Every finding on record at Avir at Mineola

Based on observation, interviews and record review, the facility failed to ensure residents were free from physical abuse for 1 of 10 residents (Resident #1) reviewed for abuse.The facility failed to ensure Resident #1 was free from physical abuse when CNA B was in Resident #1's room on the secured unit handled Resident #1 in a rough manner during patient care, pinning Resident #1 down multiple times. CNA B placed his forearm and hands on Resident #1's chest/ neck area, and CNA B placed both hands around Resident #1's neck in a choking manner while pushing Resident #1 into his bed. Resident #1 suffered bruising to his chest, right forearm, and left forearm from CNA B physical force and abuse towards him on 5/5/26.The noncompliance was identified as past noncompliance (PNC). The IJ began on 5/5/26 and ended on 5/6/26. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk for physical abuse, mental abuse, emotional abuse, and harm.Findings included: Record review of Resident #1's admission record printed on 5/8/26, indicated he was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] to the secured unit with diagnoses including anxiety disorder (is a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), neurocognitive disorder with Lewy bodies (a progressive brain disorder causing cognitive decline, confusion, hallucinations, and movement difficulties), depressive disorder (a mood disorder associated with persistent sadness and loss of interest in activities), and vascular dementia (cognitive impairment caused by reduced blood flow to the brain resulting in memory loss, confusion, and behavioral changes). Record review of Resident #1's significant change MDS dated [DATE] indicated the resident had unclear speech and was limited to making concrete requests. Resident #1 responded adequately to simple, direct communication only. Section C1000 indicated Resident #1's cognitive skills for daily decision-making were severely impaired, meaning the resident rarely or never made decisions. Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, personal hygiene, and toileting. Resident #1 was incontinent of bowel and bladder, used a manual wheelchair, and had hospice services initiated within the last 14 days while a resident of the facility. Record review of Resident #1's undated care plan initiated on 3/10/26 indicated: *Resident #1 had cognitive loss. Intervention included: anticipate needs and observe, for non-verbal cues, approach in calm manner, explain what you intend to do while providing care, introduce yourself, and orient PRN to person, place and time. Record review of an undated Termination request template indicated CNA B's DOH was on 3/16/26; Summary of Facts: 5/5/26, employee choked [Resident #1]. Incident occurred on unit and involved [CNA B and Resident #1] and caught on surveillance provided by a family member. On 5/6/26 [CNA B] was arrested for Abuse. Impacts: Policy violation; Professional conduct and code of conduct; Automatic Termination. This Request meets the threshold for termination approval. A clear final incident had been identified with specific details and written documentation. Documentation supported violation of company policy and expectations. Progressive discipline had been appropriately followed. Record review of CNA B's termination record dated 5/5/26 completed by the Administrator indicated CNA B's DOH was 3/16/26. Last Day Worked: 5/5/26; Termination Date: 5/5/26. Reason for termination: misconduct; Notes: Was there a final incident that led to the decision: Abuse of a resident. Record review of Resident #1's Progress notes indicated the following:-On 5/6/26 at 10:16 am; completed by DON: this nurse was informed by CNA that [Resident #1's family] had made report that a male CNA [CNA B] had been seen on video with his hands around [Resident #1's] neck; [Resident #1's family] was able to provide video for this nurse to view; administrator notified immediately and police were called to facility; [Resident #1's family] remained present officer arrived and took report; video had been sent to officer; pictures taken by officer with [Resident #1's family] present, officer provided report number and will update with any further findings or needs from facility.-On 5/6/26 at 10:35 am; completed by LVN C: [Resident #1] was sent out to the ER via/EMS to be evaluated and treated via family request. DON/ADON aware. NP notified of [Resident #1] being transferred to the ER for evaluation. Family aware.-On 5/6/26 at 10:52 am; completed by LVN C: Skin Issue#001-New. Location: Right front axilla (front region of the right armpit). Laterality/orientation: Medial. Issue type: Brusing. Wound acquired in-house. Exact dated: 5/6/26 Painful: No; Length (cm): 7 Width (cm):10; Other additional care: monitor.Skin Issue#002- New. Location: Left front axilla (front region of the left armpit). Laterality/Orientation: Lateral. Additional location information: Resident has petechiae (tiny red, flat spots that appear on your skin. They are a sign of blood leaking from capillaries under your skin) to lower bilateral arms Issue type: Bruising. Wound acquired in-house. Wound is new. Signs and symptoms of infection: None. Painful: No; Other additional care: monitor.Skin Issues Note: [Resident #1] has bruising to bilateral upper arms, petechiae to chest and lower armsSkin issue notification: Family. Skin issue notification: Provider. Skin issue notification: Manager.-On 5/6/26 at 2:10 pm; completed by LVN C: [Resident #1] returned to facility via facility vehicle with no new orders received. [Resident#1] was alert and responsive but confused/disoriented x3 per resident's baseline. No distress noted. Record review of Resident #1's incident report dated 5/6/26 completed by the DON indicated the incident happened in Resident #1's room on the secured unit. Incident Description: Nursing Description- Notified by CNA that [Resident #1's family] was there and had reported to [DON] that [Resident #1] had been assaulted by a male [CNA B] last night. Resident Description: [Resident #1] unable to give description. Immediate Action Taken: [Resident #1] was assessed from head to toe; administrator, RNC, RDO and police notified, [Resident #1] to transferred to ER for evaluation. Injuries Observed at Time of Incident: Bruise to chest; Bruise to Right forearm; Bruise to Left forearm. Level of Pain: Zero. Predisposing physiological factors: confused and impaired memory. Record review of Resident #1's ER after visit summary dated 5/6/26 indicated reason for visit Assault victim. Diagnosis: Assault. Notes:[Resident #1] arrived by EMS from [name of facility] for physical assault by NH staff member [CNA B]. NH reports to EMS there was video footage of [Resident #1] lying in bed last night when [CNA B] grabbed [Resident #1] by the shoulders and shook [Resident #1] by pressing [Resident #1] into the bed. NH also reported [Resident #1] was grabbed by the throat and shook. EMS stated bruising was found to [Resident #1's] shoulders but none to neck or chest. A police investigation was active, and x-rays of [Resident #1] chest, shoulders, and forearms had been requested. [Resident #1] denied pain and did not remember the incident. [Resident #1 resided in the memory care unit and staff reported [Resident #1 mental status was at its baseline. Record review of Resident #1's hospice note dated 5/6/26 indicated it was a PRN visit following [Resident #1's] return from the ER after an incident of assault by [CNA B], where [CNA B] allegedly tried to chock and restrain [Resident #1]. Though no significant injuries were reported, ER transfer was per policy. On arrival, [Resident #1] was reclined in the memory care unit sleeping soundly. Facility staff informed hospice staff that [Resident #1] had also had a fall last night with no injuries. [Resident #1] briefly awoke, asked about food, and then returned to sleep. Resident #1 was assessed and monitored for pain and/or anxiety/agitation; no bruising was noted on his neck. Staff mentioned bruising on his arms, possibly from restraint, though due to [Resident #1] frequent falls, it was difficult to differentiate. Overall, [Resident #1] was stable and comfortable at the time of the visit. Record review of provider self-reporting of LTC incident #1088520 printed on 5/6/26 indicated Incident Date 5/5/26; Date/Time Facility first learned of the incident: 5/6/26 at 8:45am; Incident Category: Abuse; Resident/Client: [Resident #1]; Alleged perpetrator information: [CNA B]; Brief narrative of the incident: [Resident #1's family member] made a report that a male [CNA B] had been seen on video with his hands around [Resident #1's] neck; [Resident #1's family member] provided video for nurse to view; police were called to facility; [Resident #1's family] remained present; officer arrived and took report; video had been sent to officer; and pictures taken by officer with [Resident #1's family] present; officer provided report number and will update with any further findings or needs from facility.; [Resident #1] was assessed and noted bruising to bilateral forearms and chest area; no respiratory distress present; no injury visible to neck; spoke with MD and order received to send to ER for evaluation; [Resident #1] was unable to recall incident at that time due to poor cognition. On what shift did the incident occur: Night; Actions and Notifications: Notified the local police department, MD, medical director, family, ombudsman, employee was suspended pending investigation, initiated safe surveys with residents potentially affected, employee interviews, in-service on abuse and neglect policy and procedure; full skin assessment for all residents on the affected unit; interviews with various residents on opposing assignments on which the employee had worked previously; employee had not worked since 4/21/26. Record review of the police report dated 05/12/2026 indicated that on 05/06/2026 at approximately 9:13 a.m., an officer with the local Police Department responded to [Name of Facility] regarding a report and video footage of staff-to-resident abuse involving [CNA B and Resident #1]. Facility staff reported observing video footage showing [CNA B] physically assaulting [Resident #1] during incontinent care on 05/05/2026 at approximately 7:45 p.m. According to the police report and video review, [CNA B] was observed forcibly pushing [Resident #1] backward onto the bed, striking [Resident #1] in the chest with an open hand, and repeatedly placing his hands and forearm around [Resident #1's] throat while [Resident #1] struggled and gasped for air. [Resident #1], who has late-stage dementia and was fully dependent on staff for care, could be heard saying, I can't, and was observed resisting care throughout the incident. The police report further indicated [CNA B] was heard making threatening and intimidating statements toward [Resident #1] during the encounter. The police report indicated the reporting party and facility administration provided the video footage to law enforcement. The report further indicated [Resident #1's] family member requested criminal charges. The responding officer documented visible injuries to [Resident #1] through photographs and determined [Resident #1] lacked the mental capacity to provide an interview regarding the incident. Based on the investigation and video evidence, the responding officer sought an arrest warrant for [CNA B] for Injury to a Child, Elderly Individual, or Disabled Individual under Texas Penal Code S22.04, a first-degree felony. On 05/07/2026, CNA B was taken into custody at [Name of Facility] and transported to the local county detention center. A $100,000 bond was issued. The case was forwarded to the local Police Department Administrative Division for further review and investigation. During an observation and attempted interview on 5/8/26 at 6:13pm, Resident #1 was sitting in his wheelchair stationed directly in front of the west nurse station. Resident #1 was clean, well-groomed with no unpleasant odor and there were no visible bruising, skin tears or marks. Resident #1 was not interviewable due to cognitive impairment and inability to provide reliable information regarding the incident. During a telephone interview on 5/8/26 at 4:25 p.m. with Resident #1's family member, she stated she was the individual who initially observed the video footage involving CNA B and Resident #1 and immediately notified facility administration of the incident. Resident #1's family member stated it was very upsetting and difficult to watch the video showing CNA B physically abusing Resident #1. She voiced concerns regarding Resident #1's safety and wellbeing due to the nature of the incident. Resident #1's family member stated she felt the facility addressed the allegation immediately after being notified and was satisfied with how the facility handled the situation, including contacting law enforcement and removing CNA B from the facility. Resident #1's family member stated she felt the physical and emotional impact on Resident #1 had been significant, as Resident #1 had experienced increased confusion, periods of incoherence, fearfulness, emotional distress, and a loss of trust in caregivers following the incident. Resident #1's family member stated the family was deeply concerned that the combination of the alleged abuse, rough handling, inconsistent care, and other ongoing issues had contributed to both Resident #1's physical decline and emotional trauma during an already vulnerable stage of his life. CNA B was not interviewed due to being incarcerated during the time of investigation on assault charges related to the alleged incident involving Resident #1. During an interview on 5/8/26 at 1:20 p.m., the Administrator said he was the abuse coordinator and followed their abuse policy, did criminal history checks upon hire, did in-services with his staff and reported everything to the state. The Administrator said CNA B was terminated due to the incident and said he could not control other human behaviors. During an interview on 5/8/26 at 6:42 p.m., LVN E stated he was the charge nurse assigned to the secured unit during the 6pm to 6am night shift and had worked at the facility for approximately one year. LVN E stated he did work the night of the incident, but he was not aware of the alleged incident involving Resident #1 and CNA B until the following day on 5/6/26. LVN E stated he provided a witness statement regarding the incident and said the information contained in the statement was accurate. LVN E stated Resident #1 could become combative at times during care. LVN E stated he had not observed CNA B handle residents aggressively and had not received complaints from residents or staff regarding CNA B's care or conduct toward residents. During a telephone interview on 5/9/26 at 1:54 p.m., LVN C stated she was the charge nurse assigned to the secured unit during the 6am to 6pm day shift and had worked at the facility for approximately two months. LVN C stated she worked on 5/6/26, the morning following the alleged incident involving Resident #1 and CNA B. LVN C stated she observed bruising to Resident #1's upper arms and chest area, which appeared consistent with someone having grabbed or held the resident down. LVN C stated she was the nurse who sent Resident #1 to the emergency room for evaluation, and Resident #1 returned the same day with no new orders. LVN C stated she did not know CNA B personally and had not previously worked with him.During an interview on 5/9/26 at 6:41 p.m., CNA D stated she was assigned to the secured unit during the 6pm to 6am shift and had been employed at the facility since 2017. CNA D stated she worked the night of the alleged incident involving Resident #1 and CNA B but was unaware of the incident until the following day on 5/6/26 when a nurse contacted her asking if she had witnessed anything. CNA D stated she provided a witness statement and confirmed the information in the statement was accurate. CNA D stated she was assisting other residents to bed and recalled walking past Resident #1's room and noticing his call light on. CNA D stated she entered Resident #1's room and recalled Resident #1 attempting to tell her something, repeatedly asking, where's that heavy set man? CNA D stated she could not fully understand Resident #1 and knelt closer to hear him. CNA D stated she touched Resident #1's arms and noticed he was clammy and sweating, which she stated was not normal for him. CNA D stated Resident #1's roommate then began coughing, making it difficult to hear Resident #1. CNA D stated that prior to Resident #1's cognitive decline, he often preferred male CNAs for care assistance. CNA D stated she assumed Resident #1 was asking for the male CNA to assist him. CNA D stated that after learning of the allegation, she felt horrible because she unknowingly brought CNA B back into Resident #1's room shortly after the alleged incident. CNA D stated she had never previously witnessed CNA B handle residents roughly and had not heard complaints from residents or family members regarding CNA B. During an interview on 5/11/26 at 4:35 p.m., the Regional Nurse said placing hands on around a resident's neck, pinning them down or placing forearms on a resident's chest was never appropriate while providing care. He said CNA B had been trained on abuse neglect and exploitation and resident rights. The Regional Nurse said CNA B should have given Resident #1 space and provided behavioral interventions to de-escalate Resident #1combative behaviors and situation. Record review of revised Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated April 2021 indicated the following: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. The facility had corrected the noncompliance on 5/6/2026 by the following: -They immediately suspended CNA B pending investigation. -On 5/6/26 Resident #1 was assessed head - to - toe -On 5/6/26 Resident #1 went to the ER for evaluation. -On 5/6/26 Hospice nurse assessed Resident #1 after return from ER. -On 5/6/26 Full skin assessments completed on all 18 residents on the secured unit. -On 5/6/26 Local police were notified and arrived at the facility. With police corroboration, CNA B was not suspended immediately until he returned for his shift on 5/6/26 . Police returned to the facility and CNA B was arrested in the parking lot when he arrived for his 6p-6a shift. CNA B did not enter the facility prior to his arrest. -On 5/6/26 Facility had in-serviced and trained staff in the following areas: Abuse and Neglect, Resident Rights, De- Escalation, and managing a difficult/combative resident. In-Services addressed immediate recognition and reporting of any behaviors or incidents that may place a resident at risk. Staff were in-serviced on Effective de-escalation methods, including calm verbal responses, allowing personal space, avoiding confrontation, and using redirection techniques. Resident rights, ensuring residents are treated with dignity, and staff do not use any form of intimidation or retaliation. Staff were educated on accurate and timely documentation of resident behavior, attempted interventions, and escalation to supervisory personnel. In-service emphasized following individualized care plans, including implementing interventions for residents with behavioral risks and increasing monitoring when indicated. This was verified by record review of staff in-services signature sheets and staff interviews. -On 5/6/26 Safe surveys throughout the facility were completed. The residents reported that staff were courteous, respectful, and kind, and stated they felt comfortable and safe with the care provided. The residents indicated that staff were careful when assisting or transferring them and confirmed that they were receiving the care they needed. This was verified by record review of safe survey sheets. Interviews and record reviews were conducted from 5/8/26 through 5/11/26 from 9:00 a.m. to 7:30 p.m. and included 4 LVNs, 11 CNAs, 2 CMAs, ADON, RN, and MDS Coordinator. Staff were able to explain abuse and neglect prevention, resident rights, and the facility's expectations for immediate intervention and reporting. Staff were able to explain how to identify early signs of behavioral escalation and proper use of effective and calm communication techniques and apply de-escalation strategies. Staff had knowledge to intervene immediately, maintain resident dignity, notify supervisory staff and the physician without delay, follow the care plan, and accurately document all actions taken. During observations from 5/8/26 through 5/11/26 at various times from 9:00 a.m. to 7:30 p.m. on the secured memory care unit, residents were noted to engage in calm and non-confrontational interactions. Residents appeared generally quiet, with limited verbal engagement, and interactions were primarily passive or casual in nature. Some residents were observed walking in common areas or sitting near one another without signs of agitation or distress. No instances of verbal or physical aggression were observed. Residents did not demonstrate behaviors that suggested intimidation or fear. Staff were present in the area, providing routine supervision and re-direction as needed, and were observed promptly intervening if any residents began to appear anxious or confused. Residents appeared to be appropriately monitored, and no residents displayed behaviors that posed a risk to others during the period of observation. Interactions were consistent with the cognitive and functional levels of the residents on the memory care unit. The noncompliance was identified as past noncompliance (PNC). The IJ began on 5/05/26 and ended on 5/06/26. The facility had corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to ensure they did not employ an individual who was found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law for 1 of 1 (Cook A) employees reviewed for abuse and neglect. The facility did not disqualify [NAME] A from working when her criminal history record indicated she had a criminal conviction barring employment in a nursing facility. [NAME] A worked in the facility from 11/04/24 through 04/24/26. This failure could place residents at risk for possible abuse, neglect, exploitation or mistreatment. Findings included: Record review of an undated personnel file for [NAME] A indicated a hire date of 11/04/24. The file further indicated that [NAME] A's criminal history was checked on 11/04/24, 10/22/25 and 04/22/26. During an interview on 04/22/26 at 12:15PM, [NAME] A said she was convicted of Aggravated assault with a deadly weapon back in the late 1990's. She said she was in jail for 4 years and it was not adjudicated. She said she was released in 2002.During an interview on 04/22/26 at 01:04PM, the HR Director said she pulled and reviewed [NAME] A's criminal history. She said if [NAME] A were applying for a job on this day she would not hire her due to what her report contained. She said she had a felony back in 1996.During an interview on 04/22/26 at 01:45PM, [NAME] A said she was arrested by [arresting county] and her judge was [Judge's name]. She said she did 4 years in jail from 1998-2002.During an interview on 04/23/26 at 09:52AM, the HR Director said she took over as the HR Director on 03/15/26. She said the previous HR Director left in February 2026 and had worked in the facility for approximately 16 years. She said [NAME] A was hired on 11/04/24.During an interview on 04/23/26 at 10:21AM, the Administrator said [NAME] A was eligible for hire. He said the HR Director was incorrect.During an interview on 04/24/26 at 09:12AM, the Dietary Manager said the HR Director and Administrator review background checks on employees at the time of hire. She said they let her know if an applicant is good for hire or not. She said at the time [NAME] A was hired she was told by the old HR Director that she was ok to hire.During an interview on 04/24/26 at 09:35AM, the DON said the HR Director was responsible for ensuring criminal history is checked on new-hires and annually. She said the Administrator was responsible for ensuring the HR Director was reviewing criminal history correctly.During an interview on 04/24/26 at 09:50AM, the HR Director said [NAME] A is not eligible for hire and has a lifetime bar to employment because she was convicted of aggravated assault with a deadly weapon.During an interview on 04/24/26 at 10:35AM, the Administrator said his understanding of [NAME] A's criminal history was that she was convicted then sent to prison for 4 years. He said after this it was likely deferred. He said their process was that they forward an abnormal background check to the corporate office. He said he was unsure of the process for the previous corporate entity. The new corporate entity took over in October 2025.During an interview on 04/24/26 at 11:02AM, the HR Director reviewed [NAME] A's criminal history and recanted it out loud with this surveyor. She said [NAME] A was arrested on 04/04/96. She said the charge for the arrest date 04/04/96 was aggravated assault with a deadly weapon. She said the arrest offense citation was 22.02(A)(2) [a section of the Texas Penal code that identifies and defines what is considered an aggravated assault]. She said the level and degree of offense was felony 2nd degree. She said the date of offense was 04/04/96. She said the arrest disposition date was 04/04/96. The arrest disposition was held. She said the prosecutor accepted the charge. The prosecutor offence citation was 22.02(A)(2). The prosecutor offense was aggravated assault with a deadly weapon. The level and degree prosecuted was felony 2nd degree. She said the court status was A. The court offense was aggravated assault with a deadly weapon felony 2nd degree. The court disposition was deferred. She said the court disposition date and date of sentence/status was 12/16/96. She said the final pleading was unreported or unknown. She said it further reflected in this section court probation by agency receiving custody, and it also reflected that the court provision was deferred adjudication (a special form of judge-ordered community supervision that permits a defendant to accept responsibility for a crime without an actual conviction being placed on the record) in this section.The HR Director also said there was another section that reflected court status B, and contained the following information:The court offense was aggravated assault with a deadly weapon. The court offence citation was 22.02(A)(2). She said the level and degree offense was felony 2nd degree. She said the court disposition was convicted. The court disposition date was 12/16/96. The date of sentence/status was 08/18/98. The final pleading was unreported/unknown. She said it reflected court confinement for 4 years. The sentence expiration date was 08/09/02. The status starting date was 09/23/98.During an interview on 04/24/26 at 11:22AM, the Administrator said he did not think [NAME] A was barred from employment because he has family that worked in law enforcement and his understanding was that you have to have a conviction and serve your time before you can get deferred adjudication. He said he believed she was still eligible to work in the facility. Record review of the State of Texas, Health and Safety Code, Chapter 250, Section 250.006 Convictions Barring Employment reflected (Revision 24-1, Effective Sept. 6, 2024): .a. A person for whom the facility or the individual employer is entitled to obtain criminal history record information may not be employed in a facility or by an individual employer if the person has been convicted of an offense listed in this subsection:.5. an offense under Section 22.02, Penal Code, aggravated assault;. Record review of the Facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised April 2021, reflected: .4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has:a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; orc. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment or residents or misappropriation of resident property.

Based on observation, interview, and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 4 (Resident #1) residents reviewed for notification of change. The facility failed to ensure Resident #1's physician was notified when she had a fall which resulted in an abrasion to her face on 03/18/2026. This failure could place residents at risk for experiencing unnecessary pain, not receiving necessary treatments and medications, and a decreased quality of life.Findings included: Record review of Resident #1's face sheet, dated 03/26/2026, indicated a [AGE] year-old female, admitted [DATE], with diagnoses including Alzheimer's disease (a progressive irreversible neurodegenerative disease resulting in a memory decline), dysphagia (difficulty swallowing), lack of coordination, and cognitive communication deficit. Record review of Resident 1's Quarterly MDS assessment, dated 12/09/2025, indicated she was understood by others and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 08, which indicated moderate cognitive impairment. The MDS assessment indicated Resident #1 required assistance with showering/bathing, toileting hygiene, and required supervision or touching assistance for personal hygiene. The MDS assessment indicated Resident #1 had falls. Record review of Resident #1's care plan, with a target date of 03/09/2026, indicated she had a history of falling and potential for future falls related to Alzheimer's disease, unsteady gait, wandering and psychotropic medications. Interventions included giving resident verbal reminders not to ambulate/transfer without assistance, to keep bed in lowest position with brakes locked, keep call light in reach at all times, and keep personal items and frequently used items within reach. Record review of Resident #1's Order Summary Report, dated 03/26/2026, indicated May admit to the secured unit due to exiting seeking behavior dated 12/09/2025. Record review of the Fall (unwitnessed) Incident Report, dated 03/18/2026, indicated LVN A notified Resident #1's physician of the fall on 3/18/2026 at 5:50 p.m. Record review of Resident #1's Progress Note, dated 03/18/2026 at 7:52 p.m., signed by LVN A, indicated, called to the secure unit with resident noted on floor lying on right side in hallway. Per CNA resident was lying on left side when noticed she had fallen. Moving all extremities same as prior to fall. Very light bruise noted to left side of forehead 2.5 cm x 2 cm. Neuros initiated per protocol. Son made aware. Denies pain. Record review of Resident #1's hospital discharge, dated 03/19/2026 at 8:40 a.m., indicated, Patient is well appearing. She is pleasantly demented denied any complaint other than pain to the superficial area of the head with bruising and hematoma. CT scan was performed today which was without signs of skull fracture or intracranial hemorrhage (brain bleed). Overall, it was reasonable to discharge patient to the nursing facility with close follow-up. There were no new orders indicated per the hospital discharge. During an interview and observation on 03/26/2026 at 06:40 a.m., Resident #1 was observed lying bed with a hematoma approximately the size of an egg to the left side of her forehead with blueish discoloration from the eye down to her cheek bone area. Resident #1 was not a good historian related to the Alzheimer's disease process. Resident #1 said she was not sure what happened, but it happened real good. Resident #1 said she had some pain at some point, but she could not recall when. Resident #1 pointed out to the hallway as she was talking about the incident. Resident #1's bed was observed in the lowest position with the call light in reach. Resident #1's room was observed free of clutter. During an interview on 03/26/2026 at 10:40 a.m., LVN A said she documented that she contacted Resident #1's physician when the fall occurred, but she did not notify the physician. LVN A said she documented it and forgot to call the physician during all the excitement between Resident #1 and a different resident that was having issues at the same time. LVN A said it was very important to notify the physician when a fall, incident, or change in condition occurred to ensure the resident received the proper care they required such as new orders for treatments to identify any fractures or bleeds. LVN A stated she had initiated the neuro checks at the time of Resident #1's fall with unremarkable vital signs and neurologic results. LVN A stated Resident #1 had not complained of pain. LVN A stated she notified the ADON, DON and Resident #1's family member at the time of the incident. During an interview on 03/31/2026 at 02:15 p.m., LVN B said Resident #1 had increased facial pain and bruising, so she notified Resident #1's physician. LVN B said when she contacted Resident #1's physician he stated he was not aware Resident #1 fell the previous day (03/18/2026). LVN B said she was given the order to send Resident #1 out to the hospital immediately. LVN B said the physician should have been notified when the fall occurred to prevent complications that could occur related to fractures or a brain bleed. During an interview on 03/31/2026 at 04:30 p.m., the Physician said he was notified of Resident #1's fall the day after she fell (03/19/2026). The Physician said when he was notified, he sent Resident #1 out to the hospital immediately because she had increased facial pain and bruising. The Physician said if he would have been notified the day Resident #1 fell, he would have sent her to the ER immediately because she hit her head. The Physician said when a resident fell and hit their head, he wanted to rule out anything major, like a brain bleed or swelling, immediately. During an interview on 03/31/2026 at 03:35 p.m., the DON said she was aware of Resident #1's fall on 03/18/2026. The DON said she was not aware that LVN A did not notify the physician. The DON said it was very important to always notify the physician regarding falls or changes in condition to receive new orders for treatments and to ensure the resident did not have any fractures or bleeding. During an interview on 03/31/2026 at 04:35 p.m., the ADON said was aware of Resident #1's fall on 03/18/2026. The ADON said she was not aware until the following day on 03/19/2026 when the resident was sent out to the hospital with increased pain and bruising that the physician had not been notified at the time the fall occurred. The ADON said the physician should have been notified at the time the incident occurred in case the physician gave new orders or treatments, and to ensure the resident had not experienced a fracture or a bleed that had not been identified. During an interview on 04/01/2026, the Administrator said he expected the physician to be made aware of any changes in condition regarding the residents when they occurred. The Administrator said he expected the DON and ADON to provide oversight to the clinical staff to ensure the physician was being notified. The Administrator said it was important for the physician to be notified to ensure continuity of care for the residents, and so injuries were identified and proper treatments were completed. Record review of the facility's policy titled, Change in Resident's Condition or Status, revised April of 2025, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; .

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 10/06/25, 10/10/25, 10/14/25, 10/16/25, 10/17/25, 10/17/25, 10/18/25, 10/19/25, 10/20/25, 10/24/25, 10/29/25, 10/30/25, 10/31/25, 11/04/25, 11/07/25, 11/10/25, 11/14/25, 11/19/25, 11/21/25, 11/26/25, 11/27/25, 11/28/25, 12/01/25, 12/02/25, 12/03/25, 12/04/25, and 12/05/25 (27 days from 10/06/25 through 12/09/25). This deficient practice had the potential to place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings included: During an interview on 12/08/2025 at 8:20 AM, the ADON said the facility has not had a DON since 10/05/25. She said they have weekend RN coverage but do not have 8 hours coverage during the week. She said the corporate nurse was the acting DON but was not in the building 8 hours a day during the week.During an interview on 12/08/2025 at 1:47 PM, The RNC/Acting DON said he was not here at all the week of 11/30/25 - 12/06/25. He said the week of thanksgiving he was in the facility 3 days for 8 hours. During an interview on 12/10/25 at 12:24PM, the MDS Coordinator said she was not aware of any other RN working in the facility than the corporate RNC and the weekend nurse. She said the weekend nurse does not work during the week. During an interview on 12/10/25 at 12:43PM, the ADON said the only two RN's that are currently working at the facility are the RNC/acting DON and the Weekend nurse. She said the weekend nurse does not work during the week. She said the previous DON quit on 10/05/25 via telephone. She said they have not had an RN in the facility every day since the DON left. She said The RNC/acting DON has been in the facility some days but not all. She said some assessments may not be able to be completed and they would be without RN supervision. During an interview on 12/10/25 at 12:51PM the Administrator said the old DON quit on 10/05/25 and they only have two RN's working in the facility. He said the weekend nurse does not work during the week. He said to his knowledge they had not met the RN hours requirement. He said the risk was no RN hours and some assessments may not be able to be completed. During an interview on 12/10/25 at 01:05PM, the RNC/Acting DON said him and the weekend nurse were the only RN's working at the facility. He said they have not been able to meet the 8 hour 5 day requirement for the RN hours. He said the risk was no RN supervision, he said it was possible some assessments may not be able to be completed due to no RN. Record review of a staffing schedule provided by the RNC/Acting DON on 12/09/25 at 2:54PM, reflected the RNC/Acting DON was present and working in the facility on the following days:*10/07/25, 10/08/25, 10/09/25, 10/13/25, 10/15/25, 10/21/25, 10/22/25, 10/23/25, 10/27/25, 10/28/25, 11/03/25, 11/05/25, 11/06/25, 11/11/25, 11/12/25, 11/13/25, 11/17/25, 11/18/25, 11/20/25, 11/24/25, 11/25/25, 12/08/25, and 12/09/25. Record review of RN E's employee timecard report for October and November 2025 reflected she worked the following days for at least 8 hours:*10/11/25, 10/12/25, 10/25/25, 10/26/25, 11/01/25,11/02/25, 11/08/25, 11/09/25, 11/15/25, 11/16/25, 11/22/25, 11/23/25, 11/29/25, and 11/30/25. Record review of the facility's policy, Staffing, Sufficient and Competent Nursing, last revised August 2022, reflected: .Sufficient Staff.3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on observation, interview, and record review, the facility failed to 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 3 of 14 residents (Resident #17, Resident #38 and Resident #60) reviewed for infection control practices. 1.The facility failed on12/09/25 to ensure that LVN A sanitized her hands while passing medications to Resident #38 and Resident #60. 2.The facility failed on 12/08/2025 to ensure that Resident #17's room was cleaned of feces, urine, and a unidentified black marks on the tile floor and bathroom. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1.Record review of Resident #38's face sheet, dated 12/10/25, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnosis included dementia (a decline in mental ability severe enough to interfere with daily life), candidiasis (a fungal infection), Alzheimer's (a progressive brain disorder) Other seasonal allergic rhinitis and shortness of breath. Record review of Resident #38's quarterly MDS assessment, dated 09/19/25, reflected that she had a BIMS score of 9, which indicated moderate cognitive impairment. She was also always continent of bladder and bowel. Shows that Resident #38 also triggered for dementia and loss of cognition. Record review of Resident #38's Order summary report, dated 12/10/25, reflected that she does not have an order for Geri-Tussin in oral liquid (Guaifenesin). Record review of Resident #38's care plan, dated 09/25/2025, reflected Resident #38 has a diagnosis of unspecified dementia (a decline in mental ability severe enough to interfere with daily life) with other disturbances. Interventions: administer prescribed medications per physician's orders. Record review of Resident #60's face sheet, dated 12/10/25, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnosis included dysphagia (difficulty swallowing food or liquids), Parkinson's disease (a progressive brain disorder causing movement issues), nonrheumatic aortic valve disorder (happens when the heart's main valve stiffens or doesn't close properly) and extended-spectrum beta-lactamases (bacterial enzymes that break down common antibiotics). Record review of Resident #60's quarterly MDS assessment, dated 07/24/25, reflected that she had a BIMS score of 15, which indicated she was cognitively intact. She was also always incontinent of bladder and bowel. Record review of Resident #60's Order summary report, dated 12/10/25, reflected Tylenol Tablet 325 mg (Acetaminophen). Give 2 tablets by mouth every 6 hours as needed for mild pain, start date 11/12/25. Record review of Resident #60's care plan, dated 10/30/25, reflected Resident #60 has complaints of chronic pain at times. Interventions include monitoring and recording any complaints of pain: location, duration, duration, quantity, quality, alleviating factors, aggravating factors. During an observation of medications pass on 12/09/25 at 8:24 A.M., with LVN A. LVN A gave Resident #38 Geri-Tussin oral Liquid 30ml by mouth in a cup and gave and gave Resident #60 Tylenol tablet 325 mg (Acetaminophen) 2 tablets by mouth in a cup without sanitizing her hands. During an interview on 12/09/25 at 3:41 P.M., with LVN A said she was supposed to sanitize her hands between giving medications to residents. She said she was acknowledged that she did not sanitize her hands between giving Resident #38 and Resident #60's medications. She said she was in a rush this morning and she admitted it was wrong for her not to sanitize since the different upper respiratory infections were going around throughout the facility. She said s negative effect of improper hand hygiene was passing germs from one resident to another. She said the main concern was infection control. She said the facility had standing orders for the geri-tussin and she would make sure Resident #38 has an order for the medication. During an interview on 12/10/25 at 12:34 P.M., with ADON [NAME] said she except the staff to sanitize their hands between giving residents medications. She said improper hand hygiene puts the residents at risk for infection. She said a negative effect was infection control. She said the facility had standing orders for geri-tussin DM, but she needed to check to make sure LVN A had orders in for Resident #38. During an interview on 12/10/25 at 12:45 P.M., with Acting Director of Nursing he said expect for the nurses and staff to sanitize their hands between giving medications to residents. He said improper hand hygiene would place the resident at risk for an infection issue and cross contamination. He said he would ensure the order for the geri-tussin was placed under medications summary report. During an interview on 12/10/25 at 1:17 P.M., with the Administrator he said he expected the staff to sanitize their hands between giving residents medications. He said the risk of improper hand hygiene was an infection control issue. 2. Record review of Resident #17's face sheet, dated 12/10/25, reflected he was a [AGE] year-old male, initially admitted to the facility on [DATE], and most recently re-admitted on [DATE]. His diagnosis included Cerebral Infarction (happens when a blood clot blocks an artery supplying the brain, cutting off oxygen and nutrients, causing brain cells to die), Muscle Wasting and Atrophy (the decrease in muscle mass and strength, happening when protein breakdown exceeds synthesis, caused by inactivity (bed rest, immobilization), aging (sarcopenia), malnutrition, or diseases (cancer, heart failure, nerve damage), Chronic Pain (persistent pain lasting over three months, longer than normal healing, characterized by dull, throbbing, or burning sensations that affect daily life and can lead to depression, fatigue, and disability). Record review of Resident #17's quarterly MDS assessment, dated 08/25/25, reflected that she had a BIMS score of 10, which indicated moderate cognitive impairment. She was also frequently incontinent of bowel. Shows that Resident #17 also triggered for dementia and loss of cognition. Record review of Resident #17's care plan, dated 6/5/2024, reflected a focus of Resident #17 had experienced bladder incontinence at times. Additionally Resident #17 was limited in ability to bathe himself regarding his weakness and he would get tired easily. During an observation and attempted interview on 12/08/2025 at 9:09 a.m. it was observed that Resident # 17's room had black streaks of an unknown substance on the tile floor. The floor was sticky when walking on it. The room smelled of urine and feces. There was a yellow and brown liquid on the floor surrounding the toilet. Resident #17 was unable to answer questions when spoken to. During an interview on 12/08/2025 at 9:12 a.m. CNA C said the floor in Resident #17's room had been filthy, like the way it was for at least 5 days. He said he had not seen housekeeping in the B hall in several days. During an observation on 12/08/2025 at 11:30 a.m. it was observed that Resident #17's room had black streaks of an unknown substance on the tile floor. The floor was sticky when walking on it. The room smelled of urine and feces. There was a yellow and brown liquid on the floor surrounding the toilet. Resident #17's room is located on B hall. During an interview on 12/08/2025 11:35 a.m. with the Housekeeping Supervisor D she said that she has a housekeeper that works halls A and C. She said that she was working B hall, the hall Resident #17 resided on. She said she cannot do too much work because she was pregnant and could not do any labor. She said that Resident # 17 room was very dirty and needed to be cleaned every day. She said that Resident # 17 was using the bathroom on the floor and tracked it all over the room. She said that was the black areas which were on the floor. She said that she hired last Friday a new housekeeper to work the B hall but he called in today, said he had an emergency, and would not be at work. She said he worked last Saturday and Friday. She said she was responsible for B hall today. She said she doesn't know if her new hire housekeeper actually cleaned Resident #17's room last Saturday and Friday. She said the resident's rooms on B hall were not getting cleaned every day. She said when she could she would get in the room and clean it. During an interview on 12/8/2025 at 11:55 a.m. with CNA C he said to kitchen staff in the dining area that Resident #17 would be eating in his room. Surveyor who overheard this comment intervened and asked CNA C if Resident #17 would be eating in his room with urine, feces, and other black matter on the floor. CNA C said yes Resident #17 would be eating in his room in his room in the condition it was in. Surveyor asked CNA C if he was capable of mopping and cleaning Resident #17's room prior to him eating in his room. CNA C said that the cleaning supplies and mops were locked up and he didn't have access to them. Surveyor asked CNA C if he was capable of asking for someone for a mop and cleaning supplies since housekeeping was not cleaning Resident #17's room. CNA C left dining area. During an observation on 12/08/2025 at 12:11 p.m. it was observed that Resident #17 had the immediate area around his toilet mopped and the door was shut to the bathroom. The rest of Resident #17's room was not cleaned. Resident #17's room had black streaks of an unknown substance covering most of the resident's room. During an interview on 12/10/25 at 12:18 p.m. the ADON said that it was the responsibility of housekeeping to ensure that resident's floors are clean and not contaminated with urine and feces. She said that residents could be placed at risk of infection if floors were not clean and residents and staff are spreading urine and feces all over the facility. During an interview on 12/10/25 at 12:30 p.m. the Administrator said that housekeeping was responsible to ensure that floors are clean. He said that it was not acceptable to leave a resident's floor contaminated in urine and feces for long periods of time or to feed a resident in a room that was in that condition. He said that if housekeeping was not cleaning a resident's room a CNA or a nurse could clean a resident's room as well. During an interview on 12/10/25 at 1:02 p.m. with the Acting Director of Nurses he said that he expects that the facility be kept clean and that it was unacceptable for a resident's room to remain soiled with feces and urine for long periods of time. He said that residents could be placed at risk of infections if they were exposed to urine and feces. Record review of a facility policy titled, Homelike Environment revised February 2021. Administration was asked for a infection control policy related to keeping the facility clean and was provided the following: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary and orderly environment. Record review of a facility policy titled, Hand washing/Hand Hygiene revised January 2025. Policy statement This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.1. All personnel are trained and regularly in serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, ect.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol based hand rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility. Indications for Hand Hygiene 1. Hand hygiene is indicated: a. immediately before touching a resident; d. after touching a resident.

Based on observation, interview and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 1 facility reviewed for nurse staffing posting. The facility failed to post the required current daily staffing information on 12/8/25 and 12/9/25. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.Findings included: During an observation on 12/8/25 at 3:39 PM, nurse staffing data was posted on a table, behind a Christmas tree, not easily visible, and was dated 10/3/25. During an observation and interview on 12/09/2025 at 10:40 AM, the ADON found nurse staffing posted by the front door on a table behind a Christmas tree. The staffing was dated 10/3/25. She said the staffing had not been posted or updated since that date. She said the DON was responsible for posting staffing, but she left on 10/5/25. She said since the DON was not here, she was not sure who was responsible, but she would find out. She said the risk of not posting nurse staffing was that no one would know how many staff were in the building or if they were adequately staffed. During an interview on 12/09/2025 at 10:57 AM, the ADON said no one was responsible for posting the staffing after the DON left on 10/5/25. She said someone should have been assigned but no one was. She said she just talked to the ADM and now she was assigned to post nurse staffing daily. She showed the surveyor the posted staffing sheet for today, (12/9/25.) During an interview on 12/9/25 at 2:14 PM, the BOM said she could not see the nurse staffing information because it was behind a Christmas tree on a table. She looked from different angles in the lobby and said she still could not see it. During an interview and observation on 12/9/25 at 2:16 PM, the ADON said she could not see the nurse staffing information on the table in the lobby because a Christmas tree was in front of it. The ADON moved the nurse staffing information in front of the Christmas tree. During an interview on 12/9/25 at 2:19 PM, the acting DON said the nurse staffing posting should be updated daily and should be visible, where everyone could see it. He said the risk of not posting nurse staffing information was that no one would be aware of how many staff were in the facility. During an interview on 12/10/2025 at 9:07 AM, the ADM said staffing should be updated daily and posted in an easily visible location. He said the risk of not having staffing posted was staff, visitors, and residents would not know how many staff were in the facility. During an interview on 12/10/25 at 1:15 PM, the ADM said the prior DON was responsible for the nurse staffing posting. He said since she left on 10/5/25 no one was responsible for making sure it was done. The ADM said yesterday (12/9/25) he and the ADON were responsible for posting the staffing daily. He said prior to yesterday, the last staffing post was 10/3/25. He said the daily nurse staffing posting should be updated daily and clearly visible/not blocked by anything, so everyone could see it. Record review of a Posting Direct Care Daily Staffing Numbers with a revised date of August 2022 indicated: Policy StatementOur facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.Policy Interpretation and Implementation1.Within two (2) hours of the beginning of each shift, the number of licensed nurses (RN's, LPN's, and LVN's) and the number of unlicensed nursing personnel (CNA's and NA's) directly responsible for resident care is posted [NAME] prominent location (accessible to residents and visitors) and in a clear and readable format.A.The name of the facility;B.The current date (the date for which the information is posted);C.The resident census at the beginning of the shift for which the information is posted;D.Twenty-four (24)-hour shift schedule operated by the facility;E.The shift for which the information is posted; F.Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during the shift who are paid by the facility (including contract staff);G.The actual time worked during that shift for each category and type of nursing staff; and H.Total number of licensed and non-licensed nursing staff working for the posted shift. 3.Within two (2) hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the Nurse Staffing Information form. The charge nurse completes the form and posts the staffing information in the location(s) designated by the administrator.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary clean, comfortable, and homelike environment for 3 of 21 residents reviewed for environment. (Resident #28, Resident #63 and Resident #66) 1.The facility failed on 12/08/2025 to ensure that Resident #28's bathroom was cleaned of water, an unidentified black track marks on the tile when the sink was leaking. 2.The facility failed to replace missing pieces from Resident #63 and Resident #66 window blinds. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: Record review of Resident #28's face sheet, dated 12/10/25, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnosis included memory deficit following nontraumatic subcarotid hemorrhage, depression, vascular dementia (caused by impaired blood flow to the brain), anxiety disorder, epilepsy (a neurological disorder causing recurrent seizures), muscle wasting and atrophy, muscle weakness, dyspnea (shortness of breath), unsteadiness on feet, ither lack of coordination and fall on same level from slipping, tripping and stumbling without subsequent string against object, subsequent encounter.Record review of Resident #28's comprehensive MDS assessment, dated 10/29/25, reflected that she had a BIMS score of 4, which indicated severe cognitive impairment. She was also always continent of bladder and bowel. Record review of Resident #28's care plan, dated 10/24/25, reflected Resident #28 needed assistance with her ADL's. Record review of Resident #63's face sheet, date 12/10/25, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included attention and concentration deficit following cerebral infarction (brain tissue death), epilepsy (a neurological disorder causing recurrent seizures) and cerebral infarction (brain tissue death).Record review of Resident #63's comprehensive MDS assessment, dated 10/31/25, reflected that he had a BIMS score of 4, which indicated severe cognitive impairment. He was frequently continent with bladder and bowel. Record review of Resident #63's care plan, dated 10/24/2025, reflected Resident #63 has impaired temporal orientation (orientation to year, month and days related to diagnosis: dementia and memory deficit. Record review of Resident #66's face sheet, date 12/10/25, reflected he was a [AGE] year-old male, ordinally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included transient cerebral ischemic attack (a temporary blockage of blood flow to the brain), nontraumatic subdural hemorrhage (bleeding directly into the brain), dementia (a decline in mental ability severe enough to interfere with daily life), malaise (a general feeling of discomfort), headache and major depressive disorder (a serious mood disorder causing persistent sadness). Record review of Resident #66's quarterly MDS assessment, dated 06/13/25, reflected that he had a BIMS score of 3, which indicated severe cognitive impairment. He required assistance with toileting and supervision with showers. Record review of Resident #66's care plan, dated 09/05/2024, reflected Resident #66 has socially inappropriate disruptive behaviors at times. Assess resident for placement in a specially designed therapeutic unit. Convey an attitude of acceptance toward the resident, maintain a calm environment and approach the resident. During observation on 12/08/2025 at 9:10 A.M., Resident #28's bathroom floor was dirty with unidentified black track marks and water on the tile floor. Observations of the blinds in the resident rooms on the secured unit:12/08/2025 8:41 AM room [ROOM NUMBER]A- blinds missing pieces.12/08/2025 8:42 AM room [ROOM NUMBER]B- blinds missing pieces.12/08/2025 8:53 AM room [ROOM NUMBER]B- blinds missing pieces.12/08/2025 8:55 AM room [ROOM NUMBER]A-blinds missing pieces.12/08/2025 8:57 AM room [ROOM NUMBER]B-blinds missing pieces. 12/08/2025 9:00 AM room [ROOM NUMBER]A- blinds missing pieces.12/08/2025 9:03 AM room [ROOM NUMBER]B- blinds missing pieces.12/09/2025 10:37 AM room [ROOM NUMBER]-blinds missing pieces.12/09/2025 10:40 AM room [ROOM NUMBER]B-blinds missing pieces.12/09/2025 10:41 AM room [ROOM NUMBER] A&B- blinds missing pieces.12/09/2025 10:42 AM room [ROOM NUMBER]B- blinds missing pieces.12/09/2025 10:43 AM room [ROOM NUMBER] A&B- blinds missing pieces.12/09/2025 10:37 AM room [ROOM NUMBER]A-blinds missing pieces.12/09/2025 10:59 AM room [ROOM NUMBER]-blinds missing pieces. During an interview on 12/09/25 at 10:45 A.M., Resident 28 said she told staff that the sink leaked in the bathroom and when she turned on the water it got on the floor. She said she did not know the lady's name she told. She said the facility finally cleaned the floor yesterday; she said it had been dirty since she had been there for several weeks. During an interview on 12/09/25 at 11:08 A.M., CNA F said she agreed that the floor in Resident #28's room was very dirty yesterday, and the floor had not been cleaned in several days. She said the dirty floor with the sink leaking and the water on the floor could be a safety issue. She said some of the residents had complained about the damaged blinds, because of the sunlight coming in during the day. She said she would go get maintenance immediately. During an interview on 12/09/2025 at 11:15 A.M., LVN G said she agreed she saw Resident #28's bathroom floor yesterday and it was dirty; she said it was an ongoing thing with her. She said she had not been notified of the Resident #28's sink leaking in her bathroom. She said the bathroom floor was a safety issue and fall risk from the sink leaking water. She said she could turn off the water in the bathroom until maintenance could look at the sink. She said she agreed that when the residents tried to sleep with the pieces missing from the blinds it was an issue, because some of the residents liked to sleep during the day and the sunlight came in through the damaged areas. During an interview on 12/09/25 at 11:19 A.M., Resident #63 he said sometimes the sunlight got in his eyes when he tried to sleep and it made it hard for him to sleep during the day. During an interview on 12/09/25 at 11:21 A.M., Resident #66 he said sometimes the sunlight bothered him when he tried to sleep, but the facility just needed to stay on top of it. During an interview on 12/10/25 at 10:44 A.M., Maintenance Supervisor H said he had not fixed the sink Resident #28's room, he said it was next on his list. He said LVN G wrote the issue on his list yesterday (12/09/2025). He said he was not aware of the sink leaking until LVN G and CNA F mentioned it to him yesterday. He said the water was shut off from the main valve until he could fix the sink. He said the risk of the sink leaking and the water on the floor in the bathroom was a slip hazard. He said he had not noticed the floor in Resident #28's room was dirty. He said the blinds back in the secured unit was an issue. He said he usually changed the blinds on the secured unit once a week. He said he thought the condition of the blinds on the secured unit would affect the residents' sleep and quality of sleep during the day. During an interview on 12/10/25 at 11:11 A.M., Housekeeping Aide J said he was not here Monday (12/08/25). He said he seen mud and dirt on Resident #28's bathroom floor. He said he was there on Tuesday (12/09/25), and he cleaned Resident #28's bathroom. He said when he cleaned her bathroom floor Tuesday (12/09/25) it was filthy with tracks of water and dirt. He said the floor was a risk; he said the floor was dirty, wet and was a risk for slips or falls. During an interview on 12/10/25 at 12:34 P.M., the ADON said she did not know Resident #28's floor was dirty, water was on her floor, and her sink was leaking. She said if the floor was wet that would be a fall risk. She said way the floor looked was unacceptable. She said she would not want her home to look like that. She said the residents fiddled with the blinds on the unit a lot, but the facility does need to be replacing them as we find an issue. She said it was the residents' right not to have the light in their room in their eyes to the best of our ability. During an interview on 12/10/25 at 12:45 P.M., Acting Director of Nursing he agreed the facility needed to fix the blinds for a better homelike environment in the residents' rooms on the secured unit. He said the dirty floor and leaking sink in Resident #28's room was a fall hazard for sure. He said he would expect staff to keep the residents' room clean and if there were any items identified staff would address them immediately. During an interview on 12/10/25 at 1:17 P.M., the Administrator said he would agree that the light coming in during the day, with the damaged blinds, was a homelike environment issue. He said he would notify the maintenance guy to replace the blinds. He said Resident #28's bathroom floor was unacceptable. He said he would not want his floors in his home to look like that. He said the water leaking from the sink was a fall hazard. Record review of a facility policy titled, Homelike Environment revised February 2021. Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary and orderly environment.

Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 6 residents (Resident #9) reviewed for PASRR. The facility failed to refer Resident #9 for PASRR level II assessment, to the state-designated authority, upon receipt of a psychosis (symptoms that happen when a person is disconnected from reality) diagnosis. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.Findings included: Record review of Resident #9's face sheet, dated 12/09/25, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included unspecified psychosis. Dementia was not on his diagnosis list, and it was not designated as primary. The psychosis diagnosis was dated 11/06/24. Record review of Resident #9's quarterly MDS assessment, dated 11/21/25, reflected he had a BIMS score of 00, which indicated severe cognitive impairment. He was usually able to make himself understood and he was able to usually understand others. He had unclear speech. He received an antipsychotic and an antianxiety medication routinely. Record review of Resident #4's PASRR Level 1 Screening, dated 10/18/24, reflected that in Section C, Mental Illness was marked as no, which indicated Resident #9 did not have a mental illness. During an interview on 12/10/2025 at 12:24 PM, the MDS coordinator said she did not think Resident #9's PL1 should be positive because sometimes they do not have all of the diagnoses when they first receive the PL1 from the admitting facility. She said if the resident received the diagnosis of psychosis after he admitted , then she may have submitted a 1012 form and sent it to the Local authority. She said if she had submitted a positive PL1 form or a 1012 then the local authority would have come out and evaluated the resident. During an interview on 12/10/2025 at 12:43 PM, the ADON said she does not deal with PASRR. She said she does not review the PASRR forms. During an interview on 12/10/2025 at 12:51 PM, the Administrator said he was not aware Resident #9 had a diagnosis of psychosis. He said the PL1 form should have been marked as yes for mental illness or a 1012 form should have been completed. He said it was possible that the resident may have received PASRR services if evaluated by the Local authority. During an interview on 12/10/2025 at 1:05PM, the MDS Coordinator said a yes should have been marked on the PL1 form or a 1012 form should have been completed for Resident #9. She said she spoke with her corporate PASRR person, and they thought that a 1012 form or positive PL1 should have been completed. During an interview on 12/10/2025 at 1:15 PM, the RNC/Acting DON said his expectation would be for Resident #9 to have a positive PL1 form or a 1012 form. He said the risk was that Resident #9 may not be receiving services he could be getting. Record review of the facility's policy, PASRR, dated 07/29/25, reflected: .2. Screening Process:a). Level I Screening: This initial screening determines if the individual may have a mental illness or intellectual disability.5. Ongoing Review: Resident who are admitted under PASRR guidelines may undergo periodic reviews to ensure their needs are being met and that they continue to require nursing home care.

Based on observations, interviews, and record review, the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 13 (Resident #2) residents reviewed for medication storage and 1 of 4 medication carts (#1, #2, #3, #4).The facility failed to securely store medications, albuterol inhaler, for Resident #2.The facility failed to securely store medications, nystatin topical powder, in the locked drawers of the medication cart. This failure could place residents at risk for adverse reactions.Findings included:Record review of a face sheet dated 1/23/25 indicated Resident #2 was [AGE] years old and was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including displaced intertrochanteric fracture (serious break in the upper thigh bone (femur) near the hip joint, where the broken pieces have shifted out of alignment), ocular pain (discomfort on or around the eye, ranging from stinging/burning), muscle wasting and atrophy (decrease in muscle mass and strength, happening when protein breakdown exceeds synthesis, caused by inactivity (bed rest, immobilization), aging (sarcopenia), malnutrition, or diseases (cancer, heart failure, nerve damage).Record review of the MDS dated [DATE] indicated Resident #2 had a BIMS score of 14 which indicates normal cognitive function. MDS showed that Resident #2 required partial or moderate assistance with ADLs. Record review of a care plan revised on 10/10/25 indicated Resident #2 required assistance with his ADLs. Care plan did not indicate that Resident #2 used an albuterol inhaler. Record review of a physician's order dated 10/8/2025 for Resident #2 showed an order for albuterol sulfate and staff were to administer the medication by, aerosol inhaler; 90 microgram/actuation; amount: 2 puffs; inhalation. During an observation and interview on 12/8/2025 at 8:43 a.m. Resident #2 had an albuterol inhaler on his bedside table. Resident #2 said that he uses this inhaler every day. He said he leaves it on his bedside table and does not put it away in a drawer.During an observation on 12/8/2025 at 8:52 a.m. it was observed on top of B hall medication cart in plain view on B hall, a bottle of nystatin topical powder. Medication was not locked inside the medication cart drawer and was available for anyone to reach and take. During an interview on 12/10/25 at 9:00 a.m. ADON, she stated there are no residents in the facility that can self-administer medications which included albuterol inhalers. During an interview on 12/10/2025 at 9:25 a.m. LVN A said that residents should not have albuterol inhalers in their room without nurse supervision. She said that an albuterol inhaler should be kept in the nurse's medication cart. She said that nystatin topical solution should not have been stored on top of the medication cart as well. She said it should have been stored inside the locked drawers on the medication cart. She said that residents could possibly misuse both an albuterol inhaler and nystatin topical powder. She said that a resident could be harmed if they misused medication. During an interview on 12/10/25 at 12:18 PM, the ADON said that both albuterol inhalers and nystatin powder should have been stored in the locked medication cart. She said that it was the responsibility of nurses to ensure that the medications of residents are stored inside the medication cart and secured. She said that residents could be placed at risk of harm if they misused medication.During an interview on 12/10/25 at 12:30 PM, the Administrator said that medications should have been stored inside their locked drawers on the medication cart. He said that residents could harm themselves if they had access to medications. He said that nystatin topical powder and albuterol inhalers should be locked in their respective medication carts. During an interview on 12/10/25 at 1:02 p.m. with the Acting Director of Nurses he said that he expects that all medications are secured in the appropriate medication cart and locked. He said that residents could be placed at risk of harm if they misused medications or got ahold of medication that was not theirs. Record review of a facility policy titled, Medication Labeling and Storage revised in February 2023 reflected, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on interview and record review , the facility failed to provide pharmaceutical services, including the accurate acquiring, administering, and receipt of all drugs and biologicals, to meet the needs of 1 of 18 residents (Resident #31) reviewed for pharmacy services. The facility failed to ensure that 1 tablet of Resident #31's prescribed Hydrocodone (opiate pain medication) was properly accounted for and not missing on 12/10/25. This failure could place residents at risk for decreased quality of life, unrelieved pain, and dignity.Findings included: Record Review of Resident #31's undated face sheet indicated she was an [AGE] year-old female that admitted [DATE], with diagnoses that included: Cerebral infarction (a stroke, when a blood clot blocks an artery in the brain), chronic atrial fibrillation (the upper chambers of the heart beat chaotically and rapidly leading to an irregular and often fast heartbeat), Myelodyplastic Syndrome (a group of blood cancers where the bone marrow stem fail to produce enough healthy, mature blood cells leading to fatigue, anemia, infections, and bleeding), and pain. Record review of the quarterly MDS dated [DATE] indicated Resident #31 had a BIMS score of 15 indicating she was cognitively intact. The MDS indicated she had received PRN pain medications, had occasional pain, and received an opioid medication. Record review of the care plan dated 11/11/25 indicated Resident #31 had complaints of generalized pain and prescribed pain medications should be administered per her physician's orders. Record review of Resident #31's physician's orders dated 12/10/25 reflected the following: 12/8/25 Hydrocodone-Acetaminophen Oral tablet 5-325 mg, give 1 tablet by mouth every 4 hours as needed for pain. During an observation and interview of Nurse Cart A/B with LVN A on 12/10/25 at 9:28 AM this surveyor looked at the medication card for Resident #31's Hydrocodone-Acetaminophen Oral tablet 5-325 mg. There were 27 pills left in the punch card, however LVN A said the narcotic count sheet indicated there were 28 pills left in the punch card. LVN A said that was not correct. LVN A said she had not given Resident #31 any of those pills this morning or anytime today on her shift. During an interview on 12/10/25 at 9:33 AM, LVN A said she did not count the narcotics or reconcile the narcotics with LVN B when she took over the medication cart at approximately 6:30 AM this morning. She said she did not know why she did not reconcile/or count the narcotics. During an interview and record review on 12/10/25 at 9:34 AM, the ADON double checked the narcotic sheet for Resident #31's Hydrocodone-Acetaminophen Oral tablet 5-325 mg. The narcotic sheet indicated 28 pills should be in Resident #31's medication card. The ADON said there were only 27 pills left in the medication card for Resident #31. She said it appeared someone did not sign off the last pill given. The ADON said according to the narcotic sheet the last hydrocodone pill given to Resident #31 was on 12/9/25 at approximately 2:15 PM. The ADON said Resident #31 usually got 2-3 of those pills per day. The ADON and this surveyor looked at the MAR for Resident #31's hydrocodone and it indicated for the month of December she had not had any of the medication. The ADON said it appeared no medication was given in December 2025, and she did not know why the MAR would show that because she knew Resident #31 had several of those pills daily for pain. During an interview on 12/10/25 at 9:45 AM, This surveyor went into Resident #31's room. She was sitting in her recliner. Resident #31 denied any pain. She said LVN B had given her a pain pill last night. During a telephone interview on 12/10/25 at 9:52 AM, LVN B said she had given Resident #31 her Hydrocodone-Acetaminophen but forgot to document it. She said she had a new admit and was very busy. LVN B said she should have documented it but did not. During an interview on 12/10/25 at 10:16 AM LVN A said she came on shift this morning at 6:30 AM, but her shift was supposed to start at 6:00 AM. She said she was running late. She said LVN B did not ask her if she wanted to reconcile the medication and she did not ask LVN B. She said LVN B told her the narcotic count was correct. LVN A said the narcotic count was not correct. She said she and LVN B were supposed to count all narcotics before she took over the cart. She said she was taught to do that. She said she and LVN B did not count the narcotics this morning because she was running late. She said the risk of not counting the cart was that she could be accused of taking/stealing medication, or lose her license. She said she did not take or steal that (hydrocodone) pill and she would not have taken any medication. She said Resident #31 takes pain medication at night. She said she was confident LVN B gave that pill to Resident #31 because she had a lot of pain and LVN B would have given it. She said when she and LVN B have reconciled a cart in the past, they had never had a problem with the count. LVN A said she had always counted her narcotics before taking over a medication cart or giving another staff a medication cart until today. She said she had not given Resident #31 any of her hydrocodone this morning since she arrived on shift. She said she could not document Resident #31's PRN hydrocodone in the MAR in PCC because PCC would not let her, it would not populate on the MAR. During an interview on 12/10/25 at 10:31 AM, the ADON said the PRN hydrocodone (MAR) for Resident #31 was put in PCC wrong. She said it was put in Medication Aide MAR instead of the Nurse MAR where it belonged. That was why the nurses could not document in PCC that they had given it because it would not populate. She said they were currently in the process of changing to PCC from another computer program and had moved over 1000 orders. She said it was a mistake and was put in the wrong place. The ADON said no one told her there was a problem documenting the PRN hydrocodone for Resident #31, so she did not know about it until today. During an interview on 12/10/25 at 10:40 AM, LVN A said she had tried to document on the MAR when she had given the hydrocodone to Resident #31 but PCC would not allow it to populate on the MAR. She said she should have told the ADON but she did not. She said she should have made a progress note when she had given the medication since she was not able to document it on the MAR. She said she always signed the narcotic sheet when she got out a medication. LVN A said she should have told the ADON it would not populate on the MAR in PCC, but she did not. She said she may have gotten busy and forgotten but should have addressed it immediately. She had some education on PCC but needed more. She said she got more education today after this surveyor finding the count was wrong on Resident #31's PRN hydrocodone. All her other PRN medications had been documented in PCC, but this one was on the wrong MAR. The ADON fixed it and showed her in PCC that it had been fixed and now she could document giving the PRN hydrocodone to Resident #31 on the MAR. During an interview on 12/10/25 at 11:09 AM, LVN B said she gave Resident #31 her PRN hydrocodone 5/325 mg about 5:50 AM, last night right before shift change. LVN B said she walked by Resident #31's room and Resident #31 said her right shoulder was hurting 7 out of 10, (the pain scale is 0 - 10, with 0 being no pain and 10 being the worse pain imaginable), so she gave her a PRN hydrocodone. She said she took full responsibility for not documenting that and she should have documented it. She said she was very busy for her shift but that was no excuse for not documenting what she should have. She said she could not document giving the PRN medication on the MAR in PCC because it would not populate. She said Resident #31's hydrocodone was the only medication that she gave that would not populate on the MAR in PCC. She said she did not tell anyone that she could not document it in PCC, but she should have because she could have been accused of a diversion and did not want to ever overmedicate a resident. LVN B said normally she would document giving the medication on the narcotic sheet and in PCC, but she could not document it in PCC because PCC did not allow her to. She said she and LVN A did not reconcile/count the medication/narcotics when she gave the medication cart to LVN A this morning. She said LVN A was running late, there was a lot going on and they just did not do it. She said there was no excuse, and she apologized. She said this was the first and only time they had not reconciled the medications, and it was a stupid mistake. She said did not take, swallow, or steal that pill. She had given it to Resident #31. During an interview and record review on 12/10/25 at 11:18 AM, the ADON said she could not print out the incorrect MAR from earlier this morning that indicated no PRN hydrocodone had been given to Resident #31 in December 2025 because she already changed it to make it correct, but showed this surveyor an Order Audit Report that indicated she made the change and fixed the problem getting Resident #31's PRN hydrocodone on the correct MAR with a date of 12/10/25 at 10:29 AM. During an interview on 12/10/25 at 12:29 AM, the ADON said it was the expectation that the nurses reconcile the narcotic medication count at the beginning and end of each shift change. The reason was to prevent medication errors. She said LVN A and LVN B were in the wrong because they did not do that. She said both had been given a disciplinary write up for not following policy. She believes Resident #31 received her pain pill because Resident #31 told her she did. She said Resident #31 told her this morning about 10:00 AM that she had no pain and that LVN B had given her a pain pill. No one told her there was an issue with documenting Resident #31's PRN hydrocodone in PCC. She found out today. The ADON said when she checked to see what the problem was, she realized that particular medication (Hydrocodone) was a PRN medication on the wrong MAR sheet and was not showing up on the Nurse MAR sheet so they could not check off/document that they given it. She said she fixed it this morning at 10:29 AM and educated the nurses on PCC documentation. The risk of not documenting that medication was given on the narcotic sheet or in PCC was the resident could fail to have pain control, there could be a drug diversion, or the resident could get an extra pain pill. During an interview on 12/10/25 at 12:42 PM, the acting DON said nurses should always reconcile their medication carts at shift change and all narcotics should be counted. He said all medications given should be documented so staff know what has been given to the resident. He said the risk of not reconciling/counting narcotics on a medication cart could be a drug diversion, a missed or double dose of medication to a resident, and/or not knowing when a resident got their medication. During an interview on 12/10/25 at 12:45 PM, the ADM said LVN B should have documented the PRN hydrocodone immediately on the narcotic sheet when she gave it to Resident #31. He said if LVN A and LVN B had reconciled the cart like they were supposed to they would have realized LVN B did not document she gave Resident #31 the medication. He said when the nurses realized they could not document the medication in the MAR in PCC they should have reported it so that it could have been fixed. He said the risk of not documenting medications given to a resident was that they could get more than they should. Record review of a Controlled Substances policy with a revised date of November 2022 indicated: .Dispensing and Reconciling Controlled Substances1.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2.The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following:a.Records of personnel access and usage;b.Medication administration records;c.Declining inventory records; andd.Destruction, waste and return to pharmacy records.3.Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.4.The nurse coming on duty and the nurse going off duty make the count together and document and dreport any discrepancies to the director of nursing services. Missing observation in the DPS.

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident (Resident #6) reviewed for respiratory care and services. The facility failed to clean the filter on an oxygen concentrator machine that was in use for Resident #6 on 12/08/25 and 12/09/25. This failure could place residents at risk for developing respiratory complications.Findings included: Record review of Resident #6's face sheet, dated 12/10/25, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included pneumonia (an infection that inflames the air sacs in one or both lungs). Record review of Resident #6's quarterly MDS assessment, dated 08/22/25, reflected he had a BIMS score of 09, which indicated moderate cognitive impairment. Record review of Resident #6's Order Summary Report, dated 12/09/25, reflected the following orders:*Change oxygen filter for placement and cleanliness weekly on Sunday night and as needed. The start date was 12/09/25.*oxygen at 2 liters per minute via nasal cannula. The start date was 12/09/25. During an in observation on 12/08/2025 at 8:38 AM, Resident #6 was lying in bed in his room with oxygen in place via a nasal cannula. The oxygen concentrator filter was covered in a gray debris. During an observation on 12/09/2025 at 10:28 AM, Resident #6 was in his room lying in bed. He had oxygen in place via a nasal cannula. The oxygen concentrator filter was still covered in a gray debris. During an interview on 12/10/25 at 12:43PM the ADON said she washed Resident #6's concentrator filter on this day. She said every Sunday night and as needed, the filter should be cleaned by the nurse. She said the filter should be checked each shift by the nurse. She said the risk was infection control and the resident could get sick. During an interview on 12/10/25 at 12:51PM the Administrator said Resident #6's oxygen filter should have been cleaned. He said it was possible the resident could get sick. He said it could also affect airflow. During an interview on 12/10/25 at 01:15PM, the RNC/Acting DON said Resident #6's filter should be cleaned every Sunday night. He said the risk was that Resident #6 could have respiratory complications or illness. Record review of the facility's policy, Oxygen Administration, last revised October 2010, reflected that it did not mention the oxygen concentrator filter or its cleanliness.

Based on observation and interview the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 1 secured unit living rooms observed. The facility failed to ensure CNA D and LVN B did not have a blanket covering the overhead light in the secured unit living room on 9/18/25. This failure places residents at risk for a fire hazard and decreased quality of life.Findings Include:During an observation on 9/18/25 at 4:35 a.m. LVN B and CNA D were in the secured unit living room with a blanket covering the overhead light. LVN B was observed removing the blanket when the surveyor and a CNA walked into the secured unit living room. During an interview on 9/18/25 at 4:41 a.m. LVN B said covering the overhead light in the living room of the secured unit was not safe. LVN B said CNA D usually covered the overhead light in the secured unit dining room with a blanket. LVN B said a blanket covering a light could get too hot and catch fire. During an interview on 9/18/25 at 4:45 a.m. CNA D said she usually hung a blanket over the overhead light in the secured unit living room because the light could not be turned off and it shined directly into Resident #1's room. CNA D said the switch to the light in the secured unit living room did not work. CNA D said she kept Resident #1's door open so she could hear him because of his history of wandering. CNA D said she did not know if it was safe or not to cover the overhead light with a blanket. During an interview on 9/18/25 at 8:00 a.m. the Maintenance Director said the light switch in the living room of the secured unit was disconnected and not dysfunctional. The Maintenance Director said the light switch was disconnected before he had started at the facility, and it was disconnected to prevent staff from turning it off at night and sleeping while on the job. The Maintenance Director said staff should not be hanging a blanket over any light in the facility. The Maintenance Director said it was a fire hazard to hang a blanket or cloth over a light because light bulbs get hot and can catch the fabric on fire. During an interview on 9/18/25 at 8:22 a.m. the Administrator said he was not aware of the light switch in the living room of the secured unit being disconnected. The Administrator said staff should not cover lights with anything. The Administrator said covering lights with cloth was a fire hazard. During an interview on 9/18/25 at 9:29 a.m. the Administrator said the facility did not have a policy regarding covering lights with anything including cloth items.

Based on observation, interview, and record review, in accordance with State and Federal laws, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys on 3 of 7 (Medication Cart #1, Medication Cart #2, and Medication Cart #3) medication carts reviewed for labeling and storage of medication. The facility did not ensure the Medication Cart #1 (medication cart for the secured unit), Medication Cart #2 (nurse's medication cart for the west side of the building) and Medication Cart #3 ((nurse's medication cart for the east side of the building) were secured and unable to be accessed by unauthorized personnel on 9/18/25. This failure could place residents at risk for not receiving drugs and biologicals as needed or a drug diversion.Findings include: 1. During an observation on 9/18/25 at 4:30 a.m. Medication Cart #1 was in of the hallway unsupervised and unlocked. A CNA was walking by Medication cart #1 pushing a resident in their wheelchair down the hallway. 2. During an observation on 9/18/25 at 4:32 a.m. Medication Cart #2 was in of the hallway unsupervised and unlocked. A resident was wheeling themselves in their wheelchair down the hallway past Medication Cart #2. During an interview on 9/18/25 at 4:42 a.m. LVN B said Medication Cart #1 was the med cart for the secured unit and Medication Cart #2 was the nurse's med cart for the west side of the building. LVN B said both med carts had medication in them. LVN B said he did not usually keep the medication carts unlocked. LVN B said the medication cart was unlocked because he had recently used them. LVN B said the importance of keeping medication carts locked was to prevent the loss of medications and to keep residents from getting into them. 2. During an observation on 9/18/25 at 4:36 a.m. Medication Cart #3 was unlocked. LVN A was walking down the hall away from Medication Cart #3 with his back to the med cart. During an interview on 9/18/25 at 4:48 a.m. LVN A said Medication Cart #3 was the nurse's med cart for the east side of the building. LVN A said Med Cart #3 was unlocked because he had been working out of the nurse's med cart, the med aide med cart, and the treatment cart. LVN A said he would lock Medication Cart #3 if the surveyor wanted him to. LVN A said Medication Cart #3 was in his sight. LVN A said the importance of keeping the medication cart locked was so someone did not get into them and take medications. LVN A said Medication Cart #3 had PRN medication in it. 3. During an observation on 9/18/25 at 6:50 a.m. Medication Cart #1 was unlocked in hallway of secured unit with 2 residents sitting in wheelchairs on either side of the med cart. During an interview on 9/18/25 at 6:52 am LVN C said she had left Medication Cart #1 unlocked while trying to get residents' blood pressures so she could pass medication prior to breakfast. LVN C said sometimes she did leave her med cart unlocked. LVN C said the importance in ensuring medication cart were locked was to prevent residents from getting medication out of the medication cart and taking a medication, they were not prescribed. During an interview on 9/18/25 at 8:22 a.m. the Administrator said medication carts should be locked when staff are not getting something out of them. The Administrator said the importance of keeping medication carts locked was to prevent residents from getting in them and taking medication not prescribed to them and to prevent staff from being able to get in the carts and steal medications. During an interview on 9/18/25 at 8:52 a.m. the ADON said medication carts should not be unlocked unless the staff member assigned to that particular cart is actively getting medications out of it or standing directly in front of the medication cart. The ADON said the importance of ensuring medications cart were locked was to prevent anyone else accessing the medications, cream, insulins, etc. that are store on the cart. Record review of the facility's Medication Storage in the Facility policy dated 6/1/22 indicated, Medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.

Based on interview and record reviews, the facility failed to ensure registry verification was received that the individual had met competency evaluation requirements before they were allowed to work as a nurse aide for 1 of 4 (CNA E) employees reviewed for registry verification. The facility failed to ensure CNA E had a current nurse aide certification while employed at the facility and actively providing care for residents from [DATE] through [DATE]. CNA E certificate expired on [DATE]. This failure placed residents at risk for decreased quality of care. Findings included:Record review of CNA E's employee file indicated her nurse aide certification was issued on [DATE] and would expire on [DATE]. The employee file indicated CNA E's initial nurse aide certification was issued on [DATE]. The employee file indicated she applied to the facility on [DATE] and was available for work on [DATE]. The employee application indicated her nurse aide certification would expire on [DATE]. Record review of CNA E's time sheets from [DATE] through [DATE] indicated other than 4 days of PTO, she had taken CNA E had worked her normal full-time shift at the facility. During an interview on [DATE] at 11:50 a.m. the BOM said CNA E's nurse aide certification expired on [DATE]. The BOM said when LVN C brought it to her attention that CNA E had an expired nurse aide certification she pulled the certification in TULIP and saw it had been renewed on [DATE]. The BOM said she did not know how many if any days CNA E had worked with an expired nurse aide certification or why CNA E did not renew her nurse aide certification by [DATE]. The BOM said she did not know how LVN C was aware of CNA E's expired nurse aide certification or what date she was notified on. During an interview on [DATE] at 12:35 p.m. the Administrator said he had not been aware CNA E had been working with an expired nurse aide certification until she told them. The Administrator said the facility and corporate do monitor for expired or expiring license and certifications, but CNA E had not showed up on any of their lists. The Administrator said CNA E told them she had not renewed her certification because she did not know how to work TULIP. During an interview on [DATE] at 12:41 p.m. CNA E said her nurse aide certification was expired for several months without her realizing it because she thought the facility would renew it for her like her previous facility did. CNA E said when she realized her nurse aide certification was expired due to her working nights, she had not gone up to the facility to have them assist her with the renewal paperwork. CNA E said there was really no excuse for her nurse aide certification being expired for so long. During an interview on [DATE] at 2:25 p.m. the Administrator said the facility did not have a policy regarding nurse aide certification renewal/expirations/registry. The Administrator said the facility did have an annual employee checklist that was supposed to be completed on all employees annually.

Based on interview and record review the facility failed to ensure residents were free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms 1 of 13 (Resident #1) residents reviewed for restraints. The facility failed to ensure Resident #1 was administered her Xanax (medication used to treat anxiety) every 8 hours as needed per the physician's orders instead of Resident #1 having it administered in less than 8 hours on several dates in July 2025 by LVN A and LVN B to keep Resident #1 quiet. This failure could place residents who receive psychotropic medications at risk of not receiving the intended therapeutic benefit of the medications.Findings included: Record review of the face sheet dated 8/29/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including anxiety, dementia, muscle weakness, lack of coordination, and restlessness and agitation. Record review of the entry MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 09 and was moderately cognitively impaired. Record review of the care plan revised on 8/14/25 indicated Resident #1 was at risk for variations in mood related to impaired cognition, major depressive disorder, anxiety, and schizoaffective disorder bipolar type (a mental health condition that combines symptoms of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings). Record review of the order history dated 7/29/25 through 8/29/25 indicated Resident #1 had an order for a Xanax 1mg every 8 hours as needed starting 3/26/25. Record review of the narcotic count sheet for Resident #1's Xanax 1mg indicated Resident #1 was administered the Xanax in less than 8 hours on the following dates: 7/17/25 administered at 4:00 a.m. by an unknown nurse and again at 8:00 a.m. by LVN B. 7/21/25 administered at 9:30 a.m. by LVN B and again at 2:30 p.m. by LVN B. 7/22/25 administered at 8:45 a.m. by LVN B and again at 2:30 p.m. by LVN B. 7/27/25 administered at 10:15 a.m. by LVN B and again at 4:15 p.m. by LVN B. 7/28/25 administered at 4:00 a.m. by the AON and again at 10:15 a.m. by LVN B. 7/29/25 administered at 8:16 a.m. by LVN A and again at 3:00 p.m. by LVN A. 7/31/25 administered at 2:00 p.m.by LVN A and again at 6:00 p.m. by LVN A. Record review of the MAR indicated Resident #1's Xanax administration was not documented on 7/17/25, 7/21/25, 7/22/25, 7/27/25, or 7/31/25. The MAR indicated Resident #1's Xanax administration was only documented on 7/28/25 at 4:00 a.m. and 7/29/25 at 8:17 a.m. During an interview on 8/29/25 at 8:44 a.m. the ADON said LVN A was no longer employed at the facility. During an interview on 8/29/25 at 8:45 am LVN B said she had administered Resident #1's Xanax in less than the ordered 8 hours because giving Resident #1 her as needed Xanax was LVN B's answer to Resident #1's behaviors. LVN B said she felt like she needed to keep Resident #1 quiet when she was having behaviors of yelling out. LVN B said she has since learned there are other ways to handle resident behaviors. LVN B said she should have been documenting the as needed Xanax administration on the MAR. LVN B said she was getting better about documenting as needed medication administration on residents' MARs. During an interview on 8/29/25 at 2:06 pm the DON said she expected the nurses to assess and document assessment prior to administering as needed medication. The DON said she expected the nurses to administer as needed medication as ordered and in at least the minimum time frame ordered if needed. The DON said as needed medication do not fall in the hour before hour after parameters that scheduled medication can be given. The DON said as needed medication effectiveness should be documented and if a nurse determines the medication was not being effective within the time frames it is ordered, then she expected them (staff) to notify the physician, and not give the medication earlier than ordered. The DON said the importance of following the physician's orders and administering as needed medications as ordered was not to overmedicate the resident and be able to signify if a medication was effective within the parameters ordered. The DON said she expected all medications including as needed medications to be documented in the EMR. The DON said the importance of documenting in the EMR was that was the official documentation indicating a medication had been administered and it allowed other nurses to know when a resident least had a medication and the medications effectiveness. Record review of the facility's Medication Administration-General Guidelines policy dated 6/1/22 indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.A. Preparation.4. Five Rights- right resident, right drug, right dose, right route, and right time, are applied for each medication being administered .5. The medication administration record (MAR) is always employed during medication administration.B. Administration.2. Medications are administered in accordance with written orders of the prescriber.

Based on observation, interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) 1 of 13 (Resident #2) residents reviewed for notification of change. The facility did not notify the physician of Resident #2's weeping edema (a condition where fluid leaks from the skin), redness, and blister to her right leg. LVN B or D had not notified the physician or NP to obtain an order for an ace wrap or notify them of the swelling and weeping to Resident #2's right leg on 08/29/2025. The facility did not ensure physician orders were obtained for treatment of Resident #'2's swollen and weeping leg or application of dressings prior to applying dressings to Resident #2's leg. This failure could place residents at risk for not receiving care and services to meet resident needs.Findings included: Record review of the face sheet dated 8/29/25 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including edema (swelling that occurs when fluid builds up on the body's tissues), hypertension (elevated blood pressure), and congestive heart failure (a chronic condition in which the heart does not pump blood as good as it should with symptoms including swollen legs). Record review of the MDS dated [DATE] indicated Resident #2 was admitted to the facility on [DATE]. Record review of the base line care plan dated 8/20/25 indicated Resident #2's needs, risks, strengths, and goals would be identified for the first 48 hours. Record review of Resident #2's orders dated 7/29/25 through 8/29/25 indicated she did not have an order for wound care or a dressing to be applied to her right leg. During an observation and interview on 8/29/25 at 10:12 a.m. Resident #2 was observed with a nonstick dressing to her right shin and wrap gauze down around her ankle. Resident #2's right leg was observed to be swollen with redness from approximately mid shin to her ankle. Resident #2 said a nurse (name unknown) had put the dressing and gauze on her leg due to a weeping blister on her shin. Resident #2 said another nurse (name unknown) after she first admitted to the facility (date unknown) had wrapped her leg with an ace bandage to catch the weeping due to her leg weeping and getting her sheets wet. During an interview on 8/29/25 at 10:36 a.m. the Physician said he was unsure whether he had been contacted regarding Resident #2's leg weeping or need for a dressing. The Physician said his NP usually takes daily calls from nursing facilities. The Physician said he was taking the calls at this time due to his NP being out of the country. The Physician said if he had been contacted regarding swelling to a resident's leg, he probably would have added a diuretic medication (a medication that increases urine production and sodium excretion to treat fluid buildup). The Physician asked the surveyor to have the DON look at Resident #2's leg and call him. During an observation and interview on 8/29/25 on 10:45 a.m. the surveyor observed Resident #2's right leg with the DON. The DON said she was not aware a dressing had been put on Resident #2's right leg. The DON removed the dressing and assessed Resident #2's right leg. The DON said Resident #2's right leg was red and swollen. The DON said she was aware that LVN B had previously wrapped Resident #2's right leg with an ace wrap due to swelling and weeping. The DON said LVN B had not notified the physician or NP to obtain an order for the ace wrap or to notify them of the swelling and weeping to Resident #2's right leg. The DON said the LVN C, had been the nurse who had discovered and reported to the ADON that Resident #2's right leg was wrapped with an ace wrap. During an interview on 8/29/25 at 10:50 a.m. LVN D said she was working on 8/28/25 and Resident #2 came to her after dinner and showed her what appeared to be a burst blister with drainage to her right leg. LVN D said she applied a non-stick dressing to the area and wrapped it with wrap gauze. LVN D said she had intentions to but never notified the physician or obtained an order for the dressing. During an interview on 8/29/25 at 10:55 a.m. the DON said she expected staff to notify the physician of changes in condition including skin conditions, swelling, or weeping. During an interview attempt on 8/29/25 at 12:16 p.m. LVN B did not answer the phone and her voicemail was full. During an interview on 8/29/25 at 2:06 p.m. the DON the importance of notifying the physician of a change in condition was to get the appropriate diagnosis and treatment for a resident. Record review of the facility's Change in a Resident's Condition or Status policy last revised 6/2025 indicated, Our facility promptly notifies the resident, his or her attending physician, healthcare provider, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician, healthcare provider, or physician on call when there had been a(an):.b. discovery of injuries of unknown origin.d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly.Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status.

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 13 (Resident #2) residents reviewed for quality of care. The facility did not notify the physician of Resident #2's weeping edema (a condition where fluid leaks from the skin), redness, and blister to her right leg. The facility did not ensure physician orders were obtained for treatment of Resident #'2's swollen and weeping leg or application of dressings prior to applying dressings to Resident #2's leg. These failures could place residents at risk for not receiving care and services to meet resident needs and decreased quality of life. Findings included: Record review of the face sheet dated 8/29/25 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including edema (swelling that occurs when fluid builds up on the body's tissues), hypertension (elevated blood pressure), and congestive heart failure (a chronic condition in which the heart does not pump blood as good as it should with symptoms including swollen legs). Record review of the MDS dated [DATE] indicated Resident #2 was admitted to the facility on [DATE]. Record review of the base line care plan dated 8/20/25 indicated Resident #2's needs, risks, strengths, and goals would be identified for the first 48 hours. Record review of Resident #2's orders dated 7/29/25 through 8/29/25 indicated she did not have an order for wound care or a dressing to be applied to her right leg. During an observation and interview on 8/29/25 at 10:12 a.m. Resident #2 was observed with a nonstick dressing to her right shin and wrap gauze down around her ankle. Resident #2's right leg was observed to be swollen with redness from approximately mid shin to her ankle. Resident #2 said a nurse (name unknown) had put the dressing and gauze on her leg due to a weeping blister on her shin. Resident #2 said another nurse (name unknown) after she first admitted to the facility (date unknown) had wrapped her leg with an ace bandage to catch the weeping due to her leg weeping and getting her sheets wet. During an interview on 8/29/25 at 10:36 a.m. the Physician said he was unsure whether he had been contacted regarding Resident #2's leg weeping or need for a dressing. The Physician said his NP usually takes daily calls from nursing facilities. The Physician said he was taking the calls at this time due to his NP being out of the country. The Physician said if he had been contacted regarding swelling to a resident's leg, he probably would have added a diuretic medication (a medication that increases urine production and sodium excretion to treat fluid buildup). The Physician asked the surveyor to have the DON look at Resident #2's leg and call him. During an observation and interview on 8/29/25 on 10:45 a.m. the surveyor observed Resident #2's right leg with the DON. The DON said she was not aware a dressing had been put on Resident #2's right leg. The DON removed the dressing and assessed Resident #2's right leg. The DON said Resident #2's right leg was red and swollen. The DON said she was aware that LVN B had previously wrapped Resident #2's right leg with an ace wrap due to swelling and weeping. The DON said LVN B had not notified the physician or NP to obtain an order for the ace wrap or to notify them of the swelling and weeping to Resident #2's right leg. The DON said the LVN C, had been the nurse who had discovered and reported to the ADON that Resident #2's right leg was wrapped with an ace wrap. During an interview on 8/29/25 at 10:50 a.m. LVN D said she was working on 8/28/25 and Resident #2 came to her after dinner and showed her what appeared to be a burst blister with drainage to her right leg. LVN D said she applied a non-stick dressing to the area and wrapped it with wrap gauze. LVN D said she had intentions to but never notified the physician or obtained an order for the dressing. During an interview on 8/29/25 at 10:55 a.m. the DON said she expected staff to notify the physician of changes in condition including skin conditions, swelling, or weeping. During an interview attempt on 8/29/25 at 12:16 p.m. LVN B did not answer the phone and her voicemail was full. During an interview on 8/29/25 at 2:06 p.m. the DON the importance of notifying the physician of a change in condition was to get the appropriate diagnosis and treatment for a resident. Record review of the facility's Change in a Resident's Condition or Status policy last revised 6/2025 indicated, Our facility promptly notifies the resident, his or her attending physician, healthcare provider, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician, healthcare provider, or physician on call when there had been a(an):.b. discovery of injuries of unknown origin.d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly.Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical record maintained for each resident were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for resident records. The facility failed to ensure accurate documentation was documented for Resident #1's wound care on 3/21/25 when the DON (who did not perform the wound care) edited LVN B's (the nurse that performed the wound care) progress note for Resident #1 five days after the wound care (3/26/25). This failure could place residents at risk for delayed interventions, appropriate interventions, health complications and decreased quality of life. Findings include: Record review of Resident #1's face sheet dated 5/8/25 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of buttock with fat layer exposed, unspecified skin changes, and history of cellulitis (a common bacterial infection of the skin and underlying tissues). Record review of the MDS dated [DATE] indicated Resident #1 made herself understood and usually understood others. The MDS indicated Resident #1 had moderate cognitive impairment (BIMS of 12). The MDS indicated Resident #1 was dependent on staff for toileting, showering, and lower body dressing. The MDS also indicated Resident #1 required substantial assistance for dressing the upper body and personal hygiene. The MDS indicated she had a surgical wound. Record review of the care plan revised on 4/15/25 indicated Resident #1 had an open area to the left hip and was a surgical sight. The care plan interventions included treat area per physician order, cleanse area to left hip with normal saline, pat dry, apply calcium alginate and cover with a dry dressing. During an interview and observation on 5/5/25 at 12:08 p.m., Resident #1 said she received her wound care daily and had no complaints with the care she received. Resident #1 said she had already received wound care for the day. Resident #1 said she had not missed any days of wound care to her knowledge. Record review of the nursing note dated 3/21/25 written by LVN B stated changed dressing to left hip. Previous dressing was dated 3/18/25. Tolerated well. The note was edited by the DON on 3/26/25 and read Changed dressing to left hip. Tolerated well. During an interview on 5/5/25 at 1:00 p.m., LVN B said her note read the previous dressing was dated 3/18/25 because that was the date on the dressing when she went to perform the daily dressing change on 3/21/25. LVN B said she did not know why the DON had changed her note. During an interview on 5/8/25 at 2:00 p.m., the DON said she edited the note because it was a red flag and suggested Resident #1 had not received daily wound care. The DON said she had not performed the wound care herself. The DON said she suspected LVN B had falsified the note to cause trouble. The DON said she should not have changed the note but should have talked to LVN B and documented her concerns but should not have changed the note. The DON said she should have handled it differently. During an interview on 5/8/25 the Administrator said he expected resident records to be complete and accurate. Record review of the facility policy and procedure, revised April 2012 title Guidelines for charting and Documentation stated .the purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., and the progress of the resident's care .a legal record that protects the resident the care providers and the facility .General rules .2. Be concise, accurate and complete .

Based interviews and record review, the facility failed to ensure each resident was free from misappropriation of resident property for 2 of 3 residents (Resident #2 and Resident #3), reviewed for drug diversion. The facility failed to prevent the misappropriation of Resident #2 and Resident #3's hydrocodone-acetaminophen 5-325 mg (formerly known under the brand name Norco, this combination medication containing 5 mg of hydrocodone [an opioid analgesic] and 325 mg of acetaminophen [also known as Tylenol] is used to treat pain). This failure could place residents at risk for not receiving their prescribed medications, unrelieved pain, and decreased quality of life. Findings include: 1.Record review of Resident #2's face sheet dated 5/8/25 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, Herpes viral vesicular dermatitis (a painful skin infection caused by the Herpes Simplex Virus); myelopathy (neurological deficits and pain stemming from damage or injury to the spinal cord, often resulting from compression or other forms of injury); peripheral vascular disease (a circulatory condition where blood vessels outside the heart and brain narrow, block, or spasm, restricting blood flow which can cause pain) and unspecified pain. Record review of the MDS dated [DATE] indicated Resident #2 usually made himself understood. The MDS indicated Resident #2 had mildly impaired cognitive ability (BIMS of 9). The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, and toilet use. Record review of the care plan dated 3/31/25 indicated Resident #2 had chronic pain. The care plan interventions included administer prescribed medications as ordered by the physician. Record review of the active physician order with a start date of 3/21/25 detailed Resident #2 was to be administered hydrocodone-acetaminophen 5-325 mg 1 tablet every four hours as needed for moderate to severe pain. During an observation and interview on 5/8/25 at 1:55 p.m., Resident #2 sat in his wheelchair in his room. Resident #2 said his pain had been well managed since she had been at the facility and no complaints. Resident #2 said the pain medication the facility administered him for pain was effective. Resident #2 said he was not in any pain at the time of the interview and observation. 2.Record review of the face sheet for Resident #3 dated 5/8/25, indicated she was [AGE] years old, admitted to the facility on [DATE] with diagnoses including cirrhosis of the liver (chronic liver disease where scar tissue replaces healthy liver tissue, impairing the liver's ability to function normally, an often painful condition), muscle spasm, chronic pain, and polyneuropathy (a painful condition where damage or dysfunction affects multiple peripheral nerves throughout the body). Record review of the MDS dated [DATE], indicated Resident #3 made herself understood and understood others. The MDs indicated she had intact cognitive function (BIMS of 15). The MDS indicated Resident #3 required extensive assistance with showering, dressing the lower body, and personal hygiene. The MDS indicated Resident #3 frequently experienced pain during the 5 day look back period which occasionally made it difficult for her to sleep at night, rarely or not at all interfered with rehabilitation services, and occasionally interfered with day to day activities. Record review of the care plan dated 4/4/25 indicated Resident #3 experienced chronic pain in her back and both legs. The car plan interventions included, administer prescribed medications as ordered by the physician. Record review of the active physician order with a start date of 4/7/25 detailed Resident #3 was to be administered hydrocodone-acetaminophen 5-325 mg 1 tablet every six hours as needed for pain. During an observation and interview on 5/7/25 at 1:00 p.m., Resident #3 sat smiling in her wheelchair. Resident #3 said her pain had been well managed since she had been at the facility and no complaints. Resident #3 said sometimes she would have increase in pain after therapy but added the pain medication the facility administered her for pain was effective. Resident #3 said she was not in any pain at the time of the interview and observation. Record review of the provider investigation report (PIR) dated 4/23/25 detailed that LVN A discovered on 4/15/25 at approximately 9:00 pm that Resident #2 had 29 tablets of hydrocodone/acetaminophen 5-325 mg replaced with extra strength Tylenol and Resident #3 had 7 tablets of hydrocodone/acetaminophen 5-325 mg replaced with extra strength Tylenol. The provider investigation report detailed that the narcotic sheets and pill bottles were confiscated and locked up, medication cart and medication room audits were performed by the DON and no other issues were identified. Pain assessments for all residents were completed on the hall on which Resident #2 and Resident #3 resided with no adverse findings. The pharmacy consultant was notified and also performed medication cart and medication room audits with no additional issues identified. The extra strength Tylenol was replaced with the prescribed hydrocodone/acetaminophen 5-325 mg. The provider investigation report detailed the facility identified six nurses who had access to the locked medication cart from which the pills were taken. Those nurses provided witness statements. The nurses that had access to the cart on Wednesday the 14th and Thursday the 15th were drug tested . Of those nurses LVN A tested positive. Her results were sent for additional testing as she provided evidence she (LVN A) had a prescription for the medication herself. (The additional testing was to determine if the medication in her system was outside of the prescribe range). The local police department, state agency resident physician and medical director were notified. Record review of the signed witness statement dated 4/17/25 signed by LVN A detailed that she worked the evening shift of 4/15/25. The statement detailed that at approximately 8:30 p.m., Resident #3 asked for a pain pill and a muscle relaxer. LVN A retrieved the bottle of hydrocodone/acetaminophen Resident #3 had brought from home with her upon her admission to the facility. LVN A detailed that when she opened the bottle to dispense 1 tablet she noticed the medication did not appear to be Hydrocodone/acetaminophen but looked more like Tylenol. LVN A detailed she used pill identifier to confirm her suspicion and the pills were Tylenol. LVN A said she knew one other resident also took Hydrocodone/acetaminophen from a pill bottle that had been sent with him form another nursing facility, so she checked that resident's (Resident #2's) medication as well, and found that it too was Tylenol. An interview with LVN A was attempted on 5/5/25 at approximately 10:00 a.m. and 5/8/25 at 10:58 a.m., detailed messages were left on her voicemail each time. No return call was received. Record review of the police report date 4/16/25 detailed that the officer responded to call at the facility in reference to theft of pills. The officer reported he spoke the DON and the administrator who informed him LVN had found that hydrocodone pills were missing and had been replaced with extra strength Tylenol. The reported detailed that the DON explained both residents had admitted to the facility with the pill bottles and that the pills had been counted and returned to the bottles on their admission. The report detailed that the DON reported she could not be sure the bottles had hydrocodone in the bottles when the residents arrived to the facility. The report detailed the Administrator wished to file charges in the manner . An interview with the police officer that took the police report was attempted on 5/8/25 at 2:20 p.m. the dispatcher took the investigators information and indicated she would have the officer return the call, no return call was received. During an interview on 5/8/25 at 2:00 p.m., the DON said the facility tested nurses with access to the carts for the 48 hours prior to discovery of the event as neither resident reported increased or unrelieved pain so it was thought the switch had happened recently. In addition, when all the findings were presented to the corporate office the instruction they (the DON and Administrator) received was to test nurses for the past 48 hours with access to the cart. The DON said LVN A tested positive but reported she had a prescription for the medication. The DON said the decision was made to send the sample to an outside lab to perform additional testing to see if the levels in her sample indicated levels above the prescribed amount. However, the results from that lab were inconclusive. The DON explained apparently in the transport of the sample to the lab the requisition slip was separated from the specimen so the lab refused to run the test. The DON said LVN A had been suspended pending the investigation and was phoned and told the results were inconclusive and she would be allowed to return to work. The DON said however, LVN A no called no showed and has not returned. The DON said LVN A not returning to work was suspicious but they could not substantiate she had swapped the pills. The DON said we really could not say when the swap occurred. The DON said going forward they will not accept pills bottles/administer controlled substances from pill bottles. The DON said in the event the pills are provided to the facility they will be sent to the pharmacy for verification and placed in blister packs (a blister pack is a type of packaging where a product [often a pill] is encased in a plastic bubble attached to a card. The primary purpose of a blister pack is to protect the product, offer a clear display for consumers, and sometimes provide tamper-evident features). The DON said if a controlled medication for pain is needed while this process takes place the medications will be administered from the facilities emergency kit. During an interview on 5/8/25 at 2:50 p.m., the Administrator said misappropriation had occurred and while he suspected LVN A he did not know for certain. The Administrator said the facility performed and in-services and going forward no pill bottles would be accepted. He said if a resident came from home or another facility with the pain pills in bottles the pills would be sent to the pharmacy for verification and the pills would be placed in blister packs. Review of the facility policy and procedure titled Abuse, Neglect and Exploitation, revised October of 2023, stated The facility will provide protection for the health welfare and rights of each resident .prohibit and prevent the .misappropriation of resident property. Review of the facility policy and procedure titled Controlled Substances, dated 6/1/22, stated 9. Upon receipt the nurse receiving the medication and the individual delivering the medication verify the name, dose, and quantity of each controlled substance being delivered . The policy and procedure did not address receiving pills in bottles and those pills being verified by pharmacy consultant and placed in blister packs.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 2 shower rooms (B hall) reviewed for homelike environment. The facility failed to ensure the shower room on B hall did not have black grime buildup on the walls and missing tiles on the floor. This failure could place the residents at risk for a decreased quality of life, an uncomfortable, unhomelike environment due to unsanitary conditions. Findings included: During an observation and interview on 04/09/2025 at 4:04 PM, an observation of the shower room on B hall revealed the shower was missing tiles on the floor, the walls of the shower room had thick black gunk on them. LVN A said it looked like the shower room had not been cleaned. LVN A said housekeeping should be cleaning the shower, but she had not seen them clean it recently. LVN A said it was important for the shower to be clean for hygiene purposes and cleanliness, and the tile missing could result in mildew. During an observation on 04/10/2025 at 8:38 AM, the shower on B hall had black gunk on the walls, a pink stain on the floor, and tiles on the shower floor were missing. During an interview on 04/10/2025 at 8:42 AM, CNA F said housekeeping was responsible for cleaning the showers. CNA F said he had seen one of the housekeepers cleaning the shower on B hall yesterday (04/09/2025). CNA F said the tile on the shower floor had been missing for about 40-45 days. CNA F said he did not know if the missing tile had been logged on the maintenance log for it to be repaired. CNA F said it was important for the shower to be clean for infection control and to prevent cross contamination. CNA F said it was important for the missing tile to be repaired because it could cut somebody, cause the shower chair to get stuck, and cause an accident. During an interview on 04/10/2025 at 8:48 AM, the Maintenance Director said he was aware that the shower on B hall had missing tiles on the floor, and it had been going on for a few months. The Maintenance Director said the repair was the next one in line to be done. The Maintenance Director said it was important for the shower room not to have missing tiles because nobody wanted a nasty shower, and it could cause a slight injury to the residents. During an interview on 04/10/2025 at 10:39 AM, Housekeeper L said she was not responsible for cleaning the shower on B hall. Housekeeper L said one of the other housekeepers was responsible, but she did not know who. Housekeeper L said the CNAs were responsible for cleaning the shower when they did their showers, and then the housekeeper cleaned it. During an interview on 04/10/2025 at 10:42 AM, the Housekeeping/Laundry Supervisor said the showers should be cleaned every day by the housekeepers. The Housekeeping/Laundry Supervisor said she was aware of the shower room on B hall having the black gunk on the walls. The Housekeeping/Laundry Supervisor said they had to scrub the walls to get them clean, but then every couple of days it would come back. The Housekeeping/Laundry Supervisor said Housekeeper M was responsible for cleaning the shower on B hall. The Housekeeping/Laundry Supervisor said it was important for the showers to be clean because it can end up with germ buildup and infection could go through the roof and everybody will start getting sick. During an interview on 04/10/2025 at 10:51 AM, Housekeeper M said the showers should be cleaned every week. Housekeeper M said when she scrubbed the shower walls most of the black build up came off. Housekeeper M said the last time she cleaned the shower on B hall was Monday (04/07/2025). Housekeeper M said she had notified her supervisor about having difficulty removing the black build up on the walls of the shower. Housekeeper M said she had noticed the missing tiles on the floor of the shower but had not reported it to anybody because sometimes she got busy and forgot about it. Housekeeper M said it was important for the shower to be clean for the residents because it could make them sick if it was dirty. Housekeeper M said the missing tiles on the floor of the shower could cause the residents to fall. During an interview on 04/10/2025 at 11:22 AM, the Administrator said he was made aware of the condition of the shower on B hall that morning (the morning of 04/10/2025). The Administrator said housekeeping was responsible for cleaning the showers. The Administrator said the showers should be cleaned daily by housekeeping and then a deep clean was completed weekly by the Housekeeping/Laundry Supervisor. The Administrator said the shower room should be clean for cleanliness and because they did not want to deal with dirt, and it could affect the resident's psychological well-being. The Administrator said the shower missing tiles on the floor should be repaired because it was just a bumpy ride for the shower chair in or out, and it needed to look good. Record review of the Maintenance Log Work Order requests for the months of May 2024 through the Month of March 2025 did not indicate a work order for the shower on B hall. There were no work orders for the month of April 2025. Record review of the facility's policy titled, Resident Rights, revised February 2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity .

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 6 (Resident #55) reviewed for quality of care. The facility failed to obtain treatment for Resident #55's urinary tract infection thus leading to Resident #55's hospitalization . An IJ was identified on 8/09/2023. The IJ template was provided to the facility on [DATE] at 1:24 p.m. While the IJ was removed on 8/09/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on notification of changes and evaluate the effectiveness of the corrective systems. This failure could place residents at an increased risk for exacerbation of infections, septicemia, and even death. Findings included: Record review of an undated face sheet indicated Resident #55 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of acute and chronic respiratory failure (a serious condition that makes it difficult to breath on your own), extended spectrum beta lactamase (ESBL) resistance (an enzyme that makes bacteria resistant to antibiotics), heart failure (when the heart muscle does not pump blood as well as it should). Record review of a Quarterly MDS dated [DATE] indicated Resident #55 understood others and was understood by others. Resident #55's BIMS score was 15, and she had no cognitive problems. The MDS indicated Resident #55 had not displayed rejection of care. The MDS indicated Resident #55 required supervision of one staff for toileting and personal hygiene. The MDS indicated Resident #55 did not have an indwelling foley catheter, had occasional urinary incontinence, and frequent bowel incontinence. The MDS indicated in the Active Diagnoses Section I indicated Resident #55 had septicemia (a life-threatening condition that arises when the body's response attacks the body's own tissue and organs) and MDRO {(multidrug-resistant organism) when a drug that could normally be used to treat an infection does not work to treat the organism causing the infection, the organism is called resistant}. The MDS indicated Resident #55 received 4 days of antibiotic therapy during the assessment period of 7 days. The MDS also indicated Resident #55 received intravenous antibiotic medications and was isolated for an active infection. Record review of a progress note dated 7/02/2023 at 3:58 p.m., the treatment nurse notified the nurse practitioner of Resident #55's complaint of pain and frequency with urination. The note indicated the nurse practitioner ordered a urinalysis with a culture and sensitivity, and a referral to a urologist for chronic urinary tract infections. Record review of a urinalysis dated as collected on 7/02/2023 at 7:30 p.m., and received by the laboratory on 7/03/2023 at 7:22 a.m. and resulted on 7/03/2023 at 10:15 a.m., indicated Resident #55 had slightly cloudy urine, abnormal amount of glucose (sugars in the urine), anormal amount of blood, the presence of leukocyte esterase (test to determine white blood cells in the urine), and the urine was positive for catalase bacteria {(used to differentiate staphylococci (catalase-positive) or streptococci (catalase-negative) the enzyme, catalase, produced by bacteria that respire using oxygen, and protects them from the toxic by-products of oxygen metabolism. The laboratory results had no documented evidence the physician was notified, or the physician signed as reviewed. Record review of a urine culture collected on 7/02/2023 7:30 p.m., received by the laboratory on 7/03/2023 at 11:00 a.m., and resulted on 7/05/2023 at 2:14 p.m., indicated Resident #55 had >100,000 Escherichia Coli (high range) and a low range of 10,000 - 50,000 Streptococcus Agalactiae pathogens in the sample. The report indicated under the heading of Antibiotic Notes that Resident #55 had ESBL (extended spectrum beta-lactamase) detected. The note indicated these organisms tend to be uniformly resistant. The laboratory results had no documented evidence the physician was notified, or the physician signed as reviewed. Record review of the 24-hour report dated 7/03/2023 did not list Resident #55 as having a change of condition. Record review of the 24-hour report dated 7/04/2023 did not list Resident #55 as having a change of condition. Record review of the 24-hour report dated 7/05/2023 indicated Resident #55 as a FYI (for your information) awaiting final results of the urinalysis. Record review of the 24-hour report dated 7/06/2023 indicated Resident #55 as a FYI (for your information) awaiting results of the urinalysis. Record review of the progress notes dated 7/03/2023- 7/05/2023 revealed there was no documentation of Resident #55's condition, no mention of the urinalysis, or the urine culture. Record review of a progress note dated 7/06/2023 by LVN T (no longer employed) documented she faxed the initial urinalysis to the nurse practitioner, but she was waiting on the culture and sensitivity. Record review of a progress note dated 7/06/2023 at 8:29 p.m., indicated the DON notified the nurse practitioner of Resident #55's blood sugar readings but failed to mention the urine culture results. Record review of a progress note dated 7/07/2023 at 9:07 p.m., indicated an agency nurse documented she completed a communication form for Resident #55 regarding the ordered urology consult due to frequent urinary tract infections. Record review of the 24-hour report dated 7/08/2023 indicated Resident #55 needed a urology and dermatology consult and was on Diflucan. Record review of a progress note dated 7/08/2023, an agency nurse indicated Resident #55 was to start Diflucan for yeasty rash to her skin folds. Record review of the 24-hour report dated 7/09/2023 (night shift) indicated Resident #55 needed the urinalysis picked up on Monday. Record review of the 24-hour report dated 7/09/2023 indicated Resident #55 needed a urology and dermatology appointment. Record review of a progress note dated 7/09/2023 indicated the initial dose of Diflucan 100 milligrams by mouth for a rash to Resident #55's skin folds was administered. During an interview on 8/09/2023 at 9:21 a.m., Resident #55 said she felt ill during the time of her urinary tract infection. Resident #55 said she had not seen a urologist since her discharge from the hospital, and she was unaware of any appointment that might had been scheduled. During an interview on 8/09/2023 at 9:35 a.m., the DON said she was unaware of Resident #55's urinalysis results with ESBL and the non-treatment of the infection. The DON said she would have to get with the ADON infection preventionist who was responsible for the infection control program. During an interview on 8/09/2023 at 9:40 a.m., the nurse practitioner for Resident #55 indicated her usual practice when she received faxed laboratory results would be to order one dose of the medication Fosfoamycin (a one dose treatment for urinary tract infections) 3 grams. The nurse practitioner said she writes her orders on the laboratory results and will return the fax to the facility for implementation. During an interview on 8/09/2023 at 9:51 a.m., the Infection Preventionist ADON said when a resident had ESBL in their urine she would place the resident on contact isolation. The ADON said she was unaware Resident #55 never received treatment for her UTI. The ADON said she was new to her position; she had been out and has had little opportunity to have instruction on her current position. During an interview on 8/09/2023 at 10:13 a.m., the physician for Resident #55 said mostly the facility would consult his nurse practitioner first. The physician said if he had been consulted, he would have prescribed an antibiotic therapy regimen. The physician said the risk when a urinary tract infection not treated was septicemia (life-threatening complication of an infection) and even death. The physician indicated he expected the nurse practitioner or himself to be notified of changes of condition. During an interview on 8/09/2023 at 12:00 p.m., the nurse practitioner for Resident #55 said after reviewing her records she had not been notified of the culture results from Resident #55's urinalysis. The nurse practitioner said she was notified of the yeast infection under Resident #55's abdominal folds thus ordering the Diflucan for the treatment. The nurse practitioner said she expected to be notified when the culture returned and when any changes of condition. Record review of the 24-hour report dated 7/10/2023 (night shift) indicated Resident #55 was on day 2 of 7 Diflucan for rash to skin folds. The report indicated Resident #55 complained of not feeling well, slight temperature, administered Tylenol Record review of the 24-hour report dated 7/10/2023 (day shift) indicated Resident #55 was on day 2 of 7 on Diflucan for a UTI, as needed analgesics for fever and pain was provided, and required an appointment with urology and dermatology. Record review of a progress note dated 7/10/2023 at 12:39 p.m., indicated LVN F had notified the ADON, DON, and facility team aware of the need for Resident #55 to be scheduled for a urology and dermatology appointment. Record review of a progress note dated 7/10/2023 at 12:39 p.m., indicated LVN F had notified the ADON, DON, and facility team aware of the need for Resident #55 to be scheduled for a urology and dermatology appointment. Record review of a progress note dated 7/10/2023 at 1:55 a.m., the agency nurse documented Resident #55 got up to go to the restroom and turned on the call light and indicated she was not feeling well. The agency nurse documented Resident #55's vital signs were 111/44 heart rate 97, respirations 20 and temperature 100.5. The agency nurse asked Resident #55 if she had gotten up too fast due to her diastolic blood pressure reading of 44. The progress note indicated the agency nurse administered Tylenol 325 milligrams two tablets by mouth for increased temperature, and generalized discomfort. The note indicated Resident #55 was encouraged to use the call light for assistance due to not feeling well. The note did not indicate if Resident #55's physician was notified. Record review of a progress note dated 7/10/2023 at 4:42 p.m., the agency nurse documented Resident #55's systolic blood pressure was 44 and not the diastolic blood pressure in the previous note. The note did not indicate the physician was notified of either result of a diastolic blood pressure reading of 44 or a systolic blood pressure reading of 44. Record review of an Infection Progress note dated 7/10/2023 at 12:40 p.m., LVN F documented Resident #55 was being monitored for an active urinary infection. The note indicated Resident #55 had received standard transmission-based precautions for a urinary tract infection. Resident #55 was receiving antibiotics of Diflucan for 7 days. The Infection Progress note indicated Resident #55 had experienced fever, was encouraged fluids, and administered fever reducing medications. The infection progress note did not indicate Resident #55's physician was notified. Record review of the 24-hour report dated 7/11/2023 did not indicate Resident #55 was sent to the emergency room or was admitted to the hospital. Record review of an Infection Progress note dated 7/11/2023 at 3:20 a.m., an agency nurse documented Resident #55 was monitored for an active infection. The note indicated Resident #55 was on standard precautions, due to her urinary tract infection. The note indicated Resident #55 was receiving antibiotic therapy Diflucan and today was day 3 of the treatment. The note indicated Resident #55 was experiencing new or increased urinary urgency, increased assistance with her ADL's and malaise, and weakness. The note indicated the agency nurse provided a breathing treatment and encouraged fluids. The note did not indicate Resident #55's physician was notified. Record review of a progress note dated 7/11/2023 at 4:16 a.m., indicated the agency nurse documented at 4:00 a.m., Resident #55 continued to have malaise and subjective complaints of weakness. The progress note indicated Resident #55's blood sugars were fluctuating. The progress note did not indicate the agency nurse notified Resident #55's physician. Record review of a progress note dated 7/11/2023 at 7:28 a.m., LVN F completed an assessment of Resident #55, and the assessment revealed a blood pressure of 144/60, heart rate of 83, oxygen saturation on room air was 90, and a temperature was 103.8 Fahrenheit, respirations 24 and pain was 3 out of 10. The note indicated Resident #55 was being treated with Diflucan. LVN F called the physician and Resident #55 was sent to the local emergency department for further care. Record review of a history and physical dated 7/11/2023 at 12:02 p.m., the hospitalist indicated Resident #55 had both lower extremities had cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), fever, acute bladder infection, and acute kidney injury likely due to infection. The note indicated the history of the present illness was Resident #55 had a urinary tract infection but was not prescribed any antibiotics nor was she scheduled to see the urologist. The physical examination indicated Resident #55 had to both lower legs up to the mid shin redness, scaling skin, warmth, no discharge, and no erosions lesions. Resident #55 had a bright red rash under both breasts and under her belly with a foul odor, no erosions, no discharge, and mild warmth. Record review of a urine culture collected on 7/11/2023 and resulted on 7/13/2023 indicated Resident #55 had >100,000 ESBL Escherichia coli. The urine culture laboratory report reviewed had no orders written on the form or any indication a prescribing physician or nurse practitioner signed indicating the results had been reviewed and/or prescribed treatment. Record review of a progress note dated 7/16/2023 at 3:37 p.m., indicated the admitting hospital called LVN F for discharge report. The progress note dated Resident #55 had a yeast rash and was treated for ESBL. Record review of a hospital transfer report dated 7/16/2023 at 3:11 p.m., indicated Resident #55 was admitted on [DATE] and discharged on [DATE] with the active problems of acute kidney injury, acute cystitis with hematuria (inflammation of the bladder with bleeding) secondary to ESBL E. coli Record review of a comprehensive care plan edited on 7/18/2023 did not indicate Resident #55 had a history of ESBL resistance urinary tract infections requiring prompt interventions to prevent worsening of the infection and spreading the contagious infection. Record review of the July 2023 infection control tracking and trending log indicated the facility had 6 urinary tract infections and 2 skin infections logged. The logged treatments reviewed for Resident #55 were 7/10/2023 Diflucan (antifungal medication) 100 milligrams one by mouth daily for 6 days. After hospitalization s Resident #55 received on 7/17/2023 Fosfomycin 3 grams by mouth for one dose. Resident #55 has received Linezolid (antibiotic therapy used as a last resort to fight bacterial infection that have been resistant to other antibiotics) 600 milligrams twice daily from 7/17/2023 - 7/22/2023. Record review of a Guidelines to Notifying Physicians of Clinical Problems policy dated 2005 and revised September 2017 indicated these guidelines are intended to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and that 2) all significant changes in resident status are assessed and documented in the medical record. The immediate and non-immediate problems listed below are not meant to be all-inclusive. The charge nurse or supervisor should contact the attending physician if a clinical situation appears to require immediate discussion and management . Immediate Notification (Acute) Problems: The following symptoms, signs, and laboratory values (which are not all-inclusive) should prompt immediate notification of the physician after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible, either by phone pager, text messaging, or other means. These situations include: 1. Witnessed cardiac or respiratory arrest for individuals who have full code status. 2. Rapid decline or continued instability (for example, markedly fluctuating vital signs), unless the individual is receiving palliative care and has declined workup or treatment. 3. The following symptom A. Sudden in onset or a marked change (for example, much more severe or frequent) compared to usual (baseline) status, and are B. Unrelieved by measures which have already been prescribed and/or attempted. 4. The following signs: The following list of physical signs is not meant to be all-inclusive. Depending on the situation, other physical findings may warrant physician notification. A. Changes in vital signs. Follow these general guidelines: a. Temperature greater than 101 degrees rectally b. Respiratory rate greater than 28 per minute or lower rate with respiratory distress c. Pulse greater than 110 or less than 55 per minute d. Blood pressure greater than 210 or less than 90 systolic; or greater than 120 diastolic. Record review of a Change in a Resident's Condition or Status policy dated 4/20/2023 indicated the facility would promptly notify the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (changes in the level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a (an): a. Accident or incident involving the resident b. Discovery of injuries of an unknown source. c. Adverse reaction to medication d. Significant change in the resident's physical/emotional/mental condition e. Need to alter the resident's medical treatment significantly f. Refusal of treatment or medications g. Need to transfer the resident to a hospital or treatment center h. Discharge against medical advice i. Specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions b. Impacts more than one area of the resident's health status c. Requires interdisciplinary review and/or revision to the car plan d. Ultimately is based on the judgement of the clinical staff and the guidelines outline in the Resident Assessment Instrument. Review of https://www.hopkinsmedicine.org/health/conditions-and-diseases/septicemia accessed on 8/14/2023: Septicemia, or sepsis, is the clinical name for blood poisoning by bacteria. It is the body's most extreme response to an infection. Sepsis that progresses to septic shock has a death rate as high as 50%, depending on the type of organism involved. Sepsis is a medical emergency and needs urgent medical treatment. Without treatment, sepsis can quickly lead to tissue damage, organ failure, and death. An infection can happen to anyone, but there are certain risk factors that put people at higher risk for developing sepsis. These include people with: Chronic medical conditions such as diabetes, cancer, lung disease, immune system disorders, and kidney disease Weak immune systems Community-acquired pneumonia A previous hospitalization (especially hospitalization for an infection) Also, at risk are: Children younger than 1 year of age Adults aged 65 and older These infections are most often associated with sepsis: Lung infections (pneumonia) Urinary tract infections Skin infections Infections in the intestines or gut These 3 germs most frequently develop into sepsis are: Staphylococcus aureus (staph) Escherichia coli (E. coli) Some types of Streptococci The following are the most common symptoms of sepsis. However, each person may experience symptoms differently. People with sepsis often develop a hemorrhagic rash-a cluster of tiny blood spots that look like pinpricks in the skin. If untreated, these gradually get bigger and begin to look like fresh bruises. These bruises then join to form larger areas of purple skin damage and discoloration. Sepsis develops very quickly. The person rapidly becomes very ill, and may: Lose interest in food and surroundings Become feverish Have a high heart rate Become nauseated Vomit Become sensitive to light Complain of extreme pain or discomfort Feel cold, with cool hands and feet Become lethargic, anxious, confused, or agitated Experience a coma and sometimes death Those who become ill more slowly may also develop some of the signs of meningitis. The symptoms of sepsis may look like other conditions or medical problems. Always see your healthcare provider for a diagnosis. The diagnose sepsis, your healthcare provider will look for a variety of physical finding such as low blood pressure, fever, increased heart rate, and increased breathing rate. Your provider will also do a variety of lab tests that check for signs of infection and organ damage. Since some sepsis symptoms (such as fever and trouble breathing) can often be seen in other conditions, sepsis can be hard to diagnose in its initial stages. Specific treatment for sepsis will be determined by your healthcare provider based on: Your age, overall health, and medical history Extent of the condition Your tolerance for specific medicines, procedures, or therapies Expectations for the course of the condition Your opinion or preference Sepsis is a life-threatening emergency that needs immediate medical attention. People with sepsis are hospitalized and treatment is started as quickly as possible. Treatment includes antibiotics, managing blood flow to organs, and treating the source of the infection. Many people need oxygen and IV (intravenous) fluids to help get blood flow and oxygen to the organs. Depending on the person, help with breathing with a ventilator or kidney dialysis may be needed. Surgery is sometimes used to remove tissue damaged by the infection. Review of https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/low-blood-pressure-when-blood-pressure-is-too-low accessed on 8/14/2023: Within certain limits, the lower your blood pressure reading is, the better. While there is no specific number at which day-to-day blood pressure is considered too low, a reading of less than 90/60 mm Hg is considered hypotension. Hypotension is the term for blood pressure that is too low. The condition is benign as long as none of the symptoms showing lack of oxygen are present. Most health care professionals will only consider chronically low blood pressure as dangerous if it causes noticeable signs and symptoms, such as: Confusion Dizziness or lightheadedness Nausea Fainting Fatigue Neck or back pain Headache Blurred vision Heart palpitations, or feelings that your heart is skipping a beat, fluttering, or beating too hard or too fast Low blood pressure can occur with: Severe infection (septic shock): Septic shock can occur when bacteria leave the original site of an infection, most often in the lungs, abdomen, or urinary tract, and enter the bloodstream. The bacteria then produce toxins that affect blood vessels, leading to a profound and life-threatening decline in blood pressure. The Administrator was notified on 8/09/2023 at 1:24 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 8/09/2023 at 1:29 p.m. The facility's Plan of Removal was accepted on 8/09/2023 at 3:06 p.m. and included: Resident #55's physician has been notified of abnormal UA results, change in condition (low diastolic blood pressure), temperature of being at 100.5, and new/increase of urine urgency, increase in ADL assistance, malaise, and weakness. Resident #55 has been referred to a Urologist. Resident #55's physician does not wish to treat Resident #55 as of 8/09/2023 for ESBL and does not recommend precautions at this time History of ESBL in the urine and history of UTI added to Resident #55's care plan. Audit conducted of all resident's labs. Any abnormal results will be communicated with the resident's physician. MD's orders will then be followed. Any identified residents with abnormal labs care plans will be updated to reflect the current condition/problem. Any labs indicating infections requiring precautions will follow MD's orders. Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes for previous 30 days to identify any change in conditions and will notify the MD. MD's orders will then be followed. All LVNs and RNs will be in-serviced over: Physician Notification Change in Condition Lab and Diagnostic Test Results- Clinical Protocol Key Takeaway for staff When to notify the physician, what to notify the physician regarding (change in conditions, abnormal labs, abnormal vital signs, abnormal radiology results, sudden loss of consciousness, more than minimal bleeding, seizure activity, stroke/heart attack like symptoms), reviewing labs and notifying MD and Director of Nursing of abnormal results. All LVNs and RNs will be educated prior to working their next shift. The facility management completed an Ad Hoc QAPI performed with Medical Director reviewing the IJ template for 580- Physician Notification and the plan of removal. Will follow MD's recommendations Record review of implementation of the Plan of Removal on 8/09/2023: Record review of the lab audit completed today for the last 30 days completed. The lab audit indicated 1 laboratory was draw on 8/09/2023 as a result of the audit. Record review of the Ad hoc meeting reviewed for 8/09/2023. Record review of Resident #55's care plan updated on 8/09/2023 to reflect a history of ESBL of the urine. Review of a attestation pages done and indicated progress notes were reviewed for change of condition from the last 30 days. On 8/09/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verification the Medical Director was notified of the Immediate Jeopardy. During interviews on 8/09/2023 at 3:30 p.m. - 6:00 p.m., of Licensed Nurses (LVN A, LVN B, LVN C, ADON N, ADON O, LVN T, LVN P, LVN U, and LVN P) were performed. During the interviews all licensed nurses were able to correctly identify a change on condition, when to notify the physician of a residents change of condition including abnormal laboratory results. On 8/09/2023 at 6:15 p.m., the Administrator was notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at actual harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 6 (Resident#55) residents reviewed for notification of change of condition. The facility failed to consult with the physician when Resident #55 who had a low blood pressure reading, malaise (general feelings of discomfort, illness), fever, and weakness. The facility failed to consult Resident #55's physician of the urinalysis results and obtain a treatment. An IJ was identified on 8/09/2023. The IJ template was provided to the facility on [DATE] at 1:24 p.m. While the IJ was removed on 8/09/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on notification of changes and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving services to meet the resident's medical needs, and treatment of infections leading to sepsis and even death. Findings included: Record review of an undated face sheet indicated Resident #55 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of acute and chronic respiratory failure (a serious condition that makes it difficult to breath on your own), extended spectrum beta lactamase (ESBL) resistance (an enzyme that makes bacteria resistant to antibiotics), heart failure (when the heart muscle does not pump blood as well as it should). Record review of a Quarterly MDS dated [DATE] indicated Resident #55 understood others and was understood by others. Resident #55's BIMS score was 15, and she had no cognitive problems. The MDS indicated Resident #55 had not displayed rejection of care. The MDS indicated Resident #55 required supervision of one staff for toileting and personal hygiene. The MDS indicated Resident #55 did not have an indwelling foley catheter, had occasional urinary incontinence, and frequent bowel incontinence. The MDS indicated in the Active Diagnoses Section I indicated Resident #55 had septicemia (a life-threatening condition that arises when the body's response attacks the body's own tissue and organs) and MDRO {(multidrug-resistant organism) when a drug that could normally be used to treat an infection does not work to treat the organism causing the infection, the organism is called resistant}. The MDS indicated Resident #55 received 4 days of antibiotic therapy during the assessment period of 7 days. The MDS also indicated Resident #55 received intravenous antibiotic medications and was isolated for an active infection. Record review of a progress note dated 7/02/2023 at 3:58 p.m., the treatment nurse notified the nurse practitioner of Resident #55's complaint of pain and frequency with urination. The note indicated the nurse practitioner ordered a urinalysis with a culture and sensitivity, and a referral to a urologist for chronic urinary tract infections. Record review of a urinalysis dated as collected on 7/02/2023 at 7:30 p.m., and received by the laboratory on 7/03/2023 at 7:22 a.m. and resulted on 7/03/2023 at 10:15 a.m., indicated Resident #55 had slightly cloudy urine, abnormal amount of glucose (sugars in the urine), anormal amount of blood, the presence of leukocyte esterase (test to determine white blood cells in the urine), and the urine was positive for catalase bacteria {(used to differentiate staphylococci (catalase-positive) or streptococci (catalase-negative) the enzyme, catalase, produced by bacteria that respire using oxygen, and protects them from the toxic by-products of oxygen metabolism. The laboratory results had no documented evidence the physician was notified, or the physician signed as reviewed. Record review of a urine culture collected on 7/02/2023 7:30 p.m., received by the laboratory on 7/03/2023 at 11:00 a.m., and resulted on 7/05/2023 at 2:14 p.m., indicated Resident #55 had >100,000 Escherichia Coli (high range) and a low range of 10,000 - 50,000 Streptococcus Agalactiae pathogens in the sample. The report indicated under the heading of Antibiotic Notes that Resident #55 had ESBL (extended spectrum beta-lactamase) detected. The note indicated these organisms tend to be uniformly resistant. The laboratory results had no documented evidence the physician was notified, or the physician signed as reviewed. Record review of the 24-hour report dated 7/03/2023 did not list Resident #55 as having a change of condition. Record review of the 24-hour report dated 7/04/2023 did not list Resident #55 as having a change of condition. Record review of the 24-hour report dated 7/05/2023 indicated Resident #55 as a FYI (for your information) awaiting final results of the urinalysis. Record review of the 24-hour report dated 7/06/2023 indicated Resident #55 as a FYI (for your information) awaiting results of the urinalysis. Record review of the progress notes dated 7/03/2023- 7/05/2023 revealed there was no documentation of Resident #55's condition, no mention of the urinalysis, or the urine culture. Record review of a progress note dated 7/06/2023 by LVN T (no longer employed) documented she faxed the initial urinalysis to the nurse practitioner, but she was waiting on the culture and sensitivity. Record review of a progress note dated 7/06/2023 at 8:29 p.m., indicated the DON notified the nurse practitioner of Resident #55's blood sugar readings but failed to mention the urine culture results. Record review of a progress note dated 7/07/2023 at 9:07 p.m., indicated an agency nurse documented she completed a communication form for Resident #55 regarding the ordered urology consult due to frequent urinary tract infections. Record review of the 24-hour report dated 7/08/2023 indicated Resident #55 needed a urology and dermatology consult and was on Diflucan. Record review of a progress note dated 7/08/2023, an agency nurse indicated Resident #55 was to start Diflucan for yeasty rash to her skin folds. Record review of the 24-hour report dated 7/09/2023 (night shift) indicated Resident #55 needed the urinalysis picked up on Monday. Record review of the 24-hour report dated 7/09/2023 indicated Resident #55 needed a urology and dermatology appointment. Record review of a progress note dated 7/09/2023 indicated the initial dose of Diflucan 100 milligrams by mouth for a rash to Resident #55's skin folds was administered. During an interview on 8/09/2023 at 9:21 a.m., Resident #55 said she felt ill during the time of her urinary tract infection. Resident #55 said she had not seen a urologist since her discharge from the hospital, and she was unaware of any appointment that might had been scheduled. During an interview on 8/09/2023 at 9:35 a.m., the DON said she was unaware of Resident #55's urinalysis results with ESBL and the non-treatment of the infection. The DON said she would have to get with the ADON infection preventionist who was responsible for the infection control program. During an interview on 8/09/2023 at 9:40 a.m., the nurse practitioner for Resident #55 indicated her usual practice when she received faxed laboratory results would be to order one dose of the medication Fosfoamycin (a one dose treatment for urinary tract infections) 3 grams. The nurse practitioner said she writes her orders on the laboratory results and will return the fax to the facility for implementation. During an interview on 8/09/2023 at 9:51 a.m., the Infection Preventionist ADON said when a resident had ESBL in their urine she would place the resident on contact isolation. The ADON said she was unaware Resident #55 never received treatment for her UTI. The ADON said she was new to her position; she had been out and has had little opportunity to have instruction on her current position. During an interview on 8/09/2023 at 10:13 a.m., the physician for Resident #55 said mostly the facility would consult his nurse practitioner first. The physician said if he had been consulted, he would have prescribed an antibiotic therapy regimen. The physician said the risk when a urinary tract infection not treated was septicemia (life-threatening complication of an infection) and even death. The physician indicated he expected the nurse practitioner or himself to be notified of changes of condition. During an interview on 8/09/2023 at 12:00 p.m., the nurse practitioner for Resident #55 said after reviewing her records she had not been notified of the culture results from Resident #55's urinalysis. The nurse practitioner said she was notified of the yeast infection under Resident #55's abdominal folds thus ordering the Diflucan for the treatment. The nurse practitioner said she expected to be notified when the culture returned and when any changes of condition. Record review of the 24-hour report dated 7/10/2023 (night shift) indicated Resident #55 was on day 2 of 7 Diflucan for rash to skin folds. The report indicated Resident #55 complained of not feeling well, slight temperature, administered Tylenol Record review of the 24-hour report dated 7/10/2023 (day shift) indicated Resident #55 was on day 2 of 7 on Diflucan for a UTI, as needed analgesics for fever and pain was provided, and required an appointment with urology and dermatology. Record review of a progress note dated 7/10/2023 at 12:39 p.m., indicated LVN F had notified the ADON, DON, and facility team aware of the need for Resident #55 to be scheduled for a urology and dermatology appointment. Record review of a progress note dated 7/10/2023 at 12:39 p.m., indicated LVN F had notified the ADON, DON, and facility team aware of the need for Resident #55 to be scheduled for a urology and dermatology appointment. Record review of a progress note dated 7/10/2023 at 1:55 a.m., the agency nurse documented Resident #55 got up to go to the restroom and turned on the call light and indicated she was not feeling well. The agency nurse documented Resident #55's vital signs were 111/44 heart rate 97, respirations 20 and temperature 100.5. The agency nurse asked Resident #55 if she had gotten up too fast due to her diastolic blood pressure reading of 44. The progress note indicated the agency nurse administered Tylenol 325 milligrams two tablets by mouth for increased temperature, and generalized discomfort. The note indicated Resident #55 was encouraged to use the call light for assistance due to not feeling well. The note did not indicate if Resident #55's physician was notified. Record review of a progress note dated 7/10/2023 at 4:42 p.m., the agency nurse documented Resident #55's systolic blood pressure was 44 and not the diastolic blood pressure in the previous note. The note did not indicate the physician was notified of either result of a diastolic blood pressure reading of 44 or a systolic blood pressure reading of 44. Record review of an Infection Progress note dated 7/10/2023 at 12:40 p.m., LVN F documented Resident #55 was being monitored for an active urinary infection. The note indicated Resident #55 had received standard transmission-based precautions for a urinary tract infection. Resident #55 was receiving antibiotics of Diflucan for 7 days. The Infection Progress note indicated Resident #55 had experienced fever, was encouraged fluids, and administered fever reducing medications. The infection progress note did not indicate Resident #55's physician was notified. Record review of the 24-hour report dated 7/11/2023 did not indicate Resident #55 was sent to the emergency room or was admitted to the hospital. Record review of an Infection Progress note dated 7/11/2023 at 3:20 a.m., an agency nurse documented Resident #55 was monitored for an active infection. The note indicated Resident #55 was on standard precautions, due to her urinary tract infection. The note indicated Resident #55 was receiving antibiotic therapy Diflucan and today was day 3 of the treatment. The note indicated Resident #55 was experiencing new or increased urinary urgency, increased assistance with her ADL's and malaise, and weakness. The note indicated the agency nurse provided a breathing treatment and encouraged fluids. The note did not indicate Resident #55's physician was notified. Record review of a progress note dated 7/11/2023 at 4:16 a.m., indicated the agency nurse documented at 4:00 a.m., Resident #55 continued to have malaise and subjective complaints of weakness. The progress note indicated Resident #55's blood sugars were fluctuating. The progress note did not indicate the agency nurse notified Resident #55's physician. Record review of a progress note dated 7/11/2023 at 7:28 a.m., LVN F completed an assessment of Resident #55, and the assessment revealed a blood pressure of 144/60, heart rate of 83, oxygen saturation on room air was 90, and a temperature was 103.8 Fahrenheit, respirations 24 and pain was 3 out of 10. The note indicated Resident #55 was being treated with Diflucan. LVN F called the physician and Resident #55 was sent to the local emergency department for further care. Record review of a history and physical dated 7/11/2023 at 12:02 p.m., the hospitalist indicated Resident #55 had both lower extremities had cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), fever, acute bladder infection, and acute kidney injury likely due to infection. The note indicated the history of the present illness was Resident #55 had a urinary tract infection but was not prescribed any antibiotics nor was she scheduled to see the urologist. The physical examination indicated Resident #55 had to both lower legs up to the mid shin redness, scaling skin, warmth, no discharge, and no erosions lesions. Resident #55 had a bright red rash under both breasts and under her belly with a foul odor, no erosions, no discharge, and mild warmth. Record review of a urine culture collected on 7/11/2023 and resulted on 7/13/2023 indicated Resident #55 had >100,000 ESBL Escherichia coli. The urine culture laboratory report reviewed had no orders written on the form or any indication a prescribing physician or nurse practitioner signed indicating the results had been reviewed and/or prescribed treatment. Record review of a progress note dated 7/16/2023 at 3:37 p.m., indicated the admitting hospital called LVN F for discharge report. The progress note dated Resident #55 had a yeast rash and was treated for ESBL. Record review of a hospital transfer report dated 7/16/2023 at 3:11 p.m., indicated Resident #55 was admitted on [DATE] and discharged on [DATE] with the active problems of acute kidney injury, acute cystitis with hematuria (inflammation of the bladder with bleeding) secondary to ESBL E. coli Record review of a comprehensive care plan edited on 7/18/2023 did not indicate Resident #55 had a history of ESBL resistance urinary tract infections requiring prompt interventions to prevent worsening of the infection and spreading the contagious infection. Record review of the July 2023 infection control tracking and trending log indicated the facility had 6 urinary tract infections and 2 skin infections logged. The logged treatments reviewed for Resident #55 were 7/10/2023 Diflucan (antifungal medication) 100 milligrams one by mouth daily for 6 days. After hospitalization s Resident #55 received on 7/17/2023 Fosfomycin 3 grams by mouth for one dose. Resident #55 has received Linezolid (antibiotic therapy used as a last resort to fight bacterial infection that have been resistant to other antibiotics) 600 milligrams twice daily from 7/17/2023 - 7/22/2023. Record review of a Guidelines to Notifying Physicians of Clinical Problems policy dated 2005 and revised September 2017 indicated these guidelines are intended to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and that 2) all significant changes in resident status are assessed and documented in the medical record. The immediate and non-immediate problems listed below are not meant to be all-inclusive. The charge nurse or supervisor should contact the attending physician if a clinical situation appears to require immediate discussion and management . Immediate Notification (Acute) Problems: The following symptoms, signs, and laboratory values (which are not all-inclusive) should prompt immediate notification of the physician after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible, either by phone pager, text messaging, or other means. These situations include: 1. Witnessed cardiac or respiratory arrest for individuals who have full code status. 2. Rapid decline or continued instability (for example, markedly fluctuating vital signs), unless the individual is receiving palliative care and has declined workup or treatment. 3. The following symptom A. Sudden in onset or a marked change (for example, much more severe or frequent) compared to usual (baseline) status, and are B. Unrelieved by measures which have already been prescribed and/or attempted. 4. The following signs: The following list of physical signs is not meant to be all-inclusive. Depending on the situation, other physical findings may warrant physician notification. A. Changes in vital signs. Follow these general guidelines: a. Temperature greater than 101 degrees rectally b. Respiratory rate greater than 28 per minute or lower rate with respiratory distress c. Pulse greater than 110 or less than 55 per minute d. Blood pressure greater than 210 or less than 90 systolic; or greater than 120 diastolic. Record review of a Change in a Resident's Condition or Status policy dated 4/20/2023 indicated the facility would promptly notify the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (changes in the level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a (an): a. Accident or incident involving the resident b. Discovery of injuries of an unknown source. c. Adverse reaction to medication d. Significant change in the resident's physical/emotional/mental condition e. Need to alter the resident's medical treatment significantly f. Refusal of treatment or medications g. Need to transfer the resident to a hospital or treatment center h. Discharge against medical advice i. Specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions b. Impacts more than one area of the resident's health status c. Requires interdisciplinary review and/or revision to the car plan d. Ultimately is based on the judgement of the clinical staff and the guidelines outline in the Resident Assessment Instrument. Review of https://www.hopkinsmedicine.org/health/conditions-and-diseases/septicemia accessed on 8/14/2023: Septicemia, or sepsis, is the clinical name for blood poisoning by bacteria. It is the body's most extreme response to an infection. Sepsis that progresses to septic shock has a death rate as high as 50%, depending on the type of organism involved. Sepsis is a medical emergency and needs urgent medical treatment. Without treatment, sepsis can quickly lead to tissue damage, organ failure, and death. An infection can happen to anyone, but there are certain risk factors that put people at higher risk for developing sepsis. These include people with: Chronic medical conditions such as diabetes, cancer, lung disease, immune system disorders, and kidney disease Weak immune systems Community-acquired pneumonia A previous hospitalization (especially hospitalization for an infection) Also, at risk are: Children younger than 1 year of age Adults aged 65 and older These infections are most often associated with sepsis: Lung infections (pneumonia) Urinary tract infections Skin infections Infections in the intestines or gut These 3 germs most frequently develop into sepsis are: Staphylococcus aureus (staph) Escherichia coli (E. coli) Some types of Streptococci The following are the most common symptoms of sepsis. However, each person may experience symptoms differently. People with sepsis often develop a hemorrhagic rash-a cluster of tiny blood spots that look like pinpricks in the skin. If untreated, these gradually get bigger and begin to look like fresh bruises. These bruises then join to form larger areas of purple skin damage and discoloration. Sepsis develops very quickly. The person rapidly becomes very ill, and may: Lose interest in food and surroundings Become feverish Have a high heart rate Become nauseated Vomit Become sensitive to light Complain of extreme pain or discomfort Feel cold, with cool hands and feet Become lethargic, anxious, confused, or agitated Experience a coma and sometimes death Those who become ill more slowly may also develop some of the signs of meningitis. The symptoms of sepsis may look like other conditions or medical problems. Always see your healthcare provider for a diagnosis. The diagnose sepsis, your healthcare provider will look for a variety of physical finding such as low blood pressure, fever, increased heart rate, and increased breathing rate. Your provider will also do a variety of lab tests that check for signs of infection and organ damage. Since some sepsis symptoms (such as fever and trouble breathing) can often be seen in other conditions, sepsis can be hard to diagnose in its initial stages. Specific treatment for sepsis will be determined by your healthcare provider based on: Your age, overall health, and medical history Extent of the condition Your tolerance for specific medicines, procedures, or therapies Expectations for the course of the condition Your opinion or preference Sepsis is a life-threatening emergency that needs immediate medical attention. People with sepsis are hospitalized and treatment is started as quickly as possible. Treatment includes antibiotics, managing blood flow to organs, and treating the source of the infection. Many people need oxygen and IV (intravenous) fluids to help get blood flow and oxygen to the organs. Depending on the person, help with breathing with a ventilator or kidney dialysis may be needed. Surgery is sometimes used to remove tissue damaged by the infection. Review of https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/low-blood-pressure-when-blood-pressure-is-too-low accessed on 8/14/2023: Within certain limits, the lower your blood pressure reading is, the better. While there is no specific number at which day-to-day blood pressure is considered too low, a reading of less than 90/60 mm Hg is considered hypotension. Hypotension is the term for blood pressure that is too low. The condition is benign as long as none of the symptoms showing lack of oxygen are present. Most health care professionals will only consider chronically low blood pressure as dangerous if it causes noticeable signs and symptoms, such as: Confusion Dizziness or lightheadedness Nausea Fainting Fatigue Neck or back pain Headache Blurred vision Heart palpitations, or feelings that your heart is skipping a beat, fluttering, or beating too hard or too fast Low blood pressure can occur with: Severe infection (septic shock): Septic shock can occur when bacteria leave the original site of an infection, most often in the lungs, abdomen, or urinary tract, and enter the bloodstream. The bacteria then produce toxins that affect blood vessels, leading to a profound and life-threatening decline in blood pressure. The Administrator was notified on 8/09/2023 at 1:24 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 8/09/2023 at 1:29 p.m. The facility's Plan of Removal was accepted on 8/09/2023 at 3:06 p.m. and included: Resident #55's physician has been notified of abnormal UA results, change in condition (low diastolic blood pressure), temperature of being at 100.5, and new/increase of urine urgency, increase in ADL assistance, malaise, and weakness. Resident #55 has been referred to a Urologist. Resident #55's physician does not wish to treat Resident #55 as of 8/09/2023 for ESBL and does not recommend precautions at this time History of ESBL in the urine and history of UTI added to Resident #55's care plan. Audit conducted of all resident's labs. Any abnormal results will be communicated with the resident's physician. MD's orders will then be followed. Any identified residents with abnormal labs care plans will be updated to reflect the current condition/problem. Any labs indicating infections requiring precautions will follow MD's orders. Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes for previous 30 days to identify any change in conditions and will notify the MD. MD's orders will then be followed. All LVNs and RNs will be in-serviced over: Physician Notification Change in Condition Lab and Diagnostic Test Results- Clinical Protocol Key Takeaway for staff When to notify the physician, what to notify the physician regarding (change in conditions, abnormal labs, abnormal vital signs, abnormal radiology results, sudden loss of consciousness, more than minimal bleeding, seizure activity, stroke/heart attack like symptoms), reviewing labs and notifying MD and Director of Nursing of abnormal results. All LVNs and RNs will be educated prior to working their next shift. The facility management completed an Ad Hoc QAPI performed with Medical Director reviewing the IJ template for 580- Physician Notification and the plan of removal. Will follow MD's recommendations Record review of implementation of the Plan of Removal on 8/09/2023: Record review of the lab audit completed today for the last 30 days completed. The lab audit indicated 1 laboratory was draw on 8/09/2023. Record review of the Ad hoc meeting reviewed for 8/09/2023. Record review of Resident #55's care plan updated on 8/09/2023 to reflect a history of ESBL of the urine. Review of a attestation pages done and indicated progress notes were reviewed for change of condition from the last 30 days. On 8/09/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verification the Medical Director was notified of the Immediate Jeopardy. During interviews on 8/09/2023 at 3:30 p.m. - 6:00 p.m., of Licensed Nurses (LVN A, LVN B, LVN C, ADON N, ADON O, LVN T, LVN P, LVN U, and LVN P) were performed. During the interviews all licensed nurses were able to correctly identify a change on condition, when to notify the physician of a residents change of condition including abnormal laboratory results. On 8/09/2023 at 6:15 p.m., the Administrator was notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to provide adequate supervision to prevent accidents for 1 of 12 residents reviewed for accidents. (Resident #1) CNA A failed to prevent Resident #1 from falling off the bed while changing his bed linens resulting in a subarachnoid hematoma (bleeding inside of the brain). Resident #1 was admitted into ICU (area of the hospital for patients who are acutely ill and that requires critical medical care). This failure could place residents at risk of falls and not receiving proper treatment resulting in injury, pain and hospitalization . Findings included: A Face Sheet showed Resident #1 was [AGE] years old and admitted on [DATE]. He had diagnoses of Diabetes, [CONDITION(S)], Gout (a common form of [CONDITION(S)] arthritis that is very painful), Low back pain, muscle wasting and atrophy to right and left lower leg, muscle weakness, unspecified abnormalities of gait and mobility, unspecified lack of coordination, and need for assistance with personal care. An Physician's Order showed on 9/3/21 Resident #1 was prescribed [MEDICATION(S)] (blood thinner) 90 mg to be administered daily. An MDS dated [DATE] showed Resident #1 had a BIMS score of 11, which indicated he had moderately impaired cognition. He required limited assistance of two-person physical assist for bed mobility and personal hygiene. It showed Resident #1 required 2-person physical assist for toileting. An ADL functional/rehabilitation care plan showed and edited date of 10/4/2021 showed Resident #1's goal was to achieve maximum functional mobility was Assist x 1 occasionally requires assist x 2. Progress Notes for Resident #1 indicated the following: On 10/2/2021 at 5:49 a.m. - Spoke with nurse at the ER. Resident admitted to ICU with subdural hematoma. Resident is awake and alert. Admitting as a precaution. electronically signed by LVN A. On 10/1/2021 at 11:39 p.m. - Called to room by CNA. Resident on floor next to bed lying on left side. Moderate amount blood noted from left side of head and elbow. Pressure applied to head wound and 911 notified. electronically signed by LVN A. A handwritten statement dated 10/2/2021 at 12:00 a.m. showed I was cleaning Resident #1. Everything was going as normal. Resident #1 had stopped talking, his body appeared to go limp and he rolled off the bed hitting the floor. For approximately 5 minutes he did not respond to verbal prompts even though his eyes were open and blinking. When Resident #1 appeared to start coming around he was talking and asking what happened. When the ambulance arrived, he was able to stand with assistance and put his self on the stretcher. CNA B signed the statement. An emergency department triage notes dated 10/2/2021 at 1:25 a.m. showed Resident #1 presented to the emergency department with laceration (cut) to left eyebrow and skin tear to left elbow because he fell out of the bed at the nursing home while being changed by staff. An emergency department provider note dated 10/2/2021 at 2:46 a.m. showed Resident #1 presented to emergency department via emergency medical service with head injury status post fall. Emergency medical service. Patient rolled off the bed and hit his head. Patient is currently on blood thinners. Resident #1's admitting diagnoses were contusion (bruise) of left elbow, head injury and subdural hematoma (bleeding inside of the brain). A consult notes with dated 10/2/2021 at 11:50 a.m. indicated Resident #1 had a ground level fall in the nursing home, and his computed tomography (medical imaging technique used in radiology to get detailed imaging) showed he had sustained a subarachnoid hemorrhage (bleeding in the brain). On 10/5/2021 at 12:35 p.m., an attempt was made to call LVN A for an interview and the call was unsuccessful. During a telephone interview on 10/5/2021 at 1:15 p.m., CNA B said on 10/2/2021 at around 1:00 a.m. she was the CNA taking care of Resident #1. CNA B said during rounds she noted Resident #1 had urinated on his self and his sheets were wet. She said she cleaned Resident #1 and rolled him onto his right side in order to remove the wet sheets and to apply the clean dry sheet. She said she went around the bed to tuck the sheets and Resident #1 suddenly stopped talking to her and rolled out of the bed onto the floor. She said his eyes were open, but he was unresponsive, and blood was coming from a laceration on his head. She said she stepped into the doorway and called for LVN A. CNA B said LVN A came to the room, assessed the resident, asked her to apply pressure to the laceration onto Resident #1's head to control the bleeding. LVN A left the room and called 911. She said she always did bed mobility to the resident by herself. She said she was unaware Resident #1 was supposed to have 2 people to assist him for bed mobility. During an interview on 10/5/2021 at 2:14 p.m., the DON said CNA B was performing incontinent care to Resident #1 and the resident passed out and fell on the floor. DON said Resident #1's care plan indicated he was a 1 person assist with bed mobility and he occasionally required 2 people to assist him. She stated at times Resident #1 would be weaker and on those days, he would require 2 people instead of one. During an interview on 10/5/2021 at 3:48 p.m., the MDS coordinator said she was the one that updated Resident #1's care plan on 10/4/2021 to include the required 1 person assist with bed mobility and he occasionally required 2 people assist. She said that the most recent MDS stated Resident #1 required a 2-person physical assist for bed mobility. She said that the care plan would not always match the MDS because the MDS is based on a 7 day look back period. She said Resident #1 was working with therapy and at times he would require 1 person for bed mobility and sometimes he would require 2 people for bed mobility, and it depended on his condition at the time it occurred. Record review of Activities of Daily Living Supporting policy with a revision date of March 2018 indicated: 2. Appropriate care and services will be provided for residents who are able to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care. 5. A resident's ability to perform activity of daily living will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date and the following MDS definitions: c. Limited Assistance- Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 3 or more times during the last 7 days. During the exit on 10/5/2021 at 4:25 p.m., the administrator and DON stated they had no additional information to present to the surveyor.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 4 residents reviewed for pressure injuries. (Residents #54) The facility did not prevent the development of 3 facility acquired pressure injuries for Resident #54. Resident #54 developed a facility acquired stage 2 pressure injury her left outer ankle on 02/21/19. The facility did not obtain orders for how often Resident #54 was to wear the walking boot and the boot was not removed for 6 days. The resident's stage 2 pressure injury worsened and she developed 2 additional facility acquired suspected deep tissue pressure injuries. The resident was not provided pressure reduction interventions and one of the injuries worsened to an unstageable pressure injury. This failure could place residents who had pressure injuries at risk for new development or worsening of existing pressure injuries. Findings included: Physician orders dated (MONTH) 1, 2019 indicated Resident #54, was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #54 had clear speech, was usually understood and sometimes understood. The resident's cognition was severely impaired. Resident #54 required extensive 2 person assist with bed mobility, transfers, and toilet use. The MDS indicated Resident #54 had 3 unstageable pressure injuries presenting as deep tissue injuries. A Braden Scale for Predicting Pressure Ulcer Risk dated 04/01/19 indicated Resident #54 was at high risk for pressure injuries. A weekly skin assessment dated [DATE] for Resident #54 was identified with a facility acquired stage 2 pressure injury on her left outer ankle measuring 0.5 centimeter (cm) x 0.5 cm. No other wounds were noted. A weekly skin assessment dated [DATE] indicated Resident #54's stage 2 pressure injury on her left outer ankle measured 0.2 cm x 0.2 cm with pink granulation tissue and the surrounding tissue was healthy. An incident report dated 03/25/19 indicated Resident #54 sustained a fracture to her left ankle. The resident was transferred to a local emergency roiagnom on [DATE] and Resident #54 was transferred back to the facility on [DATE]. A nursing note dated 03/26/19 at 8:00 p.m., LVN G documented Resident #54 returned to the facility with a splint in place to the lower left extremity. During an interview on 05/09/19 at 12:06 p.m., LVN G said when Resident #54 returned from the hospital on [DATE] she had a splint made up of an ACE wrap which started about 3 inches above her left knee and continued to the resident's toes. The LVN said there were hard splints in the wrap going down the inner and outer left leg. LVN G said the papers from the hospital indicated to leave the splint in place until seen by an orthopedic clinic. She said she did not assess Resident #54's skin. The clinical record from 03/26/19 through 04/02/19 for Resident #54 indicated no physician order for [REDACTED]. An orthopedic discharge report dated 03/28/19 indicated Resident #54 was seen and provided a walking boot and noted to use the boot as directed. The clinical record from 03/26/19 through 04/02/19 for Resident #54 indicated no orders for the splint (worn 03/26/19 - 03/28/19), no order for the walking boot, or directions on when to check the resident's skin. There were no directions instructing how the boot was to be worn. A telephone order dated 04/03/19 indicated Resident #54 was to, wear walking boot when bearing weight to lower left extremity (transfers, exercising etc.) leave boot in medication room when not in use. The care plan revised 03/14/19 and updated on 04/03/19 indicated Resident #54 had 3 suspected deep tissue injuries (SDTI) on her left ankle and heel. The care plan indicated the .Stage II to left lateral ankle was noted 02/19/19 . The care plan noted interventions included to provide treatment as ordered. During an interview on 05/08/19 at 11:05 a.m. the treatment nurse said she identified the 2 additional SDTIs on Resident #54's inner left ankle and left heel on 04/03/19. She said the additional pressure injuries were caused by the walking boot applied due to a fractured left ankle from 03/26/19. The treatment nurse said she was providing treatment to the SDTI on the resident's outer left ankle every 3 days as ordered. The wound care nurse progress notes for Resident #54 indicated the following: 04/03/19- .3 wounds to left ankle/heel. -Left outer ankle STDI measuring 2.0 cm x 1.0 cm, -Left inner ankle STDI measuring 1.0 cm x 1.0 cm -Left heel with red skin measuring 4.0 cm x 3.0 cm with an STDI measuring 3.0 cm x 2.0 cm in the center of redness . *04/05/19 - Left outer ankle STDI measuring 2.0 cm x 1.0 cm -Left inner ankle STDI measuring 1.0 cm x 1.0 cm -Left heel with red skin measuring 4.0 cm x 3.0 cm with an STDI measuring 3.0 cm x 2.0 cm SDTI. Wounds to left inner/outer ankle and left heel all purple in color. *04/12/19- -Left outer ankle STDI measuring 2.0 cm x 1.0 cm, -Left inner ankle STDI measuring 1.0 cm x 1.0 cm, -Left heel with red skin 4.0 cm x 3.0 cm with an STDI measuring 3.0 cm x 2.0 cm. Wounds to left inner/outer ankle and left heel all purple in color. *04/19/19- indicated wounds to left heel, left inner and outer ankle. No measurements indicated. *04/26/19- -Left outer ankle STDI measuring 1.0 cm x 1.0 cm, -Left inner ankle STDI measuring 1.0 cm x 1.0 cm, -Left heel STDI measuring 8.0 cm x 3.0 cm. Wounds to left inner/outer ankle and left heel all purple in color. *05/06/19- -Left outer ankle STDI measuring 1.0 cm x 1.0 cm, -Left inner ankle STDI measuring 1.0 cm x 1.0 cm, -Left heel STDI measuring 7.0 cm x 3.0 cm. Brown/firm tissue to left heel, left outer ankle, and left inner ankle. During an observation on 05/07/19 at 10:55 a.m., Resident #54 was lying on her back with no pillows to off-load her heels. The resident was not wearing a splint or the walking boot. The treatment nurse provided wound care for Resident #54 and the following wounds were observed: -Left outer ankle had a non-blanchable dark purple wound less than a dime size. -Left inner ankle had a non-blanchable dark purple wound less than a dime size. -Left heel had a wound with black hard tissue covering the wound bed. During an interview on 05/09/19 at 11:15 a.m., LVN H said Resident #54 was wearing the walking continuously at first (03/28/19) but the order changed to wearing when bearing weight (on 04/03/19). LVN H indicated Resident #54's skin should have been checked periodically when she was wearing the boot continuously. LVN H said she had at times checked the resident's skin under the boot from 03/28/19 through 04/02/19. The LVN said she was unable to find an order for [REDACTED]. During an interview on 05/09/19 at 11:35 a.m., the treatment nurse said from 03/28/19, when the resident received the walking boot, until 04/03/19, when she called and obtained clarification orders for the boot, there were no orders to assess the resident's skin present. The treatment nurse said she contacted the physician to see if Resident #54 was required to wear the boot continuously as she felt the boot had caused the new SDTI areas. The treatment nurse said the physician indicated Resident #54 was to wear the boot when bearing weight such as for transfers and the boot was to be kept in the medication room when not in use. The treatment nurse said was responsible for assessing and staging the pressure injuries for the facility. During an interview on 05/09/19 at 11:43 a.m., the ADON said treatment nurse informed her of Resident #54's new pressure injuries (SDTIs) to the inner left ankle and the left heel. The ADON said she was informed by the treatment nurse there was no order for the walking boot and she conducted an in-service for Brace Instructions on 04/03/19. The ADON said she expected the nurse to obtain orders for Resident #54's splint and walking boot and assessing her skin. An in-service for Brace Instructions dated 04/03/19 indicated the following: .If a resident was received from a doctor's appointment with a brace. Make sure you have instructions and orders for the brace, weight bearing status, and order for skin checks . During an interview on 05/09/19 at 11:52 a.m., the DON said she expected the nurses to obtain clarification orders regarding splints and walking boots regarding how long the devices were to be in place and how often to check a resident's skin. The National Pressure Ulcer Advisory Panel at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 5/16/19 noted the following pressure ulcer definitions: .The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. The initial pressure ulcer stage does not change despite healing. If the pressure ulcer has been classified at a higher numerical stage than what it was observed, it should be continued to be classified as the higher numerical stage . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions) . Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on an ischemic limb or the heel(s) should not be removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury,or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Additional pressure injury definitions .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 5 residents reviewed for accidents. (Resident #54) CNA C did not provide Resident #54 with a 2 person assist transfer as indicated by the MDS. She transferred Resident #54 by herself with no gait belt. Resident #54 received a fracture to her left ankle. This failure could place residents who required two staff assistance stand at risk of injury during transfers. Findings included: Physician orders [REDACTED].#54, was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated Resident #54 had severely impaired cognition, clear speech, was usually understood, and sometimes understood. The MDS indicated Resident #54 required extensive 2- person physical assist with transfers and toilet use. Bed mobility indicated extensive 1- person physical assist with bed mobility. The care plan revised 03/14/19 indicated Resident #54 required extensive assist with transfers of 1-2 staff members depending on time of day and/or mental status. An incident report dated 03/25/19 indicated Resident #54 was in the bathroom on the secured unit. She was assisted with by 1 person, CNA C, to the bathroom. The resident had loose stool, became upset and slipped down. Resident #54's left ankle became lodged between the toilet and the leg of the toilet extender causing a fracture to the resident's left ankle. A nursing noted dated 03/25/19 at 10:00 p.m., noted Resident #54 complained of pain to the left ankle. An x-ray was ordered. A nursing noted dated 03/26/19/ at 1:40 a.m., indicated mobile x-ray was present for Resident #54. A nursing note dated 03/26/19 at 1:48 p.m., indicated Resident #54 was sent to the emergency room for treatment and evaluation. The x-ray dated 03/26/19 indicated Resident #54 had an acute nondisplaced [MEDICAL CONDITION] fibula (ankle). During an interview on 05/09/19 at 9:24 a.m., CNA C said on 03/25/19 Resident #54 was partially in the bathroom with her wheelchair in the day room area of the secured unit. The CNA said the resident indicated she needed to go. The CNA said she rolled Resident #54's wheelchair further into the bathroom so the resident could grab the assist bar. CNA C said she did not have a gait belt on the Resident #54 while assisting her to stand. CNA C said she had 1 hand on Resident #54's back and the other her side. She said while in the process of turning Resident #54 into position over the toilet seat, the resident had loose stool coming out. CNA C said Resident #54 became very upset over the loose stool, yelled out woohoo and started to sit before being completely over the toilet. The CNA said she managed to get her leg under Resident # 54's right buttock and her left buttock was partially over a part of the toilet seat. CNA C said Resident #54 let go of the hand rail in the bathroom and slid down her leg to the floor. The CNA said the diarrhea made everything slippery and Resident #54 was quite upset at that point. CNA C said she was unaware of Resident #54's foot placement when the resident was on the floor. The CNA said the bathroom in the secured unit day room, where the incident occurred was, tight and dark. CNA C said LVN D came to the unit after she yelled and got an aide to notify the nurse. She said LVN D assisted her by getting Resident #54 clean enough to stand. CNA C after standing Resident #54 up, they realized her left leg was between the toilet and the toilet extender. CNA C said Resident #54 at times required a 1 person assist with transfers and sometimes a 2 person assist. She said staff was also aware at times Resident #54 attempted to transfer independently. The CNA said it just depended on Resident #54's mood as to whether it would take 1 or 2 persons to transfer her. CNA C said if Resident #54 was okay with being transferred she would cooperate by standing and pivoting on her right leg with just 1 person. The CNA said, right after the incident a co-worker said Resident #54 was a 2 person transfer but I had not been aware she was a 2-person transfer. CNA C said when she transferred the resident in the bathroom she still thought the resident was a 1person transfer. A quarterly MDS dated [DATE] indicated Resident #54 had severely impaired cognition, clear speech, was usually understood, and sometimes understood. The MDS indicated Resident #54 required extensive 2- person physical assist with bed mobility, transfers, and toilet use. During an interview on 05/08/19 at 10:56 a.m., the DON said Resident #54 was a 1 or 2 person transfer prior to the 03/25/19 incident when she fractured her left ankle. She said staff knew it depended on the resident's mood and behavior as to how many staff it would take to transfer her. During an observation and interview on 05/07/19 at 11:24 a.m., Resident #54 was sitting in her wheelchair in the secured unit. She was unable to recall the incident. During an interview on 05/08/19 at 11:00 a.m., the ADON said Resident #54's MDS for (MONTH) 2019 indicated she required extensive 2- person assist with transfers. She said the resident was identified as requiring 2- person assist with transfers because the CNAs indicated in the kiosk at least once the resident required 2- person assist with a transfer during that look back time. The ADON said Resident #54 was care planned as a 1 or 2- person extensive assist with transfers because of her being uncooperative and based on her mood at the time of the transfer.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures to prohibit and prevent neglect for 1 of 29 residents reviewed for neglect. (Resident #81) The facility did not provide CPR to Resident #81 who was a full code. The resident became unresponsive and was drooling while at the nursing station. Resident #81 was taken to her room and transferred to her bed, still not responsive to verbal or tactile stimuli. Two RNs did not verify the resident's code status and did not provide CPR. Resident #81 was pronounced dead at the facility. An Immediate Jeopardy was identified on [DATE] at 8:56 a.m. The Immediate Jeopardy (IJ) was removed on [DATE] at 2 p.m.; however, the facility remained out of at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 30 residents who had a full code status at risk for death. Findings included: A facility policy regarding the prevention and reporting of suspected resident abuse and neglect indicated the following: .This facility has designed and implement processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect . 7.D. Neglect Allegation - Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Physician orders [REDACTED].#81 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated the resident had a full code status. An advance directive/DNR policy form signed by Resident #81's son on [DATE] indicated he had received information regarding the Out-of-Hospital-Do-Not-Resuscitate (OOHDNR). The form indicated Resident #81 did not have an OOHDNR and that the facility would perform CPR unless otherwise documented in the medical record. A geriatric evaluation dated [DATE] completed by a physician indicated Resident #81 was able to verbalize her needs and follow all commands, had [DIAGNOSES REDACTED]. The physician indicated that Resident #81 overall appeared to be doing well and remained a full code. A nursing note completed by RN A, dated [DATE] at 5:45 p.m. indicated Resident #81 was sitting at the nursing station talking. A nursing note completed by RN A dated [DATE] at 6:06 p.m. indicated Resident #81 was slightly slumped over in her wheelchair while still at the nursing station. The note indicated Resident #81's eyes were closed and noted the resident had some drooling. CNA took the resident to her room/bed at that time. A nursing note completed by RN B dated [DATE] at 6:07 p.m. indicated Resident #81 was sitting at the nursing desk talking with staff. The note indicated the resident was seen by the nurse drooling. Aide told to take resident to her room to lay down. Nurse aide found her not to be responsive when transferring her to bed. A nursing note completed by RN B dated [DATE] at 6:10 p.m. stated Nurse called to her (Resident #81) room. Found resident nonresponsive. No respirations, no carotid, radial and ankle pulses present. She was pale and cool to touch. Purple mottling noted to soles of feet and up to ankles. Performed sternal rub with no response. Resident's death called by this RN and one other RN at 1815 (6:15 p.m.). Son called and informed of her death. Director of nursing notified also. A nursing note completed by RN A dated [DATE] at 6:12 p.m. indicated Resident #81 was found with no respirations, no heartbeat or carotid pulse, and no dp pulse (pulse in the foot). The note indicated the resident's bilateral feet/ankles bluish/purple, cold to touch, and mottling was noted to the resident's feet and lower legs/ankles. The resident's pupils were fixed. Resident #81 was pronounced at 18:15 (6:15 p.m.) by this and another RN. A nursing note completed by the DON dated [DATE] at 7:35 p.m. for Resident #81 indicated the following: Was summoned up to nursing home per nursing staff regarding resident. Her color was pale and was cold and clammy. Notified the Justice of Peace .as we have no out of hospital DNR for resident he said that 2 RNs could pronounce as he usually does not pronounce a death except when there is a cause. Notified nurse practitioner .and told her of . (Resident #81's) passing. And that we do not have an out of hospital DNR. She consulted .a physician and he said if the Justice of the Peace said that 2 RNs could pronounce, then as medical director the Justice of the Peace has priority on pronouncing the death and if he said 2 RNs could pronounce then it was alright. So done by 2 RNs that were on staff at that time . During an interview on [DATE] at 2:15 p.m., the DON indicated she was called the evening Resident #81 died . The DON said she thought emergency medical services (EMS) was called but was then cancelled after the physician said it was alright for 2 RNs to pronounce the death of Resident #81. The DON said RN B did a sternal rub on Resident #81 and got no response. The DON said she did not think RN B initiated CPR. The DON said she had not investigated or self-reported the incident to the state agency and did not follow up with an in-service. During a telephone interview on [DATE] at 5:51 p.m. RN B said on the evening Resident #81 died , RN B was in the dining room attempting to feed Resident #81. RN B said Resident #81 was not eating and was stooped over. RN B said Resident #81 was verbally responsive to questions but would not eat. RN B said she took Resident #81 to the nursing station on West Hall and left her there. RN B said she went back to the dining room to finish monitoring meal service. RN B said after dinner she went back to the nursing station and Resident #81 was still sitting in the same place. RN B said she could not remember how long Resident #81 was sitting at the nursing station. RN B said RN A told an aide to take Resident #81 to her room. RN B said the CNA said she did not think Resident #81 was breathing. RN B said she checked Resident #81 to see if she had a pulse and did not feel a pulse. RN B said she and the CNA took Resident #81 to her room and put her in the bed. RN B said she listened to Resident #81 for a heartbeat, checked for a carotid pulse, and listened for any air movement and got nothing. RN B said she really could not remember clearly what happened after that. RN B said someone called EMS, but she was not sure who called or if any EMS personnel ever came to the facility. RN B said she started CPR by giving Resident #81 a couple of breaths and doing some chest compressions. RN B said she only did this for a few minutes but probably should have kept going until EMS showed up. RN B said she felt like CPR was not helping Resident #81 and thought Resident #81 may have been gone too long. RN B said she did not call for assistance and was in Resident #81's room alone. RN B said she did not know if Resident #81 was a full code or not. RN B said there was supposed to be something in the chart that indicated a code status for residents. RN B said she thought it was in the front of the chart. RN B said she sent someone to check the code status but did not remember who checked or what the status was. RN B said at that time she did not know there was an automated external defibrillator (AED) in the building. RN B said she had not received training on the AED. RN B said she had not received much training on CPR and was not certified in CPR. RN B said her CPR card had expired a long time ago. RN B said she did not know if anyone else in the building that evening was CPR certified. RN B said no one else provided CPR on Resident #81 that night that she knew of. RN B said RN A came into Resident #81's room and listened to Resident #81. RN B said she and RN A pronounced Resident #81s death. RN B said the DON came to the facility and made some phone calls, but she did not know who was called or what was discussed. RN B said she had worked at the facility for approximately 3 years as a full-time employee. RN B said she was changed to PRN (as needed) status after the death of Resident #81. RN B said she had not receive any further training in CPR or AED since the death of Resident #81. RN B said she had worked some shifts since the death of Resident #81. During an interview on [DATE] at 2:30 p.m., RN A said she was working the night Resident #81 passed away. She said Resident #81 was not her patient. RN A said she saw Resident #81 sitting at the nursing station with drool on her face. She asked a CNA to wipe Resident #81's face. The CNA said she would go ahead and take Resident #81 to her room. RN A said a few minutes later RN B asked her to come listen to see if Resident #81 was breathing because RN B did not have a stethoscope. RN A said Resident #81 did not have respirations or a pulse when she listened to her. RN A said Resident #81's feet were cool and her lower legs were kind of splotched. RN A said she told RN B Resident #81 was not breathing and did not have a pulse. RN A said she asked RN B if she needed help and RN B said she did not need help RN A said she started walking away, then turned around and asked RN B if Resident #81 was a full code. RN A said she told RN B if Resident #81 was a full code she would have to start CPR and call 911. RN B said Resident #81 was not a full code. RN A said she did not question RN B because Resident #81 was RN B's patient. RN A said the code status of each resident was in the front of each resident's chart. RN A said she did not know if EMS was called. RN A said she did not initiate CPR and did not see anyone performing CPR on Resident #81. RN A said she believed RN B made a mistake and thought resident was a no code because Resident #81 was old and frail. During an interview on [DATE] at 3:39 p.m., CNA D said she thought she remembered the evening Resident #81 died . She indicated a nurse pushed Resident #81 out of the dining room to the nursing station and Resident #81 was leaned over and slobbering. CNA D indicated she did not remember which nurses were working that evening. CNA D said she told a nurse that Resident #81 was unresponsive. CNA D said a nurse looked Resident #81 over and she and the nurse took Resident #81 to her room and transferred her to the bed. CNA D said the nurse took Resident #81's vital signs and then started CPR. CNA D said she went to the kiosk and checked to see if Resident #81 was a full code. CNA D said Resident #81 was a full code. CNA D said two nurses started CPR on Resident #81. CNA D said EMS came and hooked Resident #81 up to a machine and pronounced her as dead. CNA D said she would report an unresponsive resident immediately to a nurse. During a telephone interview on [DATE] at 4:15 p.m., a representative from the EMS indicated they had not received a call for assistance on [DATE] from the facility. During an interview on [DATE] at 10:00 a.m., RN C said she was not working on West Hall the evening Resident #81 died . RN C said she was CPR certified. RN C said she was not called to assess Resident #81 or provide CPR on Resident #81 the evening Resident #81 died . RN C said she was notified she needed to come in for training today (approximately 3 months after Resident #81's death) on CPR protocol and the AED. During an interview on [DATE] at 8:56 a.m., the DON said she expected nurses to assess residents who had a change in condition. The DON said if a nurse found a resident to be unresponsive with no respirations and pulses the nurse should start CPR and call 911 if the resident was a full code. The DON said a sheet was in the front of the chart that identified a resident as full code or do not resuscitate. The DON said she was aware the requirement was that at least one employee working on each shift should be CPR certified. The DON said the facility did not keep track of which nurses were CPR certified and when their CPR certification expired. The DON said it was the responsibility of nursing staff to maintain their CPR certification and make sure it was current. The DON said she did not specifically make sure each shift had someone CPR certified. The DON said she did not have a system in place to be sure every shift had someone who was CPR certified. She said she did not know if the nursing staff working on the evening of [DATE] were CPR certified. The DON said there was no way for nursing staff working a shift to know who was CPR certified. The DON said she believed RN B was provided with education about CPR protocol and AED training after the death of Resident #81 but could not find the documentation. The DON said their education website had an online class about the AED, but nursing staff were not required to take the class prior to employment. She said the AED class was an optional class. The DON said RN B worked as needed since the death of Resident #81. RN B's personnel file did not indicate RN B received any training in CPR or AED use since her hire date of [DATE]. The record indicated RN B not been counseled by the DON following Resident #81's death. During an interview on [DATE] at 8:56 a.m., the administrator indicated end of life decisions of residents should be honored. The administrator said she did not report the death of Resident #81 to the state agency. The administrator said she relied on the nursing staff to notify her if a death needed to be reported to the state agency. The administrator said all incidents of abuse or neglect should be reported and investigated as the facility policy states. An undated policy entitled Cardio [MEDICAL CONDITION] Resuscitation Certification Policy indicated the following: It is the goal of this facility to have at least one staff member, preferably a nurse but not required, certified in Cardio [MEDICAL CONDITION] Resuscitation (CPR) present for 24 hours a day. This facility will offer CPR training and certification once every 2 years from an accredited training company. Should a staff member's certification expire prior to the facility sponsored training date then that staff member, at their own cost and time, is responsible for renewing if they so choose. When the facility offers the training class all nurses are required to attend. During an interview on [DATE] at 8:56 a.m. the administrator indicated the above policy was put in place when the new company took over in August. She said they did not do an initial class to certify all nurses. An undated policy entitled Automated External Defibrillator (AED) Use indicated the following: .In order to be eligible to use and AED on an appropriate patient, authorized individuals will: 1. Meet the educational requirements set forth in these policies and procedures 2. Comply with the requirements set forth in these policies and procedures. Failure to comply with these requirements including but not limited to an approved educational course/class shall result in the suspension of the individual's authorization. Internal Emergency Response System The first person on the scene: 1. Initiate the chain of survival by calling out for help with a medical emergency. The nearest person will call 911 and delegate someone to go outside and escort the paramedics to the scene upon arrival. The AED and other medical supplies are to be brought to the patient. If trained, the responder will initiate CPR until the AED arrives. Initial Protocol for the unconscious victim is as follows: 1. Upon arrival assess the safety of the scene; use universal precautions. 2. Assess patient for unresponsiveness. a. call 911 (you will call if you are alone). b. Send someone to get the AED . 3. Assess breathing. a. If not breathing, give 2 breaths. 4. If warranted, perform CPR until the AED arrives . A policy entitled Code Status Policy indicated the following: Purpose: To provide each resident/responsible party with the education and opportunity to make an informed decision regarding their code status. The facility will maintain a system of clearly identifying, documenting, and communicating the resident's code status decisions to essential facility personnel . Execution: Upon admission, the resident/RP will execute written authorization representing their code status decision and/or Advanced Directives .In lieu of an Advanced Directive, OOHDNR, or appropriately executed Advanced Directive Worksheet indicating the resident/RPs decision, the resident will be considered a full code . The administrator and DON were notified on [DATE] at 8:56 a.m. that an Immediate Jeopardy was identified due to the above failures. The facility's plan of removal was accepted on [DATE] at 12:13 p.m , and included: The alleged failure is as follows: NEGLECT FAILURE TO INITIATE CPR In-servicing/education provided in response: [DATE], (YEAR) at 9:50a.m. Director of Nurses with the Business Officer Manager reviewed all CPR status of all licensed nurses to verify current CPR certification. ADON is doing the in-service on CPR and AED policies and proper usage of AED. All licensed staff will complete CPR/AED policies and proper AED usage by (MONTH) 25,2018 at 11:30a.m. With newly hired licensed staff CPR/AED policies will be reviewed. CPR training will be verified. (named) LVN is doing the in-service training for all the license nursing staff. The in-service will start at approximately 10:30 a.m. and was completed at 11:30 a.m. All licensed staff that were not present will have completed the training prior to their next shift. Competency will be shown by return demonstration. The Medical Director was notified of I-J on (MONTH) 25, (YEAR) at approximately 10:30a.m. The person involved was . was terminated. How will you prevent reoccurrence? CPR verification will be done on hire. All current staff that is not current with their CPR will have their renewal done by the end of the day. All licensed staff will be educated on hire and annually on CPR/AED policies. The Business Office Manager will maintain a record of all licensed staff and their current CPR certifications. She will notify the staff member and the Director of Nurses when a certificate about one month prior to expiration of certification. Staff will renew their certification and will not be placed on the schedule to work until certification is validated. Administrator will place color coded indicators in residents' room to signal to staff code status. Was there any assessment done for the residents related to the I-J? All residents were assessed to verify code status. How will this be monitored for effectiveness of the Plan of Removal? The Administrator, the Director of Nursing RN, and the Assistant Director of Nursing LVN will monitor for effectiveness of this Plan of Removal. Frequency of monitoring will be done 1Xday for 7 days: then 3x/week for 30 days and 1x/week thereafter. On [DATE] at 2:00 p.m. the survey team confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by the following: On [DATE] the survey interviewed 10 nursing staff regarding basic life support during an emergency and they were able to describe the correct procedures. On [DATE] the survey team observed a new tracking system on the beds to determine code status, and the new system for ensuring nurses were CPR certified. [DATE] the survey team reviewed in-service records regarding AED training with return demonstration, CPR policy, calling for assistance during emergency situations and CPR certification documentation. On [DATE] at 2:00 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system. A list provided by the facility on [DATE] at 4:46 p.m. indicated 30 residents were a full code.

Based on observation, interview, and record review, the facility failed to ensure the right to be free from neglect was provided for 1 of 29 residents reviewed for neglect. (Resident #81) The facility did not provide CPR to Resident #81 who was a full code. The resident became unresponsive and was drooling while at the nursing station. Resident #81 was taken to her room and transferred to her bed, still not responsive to verbal or tactile stimuli. Two RNs did not verify the resident's code status and did not provide CPR. Resident #81 was pronounced dead at the facility. An Immediate Jeopardy was identified on [DATE] at 8:56 a.m. The Immediate Jeopardy (IJ) was removed on [DATE] at 2 p.m.; however, the facility remained out of at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 30 residents who had a full code status at risk for death. Findings included: Physician orders [REDACTED].#81 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated the resident had a full code status. An advance directive/DNR policy form signed by Resident #81's son on [DATE] indicated he had received information regarding the Out-of-Hospital-Do-Not-Resuscitate (OOHDNR). The form indicated Resident #81 did not have an OOHDNR and that the facility would perform CPR unless otherwise documented in the medical record. A geriatric evaluation dated [DATE] completed by a physician indicated Resident #81 was able to verbalize her needs and follow all commands, had [DIAGNOSES REDACTED]. The physician indicated that Resident #81 overall appeared to be doing well and remained a full code. A nursing note, completed by RN A, dated [DATE] at 5:45 p.m. indicated Resident #81 was sitting at the nursing station talking. A nursing note, completed by RN A, dated [DATE] at 6:06 p.m. indicated Resident #81 was slightly slumped over in her wheelchair while still at the nursing station. The note indicated Resident #81's eyes were closed and noted the resident had some drooling. A CNA took the resident to her room/bed at that time. A nursing note completed by RN B dated [DATE] at 6:07 p.m. indicated Resident #81 was sitting at the nursing desk talking with staff. The note indicated the resident was seen by the nurse drooling. Aide told to take resident to her room to lay down. Nurse aide found her not to be responsive when transferring her to bed. A nursing note completed by RN B dated [DATE] at 6:10 p.m. stated Nurse called to her (Resident #81) room. Found resident nonresponsive. No respirations, no carotid, radial and ankle pulses present. She was pale and cool to touch. Purple mottling noted to soles of feet and up to ankles. Performed sternal rub with no response. Resident's death called by this RN and one other RN at 1815 (6:15 p.m.). Son called and informed of her death. Director of nursing notified also. A nursing note completed by RN A dated [DATE] at 6:12 p.m. indicated Resident #81 was found with no respirations, no heartbeat or carotid pulse, and no dp pulse (pulse in the foot). The note indicated the resident's bilateral feet/ankles bluish/purple, cold to touch, and mottling was noted to the resident's feet and lower legs/ankles. The resident's pupils were fixed. Resident #81 was pronounced at 18:15 (6:15 p.m.) by this and another RN. A nursing note completed by the DON dated [DATE] at 7:35 p.m. for Resident #81 indicated the following: Was summoned up to nursing home per nursing staff regarding resident. Her color was pale and was cold and clammy. Notified the Justice of Peace .as we have no out of hospital DNR for resident he said that 2 RNs could pronounce as he usually does not pronounce a death except when there is a cause. Notified nurse practitioner .and told her of . (Resident #81's) passing. And that we do not have an out of hospital DNR. She consulted .a physician and he said if the Justice of the Peace said that 2 RNs could pronounce, then as medical director the Justice of the Peace has priority on pronouncing the death and if he said 2 RNs could pronounce then it was alright. So done by 2 RNs that were on staff at that time . During an interview on [DATE] at 2:15 p.m., the DON indicated she was called the evening Resident #81 died . The DON said she thought emergency medical services (EMS) was called but was then cancelled after the physician said it was alright for 2 RNs to pronounce the death of Resident #81. The DON said RN B did a sternal rub on Resident #81 and got no response. The DON said she did not think RN B initiated CPR. The DON said she had not investigated or self-reported the incident to the state agency and did not follow up with an in-service. During a telephone interview on [DATE] at 5:51 p.m., RN B said on the evening Resident #81 died , RN B was in the dining room attempting to feed Resident #81. RN B said Resident #81 was not eating and was stooped over. RN B said Resident #81 was verbally responsive to questions but would not eat. RN B said she took Resident #81 to the nursing station on West Hall and left her there. RN B said she went back to the dining room to finish monitoring meal service. RN B said after dinner she went back to the nursing station and Resident #81 was still sitting in the same place. RN B said she could not remember how long Resident #81 was sitting at the nursing station. RN B said RN A told an aide to take Resident #81 to her room. RN B said the CNA said she did not think Resident #81 was breathing. RN B said she checked Resident #81 to see if she had a pulse and did not feel a pulse. RN B said she and the CNA took Resident #81 to her room and put her in the bed. RN B said she listened to Resident #81 for a heartbeat, checked for a carotid pulse, and listened for any air movement and got nothing. RN B said she really could not remember clearly what happened after that. RN B said someone called EMS, but she was not sure who called or if any EMS personnel ever came to the facility. RN B said she started CPR by giving Resident #81 a couple of breaths and doing some chest compressions. RN B said she only did this for a few minutes but probably should have kept going until EMS showed up. RN B said she felt like CPR was not helping Resident #81 and thought Resident #81 may have been gone too long. RN B said she did not call for assistance and was in Resident #81's room alone. RN B said she did not know if Resident #81 was a full code or not. RN B said there was supposed to be something in the chart that indicated a code status for residents. RN B said she thought it was in the front of the chart. RN B said she sent someone to check the code status but did not remember who checked or what the status was. RN B said at that time she did not know there was an automated external defibrillator (AED) in the building. RN B said she had not received training on the AED. RN B said she had not received much training on CPR and was not certified in CPR. RN B said her CPR card had expired a long time ago. RN B said she did not know if anyone else in the building that evening was CPR certified. RN B said no one else provided CPR on Resident #81 that night that she knew of. RN B said RN A came into Resident #81's room and listened to Resident #81. RN B said she and RN A pronounced Resident #81s death. RN B said the DON came to the facility and made some phone calls, but she did not know who was called or what was discussed. RN B said she had worked at the facility for approximately 3 years as a full-time employee. RN B said she was changed to PRN (as needed) status after the death of Resident #81. RN B said she had not receive any further training in CPR or AED since the death of Resident #81. RN B said she had worked some shifts since the death of Resident #81. During an interview on [DATE] at 2:30 p.m., RN A said she was working the night Resident #81 passed away. She said Resident #81 was not her patient. RN A said she saw Resident #81 sitting at the nursing station with drool on her face. She asked a CNA to wipe Resident #81's face. The CNA said she would go ahead and take Resident #81 to her room. RN A said a few minutes later RN B asked her to come listen to see if Resident #81 was breathing because RN B did not have a stethoscope. RN A said Resident #81 did not have respirations or a pulse when she listened to her. RN A said Resident #81's feet were cool and her lower legs were kind of splotched. RN A said she told RN B Resident #81 was not breathing and did not have a pulse. RN A said she asked RN B if she needed help and RN B said she did not need help RN A said she started walking away, then turned around and asked RN B if Resident #81 was a full code. RN A said she told RN B if Resident #81 was a full code she would have to start CPR and call 911. RN B said Resident #81 was not a full code. RN A said she did not question RN B because Resident #81 was RN B's patient. RN A said the code status of each resident was in the front of each resident's chart. RN A said she did not know if EMS was called. RN A said she did not initiate CPR and did not see anyone performing CPR on Resident #81. RN A said she believed RN B made a mistake and thought resident was a no code because Resident #81 was old and frail. During an interview on [DATE] at 3:39 p.m., CNA D said she thought she remembered the evening Resident #81 died . She indicated a nurse pushed Resident #81 out of the dining room to the nursing station and Resident #81 was leaned over and slobbering. CNA D indicated she did not remember which nurses were working that evening. CNA D said she told a nurse that Resident #81 was unresponsive. CNA D said a nurse looked Resident #81 over and she and the nurse took Resident #81 to her room and transferred her to the bed. CNA D said the nurse took Resident #81's vital signs and then started CPR. CNA D said she went to the kiosk and checked to see if Resident #81 was a full code. CNA D said Resident #81 was a full code. CNA D said two nurses started CPR on Resident #81. CNA D said EMS came and hooked Resident #81 up to a machine and pronounced her as dead. CNA D said she would report an unresponsive resident immediately to a nurse. During a telephone interview on [DATE] at 4:15 p.m., a representative from EMS indicated they had not received a call for assistance on [DATE] from the facility. During an interview on [DATE] at 10:00 a.m., RN C said she was not working on West Hall the evening Resident #81 died . RN C said she was CPR certified. RN C said she was not called to assess Resident #81 or provide CPR on Resident #81 the evening Resident #81 died . RN C said she was notified she needed to come in for training today (approximately 3 months after Resident #81's death) on CPR protocol and the AED. During an interview on [DATE] at 8:56 a.m., the DON said she expected nurses to assess residents who had a change in condition. The DON said if a nurse found a resident to be unresponsive with no respirations and pulses the nurse should start CPR and call 911 if the resident was a full code. The DON said a sheet was in the front of the chart that identified a resident as full code or do not resuscitate. The DON said she was aware the requirement was that at least one employee working on each shift should be CPR certified. The DON said the facility did not keep track of which nurses were CPR certified and when their CPR certification expired. The DON said it was the responsibility of nursing staff to maintain their CPR certification and make sure it was current. The DON said she did not specifically make sure each shift had someone CPR certified. The DON said she did not have a system in place to be sure every shift had someone who was CPR certified. She said she did not know if the nursing staff working on the evening of [DATE] were CPR certified. The DON said there was no way for nursing staff working a shift to know who was CPR certified. The DON said she believed RN B was provided with education about CPR protocol and AED training after the death of Resident #81 but could not find the documentation. The DON said their education website had an online class about the AED, but nursing staff were not required to take the class prior to employment. She said the AED class was an optional class. The DON said RN B worked as needed since the death of Resident #81. RN B's personnel file did not indicate RN B received any training in CPR or AED use since her hire date of [DATE]. The record indicated RN B not been counseled by the DON following Resident #81's death. During an interview on [DATE] at 8:56 a.m., the administrator indicated end of life decisions of residents should be honored. The administrator said she did not report the death of Resident #81 to the state agency. The administrator said she relied on the nursing staff to notify her if a death needed to be reported to the state agency. The administrator said all incidents of abuse or neglect should be reported and investigated as the facility policy states. An undated policy entitled Cardio [MEDICAL CONDITION] Resuscitation Certification Policy indicated the following: It is the goal of this facility to have at least one staff member, preferably a nurse but not required, certified in Cardio [MEDICAL CONDITION] Resuscitation (CPR) present for 24 hours a day. This facility will offer CPR training and certification once every 2 years from an accredited training company. Should a staff member's certification expire prior to the facility sponsored training date then that staff member, at their own cost and time, is responsible for renewing if they so choose. When the facility offers the training class all nurses are required to attend. During an interview on [DATE] at 8:56 a.m. the administrator indicated the above policy was put in place when the new company took over in August. She said they did not do an initial class to certify all nurses. An undated policy entitled Automated External Defibrillator (AED) Use indicated the following: .In order to be eligible to use and AED on an appropriate patient, authorized individuals will: 1. Meet the educational requirements set forth in these policies and procedures 2. Comply with the requirements set forth in these policies and procedures. Failure to comply with these requirements including but not limited to an approved educational course/class shall result in the suspension of the individual's authorization. Internal Emergency Response System The first person on the scene: 1. Initiate the chain of survival by calling out for help with a medical emergency. The nearest person will call 911 and delegate someone to go outside and escort the paramedics to the scene upon arrival. The AED and other medical supplies are to be brought to the patient. If trained, the responder will initiate CPR until the AED arrives. Initial Protocol for the unconscious victim is as follows: 1. Upon arrival assess the safety of the scene; use universal precautions. 2. Assess patient for unresponsiveness. a. call 911 (you will call if you are alone). b. Send someone to get the AED . 3. Assess breathing. a. If not breathing, give 2 breaths. 4. If warranted, perform CPR until the AED arrives . A policy entitled Code Status Policy indicated the following: Purpose: To provide each resident/responsible party with the education and opportunity to make an informed decision regarding their code status. The facility will maintain a system of clearly identifying, documenting, and communicating the resident's code status decisions to essential facility personnel . Execution: Upon admission, the resident/RP will execute written authorization representing their code status decision and/or Advanced Directives .In lieu of an Advanced Directive, OOHDNR, or appropriately executed Advanced Directive Worksheet indicating the resident/RPs decision, the resident will be considered a full code . A facility policy regarding the prevention and reporting of suspected resident abuse and neglect indicated the following: .This facility has designed and implement processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect . 7.D. Neglect Allegation - Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The administrator and DON were notified on [DATE] at 8:56 a.m. that an Immediate Jeopardy was identified due to the above failures. The facility's plan of removal was accepted on [DATE] at 12:13 p.m , and included: The alleged failure is as follows: NEGLECT FAILURE TO INITIATE CPR In-servicing/education provided in response: [DATE], (YEAR) at 9:50a.m. Director of Nurses with the Business Officer Manager reviewed all CPR status of all licensed nurses to verify current CPR certification. ADON is doing the in-service on CPR and AED policies and proper usage of AED. All licensed staff will complete CPR/AED policies and proper AED usage by (MONTH) 25,2018 at 11:30a.m. With newly hired licensed staff CPR/AED policies will be reviewed. CPR training will be verified. (named) LVN is doing the in-service training for all the license nursing staff. The in-service will start at approximately 10:30 a.m. and was completed at 11:30 a.m. All licensed staff that were not present will have completed the training prior to their next shift. Competency will be shown by return demonstration. The Medical Director was notified of I-J on (MONTH) 25, (YEAR) at approximately 10:30a.m. The person involved was . was terminated. How will you prevent reoccurrence? CPR verification will be done on hire. All current staff that is not current with their CPR will have their renewal done by the end of the day. All licensed staff will be educated on hire and annually on CPR/AED policies. The Business Office Manager will maintain a record of all licensed staff and their current CPR certifications. She will notify the staff member and the Director of Nurses when a certificate about one month prior to expiration of certification. Staff will renew their certification and will not be placed on the schedule to work until certification is validated. Administrator will place color coded indicators in residents' room to signal to staff code status. Was there any assessment done for the residents related to the I-J? All residents were assessed to verify code status. How will this be monitored for effectiveness of the Plan of Removal? The Administrator, the Director of Nursing RN, and the Assistant Director of Nursing LVN will monitor for effectiveness of this Plan of Removal. Frequency of monitoring will be done 1Xday for 7 days: then 3x/week for 30 days and 1x/week thereafter. On [DATE] at 2:00 p.m. the survey team confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by the following: On [DATE] the survey interviewed 10 nursing staff regarding basic life support during an emergency and they were able to describe the correct procedures. On [DATE] the survey team observed a new tracking system on the beds to determine code status, and the new system for ensuring nurses were CPR certified. [DATE] the survey team reviewed in-service records regarding AED training with return demonstration, CPR policy, calling for assistance during emergency situations and CPR certification documentation. On [DATE] at 2:00 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system. A list provided by the facility on [DATE] at 4:46 p.m. indicated 30 residents were a full code.

Based on observation, interview, and record review the facility failed to ensure appropriate treatment and care was provided in accordance with professional standards and resident choices for 1 of 29 residents reviewed for quality of care. (Resident #81). The facility did not adequately assess Resident #81 when she experienced a significant change. The resident became unresponsive and was drooling while at the nursing station. Resident #81 was taken to her room and transferred to her bed, still not responsive to verbal or tactile stimuli. Two RNs did not verify the resident's code status and did not provide CPR. Resident #81 was pronounced dead at the facility. An Immediate Jeopardy was identified on [DATE] at 8:56 a.m. The Immediate Jeopardy (IJ) was removed on [DATE] at 2 p.m.; however, the facility remained out of at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 30 residents who had a full code status at risk for death. Findings included: Physician orders [REDACTED].#81 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated the resident had a full code status. An advance directive/DNR policy form signed by Resident #81's son on [DATE] indicated he had received information regarding the Out-of-Hospital-Do-Not-Resuscitate (OOHDNR). The form indicated Resident #81 did not have an OOHDNR and that the facility would perform CPR unless otherwise documented in the medical record. A geriatric evaluation dated [DATE] completed by a physician indicated Resident #81 was able to verbalize her needs and follow all commands, had [DIAGNOSES REDACTED]. The physician indicated that Resident #81 overall appeared to be doing well and remained a full code. A nursing note, completed by RN A, dated [DATE] at 5:45 p.m. indicated Resident #81 was sitting at the nursing station talking. A nursing note, completed by RN A dated [DATE] at 6:06 p.m. indicated Resident #81 was slightly slumped over in her wheelchair while still at the nursing station. The note indicated Resident #81's eyes were closed and noted the resident had some drooling. A CNA took the resident to her room/bed at that time. The note did not address if the resident was assessed at that time. A nursing note, completed by RN B dated [DATE] at 6:07 p.m. indicated Resident #81 was sitting at the nursing desk talking with staff. The note indicated the resident was seen by the nurse drooling. Aide told to take resident to her room to lay down. Nurse aide found her not to be responsive when transferring her to bed. A nursing note completed by RN B dated [DATE] at 6:10 p.m. stated Nurse called to her (Resident #81) room. Found resident nonresponsive. No respirations, no carotid, radial and ankle pulses present. She was pale and cool to touch. Purple mottling noted to soles of feet and up to ankles. Performed sternal rub with no response. Resident's death called by this RN and one other RN at 1815 (6:15 p.m.). Son called and informed of her death. Director of nursing notified also. A nursing note completed by RN A dated [DATE] at 6:12 p.m. indicated Resident #81 was found with no respirations, no heartbeat or carotid pulse, and no dp pulse (pulse in the foot). The note indicated the resident's bilateral feet/ankles bluish/purple, cold to touch, and mottling was noted to the resident's feet and lower legs/ankles. The resident's pupils were fixed. Resident #81 was pronounced at 18:15 (6:15 p.m.) by this and another RN. A nursing note completed by the DON dated [DATE] at 7:35 p.m. for Resident #81 indicated the following: Was summoned up to nursing home per nursing staff regarding resident. Her color was pale and was cold and clammy. Notified the Justice of Peace .as we have no out of hospital DNR for resident he said that 2 RNs could pronounce as he usually does not pronounce a death except when there is a cause. Notified nurse practitioner .and told her of . (Resident #81's) passing. And that we do not have an out of hospital DNR. She consulted .a physician and he said if the Justice of the Peace said that 2 RNs could pronounce, then as medical director the Justice of the Peace has priority on pronouncing the death and if he said 2 RNs could pronounce then it was alright. So done by 2 RNs that were on staff at that time . During an interview on [DATE] at 2:15 p.m., the DON indicated she was called the evening Resident #81 died . The DON said she thought emergency medical services (EMS) was called but was then cancelled after the physician said it was alright for 2 RNs to pronounce the death of Resident #81. The DON said RN B did a sternal rub on Resident #81 and got no response. The DON said she did not think RN B initiated CPR. The DON said she had not investigated or self-reported the incident to the state agency and did not follow up with an in-service. During a telephone interview on [DATE] at 5:51 p.m., RN B said on the evening Resident #81 died , RN B was in the dining room attempting to feed Resident #81. RN B said Resident #81 was not eating and was stooped over. RN B said Resident #81 was verbally responsive to questions but would not eat. RN B said she took Resident #81 to the nursing station on West Hall and left her there. RN B said she went back to the dining room to finish monitoring meal service. RN B said after dinner she went back to the nursing station and Resident #81 was still sitting in the same place. RN B said she could not remember how long Resident #81 was sitting at the nursing station. RN B said RN A told an aide to take Resident #81 to her room. RN B said the CNA said she did not think Resident #81 was breathing. RN B said she checked Resident #81 to see if she had a pulse and did not feel a pulse. RN B said she and the CNA took Resident #81 to her room and put her in the bed. RN B said she listened to Resident #81 for a heartbeat, checked for a carotid pulse, and listened for any air movement and got nothing. RN B said she really could not remember clearly what happened after that. RN B said someone called EMS, but she was not sure who called or if any EMS personnel ever came to the facility. RN B said she started CPR by giving Resident #81 a couple of breaths and doing some chest compressions. RN B said she only did this for a few minutes but probably should have kept going until EMS showed up. RN B said she felt like CPR was not helping Resident #81 and thought Resident #81 may have been gone too long. RN B said she did not call for assistance and was in Resident #81's room alone. RN B said she did not know if Resident #81 was a full code or not. RN B said there was supposed to be something in the chart that indicated a code status for residents. RN B said she thought it was in the front of the chart. RN B said she sent someone to check the code status but did not remember who checked or what the status was. RN B said at that time she did not know there was an automated external defibrillator (AED) in the building. RN B said she had not received training on the AED. RN B said she had not received much training on CPR and was not certified in CPR. RN B said her CPR card had expired a long time ago. RN B said she did not know if anyone else in the building that evening was CPR certified. RN B said no one else provided CPR on Resident #81 that night that she knew of. RN B said RN A came into Resident #81's room and listened to Resident #81. RN B said she and RN A pronounced Resident #81s death. RN B said the DON came to the facility and made some phone calls, but she did not know who was called or what was discussed. RN B said she had worked at the facility for approximately 3 years as a full-time employee. RN B said she was changed to PRN (as needed) status after the death of Resident #81. RN B said she had not receive any further training in CPR or AED since the death of Resident #81. RN B said she had worked some shifts since the death of Resident #81. During an interview on [DATE] at 2:30 p.m., RN A said she was working the night Resident #81 passed away. She said Resident #81 was not her patient. RN A said she saw Resident #81 sitting at the nursing station with drool on her face. She asked a CNA to wipe Resident #81's face. The CNA said she would go ahead and take Resident #81 to her room. RN A said a few minutes later RN B asked her to come listen to see if Resident #81 was breathing because RN B did not have a stethoscope. RN A said Resident #81 did not have respirations or a pulse when she listened to her. RN A said Resident #81's feet were cool and her lower legs were kind of splotched. RN A said she told RN B Resident #81 was not breathing and did not have a pulse. RN A said she asked RN B if she needed help and RN B said she did not need help RN A said she started walking away, then turned around and asked RN B if Resident #81 was a full code. RN A said she told RN B if Resident #81 was a full code she would have to start CPR and call 911. RN B said Resident #81 was not a full code. RN A said she did not question RN B because Resident #81 was RN B's patient. RN A said the code status of each resident was in the front of each resident's chart. RN A said she did not know if EMS was called. RN A said she did not initiate CPR and did not see anyone performing CPR on Resident #81. RN A said she believed RN B made a mistake and thought resident was a no code because Resident #81 was old and frail. During an interview on [DATE] at 3:39 p.m., CNA D said she thought she remembered the evening Resident #81 died . She indicated a nurse pushed Resident #81 out of the dining room to the nursing station and Resident #81 was leaned over and slobbering. CNA D indicated she did not remember which nurses were working that evening. CNA D said she told a nurse that Resident #81 was unresponsive. CNA D said a nurse looked Resident #81 over and she and the nurse took Resident #81 to her room and transferred her to the bed. CNA D said the nurse took Resident #81's vital signs and then started CPR. CNA D said she went to the kiosk and checked to see if Resident #81 was a full code. CNA D said Resident #81 was a full code. CNA D said two nurses started CPR on Resident #81. CNA D said EMS came and hooked Resident #81 up to a machine and pronounced her as dead. CNA D said she would report an unresponsive resident immediately to a nurse. During a telephone interview on [DATE] at 4:15 p.m., a representative from the EMS indicated they had not received a call for assistance on [DATE] from the facility. During an interview on [DATE] at 10:00 a.m., RN C said she was not working on West Hall the evening Resident #81 died . RN C said she was CPR certified. RN C said she was not called to assess Resident #81 or provide CPR on Resident #81 the evening Resident #81 died . RN C said she was notified she needed to come in for training today (approximately 3 months after Resident #81's death) on CPR protocol and the AED. During an interview on [DATE] at 8:56 a.m., the DON said she expected nurses to assess residents who had a change in condition. The DON said if a nurse found a resident to be unresponsive with no respirations and pulses the nurse should start CPR and call 911 if the resident was a full code. The DON said a sheet was in the front of the chart that identified a resident as full code or do not resuscitate. The DON said she was aware the requirement was that at least one employee working on each shift should be CPR certified. The DON said the facility did not keep track of which nurses were CPR certified and when their CPR certification expired. The DON said it was the responsibility of nursing staff to maintain their CPR certification and make sure it was current. The DON said she did not specifically make sure each shift had someone CPR certified. The DON said she did not have a system in place to be sure every shift had someone who was CPR certified. She said she did not know if the nursing staff working on the evening of [DATE] were CPR certified. The DON said there was no way for nursing staff working a shift to know who was CPR certified. The DON said she believed RN B was provided with education about CPR protocol and AED training after the death of Resident #81 but could not find the documentation. The DON said their education website had an online class about the AED, but nursing staff were not required to take the class prior to employment. She said the AED class was an optional class. The DON said RN B worked as needed since the death of Resident #81. RN B's personnel file did not indicate RN B received any training in CPR or AED use since her hire date of [DATE]. The record indicated RN B not been counseled by the DON following Resident #81's death. During an interview on [DATE] at 8:56 a.m., the administrator indicated end of life decisions of residents should be honored. The administrator said she did not report the death of Resident #81 to the state agency. The administrator said she relied on the nursing staff to notify her if a death needed to be reported to the state agency. The administrator said all incidents of abuse or neglect should be reported and investigated as the facility policy states. An undated policy entitled Cardio [MEDICAL CONDITION] Resuscitation Certification Policy indicated the following: It is the goal of this facility to have at least one staff member, preferably a nurse but not required, certified in Cardio [MEDICAL CONDITION] Resuscitation (CPR) present for 24 hours a day. This facility will offer CPR training and certification once every 2 years from an accredited training company. Should a staff member's certification expire prior to the facility sponsored training date then that staff member, at their own cost and time, is responsible for renewing if they so choose. When the facility offers the training class all nurses are required to attend. During an interview on [DATE] at 8:56 a.m., the administrator indicated the above policy was put in place when the new company took over in August. She said they did not do an initial class to certify all nurses. An undated policy entitled Automated External Defibrillator (AED) Use indicated the following: .In order to be eligible to use and AED on an appropriate patient, authorized individuals will: 1. Meet the educational requirements set forth in these policies and procedures 2. Comply with the requirements set forth in these policies and procedures. Failure to comply with these requirements including but not limited to an approved educational course/class shall result in the suspension of the individual's authorization. Internal Emergency Response System The first person on the scene: 1. Initiate the chain of survival by calling out for help with a medical emergency. The nearest person will call 911 and delegate someone to go outside and escort the paramedics to the scene upon arrival. The AED and other medical supplies are to be brought to the patient. If trained, the responder will initiate CPR until the AED arrives. Initial Protocol for the unconscious victim is as follows: 1. Upon arrival assess the safety of the scene; use universal precautions. 2. Assess patient for unresponsiveness. a. call 911 (you will call if you are alone). b. Send someone to get the AED . 3. Assess breathing. a. If not breathing, give 2 breaths. 4. If warranted, perform CPR until the AED arrives . A policy entitled Code Status Policy indicated the following: Purpose: To provide each resident/responsible party with the education and opportunity to make an informed decision regarding their code status. The facility will maintain a system of clearly identifying, documenting, and communicating the resident's code status decisions to essential facility personnel . Execution: Upon admission, the resident/RP will execute written authorization representing their code status decision and/or Advanced Directives .In lieu of an Advanced Directive, OOHDNR, or appropriately executed Advanced Directive Worksheet indicating the resident/RPs decision, the resident will be considered a full code . A facility policy regarding the prevention and reporting of suspected resident abuse and neglect indicated the following: .This facility has designed and implement processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect . 7.D. Neglect Allegation - Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The administrator and DON were notified on [DATE] at 8:56 a.m. that an Immediate Jeopardy was identified due to the above failures. The facility's plan of removal was accepted on [DATE] at 12:13 p.m , and included: The alleged failure is as follows: NEGLECT FAILURE TO INITIATE CPR In-servicing/education provided in response: [DATE], (YEAR) at 9:50a.m. Director of Nurses with the Business Officer Manager reviewed all CPR status of all licensed nurses to verify current CPR certification. ADON is doing the in-service on CPR and AED policies and proper usage of AED. All licensed staff will complete CPR/AED policies and proper AED usage by (MONTH) 25,2018 at 11:30a.m. With newly hired licensed staff CPR/AED policies will be reviewed. CPR training will be verified. (named) LVN is doing the in-service training for all the license nursing staff. The in-service will start at approximately 10:30 a.m. and was completed at 11:30 a.m. All licensed staff that were not present will have completed the training prior to their next shift. Competency will be shown by return demonstration. The Medical Director was notified of I-J on (MONTH) 25, (YEAR) at approximately 10:30a.m. The person involved was . was terminated. How will you prevent reoccurrence? CPR verification will be done on hire. All current staff that is not current with their CPR will have their renewal done by the end of the day. All licensed staff will be educated on hire and annually on CPR/AED policies. The Business Office Manager will maintain a record of all licensed staff and their current CPR certifications. She will notify the staff member and the Director of Nurses when a certificate about one month prior to expiration of certification. Staff will renew their certification and will not be placed on the schedule to work until certification is validated. Administrator will place color coded indicators in residents' room to signal to staff code status. Was there any assessment done for the residents related to the I-J? All residents were assessed to verify code status. How will this be monitored for effectiveness of the Plan of Removal? The Administrator, the Director of Nursing RN, and the Assistant Director of Nursing LVN will monitor for effectiveness of this Plan of Removal. Frequency of monitoring will be done 1Xday for 7 days: then 3x/week for 30 days and 1x/week thereafter. On [DATE] at 2:00 p.m. the survey team confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by the following: On [DATE] the survey interviewed 10 nursing staff regarding basic life support during an emergency and they were able to describe the correct procedures. On [DATE] the survey team observed a new tracking system on the beds to determine code status, and the new system for ensuring nurses were CPR certified. [DATE] the survey team reviewed in-service records regarding AED training with return demonstration, CPR policy, calling for assistance during emergency situations and CPR certification documentation. On [DATE] at 2:00 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system. A list provided by the facility on [DATE] at 4:46 p.m. indicated 30 residents were a full code.

Based on observation, interview, and record review, the facility failed to have evidence that all allegations of neglect were thoroughly investigated and preventative interventions were implemented to prevent further neglect from occurring for 1 of 29 residents reviewed for neglect. (Resident #81). The facility did not provide CPR to Resident #81 who was a full code. The resident became unresponsive and was drooling while at the nursing station. Resident #81 was taken to her room and transferred to her bed, still not responsive to verbal or tactile stimuli. Two RNs did not verify the resident's code status and did not provide CPR. Resident #81 was pronounced dead at the facility. The facility did not investigate the failure to provide CPR on Resident #81 and did not implement interventions to prevent further potential neglect from occurring. An Immediate Jeopardy was identified on [DATE] at 8:56 a.m. The Immediate Jeopardy (IJ) was removed on [DATE] at 2 p.m.; however, the facility remained out of at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 30 residents who were a full code status at risk for death. Findings included: Physician orders [REDACTED].#81 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated the resident had a full code status. An advance directive/DNR policy form signed by Resident #81's son on [DATE] indicated he had received information regarding the Out-of-Hospital-Do-Not-Resuscitate (OOHDNR). The form indicated Resident #81 did not have an OOHDNR and that the facility would perform CPR unless otherwise documented in the medical record. A geriatric evaluation dated [DATE] completed by a physician indicated Resident #81 was able to verbalize her needs and follow all commands, had [DIAGNOSES REDACTED]. The physician indicated that Resident #81 overall appeared to be doing well and remained a full code. A nursing note completed by RN A, dated [DATE] at 5:45 p.m. indicated Resident #81 was sitting at the nursing station talking. A nursing note completed by RN A dated [DATE] at 6:06 p.m. indicated Resident #81 was slightly slumped over in her wheelchair while still at the nursing station. The note indicated Resident #81's eyes were closed and noted the resident had some drooling. CNA took the resident to her room/bed at that time. A nursing note completed by RN B dated [DATE] at 6:07 p.m. indicated Resident #81 was sitting at the nursing desk talking with staff. The note indicated the resident was seen by the nurse drooling. Aide told to take resident to her room to lay down. Nurse aide found her not to be responsive when transferring her to bed. A nursing note completed by RN B dated [DATE] at 6:10 p.m. stated Nurse called to her (Resident #81) room. Found resident nonresponsive. No respirations, no carotid, radial and ankle pulses present. She was pale and cool to touch. Purple mottling noted to soles of feet and up to ankles. Performed sternal rub with no response. Resident's death called by this RN and one other RN at 1815 (6:15 p.m.). Son called and informed of her death. Director of nursing notified also. A nursing note completed by RN A dated [DATE] at 6:12 p.m. indicated Resident #81 was found with no respirations, no heartbeat or carotid pulse, and no dp pulse (pulse in the foot). The note indicated the resident's bilateral feet/ankles bluish/purple, cold to touch, and mottling was noted to the resident's feet and lower legs/ankles. The resident's pupils were fixed. Resident #81 was pronounced at 18:15 (6:15 p.m.) by this and another RN. A nursing note completed by the DON dated [DATE] at 7:35 p.m. for Resident #81 indicated the following: Was summoned up to nursing home per nursing staff regarding resident. Her color was pale and was cold and clammy. Notified the Justice of Peace .as we have no out of hospital DNR for resident he said that 2 RNs could pronounce as he usually does not pronounce a death except when there is a cause. Notified nurse practitioner .and told her of . (Resident #81's) passing. And that we do not have an out of hospital DNR. She consulted .a physician and he said if the Justice of the Peace said that 2 RNs could pronounce, then as medical director the Justice of the Peace has priority on pronouncing the death and if he said 2 RNs could pronounce then it was alright. So done by 2 RNs that were on staff at that time . During an interview on [DATE] at 2:15 p.m., the DON indicated she was called the evening Resident #81 died . The DON said she thought emergency medical services (EMS) was called but was then cancelled after the physician said it was alright for 2 RNs to pronounce the death of Resident #81. The DON said RN B did a sternal rub on Resident #81 and got no response. The DON said she did not think RN B initiated CPR. The DON said she had not investigated or self-reported the incident to the state agency and did not follow up with an in-service. During a telephone interview on [DATE] at 5:51 p.m., RN B said on the evening Resident #81 died , RN B was in the dining room attempting to feed Resident #81. RN B said Resident #81 was not eating and was stooped over. RN B said Resident #81 was verbally responsive to questions but would not eat. RN B said she took Resident #81 to the nursing station on West Hall and left her there. RN B said she went back to the dining room to finish monitoring meal service. RN B said after dinner she went back to the nursing station and Resident #81 was still sitting in the same place. RN B said she could not remember how long Resident #81 was sitting at the nursing station. RN B said RN A told an aide to take Resident #81 to her room. RN B said the CNA said she did not think Resident #81 was breathing. RN B said she checked Resident #81 to see if she had a pulse and did not feel a pulse. RN B said she and the CNA took Resident #81 to her room and put her in the bed. RN B said she listened to Resident #81 for a heartbeat, checked for a carotid pulse, and listened for any air movement and got nothing. RN B said she really could not remember clearly what happened after that. RN B said someone called EMS, but she was not sure who called or if any EMS personnel ever came to the facility. RN B said she started CPR by giving Resident #81 a couple of breaths and doing some chest compressions. RN B said she only did this for a few minutes but probably should have kept going until EMS showed up. RN B said she felt like CPR was not helping Resident #81 and thought Resident #81 may have been gone too long. RN B said she did not call for assistance and was in Resident #81's room alone. RN B said she did not know if Resident #81 was a full code or not. RN B said there was supposed to be something in the chart that indicated a code status for residents. RN B said she thought it was in the front of the chart. RN B said she sent someone to check the code status but did not remember who checked or what the status was. RN B said at that time she did not know there was an automated external defibrillator (AED) in the building. RN B said she had not received training on the AED. RN B said she had not received much training on CPR and was not certified in CPR. RN B said her CPR card had expired a long time ago. RN B said she did not know if anyone else in the building that evening was CPR certified. RN B said no one else provided CPR on Resident #81 that night that she knew of. RN B said RN A came into Resident #81's room and listened to Resident #81. RN B said she and RN A pronounced Resident #81s death. RN B said the DON came to the facility and made some phone calls, but she did not know who was called or what was discussed. RN B said she had worked at the facility for approximately 3 years as a full-time employee. RN B said she was changed to PRN (as needed) status after the death of Resident #81. RN B said she had not receive any further training in CPR or AED since the death of Resident #81. RN B said she had worked some shifts since the death of Resident #81. During an interview on [DATE] at 2:30 p.m., RN A said she was working the night Resident #81 passed away. She said Resident #81 was not her patient. RN A said she saw Resident #81 sitting at the nursing station with drool on her face. She asked a CNA to wipe Resident #81's face. The CNA said she would go ahead and take Resident #81 to her room. RN A said a few minutes later RN B asked her to come listen to see if Resident #81 was breathing because RN B did not have a stethoscope. RN A said Resident #81 did not have respirations or a pulse when she listened to her. RN A said Resident #81's feet were cool and her lower legs were kind of splotched. RN A said she told RN B Resident #81 was not breathing and did not have a pulse. RN A said she asked RN B if she needed help and RN B said she did not need help RN A said she started walking away, then turned around and asked RN B if Resident #81 was a full code. RN A said she told RN B if Resident #81 was a full code she would have to start CPR and call 911. RN B said Resident #81 was not a full code. RN A said she did not question RN B because Resident #81 was RN B's patient. RN A said the code status of each resident was in the front of each resident's chart. RN A said she did not know if EMS was called. RN A said she did not initiate CPR and did not see anyone performing CPR on Resident #81. RN A said she believed RN B made a mistake and thought resident was a no code because Resident #81 was old and frail. During an interview on [DATE] at 3:39 p.m., CNA D said she thought she remembered the evening Resident #81 died . She indicated a nurse pushed Resident #81 out of the dining room to the nursing station and Resident #81 was leaned over and slobbering. CNA D indicated she did not remember which nurses were working that evening. CNA D said she told a nurse that Resident #81 was unresponsive. CNA D said a nurse looked Resident #81 over and she and the nurse took Resident #81 to her room and transferred her to the bed. CNA D said the nurse took Resident #81's vital signs and then started CPR. CNA D said she went to the kiosk and checked to see if Resident #81 was a full code. CNA D said Resident #81 was a full code. CNA D said two nurses started CPR on Resident #81. CNA D said EMS came and hooked Resident #81 up to a machine and pronounced her as dead. CNA D said she would report an unresponsive resident immediately to a nurse. During a telephone interview on [DATE] at 4:15 p.m., a representative from the EMS indicated they had not received a call for assistance on [DATE] from the facility. During an interview on [DATE] at 10:00 a.m. RN C said she was not working on West Hall the evening Resident #81 died . RN C said she was CPR certified. RN C said she was not called to assess Resident #81 or provide CPR on Resident #81 the evening Resident #81 died . RN C said she was notified she needed to come in for training today (approximately 3 months after Resident #81's death) on CPR protocol and the AED. During an interview on [DATE] at 8:56 a.m., the DON said she expected nurses to assess residents who had a change in condition. The DON said if a nurse found a resident to be unresponsive with no respirations and pulses the nurse should start CPR and call 911 if the resident was a full code. The DON said a sheet was in the front of the chart that identified a resident as full code or do not resuscitate. The DON said she was aware the requirement was that at least one employee working on each shift should be CPR certified. The DON said the facility did not keep track of which nurses were CPR certified and when their CPR certification expired. The DON said it was the responsibility of nursing staff to maintain their CPR certification and make sure it was current. The DON said she did not specifically make sure each shift had someone CPR certified. The DON said she did not have a system in place to be sure every shift had someone who was CPR certified. She said she did not know if the nursing staff working on the evening of [DATE] were CPR certified. The DON said there was no way for nursing staff working a shift to know who was CPR certified. The DON said she believed RN B was provided with education about CPR protocol and AED training after the death of Resident #81 but could not find the documentation. The DON said their education website had an online class about the AED, but nursing staff were not required to take the class prior to employment. She said the AED class was an optional class. The DON said RN B worked as needed since the death of Resident #81. RN B's personnel file did not indicate RN B received any training in CPR or AED use since her hire date of [DATE]. The record indicated RN B not been counseled by the DON following Resident #81's death. During an interview on [DATE] at 8:56 a.m., the administrator indicated end of life decisions of residents should be honored. The administrator said she did not report the death of Resident #81 to the state agency. The administrator said she relied on the nursing staff to notify her if a death needed to be reported to the state agency. The administrator said all incidents of abuse or neglect should be reported and investigated as the facility policy states. An undated policy entitled Cardio [MEDICAL CONDITION] Resuscitation Certification Policy indicated the following: It is the goal of this facility to have at least one staff member, preferably a nurse but not required, certified in Cardio [MEDICAL CONDITION] Resuscitation (CPR) present for 24 hours a day. This facility will offer CPR training and certification once every 2 years from an accredited training company. Should a staff member's certification expire prior to the facility sponsored training date then that staff member, at their own cost and time, is responsible for renewing if they so choose. When the facility offers the training class all nurses are required to attend. During an interview on [DATE] at 8:56 a.m., the administrator indicated the above policy was put in place when the new company took over in August. She said they did not do an initial class to certify all nurses. An undated policy entitled Automated External Defibrillator (AED) Use indicated the following: .In order to be eligible to use and AED on an appropriate patient, authorized individuals will: 1. Meet the educational requirements set forth in these policies and procedures 2. Comply with the requirements set forth in these policies and procedures. Failure to comply with these requirements including but not limited to an approved educational course/class shall result in the suspension of the individual's authorization. Internal Emergency Response System The first person on the scene: 1. Initiate the chain of survival by calling out for help with a medical emergency. The nearest person will call 911 and delegate someone to go outside and escort the paramedics to the scene upon arrival. The AED and other medical supplies are to be brought to the patient. If trained, the responder will initiate CPR until the AED arrives. Initial Protocol for the unconscious victim is as follows: 1. Upon arrival assess the safety of the scene; use universal precautions. 2. Assess patient for unresponsiveness. a. call 911 (you will call if you are alone). b. Send someone to get the AED . 3. Assess breathing. a. If not breathing, give 2 breaths. 4. If warranted, perform CPR until the AED arrives . A policy entitled Code Status Policy indicated the following: Purpose: To provide each resident/responsible party with the education and opportunity to make an informed decision regarding their code status. The facility will maintain a system of clearly identifying, documenting, and communicating the resident's code status decisions to essential facility personnel . Execution: Upon admission, the resident/RP will execute written authorization representing their code status decision and/or Advanced Directives .In lieu of an Advanced Directive, OOHDNR, or appropriately executed Advanced Directive Worksheet indicating the resident/RPs decision, the resident will be considered a full code . A facility policy regarding the prevention and reporting of suspected resident abuse and neglect indicated the following: .This facility has designed and implement processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect . 7.D. Neglect Allegation - Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The administrator and DON were notified on [DATE] at 8:56 a.m. that an Immediate Jeopardy was identified due to the above failures. The facility's plan of removal was accepted on [DATE] at 12:13 p.m , and included: The alleged failure is as follows: NEGLECT FAILURE TO INITIATE CPR In-servicing/education provided in response: [DATE], (YEAR) at 9:50a.m. Director of Nurses with the Business Officer Manager reviewed all CPR status of all licensed nurses to verify current CPR certification. ADON is doing the in-service on CPR and AED policies and proper usage of AED. All licensed staff will complete CPR/AED policies and proper AED usage by (MONTH) 25,2018 at 11:30a.m. With newly hired licensed staff CPR/AED policies will be reviewed. CPR training will be verified. (named) LVN is doing the in-service training for all the license nursing staff. The in-service will start at approximately 10:30 a.m. and was completed at 11:30 a.m. All licensed staff that were not present will have completed the training prior to their next shift. Competency will be shown by return demonstration. The Medical Director was notified of I-J on (MONTH) 25, (YEAR) at approximately 10:30a.m. The person involved was . was terminated. How will you prevent reoccurrence? CPR verification will be done on hire. All current staff that is not current with their CPR will have their renewal done by the end of the day. All licensed staff will be educated on hire and annually on CPR/AED policies. The Business Office Manager will maintain a record of all licensed staff and their current CPR certifications. She will notify the staff member and the Director of Nurses when a certificate about one month prior to expiration of certification. Staff will renew their certification and will not be placed on the schedule to work until certification is validated. Administrator will place color coded indicators in residents' room to signal to staff code status. Was there any assessment done for the residents related to the I-J? All residents were assessed to verify code status. How will this be monitored for effectiveness of the Plan of Removal? The Administrator, the Director of Nursing RN, and the Assistant Director of Nursing LVN will monitor for effectiveness of this Plan of Removal. Frequency of monitoring will be done 1Xday for 7 days: then 3x/week for 30 days and 1x/week thereafter. On [DATE] at 2:00 p.m. the survey team confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by the following: On [DATE] the survey interviewed 10 nursing staff regarding basic life support during an emergency and they were able to describe the correct procedures. On [DATE] the survey team observed a new tracking system on the beds to determine code status, and the new system for ensuring nurses were CPR certified. [DATE] the survey team reviewed in-service records regarding AED training with return demonstration, CPR policy, calling for assistance during emergency situations and CPR certification documentation. On [DATE] at 2:00 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system. A list provided by the facility on [DATE] at 4:46 p.m. indicated 30 residents were a full code. .