stated she was not able to find any RN's that were willing to work at that facility. During an interview on 9/27/24 at 12:08 PM, the DON stated the facility was actively trying to employ an RN. She stated they had a strong online recruitment presence in social media and recruitment websites. She stated they had a job fair last year and would have another one on 10/8/24. She stated they were in communication with the Texas Workforce Commission. She stated, last year the previous ADM went to Midwestern University to try to recruit new graduates. She stated they did not have RN coverage in April, May, and June 2024 except on the days she worked because they were not able to get anyone hired and their weekend RN quit. She stated they started using a new contracted agency for RNs on June 26th to help provide RN staff when needed and have had coverage since. She stated the previous contracted staffing agency they used in April, May, and most of June were not consistent and most of the agency staff they said they assigned would not show up for the shift. She stated the facility policy required RN coverage 8 hours 7 days a week. She stated she was aware of all the days in April, May, and June that there was no RN coverage. She informed the corporate office of not having the RN coverage and was told to continue to actively look for one. She stated she was contacted by staff on each day of when the agency staff did not show up. She stated she thought the ADM was responsible to ensure RN coverage. She stated she was not required to fill those shifts to her understanding. She stated there was not necessarily a training she received for RN coverage requirements, but she was aware of the requirement from the Code of Federal Regulations and the State Operations Manual. She stated having an RN on coverage provided additional clinical skills. She stated LVNs could not administer IV lines (tube placed inside a vein) or IV push medications, however they did not accept those type of residents who require services that only RNs could do. She stated Hospice and she could pronounce deaths. She stated she did not think there was a negative outcome to not having RN coverage because the facility had all the necessary resources for LVNs to utilize such as Telehealth, a medical director they could call, the hospital was one block away from the facility, and emergency medical services could arrive within one minute. She stated she felt residents would get all their needs met by the LVNs, CNAs, and all other staff working at the facility. She stated she felt the RN was just another person working in the building. During an interview on 9/27/24 at 12:55 PM, the ADM stated he believed the facility policy required RN coverage for 8 hours per day, but he was not sure because he did not have the policy in front of him. He stated he was aware there were issues with RN coverage because they had implemented a Performance Improvement Plan during a Quality Assessment and Performance Improvement meeting. He stated he had been trying to get staff hired. He stated he placed advertisements in various places such as social media and the newspaper, and they will attend a job fair soon. He stated the facility used agency RNs to try and fill RN coverage shifts as well. He stated they facility and staff had access to Telehealth and their Medical Director was very responsive on weekends and holidays. He stated he could not recall receiving a specific training on RN coverage. He stated there were no other RNs on staff during the months of April, May, and June 2024 besides the DON. He stated he was responsible for ensuring RN coverage. He stated he did not think he could answer that question of what a negative outcome to the resident could be by not having RN coverage since he was not a clinician. He stated staff had access to Telehealth, if needed. He stated the DON could cover some of the shifts when an RN was needed however, he did not expect her to cover every shift because she could not work every day. Record review of the policy provided by the facility titled, Staffing, revised 9/28/23 revealed in part the following: Policy Statement - Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with resident care plans and the facility assessment. Policy and Implementation 4. The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 14 residents (Resident #11, #30 and #34) and 1 of 4 staff (LVN A) reviewed for infection control. LVN A failed to properly clean a multi-use medical device between each resident during medication administration for Resident #11, #30 and #34. These failures could place residents at risk for spread of infection and cross contamination. Findings included: During a medication pass observation on 10/03/24 at 08:58 AM, LVN A picked up the wrist blood pressure device from the top of the medication cart and took it to the room of Resident #11 and took her blood pressure on the left wrist. She then took the wrist blood pressure device and placed it on top of the medication cart. LVN A did not sanitize the wrist blood pressure device before or after use. During a medication pass observation on 10/03/24 at 09:27 AM, LVN A picked up the wrist blood pressure device from the top of the medication cart and took it to the room of Resident #30 and took her blood pressure on the right wrist. She then took the wrist blood pressure device and placed it on top of the medication cart. LVN A did not sanitize the wrist blood pressure device before or after use. During a medication pass observation on 10/03/24 at 09:46 AM, LVN A picked up the wrist blood pressure device from the top of the medication cart and took it to the room of Resident #34 and took her blood pressure on the left wrist. She then took the wrist blood pressure device and placed it on top of the medication cart. LVN A did not sanitize the wrist blood pressure device before or after use. During an interview on 10/03/24 at 10:04 AM with LVN A, she stated she did not sanitize the wrist blood pressure device prior to initial use on medication pass. She stated she did not sanitize the wrist blood pressure device between residents. LVN A stated the wrist blood pressure device should be sanitized between residents. She stated she had been trained on cross-contamination through her nursing education. She stated she was an agency nurse but received training by the DON for proper infection control practices as needed. LVN A stated the DON updated her on current training prior to working assigned shifts at the facility. LVN A stated there was a book of training kept at the nurse's station and it was the nurses' responsibility to review current training in the book. She stated a potential negative outcome for failure to sanitize multi-use devices between residents would be the transfer of diseases and infection. During an interview on 10/03/24 at 10:11 AM with the DON, she stated staff had not been trained to sanitize multi-use blood pressure cuffs between residents. She stated blood pressure cuffs were considered a non-critical item and the facility's policy did not require sanitizing those items. She stated she was responsible for conducting training for nursing staff and training was usually conducted on a one-to-one basis. She stated staff were trained on infection control practices upon hire and as needed. The DON stated a potential negative outcome for failure to sanitize multi-use devices between residents would be increased risk of infection to residents. In a subsequent interview on 10/04/24 at approximately 01:30 PM with the DON, she stated staff should sanitize multi-use blood pressure cuffs at the end of each shift and when they became soiled. The DON stated the best quality of care practice would be to sanitize all multi-use devices between residents. During an interview on 10/04/24 at 12:34 PM with the ADM, he stated he was not aware that staff were not sanitizing multi-use blood pressure devices between residents. He stated he could not quote the facility policy for properly sanitizing multi-use devices. The ADM stated nursing administration was responsible for staff training on infection control practices and proper sanitizing of multi-use devices. He stated his expectation of staff for properly sanitizing multi-use devices was that they follow orders. He stated a potential negative outcome for failure to properly sanitize multi-use devices would be the transmission of infection. Record review of the facility-provided policy titled Cleaning and Disinfection of Non-Critical Resident-Care Items, revised April 2020, revealed: Purpose The purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items. General Guidelines . 3. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: . c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (I) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. (2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). . 4. Intermediate and low-level disinfectants for non-critical items include: a. Ethyl or isopropyl alcohol; b. Sodium hypochlorite (5.25-6.15% diluted 1:500 or per manufacturer's instructions); c. Phenolic germicidal detergents; d. Iodophor germicidal detergents; and e. Quaternary ammonium germicidal detergents (low-level disinfection only). Record review of the facility-provided policy titled Administering Medications, revised April 2019, revealed: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 21. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, Gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Based on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, on facility grounds in 1 of 2 smoking areas (North patio smoking area). The facility failed to ensure the grounds in the smoking area was free from trash. This failure could attract unwanted pests and cause the facility to have an unsightly appearance. The findings included: On 10/03/24 at 2:47 PM, an observation was made of the North patio smoking area. 1 plastic spoon, 10 pieces of white and clear miscellaneous trash, and 11 cigarette butts were noted in the grass area. On 10/03/24 at 4:51 PM, an observation was made of the North patio smoking area. 1 plastic spoon, 10 pieces of white and clear miscellaneous trash, and 11 cigarette butts were noted in the grass area. On 10/04/24 at 9:51 AM, an observation was made of the North patio smoking area. 1 plastic spoon, 10 pieces of white and clear miscellaneous trash, and 11 cigarette butts were noted in the grass area. On 10/04/24 at 10:16 AM, an interview was conducted with the Housekeeping Supervisor (HS) and he stated the Maintenance Supervisor (MS) and himself were responsible for keeping the grounds outside the facility clean of trash. The HS stated the housekeepers went to the smoking area to take out the trash only, not to pick up the trash in the grass/yard. The HS stated the MS and himself usually cleaned trash out of the yard every Wednesday, but it did not happen this week. The HS stated the last time the smoking area grounds had been cleaned of trash was the previous Wednesday on 09/25/24. The HS stated he was busy with survey duties this week and that was why the trash had not been picked up yet. The HS stated he did not know of a potential negative outcome to the residents and stated the trash did look bad in the North patio smoking area. On 10/04/24 at 10:31 AM, an interview was conducted with the MS and he stated the HS and himself were responsible for keeping the grounds outside the facility clean from trash. The MS stated they were trained to pick up trash on Wednesdays, but it was not done this week due to survey duties performed. The MS stated he did not know a potential negative outcome to the residents. On 10/04/24 at 10:41 AM, an interview was conducted with the Adm and he stated the HS and the MS were responsible for picking up trash outside on the facility grounds. The Adm stated the wind blows frequently in that area and that was probably why there was trash in the North patio smoking area. The Adm stated he did not know a potential negative outcome to the residents. The Adm was asked for a policy related to trash in the smoking area or on facility grounds outside and he stated he was not sure if the facility had one, but he would look. Record review of the facility policy and procedure titled, Maintenance Policies & Procedures, undated, reflected the following: b. Clean up any debris, especially broken glass, on sidewalks and patios immediately. All debris is a potential hazard to our residents

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice for 1 (Resident #28) of 5 residents reviewed for respiratory care. The facility failed to ensure that Resident #28's oxygen tubing was replaced every seven (7) days, according to physician's orders. This failure could place residents at risk for respiratory compromise and infection. Findings included: Review of Resident #28's face sheet revealed a [AGE] year-old male with an admitted [DATE] with the following diagnoses: Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Congestive Heart Failure (heart condition), Chronic Kidney Disease (condition causing kidneys to not function properly ), Gastroesophageal Reflux Disease (digestive condition), Peripheral Vascular Disease (circulatory condition that reduces blood flow to the limbs), acquired absence of right leg below the knee, complete traumatic amputation of left leg at knee level, anxiety disorder, and hypertension (high blood pressure). Record review of Resident #28's annual MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident was cognitively intact. Section O - Special Treatments, Procedures and Programs revealed Resident #28 used oxygen therapy while a resident. Record review of Resident #28's comprehensive care plan, dated 07/25/24, revealed resident #28 required oxygen therapy related to Chronic Obstructive Pulmonary Disease. Record review of #28's current Physician Orders dated 03/06/24 revealed an order for oxygen to be administered at 2 liters/minute per nasal cannula (tube in nostrils) every shift as needed. Record review of Resident #28's Medication Administration History dated 09/01/24-09/30/24, revealed an order to change oxygen tubing, cannula/mask once a week. During an observation and interview on 10/02/24 at 11:30 AM, Resident #28 had oxygen being administered at 2 liters/minute via nasal cannula. Oxygen tubing was dated 09/22/24. Resident stated staff usually changed out his oxygen tubing on the night shift and he did not recall when staff had last changed it. During an observation on 10/02/24 at 2:16 PM, Resident #28's oxygen tubing was dated 09/22/24. During an observation on 10/03/24 at 11:07 AM, Resident #28's oxygen tubing was dated 09/22/24. During an interview on 10/04/24 at 12:34 PM with the ADM, he stated he was not sure what the facility policy stated regarding changing of oxygen tubing. He stated nursing administration was responsible for assuring oxygen tubing was changed according to physician's orders. He stated he assumed staff had been trained on proper dispensing of oxygen therapy and changing oxygen tubing per orders. When asked to give a potential negative outcome for failure to change oxygen tubing per orders, the ADM stated he was not comfortable answering the question because he was not a clinician. During an interview on 10/04/24 at 12:50 PM with the DON, she stated the facility policy for changing oxygen tubing was that it was done every Sunday on the night shift and as needed. She said the night shift nurse was responsible for changing oxygen tubing. She stated she was responsible for assuring oxygen tubing was changed according to physician's orders. She stated staff are trained on proper dispensing of oxygen upon hire, annually and as needed. The DON stated a potential negative outcome for failure to change oxygen tubing according to physician's orders was an increased risk for infection. Record review of the facility-provided policy titled Oxygen Administration, revised October 2010, revealed: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #28) of 13 residents reviewed for clinical records. The facility failed to accurately document an oxygen tubing change for resident #28. This failure could place residents at risk of inaccurate and incomplete care. Findings included: Review of Resident #28's face sheet revealed a [AGE] year-old male with an admitted [DATE] with the following diagnoses: Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Congestive Heart Failure (heart condition), Chronic Kidney Disease (condition causing kidneys to not function properly ), Gastroesophageal Reflux Disease (digestive condition), Peripheral Vascular Disease (circulatory condition that reduces blood flow to the limbs), acquired absence of right leg below the knee, complete traumatic amputation of left leg at knee level, anxiety disorder, and hypertension (high blood pressure). Record review of Resident #28's annual MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident was cognitively intact. Section O - Special Treatments, Procedures and Programs revealed Resident #28 used oxygen therapy while a resident. Record review of Resident #28's comprehensive care plan, dated 07/25/24, revealed resident #28 required oxygen therapy related to Chronic Obstructive Pulmonary Disease. Record review of #28's current Physician Orders dated 03/06/24 revealed an order for oxygen to be administered at 2 liters/minute per nasal cannula (tube in nostrils) every shift as needed. Record review of Resident #28's Medication Administration History dated 09/01/24-09/30/24, revealed an order to change oxygen tubing, cannula/mask once a week. Record review of Resident #28's Medication Administration History dated 09/01/24-09/30/24 revealed LVN A inaccurately signed for an oxygen tubing change on 09/29/24 for Resident #28, that did not occur. During an observation and interview on 10/02/24 at 11:30 AM, Resident #28 had oxygen being administered at 2 liters/minute via nasal cannula. Oxygen tubing was dated 09/22/24. Resident stated staff usually changed out his oxygen tubing on the night shift and he did not recall when staff had last changed it. During an observation on 10/02/24 at 2:16 PM, Resident #28's oxygen tubing was dated 09/22/24. During an observation on 10/03/24 at 11:07 AM, Resident #28's oxygen tubing was dated 09/22/24. During a phone interview on 10/04/24 at 11:39 AM with LVN A, she stated she worked the night shift, and she took care of Resident #28. She stated the facility policy for changing oxygen tubing was that the night nurses change them once a week, usually on Sunday night. She stated on 9/29/24 she documented that she changed Resident #28's oxygen tubing but did not change the tubing. She stated she usually pre-charts her initials ahead of time on routine things that she will be performing during her shift. She stated on 09/29/24 she failed to go back and remove her initials from Resident #28's Medication Administration History for the ordered oxygen tubing change. LVN A stated a potential negative outcome for not changing oxygen tubing and inaccurately documenting the change would be increased risk of infection and inaccurate resident care. During an interview on 10/04/24 at 12:34 PM with the ADM, he stated he assumed that the facility policy for accurate documentation of resident health records was that they were kept accurately. He stated nursing administration was responsible for staff training and monitoring of accurate documentation. He stated his expectation of staff for accurate documentation was that they follow policy and always document accurately in the health record. The ADM stated he did not want to speculate on the potential negative outcome for failure to accurately document resident health records because he was not a clinician. During an interview on 10/04/24 at 12:50 PM with the DON, she stated she was not aware that Resident #28's Medication Administration History contained inaccurate documentation for an oxygen tubing change on 09/29/24. She stated the facility policy for accurate documentation of resident health records was that nursing staff do not predate while charting and they assure accuracy of the health record. She stated staff were trained on proper documentation practices approximately quarterly. She stated her expectation of staff for accurate documentation practices was that they practice documentation accuracy at all times. She stated accuracy of documentation was monitored by the DON doing rounds and reviewing the records. She stated a potential negative outcome for failure to accurately document resident health records was inaccuracies and errors in care. Record review of the facility-provided policy titled Charting and Documentation, revised July 2017, revealed: Policy Statement .The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. . 7. Documentation of procedures and treatments will include care specific details, including: a. The date and time the procedure/treatment was provided.

Based on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles when applicable for 2 of 7 residents (Resident #1 and #2) reviewed for pharmacy services. The facility failed to prevent the misappropriation of Resident #1's Depakote (Divalproex for mood/behavior), when LVN A took a blister pack of Depakote from Resident #2 and placed Resident #1's pharmacy label on top of Resident #2's pharmacy label. This failure could place residents at an increased risk for not receiving their prescribed medication as ordered. This failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. Findings include: Record review of Resident #1's Resident Face Sheet dated 09/05/24 indicated she was a [AGE] year-old female who was admitted to the facility 05/05/16. Resident #1 diagnoses included Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), mild cognitive impairment (early stage of memory loss or other cognitive ability loss), and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Record review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed she scored a 99 on her Brief Interview for Mental Status (BIMS), because she was unable to complete the interview; Section E indicated she displayed physical behavioral symptoms towards others (hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) every one to three days. Record review of Resident #1's Care Plan dated 06/19/24 indicated on 06/18/24 Divalproex for mood/behavior was included to this plan. Record review of Resident #1's Prescription Order dated 02/09/24 revealed an order for Divalproex sprinkles, delayed release sprinkles, 125 milligrams (mg) amount: 4 capsules, oral. Record review of Resident #1's Medication Administration Record dated 08/01/24 to 08/31/24 included Divalproex sprinkles capsule, delayed sprinkles, 125 mg, administer 4 capsules orally at 5:30 pm, and 3 capsules orally at 9 am and 12 pm. The record indicated Resident #1 was administered the medication throughout August 2024. Record review of Resident #1's Progress Note dated 08/24/14 indicated the pharmacy was contacted by the DON and questioned as to why Resident #1's Divalproex was not sent when it was ordered on 08/22/24. The Pharmacist stated it was too soon to fill the order; however, once the pharmacist clarified the order, he would send backup medication. -Record review of Resident #2's Resident Face Sheet dated 09/05/24 indicated he was a [AGE] year-old-man admitted to the facility on [DATE] and readmitted [DATE]. Resident #2's diagnoses included neuroleptic parkinsonism (parkinsonism symptoms develop because of taking neuroleptic drugs/antipsychotics), schizoaffective disorder, (symptoms of hallucinations, delusions, and mood disorders) and cognitive communication deficit (difficulty with communication that's caused by a problem with cognition). Record review of Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE] revealed he scored a 3 on his BIMS, indicating he had severe cognitive impairment. Record review of Resident #2's Care Plan dated 06/19/24 indicated on 08/29/24 medication (not specified) for his schizoaffective disorder bipolar type was added to this plan. Record review of Resident #2's Prescription Order dated 07/26/24 with start dated 07/26/24 included Depakote (Divalproex) capsule, delayed release sprinkle, 125 mg: amt: 4 caps: oral, once a day at 1:00 pm, for schizoaffective disorder, bipolar type related to aggressive/combative behavior. Record review of Resident #2's Medication Administration Record dated 08/01/24 to 08/31/24 included Divalproex sprinkles capsule, delayed sprinkles, 125 mg, administer 3 capsules orally at 9 am and 6 pm, and 4 capsules orally at 1 pm. The record indicated Resident #2 was administered the medication throughout August 2024. Record review of LVN B's written statement dated 08/24/24 at 5:14 pm indicated she informed the Director of Nurses (DON) that she discovered Resident #1's Depakote blister pack label was placed on top of Resident #2's Depakote blister pack label. LVN B indicated the StatSafe (facility's e-kit with back up medications) supply had enough to administer the medication as needed. On 08/21/24 LVN B said she notified the DON that Resident #1 would run out of Depakote on 08/21/24 and she had ordered the medication. LVN B said she was reminded by the DON that she should utilize StatSafe supply to prevent Resident #1 from missing her medication. Record review of LVN A's written statement dated 08/25/24 indicated she ordered Resident #1's Divalproex on 08/22/24; however, it was not delivered. LVN A said she borrowed Resident #2's Divalproex because he had 10 blister packs of the medication and once the medication was delivered for Resident #1, she would return a blister pack to Resident #2. LVN A said she did not want Resident #1 to miss her dosage of Divalproex because of her behaviors. Observation 0n 9/05/24 at 5:15 pm of Resident #2's Divalproex blister pack revealed it had Resident #2's label, which included Resident #2's name, room number, Divalproex 125 mg capsule (sprinkle), the brand: Depakote 125 mg capsule, and administer 3 capsules by mouth twice daily. On top of this label was Resident #1's label that had Resident #1's name, room number, Divalproex 125 mg capsule (sprinkle), the brand: Divalproex 125 mg capsule and administer 3 capsules by mouth twice daily at 9 am and 1 pm, and expiration date 07/30/25. During an interview on 09/05/24 at 1:55 pm with LVN A indicated on 08/24/24 at 5:14 pm she borrowed 1 card of Divalproex from Resident #2 to prevent Resident #1 from not receiving her Divalproex on the next shift, if case the pharmacy did not deliver this medication on time. Once Resident #1's Divalproex was delivered, she was going to return the new blister pack to Resident #2. LVN A said she was not aware Resident #1's Divalproex was increased and that's why she ran out early. LVN A said she did not notify Resident #1's physician or the DON that she was taking Resident #2's Depakote to give to Resident #1, and she knew that was not ok; however, Resident #1 needed it. LVN A said she did not administer Resident #2's medication to Resident #1, she was just making sure the next shift nurse had the medication to administer to Resident #1. LVN A said that was the first time she had ever taken a resident's medication to give to a different resident. During an interview on 09/05/24 at 4:55 pm with the Pharmacist indicated he had received a request to refill Resident #1's Divalproex on 08/24/24; however, it was after the pharmacy had closed. On 08/25/24, after receiving a call from the DON, he clarified Resident #1's multiple orders for Divalproex and then refilled the Divalproex . The Pharmacist said he would not advise anyone to change prescription labels between residents' blister packs and said there was a warning statement that's included on the blister packs that reflected: Caution/Warning: Federal and/or State law prohibits the transfer of this drug to any person other than patient for whom it was prescribed. During an interview on 09/05/24 at 4:09 pm with the DON said she was informed by LVN B that Resident #1 was running out of her Depakote, and she had ordered it. The DON said she called the pharmacy and questioned why Resident #1's medication was not refilled, and he said it was not time. Afterwards the pharmacist clarified Resident #1's Depakote order and confirmed he would immediately send the medication to the facility. The DON said the StatSafe had 10 Depakote capsules to use during an emergency and there was no need to take Resident #2's Depakote to give to Resident #1. The DON said Residents #2's Depakote was never administered to Resident #1 because the pharmacist sent the backup supply to the facility before Resident #1 ran out of her Depakote. The DON said she audited the residents' medications and found no concerns, nor did she discover any medication blister packs with a label belonging to a different resident. During an interview on 09/05/24 at 3:03 pm Physician C indicated he was informed LVN A placed Resident #1's label over Resident #2's label that was on his Depakote blister pack. Physician C said medically Resident #1 was not harmed, but administratively it was not appropriate for the nurse to borrow medication from a resident to give to another resident. The facility's Policy Statement for Labeling of Medication Containers dated 08/26/24 included All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. The label must include the name of the resident and physician, (Note: the name of the resident and physician do not have to be on each unit dose package, but [NAME] be identified within the package in such a manner as to ensure that the drug is administer to the right resident. And only the dispensing pharmacy can label or alter the label on a medication container or package. The facility's Policy Statement for Emergency Medications dated April 2021 included that the emergency medication kit will include medication and biologicals that are essential in providing emergency treatment, and a physician's order is required to administer emergency medications and biologicals from this kit.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 8 residents (Resident #2) reviewed for accidents. The facility failed to use an appropriate transfer for Resident #2 which resulted in a fall for Resident #2 and caused Resident #2's surgical wound from a below the right knee amputation to bleed. This failure could place residents at risk for harm and further injuries. The findings included: Record review of Resident #2's undated face sheet reflected Resident #2 was a [AGE] year-old male whose current admitted was on 2/4/2021, and a readmission to the facility on [DATE]. Resident #2 had the following diagnoses: chronic obstructive pulmonary disease (airflow blockage and breathing-related problems), muscle weakness, acquired absence of right leg below knee (partial amputation of the right leg), complete traumatic amputation at knee level, left lower leg, subsequent encounter (partial amputation of the left leg), unspecified systolic (congestive) heart failure (heart condition), essential primary hypertension (high blood pressure), mood disorder (mental health condition), Anxiety disorder due to known physiological condition (mental health condition), and chronic kidney disease (gradual loss of kidney function). Record review of Resident #2's clinical record reflected his comprehensive MDS assessment was completed on 4/10/2024 listing him with a BIMS score of 13, which indicated he was moderately cognitively intact. Additionally, section GG - Functional Abilities and Goals revealed Resident #2 is dependent- requires supervision or touching assistance - Helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity. For chair/bed-to-chair transfers. Record review of Resident #2's physician orders dated 4/01/24 to 4/30/24 revealed an order dated 4/09/24 to maintain ace bandage to right stump until appointment on 4/17/20 and to monitor for bleeding and signs of complication during every shift. Physician orders further revealed an order dated 4/23/24 to change dressing to stump 3 times a week and to monitor for bleeding and signs of complication during every shift. Record Review of Resident #2's Care Plan, dated 4/25/24, revealed Resident #2 had a below the knee amputation. Interventions included the use of a sliding board for transfers or mechanical lift for transfers PRN. Evaluation notes dated 06/19/24 revealed Resident #2 was able to transfer themselves from the bed to the wheelchair with or without the use of a sliding board and that Resident #2 declined to use the mechanical lift. Record review of Resident #2's progress notes from 4/1/24 to 6/26/24 revealed no documentation of the fall described by the resident or facility staff. During an interview on 6/25/24 at 12:03 PM the DON stated LVN B presented her with a letter she received in the mail from the Texas Board of Nursing that stated she was being investigated for allowing a resident to fall causing an injury. The DON stated she was not aware the allegations listed in the letter against LVN B until being shown the letter as it was not reported to her by staff or the resident. During an interview on 6/25/24 at 1:37 PM, Admin D stated he spoke with LVN B about the letter she had received from the BON and the details in the letter, one was an allegation of an improper transfer that resulted in a fall. He stated the LVN B did try to transfer a resident and a fall happened. During an interview on 6/25/24 at 2:16 PM the corporate nurse stated she could not locate any documentation or any other records in the electronic health record referencing the fall involving Resident #2 and LVN B. During an interview on 6/25/24 at 3:36 PM, CNA E stated she witnessed LVN B and Resident #2 fall during a transfer. She stated she was not able to determine the date or time frame of when this incident occurred, but she believed it was shortly after Resident #2's surgery of when his leg was amputated a couple of months ago. She stated she could not recall the time of when it occurred, but she believed it would have happened between 3:00 PM and 7:00 PM. She stated on the day of the incident she, CNA F, and another staff were all asked to go into Resident #2's bedroom to assist with transferring him from the wheelchair to his bed. LVN B was asked if they were going to use the mechanical lift and LVN B replied she was going to transfer Resident #2 by bear hugging him and lifting him from the wheelchair to the bed. CNA E stated she observed LVN B bear hug Resident #2 face to face, then she stumbled backwards while lifting him, and then both she and Resident #2 fell backwards into a refrigerator, and then onto the floor. CNA E stated Resident #2 hit the incision on his right leg on the floor then it started to bleed. CNA E stated Resident #2 was on top of LVN B CNA E with his arms around her and his legs straddled around her body. CNA E stated she could not recall how LVN B got out from under resident #2. CNA E stated afterwards, they all worked together to lift Resident #2 off the ground and onto his bed. CNA E stated she left about 10 minutes later to return to her assigned hall to assist other residents. CNA E stated Resident #2 has never refused a transfer with a sliding board or the mechanical lift. CNA E stated Resident #2 used the sliding board to transfer himself or instructed staff to push his chair against his bed to transfer himself. During an interview on 6/25/24 at 3:54 PM CNA F stated she witnessed LVN B and Resident #2 fall during a transfer. She stated she could not determine the date or time frame of when this incident occurred, but she believed it was shortly after Resident #2's surgery of when his leg was amputated a couple of months ago (04/2024). CNA F stated she believed the incident occurred before 7:00 PM on the day it occurred. CNA F stated Resident #2 used his call light and told her he needed assistance with a transfer from his wheelchair to his bed. CNA F stated LVN B had transferred Resident #2 into his wheelchair earlier that day, so she understood that was why she was responsible to transfer him back to his bed. CNA F stated LVN B bear-hugged Resident #2 and picked him up from his wheelchair and stumbled and fell back into the refrigerator, and then they both fell on to the floor. CNA F stated they all helped get Resident #2 up and into bed by grabbing under his legs and arms and his leg when she saw blood on his leg. CNA F stated LVN B then went to get supplies for the blood and called the DON. CNA F stated the DON came and helped put new dressing on Resident #2's leg. CNA F stated Resident #2 moaned and made noises but did not say anything. CNA F stated Resident #2 asked about the blood, but he had not say he was in pain. CNA F stated she could not remember how LVN B got Residents #2 off her. CNA F stated Resident #2 was not taken to the hospital nor was emergency assistance called after the incident. During an interview on 6/25/24 at 4:47 PM, LVN C stated she was the charge nurse on the day LVN B and Resident #2 fell during a transfer. She stated she could not to determine the date or time frame of when this incident occurred, but she believed it may have been on a day that was not her regular workday that she came in to fill a shift. She stated the incident may have been two or three days after Resident #2's surgery of when his leg was amputated a couple of months ago. She stated she was aware that Resident #2's surgical incision had been bleeding when he readmitted from the hospital. She stated Resident #2 wanted to get in his wheelchair, but he refused to be transferred with the lift. She stated staff told Resident #2 that they must use the lift for transfers, but he refused again. She stated she had not wanted to transfer Resident #2 as it would not have been safe to transfer him without the lift. She stated she had been concerned that there would not have been any male staff on shift in the evening to help put him back in bed. LVN C stated she went on her lunch break. She stated she observed Resident #2 in his wheelchair when she returned from her lunch break. She stated staff told her that Resident #2 asked LVN B to transfer him into his wheelchair when she had walked by coming back from a smoke break. LVN C stated Resident #2 was ready to get back in bed later that evening, so she told CNA F to get LVN B, who was the charge nurse on a different unit, and to tell her she needed to put Resident #2 back in bed, and then she went to chart records. She stated LVN B approached her and asked why her staff could not complete the transfer, in which she replied to LVN B that since she was the one to take him out of bed then she needed to figure out how to put him back in bed. LVN C stated LVN B walked away. LVN C stated she had been charting records when she heard a loud commotion. She stated CNA E, CNA F, and another staff came and told her that LVN B hit the refrigerator and dropped Resident #2 on the floor. She stated LVN B said she called the DON due to the blood. She stated staff went to get supplies and the DON arrived about that time. She stated she observed blood on his bed the size of a soccer ball and that his bandage was soaked with blood. She stated the DON called the surgeon and was advised to monitor the incision for infection, and to call back if infection appeared. She stated she then left for the evening. She stated Resident #2 had not been taken to the hospital for this incident. She stated the next day, she was told not to document the incident in the post log by the DON because it was considered a transfer and not a fall. She stated there had not been any documentation completed to record the incident. She stated she helped apply the new dressing and observed the incision to be opened about one inch. She stated she helped put pressure on the incision and put a bandage on it. She stated she helped apply gauze and they were able to get the bleeding to stop after wrapping it for the third time. She stated Resident #2 already had an appointment that was scheduled shortly after (possibly a week's time), and that was the first time the incision was observed by a physician after the incident. She stated they received new orders from the physician and that they physician applied additional dressing on it. She stated at that time, there was not an order to use a mechanical lift for transfers, but she felt it was best to use it. She stated Resident #2 seemed to like to use the sliding board for transfers and that he refused the mechanical lift. Record review of a facility in-service dated 6/19/24 titled Falls and use of gait belt revealed: 26 staff signed. Record review of letter signed by ADM D on 6/20/24 titled LVN B Interview revealed: I interviewed LVN B on June 20, 2024. In response to the allegations contained in the letter that she received from the Board of Nursing, she reported the following: 2. As to Resident #2's fall, LVN B told me that she was working on the secured unit when the aides came and asked for her help in transferring Resident #2 into his bed. She had successfully transferred him to his wheelchair earlier that day. She left the unit to help them with the transfer. She entered Resident #2's room and attempted to lift him from his chair and into his bed. As she was doing this, he began kicking the stumps of his legs and this threw her off balance. She stumbled backwards and both of them landed on the floor with him on top of her. His brief was soaked with urine, and it went all over her scrubs. After that she helped the aides get him off the floor and into his bed. His stump was bleeding, and she told LVN C, his charge nurse about it bleeding. LVN C told LVN B that she had urine all over her and she shouldn't be changing his dressing. LVN B then gathered the supplies she needed and went to change Resident #2's dressing. LVN B then returned to the secured unit. She did not call the D.O.N. at that time to come in to help with the dressing. LVN B said she did call the DON the day that Resident #2 returned from the hospital after his amputation. He needed his dressing changed and she wasn't sure how to change it properly. She called the DON, and the DON came to the facility and helped her change the dressing. This was prior to when the fall occurred. The fall occurred one afternoon while the DON came to the facility on e night to help with the dressing change . Record review of competency skills checklist and competency evaluation form dated 6/21/24 revealed LVN B demonstrated competencies met on transfers from bed to wheelchair using transfer belt and slide board transfer. LVN B also demonstrated competencies met on all but one competency on the assessment for lifting machine, using a mechanical. Record review of the facility in-service dated 6/24/24 titled Slide board transfer training revealed: 8 staff signed. Record review of the facility in-service dated 6/25/24 titled Abuse/Neglect/Exploitation/Misappropriation revealed: 22 staff signed. Record review of the facility in-service dated 6/25/24 titled Abuse, and neglect, and reporting revealed: 2 staff signed. Record review of letter signed by LVN C on 6/19/24 titled LVN C Interviewed revealed: On June 29, 2024, at approximately 1 :45 p.m., I interviewed LVN C about any information she may have concerning the allegations the facility had received about LVN B . LVN B also said that she was aware of Resident #2 falling soon after returning from the hospital from having his leg amputated. She stated that earlier in the day, LVN B had transferred him without using a lift. Resident #2 does not like to use the lift for transfer. Later in the day, he wanted to transfer again. LVN B again came to transfer him by herself without using a lift. At this time, when she lifted him, she stumbled backwards, hit the small refrigerator in his room, and both of them fell to the floor. She said that CNA F, CNA E, and another CNA had witnessed the fall. She had not. During an interview on 6/25/24 at 5:47 PM ADM A stated a bear hug transfer was an improper transfer and that staff were not trained to complete bear hug transfers on residents. During an interview on 6/25/24 at 5:55 PM, the Corporate Nurse stated their policy did not instruct staff to use bear hug transfers and that staff should not have done a bear hug transfer on Resident #2. She stated she was not able to locate any documentation referencing the fall. She stated LVN C was the charge nurse on Resident #2's hall and LVN B was the charge nurse on a different unit during the time of that incident. She stated she was able to determine LVN C was on lunch when LVN B transferred Resident #2 to his wheelchair that day. She stated LVN B was his preferred staff, so she helped. She stated he did not like the mechanical lift and sometimes he did not like use the sliding board for transfers. She stated they could not determine when it happened. She stated Resident #2 has said the lift chokes him and he refuses it. She stated a bear hug was not an appropriate transfer. She stated in that situation, she would have done a two person transfer with a sheet due to his weight. During an interview on 6/25/24 at 5:55 PM, the DON stated she used an Ace bandage and the bleeding resolved. She stated there was nothing more she needed to do. The DON she would not have transferred Resident #2 that day, but she cannot speak for LVN B on why she transferred him. She stated she preferred for Therapy to evaluate him before he was transferred, but they were not there that day. She stated it was not required for Therapy to assess the resident before he can be transferred but she would have used the mechanical lift instead. She stated LVN B was not told to transfer him that way. During an interview on 6/25/24 at 6:15 PM, LVN B stated she could not recall the date of the fall with Resident #2 but recalled the fall. LVN B stated staff asked her to transfer Resident #2 to bed. She stated she went in the room and Resident #2 refused the Hoyer, so she decided to lift him on her own. LVN B stated she stood in front of Resident #2 and he bear hugged her. LVN B stated, Resident #2 placed his arms around her neck and she placed her arms under his arms around his body and she lifted him up. LVN B stated, she stepped backwards lost her balance and fell and Resident #2 landed on top of her, straddling her. She stated Resident #2 pushed himself up with his hands and she scooted out from under him. She stated three staff assisted him off the floor and back in bed. LVN B stated Resident #2's stump was bleeding. She stated she had been trained on how to complete a proper transfer, but Resident #2 refused the Hoyer and she attempted to lift him herself to transfer him. During an interview on 6/26/24 at 1:00 PM, Resident #2 stated he recalled a fall where LVN B transferred him from his chair to his bed. Resident #2 stated he could not recall the date of this fall. Resident #2 stated LVN B transferred him by herself, without assistance from another staff. Resident #2 stated LVN B instructed him to put his arms around her, and LVN B wrapped her arms around his torso and lifted him. Resident #2 stated LVN B was supposed to turn and place him on the bed, but LVN B lost her balance and fell back, into his refrigerator. Resident #2 stated he fell on top of LVN B, straddling her. Resident #2 stated he was face to face with LVN B and was very close to her. Resident #2 stated he scooted himself off LVN B by pushing himself with his hands on LVN B's stomach until he reached the floor, in between LVN's legs. Resident #2 stated he hit both of his legs, on his stumps, when he fell with LVN B. Resident #2 stated it was painful on his right leg that had been recently amputated. Resident #2 stated the incision site, on his right leg bled after the fall, but he stated that it was not a lot. Resident #2 stated the DON and LVN B checked the incision site on his right leg and changed the dressings. Resident #2 stated he was usually transferred with two staff, using a sliding board. Resident #2 stated he did not like using the Hoyer lift because he felt claustrophobic and [NAME] as if he was choking. Resident #2 stated he could not remember exactly who was present during the fall, but he recalled CNA E, was present. Resident #2 stated LVN B did not ask for help when she transferred him from the CNA's that were present, and he did not know why. Resident #2 stated LVN B said she thought she could do it on her own, and he thought she could do it also. Resident #2 stated he has never been transferred by just one person before. Resident #2 stated LVN B did not say anything to him after the fall. During an interview on 6/26/24 at 1:59 PM, the COTA was asked if she would consider Resident #2 to be a safe one-person transfer and she stated, Absolutely not, it would not be safe. He was too heavy, and it could hurt the resident or myself. The COTA stated Resident #2 should never be transferred using a bear hug method due to having bilateral below the knee amputations and not being able to pivot to assist the person transferring him. Record review of facility provided policy titled, Falls and Fall Risks, Managing dated 07/2019, revealed: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Definition: According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor, or other lower level, but not a s a result of an overwhelming external force (e.g. a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Challenging a resident's balance and training him/her to recover form loss of balance is an intentional therapeutic intervention. The losses of balance that occur during supervised therapeutic interventions are not considered a fall. Fall Risk Factors: 1. Environmental factors that contribute to the risk of falls include: a. Wet floors; b. Poor lighting; c. Incorrect bed height or width; d. Obstacles in the footpath e. Improperly filled or maintained wheelchairs, and f. Footwear that is unsafe or absent 2. Resident conditions that may contribute to the risk of falls include: a. Fever; b. Infection; c. Delirium and other cognitive impairment; d. Pain; e. Lower extremity weakness; f. Poor grip strength; g. Medication side effects; h. Orthostatic hypotension; i. Functional impairments; j. Visual deficits, and k. Incontinence 3. Medical factors that contribute to the risk of falls include: a. Arthritis; b. Heart failure; c. Anemia; d. Neurological disorders; and e. Balance and gait disorders; etc. Resident Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Monitoring Subsequent Falls and Fall Risk 1. The staff with monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. Record review of facility provided policy titled, Assessing Falls and Their Causes dated 3/2018, revealed: The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Steps in the Procedure After a Fall: 3. If there is evidence of injury, provide appropriate first aid and obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying or standing position, and then document relevant details. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility, and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 7. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services. Defining Detains of Falls: 1. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. 2. For each individual, distinguish falls in the following categories: a. Rolling, sliding or dropping from an object (e.g., from bed or chair or floor) b. Falling while attempting to stand up from a sitting or lying position, or c. Falling while already standing and trying to ambulate Identifying Causes of a Fall or Fall Risk 1. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to resident specific chains of events or circumstances proceeding a recent fall, including : a. Time of day of the fall; b. Time of the last meal; c. What the resident was doing; d. Whether the resident was standing, walking, reaching, or transferring from one position to another; e. Whether the resident was among other persons or alone; f. whether any environmental risk factors were involved (e.g. slippery floor, poor lighting, furniture, or objects in the way) and/or g. Whether the resident was trying to get to the toilet h. whether there is a pattern of this balls for this resident 3. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found. 4. as indicated, the attending physician will examine the resident or may initiate testing to try to identify causes. 5. consult with the attending physician or medical director to confirm specific causes from among multiple possibilities. when possible, document the basis for identifying specific factors as the cause. 6. if the cause is unknown but no additional evaluation is done, the physician or nursing staff should note why (e.g. workup already done, finding A cause would not change the approach, etc.). Documentation When a resident falls, the following information should be recorded in the residence medical record: 1. The condition in which the resident was found (e.g resident found lying on the floor between bed and chair) 2. Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family, as indicated. 5. Completion of a fall risk assessment. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. Reporting 1. Notify the following individuals when a resident falls: a. The resident's family b. The attending physician (timing of notification may vary depending on whether injury was involved); c. The director of nursing services and d. The nursing supervisor on duty 2. Report other information in accordance with facility policy and professional standards of practice. Record review of facility provided policy titled, Falls - Clinical Protocol dated 3/2018, revealed: Assessment and recognition: 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in condition or level of consciousness; e. Neurological status; f. pain; g. Frequency and number of falls since the last position visit; h. Precipitating factors; details on how far all occurred; i. All current medications, especially those associated with dizziness or lethargy; and j. All active diagnosis 5. The staff will evaluate and document falls that occur while they invent individual is in the facility, for example when and where they happen, any observations of the event, etc. 6. All should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed on the floor 7. Falls should also be identified as witnessed or unwitnessed events Record review of facility provided policy titled, Fall Prevention - Potential Interventions dated 5/2019, revealed: Intervention: Assistive Devices; Description: Other Intervention: Mobility; Description: Review transfer status Record review of facility provided policy titled, Safe Lifting and Movement of Residents dated 3/31/2023, revealed: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of resident. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff in conjunction with the real habilitation staff, shall assess individual residents needs 4 transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Residents' preferences for assistance, b. Residents' mobility (degree of dependency), c. Resident size, d. Weight bearing ability, e. Cognitive status, f. Whether the resident is usually cooperative with staff, and g. The residents' goal for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/ transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. 12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies; b. addresses reports of workplace injuries; c. provides training on safety, ergonomic and proper use of equipment, and d. continually evaluates the effectiveness of workplace safety and injury prevention strategies.

Based on interview and record review, the facility failed to ensure a resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation for 1 of 8 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Synthroid/Levothyroxine (thyroid medication), when LVN B took the medication out LVN C's medication cart for her own personal use between 4/21/2024 through 4/28/2024 and/or 5/2/2024. This incident was witnessed by LVN C. This failure could place residents at an increased risk for not receiving their prescribed medication as ordered. Findings included: Record review of Resident #1's undated face sheet reflected Resident #1 was a [AGE] year-old male whose latest readmission to the facility on was 6/11/24, a current readmitted [DATE], as well as a discharge date of [DATE]. Resident #1 was his own resident representative with the following diagnoses: acute on chronic diastolic (congestive) heart failure (heart condition), Type 2 diabetes mellitus without complications (when the body does not use insulin properly), other specified hypothyroidism (underactive thyroid), schizoaffective disorder (mental health condition), and unspecified kidney failure (when your kidneys suddenly become unable to filter waste products from your blood). Record review of Resident #1's clinical record reflected his annual MDS assessment was completed on 6/28/2023 listing him with a BIMS score of 09, which indicated he was moderately cognitively impaired. Record review of Resident #1's medication administration record dated 4/1/2021 to 4/30/24 revealed an order for Levothyroxine tablet: 25 mcg; 1 tab once, a day, for a diagnosis of other specified hypothyroidism, for management of thyroid problems, with a start date of 12/06/23, and an end date of open ended. Record review of Resident #1's medication administration record dated 5/1/2021 to 5/31/24 revealed an order for Levothyroxine tablet: 25 mcg; 1 tab, once a day, for a diagnosis of other specified hypothyroidism, for management of thyroid problems, with a start date of 12/06/23, and an end date of open ended. Record review of letter signed by LVN C on 6/19/24 titled LVN C Interviewed revealed: On June 29, 2024, at approximately 1 :45 p.m., I interviewed LVN C about any information she may have concerning the allegations the facility had received about LVN B. LVN C reported there had been a day when she had left her med cart to get some supplies. When she returned, LVN B was in her cart. LVN B told LVN C that she needed some of Resident #1's Levo. LVN B was short of her own medication for a medical condition. LVN C said she does not give that med, other nurses do, but LVN B had a pill her hand and told LVN C she had taken some. Record review of letter signed by ADM D on 6/20/24 titled LVN B Interview revealed: I interviewed LVN B on June 20, 2024. In response to the allegations contained in the letter that LVN B received from the Board of Nursing, she reported the following: 3. I asked her about the allegation that she had taken one of Resident #1's Levothyroxine for her own personal use. She replied that she takes Levo and her prescription calls for her to take 175 Mg. The meds she has at her home are only 150 MG, they're 25 Mg short of what she needs. She said that she did go to the med cart and take one of Resident #1's out of the cart because his are 25 Mg and would make up the difference. She said that she did tell LVN B, that she needed to take the pill for herself because she was short. She carried the pill with her and went back to the unit. However, the more she thought about it, the more she realized she couldn't take it. LVN B reports that she then put the medication in a sharps container so that it would be destroyed. She also said that there was someone else on the unit at the time that saw her place the pill in the sharp's container, but she didn't recall exactly who was there. Record review of the facility in-service dated 6/21/24 titled Medication administration policy: Do not take meds for personal use revealed: LVN A signed. During an interview on 6/25/24 at 2:30 PM, the DON stated LVN B notified the facility on 6/18/2024 that she received a letter from The Texas Board of Nursing that LVN B was being investigated for taking a resident's medication. The DON stated the medication that LVN B took from the medication cart was Synthroid. The DON stated LVN B told another nurse (LVN C), she was going to take the medication out of the medication cart and take it for herself. The DON stated LVN B told her she decided to not take the pill and discarded it in the sharps container. During an interview on 6/25/24 at 4:47 PM, LVN C stated she was the charge nurse on the shift and had passed out medications, but she could not remember the date. She stated she parked the medication cart on south hall by the dining room when she stepped away to deal with another resident. She stated she turned around and saw LVN B in her medication cart. She said she had asked LVN B what she was doing and LVN B told her she was taking Resident #1's Levothyroxine because she had the same prescription at home but was short on her pills. She stated she observed LVN B pop the pill in her mouth, then she walked to the back of the facility. She stated LVN B was able to gain access to the medication cart because she left it unlocked. She stated she was not supposed to leave it unlocked. She stated staff were not supposed to take medications from the cart for personal use. During an interview on 6/25/24 at 6:15 PM, LVN B stated she had a prescription for Levothyroxine 150mg but needed to take 175mg pill, and off the top of her head she thought she would take one of Resident #1 Levothyroxine pills out of the medication cart. LVN B stated she walked to the front lobby and saw the medication cart and it was unlocked. She stated she took the pill and walked away. LVN B stated when she returned to her unit, she decided to not take the pill and placed it in the sharps container. She stated she had been trained on misappropriation and that she should not have taken the pill out of the medication cart. During an interview on 6/26/24 at 3:26 PM, the DON stated LVN C told her that LVN B told hershe had taken medication from LVN C's medication cart. The DON stated staff are not supposed to take or borrow medications from residents for personal use. She stated LVN C told her she had witnessed LVN B take the medication. Record review of the facility in-service undated topic Do not borrow meds from other resident to give to another resident or for personal use. Follow facility protocol. Follow medication administration procedure. Be survey ready. Mock survey 6/25/2024. Keep medication cart locked. revealed: the DON and 2 other staff signed on 5/5/24; LVN B and the ADON signed on 5/6/24; LVN C signed on 5/8/2024. Record review of the facility in-service dated 6/25/24 titled Abuse/Neglect/Exploitation/Misappropriation provided to staff. Record review of the facility in-service dated 6/25/24 titled Abuse, and neglect, and reporting revealed: signed by DON and ADM A. During an interview on 6/26/24 at 1:37 PM, Admin D, stated he spoke with LVN B about the letter she had received from the BON and the details in the letter, one was an allegation that she had taken a resident's certain medication. The Admin D stated LVN B was short of her own medication and she borrowed from the resident to make up for herself . Admin D stated he reported the incident to HHSC. The facility in serviced staff and LVN B was suspended pending investigation. Record review of facility provided policy titled, Abuse, Neglect, and Exploitation dated 10/2023, revealed: The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect and misappropriation of resident property and exploitation that achieves: B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the residents' care needs and behavioral symptoms. F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution, and providing feedback regarding the concerns that have been expressed. G. Addressing features of the physical environment that may make abuse, neglect, and exploitation, and misappropriation of resident property more likely to occur. H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. Identification of Abuse, Neglect, and Exploitation: B. Possible indicators of abuse include, but are not limited to 8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and positioning . Investigation of Alleged Abuse, Neglect, and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur B. Written procedures of investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence) 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause, and 6. Providing complete and thorough documentation of the investigation. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staff changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed, and G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change because of an incident of abuse. Reporting/Response: 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property, or exploitation occurred and what changes are needed to prevent future occurrences.

Based on interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 2 medication carts (medication cart on front hall). The facility failed to ensure that medication 1 of 2 medication carts were secured when unattended on or about 4/21/2024 through 4/28/2024 and/or 5/2/2024. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversions. Findings included: During an interview on 6/25/24 at 2:30 PM, the DON stated LVN B notified the facility she received a letter from The Texas Board of Nursing that LVN B was being investigated for taking a resident's medication. The DON stated the medication that LVN B took from the medication cart was Synthroid. The DON stated LVN B told another nurse (LVN C), she was going to take the medication out of the take and take it for herself. The DON stated LVN B told her she decided to not take the pill and discarded it in the sharps container. During an interview on 6/26/24 at 3:26 PM, the DON stated LVN C told her that LVN B told her she was going to take medication from her cart. The DON stated she did not know if LVN C left the cart unlocked, but it was not supposed to be unlocked when unattended. During an interview on 6/25/24 at 4:47 PM, LVN C stated she was the charge nurse on the shift and had passed out medications, but she could not remember the date. She stated she parked the medication cart on south hall by the dining room when she stepped away to deal with another resident. She stated she turned around and saw LVN B in her medication cart. She said she had asked LVN B what she was doing and LVN B told her she was taking Levothyroxine out of the cart because she had the same prescription at home but was short on her pills. She stated she saw that LVN B had more than one pill in her hand but did not know how many. She stated she observed LVN B swallow the pills, then she walked to the back of the facility. She stated LVN B was able to gain access to the medication cart because she left it unlocked. She stated she was not supposed to leave it unlocked. She stated staff were not supposed to take medications from the cart for personal use. Record review of the facility in-service undated topic Do not borrow meds from other resident to give to another resident or for personal use. Follow facility protocol. Follow medication administration procedure. Be survey ready. Mock survey 6/25/2024. Keep medication cart locked. revealed: the DON and 2 other staff signed on 5/5/24; LVN B and the ADON signed on 5/6/24; LVN B signed on 5/8/2024. Record review of the facility in-service dated 6/21/24 titled Medication administration policy: Do not take meds for personal use revealed: LVN B signed. Record review of the facility in-service dated 6/25/24 titled Abuse/Neglect/Exploitation/Misappropriation revealed: 24 staff signed. Record review of letter signed by ADM D on 6/20/24 titled LVN B Interview revealed: I interviewed LVN B on June 20, 2024. In response to the allegations contained in the letter that she received from the Board of Nursing, she reported the following: 3. I asked her about the allegation that she had taken a Levothyroxine pill for her own personal use. She replied that she takes Levo and her prescription calls for her to take 175 Mg. The meds she has at her home are only 150 MG, they're 25 Mg short of what she needs. She said that she did go to the med cart and took a resident's pill out of the cart because his are 25 Mg and would make up the difference. She said that she did tell LVN B, that she needed to take the pill for herself because her's were short. She carried the pill with her and went back to the unit. However, the more she thought about it, the more she realized she couldn't take it. LVN B reports that she then put the medication in a sharps container so that it would be destroyed. She also said that there was someone else on the unit at the time that saw her place the pill in the sharp's container, but she didn't recall exactly who was there. Record review of letter signed by LVN C on 6/19/24 titled LVN C Interviewed revealed: On June 29, 2024 at approximately 1:45 p.m., I interviewed LVN C about any information she may have concerning the allegations the facility had received about LVN B. LVN C reported there had been a day when she had left her med cart to get some supplies. When LVN C returned, LVN B was in her cart. LVN B told LVN C that she needed some of a resident's Levo. LVN B was short of hers and she had a medical condition. LVN C said she does not give that med, other nurses do, but LVN B had a pill her hand and told LVN C she had taken some. During an interview on 6/25/24 at 6:15 PM, LVN B stated she walked to the front lobby and saw the medication cart and it was unlocked. She stated that the medication cart belonged to LVN C, was unattended and unlocked. She stated that she had been trained to lock the medication cart anytime it is left unattended. Record review of facility provided policy titled, Administering Medications dated 4/2019, revealed: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 16. during administration of medications comma the medication card is kept closed and locked when out of site of the medication nurse or aid. It may be kept in the doorway of the residence room, with open drawers facing inward and all other sides closed. No medications are kept on the top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, medical records maintained on each resident were accurately documented for 1 of 8 residents (Resident #1) reviewed for accuracy of records. LVN B failed to document a fall with injury in the medical record progress note for Resident #2. This failure could place residents at risk for not receiving needed care or treatment after an incident occurred. The findings included: Record review of Resident #2's undated face sheet reflected Resident #2 was a [AGE] year-old male whose current admitted was on 2/4/2021, and a readmission to the facility on [DATE]. Resident #2 had the following diagnoses: chronic obstructive pulmonary disease (airflow blockage and breathing-related problems), muscle weakness, acquired absence of right leg below knee (partial amputation of the right leg), complete traumatic amputation at knee level, left lower leg, subsequent encounter (partial amputation of the left leg), unspecified systolic (congestive) heart failure (heart condition), essential primary hypertension (high blood pressure), mood disorder (mental health condition), Anxiety disorder due to known physiological condition (mental health condition), and chronic kidney disease (gradual loss of kidney function). Record review of Resident #2's clinical record reflected his comprehensive MDS assessment was completed on 4/10/2024 listing him with a BIMS score of 13, which indicated he was moderately cognitively intact. Additionally, section GG - Functional Abilities and Goals revealed Resident #2 requires supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently for chair/bed-to-chair transfers. Record review of Resident #2's physician orders dated 4/01/24 to 4/30/24 revealed an order dated 4/09/24 to maintain ace bandage to right stump until appointment on 4/17/20 and to monitor for bleeding and signs of complication during every shift. Physician orders further revealed an order dated 4/23/24 to change dressing to stump 3 times a week and to monitor for bleeding and signs of complication during every shift. Record Review of Resident #2's Care Plan, dated 4/25/24, revealed Resident #2 had a below the knee amputation. Interventions included the use of a sliding board for transfers or mechanical lift for transfers PRN. Evaluation notes dated 06/19/24 revealed Resident #2 was able to transfer themselves from the bed to the wheelchair with or without the use of a sliding board and that Resident #2 declined to use the mechanical lift. Record review of Resident #2's progress notes from 4/1/24 to 6/26/24 revealed no documentation of the fall described by the resident or facility staff. During an interview on 6/25/24 at 1:37 PM, Admin D stated he spoke with LVN B about the letter she had received from the BON and the details in the letter, one was an allegation of an improper transfer that resulted in a fall. He stated the LVN B did try to transfer a resident and a fall happened. During an interview on 6/25/24 at 2:16 PM the corporate nurse stated she could not locate any documentation or any other records in the electronic health record referencing the fall involving Resident #2 and LVN B. During an interview on 6/25/24 at 3:36 PM, CNA E stated she witnessed LVN B and Resident #2 fall during a transfer. She stated she was not able to determine the date or time frame of when this incident occurred, but she believed it was shortly after Resident #2's surgery of when his leg was amputated a couple of months ago. She stated she could not recall the time of when it occurred, but she believed it would have happened between 3:00 PM and 7:00 PM. She stated on the day of the incident she, CNA F, and another staff were all asked to go into Resident #2's bedroom to assist with transferring him from the wheelchair to his bed. LVN B was asked if they were going to use the mechanical lift and LVN B replied she was going to transfer Resident #2 by bear hugging him and lifting him from the wheelchair to the bed. CNA E stated she observed LVN B bear hug Resident #2 face to face, then she stumbled backwards while lifting him, and then both she and Resident #2 fell backwards into a refrigerator, and then onto the floor. CNA E stated Resident #2 hit the incision on his right leg on the floor then it started to bleed. CNA E stated Resident #2 was on top of LVN B CNA E with his arms around her and his legs straddled around her body. CNA E stated she could not recall how LVN B got out from under resident #2. CNA E stated afterwards, they all worked together to lift Resident #2 off the ground and onto his bed. CNA E stated she left about 10 minutes later to return to her assigned hall to assist other residents. CNA E stated Resident #2 has never refused a transfer with a sliding board or the mechanical lift. CNA E stated Resident #2 used the sliding board to transfer himself or instructed staff to push his chair against his bed to transfer himself. During an interview on 6/25/24 at 3:54 PM CNA F stated she witnessed LVN B and Resident #2 fall during a transfer. She stated she could not determine the date or time frame of when this incident occurred, but she believed it was shortly after Resident #2's surgery of when his leg was amputated a couple of months ago. CNA F stated she believed the incident occurred before 7:00 PM on the day it occurred. CNA F stated Resident #2 used his call light and told her he needed assistance with a transfer from his wheelchair to his bed. CNA F stated LVN B had transferred Resident #2 into his wheelchair earlier that day, so she understood that was why she was responsible to transfer him back to his bed. CNA F stated LVN B bear-hugged Resident #2 and picked him up from his wheelchair and stumbled and fell back into the refrigerator, and then they both fell on to the floor. CNA F stated they all helped get Resident #2 up and into bed by grabbing under his legs and arms and his leg when she saw blood on his leg. CNA F stated LVN B then went to get supplies for the blood and called the DON. CNA F stated the DON came and helped put new dressing on Resident #2's leg. CNA F stated Resident #2 moaned and made noises but did not say anything. CNA F stated Resident #2 asked about the blood, but he had not say he was in pain. CNA F stated she could not remember how LVN B got Residents #2 off her. CNA F stated Resident #2 was not taken to the hospital nor was emergency assistance called after the incident. During an interview on 6/25/24 at 4:47 PM, LVN C stated she was the charge nurse on the day LVN B and Resident #2 fell during a transfer. She stated she could not to determine the date or time frame of when this incident occurred, but she believed it may have been on a day that was not her regular workday that she came in to fill a shift. She stated the incident may have been two or three days after Resident #2's surgery of when his leg was amputated a couple of months ago. She stated she was aware that Resident #2's surgical incision had been bleeding when he readmitted from the hospital. She stated Resident #2 wanted to get in his wheelchair, but he refused to be transferred with the lift. She stated staff told Resident #2 that they must use the lift for transfers, but he refused again. She stated she had not wanted to transfer Resident #2 as it would not have been safe to transfer him without the lift. She stated she had been concerned that there would not have been any male staff on shift in the evening to help put him back in bed. LVN C stated she went on her lunch break. She stated she observed Resident #2 in his wheelchair when she returned from her lunch break. She stated staff told her that Resident #2 asked LVN B to transfer him into his wheelchair when she had walked by coming back from a smoke break. LVN C stated Resident #2 was ready to get back in bed later that evening, so she told CNA F to get LVN B, who was the charge nurse on a different unit, and to tell her she needed to put Resident #2 back in bed, and then she went to chart records. She stated LVN B approached her and asked why her staff could not complete the transfer, in which she replied to LVN B that since she was the one to take him out of bed then she needed to figure out how to put him back in bed. LVN C stated LVN B walked away. LVN C stated she had been charting records when she heard a loud commotion. She stated CNA E, CNA F, and another staff came and told her that LVN B hit the refrigerator and dropped Resident #2 on the floor. She stated LVN B said she called the DON due to the blood. She stated staff went to get supplies and the DON arrived about that time. She stated she observed blood on his bed the size of a soccer ball and that his bandage was soaked with blood. She stated the DON called the surgeon and was advised to monitor the incision for infection, and to call back if infection appeared. She stated she then left for the evening. She stated Resident #2 had not been taken to the hospital for this incident. She stated the next day, she was told not to document the incident in the post log by the DON because it was considered a transfer and not a fall. She stated there had not been any documentation completed to record the incident. She stated she helped apply the new dressing and observed the incision to be opened about one inch. She stated she helped put pressure on the incision and put a bandage on it. She stated she helped apply gauze and they were able to get the bleeding to stop after wrapping it for the third time. She stated Resident #2 already had an appointment that was scheduled shortly after (possibly a week's time), and that was the first time the incision was observed by a physician after the incident. She stated they received new orders from the physician and that they physician applied additional dressing on it. She stated at that time, there was not an order to use a mechanical lift for transfers, but she felt it was best to use it. She stated Resident #2 seemed to like to use the sliding board for transfers and that he refused the mechanical lift. During an interview on 6/25/24 at 6:15 PM, LVN B stated she could not recall the date of the fall with Resident #2 but recalled the fall. LVN B stated staff asked her to transfer Resident #2 to bed. She stated she went in the room and Resident #2 refused the Hoyer, so she decided to lift him on her own. LVN B stated she stood in front of Resident #2 and he bear hugged her. LVN B stated, Resident #2 placed his arms around her neck and she placed her arms under his arms around his body and she lifted him up. LVN B stated, she stepped backwards lost her balance and fell and Resident #2 landed on top of her, straddling her. She stated Resident #2 pushed himself up with his hands and she scooted out from under him. She stated three staff assisted him off the floor and back in bed. LVN B stated Resident #2's stump was bleeding. She stated she had been trained on how to complete a proper transfer, but Resident #2 refused the Hoyer and she attempted to lift him herself to transfer him. During an interview on 6/26/24 at 1:00 PM, Resident #2 stated he recalled a fall where LVN B transferred him from his chair to his bed. Resident #2 stated he could not recall the date of this fall. Resident #2 stated LVN B transferred him by herself, without assistance from another staff. Resident #2 stated LVN B instructed him to put his arms around her, and LVN B wrapped her arms around his torso and lifted him. Resident #2 stated LVN B was supposed to turn and place him on the bed, but LVN B lost her balance and fell back, into his refrigerator. Resident #2 stated he fell on top of LVN B, straddling her. Resident #2 stated he was face to face with LVN B and was very close to her. Resident #2 stated he scooted himself off LVN B by pushing himself with his hands on LVN B's stomach until he reached the floor, in between LVN's legs. Resident #2 stated he hit both of his legs, on his stumps, when he fell with LVN B. Resident #2 stated it was painful on his right leg that had been recently amputated. Resident #2 stated the incision site, on his right leg bled after the fall, but he stated that it was not a lot. Resident #2 stated the DON and LVN B checked the incision site on his right leg and changed the dressings. Resident #2 stated he was usually transferred with two staff, using a sliding board. Resident #2 stated he did not like using the Hoyer lift because he felt claustrophobic and [NAME] as if he was choking. Resident #2 stated he could not remember exactly who was present during the fall, but he recalled CNA E, was present. Resident #2 stated LVN B did not ask for help when she transferred him from the CNA's that were present, and he did not know why. Resident #2 stated LVN B said she thought she could do it on her own, and he thought she could do it also. Resident #2 stated he has never been transferred by just one person before. Resident #2 stated LVN B did not say anything to him after the fall. Record review of facility provided policy titled, Assessing Falls and Their Causes dated 3/2018, revealed: The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Steps in the Procedure After a Fall: 3. If there is evidence of injury, provide appropriate first aid and obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying or standing position, and then document relevant details. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility, and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 1. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services. Defining Detains of Falls: 1. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. 2. For each individual, distinguish falls in the following categories: a. Rolling, sliding or dropping from an object (e.g., from bed or chair or floor) b. Falling while attempting to stand up from a sitting or lying position, or c. Falling while already standing and trying to ambulate Identifying Causes of a Fall or Fall Risk 1. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to resident specific chains of events or circumstances proceeding a recent fall, including : a. Time of day of the fall; b. Time of the last meal; c. What the resident was doing; d. Whether the resident was standing, walking, reaching, or transferring from one position to another; e. Whether the resident was among other persons or alone; f. whether any environmental risk factors were involved (e.g. slippery floor, poor lighting, furniture, or objects in the way) and/or g. Whether the resident was trying to get to the toilet h. whether there is a pattern of this balls for this resident 3. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found. 4. as indicated, the attending physician will examine the resident or may initiate testing to try to identify causes. 5. consult with the attending physician or medical director to confirm specific causes from among multiple possibilities. when possible, document the basis for identifying specific factors as the cause. 6. if the cause is unknown but no additional evaluation is done, the physician or nursing staff should note why (e.g. workup already done, finding A cause would not change the approach, etc.). Documentation When a resident falls, the following information should be recorded in the residence medical record: 1. The condition in which the resident was found (e.g resident found lying on the floor between bed and chair) 2. Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family, as indicated. 5. Completion of a fall risk assessment. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. Reporting 1. Notify the following individuals when a resident falls: a. The resident's family b. The attending physician (timing of notification may vary depending on whether injury was involved); c. The director of nursing services and d. The nursing supervisor on duty 2. Report other information in accordance with facility policy and professional standards of practice. Record review of facility provided policy titled, Falls - Clinical Protocol dated 3/2018, revealed: Assessment and recognition: 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in condition or level of consciousness; e. Neurological status; f. pain; g. Frequency and number of falls since the last position visit; h. Precipitating factors; details on how far all occurred; i. All current medications, especially those associated with dizziness or lethargy; and j. All active diagnosis 5. The staff will evaluate and document falls that occur while they invent individual is in the facility, for example when and where they happen, any observations of the event, etc. 6. All should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed on the floor 7. Falls should also be identified as witnessed or unwitnessed events.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 9 of 30 days (08/13/23, 08/19/23, 08/20/23, 08/26/23, 08/27/23, 09/02/23, 09/03/23, 09/09/23, and 09/10/23) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 08/13/23, 08/19/23, 08/20/23, 08/26/23, 08/27/23, 09/02/23, 09/03/23, 09/09/23, and 09/10/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster dated 08/04/23 revealed there were one RN employed at the facility. Record Review of the employee roster update provided by the ADM dated 09/13/23 revealed RN A termination date 07/20/23 and had written on document No RN time sheet for last 30 days. During an interview on 09/13/23 at 11:45 AM with the ADM he stated there were no RN times for the last 30 days. During an interview on 09/13/23 at 11:50 AM with the DON she stated she was currently the only RN employed. She stated she worked Monday through Friday 08:00 AM to 05:00 PM unless she covered a shift on the floor. She stated the facility can use telehealth 24/7 on the weekends and after 07:00 PM on the weekdays. She stated the medical director was also available 24/7. She stated they currently have an ad out for weekend RN through there corporation and have planned a job fair for 09/14/23. During an interview on 09/13/23 at 11:58 AM with the ADM, he stated they were posting ads all around the area on Facebook job sites, indeed, and the corporate office was posting as well. He stated he currently does not have any contract with agency. He stated they have a corporate nursing pool that was like agency, but they currently have no RN available to send. During an interview on 09/15/23 at 09:14 AM with the DON, she stated she and the ADM were responsible for RN coverage. She stated if staff needs an RN, staff could call her 24/7. She stated the nurse consultant was also available by phone if needed. She stated the facility policy was to have RN coverage 8 hours a day 7 days a week. She stated it was important to have an RN to add clinical assessments and supervision. She stated there was treatments and assessments that only the RN could do. She stated if the resident was acutely ill the nurse would send resident to the hospital. She stated the potential negative outcome could be the resident would not get the services required by an RN. She stated the facility does not use outside agencies. She stated she had requested an RN for the corporate pool but there was not an RN available. During an interview on 09/15/23 at 09:30 AM with the ADM, he stated he was responsible for RN coverage. He stated if the staff needed and RN they were to work with the DON. He stated the facility policy was to have an RN 8 hours a day 7 days a week. He stated it was important to have an RN to manage the whole aspect of the building. He stated LVN's were only allowed to do certain things. He stated the potential negative effect would be depending on the certain need of the resident and general overall care of resident. He stated the agency he had spoken with stated they could not provide him with an RN they only had LVN's, so he does not need an agency if they cannot provide an RN. He stated RN's have a higher level of education and can perform certain duties like PICC lines and various procedures. He stated his expectations were to have coverage 8 hours a day 7 days a week to meet the regulation in place. Record review facility ad dated 09/13/23 revealed an ad for weekend RN. Record review [name] Bulletin Board Print Document dated 09/08/23 revealed job order for registered nurse (RN) - [facility location]. Record review hireology.com dated 09/07/23 revealed ad for weekend RN. During an interview with ADM on 09/15/23 at 10:00 AM surveyor request policy on RN Coverage. During exit conference 09/15/23 at 12:00 PM ADM was asked if there were any additional information, they want to present that was requested, she stated No. During an interview on 09/22/23 at 11:56 AM with the ADM surveyor requested facility policy on RN Coverage. Record review email from ADM on 09/22/23 at 01:23 PM revealed I do not think we have one for just RN coverage.

Based on observation, interview and record review the facility failed to immediately consult with the resident's physician; and notify the resident's responsible party/family member when there was an accident involving the resident which resulted in injury and a significant change in the resident's physical condition with a need for medical/physician intervention for 1 (resident # 7) of 5 residents reviewed for notification of change due to injury. LVN I failed to notify resident # 7's physician and responsible party when resident # 7 sat down on the bed frame, and hollered out in pain while being assisted to bed on the night of 10/19/2016 at an undocumented time. Resident # 7 declined getting out of bed, eating and complained of pain, after the incident. Licensed Vocational Nurse (LVN) I sent a fax to resident #7's physician ' s office on 10/21/16 at 12:26 AM (office was closed) and the Director of Nurses (DON) sent a fax on 10/21/16 documented at 10:00 AM, 2 days after the incident. An x-ray report on 10/21/16 revealed a fractured femur. This failure resulted in delayed medical treatment for [REDACTED]. The finding included: Record review of the face sheet dated 11/07/16 documented resident # 7 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly MDS dated [DATE] for resident # 7 documented in section C resident # 7 was not able to be assessed for cognitive function and resident # 7 ' s mood state in section D was assessed. Section G documented resident # 7 required standby assistance for transfers, and was independently ambulatory. Record review of the care plan initiated 6/12/14 documented resident # 7 had - behaviors of wandering and was at risk for elopement and falls. - a cognitive deficit/dementia and difficulty expressing herself. Resident # 7 ' s needs had to be anticipated and met by staff and resident # 7 required cues to redirect her, provide care and treatments. - risk for falls due to pacing, wandering and use of [MEDICAL CONDITION] drug use requiring monitoring and the following of the facility fall protocol (plan to decrease/prevent falls). Record review of the facility's incident report dated 10/19/16 at 2200 (10:00 PM) and revised on 10/20/16 at 2330 (11:30 PM) documented staff called LVN I to resident # 7's room stating while transferring resident # 7 to bed resident # 7's left leg hit the bed rail, no bruising or swelling was noted. The report documented, under people notified, resident #7's physician was notified on 10/20/16 at 2330 (11:30 PM), the means of notification was not documented. Record review of the nurse notes for resident # 7 dated 10/19/16 and 10/20/16 contained no assessment and no documentation no notification of resident # 7s physician or family of resident # 7's incident on 10/19/16 when she sat down on the bed frame. In an interview on 11/07/16 at 4:06 PM CNA E said on 10/19/16 resident # 7 had been put to bed twice, and they were backing resident # 7 to the bed, she sat down on the bed frame, pushing the mattress back, sat down too soon, not real hard. Resident # 7 did say ' oh, oh ' and complained of her hip when lifted her legs into the bed. Reported the incident to the nurse, LVN I. CNA E said when came to work the next morning, CNA E ask LVN B if he knew about the incident with resident # 7 and LVN B said no, and went to check resident # 7. CNA E said resident # 7 did not get up, was fed breakfast, CNA E did not provide any further care to resident # 7 that day, said resident # 7 usually got up and walked constantly. CNA E said resident # 7 would sit down when told in Spanish to sit down. Record review of the nurse notes dated 10/20/16 at 5:52 PM for resident # 7 documented: the administration of [MEDICATION NAME] 1000 milligrams (mg) by mouth every 4 hours as needed for pain/temp >100.4. The notes were documented by LVN I and did not document an assessment of why medication was given. Record review of the nurse notes dated 10/20/16 at 10:58 PM by LVN I documented the [MEDICATION NAME] was effective; resident # 7's temp was 98.9 at that time. Record review of the Fax prepared by LVN I for resident # 7 ' s physician dated 10/20/16 at 11:40 pm documented resident # 7 had been in bed the majority of the day and her meal intake had been 5% or less. Documented resident # 7 ' s temperature was 99.3 and the APAP (tylenol) was given. The Fax then documented the staff had also reported resident # 7 had hit her leg on the bed rail while resident # 7 was being put to bed. Resident # 7 had not complained of pain, had any bruising or swelling on 10/19/16 at 10 PM. The fax dated and time stamp documented the fax was sent to the physician ' s office on 10/21/16 at 12:26 AM (the office was closed at that time). Record review of the nurse notes dated 10/21/16 at 6:00 AM documented by LVN B , the administration of [MEDICATION NAME] 1000 mg by mouth for complain of pain scale 9/10. At 6:16 AM LVN B documented resident # 7 complained of severe pain to the left hip when the Certified Nurses Aide (CNA) was doing incontinent rounds, and would continue to monitor. No assessment of the hip or source of pain was documented. Record review of the nurses ' notes dated 10/21/16 at 7:00 AM the DON documented resident # 7 was in bed, with swelling of the left thigh. Resident # 7 did not want to get up for breakfast and pushed it away. The DON documented resident # 7 had no facial grimacing. At 9:00 AM the notes documented the DON attempted to call the physician ' s clinic 3 times and messages were left. At 10:00 AM the notes document an appointment was scheduled at the clinic in another town for 10:45 AM. The notes documented resident # 7 remained in bed, the left thigh was still swelling, and resident was able to lift the leg without pain, was confused and had no facial grimacing. A reply fax from the physician ' s office dated 10/21/16 at 10:29 AM, in response to the 10 AM fax from LVN I, documented resident # 7 was to come to the clinic. No other documentation of the physician being notified of the change in resident # 7 ' s condition was documented. Record review of the fax sent by the DON, to resident # 7's physician dated 10/21/16 at 10 AM documented resident # 7 had a change in mobility, significant for this resident as resident # 7 usually wandered but now refused to get up, had swelling of the left thigh and APA ([MEDICATION NAME]) was given. The returned fax orders, from the physicians clinic was dated 10/21/16 at 14:20 (2:40 PM); after resident # 7 had already been sent to the clinic and then to the ER. Record review of the nurse notes dated 10/21/16 at 10:45 AM documented by the DON - resident # 7 was out of the facility in geri-chair and facility van. The note documented resident # 7 was resisting to get up and called out ahh, ahh . The note documented resident # 7 had no bone protrusion or legs not askew or hip malformation. Record review of the nurses notes dated 10/21/16 by the DON at 11:00 AM documented resident # 7 ' s family was notified of the appointment with the nurse practitioner and was being sent to the hospital for x-ray. Record review of the x-ray reports from the ER visit on 10/21/16 documented resident # 7 was examined by x-ray at 11:49 AM on 10/21/16 and the findings were an acute, comminuted, impacted intertrochanteric [MEDICAL CONDITION] aspect of the left femur. Chronic [MEDICAL CONDITION] changes were noted in the lower lumbar spine, pubic symphysis and knee. Review of the x-ray reports from the second hospital dated 10/21/16 at 3:02 PM documented resident #7 had a highly comminuted left intertrochanteric fracture with various deformity and documented the bones were osteopenic. Record review of the nurse ' s notes dated 10/23/16 at 17:55 (5:55 PM) documented resident # 7 returned to the facility via EMS (ambulance) transport and was admitted to Hospice services. Record review of the discharge summary from the second hospital dated 10/23/16 documented resident # 7 [DIAGNOSES REDACTED]. Record review of the nurses notes dated 10/21/16 by the DON at 11:30 AM the DON documented the hospital had called stating resident # 7 was being transferred to a different hospital for treatment. Interview on 11/07/16 at 11:30 AM the DON said the staff reported resident # 7 did sit down too soon, resident # 7 would resist sitting down, and was not able to understand to sit down or to reason/understand taking a shower and such. The DON said it would sometimes take 2 people to get resident # 7 to understand to sit down, did not force resident to sit. Observation of resident # 7 on 11/07/16 at 11:47 AM revealed resident # 7 was in bed, appeared asleep, did not respond to name being called. Resident # 7 had an air flotation mattress, and catheter (tube into the bladder), the bed was low with an alarm and a mat on the floor. Resident # 7 ' s tray was sitting in the room, untouched appearing. Interview at 2:00 PM on 11/07/16 the DON said she called resident # 7 ' s doctors office and sent faxes, left messages. When the DON was ask why resident was not transferred to the emergency room when the change in condition was noted the DON said she was busy, passing meds and trying to get things done. In an interview on 11/07/16 at 2:13 PM CNA G said she noticed resident # 7 was more resistive to stand up a day or 2 before going to the hospital. CNA G said resident # 7 usually did not sit down, but was sitting that day. Was not assigned to resident # 7 that day, saw resident sitting in the lobby and that was unusual. In an interview of 11/07/16 at 2:27 PM LVN J said the dash board on the computer program the facility used would show changes, incident reports, they used when doing end of shift report. When reviewed with LVN J for 10/19/16 and 10/21/16 the dash board did not show any information related the changes or incident with resident # 7. LVN J said a resident with injury should not be moved or got up. In a telephone interview on 11/07/16 at 3:29 PM with resident # 7 ' s current physician, it was said resident # 7 ' s physician at the time of the incident was no longer [MEDICATION NAME] there. It was not known how to contact that physician. Resident # 7 ' s current physician said he would review the clinical chart, then said a telephone message was there, dated 10/21/16 at 10:00 AM that resident # 7 had a change in mobility, with swelling and unable to lift leg without pain. A fax was also there dated and timed 10/20/16 at 11:40 PM documenting a change in condition and resident # 7 had set hard on the side of the bed. It was not possible to tell when the messages were received by the physician or nurse practitioner. In an interview on 11/07/16 at 4:04 PM LVN I said she was surprised to see the incident was not charted, she felt the computer did not save her charting, she did the incident report then had to come back and clarify the bed, not bed rail, the next day. In an interview at 4:16 PM the DON said she called the clinic and could not get an answer, the DON said she left messages and got a fax to make an appointment. When ask if the doctor was aware of resident not walking the DON said she sent a fax, when ask why resident was not transferred by ambulance instead of the geri-chair the DON replied there was not an order to call the ambulance. The DON did not reply when ask if an ambulance order was required. A message was left on 11/07/16 at 3:31 PM for the nurse practitioner, who was out of the office, to return a call to the investigator; a return call was received from the treating Nurse Practitioner on 11/08/16 at 8:05 AM, the Nurse Practitioner stated a fax was received that resident # 7 had sat down and the nurse practitioner stated the facility staff brought resident # 7 into the clinic in a geri-chair, the Nurse Practitioner said when resident # 7 was seen, resident # 7 ' s injury was apparent and resident # 7 was sent straight to the emergency room . In a telephone interview on 11/08/16 at 9:50 AM CNA K returned a call and said on the 21st the CNA could tell resident # 7 was hurting and ask CNA L why resident # 7 ' s meal tray was on the hall cart. Was told resident # 7 had not been wanting to walk. CNA K said when attempted to take resident # 7 to the bathroom, resident # 7 screamed and hollered. CNA K said she put resident # 7's legs back in the bed and reported to the DON who said she would check resident # 7. A little later the Administrator told her to put resident # 7 in the van geri-chair, CNA K said she told the Administrator would not without help. She then got help and carefully set resident #7 in the geri-chair and the van driver took resident # 7 to the doctor. The Administrator provided the following policy for incident/accident reporting: Record review of the undated facility incident/accident reporting for nurses ' policy documented: - an incident was any happening which is not consistent with the routine operation of the facility or the routine care of a particular resident. It is an event without evidence of an injury or a change. An accident is an event with visible injury or change in status. - Incidents/accidents that should be documented in both incident/accident report and nurses notes included (in part) fractures - confirmed or suspected bruises and other skin injuries, and falls with or without visible injury. The facility CMS 802 dated 11/07/16 documented 6 residents with a history of falls.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain the highest practicble physical and mental well being according to the plan of care for 1 (resident # 7) of 5 residents reviewed for falls and appropriate care and services for pain and injuries. LVN I failed to notify resident # 7's physician and responsible party when resident # 7 sat down on the bed frame, and hollered out in pain while being assisted to bed on the night of 10/19/2016 at an undocumented time. Resident # 7 declined getting out of bed, eating and complained of pain, after the incident. Licensed Vocational Nurse (LVN) I sent a fax to resident #7's physician ' s office on 10/21/16 at 12:26 AM (office was closed) and the Director of Nurses (DON) sent a fax on 10/21/16 documented at 10:00 AM, 2 days after the incident. An x-ray report on 10/21/16 revealed a fractured femur. This failure resulted in delayed medical treatment for [REDACTED]. The finding included: Record review of the face sheet dated 11/07/16 documented resident # 7 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly MDS dated [DATE] for resident # 7 documented in section C resident # 7 was not able to be assessed for cognitive function and resident # 7 ' s mood state in section D was assessed. Section G documented resident # 7 required standby assistance for transfers, and was independently ambulatory. Record review of the care plan initiated 6/12/14 documented resident # 7 had - behaviors of wandering and was at risk for elopement and falls. - a cognitive deficit/dementia and difficulty expressing herself. Resident # 7 ' s needs had to be anticipated and met by staff and resident # 7 required cues to redirect her, provide care and treatments. - risk for falls due to pacing, wandering and use of [MEDICAL CONDITION] drug use requiring monitoring and the following of the facility fall protocol (plan to decrease/prevent falls). Record review of the facility's incident report dated 10/19/16 at 2200 (10:00 PM) and revised on 10/20/16 at 2330 (11:30 PM) documented staff called LVN I to resident # 7's room stating while transferring resident # 7 to bed resident # 7's left leg hit the bed rail, no bruising or swelling was noted. The report documented, under people notified, resident #7's physician was notified on 10/20/16 at 2330 (11:30 PM), the means of notification was not documented. Record review of the nurse notes for resident # 7 dated 10/19/16 and 10/20/16 contained no assessment and no documentation no notification of resident # 7s physician or family of resident # 7's incident on 10/19/16 when she sat down on the bed frame. In an interview on 11/07/16 at 4:06 PM CNA E said on 10/19/16 resident # 7 had been put to bed twice, and they were backing resident # 7 to the bed, she sat down on the bed frame, pushing the mattress back, sat down too soon, not real hard. Resident # 7 did say ' oh, oh ' and complained of her hip when lifted her legs into the bed. Reported the incident to the nurse, LVN I. CNA E said when came to work the next morning (10/20/16), CNA E asked LVN B if he knew about the incident with resident # 7 and LVN B said no, and went to check resident # 7. CNA E said resident # 7 did not get up, was fed breakfast, CNA E did not provide any further care to resident # 7 that day, said resident # 7 usually got up and walked constantly. CNA E said resident # 7 would sit down when told in Spanish to sit down. Record review of the nurse notes dated 10/20/16 at 5:52 PM for resident # 7 documented: the administration of [MEDICATION NAME] 1000 milligrams (mg) by mouth every 4 hours as needed for pain/temp >100.4. The notes were documented by LVN I and did not document an assessment of why medication was given. Record review of the nurse notes dated 10/20/16 at 10:58 PM by LVN I documented the [MEDICATION NAME] was effective; resident # 7's temp was 98.9 at that time. Record review of the Fax prepared by LVN I for resident # 7 ' s physician dated 10/20/16 at 11:40 pm documented resident # 7 had been in bed the majority of the day and her meal intake had been 5% or less. Documented resident # 7 ' s temperature was 99.3 and the APAP (tylenol) was given. The Fax then documented the staff had also reported resident # 7 had hit her leg on the bed rail while resident # 7 was being put to bed. Resident # 7 had not complained of pain, had any bruising or swelling on 10/19/16 at 10 PM. The fax dated and time stamp documented the fax was sent to the physician ' s office on 10/21/16 at 12:26 AM (the office was closed at that time). Record review of the nurse notes dated 10/21/16 at 6:00 AM documented by LVN B , the administration of [MEDICATION NAME] 1000 mg by mouth for complaint of pain scale 9/10. At 6:16 AM LVN B documented resident # 7 complained of severe pain to the left hip when the Certified Nurses Aide (CNA) was doing incontinent rounds, and would continue to monitor. No assessment of the hip or source of pain was documented. Record review of the nurses ' notes dated 10/21/16 at 7:00 AM the DON documented resident # 7 was in bed, with swelling of the left thigh. Resident # 7 did not want to get up for breakfast and pushed it away. The DON documented resident # 7 had no facial grimacing. At 9:00 AM the notes documented the DON attempted to call the physician ' s clinic 3 times and messages were left. At 10:00 AM the notes document an appointment was scheduled at the clinic in another town for 10:45 AM. The notes documented resident # 7 remained in bed, the left thigh was still swelling, and resident was able to lift the leg without pain, was confused and had no facial grimacing. A reply fax from the physician ' s office dated 10/21/16 at 10:29 AM, in response to the 10 AM fax from LVN I, documented resident # 7 was to come to the clinic. No other documentation of the physician being notified of the change in resident # 7 ' s condition was documented. Record review of the fax sent by the DON, to resident # 7's physician dated 10/21/16 at 10 AM documented resident # 7 had a change in mobility, significant for this resident as resident # 7 usually wandered but now refused to get up, had swelling of the left thigh and APA ([MEDICATION NAME]) was given. The returned fax orders, from the physicians clinic was dated 10/21/16 at 14:20 (2:40 PM); after resident # 7 had already been sent to the clinic and then to the ER. Record review of the nurse notes dated 10/21/16 at 10:45 AM documented by the DON - resident # 7 was out of the facility in geri-chair and facility van. The note documented resident # 7 was resisting to get up and called out ahh, ahh . The note documented resident # 7 had no bone protrusion or legs not askew or hip malformation. Record review of the nurses notes dated 10/21/16 by the DON at 11:00 AM documented resident # 7 ' s family was notified of the appointment with the nurse practitioner and was being sent to the hospital for x-ray. Record review of the x-ray reports from the ER visit on 10/21/16 documented resident # 7 was examined by x-ray at 11:49 AM on 10/21/16 and the findings were an acute, comminuted, impacted intertrochanteric [MEDICAL CONDITION] aspect of the left femur. Chronic [MEDICAL CONDITION] changes were noted in the lower lumbar spine, pubic symphysis and knee. Review of the x-ray reports from the second hospital dated 10/21/16 at 3:02 PM documented resident #7 had a highly comminuted left intertrochanteric fracture with various deformity and documented the bones were osteopenic. Record review of the nurse ' s notes dated 10/23/16 at 17:55 (5:55 PM) documented resident # 7 returned to the facility via EMS (ambulance) transport and was admitted to Hospice services. Record review of the discharge summary from the second hospital dated 10/23/16 documented resident # 7 [DIAGNOSES REDACTED]. Record review of the nurses notes dated 10/21/16 by the DON at 11:30 AM the DON documented the hospital had called stating resident # 7 was being transferred to a different hospital for treatment. Interview on 11/07/16 at 11:30 AM the DON said the staff reported resident # 7 did sit down too soon, resident # 7 would resist sitting down, and was not able to understand to sit down or to reason/understand taking a shower and such. The DON said it would sometimes take 2 people to get resident # 7 to understand to sit down, did not force resident to sit. Observation of resident # 7 on 11/07/16 at 11:47 AM revealed resident # 7 was in bed, appeared asleep, did not respond to name being called. Resident # 7 had an air flotation mattress, and catheter (tube into the bladder), the bed was low with an alarm and a mat on the floor. Resident # 7 ' s tray was sitting in the room, untouched. Interview at 2:00 PM on 11/07/16 the DON said she called resident # 7 ' s doctors office and sent faxes, left messages. When the DON was asked why resident was not transferred to the emergency room when the change in condition was noted the DON said she was busy, passing meds and trying to get things done. In an interview on 11/07/16 at 2:13 PM CNA G said she noticed resident # 7 was more resistive to stand up a day or 2 before going to the hospital. CNA G said resident # 7 usually did not sit down, but was sitting that day. Was not assigned to resident # 7 that day, saw resident sitting in the lobby and that was unusual. In an interview of 11/07/16 at 2:27 PM LVN J said the dash board on the computer program the facility used would show changes, incident reports, they used when doing end of shift report. When reviewed with LVN J for 10/19/16 and 10/21/16 the dash board did not show any information related the changes or incident with resident # 7. LVN J said a resident with injury should not be moved or got up. In a telephone interview on 11/07/16 at 3:29 PM with resident # 7 ' s current physician, it was said resident # 7 ' s physician at the time of the incident was no longer [MEDICATION NAME] there. It was not known how to contact that physician. Resident # 7 ' s current physician said he would review the clinical chart, then said a telephone message was there, dated 10/21/16 at 10:00 AM that resident # 7 had a change in mobility, with swelling and unable to lift leg without pain. A fax was also there dated and timed 10/20/16 at 11:40 PM documenting a change in condition and resident # 7 had sat hard on the side of the bed. It was not possible to tell when the messages were received by the physician or nurse practitioner. In an interview on 11/07/16 at 4:04 PM LVN I said she was surprised to see the incident was not charted, she felt the computer did not save her charting, she did the incident report then had to come back and clarify the bed, not bed rail, the next day. In an interview on 11/07/16 at 4:16 PM the DON said she called the clinic and could not get an answer, the DON said she left messages and got a fax to make an appointment. When ask if the doctor was aware of resident not walking the DON said she sent a fax, when ask why resident was not transferred by ambulance instead of the geri-chair the DON replied there was not an order to call the ambulance. The DON did not reply when ask if an ambulance order was required. A message was left on 11/07/16 at 3:31 PM for the nurse practitioner, who was out of the office, to return a call to the investigator; a return call was received from the treating Nurse Practitioner on 11/08/16 at 8:05 AM, the Nurse Practitioner stated a fax was received that resident # 7 had sat down and the nurse practitioner stated the facility staff brought resident # 7 into the clinic in a geri-chair, the Nurse Practitioner said when resident # 7 was seen, resident # 7 ' s injury was apparent and resident # 7 was sent straight to the emergency room . In a telephone interview on 11/08/16 at 9:50 AM CNA K returned a call and said on the 21st the CNA could tell resident # 7 was hurting and ask CNA L why resident # 7 ' s meal tray was on the hall cart. Was told resident # 7 had not been wanting to walk. CNA K said when attempted to take resident # 7 to the bathroom, resident # 7 screamed and hollered. CNA K said she put resident # 7's legs back in the bed and reported to the DON who said she would check resident # 7. A little later the Administrator told her to put resident # 7 in the van geri-chair, CNA K said she told the Administrator would not without help. She then got help and carefully set resident #7 in the geri-chair and the van driver took resident # 7 to the doctor. The Administrator provided the following policy for incident/accident reporting: Record review of the undated facility incident/accident reporting for nurses ' policy documented: - an incident was any happening which is not consistent with the routine operation of the facility or the routine care of a particular resident. It is an event without evidence of an injury or a change. An accident is an event with visible injury or change in status. - Incidents/accidents that should be documented in both incident/accident report and nurses notes included (in part) fractures - confirmed or suspected bruises and other skin injuries, and falls with or without visible injury. The facility CMS 802 dated 11/07/16 documented 6 residents with a history of falls.

Based on observation, interview and record review, the facility failed to develop and implement their policies and procedures to prohibit neglect for 1 of 10 residents ( ID # 9) reviewed for neglect. The facility failed to ensure: A. staff were present and awake on the locked unit B. staff were aware of resident's DNR status and immediately initiated CPR and called 911 for resident ID # 9 who was a full code; On [DATE] at 2:20 AM, upon entry into the facility charge nurse LVN A (the only licensed person in the facility) and CNA D (the only staff assigned to the locked unit) were asleep in the front lobby. On [DATE] at 3:05 AM, during initial tour with CNA D, in the locked unit, resident ID # 9 was found unresponsive. The facility failed to immediately initiate CPR and call 911. CPR was not initiated, the first time until 3:10 AM and then again at 3:16 AM by the DON. At 3:24 AM, EMT arrived, took over and transferred resident ID # 9 to the hospital where he was pronounced deceased . These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE] at 1:35 PM. While the immediacy of the IJ was removed on [DATE] at 12:30 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This deficient practice could affect 17 residents in the facility by failing to honor their resuscitation choices. The findings included: Review of resident ID # 9's Admission Record, dated [DATE], documented he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. He resided on the locked unit of the facility. Review of resident ID # 9's Order Summary report dated [DATE] documented his code status as a full code, active on [DATE]. Record review of resident ID # 9's admission MDS assessment, dated [DATE] documented the following: his cognitive status was scored a 14, which indicates he was cognitively intact. He had no signs of [MEDICAL CONDITION], he was rated at 2 under the mood section, which indicates minimal depression and he was not scored for any behavior issues. In the area of functional status it documented he required one person physical assist in locomotion, dressing, toileting, hygiene and bathing, with supervision in all thoses areas except extensive assist with toileting. His range of motion was documented as impaired lower extremities both sides. This MDS documented he had a foley catheter and was continent of bowel. In the area of health conditions it documented he had shortness of breath or trouble breathing with exertion, when sitting at rest or when lying flat. It documented he was an obese man at 71 inches tall and weighed 264 pounds. Record review on [DATE] at 5:05 PM, plans of care documented no specific plan for resident ID # 9's Full Code status. In an observation on [DATE] at 2:20 AM, upon arrival to the facility, the front door was locked. Two staff were observed in overstuffed chairs in the front lobby. The chair closest was approximately 6 feet away from the front door. Only the back of the staffs head could be seem (later discovered it was CNA D, whom was assigned to the locked unit). The second chair was approximately 10 feet way from the front door. This chair had more of a side angle. There was a smaller, wooden chair in front of the overstuffed chair in which the staff (later discovered as LVN charge nurse A) had their feet propped up in, a pair of tennis shoes were on the floor to the right of the chair and the staff was completely covered up with a blanket, including their head. There was no movement from either of them for the seven minutes they were being observed. After the third knock on the front glass door, CNA D arose, unlocked the door, and let this surveyor in. LVN A did not arise until a conversation began between this surveyor and CNA D. As we approached the nurses's station, CNA C came from the south hall. CNA D and LVN A went behind the nurse's station. CNA C and this surveyor began initial tour on the north hall at 2:35 AM. When we finished the north hall and passed the nurse's station, toward the south hall at approximately 2:45 AM, CNA D remained seated behind the nurse's station with LVN A. In an interview on [DATE] at 2:45 AM, CNA D stated she was the only aide assigned to the locked unit that evening. She stated the staff rotate the assignment. LVN A stated she was the only charge nurse on for the evening. In an observation on [DATE] at 2:50 AM, while doing initial rounds with CNA C on the south, the last room on the right, the resident in that room was found on the floor. CNA C pulled the call light and both LVN A and CNA D came down the hall, together, from the nurses's station to assist CNA C with the resident. In an observation on [DATE] at 3:00 AM, CNA D was still at the nurse's station. CNA D and this surveyor began the initial tour on the locked unit. Upon entering the second room of the tour (3:05 AM) there were 2 male residents in the room. Resident ID # 9 was in bed B, closest to the window. He was naked and the sheet was gathered between the left side of his body and the wall. The head of his bed was raised to approximately 30 degrees. He had a Foley catheter in place and hanging on the bed railing with a scant amount of dark red urine in the bag. His nasal cannula was not in his nose but was laying across his chin. His right arm was hanging off the bed and his fingers to that hand were cyanotic (bluish discoloration of the skin and mucous membranes due to not enough oxygen in the blood (MedicineNet.com)), his face was gray in color and the rest of his body showing, was pale. There were no visible signs of respirations. His cell phone was on the floor, right below his arm. He was an obese man, (per MDS admission assessment dated [DATE] he was 71 inches tall and weighed 264 pounds). As CNA turned to leave this surveyor asked if resident ID # 9 was breathing. She returned and looked at him and then stated I don't think he is. She pulled the call light once and began to shake him and call his name. LVN A entered the room and CNA D stated she didn't think the resident was breathing. LVN A stated What. The LVN shook him and called his name. They then began discussing what to do next. At 3:07 AM this surveyor asked LVN A if she was going to do anything , if she had/was going to call an ambulance, if he was a DNR (do not resuscitate) or if she was going to start CPR. They both left the room and went to the front desk, arguing about whether or not resident # 9 was a DNR. CNA D stated he wasn't and LVN A stated he was. After looking at a sheet of paper hanging between the computers at the nurses's station they decided he was a full code. At 3:10 AM, LVN A gathered the AED (automated external defibrillator: a lightweight, portable device that delivers an electronic shock through the chest to the heart (American Heart Association)) and began to place the AED pads on resident ID # 9. The AED stated shock not advised, start CPR (cardiopulmonary resuscitation). LVN A began chest compression but did not give any breathes, as the AED indicated to do. Resident ID # 9 was not on a stable surface (backboard) so his body would sink into the bed and back up with every compression given. At 3:13 AM, LVN A removed the AED pads, did a few more chest compressions then stopped and covered him partially with the sheet. She stated I don't know what to do. At 3:15 AM she stated I've called my DON twice. At 3:16 AM, the DON arrived, walked behind the nurse's station removed a white binder from the desk, looked at it and went to resident ID # 9's room. She reapplied the AED pads and again the AED responded with shock not advised, continue CPR. She began chest compressions, did not give breathes per AED recommendations, but did place an oxygen face mask over the resident's nose and mouth. She lowered the head of the bed. LVN A began doing chest compressions and the DON did administer breathes at the next 2 cycles. At 3:20 AM, the AED again stated that shock was not advised and to continue CPR. They waited several more seconds then LVN A started chest compressions again. EMT arrived at 3:24 AM and took over. EMT asked how long he had been unresponsive. DON stated the staff had checked on him around 1:45 AM as he had asked to be helped re-positioning himself and he was fine then, per LVN A. EMT asked if they knew how long he had been in this condition and LVN A stated no. EMT left the building with resident ID # 9 at 3:32 AM. In an interview on [DATE] at 3:40 AM, the DON stated the DNR information is in a white folder kept at the nurse's station. LVN A had told DON she thought it was another resident with the same first name and had gotten them confused as to which one was the DNR. In an interview on [DATE] at 4:00 AM, CNA D stated she had performed her last round (on the locked unit) around 1 AM and then resident ID # 9 pulled his call light. She stated she thought it was about 1:30 AM but LVN A said it was closer to 1:45 AM, and that he had asked to be helped with re-positioning. She stated she would have moved a lot faster to see if resident ID # 9 was a DNR or not. She stated the DNR binder is behind the nurse's station and there is a paper hanging on the nurse's station, between the computers that tells who is a DNR. She stated they were not suppose to sleep on the job but that she had dozed off. She stated she did not know how many times this surveyor knocked on the door, she only heard one knock. In an interview on [DATE] at 4:20 AM, LVN A stated she would have been quicker to begin CPR but thought resident ID # 9 was a DNR. She stated she had called 911 but had got dead air. She stated 911 was local and that 911 called her back and she requested an ambulance then. She stated she had called the DON twice and the first time she didn't answer. She stated we don't sleep on the job, there is no excuse for that. LVN A stated she had taken some medication for a migraine headache and had covered up her head because the light hurt her eyes. She adamantly denied being asleep. She stated she did not hear this surveyor knock and did not know how many times this surveyor had knocked. In an interview on [DATE] at 4:30 AM, The ADON stated staff should not be sleeping on the job and can lose their job for that. She stated it's only eight hours, they should be able to stay awake. She stated she expected the staff, during a code, to get the AED, start CPR, call for help and check to see if the resident is a DNR. She stated the notebook that has that information is kept at the nurses's station. She stated she did not know how many people in the building knew CPR. She then stated the backboard is at the nurse's station, under the desk and all staff should know where that's at. The ADON stated a staff member should be on the locked unit at all times and should report to the charge nurse if not. She stated she did not/has not ever come out after hours to check on the staff/residents and doesn't think anyone else has either. In an interview on [DATE] at 4:55 AM, the DON stated LVN A had called her earlier to tell her a surveyor was in the building. She stated she (LVN A) texted her the second time to tell her to come to the facility but she was already in route. She stated the front door was locked. The DON stated upon arrival she was informed resident ID # 9 had no respirations. She stated she pulled the DNR book and he was a full code. She stated the resident was cyanotic and had no respirations. She stated she applied the AED and followed it's instructions. She stated the staff should know the policy to pull the call light three times or to call out for help. She stated the staff had just had an in-service for the use of the AED by their medical director with in the last few months. She stated the backboard should have been used with resident ID # 9. She stated staff should not be sleeping on the job. She also stated someone should be on the locked unit at all times. The DON stated the front door had been kept locked from the inside, for the last few years. In an interview on [DATE] at 5:25 AM, the Administrator stated the staff are aware of not sleeping on the job, that it's in their policy. He stated there should always be someone on the locked unit. The administrator stated sometimes the staff might have to leave to get supplies or use the restroom but they should be notifying someone and getting relief. When this surveyor suggested that the CNA was off of the locked unit from about 1:45 AM until she and I started rounds back there at 3:00 AM, he stated it sure does appear like that. He stated as far as the code goes, those are things the staff already know but will be in-serviced again today. He stated all the licensed staff (nurses) in the facility were CPR certified and there was a licensed individual in the building at all times. He stated he did not have a policy on staff needing to remain on the locked unit at all times. The DON was present during this interview and she stated they had pronounced resident ID # 9 deceased upon arrival to the hospital. In an interview on [DATE] at 11:50 AM, the BOM stated there was no advanced directive for resident ID # 9. She stated she had been in phone contact with the residents mother who was planning on being present during the admission process, but was not. The BOM told residents mother she would mail the admission packet to her, which she stated she did, and the mother could return it when completed. She stated the advanced directive is part of the packet. She stated she never received the packet from the mother. The BOM stated their practice is if they have nothing in writing directing us then the resident is considered a full code. Record review on [DATE] of the facility's Policy on Advance Directives, not dated, documented (in part): If a resident don't have a DNR which means they wish to be resuscitated, in the event that a resident stopped breathing, EMS will be activated. Physician is informed. Cardiopulmonary resuscitative measures will be initiated if indicated per nursing judgment until the arrival of EMS. Record review on [DATE] of the facility's policy titled, Emergency Procedure, not dated, documented, (in part): 1) IN CASE OF EMERGENCY, PULL CALL LIGHT 3X-SIGNIFIES URGENCY OF SITUATION. NURSE & OTHER PERSONNEL IMMEDIATELY CHECKS THE RESIDENT. 2) DETERMINE RESIDENTS' ADVANCE DIRECTIVE STATUS. (ENCLOSED POLICY) IF DNR INDICATED BY GREEN STICKER ON THE CHART. A) FULL CODE RESIDENTS- IF FOUND WITH NO PULSE/NOT BREATHING-INDICATE CPR PER DISCRETION OF THE NURSE ON DUTY. BACKBOARD 7 RESPIRATORY BOX LOCATED IN THE NURSES STATION. EXTRA MOUTHPIECE LOCATED ON THE TOP DRAWER OF MED CART. CALL EMS (,[DATE]) & TAKES OVER OF THE CODE. Note: the facility no longer has hard charts with green stickers, they have converted to electronic charting. Record review on [DATE] of the facility's In-service/Instruction on Defibrillator Use dated [DATE] documented it was performed by the facility's medical director. It also documented, (in part) Policy & Procedure 1) Assess for [MEDICAL CONDITION] and [MEDICAL CONDITION] symptoms. If resident collapses and becomes unconscious or unresponsive, breathing stops or breathing abnormally, no pulse, use AED on Full Code Status residents. Use universal precautions. If in doubt, apply pads. 2) Call ,[DATE] IF NO SHOCK ADVISED- start CPR compressions until AED advises you to STOP. Continue to follow AED prompts and perform CPR until EMS take over. The in-service was signed by LVN A. Record review of the facility's policy Adult Protective Services Handout, dated [DATE] documented, (in part): Neglect is defined as the failure to provide for one's self the goods or services which are necessary to avoid physical harm, mental anguish, or mental illness, or the failure of a caretaker to provide such goods or services Record review of the facility's policies and Procedures Abuse, Neglect, Involuntary Seclusion or Misappropriation of Property, provided on [DATE] at 2:20 PM by the administrator documented, (in part): Prevention: Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. This includes analysis of: - The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, .those that require heavy nursing care and/or are totally dependant on staff. The administrator and DON were notified on [DATE] at 1:35 PM, of the IJ situation due to the above failures. In an interview on [DATE] at 1:40 PM, the administrator stated the DON comes up if need be or if called but doesn't just show up. He stated that would be changing. The facility submitted 3 plans of removal with the last being accepted on [DATE] at 12:30 PM. Action Plan with Systemic Changes for Complaint Investigation dated [DATE] Emergency procedures have been reviewed and updated for all nursing staff. In-service is being conducted for current staff and all on coming staff. Contents of in-service is as follows: EMERGENCY PROCEDURES 1) IN CASE OF AN EMERGENCY, PULL CALL LIGHT 3X AND LEAVE 3RD LIGHT ON-SIGNIFYING URGENCY OF SITUATION. IF UNABLE, CALL OUT FOR HELP. NURSE AND OTHER PERSONNEL IMMEDIATELY CHECKS THE RESIDENT. 2) DETERMINE RESIDENTS ADVANCE DIRECTIVE STATUS. DO NOT RESUSCITATE-CAN BE DETERMINED BY A RED BRACELET ON RESIDENTS WRIST AND/OR A RED DOOR STICKER ON RESIDENTS NAMETAG ON THEIR ROOM DOOR. ALSO A WHITE BINDER AT THE NURSES'S STATION CONTAINS THE DNR FORMS. PLACEMENT OF BRACELET AND DOOR STICKER CHECKED/VERIFIED EVERY SHIFT BY CHARGE NURSE. FULL CODE- IF FOUND WITH NO PULSE/NOT BREATHING-INITIATE CPR, GET AED AND FOLLOW INSTRUCTIONS. MAY APPLY BACKBOARD, CALL 911. EMS WILL TAKE OVER THE CODE UPON THEIR ARRIVAL. EXTRA MOUTHPIECE IS LOCATED ON THE TOP DRAWER OF THE MED CART. SHORTNESS OF BREATH/LABORED BREATHING-APPLY OXYGEN AT ,[DATE] L/MIN USING NON REBREATHER MASK. ID CONCENTRATOR IS USED, NASAL CANNULA OR MASK MAY BE USED AT 5L/MIN. CHECK VITAL SIGNS. INFORM DOCTOR. CONGESTION OR POOLING OD SECRETIONS- USE SUCTION 3) INFORM PHYSICIAN FOR FURTHER INSTRUCTIONS. INFORM FAMILY IF ANY, PRINT FACESHEET AND ORDERS. CHART. 4) OTHER PROCEDURES-CONVULSIONS, BURN, ETC. 5) SEE ALSO [MEDICATION NAME] MANEUVER, CPR PROCEDURES REMEMBER; ONE STAFF HAS TO STAY WITH RESIDENT AT ALL TIMES. NURSE CAN DELEGATE RESPONSIBILITIES TO OTHERS. INITIALS___KNOWS LOCATION OF OXYGEN & SUPPLIES (Lobby/Med room) _____ KNOWS LOCATION OF SUCTION & SUPPLIES (Med room) _____KNOWS LOCATION OF BACKBOARD (Front- Nurses Station) (Unit-Dining room) DNR procedures have been reviewed on [DATE] with the following changes: Red DNR bracelet placed on all residents with DNR status. ADON checked each resident's orders for DNR status and personally put bracelet on each corresponding resident along with a Red dot on the name plate and in the DNR book. This was completed on [DATE]. Red dot added to resident Door Nameplate for residents with DNR. Name tag is removable and will follow resident if a room change occurs. Added systemic change to the EMAR in which nurse will check once a shift for the placement of the red DNR bracelet. DNR binder at nurse's station updated with corresponding red dots. In-services started on [DATE] are being conducted on all nursing staff for emergency procedures. As of 4:30 pm, [DATE], 12 have been completed. All Nurses were in-serviced on [DATE] on the new code procedures including the DNR identification bands and red dots and where to find them for each resident. Nurse Aide In-services are being conducted to reinforce specific care issues. Nurse Aides are not allowed to begin shift until in-service completed. In-service began [DATE], 12 have been completed. The remainder employee in-services will be completed prior to returning to work. Initiated charge nurse tracking form on [DATE], to evaluate nurse aide competencies daily each shift. Tracking includes: Call light in reach Appropriately clothed Red DNR in place Incontinence check Turned (if applicable) Only one pad if needed Rounds q 2 hrs & PRN Secure unit aide in unit Staff not asleep on duty DON and ADON will verify Charge Nurse Tracking Form initiated on [DATE] for accuracy and completeness twice weekly. ADON and DON will twice weekly, in person, in house, will monitor ,[DATE] shift's work duties and performance. On [DATE], Administrator, immediately suspended charge nurse and unit nurse aide identified pending investigation results. Record review of the facility's inservice training with all staff and review of the changes in the facility's for Emergency Procedures was completed and found acceptable. On [DATE] at 12:30 PM, the Administrator and DON were notified that the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. In an interview on [DATE] at 2:30 PM, the Administrator stated he felt the IJ came about because the biggest problem was the nurse aide was up front and not on the locked unit and their procedure for the code, or the lack there of. he stated staff rotate their breaks. Nurses take their breaks on the facility property, they don't clock in and out for breaks. he stated if there are other licensed staff in the facility they can go and get something to eat, etc. He stated the staff clock in and out for their breaks and can leave the facility. At 2:40 PM, he corrected himself after looking at the aides time cards. He stated the aides on night shift do not leave the facility, they take their breaks in-house as well. During observations on [DATE], 13 residents were seen to have red bracelets to their wrists and red dots to the name plates outside of their doors. All had current physician orders [REDACTED]. During interviews on [DATE], 6 CNA's and 3 licensed nurse's could verbalize the new code status and voiced awareness of the significance of the red dots on the name plates and the red bracelets. In an interview on [DATE] at 9:15 AM, the DON stated there had been a hiccup and 4 of the residents requested the bracelets be cut off. She stated it wasn't because of what they signified but they didn't like the bracelets themselves, they were uncomfortable. She stated those bands had been affixed to the resident's headboards. Note: Upon entry of facility, no call lights were alarming, no residents were out of bed and per visual inspection, with personal flashlight, none of the incontinent residents appeared to be soiled and no foul odors were detected. Review of a copy of the document that was hanging in between the computers, presented by the DON on [DATE] at 11:50 AM, documented there were 44 residents in the facility and 19 of those residents were a full code.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for 1 of 10 (Resident #9) residents reviewed for neglect. The facility failed to ensure: A. staff were present and awake on the secure unit B. staff were aware of resident's DNR status and immediately initiated CPR and called 911 for resident ID # 9 who was a full code. On [DATE] at 2:20 AM, upon entry into the facility charge nurse LVN A( the only licensed staff on duty in the facility) and CNA D (the only assigned to the locked unit) appeared to be asleep in the front lobby. On [DATE] at 3:05 AM, during initial tour with CNA D, in the locked unit, resident ID # 9 was found unresponsive. The facility failed to immediately initiate CPR and call 911. CPR was not initiated, the first time until 3:10 AM and then again at 3:16 AM by the DON. At 3:24 AM, EMT arrived, took over and transferred resident ID # 9 to the hospital where he was pronounced deceased . These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy of the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This deficient practice could affect 19 residents in the facility by failing to honor their resuscitation choices. The findings included: Record review of the facility's policy MISSION STATEMENT, not dated, documented (in part): ABUSE,NEGLECT, INVOLUNTARY SECLUSION, OR MISAPPROPRIATION OF PROPERTY BRAZOS VALLEY CARE HOME will not tolerate any form of ABUSE, NEGLECT, . Any suspicion of any of those kinds of acts must be reported immediately to the Administrator so that an investigation can be initiated. Any allegation will be thoroughly investigated and the proper authorities will be contacted. Concerns should be reported to the DIRECTOR OF NURSING OR ADMINISTRATOR. In the absence of the DIRECTOR OF NURSING OR ADMINISTRATOR, concerns should be expressed to the charge nurse. Record review of the facility's policy Adult Protective Services Handout, dated [DATE] documented, (in part): Neglect is defined as the failure to provide for one's self the goods or services which are necessary to avoid physical harm, mental anguish, or mental illness, or the failure of a caretaker to provide such goods or services Record review of the facility's policy titled S.B.9 STATEMENT OF NURSING HOME POLICY AND EMPLOYEE ACKNOWLEDGEMENT, not dated, documented, (in part): In accordance with the letter and spirit of the law, Arlington Villa Nursing & retirement Community offers the following information to its employees concerning recently enacted known as Senate Bill 9, aimed at curbing abuses of out patients. 1. Any employee violating any rule and/or regualtion of the licensing agency that is determined to threaten thehealth and safety of a patient can be liable for a civil penalty of $100 to $500 for each violation; 2. Any employee is guilty of a Class A misdemenor (fine up to $1,000 and/or up to 180 days in jail) that knowingly faile to report a situation of patient abuse or neglect; 3. Any employee guilty of patient abuse or neglect that causes bodily injury to the patient is guilty of a felony of the third degree (fine up to $5,000 and or 2 to [AGE] years in the Texas Department of Corrections.) A complete copy of Senate Bill 9 is in the nursing home office for your inspection at any time, and we will answer any questions you may have. Remember our policy that all residents and patients of this nursing home are to be treated with dignity and respect at all times under all circumstances. Mistreatment or abuse of any nature will not be tolerated. Resident ID # 9 Review of resident ID # 9's Admission Record, dated [DATE], documented he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. He was being housed on the locked unit of the facility. Review of resident ID # 9's Order Summary report dated [DATE] documented his code status as a full code, active on [DATE]. It also documented oxygen per nasal cannula or face mask at 3 liters continuously. Record review of resident ID # 9's admission MDS assessment, dated [DATE] documented the following: his cognitive status was scored a 14, which indicates he was cognitively intact. He had no signs of [MEDICAL CONDITION], he was rated at 2 under the mood section, which indicates minimal depression and he was not scored for any behavior issues. In the area of functional status it documented he required one person physical assist in locomotion, dressing, toileting, hygiene and bathing, with supervision in all thoses areas except extensive assist with toileting. His range of motion was documented as impaired lower extremities both sides. This MDS documented he had a foley catheter and was continent of bowel. In the area of health conditions it documented he had shortness of breath or trouble breathing with exertion, when sitting at rest or when lying flat. It documented he was an obese man at 71 inches tall and weighed 264 pounds. Record review on [DATE] at 5:05 PM, plans of care documented no specific plan for resident ID # 9's Full Code status. In an observation on [DATE] at 2:20 AM, upon arrival to the facility, the front door was locked. Two staff were observed in overstuffed chairs in the front lobby. The chair closest was approximately 6 feet away from the front door. Only the back of the staffs head could be seen (later discovered it was CNA D, whom was assigned to the locked unit). The second chair was approximately 10 feet way from the front door. This chair had more of a side angle. There was a smaller, wooden chair in front of the overstuffed chair in which the staff (later discovered as LVN charge nurse A) had their feet propped up in, a pair of tennis shoes were on the floor to the right of the chair and the staff was completely covered up with a blanket, including their head. There was no movement from either of them for the seven minutes they were being observed. After the third knock on the front glass door, CNA D arose, unlocked the door, and let this surveyor in. LVN A did not arise until a conversation began between this surveyor and CNA D. As we approached the nurses's station, CNA C came from the south hall. CNA D and LVN A went behind the nurse's station. CNA C and this surveyor began initial tour on the north hall at 2:35 AM. When we finished the north hall and passed the nurse's station, toward the south hall at approximately 2:45 AM, CNA D remained seated behind the nurse's station with LVN A. In an interview on [DATE] at 2:45 AM, CNA D stated she was the only aide assigned to the locked unit that evening. She stated the staff rotate the assignment. LVN A stated she was the only charge nurse on for the evening. In an observation on [DATE] at 2:50 AM, while doing initial rounds with CNA C on the south,upon entering one of the last rooms, the resident in that room was found on the floor. CNA C pulled the call light and both LVN A and CNA D came down the hall, together, from the nurses's station to assist CNA C with the resident. In an observation on [DATE] at 3:00 AM, CNA D was still at the nurse's station. CNA D and this surveyor began the initial tour on the locked unit. Upon entering the second room of the tour (3:05 AM) there were 2 male residents in the room. Resident ID # 9 was in bed B, closest to the window. He was naked and the sheet was gathered between the left side of his body and the wall. The head of his bed was raised to approximately 30 degrees. He had a Foley catheter in place and hanging on the bed railing with a scant amount of dark red urine in the bag. His nasal cannula was not in his nose but was laying across his chin. His right arm was hanging off the bed and his fingers to that hand were cyanotic (bluish discoloration of the skin and mucous membranes due to not enough oxygen in the blood (MedicineNet.com)), his face was gray in color and the rest of his body showing, was pale. There were no visible signs of respirations. His cell phone was on the floor, right below his arm. As CNA turned to leave this surveyor asked if resident ID # 9 was breathing. She returned and looked at him and then stated I don't think he is. She pulled the call light once and began to shake him and call his name. LVN A entered the room and CNA D stated she didn't think the resident was breathing. LVN A stated What. The LVN shook him and called his name. They then began discussing what to do next. At 3:07 AM this surveyor asked LVN A if she was going to do anything , if she had/was going to call an ambulance, if he was a DNR (do not resuscitate) or if she was going to start CPR. LVN A and CNA D both left the room and went to the front desk, arguing about whether or not resident # 9 was a DNR. CNA D stated he wasn't and LVN A stated he was. After looking at a sheet of paper hanging between the computers at the nurses's station they decided he was a full code. At 3:10 AM, LVN A gathered the AED (automated external defibrillator: a lightweight, portable device that delivers an electronic shock through the chest to the heart (American Heart Association)) and began to place the AED pads on resident ID # 9. The AED stated shock not advised, start CPR (cardiopulmonary resuscitation). LVN A began chest compression but did not give any breaths, as the AED indicated to do. Resident ID # 9 was not on a stable surface (backboard) so his body would sink into the bed and back up with every compression given. At 3:13 AM, LVN A removed the AED pads, did a few more chest compressions then stopped and covered him partially with the sheet. She stated I don't know what to do. At 3:15 AM she stated I've called my DON twice. At 3:16 AM, the DON arrived, walked behind the nurse's station removed a white binder from the desk, looked at it and went to resident ID # 9's room. She reapplied the AED pads and again the AED responded with shock not advised, continue CPR. She began chest compressions, did not give breaths per AED recommendations, but did place an oxygen face mask over the resident's nose and mouth. She lowered the head of the bed. LVN A began doing chest compressions and the DON did administer breaths at the next 2 cycles. At 3:20 AM, the AED again stated that shock was not advised and to continue CPR. They waited several more seconds then LVN A started chest compressions again. EMT arrived at 3:24 AM and took over. EMT asked how long he had been unresponsive. DON stated the staff had checked on him around 1:45 AM as he had asked to be helped re-positioning himself and he was fine then, per LVN A. EMT asked if they knew how long he had been in this condition and LVN A stated no. EMT left the building with resident ID # 9 at 3:32 AM. In an interview on [DATE] at 3:40 AM, the DON stated the DNR information is in a white folder kept at the nurse's station. LVN A had told DON she thought it was another resident with the same first name and had gotten them confused as to which one was the DNR. In an interview on [DATE] at 4:00 AM, CNA D stated she had performed her last round (on the locked unit) around 1 AM and then resident ID # 9 pulled his call light. She stated she thought it was about 1:30 AM but LVN A said it was closer to 1:45 AM, and that he had asked to be helped with re-positioning. She stated she should have moved a lot faster to see if resident ID # 9 was a DNR or not. She stated the DNR binder is behind the nurse's station and there is a paper hanging on the nurse's station, between the computers that tells who is a DNR. She stated they were not suppose to sleep on the job but that she had dozed off. She stated she did not know how many times this surveyor knocked on the door, she only heard one knock. In an interview on [DATE] at 4:20 AM, LVN A stated she would have been quicker to begin CPR but thought resident ID # 9 was a DNR. She stated she had called the DON twice and the first time she didn't answer. She stated we don't sleep on the job, there is no excuse for that. LVN A stated she had taken some medication for a migraine headache and had covered up her head because the light hurt her eyes. She adamantly denied being asleep. She stated she did not hear this surveyor knock and did not know how many times this surveyor had knocked. In an interview on [DATE] at 4:30 AM, The ADON stated staff should not be sleeping on the job and can lose their job for that. She stated it's only eight hours, they should be able to stay awake. She stated she expected the staff, during a code, to get the AED, start CPR, call for help and check to see if the resident is a DNR. She stated the notebook that has that information is kept at the nurses's station. She stated she did not know how many people in the building knew CPR. She then stated the backboard is at the nurse's station, under the desk and all staff should know where that's at. The ADON stated a staff member should be on the locked unit at all times and should report to the charge nurse if not. She stated she did not/has not ever come out after hours to check on the staff/residents and doesn't think anyone else has either. In an interview on [DATE] at 4:55 AM, the DON stated LVN A had called her earlier to tell her a surveyor was in the building. She stated she (LVN A) texted her the second time to tell her to come to the facility but she was already in route. She stated the front door was locked. The DON stated upon arrival she was informed resident ID # 9 had no respirations. She stated she pulled the DNR book and he was a full code. She stated the resident was cyanotic and had no respirations. She stated she applied the AED and followed it's instructions. She stated the staff should know the policy to pull the call light three times or to call out for help. She stated the staff had just had an in-service for the use of the AED by their medical director within the last few months. She stated the backboard should have been used with resident ID # 9. She stated staff should not be sleeping on the job. She also stated someone should be on the locked unit at all times. The DON stated the front door had been kept locked from the inside, for the last few years. In an interview on [DATE] at 5:25 AM, the Administrator stated the staff are aware of not sleeping on the job, that it's in their policy. He stated there should always be someone on the locked unit. The administrator stated sometimes the staff might have to leave to get supplies or use the restroom but they should be notifying someone and getting relief. When this surveyor suggested that the CNA was off of the locked unit from about 1:45 AM until she and I started rounds back there at 3:00 AM, he stated it sure does appear like that. He stated as far as the code goes, those are things the staff already know but will be in-serviced again today. He stated all the licensed staff (nurses) in the facility were CPR certified and there was a licensed individual in the building at all times. He stated he did not have a written policy on staff needing to remain on the locked unit at all times. The DON was present during this interview and she stated resident ID # 9 had been pronounced deceased upon arrival to the hospital. In an interview on [DATE] at 11:50 AM, the BOM stated there was no advanced directive for resident ID # 9. She stated she had been in phone contact with the residents mother who was planning on being present during the admission process, but was not. The BOM told residents mother she would mail the admission packet to her, which she stated she did, and the mother could return it when completed. She stated the advanced directive is part of the packet. She stated she never received the packet from the mother. The BOM stated their practice is if they have nothing in writing directing them then the resident is considered a full code. In an interview on [DATE], the DON stated she was aware LVN A had stopped performing CPR and had removed the AED pads from resident ID # 9. She also agreed that she had replaced the AED pads and had re-initiated CPR. She stated she did not know what had happened with LVN A, maybe she was upset due to this surveyor catching her asleep, but it had surprised her (the DON) as LVN had worked previously in a hospital setting. Record review on [DATE] of the facility's Policy on Advance Directives , not dated, documented (in part): If a resident don't have a DNR which means they wish to be resuscitated, in the event that a resident stopped breathing, EMS will be activated. Physician is informed. Cardiopulmonary resuscitative measures will be initiated if indicated per nursing judgment until the arrival of EMS. Record review on [DATE] of the facility's policy titled, Emergency Procedure, not dated, documented, (in part): 1) IN CASE OF EMERGENCY, PULL CALL LIGHT 3X-SIGNIFIES URGENCY OF SITUATION. NURSE & OTHER PERSONNEL IMMEDIATELY CHECKS THE RESIDENT. 2) DETERMINE RESIDENTS' ADVANCE DIRECTIVE STATUS. (ENCLOSED POLICY) IF DNR INDICATED BY GREEN STICKER ON THE CHART. A) FULL CODE RESIDENTS- IF FOUND WITH NO PULSE/NOT BREATHING-INDICATE CPR PER DISCRETION OF THE NURSE ON DUTY. BACKBOARD & RESPIRATORY BOX LOCATED IN THE NURSES STATION. EXTRA MOUTHPIECE LOCATED ON THE TOP DRAWER OF MED CART. CALL EMS (,[DATE]) & TAKES OVER OF THE CODE. Note: the facility no longer has hard charts with green stickers, they have converted to electronic charting. Record review on [DATE] of the facility's In-service/Instruction on Defibrillator Use dated [DATE] documented it was performed by the facility's medical director. It also documented, (in part) Policy & Procedure 1) Assess for [MEDICAL CONDITION] and [MEDICAL CONDITION] symptoms. If resident collapses and becomes unconscious or unresponsive, breathing stops or breathing abnormally, no pulse, use AED on Full Code Status residents. Use universal precautions. If in doubt, apply pads. 2) Call ,[DATE] IF NO SHOCK ADVISED- start CPR compressions until AED advises you to STOP. Continue to follow AED prompts and perform CPR until EMS take over. The in-service was signed by LVN A. The administrator and DON were notified on [DATE] at 1:35 PM, of the IJ situation due to the above failures. In an interview on [DATE] at 1:40 PM, the administrator stated the DON comes up if need be or if called but doesn't just show up. He stated that would be changing. The facility submitted 3 plans of removal with the last being accepted on [DATE] at 12:30 PM. Action Plan with Systemic Changes for Complaint Investigation dated [DATE] Emergency procedures have been reviewed and updated for all nursing staff. In-service is being conducted for current staff and all on coming staff. Contents of in-service is as follows: EMERGENCY PROCEDURES 1) IN CASE OF AN EMERGENCY, PULL CALL LIGHT 3X AND LEAVE 3RD LIGHT ON-SIGNIFYING URGENCY OF SITUATION. IF UNABLE, CALL OUT FOR HELP. NURSE AND OTHER PERSONNEL IMMEDIATELY CHECKS THE RESIDENT. 2) DETERMINE RESIDENTS ADVANCE DIRECTIVE STATUS. DO NOT RESUSCITATE-CAN BE DETERMINED BY A RED BRACELET ON RESIDENTS WRIST AND/OR A RED DOOR STICKER ON RESIDENTS NAMETAG ON THEIR ROOM DOOR. ALSO A WHITE BINDER AT THE NURSES'S STATION CONTAINS THE DNR FORMS. PLACEMENT OF BRACELET AND DOOR STICKER CHECKED/VERIFIED EVERY SHIFT BY CHARGE NURSE. FULL CODE- IF FOUND WITH NO PULSE/NOT BREATHING-INITIATE CPR, GET AED AND FOLLOW INSTRUCTIONS. MAY APPLY BACKBOARD, CALL 911. EMS WILL TAKE OVER THE CODE UPON THEIR ARRIVAL. EXTRA MOUTHPIECE IS LOCATED ON THE TOP DRAWER OF THE MED CART. SHORTNESS OF BREATH/LABORED BREATHING-APPLY OXYGEN AT ,[DATE] L/MIN USING NON REBREATHER MASK. ID CONCENTRATOR IS USED, NASAL CANNULA OR MASK MAY BE USED AT 5L/MIN. CHECK VITAL SIGNS. INFORM DOCTOR. CONGESTION OR POOLING OD SECRETIONS- USE SUCTION 3) INFORM PHYSICIAN FOR FURTHER INSTRUCTIONS. INFORM FAMILY IF ANY, PRINT FACESHEET AND ORDERS. CHART. 4) OTHER PROCEDURES-CONVULSIONS, BURN, ETC. 5) SEE ALSO [MEDICATION NAME] MANEUVER, CPR PROCEDURES REMEMBER; ONE STAFF HAS TO STAY WITH RESIDENT AT ALL TIMES. NURSE CAN DELEGATE RESPONSIBILITIES TO OTHERS. INITIALS___KNOWS LOCATION OF OXYGEN & SUPPLIES (Lobby/Med room) _____ KNOWS LOCATION OF SUCTION & SUPPLIES (Med room) _____KNOWS LOCATION OF BACKBOARD (Front- Nurses Station) (Unit-Dining room) DNR procedures have been reviewed on [DATE] with the following changes: Red DNR bracelet placed on all residents with DNR status. ADON checked each resident's orders for DNR status and personally put bracelet on each corresponding resident along with a Red dot on the name plate and in the DNR book. This was completed on [DATE]. Red dot added to resident Door Nameplate for residents with DNR. Name tag is removable and will follow resident if a room change occurs. Added systemic change to the EMAR in which nurse will check once a shift for the placement of the red DNR bracelet. DNR binder at nurse's station updated with corresponding red dots. In-services started on [DATE] are being conducted on all nursing staff for emergency procedures. As of 4:30 pm, [DATE], 12 have been completed. All Nurses were in-serviced on [DATE] on the new code procedures including the DNR identification bands and red dots and where to find them for each resident. Nurse Aide In-services are being conducted to reinforce specific care issues. Nurse Aides are not allowed to begin shift until in-service completed. In-service began [DATE], 12 have been completed. The remainder employee in-services will be completed prior to returning to work. Initiated charge nurse tracking form on [DATE], to evaluate nurse aide competencies daily each shift. Tracking includes: Call light in reach Appropriately clothed Red DNR in place Incontinence check Turned (if applicable) Only one pad if needed Rounds q 2 hrs & PRN Secure unit aide in unit Staff not asleep on duty DON and ADON will verify Charge Nurse Tracking Form initiated on [DATE] for accuracy and completeness twice weekly. ADON and DON will twice weekly, in person, in house, will monitor ,[DATE] shift's work duties and performance. On [DATE], Administrator, immediately suspended charge nurse and unit nurse aide identified pending investigation results. Verification of Plan of Removal Record review of the facility's inservice training with all staff and review of the changes in the facility's for Emergency Procedures was completed on [DATE]. In an interview on [DATE] at 2:30 PM, the Administrator stated he felt the IJ came about because the biggest problem was the nurse aide was up front and not on the locked unit and their procedure for the code, or the lack there of. He stated staff rotate their breaks. Nurses take their breaks on the facility property, they don't clock in and out for breaks. He stated if there are other licensed staff in the facility they can go and get something to eat, etc. He stated the staff clock in and out for their breaks and can leave the facility. At 2:40 PM, he corrected himself after looking at the aides time cards. He stated the aides on night shift do not leave the facility, they take their breaks in-house as well. During observations on [DATE], 13 residents were seen to have red bracelets to their wrists and red dots to the name plates outside of their doors. All had current physician orders [REDACTED]. During interviews on [DATE], 6 CNA's and 3 licensed nurse's could verbalize the new code status and voiced awareness of the significance of the red dots on the name plates and the red bracelets. In an interview on [DATE] at 9:15 AM, the DON stated there had been a hiccup and 4 of the residents requested the bracelets be cut off. She stated it wasn't because of what they signified but they didn't like the bracelets themselves, they were uncomfortable. She stated those bands had been affixed to the resident's headboards. On [DATE] at 12:30 PM, the Administrator and DON were notified that the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm and a scope of isolated; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Record review of the facility's policies and Procedures Abuse, Neglect, Involuntary Seclusion or Misappropriation of Property, provided on [DATE] at 2:20 PM by the administrator documented, (in part): Prevention: Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. This includes analysis of: - The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, .those that require heavy nursing care and/or are totally dependant on staff. Note: Upon entry of facility, no call lights were alarming, no residents were out of bed and per visual inspection, with personal flashlight, none of the incontinent residents appeared to be soiled and no foul odors were detected. Review of a copy of the document that was hanging in between the computers, presented by the DON on [DATE] at 11:50 AM, documented there were 44 residents in the facility and 19 of those residents were a full code.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain the highest level of practicable physical care, in accordance with their comprehensive assessment for 1 (resident ID # 9) of 10 residents reviewed for quality of care. On [DATE] at 2:20 AM, upon entry into the facility charge nurse LVN A(only licensed staff in the facility) and CNA D (only staff assigned to the locked unit) were asleep in the front lobby. On [DATE] at 3:05 AM, during initial tour with CNA D, in the locked unit, resident ID # 9 was found unresponsive. The facility failed to immediately initiate CPR and call 911. CPR was not initiated, the first time until 3:10 AM and then again at 3:16 AM by the DON. At 3:24 AM, EMT arrived, took over and transferred resident ID # 9 to the hospital where he was pronounced deceased . These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy of the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This deficient practice could affect 19 residents in the facility by failing to honor their resuscitation choices. The findings included: Resident ID # 9 Review of resident ID # 9's Admission Record, dated [DATE], documented he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. He resided on the locked unit of the facility. Review of resident ID # 9's Order Summary report dated [DATE] documented his code status as a full code, active on [DATE]. It also documented oxygen per nasal cannula or face mask at 3 liters continuously. Record review of resident ID # 9's admission MDS assessment, dated [DATE] documented the following: his cognitive status was scored a 14, which indicates he was cognitively intact. He had no signs of [MEDICAL CONDITION], he was rated at 2 under the mood section, which indicates minimal depression and he was not scored for any behavior issues. In the area of functional status it documented he required one person physical assist in locomotion, dressing, toileting, hygiene and bathing, with supervision in all thoses areas except extensive assist with toileting. His range of motion was documented as impaired lower extremities both sides. This MDS documented he had a foley catheter and was continent of bowel. In the area of health conditions it documented he had shortness of breath or trouble breathing with exertion, when sitting at rest or when lying flat. It documented he was an obese man at 71 inches tall and weighed 264 pounds. Record review on [DATE] at 5:05 PM, plans of care documented no specific plan for resident ID # 9's Full Code status. In an observation on [DATE] at 2:20 AM, upon arrival to the facility, the front door was locked. Two staff were observed in overstuffed chairs in the front lobby. The chair closest was approximately 6 feet away from the front door. Only the back of the staffs head could be seen (later discovered it was CNA D, whom was assigned to the locked unit). The second chair was approximately 10 feet way from the front door. This chair had more of a side angle. There was a smaller, wooden chair in front of the overstuffed chair in which the staff (later identified as LVN charge nurse A) had their feet propped up in, a pair of tennis shoes were on the floor to the right of the chair and the staff was completely covered up with a blanket, including their head. There was no movement from either of them for the seven minutes they were being observed. After the third knock on the front glass door, CNA D arose, unlocked the door, and let this surveyor in. LVN A did not arise until a conversation began between this surveyor and CNA D. As we approached the nurses's station, CNA C came from the south hall. CNA D and LVN A went behind the nurse's station. CNA C and this surveyor began initial tour on the north hall at 2:35 AM. When we finished the north hall and passed the nurse's station, toward the south hall at approximately 2:45 AM, CNA D remained seated behind the nurse's station with LVN A. In an interview on [DATE] at 2:45 AM, CNA D stated she was the only aide assigned to the locked unit that evening. She stated the staff rotate the assignment. LVN A stated she was the only charge nurse on for the evening. In an observation on [DATE] at 2:50 AM, while doing initial rounds with CNA C on the south hall, upon entering one of the last rooms, the resident in that room was found on the floor. CNA C pulled the call light and both LVN A and CNA D came down the hall, together, from the nurses's station to assist CNA C with the resident. In an observation on [DATE] at 3:00 AM, CNA D was still at the nurse's station. CNA D and this surveyor began the initial tour on the locked unit. Upon entering the second room of the tour (3:05 AM) there were 2 male residents in the room. Resident ID # 9 was in bed B, closest to the window. He was naked and the sheet was gathered between the left side of his body and the wall. The head of his bed was raised to approximately 30 degrees. He had a Foley catheter in place and hanging on the bed railing with a scant amount of dark red urine in the bag. His nasal cannula was not in his nose but was laying across his chin. His right arm was hanging off the bed and his fingers to that hand were cyanotic (bluish discoloration of the skin and mucous membranes due to not enough oxygen in the blood (MedicineNet.com), his face was gray in color and the rest of his body showing, was pale. There were no visible signs of respirations. His cell phone was on the floor, right below his arm. As CNA turned to leave this surveyor asked if resident ID # 9 was breathing. She returned and looked at him and then stated I don't think he is. She pulled the call light once and began to shake him and call his name. LVN A entered the room and CNA D stated she didn't think the resident was breathing. LVN A stated What. The LVN shook him and called his name. They then began discussing what to do next. At 3:07 AM this surveyor asked LVN A if she was going to do anything , if she had/was going to call an ambulance, if he was a DNR (do not resuscitate) or if she was going to start CPR. LVN A and CNA D left the room and went to the front desk, arguing about whether or not resident # 9 was a DNR. CNA D stated he wasn't and LVN A stated he was. After looking at a sheet of paper hanging between the computers at the nurses's station they decided he was a full code. At 3:10 AM, LVN A gathered the AED (automated external defibrillator: a lightweight, portable device that delivers an electronic shock through the chest to the heart (American Heart Association)) and began to place the AED pads on resident ID # 9. The AED stated shock not advised, start CPR (cardiopulmonary resuscitation). LVN A began chest compression but did not give any breaths, as the AED indicated to do. Resident ID # 9 was not on a stable surface (backboard) so his body would sink into the bed and back up with every compression given. At 3:13 AM, LVN A removed the AED pads, did a few more chest compressions then stopped and covered him partially with the sheet. She stated I don't know what to do. At 3:15 AM she stated I've called my DON twice. At 3:16 AM, the DON arrived, walked behind the nurse's station removed a white binder from the desk, looked at it and went to resident ID # 9's room. She reapplied the AED pads and again the AED responded with shock not advised, continue CPR. She began chest compressions, did not give breaths per AED recommendations, but did place an oxygen face mask over the resident's nose and mouth. She lowered the head of the bed. LVN A began doing chest compressions and the DON did administer breaths at the next 2 cycles. At 3:20 AM, the AED again stated that shock was not advised and to continue CPR. They waited several more seconds then LVN A started chest compressions again. EMT arrived at 3:24 AM and took over. EMT asked how long he had been unresponsive. DON stated the staff had checked on him around 1:45 AM as he had asked to be helped re-positioning himself and he was fine then, per LVN A. EMT asked if they knew how long he had been in this condition and LVN A stated no. EMT left the building with resident ID # 9 at 3:32 AM. In an interview on [DATE] at 3:40 AM, the DON stated the DNR information is in a white folder kept at the nurse's station. LVN A had told the DON she thought it was another resident with the same first name and had gotten them confused as to which one was the DNR. In an interview on [DATE] at 4:00 AM, CNA D stated she had performed her last round (on the locked unit) around 1 AM and then resident ID # 9 pulled his call light. She stated she thought it was about 1:30 AM but LVN A said it was closer to 1:45 AM, and that he had asked to be helped with re-positioning. She stated she should have moved a lot faster to see if resident ID # 9 was a DNR or not. She stated the DNR binder is behind the nurse's station and there is a paper hanging on the nurse's station, between the computers that tells who is a DNR. She stated they were not supposed to sleep on the job but that she had dozed off. She stated she did not know how many times this surveyor knocked on the door, she only heard one knock. In an interview on [DATE] at 4:20 AM, LVN A stated she should have been quicker to begin CPR but thought resident ID # 9 was a DNR. She stated she had called the DON twice and the first time she didn't answer. She stated we don't sleep on the job, there is no excuse for that. LVN A stated she had taken some medication for a migraine headache and had covered up her head because the light hurt her eyes. She adamantly denied being asleep. She stated she did not hear this surveyor knock and did not know how many times this surveyor had knocked. In an interview on [DATE] at 4:30 AM, The ADON stated staff should not be sleeping on the job and can lose their job for that. She stated it's only eight hours, they should be able to stay awake. She stated she expected the staff, during a code, to get the AED, start CPR, call for help and check to see if the resident is a DNR. She stated the notebook that has that information is kept at the nurses's station. She stated she did not know how many people in the building knew CPR. She then stated the backboard is at the nurse's station, under the desk and all staff should know where that's at. The ADON stated a staff member should be on the locked unit at all times and should report to the charge nurse if not. She stated she did not/has not ever come out after hours to check on the staff/residents and doesn't think anyone else has either. In an interview on [DATE] at 4:55 AM, the DON stated LVN A had called her earlier to tell her a surveyor was in the building. She stated she (LVN A) texted her the second time to tell her to come to the facility but she was already in route. She stated the front door was locked. The DON stated upon arrival she was informed resident ID # 9 had no respirations. She stated she pulled the DNR book and he was a full code. She stated the resident was cyanotic and had no respirations. She stated she applied the AED and followed it's instructions. She stated the staff should know the policy to pull the call light three times or to call out for help. She stated the staff had just had an in-service for the use of the AED by their medical director within the last few months. She stated the backboard should have been used with resident ID # 9. She stated staff should not be sleeping on the job. She also stated someone should be on the locked unit at all times. The DON stated the front door had been kept locked from the inside, for the last few years. In an interview on [DATE] at 5:25 AM, the Administrator stated the staff are aware of not sleeping on the job, that it's in their policy. He stated there should always be someone on the locked unit. The administrator stated sometimes the staff might have to leave to get supplies or use the restroom but they should be notifying someone and getting relief. When this surveyor suggested that the CNA was off of the locked unit from about 1:45 AM until she and I started rounds back there at 3:00 AM, he stated it sure does appear like that. He stated as far as the code goes, those are things the staff already know but will be in-serviced again today. He stated all the licensed staff (nurses) in the facility were CPR certified and there was a licensed individual in the building at all times. He stated he did not have a written policy on staff needing to remain on the locked unit at all times. The DON was present during this interview and she stated resident ID # 9 had been pronounced deceased upon arrival to the hospital. In an interview on [DATE] at 11:50 AM, the BOM stated there was no advanced directive for resident ID # 9. She stated she had been in phone contact with the residents mother who was planning on being present during the admission process, but was not. The BOM told residents mother she would mail the admission packet to her, which she stated she did, and the mother could return it when completed. She stated the advanced directive is part of the packet. She stated she never received the packet from the mother. The BOM stated their practice is if they have nothing in writing directing us then the resident is considered a full code. In an interview on [DATE], the DON stated she was aware LVN A had stopped performing CPR and had removed the AED pads from resident ID # 9. She also agreed that she had replaced the AED pads and had re-initiated CPR. She stated she did not know what had happened with LVN A, maybe she was upset due to this surveyor catching her asleep, but it had surprised her (the DON) as LVN A had worked previously in a hospital setting. Record review on [DATE] of the facility's Policy on Advance Directives , not dated, documented (in part): If a resident don't have a DNR which means they wish to be resuscitated, in the event that a resident stopped breathing, EMS will be activated. Physician is informed. Cardiopulmonary resuscitative measures will be initiated if indicated per nursing judgment until the arrival of EMS. Record review on [DATE] of the facility's policy titled, Emergency Procedure, not dated, documented, (in part): 1) IN CASE OF EMERGENCY, PULL CALL LIGHT 3X-SIGNIFIES URGENCY OF SITUATION. NURSE & OTHER PERSONNEL IMMEDIATELY CHECKS THE RESIDENT. 2) DETERMINE RESIDENTS' ADVANCE DIRECTIVE STATUS. (ENCLOSED POLICY) IF DNR INDICATED BY GREEN STICKER ON THE CHART. A) FULL CODE RESIDENTS- IF FOUND WITH NO PULSE/NOT BREATHING-INDICATE CPR PER DISCRETION OF THE NURSE ON DUTY. BACKBOARD & RESPIRATORY BOX LOCATED IN THE NURSES STATION. EXTRA MOUTHPIECE LOCATED ON THE TOP DRAWER OF MED CART. CALL EMS (,[DATE]) & TAKES OVER OF THE CODE. Note: the facility no longer has hard charts with green stickers, they have converted to electronic charting. Record review on [DATE] of the facility's In-service/Instruction on Defibrillator Use dated [DATE] documented it was performed by the facility's medical director. It also documented, (in part) Policy & Procedure 1) Assess for [MEDICAL CONDITION] and [MEDICAL CONDITION] symptoms. If resident collapses and becomes unconscious or unresponsive, breathing stops or breathing abnormally, no pulse, use AED on Full Code Status residents. Use universal precautions. If in doubt, apply pads. 2) Call ,[DATE] IF NO SHOCK ADVISED- start CPR compressions until AED advises you to STOP. Continue to follow AED prompts and perform CPR until EMS take over. The in-service was signed by LVN A. The administrator and DON were notified on [DATE] at 1:35 PM, of the IJ situation due to the above failures. In an interview on [DATE] at 1:40 PM, the administrator stated the DON comes up if need be or if called but doesn't just show up to monitor the night shift. He stated that would be changing. The facility submitted 3 plans of removal with the last being accepted on [DATE] at 12:30 PM. Action Plan with Systemic Changes for Complaint Investigation dated [DATE] Emergency procedures have been reviewed and updated for all nursing staff. In-service is being conducted for current staff and all on coming staff. Contents of in-service is as follows: EMERGENCY PROCEDURES 1) IN CASE OF AN EMERGENCY, PULL CALL LIGHT 3X AND LEAVE 3RD LIGHT ON-SIGNIFYING URGENCY OF SITUATION. IF UNABLE, CALL OUT FOR HELP. NURSE AND OTHER PERSONNEL IMMEDIATELY CHECKS THE RESIDENT. 2) DETERMINE RESIDENTS ADVANCE DIRECTIVE STATUS. DO NOT RESUSCITATE-CAN BE DETERMINED BY A RED BRACELET ON RESIDENTS WRIST AND/OR A RED DOOR STICKER ON RESIDENTS NAMETAG ON THEIR ROOM DOOR. ALSO A WHITE BINDER AT THE NURSES'S STATION CONTAINS THE DNR FORMS. PLACEMENT OF BRACELET AND DOOR STICKER CHECKED/VERIFIED EVERY SHIFT BY CHARGE NURSE. FULL CODE- IF FOUND WITH NO PULSE/NOT BREATHING-INITIATE CPR, GET AED AND FOLLOW INSTRUCTIONS. MAY APPLY BACKBOARD, CALL 911. EMS WILL TAKE OVER THE CODE UPON THEIR ARRIVAL. EXTRA MOUTHPIECE IS LOCATED ON THE TOP DRAWER OF THE MED CART. SHORTNESS OF BREATH/LABORED BREATHING-APPLY OXYGEN AT ,[DATE] L/MIN USING NON REBREATHER MASK. ID CONCENTRATOR IS USED, NASAL CANNULA OR MASK MAY BE USED AT 5L/MIN. CHECK VITAL SIGNS. INFORM DOCTOR. CONGESTION OR POOLING OD SECRETIONS- USE SUCTION 3) INFORM PHYSICIAN FOR FURTHER INSTRUCTIONS. INFORM FAMILY IF ANY, PRINT FACESHEET AND ORDERS. CHART. 4) OTHER PROCEDURES-CONVULSIONS, BURN, ETC. 5) SEE ALSO [MEDICATION NAME] MANEUVER, CPR PROCEDURES REMEMBER; ONE STAFF HAS TO STAY WITH RESIDENT AT ALL TIMES. NURSE CAN DELEGATE RESPONSIBILITIES TO OTHERS. INITIALS___KNOWS LOCATION OF OXYGEN & SUPPLIES (Lobby/Med room) _____ KNOWS LOCATION OF SUCTION & SUPPLIES (Med room) _____KNOWS LOCATION OF BACKBOARD (Front- Nurses Station) (Unit-Dining room) DNR procedures have been reviewed on [DATE] with the following changes: Red DNR bracelet placed on all residents with DNR status. ADON checked each resident's orders for DNR status and personally put bracelet on each corresponding resident along with a Red dot on the name plate and in the DNR book. This was completed on [DATE]. Red dot added to resident Door Nameplate for residents with DNR. Name tag is removable and will follow resident if a room change occurs. Added systemic change to the EMAR in which nurse will check once a shift for the placement of the red DNR bracelet. DNR binder at nurse's station updated with corresponding red dots. In-services started on [DATE] are being conducted on all nursing staff for emergency procedures. As of 4:30 pm, [DATE], 12 have been completed. All Nurses were in-serviced on [DATE] on the new code procedures including the DNR identification bands and red dots and where to find them for each resident. Nurse Aide In-services are being conducted to reinforce specific care issues. Nurse Aides are not allowed to begin shift until in-service completed. In-service began [DATE], 12 have been completed. The remainder employee in-services will be completed prior to returning to work. Initiated charge nurse tracking form on [DATE], to evaluate nurse aide competencies daily each shift. Tracking includes: Call light in reach Appropriately clothed Red DNR in place Incontinence check Turned (if applicable) Only one pad if needed Rounds q 2 hrs & PRN Secure unit aide in unit Staff not asleep on duty DON and ADON will verify Charge Nurse Tracking Form initiated on [DATE] for accuracy and completeness twice weekly. ADON and DON will twice weekly, in person, in house, will monitor ,[DATE] shift's work duties and performance. On [DATE], Administrator, immediately suspended charge nurse and unit nurse aide identified pending investigation results. Verification of Plan of Removal Record review of the facility's inservice training with all staff and review of the changes in the facility's for Emergency Procedures was completed on [DATE]. In an interview on [DATE] at 2:30 PM, the Administrator stated he felt the IJ came about because the biggest problem was the nurse aide was up front and not on the locked unit and their procedure for the code, or the lack there of. He stated staff rotate their breaks. Nurses take their breaks on the facility property, they don't clock in and out for breaks. He stated if there are other licensed staff in the facility they can go and get something to eat, etc. He stated the staff clock in and out for their breaks and can leave the facility. At 2:40 PM, he corrected himself after looking at the aides time cards. He stated the aides on night shift do not leave the facility, they take their breaks in-house as well. During observations on [DATE], 13 residents were seen to have red bracelets to their wrists and red dots to the name plates outside of their doors. All had current physician orders [REDACTED]. During interviews on [DATE], 6 CNA's and 3 licensed nurse's could verbalize the new code status and voiced awareness of the significance of the red dots on the name plates and the red bracelets. In an interview on [DATE] at 9:15 AM, the DON stated there had been a hiccup and 4 of the residents requested the bracelets be cut off. She stated it wasn't because of what they signified but they didn't like the bracelets themselves, they were uncomfortable. She stated those bands had been affixed to the resident's headboards. On [DATE] at 12:30 PM, the Administrator and DON were notified that the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm and a scope of isolated; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Review of a copy of the document that was hanging in between the computers, presented by the DON on [DATE] at 11:50 AM, documented there were 44 residents in the facility and 19 of those residents were a full code.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 2 residents (ID #s 8 and 9) having finger-stick blood sugars taken by failing to ensure: A. 1 of 1 LVNs performing glucose testing (LVN A) used one-time lancet devices and prevented the possible cross-contamination of blood-borne disease when performing finger-stick glucose testing for resident ID #s 8 and 9. Finger-stick devices (lancing pen devices) touch the skin and come in close proximity to blood with every use. Even if the lancet itself is changed between each use, there is potential for blood to contaminate the pen device. Blood-borne pathogens such as Hepatitis B, Hepatitis C, and HIV could potentially be transmitted from one person to another. On 07/31/2012, LVN A used a lancet pen device labeled for single person use only to obtain a finger-stick blood sample from resident ID #8. LVN A then used the same lancet device to obtain a finger-stick blood sample from resident ID #9. The device did not prevent the cross-contamination of blood and placed resident ID #s 8 and 9 at risk of contracting a blood-borne disease or infection. An immediate jeopardy (IJ) situation was identified on 07/31/2012. The IJ was removed on 07/31/2012; however, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm at a scope of a pattern because the facility had not yet monitored their plan of action for effectiveness. This deficient practice could place seven residents with orders for finger-stick blood sugars at risk of contracting a blood-borne disease and cause a physical decline in health. Non-IJ findings: Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 1 residents (ID #4) receiving incontinent care, 11 residents residing on the South hall, and all of the residents in the facility by failing to ensure: B. 2 of 2 CNAs performing incontinent care (CNA E and F) removed/changed her gloves after a dirty procedure and before a clean procedure while providing incontinent care to resident ID#4; C. the South hall clean linen cart was not stored in resident's room during initial tour; D. the facility was trending infections by location and organism as part of their infection control monitoring program. This deficient practice could place 17 residents who were incontinent of bladder, 9 residents who were incontinent of bowel, 11 residents who were on the South hall, or the census of 43 at risk of infection and cause a physical decline in health. The findings included: IJ findings: A. Resident ID #8 A record review of resident ID #8's July 2012 physician's orders [REDACTED]. Resident ID #8 had an order for [REDACTED]. A record review of resident ID #8's annual MDS assessment, dated 06/22/2012, documented she had a cognitive summary score of 5/15, indicative of severely impaired cognition and was independent for ADLs. In an observation on 07/31/2012 at 11:45 AM, LVN A placed a disposable lancet in an "Autolet Impression" lancing device. He used the lancing device to prick resident ID #8's finger to check her blood sugar. LVN A opened the lancing device and removed the disposable lancet. He did not sanitize the lancing device. LVN A then took the lancing device to resident ID #9's room to check resident ID #9's blood sugar. Resident ID #9 A record review of resident ID #9's July 2012 physician's orders [REDACTED]. Resident ID #9 had an order for [REDACTED]. A record review of resident ID #9's admission MDS assessment, dated 07/30/2012, documented he had a cognitive summary score of 0/15, indicative of severely impaired cognition and he required extensive assistance of one person for ADLs. In an observation on 07/31/2012 at 11:51 AM, LVN A placed a disposable lancet in an "Autolet Impression" lancing device. He used the lancing device to prick resident ID #9's finger to check his blood sugar. LVN A opened the lancing device and removed the disposable lancet. LVN A did not sanitize the lancing device. He then placed the lancing device back in the basket of blood sugar supplies. The manufacturer's instruction leaflet for the "Autolet Impression" lancing device, which was not dated, documented the following: (in part) "Autolet Impression must not be used in multi-patient clinical environments. Safety Information: Autolet Impression is for use with one end user." In an interview on 07/31/2012 at 12:35 PM, the administrator and DON stated they were unaware that the lancing device being used to obtain blood samples for glucose testing was labeled for a single user. Information posted by the Center of Disease Control, updated 08/26/10, at website http://www.cdc.gov/injectionsafety/Fingerstick-DevicesBGM.html, documented the following: "The shared use of finger-stick devices is one of the common root causes of exposure and infection in settings such as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk for transmission of blood-borne pathogens is not limited to LTC settings but can exist anywhere multiple persons are undergoing finger-stick procedures for blood sampling. For example, at a health fair in New Mexico earlier this year, dozens of attendees were potentially exposed to blood-borne pathogens when finger-stick devices were reused to conduct diabetes screening. Recommendations: Anyone performing finger-stick procedures should review the following recommendations to ensure that they are not placing persons in their care at risk for infection. - Finger-stick devices should never be used for more than one person. - Auto-disabling single-use finger-stick devices should be used for assisted monitoring of blood glucose. These recommendations apply not only to licensed healthcare facilities but also to any setting where finger-stick procedures are performed, including assisted living or residential care facilities, skilled nursing facilities, clinics, health fairs, shelters, detention facilities, senior centers, schools, and camps. Protection from infections, including blood-borne pathogens, is a basic requirement and expectation anywhere healthcare is provided." The facility's policy titled Glucometer, dated 09/18/2010, documented a sample would be obtained via manufacturer's directions and did not address the type of lancet to be used. On 07/31/2012 at 12:37 PM, the administrator and DON were informed an immediate jeopardy situation had been identified due to a failure to prevent cross-contamination by using a lancing device intended for a single user. On 07/31/2012 at 12:40 PM, the DON removed the lancing devices from the facility's supply. In an interview on 07/31/2012 at 2:15 PM, the administrator stated all nurses had been in-serviced not to use the old lancing devices and to use disposable lancets intended for one-time use only. In an interview on 07/31/2012 at 2:35 PM, LVN A stated he had been using the "Autolet Impression" lancing device since he began working in the facility one and one-half years ago. He stated he was not aware the device was intended for one user only. LVN A stated he was just in-serviced not to use the device due to the risk of cross-contamination. LVN A stated all "Autolet Impression" supplies had been removed from stock and replaced with disposable lancets. LVN A stated if he found any additional blood sugar testing supplies labeled for a single user, he would dispose of them and notify the ADON. In an interview on 07/31/2012 at 2:55 PM, the administrator stated there were no residents with AIDS, hepatitis, or any other blood-borne disease. He stated he was not sure how long the "Autolet Impression" lancing device had been used, but it had been used for "years." In an interview on 07/31/2012 at 3:40 PM, LVN D stated she was in-serviced around 1:00 PM to use only disposable single-use lancets for glucose testing. She stated if she found any lancing devices labeled for a single-user, she would dispose of them and notify the DON and ADON. On 07/31/2012 at 3:22 PM, the administrator submitted an action plan for removal, which included the following: "- Residents requiring diabetic testing are potentially affected. Residents could potentially contract a blood-borne disease from usage. - Facility will immediately discontinue the use of all types of lancet pens. Current stock removed and disposed of at 12:40 PM on 07/31/2012. ADON who is in charge of ordering medical supplies will no longer purchase lancet pens. - The facility will only use individual disposable lancets to ensure no possibility of cross-contamination. - All nurses in the building have been in-serviced on new change. All incoming nurses per shift will be retrained and sign off on the new procedures. - DON will monitor once a week for six weeks, then monthly for three months for continued compliance during normal QA rounds. - DON performed an assessment and identified residents to monitor for indications of blood-borne diseases; completed on 07/31/2012. The chart audit of all residents with glucose testing documented no residents had a blood-borne disease." The action plan was accepted on 07/31/2012 at 3:44 PM. The facility's In-service Record, dated 07/31/2012, documented all nurses were in-serviced to only use single-use disposable lancets for glucose testing. On 07/31/2012 at 3:40 PM, the surveyors confirmed through observations and interviews that the facility had in-serviced all of the nurses on using single-use lancets and who to notify if a lancet device intended for a single-user was found in the facility. On 07/31/2012 at 3:44 PM, the facility's administrator was informed the immediate jeopardy was removed. However, the facility remained out of compliance at a severity level of potential for more than minimal harm with a scope of a pattern. The facility was continuing to monitor their plan. The facility's Action Plan, dated 07/31/2012, documented there were seven residents who had orders for glucose testing. Non-IJ findings: B. Resident ID #4 A record review of resident ID #4's July 2012 physician's orders [REDACTED]. A record review of resident ID #4's quarterly MDS assessment, dated 05/31/2012, documented the following: he was totally dependent upon two or more persons for toileting; he was totally dependent upon one person for personal hygiene and bathing; he was always incontinent of urine and bowel. In an observation on 8/01/2012 at 1:30 PM, CNA E and F, after providing incontinent care, did not wash their hands or change gloves before applying clean bedding or clothing for resident ID #4. In an interview on 8/01/2012 at 1:40 PM, CNA E stated she received in-services every month. She stated she knew she should change her gloves and wash her hands before touching clean items. In an interview on 8/01/2012 at 1:45 PM, CNA F stated she received in-services every month. She stated she should change her gloves prior to touching clean items when performing incontinent care on a resident. C. In an observation on 07/31/2012 at 10:42 AM, during inital tour of the South hall, the clean linen cart was stored in room [ROOM NUMBER] at the foot of the first bed, which was occupied by a resident. In an interview on 07/31/2012 at 10:42 AM, CNA C stated the cart was normally stored in room [ROOM NUMBER], but the survey team was using room [ROOM NUMBER]. CNA C stated there was no vacant room on the hall to store the cart. D. The facility's Infection Tracking Log for May 2012, June 2012, and July 2012 documented infections were logged by resident name and origin of infection (such as UTI, tooth, respiratory). There was no trending or organism type documented. In an interview on 08/01/2012 at 1:50 PM, the DON stated she was not trending infections by resident location. She stated she was just documented the resident and type of infection on the tracking log. The DON stated she was not aware of the need to trend by organism or location. The facility's 2003 Infection Control Policy and Procedure documented the following: (in part) "The ICP (infection control professional) or designee will collect data on an ongoing basis. Each month, the ICP or designee will compile the surveillance data and submit for trending. The trending data will be submitted to the Governing Board at least quarterly for review." The facility's 2003 Urinary and Bowel Incontinence Policy and Procedure did not document the importance of hand washing or changing gloves after providing incontinent care from handling residents' soiled items to clean items. During observations on initial tour on 07/31/2012 from 10:00 AM to 11:00 AM, there were 11 residents on the South hall. The facility's CMS-672 Resident Census and Conditions of Residents, dated 07/30/2012, documented there were 17 residents occasionally or frequently incontinent of bladder, 9 residents occasionally or frequently incontinent of bowel, and the census was 43.