Every finding on record at Avir at New Braunfels

Based on interview and record review the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and, the facility failed to ensure a copy was sent of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 2 resident (Resident #1) reviewed for transfers and discharges. The facility failed to provide a 30 day discharge notice for Resident #1 and failed to provide a copy to the Ombudsman. This failure could place residents at risk of inappropriate discharges, and not informing the Ombudsman of a resident discharge, to allow for an appeal process. The findings include:Record review of Resident #1's admission Record, dated 7/8/2026, documented a [AGE] year old, female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinson's disease, age-related cognitive decline, and dementia. Record review of Resident #1's discharge MDS, dated [DATE], documented her BIMs score was 10/15 (moderate cognitive impairment). Resident #1 rejected care for 1 to 3 days. Record review of Resident #1's care plan, dated 6/17/2026, documented: she had social behaviors related to Cognitive impairment (dementia) with impaired judgment, poor impulse control, poor social, and decrease control, to interpret social cues (may include anxiety/restlessness contributing to behaviors); Physical/Verbal Aggression/ Resistant to Care-Physical and verbal aggression / resistant behaviors during care R/T: Cognitive impairment/suspected dementia and impaired coping/adjustment, evidenced by hitting staff, yelling/cussing, throwing items, and refusal of care/medications; and barricading in room / blocking Safety risk / risk for injury and delayed emergency response R/T: Cognitive impairment (dementia) with poor judgment, anxiety/restlessness, impaired impulse control and intermittent care refusal AEB: Resident barricades self in room/blocks doorway, limiting staff access. Record review of Resident #1's discharge summary report, dated 6/17/2026, documented Resident #1 was transferred to another sister facility with all her belongings and dated by the physician on 6/23/2026. At an interview on 7/10/2026 at 4:06 PM, the ADM stated that he did not provide a 30 day notice to Resident #1 or her party responsible. The ADM stated that he did not provide a copy of the discharge notice to the Ombudsman. ADM had no comments. At an interview on 7/10/2026 at 11:19 AM, the Ombudsman stated that the ADM did not provide a 30 day notice for Resident #1. IIn an interview on 7/10/2026 at 9:21 AM with Representative of Resident #1 called with no return phone call. In an attempt to interview on 7/10/2026 at 12:40 PM Resident #1 she was confused and stated that, surveyor needed to talk to her family. Record review of the policy, Transfer or Discharge, Facility- Initiated, dated May 2026, documented, Once admitted the facility, residents have the right to remain in the facility. Facility initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Notice of transfer or discharge (planned), 13. Answers or for presenting are given a 30 day advance written notice of an impending transfer or discharge from the facility. 15. A copy of the notice is sent to the office of the state long term care ombudsman at the same time the notice representative to discharge is provided to the resident and representative.

Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State for 1 of 1 facility reviewed for qualifications of activity professionals. The facility failed to have a qualified Activities Professional to direct their activities program. This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident for activities.The findings included: During an interview on 05/23/2026 at 3:46 p.m., the Administrator revealed that the Activity Director recently quit and the position was vacant for a few weeks but would need to confirm the date.During an interview on 05/23/2026 at 4:29 p.m., the Assistant Activity Director revealed that the Activity Director quit her position at the beginning of April 2026. She stated that the Activity Director came into the office and said she was done and quit abruptly. The Assistant Activity Director stated she asked the Administrator for assistance in paying the fees to begin the AD certification course, but he delayed her request as he believed once she became certified, she may leave the facility. She stated she was neither licensed nor registered as a qualified activities professional. The Assistant Activity Director stated she was a bit overwhelmed as she was responsible for performing the duties of the former AD including the scheduling of activities, both individual and groups. During a follow-up interview on 05/23/2026 at 6:45 p.m., the Administrator stated that he was actively working on filling the activity director position and had an advertisement out for the position. He stated he was currently in talks about sending the Assistant Activity Director to school to obtain her AD certification. He stated he had not gotten solid applicants for the position, and he was unable to find a certified activity director. He stated he was leaning towards providing the Assistant Activity Director with the opportunity to complete a training course approved by the state and to become a licensed Activity Director. The Administrator stated that the Assistant Activity Director was provided with training under the Activity Director for two years. He stated the Assistant Activity Director was currently directing their activities program. The Administrator stated that he understood the facility was in non-compliance and is working towards filling the AD position.During an interview on 05/23/2026 at 6:54 p.m., the Regional Nurse Consultant stated they did not have a policy specific to the activity director, and they followed state regulations for the requirement.Record review of a facility policy titled, Activity Programs, dated June 2018, revealed .Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident.

Based on observation, interview, and record review, the facility failed to ensure residents were served food that is palatable and attractive for 6 of 9 residents (Residents #1-3, and 3 anonymous residents) reviewed for nutrition. The facility failed to serve Residents #1-3 and 3 anonymous residents food that they found appetizing and attractive.These failures place residents at risk of weight loss, altered nutritional status, and diminished quality of life.Findings included:Record review of Resident #1's Face Sheet dated 5/12/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included type 2 diabetes mellitus (when the body cannot self-regulate elevated blood sugar levels).Record review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition. In an interview on 5/12/2026 at 10:12 AM, Resident #1 said he disliked the food served at the facility, and the food was often served burned, with small portion sizes, or missing items. He said he frequently signs out of the facility to go to the grocery store to buy his own food because of the quality and quantity of the food at the facility. He said alternative menu choices were offered but were often limited to sandwiches, and he prefers to not eat bread due to his medical conditions. Record review of Resident #2's Face Sheet dated 5/12/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included unspecified protein-calorie malnutrition. Record review of Resident #2's annual MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition. In an interview on 5/14/2026 at 9:40 AM, Resident #2 said the food at the facility is bad, not edible, and makes him feel sick. He said the facility limits items on the alternative menu due to shortages of ingredients, so he rarely gets to eat any food that he finds satisfying. He said the concerns about the food had been discussed at multiple resident council meetings and directly to the DSM but there had been no improvements. Record review of Resident #3's Face Sheet dated 5/12/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included type 2 diabetes mellitus with hyperglycemia (when the body cannot self-regulate elevated blood sugar levels, leading to higher-than-normal blood sugar levels). Record review of Resident #3's admission MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition. In an interview with Resident #3 on 5/12/2026 at 11:23 AM, he said his meals at the facility taste bad and he does not always eat because he dislikes the meals. He said the trays are often served with items that he dislikes or with small portions that cause him to remain hungry after mealtimes. He said he is supposed to be receiving double portions but rarely gets correctly sized portions on his meal trays. In an observation on 5/12/2026 at 1:30 PM, the lunch meal served at the facility was observed to be a ground meat dish in a red sauce. The menu posted in the dining room listed the lunch entree of BBQ CHOPPED BEEF W/ SAUCE [sic].In a confidential interview at an undisclosed date and time. two anonymous residents said their lunch meals were disgusting and they hate the food served at the facility. They said the quality had been declining over the last six months. They said they had discussed their concerns with the DSM and other leadership at the facility, but there had been no improvements. In an observation and interview on 5/15/2026 at 10:50 AM, a lunch tray was sampled. The DSM said the facility was serving a cold lunch due to unexpected maintenance issues in the kitchen affecting the ability to wash dishes and prepare hot foods. The tray contained a sandwich with two circular slices of meat and a square slice of cheese on sliced, white sandwich style bread. The tray also contained a serving of potato chips, vanilla pudding, and a packet of ketchup. The foods were served at palatable temperature. In confidential interview at an undisclosed date and time, an anonymous resident said the quality of most meals at the facility was bad, and it made him feel unhappy.In an interview on 5/14/2026 at 9:23 AM with LVN B, he said residents frequently complained about the meals served at the facility. He said the complaints were typically about the quality of the food or incorrect trays served with foods that residents are known to dislike. The RD did not respond to a telephone request for interview via a voicemail left on 5/14/2026 at 11:45 AM. In an interview with MA C on 5/14/2026 at 11:57 AM, she said residents often complain about the food. She said they dislike the type of foods on the menu or the small portion sizes. In an interview with the DSM on 5/12/2026 at 1:35 PM, he said he was aware that residents were dissatisfied with the quality of the food at times. He said food at the facility was prepared using the food ordered through the corporate system, and the kitchen staff followed the recipe exactly how it written in the manual, including portion sizes.In an interview with the DON on 5/14/2026 at 1:39 PM, she said she was aware of the residents' concerns regarding the food served at the facility. She said many residents had voiced complaints to her about the food, and she felt the facility had room for improvement to ensure resident satisfaction and overall quality of life, as well at nutritional needs. In an interview with the Admin. on 5/15/2026 at 8:25 AM, he said he was aware of the residents' concerns about the food. He said he had been invited to attend a resident council meeting recently, and the lack of food quality was discussed. He said the facility was actively working on improving the food quality, and he was working with the corporate leadership to determine a feasible plan for overall improvement. He said he felt resident satisfaction with the food quality was important to their overall quality of life and nutritional status. Record review of the facility policy titled The Dining Experience contained in the facility dining manual dated 2023, reflected the following: .The dining experience will be person centered with the purpose of enhancing each individual's quality of life and being supportive of each individual's needs during dining. Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutrition and/or special dietary needs and food preferences and are served at a safe and appetizing temperature .

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity and to provide care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 1 dining area reviewed for dining.The facility failed to ensure all residents were served meals on non-disposable dishware on 5/12/2026 through 5/15/2026.This failure could result in the loss of dignity of residents and decreased quality of life. Findings included:In an observation on 5/12/2026 at 1:20 PM, lunch was being served to residents by facility staff in the dining area. Approximately 5 out of 20 trays were observed without dishware and instead held disposable, Styrofoam containers. Upon entering the kitchen, dietary staff were observed portioning food into the Styrofoam containers for residents. Disposable containers were again observed during lunch meal services on 5/13/2026- 5/15/2026. In an interview with DA A on 5/12/2026 at 1:30 PM, she said the meals were being served in disposable containers because they did not have enough plates for the residents. She said approximately half of all meals had to be served in disposable containers, and the facility had been serving food in this way for a few months. In an interview with the DSM on 5/12/2026 at 1:35 PM, he said the facility did not have enough non-disposable utensils, cups, and plates for all residents. He said he submitted a request for the items through the corporate ordering system, but the order was pending approval. In an interview on 5/14/2026 at 9:40 AM, Resident #2 said he is frequently served meals in Styrofoam containers, and he dislikes it.In an interview with the Admin. on 5/15/2026 at 8:25 AM, he said he was aware of the shortage of plates, cups, and utensils. He said the DSM had submitted a request for the items through the corporate ordering system, but the order had not yet been approved. He said he had followed up a few days prior regarding the status of the order because he felt the disposable dishware was a risk to residents' dignity and dining experience. Record review of the facility policy titled Dining Atmosphere contained in the facility dining manual, dated 2023, reflected the following: .Dishware should be non-disposable, clean, eye appealing, matched, without chips of appropriate color to match the dining room decor . Flatware should be non-disposable, clean, neatly placed and in good condition . Glasses should be non-disposable, clean and free of stains or spots .

Based on observation, interview, and record review, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs for 1 of 6 residents (Resident #3) reviewed for nutrition. The facility failed to ensure Resident #3 was served a lunch tray on 5/12/2026 and 5/14/2026 that contained a double portion of protein dish and extra sandwich, as ordered by the physician.This failure could result in unintentional weight loss, nutritional deficits, and decreased quality of life. Findings included:Record review of Resident #3's Face Sheet dated 5/12/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included type 2 diabetes mellitus with hyperglycemia (when the body cannot self-regulate elevated blood sugar levels, leading to higher-than-normal blood sugar levels). Record review of Resident #3's admission MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition. Record review of Resident #3's Order Summary Report dated 5/13/2026 reflected the following order dated 4/20/2026:Heart healthy diet Regular texture, Regular consistency, Double portions plus additional sandwich for all meals. Avoid carb heavy meals due to diabetes, no Styrofoam plates for Diabetes Mellitus Type 2.Record review of the facility document titled Diet Roster- By Resident dated 5/12/2026 reflected Resident #3 was to receive a regular diet with regular texture and thin liquids. Additional notes indicated Diabetic Diet, lg. protein, lg. protein. lg protein [sic].In an observation and interview on 5/12/2026 at 1:00 PM, Resident #3's lunch meal arrived with a paper ticket that read lg protein. The tray appeared to have a larger portion of meat in sauce than the plates of other residents at the table. The meal was not served with a sandwich. Resident #3 said his meals are frequently served with incorrect portion sizes and without a sandwich. He said he feels frustrated by the errors. He said he did not notify any staff members that his lunch was missing the sandwich because he did not want to eat, and he declined assistance with obtaining a corrected meal tray. The FNP did not respond to a telephone request for interview via a message left with the FNP's office staff on 5/14/2026 at 10:55 AM. The RD did not respond to telephone voicemail request for interview left on 5/14/2026 at 11:45 AM. In an observation on 5/14/2026 at 1:20 PM, Resident #3's lunch meal contained a single slice of meat patty that was similar in size to the trays of other residents. The paper ticket that arrived with the plate read lg protein. Resident #3 declined to participate in an interview during this observation. In an interview on 5/14/2026 at 1:20 PM, the DSM said Resident #3's lunch tray was prepared incorrectly and did not contain a large protein portion. He said the kitchen staff were trained to include 1.5 portions for residents with physicians orders for large portions. In an interview with the Admin. on 5/15/2026 at 8:25 AM, he said residents should be served trays with double portions if it is ordered by the physician. He said nursing staff should check the trays before they are served to ensure the tray is correct to promote health and nutrition for residents. Record review of the facility policy titled Altered Portions contained within the facility's dining manual dated 2023, reflected the following: .Altered portion sizes will be served upon request or at the recommendation of the RDN (or designee) and with the consent of the individual .

Based on observations, interviews and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (Resident #1) reviewed for abuse. On [DATE] at 10:25 p.m., CNA A pried Resident # 1's hands off a chair and grabbed the wrists and physically pushed Resident # 1 causing Resident # 1 to fall to the floor and against the wall which required an evaluation at the local ER due to redness to the wrists and back. This failure was identified as past noncompliance IJ as the facility had instituted adequate corrective measure to prevent recurrence of the noncompliance. The noncompliance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. This failure could result in residents suffering injury, a diminished quality of life, and/or death.The findings included: Record Review on [DATE] of Resident # 1's face sheet revealed Resident #1 was a -[AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer' disease (a progressive neurogenerative brain disorder), bi-polar (a mental health disorder with mood shifts), anxiety, cognitively impaired, schizophrenia disorder (a mental disorder) with mania depression (symptom of bi-polar), and a lack of coordination. The RP was listed as: a family member. Record review on [DATE] of Resident #1 's quarterly MDS, dated [DATE]., reflected a BIMS score of 3 indicative of severe impairment in cognition. The ADLs (section GG) revealed: the resident was incontinent with bowel and bladder. As for Transfer and Mobility, the resident only required supervision; resident was ambulatory and a wanderer. Record review on [DATE] of Resident #1's Care Plan, undated, revealed, the goals and interventions included: the goal ofADL assistance especially for transfer because the resident had muscle weakness, impaired cognition, lacked coordination and undergoing a disease process [Alzheimer's disease]. For the goal of behaviors/agitation the interventions included: re-direction, structured activities and move to a quiet area. Record review on [DATE] of Resident #1's physician orders, dated [DATE], revealed the resident was prescribed Seroquel 50 mg, 1 tablet at bedtime for schizophrenia disorder. Record review on [DATE] of Resident #1's Nurse Note dated [DATE] authored by LVN B revealed: incident occurred on [DATE] at 10:25 p.m. where CNA A struggled with Resident #1 over a chair. During the struggle CNA A grabbed the resident by his wrists and pushed him to the floor. CNA A also pushed the resident against a wall. CNA A was sent home by LVN B. The note further revealed LVN B called the Administrator immediately after CNA A was sent home. Record review on [DATE] of Resident #1's skin assessment on [DATE] completed by LVN B revealed redness to both wrists and back. Record review on [DATE] of Resident #1's ER report dated [DATE] revealed no injury to Resident # 1 and the x-ray was negative. Record review on [DATE] of LVN B's written statement dated [DATE] repeated the same information as the nurse note dated [DATE]. Namely, incident occurred on [DATE] at 10:25 p.m. where CNA A struggled with Resident #1 over a chair. During the struggle CNA A grabbed the resident by his wrists and pushed him to the floor. CNA A also pushed the resident against a wall. CNA A was sent home by LVN B. The note further revealed LVN B called the Administrator immediately after CNA A was sent home. Record review on [DATE] of CNA C's written statement undated revealed: she witnessed the tug of war between CNA A and Resident #1 over a chair in the secure men's unit. The written statement also revealed LVN B tried to intervene. During LVN B's intervention, CNA A pushed Resident #1 to the floor and then CNA again pushed the resident into the wall. Record review on [DATE] of CNA A's email dated [DATE], revealed he was defending himself and he tried to de-escalate and the resident lost his balance. The email added CNA A had no intention of harming the resident. Record review on [DATE] Law Enforcement case number card, dated [DATE], revealed law enforcement responded but no arrest was made of CNA A who no longer was in the facility [surveyor made an email request on [DATE] for the law enforcement report] Record review of RN D's written statement undated revealed she responded to the situation and sent CNA A home. Record review of CNA A's employee file revealed: EMR and Criminal History Checks completed [DATE] with no negative information. CNA A completed ANE and dementia training on [DATE]. CNA A's competency checklist revealed he was checked off for ANE and dementia on [DATE]. SB-9 [Senate Bill-9 requiring that providers report abuse] was signed by CNA A on [DATE]. Also, CNA A's last ANE training was on [DATE]. [CNA A was hired on [DATE] and terminated on [DATE]]. During an observation and interview on [DATE] at 1:24 p.m., Resident #1 was wandering the halls in the secure unit. Observation revealed the resident had no skin tears, bruises, or visible injuries. Resident #1 stated he felt safe but could not remember any details involving the incident on [DATE]. The resident did not want to engage in a further interview. During a telephone interview on [DATE] at 3:40 p.m., CNA C stated, she was a witness to the incident on [DATE] at night where Resident #1 was carrying a chair to sit next to the nurse's office. She saw CNA A try to take the chair from the resident and a struggle ensued. She saw CNA A remove the chair from the resident and then pushed the resident down to the floor. She saw when the resident got off the floor and went after the CNA, CNA A again pushed the resident slightly to the wall. CNA C stated CNA A should have de-escalated the situation and never touched a resident and should have called for help. During a telephone interview on [DATE] at 4:09 p.m., LVN B stated she saw Resident #1 pick up a chair to sit next to the nurse station. LVN B stated she heard CNA A tell Resident #1 that he could not sit near the nurse station. LVN B then saw CNA A try to take the chair away from the resident. She then saw that the resident resisted and a struggle ensued. During the struggle, LVN B stated, she saw CNA A peeled the fingers of the resident off the chair. LVN B stated that the resident gave up the chair. LVN B stated she saw when the resident was upset and approached CNA A, and she witnessed CNA A grabbed the resident by the wrist and pushed the resident to floor. LVN B stated she tried to separate the resident and the CNA again. LVN B stated she witnessed when the resident lifted himself off the floor, and CNA A again pushed the resident against the wall. LVN B stated after she removed Resident #1 from the situation and assessed him in his room, she went to get help from other staff in the nearby unit. LVN B stated she also immediately notified the Administrator of the incident. During a telephone interview on [DATE] at 4:53 p.m., CNA A stated the email he sent to the facility was correct and he stood by the statements made in the email. CNA A stated that he took the chair away from the resident to protect the residents in the secure unit and to protect staff. CNA A stated, I held his hands because he (Resident #1) tried to hit me. CNA A stated that he did not push the resident to the floor or wall. CNA A stated he did not willfully abuse the resident but rather was trying to keep safety for the staff and residents and only defended himself. CNA A stated he attended training on ANE, and he learned to report abuse immediately to the Abuse Coordinator. CNA stated he did not remember being trained in dealing with dementia residents and de-escalation for residents in a secure unit. During an interview on [DATE] at 5:00 p.m., the Administrator stated he was notified of the incident on [DATE] around 10:30 p.m. and notified appropriate parties. Verification of PNCPrior to the investigation on [DATE], the facility put in place interventions to ensure proper safety for residents to include: Observation on [DATE] at 2:30 p.m., revealed CNA A was not in the facility [suspended [DATE] and terminated]. [Record review on [DATE] of timecard dated [DATE] with clock out date of [DATE] with time of 11:45 p.m. and termination notice dated [DATE]] Assessment of Resident #1 and sent to ER for an evaluation. [[DATE]] [Record review on [DATE] of Nurse note dated [DATE] authored by LVN B.] Resident # 1 sent to ER for an evaluation on [DATE] and results were negative for injures; and negative x-ray [Record review on [DATE] of ER report dated [DATE] at 6:12 a.m.] Inservice training to all staff related to Abuse and Neglect [[DATE]-[DATE]] Completion rate of 100% for 171 paid staff. [Record review on [DATE] of sign-in sheets] Inservice for provider staff on de-escalation [[DATE]-[DATE]]. Completion rate of 100% for 74 paid staff. [Record review on [DATE] of sign-in sheets] CP updated for Resident #1 on [DATE]: new interventions electronic monitoring; MD, RP notified and monitoring, rounding, ensure safety, and weekly skin checks. [Record review on [DATE] of latter CP] Skin check of all residents in the men's unit (N=23) done on [DATE]-[DATE]. [Record review on [DATE] of latter skin checks for 23 residents] Law enforcement notified on [DATE] with Case # 26-18168 [Surveyor made an email request for the report on [DATE]] Administrator notified HHS within the 2-hour time limit for reporting physical abuse [DATE] at 11:55 p.m. [Record review on [DATE] of email sent to HHS and TULIP documentation of email posting on [DATE] at 11:55 p.m.] Ombudsman contacted on [DATE] at 11:55 p.m. and notified her of incident. [Record review on [DATE] of Nurse Note dated [DATE] and email confirmation from the Ombudsman] Safe Surveys done on [DATE] for 10 residents on men's unit with no findings. [Record review on [DATE] of the surveys] Incident and Accident have been reviewed and no other incidents noted related to CNA A. [Record review on [DATE] of facility incident report dated [DATE]] Completion of facility's HHS 3613-A form dated [DATE] with finding of confirmed for abuse [Record review on [DATE] of HHS 3613-A form dated [DATE] and completed [DATE]] Record review on [DATE] of QAPI Action Plan dated [DATE] revealed problem statement was Allegation of Physical Abuse with the goals to keep all residents safe from ANE; plan started [DATE] and completed [DATE]. During interviews on [DATE] at 4:16 PM to 4:45 p.m., on ANE return demonstration staff stated [day shift 6:00 a.m. to 6:00 p.m., [day shift CNA E, PT G, K, OT H,J, Kitchen L, LVN M, O, Housekeeping P, Admissions Y, and SW Z] and night shift (6:00 p.m. to 6:00 a.m.) [ CNA F, Q, U, R, V, X, Kitchen Aide I, Housekeeping N, and LVN Q, S, and T] staff were eligible to work weekend ] the key highlights of the training were to report immediately any acts or suspicion of ANE and to know the signs and systems, and provide safety to the resident. During interviews on [DATE] at 4:16 PM to 4:45 PM, on de-escalation return demonstration staff stated [night shift CNA F, Q, U, and LVN Q, S, and T] [day shift CNA E, PT G, K, OT H,J, LVN M, O, and SW Z] the key highlights were to stay calm and provide safety, separate, and do not leave the victim with the perpetrator of abuse. Record review on [DATE] of facility's grievance log for the past 90 days [February -[DATE]] revealed no grievances or incidents involving CNA A with other residents. Record review on [DATE] of facility's incident accident log for the past 90 days [February-[DATE]] revealed no incidents involving Resident #1 with CNA A. Record review on [DATE] of facility's policy titled Abuse, Neglect, Exploitation Statement, dated [DATE], read, .Residents of the facility shall not be subject to abuse.Abuse [was defined as] .The negligent willful infliction of injury.with resulting with physical or emotional harm or pain to an elderly or disabled person by the person's caregiver. During exit conference on [DATE] at 5:00 PM, the Administrator and the DON were informed:This failure was identified as past noncompliance IJ as the facility had instituted adequate corrective measure to prevent recurrence of the noncompliance. The noncompliance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began.

Based on observation, interview and record review the facility failed to provide a safe, comfortable, and homelike environment, ensuring residents received care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk for 3 of 6 Residents (Resident #1, Resident #2 and Resident #3) reviewed for homelike environment. The facility failed to hire a contractor to complete the renovation of Resident #1's, Resident #2's, Resident #3's showers for a period of about 6 months. Resident #1, Resident #2 and Resident #3 had to use the toilet in another resident's room or in the main shower room away from their room. This deficient practice could place residents at risk contribute to residents experiencing feelings of dissatisfaction and inconvenience. The findings were:1.Review of Resident #1's face sheet, dated 1/30/26, revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a progressive brain disorder that slowly destroys memory and thinking skills, ultimately affecting the ability to carry out simple tasks, psychotic disorder (severe mental health condition characterized by disruptions in thought processes, perceptions, and emotional responses, often leading to a loss of touch with reality) with delusions due to known physiological condition, anxiety disorder due to known physiological condition and Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident #1's quarterly MDS assessment, dated 12/2/25, revealed her BIMS score was 12 of 15 indicative of moderate cognitive impairment, she was frequently incontinent of bowel and bladder and required set up or clean-up assistance with toileting. Review of Resident #1's Care Plan, edited on 8/10/25, revealed Resident #1 had moderate cognitive impairment and she required supervision for toileting. Observation on 1/26/26 at 4:59 p.m. revealed the bathroom door was screwed shut in Resident #1's room. Observation and interview on 1/26/26 at 5:05 p.m. revealed Resident #1 was sitting at a table in the dining room in the secured women's unit coloring. Resident #1 was observed calm, soft spoken and engaged in conversation. She stated she could not use the toilet in her bathroom because it was locked. She stated she did not like having to use a different bathroom other than her own. Interview on 1/30/26 at 9:43 p.m. with Resident #1's family member revealed in talking with Resident #1, Resident #1 could not remember where the designated bathrooms were located, the CNA's had to lead her to a designated bathroom. The family member stated Resident #1 did not like to use another resident's bathroom. The family member stated they did not know how it impacted the other residents but felt awkward walking Resident #1 into another resident's room. The family member stated the ladies stared at them. The family member expressed feeling helpless because there was nothing that could be done about the situation which had been an ongoing issue since at least October 2025. The family member reported proposing to staff to panel the shower off so that Resident #1 had access to the toilet, but the idea was denied. The family member stated she tried talking to the previous Administrator and stated he was very negative and apparently very frustrated. The family member stated the previous ADM threw his hands up in the air and stated there was nothing else he could do; it was in the hands of upper management. The previous ADM also stated they received bids but were a lot more than management expected. 2. Review of Resident #2's face sheet, dated 1/30/26, revealed she was admitted to the facility on [DATE] with diagnoses including unspecified intellectual disabilities (Primary, Admission), unspecified dementia (the specific type of dementia cannot be clearly identified, despite the presence of cognitive decline and memory loss), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and bipolar disorder (condition that causes periods of severe changes in your mood, activity levels, energy, and ability to carry out everyday tasks.) Review of Resident #2's quarterly MDS assessment, dated 11/2/25, revealed her BIMS score was 9 of 15 indicative of moderate cognitive impairment, she was occasionally incontinent of bowel and bladder and required supervision to extensive assistance with toileting. Review of Resident #2's Care Plan, revised on 11/12/25, revealed Resident #2 was identified as having ID PASRR positive status related to moderate intellectual disabilities and had moderate cognitive impairment. Further review revealed she was occasionally incontinent of bowel and bladder and one of the approaches was to assist Resident #2 with toileting routinely and PRN, and she required supervision for toileting. Observation and interview on 1/30/26 at 4:06 p.m. revealed Resident #2 was in her room. She stated she hated that she did not have her own bathroom and that she had to go to another resident's room to use the toilet. She stated the residents who shared their bathroom did not like it either. 3. Review of Resident #3's face sheet, dated 1/30/26, revealed she was admitted to the facility on [DATE] with diagnoses including age-related cognitive decline, lack of coordination and unsteadiness on feet. Review of Resident #3's quarterly MDS assessment, dated 12/2/25, revealed her BIMS score was 8 of 15 indicative of severe cognitive impairment, she was continent of bowel and bladder and required supervision or set-up assistance with toileting. Review of Resident #3's Care Plan, edited on 12/14/25, revealed Resident #3 required activities of daily living support related to age-related cognitive decline, neurological disorders, and need for safety supervision. One of the approaches indicated Resident #3 was independent with toileting. Staff was to monitor for continence changes and provide cueing PRN. Interview on 1/29/26 at 10:56 a.m. with CNA A revealed she had worked at the facility for about 1 year. She stated there were 4 bathrooms in the women's secured unit the residents could not use because the bathroom doors were screwed shut. CNA A stated a contractor started remodeling the showers in the rooms and never finished the remodeling job, so the MS screwed the doors shut so the showers did not cause a safety hazard. She stated the bathrooms had been closed and not accessible since July 2025 or August 2025. CNA A stated Resident #1, Resident #2 and Resident #3 were all instructed to use the toilet in room [ROOM NUMBER], 36, 38, the toilet in the shower room and the toilet in the room across from the shower room. She stated the shower room and the room across the shower room were a distance away and the residents did not like going to those areas especially at night when it was cold. CNA A stated some of the residents in the designated rooms questioned why Resident #1, Resident #2 and Resident #3 were using their bathroom. CNA A stated Resident #1, Resident #2, Resident #3 and other affected residents complained all the time about when the bathrooms were going to get fixed along with some of their family members. CNA A stated she felt bad for the residents because the residents should have their own bathrooms; it was inconvenient for them to have to use another bathroom. She stated it was also a privacy issue for the residents who shared their bathrooms. Observation an interview on 1/30/26 at 11:39 a.m. with ADON B and the MS revealed the doors to four bathrooms in the women's secured unit were locked down. The doors had been screwed shut. The MS stated it had been since July 2025 when a contractor started the demolition of the showers, determined there was more damage than expected, asked for more monies and it was denied. The MS stated the renovation of the showers in stated rooms came to a halt. ADON B stated the residents who resided in these rooms were directed to the bathroom in rooms 36, 38 or the shower room. ADON B stated he understood all residents should have their own bathroom and toilet and it was an inconvenience to have to use another resident's bathroom. However, there was nothing he could do about it because it was upper management to provide the approval to move forward with the renovation of the showers. He stated he understood the residents were not happy about the situation because they had voiced their concerns as well as some of the family members. ADON B stated he had not offered Resident #1 or Resident #2 to move to another room. He stated Resident #3 did not want to move. Interview on 1/30/26 at 12:20 p.m. with the ADM and the DON revealed corporate asked them to obtain bids from different contractors for the renovation of the showers. The ADM and the DON stated they completed the task given by corporate, had a number of contractors provide them with bids and all the information was sent to corporate. The ADM stated she understood that it was hung up with the main owner of the company that bought the facility out. She and the DON stated they understood it had been going on for months and the affected residents should have their own bathroom and not have to use another resident's bathroom. The ADM and DON stated it was an inconvenience for the affected residents and a privacy issue for the residents who shared their bathroom. Observation and interview on 1/30/26 at 4:04 p.m. revealed Resident #3 was lying in bed. Resident #3 stated it was an inconvenience having to use another resident's bathroom, having to walk down the cold hallway to the shower carrying all her toiletries. Resident #3 stated it had been so long since the bathroom had been locked and wished they would fix her shower. Review of facility policy. Homelike Environmental, revised February 2021), read in relevant part 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that a reflect a personalized, homelike setting.

Based on interview and record review, the facility failed to ensure agreements pertaining to services furnished by outside resources specified in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility for 1 of 1 facility reviewed for dental services. The facility did not have a written agreement with the dental facility for dental care. This failure could place residents at risk for not receiving dental services.Findings included: Record review of the facility contract binder, conducted date 01/30/2026, revealed the facility did not have a contract with the dental service provider on 01/30/2026. During an interview on 01/30/2026 at 12:00 p.m., the Administrator stated the facility contacted the dental service provider 01/29/2026, and it was an ongoing process. The Administrator said a new company bought this facility in November of 2025 and should have contracted a local dental facility to provide dental service to residents who needed dental care. The Administrator said she did not know why the facility did not have the contract with the dental service provider, but a local dentist visited the facility and provided dental care to residents on 01/27/2026 because the residents' doctors might choose the dental provider. The Administrator said she and regional company leaders were responsible for obtaining facility contracts with outside resources, and if the facility did not have a contract, residents might not have dental care. During an interview on 01/30/2026 at 12:45 p.m., the DON stated the facility residents received dental services if they needed it because the residents' doctors might choose the dental providers from community dentists. The DON stated without a contract with a dental facility there was a potential risk of residents not receiving dental care. Record review of the facility policy titled, Dental Services, dated revised 12/2016, revealed, 1. Routine and 24-hour emergency dental services are provided to our residents through: a. a contract agreement with a licensed dentist that comes to the facility monthly. b. referral to the resident's personal dentist. c. referral to community dentist. d. referral to other health care organizations that provide dental services.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 3 Residents (Resident #1) reviewed for resident rights. The facility failed to provide an accessible toilet in Resident #1's room and she urinated on another resident's floor. Resident #1 commented she felt ashamed. This deficient practice could place residents at risk for experiencing feelings of shame. The findings were: Review of Resident #1's face sheet, dated 1/30/26, revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a progressive brain disorder that slowly destroys memory and thinking skills, ultimately affecting the ability to carry out simple tasks, psychotic disorder (severe mental health condition characterized by disruptions in thought processes, perceptions, and emotional responses, often leading to a loss of touch with reality) with delusions due to known physiological condition, anxiety disorder due to known physiological condition and Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident #1's quarterly MDS assessment, dated 12/2/25, revealed her BIMS score was 12 of 15 indicative of moderate cognitive impairment, she was frequently incontinent of bowel and bladder and required set up or clean assistance with toileting. Review of Resident #1's Care Plan, edited on 8/10/25, revealed Resident #1 had moderate cognitive impairment and she required supervision for toileting. Observation on 1/26/26 at 4:59 p.m. revealed the bathroom door was screwed shut and did not open in Resident #1's room. Observation and interview on 1/26/26 at 5:05 p.m. revealed Resident #1 was sitting at a dining room table in the secured women's unit coloring. Resident #1 was observed calm, soft spoken and engaged in conversation. She stated she could not use the toilet in her bathroom because it was locked. She stated she had accidents on herself because she was not able to make it to another bathroom. Resident #1 stated she felt yucky when she had an accident on herself and she felt embarrassed. Resident #1 stated she did not like having to use a different bathroom other than her own. Interview on 1/29/26 at 10:56 a.m. with CNA A revealed she stated she had worked at the facility for about 1 year. She stated there were 4 bathrooms in the women's secured unit the residents could not use because the bathroom doors were screwed shut. CNA A stated a contractor started remodeling the showers in the rooms and never finished the remodeling job, so the MS screwed the doors shut so the showers did not cause a safety hazard. She stated the bathrooms were closed and not accessible since July 2025 or August 2025. CNA A stated Resident #1 was one of the Residents who did not have access to her bathroom and was redirected to using the toilet in room [ROOM NUMBER], 36, 38, the toilet in the shower room or the toilet across the shower room. She stated the shower room and the room across from the shower room were down the hall a distance away. CNA A stated the affected residents did not like going those areas especially at night when it was cold. CNA A stated some of the residents in the designated rooms questioned why Resident #1 and other residents were going into their room. CNA A stated Resident #1 had the sensation to urinate and have a bowel movement; however sometimes she was not able to get to another toilet in time and would have accidents on herself. She stated one time she was leading Resident #1 to the room next door to hers and she did not make it to the toilet and she urinated on the floor. She stated Resident #1 was very upset and started crying. CNA A stated Resident #1 and other affected residents complained all the time about the bathrooms and questioned when they were going to get fixed along with some of their family members. CNA A stated she felt bad for the residents because the residents should have their own bathrooms. She stated it was inconvenient for the residents to have to use another bathroom. She stated It was also a privacy issue for the residents who shared their bathroom and further stated it was a dignity issue for Resident #1. Interview on 1/30/26 at 9:43 a.m. with Resident #1's family member revealed in talking to Resident #1, Resident #1 could not remember which were the designated bathrooms. The family member stated the CNA's had to lead her to a designated bathroom to use. The family member stated one time she took Resident #1 next door, and she did not make it to the bathroom. Resident #1 urinated on the floor and she started crying frantically. The family member stated Resident #1 had tears falling down her face and stated, I feel ashamed. The family member stated they did not know how it impacted the other residents. The family member stated CNA A had to clean Resident #1 up. The family member expressed feeling awkward walking Resident #1 into another resident's room because the ladies stared at them. The family member also expressed feeling helpless because there was nothing that could be done about the situation which had been an ongoing issue since at least October 2025. The family member stated she proposed paneling the shower off to staff so that Resident #1 had access to the toilet, but the idea was denied. The family member also reported talking to the previous Administrator and stated he was very negative and apparently very frustrated. The family member stated the previous ADM threw his hands up in the air and stated there was nothing else he could do and it was in the hands of upper management. The family member stated the previous ADM also mentioned the facility received bids which were a lot more than management expected. Observation and interview on 1/30/26 at 11:39 a.m. with ADON B and the MS revealed the doors to four bathrooms in the women's secured unit were screwed shut. The MS stated it was since July 2025 when a contractor started the demolition of the showers, determined there was more damage than expected, asked for more monies and it was denied. The MS stated the renovation of the showers in stated rooms came to a halt. ADON B stated the residents who resided in these rooms were directed to use the bathroom in rooms 36, 38 or in the shower room. ADON B stated he understood all residents should have their own bathroom and toilet and it was an inconvenience to have to use another resident's bathroom. However, there was nothing he could do about it because it was upper management to provide the approval to move forward with the renovation of the showers. ADON B stated he believed the residents knew where to go or staff could lead them if they needed assistance. He stated he did not know of any of the residents having accidents on themselves, but if they did, he believed it would be a dignity issue for the resident. He stated he understood the residents were not happy about it because they had voiced their concerns as well as some of the family members. The ADON stated he had not offered Resident #1 to move to another room. Interview on 1/30/26 at 12:20 p.m. with the ADM and the DON revealed corporate asked them to obtain bids for the renovation of the showers. The ADM and DON stated they completed the task per corporate, had a number of contractors provide them with bids and all the information was sent to corporate. The ADM stated she understood that it was hung up with the main owner of the company that bought the facility. She and the DON stated they understood that it had been going on for months and the affected residents should have their own bathroom and not have to use another resident's bathroom. The ADM and DON stated it was an inconvenience for the affected residents and a privacy issue for the residents who shared their bathroom. The DON stated it was also a dignity issue if any of the residents were having accidents on themselves as a result of not having their own bathroom. Review of facility policy, Resident Rights, revised February 2021 read in relevant part Employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence,b. be treated with respect, kindness and dignity; e. self-determination; h. be supported by the facility in exercising his or her rights;

Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and prepare food by methods that conserve nutritive value, flavor, and appearance for one (1) of one (1) kitchen observed and one (1) of eight (8) residents (Resident #3) reviewed for food and nutrition services. The facility failed to serve warm food to residents. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. The findings included: Record review of Resident #3's admission Record, dated 12/30/2025, revealed a [AGE] year-old female admitted on [DATE]. Record review of Resident #3's Diagnosis Report, dated 12/30/2025, revealed diagnoses including moderate intellectual disabilities (a limitation in cognitive functioning and adaptive behavior which affects a person's ability to learn, communicate, and perform everyday tasks), gastro-esophageal reflux disease (also known as acid-reflux disease or GERD, when the stomach contents flow back into the esophagus and cause discomfort such as heartburn), and dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #3's Quarterly MDS, dated [DATE], reflected Resident #3 had a BIMS score of 13.0, indicating she was cognitively intact. Resident #3 was documented as not having had any hallucinations or delusions. She used a walker and required supervision or touching assistance when eating and walking. She had not lost or gained any significant weight in the last month or more than 6 months and received a regular diet type and texture. Record review of Concern/Grievance Forms revealed two (2) grievance forms regarding food temperature. 1. Concern/Grievance Form, dated 12/05/2025, communicated by Resident Council, reflected under describe concern in detail, food cold. The DDS was noted as the staff member assigned responsibility for the investigation, and it was noted that the food temperature logs were reviewed to assure the temperatures were within the required standard. The ADMIN signed the form on 12/09/2025. 2. Concern/Grievance Form, dated 12/05/2025, communicated by Resident #3's family/representative pertaining to Resident #3, reflected under describe concern in detail, food is served too cold or not edible. The DDS was noted as the staff member assigned responsibility for the investigation, and it was noted that the temperature log for the meal was reviewed and was within required standards at the time of service. The DDS and the ADMIN signed the form on 12/08/2025. Record review of document titled Resident council December 5, 2025, 2:00pm, reflected under Residents Concerned.Thanksgiving lunch was cold. And [sic] Residents [sic] want better meals [sic] presentation. Dinning [sic] information was giving [sic] to [the DDS] Dietary Manager. During an observation on 12/30/2025 at 08:05 a.m., the temperature of the food on the service line was checked by a food service staff member directly after the last meal was served. The dining room was observed to be the last service location for the residents' meals. The temperatures were observed to be: - oatmeal at 130 degrees Fahrenheit or 5 degrees below the minimum temperature, - grits at 132 degrees Fahrenheit or 3 degrees below the minimum temperature, - scrambled eggs at 146 degrees Fahrenheit or 11 degrees above the minimum temperature,- sausage patties and links at 150 degrees Fahrenheit or 15 degrees above the minimum temperature,- pureed bread at 132 degrees Fahrenheit or 3 degrees below the minimum temperature,- pureed sausage at 112 degrees Fahrenheit or 23 degrees below the minimum temperature,- pureed egg at 126 degrees Fahrenheit or 9 degrees below the minimum temperature, and - cream of wheat at 142 degrees Fahrenheit or 7 degrees above the minimum temperature. During an interview on 12/30/2025 at 08:35 a.m., the DDS stated she had not received recent complaints regarding cold food. She stated she tried to do temperature checks of the food on trays probably once a week, but she did not record her checks. She stated she was just checking to ensure the food was hot. She stated her expectation was for the food on the service line to be between 135-140 degrees Fahrenheit or higher. She stated food below that range was not right. She stated the cooks took the temperature of the food before service but only she would take the temperature of the food after service or on a tray and she did not document that temperature. She stated if the food service staff did not document food temperatures, then they would not know if residents were getting cold food. During an interview on 12/31/2025 at 10:50 a.m., Resident #3 revealed she thought the food served was gross. She stated the food was cold and she did not feel good after she ate. She stated that the food made her sick and she was unsure if she had lost weight. She stated she would eat in the dining room per her preference. During an interview on 12/31/2025 at 01:59 p.m., the RDN revealed she had observed food temperatures taken off the hot service line in November with all the temperatures within appropriate range. She stated she had received complaints from residents regarding the puree diet, especially the taste of the food. She stated the risk of food under the appropriate temperature range was that there was a risk for serving unsafe or contaminated food. She stated the facility had not reported any indicators for foodborne illnesses. During an interview on 12/31/2025 at 04:09 p.m. with the RNC and ADMIN, the RNC stated she had not heard any complaints regarding the food temperature. The ADMIN revealed he believed there was a grievance regarding food temperature from one person for one or two days. The ADMIN revealed he believed the resident had said that the food was not warm enough or they wanted their food to be warmer. Record review of facility policy, Food Preparation and Service, dated as revised November 2022, reflected Policy StatementFood and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.Policy Interpretation and Implementation1. 'Danger Zone' means temperatures above 31 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness.2. 'Potentially Hazardous Food (PHF)' or 'Time/Temperature Control for Safety (TCS) Food' means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation). Examples of PHF/TCS foods include ground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized eggs, milk, yogurt and cottage cheese.Food Preparation, Cooking and Holding Time/Temperatures1. The danger zone for food temperatures is above 41 [degrees] F and below 135 [degrees] F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness.3. The longer foods remain in the 'danger zone' the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained at or below 41 [degrees] F or at or above 135 [degrees] F.Food Distribution and Service1. Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held in the temperature 'danger zone' are discarded after 4 hours.2. The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition service staff.3. If time is used in place of temperature as a means of ensuring food safety, the amount of time PHF/TCS foods are held out of temperature control is tracked and foods are discarded accordingly.

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills set to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for ten (10) of ten (10) kitchen staff (Cook D, KS C, KS H, KS I, KS J, KS K, KS L, KS M, KS N, KS O) reviewed for qualified dietary staff . 1. The facility failed to ensure all (Cook D, KS C, KS H, KS I, KS J, KS K, KS L, KS M, KS N, KS O) dietary staff maintained their competencies and skills through regular in-service training. 2. The facility failed to ensure KS C met the requirements for food handling by obtaining a current and valid Food Handler's Certificate. These failures could place residents at risk of not having their nutritional needs met and foodborne illnesses.The findings included: 1. During an interview on 12/30/2025 at 08:35 a.m., when asked about providing kitchen staff trainings on completing food temperature logs, food labeling procedures, and sanitation procedures for taking food temperatures, the DDS stated the staff do not get trainings but get a text reminder. She stated the staff get sent a group text because they know what is to be done. The DDS did not state how often or what the content of the group text reminders she had provided to the kitchen staff. During an interview on 12/31/2025 at 01:59 p.m., the RDN revealed she expected the DDS to provide the food service staff with ongoing staff education. She stated she had told the DDS about concerns she had identified regarding the food temperatures in November 2025. The RDN stated she felt the kitchen staff needed training and had been told by the DDS that the DDS was providing training. During an interview on 12/31/2025 at 04:09 p.m., the RNC revealed she could not believe that there was not any documentation of food service staff trainings within the requested timeframe. She stated the DDS was not available today, 12/31/2025, but there should have been some food service training provided by the DDS and some training provided by the RDN. During an interview on 12/31/2025 at 04:09 p.m., the ADMIN revealed he could not locate food service staff in-service training documents dated within the requested 3-month period (09/29/2025- 12/29/2025). He revealed the contracted food service company was changed around 2 months ago and he knew the prior company provided training. 2. Record review of a Certificate of Training Awarded to [KS C] For successfully completing the Food Handler Essentials Course awarded to KS C, dated as issued 11/30/2023, reflected the certificate was valid for 2 years indicating the certificate expired on 11/30/2025. During an interview on 12/31/2025 at 04:09 p.m., the ADMIN revealed KS C was out of the country and stated the DDS notified him she was sure KS C had retested for a current Food Handler Certification, but they did not have the documentation. Record review of facility policy. Food Preparation and Service, dated revised November 2022, did not reflect mention of food service staff training expectations or qualifications. Record review of facility policy. Sanitation, dated revised November 2022, did not reflect mention of food service staff training expectations or qualifications. Record review of TFER accessed on 01/02/2026 at 04:27 p.m. at https://www.dshs.texas.gov/licensing-foodhandler-training-programs, (Licensing of Food Handler Training Programs | Texas DSHS) indicated: Licensing of Food Handler Training ProgramsTexas requires that many food service employees complete an accredited food handler training course within 30 days of getting a job. These courses train employees on food safety including good hygiene practices, how to avoid cross contamination, and more.

Based on observation, interview and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 (Kitchen 1) of 1 kitchen reviewed for food safety requirements. 1. The facility failed to label and date a container of cheesecake, a container of mashed potatoes, and a container of carrots in the walk-in refrigerator. 2. Food service staff failed to ensure temperatures of foods were checked as required for food safety for all three meals on 12/24/2025, 12/25/2025, and 12/28/2025; for breakfast on 12/26/2025 and 12/27/2025, and for breakfast and lunch on 12/29/2025. 3. [NAME] D failed to utilize the food safe appropriate temperature probe wipes when sanitizing the temperature probe between food items. This failure could place residents at risk for spread of infections, food contaminations, food-borne illnesses, and diminished quality of life. The findings included: 1. During an observation and interview on 12/29/2025 at 04:59 p.m., three sealed plastic containers: one with a white dense substance, one with a brownish white dense substance, and one with what appeared to be sliced carrots were identified in the walk-in refrigerator. The three containers were undated or labeled. [NAME] D identified the containers as having been without a label and date and stated the items were cheesecake, mashed potatoes, and carrots from yesterday's (12/28/2025) service. He was observed to take the items out of the walk-in refrigerator and stated he was going to throw the items out. 2. Record review of Serving Temperatures, dated December 2025, provided by [NAME] D on 12/29/2025 at 05:04 p.m. reflected:12/24/2025- no temperatures were documented for Breakfast, Lunch, or Dinner.12/25/2025- no temperatures were documented for Breakfast, Lunch, or Dinner.12/26/2025- no temperatures were documented for Breakfast.12/27/2025- no temperatures were documented for Breakfast.12/28/2025- no temperatures were documented for Breakfast, Lunch, or Dinner.12/29/2025- no temperatures were documented for Breakfast or Lunch. Dinner service had not started. The temperature log did not have any staff names, initials, signatures, or times to indicate who checked the temperatures, when the temperatures were checked, or who was responsible for checking them. During an interview on 12/29/2025 at 05:00 p.m., [NAME] D stated he worked 12/28/2025 in the morning, Breakfast and Lunch service, and due to having been so busy, he had not taken food temperatures at all. He revealed he had also worked 12/24/2025 and was not sure why the food temperatures were not documented. He stated he did not work on the other dates noted. 3. During an observation on 12/29/2025 at 05:25 p.m., [NAME] D was observed taking food temperatures of the food on the hot line. He was observed after taking the temperature of one food item, to wipe the food thermometer probe with a Sani-Cloth before inserting the food temperature probe into the next food item. Record review of Safety Data Sheet for Super Sani-Cloth Germicidal Wipes, dated revised 06/03/2020, reflected under Recommended use, Use as a disinfectant on hard, non-porous surfaces. Under Toxicological [the study of the harmful effects of chemicals, substances, or environmental agents on living systems] information, for Ingestion [swallowing], Specific test data for the substance or mixture is not available. Ingestion may cause gastrointestinal irritation, nausea, vomiting and diarrhea. May be harmful if swallowed. During an interview on 12/30/2025 at 08:35 a.m., the DDS stated she was not told about unlabeled foods having been identified the day prior, 12/29/2025. She revealed she had completed a walk-through inspection herself that morning, 12/30/2025 and found some unlabeled food items. She stated she had sent a group text to her food service staff because they knew what is to be done. She did not specify the contents or specific subject matter of the group texts she was sending to the food service staff. She stated the impact of foods not having a date was that if the staff used the food, the food could be old and residents could get sick. She stated she did not provide staff with training on labeling the food but did send a reminder to them. She stated she had not provided training to staff regarding logging and taking food temperatures but had reminded them. She stated, a lot of times, they (the food service staff) have a habit of writing down the temperatures on a piece of paper and then don't record them. She stated the impact of the staff not writing down the food temperatures was that they could not determine if the residents were getting cold food or not. She stated she expected staff to use a napkin or paper towel and then a probe wipe when cleaning the temperature probe between foods. She stated staff were not to use the Sani-Cloths. She stated she did not know staff had used the Sani-Cloths, but the dietitian had recommended to not use them, and staff were aware of that recommendation. During an interview on 12/31/2025 at 01:59 p.m., the RDN revealed she had completed kitchen tours in November and December of 2025 and had noted unlabeled and undated items in the refrigerator both times. She stated she talked to the food service staff, including the dietary manager, and her back-up following her tours and had sent a report regarding her findings to the DDS and the ADMIN. She stated the impact of foods having not been labeled or dated could be that there was a risk of food contamination. She stated she had observed blanks in the food temperature logs during her tours and did believe the temperatures had been missed. She stated she had spoken to the DDS about the log, and it was mentioned in her report to the DDS and the ADMIN. She stated the risk of not having food temperatures documented was that the residents were at risk for contamination of their food and having been served unsafe food. She stated the food service staff should not be using the Sani-Cloths for wiping the temperature probe. She revealed she had not observed the staff doing that but had told them how important it was to follow food sanitation and safety guidelines. She stated that there were certain things that they should not deviate from, and Sani-Cloths were not food grade, and therefore could be contaminated, thus contaminating the residents' food. She stated the Sani-Cloths were not made to be in contact with food. During an interview on 12/31/2025 at 04:09 p.m. with the RNC and ADMIN, the RNC stated the impact of foods having not been labeled and dated was that the food could be spoiled and could result in foodborne illnesses if consumed. She stated she was unable to answer how using the Sani-Cloth could impact residents. The RNC and ADMIN both stated they had not had any notifications of foodborne illnesses and had not received a report from the RDN. Record review of facility policy, Food Preparation and Service, dated as revised November 2022, reflected Policy StatementFood and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.Policy Interpretation and Implementation .General Guidelines .2. Cross-contamination can occur when harmful substances, i.e. chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned.4. When verifying food temperatures, staff use a thermometer which is both clean, sanitized, and calibrated to ensure accuracy.Food Distribution and Service .2. The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition service staff.3. If time is used in place of temperature as a means of ensuring food safety, the amount of time PHF/TCS foods are held out of temperature control is tracked and foods are discarded accordingly. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 01/02/2026 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.(B) Label information shall include:(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement;(2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD.(3) An accurate declaration of the net quantity of contents;(4) The name and place of business of the manufacturer, [NAME], or distributor; and(5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling.

Based on observation, interview and record review, the facility failed to post the required signage acknowledging the use of oxygen in resident room per resident care policies and procedures. The polices and procedures for respiratory care and services provided include, but are not limited to, the posting of cautionary and safety signs indicating the use of oxygen for 1 of 1 Resident's for hall. The facility failed to post cautionary and safety signs indicating the use of oxygen on 12/29/2025 for Resident #1's room. This failure could put residents, family members, and all visitors at risk for potential harm due to the flammability of oxygen.The findings included: Record review of Resident #1's admission Record, dated 12/30/2025, revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #1's Diagnosis Report, dated 12/30/2025, revealed diagnoses including cerebral ischemia (a condition in which a blockage in an artery restricts the blood flow to the brain resulting in damage to brain tissue), unspecified lack of coordination, muscle wasting and atrophy (the shrinking of muscle or nerve tissue), history of falling, and severe intellectual disabilities (a limitation in cognitive functioning and adaptive behavior which affects a person's ability to learn, communicate, and perform everyday tasks). Record review of Resident #1's Annual MDS, dated [DATE], reflected Resident #1 had a BIMS score of 0.0, indicating he was severely cognitively impaired. Record review of Resident #1's Quarterly MDS, dated [DATE], did not reflect Resident #1's need for oxygen or mental status score. Resident #1 was documented as rarely/never understood. He had range of motion impairment on both sides for upper and lower extremities, used a wheelchair, and was dependent for his self-care and mobility needs. Record review of Resident #1's Order Summary Report, dated 12/30/205, did not reflect Resident #1 as having an order for oxygen therapy. Record review of Resident #1's Care Plan, dated last care conference 10/21/2025, did not reflect Resident #1 was currently utilizing oxygen therapy for any listed diagnosis. During an observation and attempted interview on 12/29/2025 at 03:46 p.m., Resident #1 was observed in his bed asleep. Portable oxygen tank was in resident room near sink and had no oxygen tubing attached. No noted signage on or around door to room. During an interview with RNC on 12/30/2025 at 9:55a.m. when asked about the oxygen policy for the facility, the response was I told them (facility staff) last week that it needs to be posted even if not scheduled. RNC also stated that Oxygen should be posted if in room, regardless of scheduled or PRN. During an interview on 12/31/2025 at 12:21p.m. LVN floor nurse stated when asked how they let people know that oxygen could be in use in a room that there is supposed to be a sign on the door that says that there is oxygen in the room. When also asked who is responsible for posting the signage floor LVN stated that everybody is responsible for posting or ensuring it is posted. During an interview on 12/31/2025 at 04:09 p.m. with the RNC and ADMIN, both stated that when oxygen is in a room there should be a sign posted noting this, even if oxygen is not actively in use. Record review of facility policy, Oxygen Storage, dated as revised November 2022, reflected 'Policy It is the policy of this center to maintain appropriate and safe storage of oxygen.' Policy also states that 'Storage areas will be clearly identified with a no smoking sign posted on door.' Record review of facility policy. Oxygen Administration, dated October 2010, reflected the steps in the procedure of administering oxygen as 'Placing an 'Oxygen in Use' sign on the outside of the room entrance door.

Based on observation, interview and record review, the facility failed to store over the counter medications in accordance with currently accepted professional principles for medication storage room in secure Co-ed unit. The facility failed to ensure that the medication storage room held no expired medications per state and federal guidelines. This failure could cause adverse reactions to residents when ingesting expired medications. The findings included: Observation of 4 expired supplemental shakes within the medication room, each with an expiration date of 09/10/2025. Observation of the medication storage room in the secured Co-ed unit on 12/30/2025 at 8:51a.m. revealed 4 expired supplemental shakes on the counter, with expiration dates of 09/10/2025. Interview with CMA on 12/30/2025 at 8:51 surveyor asked CMA where expired liquids, such as medications and supplements, were stored. CMA responded that they are usually taken out of here and stored somewhere else. Surveyor then asked CMA What expiration date do you see on this supplement? CMA responded It says it expires September of 2025. I will let my nurse know so she can handle it. During an interview on 12/31/2025 at 12:10p.m. with RN on unit, surveyor asked RN about supplements in the medication room in the secure Co-ed unit. RN stated that the supplements were there because the resident would sometimes not eat. The dialysis clinic and the primary physician were trying to determine who would write order for resident supplements, so they had an order but it was not filled yet due to this. RN also stated that the medication aides were supposed to pull expired medications. During interview on 12/31/2025 at 04:09p.m. with RNC and ADMIN, RNC stated that all expired medications, whether over the counter or supplements, were to be pulled form medication rooms and disposed of properly.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (1) of eight (8) residents (Resident #1) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1's room was in a position accessible to the resident on 12/29/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.The findings included: Record review of Resident #1's admission Record, dated 12/30/2025, revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #1's Diagnosis Report, dated 12/30/2025, revealed diagnoses including cerebral ischemia (a condition in which a blockage in an artery restricts the blood flow to the brain resulting in damage to brain tissue), unspecified lack of coordination, muscle wasting and atrophy (the shrinking of muscle or nerve tissue), history of falling, and severe intellectual disabilities (a limitation in cognitive functioning and adaptive behavior which affects a person's ability to learn, communicate, and perform everyday tasks). Record review of Resident #1's Annual MDS, dated [DATE], reflected Resident #1 had a BIMS score of 0.0, indicating he was severely cognitively impaired. Record review of Resident #1's Quarterly MDS, dated [DATE], did not reflect Resident #1's mental status score. Resident #1 was documented as rarely/never understood. He had range of motion impairment on both sides for upper and lower extremities, used a wheelchair, and was dependent for his self-care and mobility needs. Record review of Resident #1's Care Plan, dated last care conference 10/21/2025, reflected Resident #1 was at risk for falls due to impaired mobility, inability to recognize safety/danger, and had a history of attempts to self-transfer, date as edited 08/03/2025. One of the approaches noted was Keep call light in reach at all times., date as edited 03/26/2025. During an observation and attempted interview on 12/29/2025 at 03:46 p.m., Resident #1, was observed in his bed asleep. His call light was observed to be lying across the footboard of his bed and onto the floor. Resident #1 was observed to not have a roommate and the second call light for the room was observed lying on the floor between Resident #1's bed and the unoccupied space his roommate would have occupied. Resident #1 was unrousable and did not wake up enough to follow directions or attempt to demonstrate if he could have reached the call light. During an interview on 12/29/2025 at 03:46 p.m., CNA A stated Resident #1's call light was out of reach as it was located on the end of his bed. She stated Resident #1 would often throw his sheets, clothing, and the call light off his bed. CNA A stated Resident #1 was not impacted by the call light having been out of reach because he was not capable of using or understanding how to use the call light, so staff were to keep an eye on him. During an interview on 12/31/2025 at 04:09 p.m. with the RNC and ADMIN, the RNC stated her expectation was for the call lights to be in reach. She stated that many of the residents may not know or have the capability of knowing how to use the call lights, but the resident should have been tested to determine if having the call light was a benefit or detriment to the resident's safety. She stated the staff should be trained to ensure they review if a resident should be care planned for a call light to be within reach, but if the care plan indicated that, then the call light should be in reach. The ADMIN stated if a resident was care planned for a call light to be within reach, then he expected the call light within reach. He stated the impact of the call light having been out of reach would depend on the situation, since some of the residents were not capable of understanding how or why to use it. Record review of facility policy, Call System, Residents, dated as revised September 2022 and updated January 2025, reflected Policy StatementResidents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station [sic]. Policy Interpretation and Implementation1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

Based on observation and interview, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 13 of 15 days (12/17/2025 - 12/29/2025) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information from 12/17/2025 to 12/29/2025. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. The findings included: During an observation on 12/29/2025 at 03:52 p.m., a document labeled [facility name] Federal Staffing Posting, dated 12/16/2025, was posted on a wall outside the initial nurses' station passed following entry to the facility. The document included the following information: census and the number and hours worked of registered nurses, licensed vocational nurses, medication aides, and certified nurse aides for day shift, evening shift, and night shift. During an interview on 12/29/2025 at 03:55 p.m., ADON B revealed the SC was new to her position and she was unsure if the SC had been taught the process of creating and updating the nurse staffing and census posting. ADON B stated the WC Nurse was working with the SC and initially focused on creating the staff schedule. ADON B stated the prior SC left suddenly the prior week, but the nurse staffing and census posting was usually done every morning and posted. During an interview on 12/30/2025 at 09:55 a.m., the RNC stated the facility did not have a policy on the daily nurse staffing and census posting. She stated it was a state regulation, and the facility followed state regulations. During an interview on 12/31/2025 at 09:20 a.m., the WC Nurse revealed the prior SC resigned two weeks prior and she had been assisting the new SC in creating the schedule for the current month. The WC Nurse stated she had not been involved in posting the nurse staffing and census posting and was unsure on the procedure for the document. During an interview on 12/31/2025 at 11:12 a.m., the SC revealed she had recently changed positions and became the SC. She stated the prior employee who was supposed to orient her in the new position did not stay and she was learning the job responsibilities and procedures day by day, which was resulting in some trial and error. She stated she had just been notified of the procedure for posting the nurse staffing and daily census but had assumed someone else was covering this task. She stated she was unsure how not having the daily census and nurse staffing information posted daily would have impacted residents or facility guests because she was unsure if the residents or guests knew to look for the posting. She stated that when residents or guests asked staff about facility staffing, the staff would be capable of informing the resident or facility guest of the facility's standard staffing expectation for each hall and shift. She stated the staffing schedule was also readily available for staff or facility guests to review. During an interview on 12/31/2025 at 04:09 p.m. with the RNC and ADMIN, the RNC stated the SC was responsible for posting the daily nurse staffing and census posting. She stated she was aware that ADON B had provided the SC some training for her new position but was unsure what the training entailed. The RNC stated the nurse staffing and census posting might possibly have been overlooked. She did not believe the lack of posting the daily nurse staffing and census would impact anyone because the facility had a staffing book readily available. The ADMIN stated he believed there was a breakdown in communication and following the posting procedures after the prior SC left. He stated he had never had a resident or facility guest request to view the posting, only surveyors, and therefore did not feel it impacted anything other than meeting the requirement.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, to store all drugs and biologicals under proper temperature controls in 1 of 1 central supply storage room reviewed for medication storage. The facility failed to store their over-the-counter medications (8 bottles of Acetaminophen 325 mg.) in the central supply storage room maintained within 68 to 77 degrees Fahrenheit per medication recommendations. This deficient practice could place residents at risk of the medications not being as effective as they were designed to work. The findings were:Observation and interview on 11/18/25 at 2:01 PM with CNA A in the central supply storage room revealed she was assigned as the charge person for ordering and storing medications in the central supply storage room as of 10/1/25. She stated when she started organizing the storage room, she noted it was hot in the storage room and there was no ventilation. CNA A stated they stored nursing supplies including over the counter medications, enteral feedings and med pass. A thermometer was observed hanging on a top shelf. It was not registering a reading. There was a red line all the way across to the right side into the red area which read danger. It felt very stuffy and hot in the storage room. Observation and interview on 11/18/25 at 3:10 PM with the MS and CNA A in the central supply room revealed the temperature was hot. The MS stated he talked to the ADM about it being too hot in the central supply room. the MS used a laser thermometer to take a reading, and it read 84 degrees. He stated he did not know what the regulation was but would find out. The MS stated he talked to the ADM about adding an AC unit in the back service hall where the central supply storage and laundry were located. He stated the AC unit that should be cooling the service hall did not have a thermostat attached to provide airflow in the service hall. CNA A stated she spoke with a corporate staff person about the temperature in the central supply room. She stated the corporate staff brought the ADM into the storage room while she was in the room and told him he had to get it fixed ASAP because it was too hot. Interview on 11/18/25 at 3:50 PM with the ADM revealed he talked with their previous corporate staff about the temperature in the central supply room. The ADM stated they had other issues they were also addressing at the time and then the new company bought them out about 2 months ago. He stated he had not talked to the current corporate staff about it yet. The ADM stated he knew there was a regulation for maintaining the storage area at a safe range but was not sure about the specifics. He stated if the medications were not stored within acceptable parameters, it could compromise the efficacy of the medications, and the medications would not work effectively on the residents. The ADM was asked for a policy on storage of over-the-counter medications on. It was not provided by the end of the investigation period on 11/24/25. Observation and interview in the central supply room on 11/19/25 at 2:49 PM with the DON revealed she stated it was really hot in the storage room. She stated she talked with the ADM about it but they had not had a discussion about a plan to cool the storage room. She stated she checked the temperature requirements for the over-the-counter medications and found the bottles of Acetaminophen 325 mg. read they should be stored at temperature within 68 to 77 degrees. Fahrenheit. The DON stated storing the medication exceeding the recommended storage temperature could affect the efficacy of the medication and not effectively help the residents. Observation revealed there were 8 bottles of Acetaminophen 325 mg. on a shelf. The label on the box read Store at 20-25 degree C (68-77 degrees F).

Based on observation, interview and record review the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 8 Residents (Resident #2) who were reviewed for homelike environment. The facility failed to ensure Resident #2's shower remodeling project was completed and the floor in the resident room was leveled and safe to walk across. This deficient practice could place residents at risk of unsafe living conditions and avoidable accidents. The findings were:Review of Resident #2's face sheet, dated 11/24/25, revealed she was admitted to the facility on [DATE] with diagnoses including unspecified Dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), lack of coordination, weakness, pain in right hip and difficulty in walking. Review of Resident #2's quarterly MDS, dated [DATE], revealed her BIMS score was 15 of 15 reflecting she was alert and oriented without cognitive impairment. Resident #2 was independent for most ADLs and she did not have a fall history. Review of Resident #2's Care Plan, dated 9/25/25, revealed Resident #2 was at risk for falls due to: mild cognitive decline, occasional pain to right hip. Tendency to ambulate without walker, frequently wears flip flops. Approaches included If resident is observed without walker, retrieve it for her and encourage use. Assure walker is within reach at all times as able. Review of the incident/accident log from August 2025 to November 2025 revealed Resident #2 had not had any falls. Observation on 11/20/25 at 5:09 PM in Resident #2's room revealed the shower stall in the restroom was sealed off with plastic. Some of the plastic was coming off. Observation revealed the drywall, and tile had been completely removed. It appeared like the shower was in the process of being remodeled. In the resident room revealed a large area, approximately 2 x 2-foot area, in the middle of the floor that was sunk in. The surface was unleveled and had a lip on one side. There were also brown stains on the linoleum floor under the vanity. The room and restroom smelled like mildew. Observation and interview on 11/21/25 at 3:20 PM with the MS in Resident #2's room revealed the shower room was sealed off with plastic, the floor was uneven in the middle of the resident room and there was a brown stain on the linoleum floor underneath the vanity. The MS stated the facility hired a contractor to remodel 7 resident showers including Resident #2's shower. He stated the contractor backed out and stated he wanted to re-negotiate for more money because he noted additional plumbing problems once he removed the drywall and tile. The MS stated the job came to a halt and in the meantime a new company bought out the facility. The MS stated progress had come to a standstill for about 2 months and the ADM had not asked him to call other contractors to complete the job. The MS stated he had not noticed the uneven surface in the middle of the room and thought the floor had probably been opened to get to the plumbing. He Identified the uneven surface as a trip hazard for Resident #2. He stated the building itself was old and needed a lot of repairs and stated the linoleum was stained throughout the facility. Observation and interview on 11/24/25 at 11:45 AM with Resident #2 revealed she was lying in bed. Resident #2 stated her shower had been under construction for 2 months and 2 weeks. She stated she did not like it but commented, it is what it is, she could not do anything about it. Resident #2 stated I'd rather have my own shower but stated she used the main shower room next door to her room. Resident #2 stated the MS told her they would repair the uneven surface in the middle of the room that was sunk in. She stated she did not have any problems walking over it with her rolling walker and had never had any falls. She stated the stain under the vanity did not bother her. Interview on 11/24/25 at 5:00 PM with the ADM revealed the facility hired a contractor to remodel multiple showers including Resident #2's shower right before the facility was bought out. He stated the contractor decided he wanted to negotiate for more money because it was more work than he realized. The ADM stated the company who bought out the facility was legally pursuing the contractor but stated in the meantime the remodeling project had been at a standstill for a couple of months. The ADM stated they secured/locked all restrooms that were under construction except for Resident #2's restroom because she was adamant she wanted access to the toilet. The ADM stated he understood the restroom was not in homelike condition and Resident #2 should not have to wait 2 months to have access to the shower. He stated he understood it was an inconvenience and at this time he was waiting for the new company to give them the go ahead to secure another contractor. Review of the facility's policy, Resident Rights, revised February 2021, read in relevant part Employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. Review of the facility's policy Maintenance Services, revised December 2009, read in relevant part Maintenance services shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance in federal, state and local laws, regulations and guidelines. b. maintaining the building in good repair and free from hazards.

Based on observation, interview and record review the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care 1 of 2 residents (Resident #1) reviewed for PASARR services. The nursing facility failed to submit a completed (NFSS) application to ensure Resident #1 received a specialized motorized wheelchair based on her rehabilitation assessment. This deficient practice could place residents at risk for not receiving specialized equipment and result in the decline in their physical condition. The findings were: Review of Resident #1's face sheet, dated 11/24/25, revealed she was admitted to the facility on [DATE] with diagnoses including severe intellectual disabilities, unspecified lack of coordination, muscle weakness (generalized), other specified disorders of muscles and unspecified Dementia (a general term for declining mental abilities, like memory, thinking, and reasoning, severe enough to disrupt daily life). Review of Resident #1's quarterly MDS assessment, dated 8/30/25, revealed her BIMS score was 0 out of 15 reflecting severe cognitive impairment. Resident #1 was dependent on staff for most ADLs and she used a manual wheelchair for mobility. Review of Resident #1's Care Plan, edited on 11/12/25, revealed focused area of psychosocial well-being with start date of 1/10/24, revealed Resident #1 was identified as PASRR positive related to severe intellectual disabilities and was receiving habilitation coordination and independent living skills training. The NF was unable to submit NFSS forms for habilitation PT/OT/ST or request a CMWC. The approaches were to coordinate care and services with [name of organization]. Review of PASARR Comprehensive Service Plan Form, dated 11/12/25, revealed a PASARR NFSS was completed and Resident #1 was assessed and measured for the use of a CMWC by the DOR, initial date 1/1/25. The verbiage read Patient will require a tilt in space wheelchair with custom back and cushion to support posture. Patient will use her CMWC to improve her out of bed mobility, to participate in her ADL's like dining, recreation activities, mobility within using while maintaining safe sitting posture. [NAME] approved for Medicaid will be available upon certification by the Nursing Facility. The application was denied because they required a hospice plan of care signed by the physician which was not provided by the hospice provider. Telephone interview on 11/18/25 at 1:46 PM with PASARR representative revealed Resident #1 had not received Medicaid services and a CMWC because of the following: The NF was notified and instructed to submit a NFSS Request by a specific deadline but failed to do so. The NFSS Request submittal by the NF was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for the resident. The PASARR representative stated she sent the ADM and the DON an email during September 2025 to remind them they needed to submit the NFSS application because they were out of compliance. Observation and attempted interview on 11/19/25 at 12:15 PM with Resident #1 revealed she was sitting in a manual high back wheelchair at one of the tables in the dining room. Resident #1 did not engage in conversation, did not make eye contact and did not speak. Resident #1 was not interviewable. Further observation revealed Resident #1 was leaning forward in the wheelchair and over the table. Interview on 11/19/25 at 12:30 PM with the DOR revealed Resident #1 was PASARR positive and was also receiving hospice services. He stated during an IDT meeting on 1/1/25 with PASARR he recommended Resident #1 would benefit from a specialized wheelchair that had the capability to tilt in space which would help Resident #1 with positioning in the wheelchair to keep her from leaning forward. He stated he assessed Resident #1 and was responsible for submitting the NFSS application because he was recommending a CMWC. He stated he submitted the application, but it was denied because hospice had not provided him with Resident #1's current plan of care signed by the hospice physician. The DOR stated he talked with several hospice staff including the nurse manager for months requesting a signed plan of care to no avail. The DOR stated he had brought up the issue during morning meetings and stated he explained why the NFSS application was denied. He stated he was not able to order a CMWC for Resident #1. He stated he spoke to a company resource person who recommended that he keep asking hospice to provide the resident's plan of care. The DOR stated he never thought about discussing the issue directly with the ADM, who was his immediate supervisor, in an attempt to have him assist with resolving the matter. Interview on 11/19/25 at 1:00 PM with the DOR and hospice DON revealed the DON stated she had not provided a current plan of care for Resident #1 because they had been waiting for the physician's signature. The Hospice DON stated this had been on-going since at least June 2025. Interview with the DOR revealed it had actually been on-going for about 1 year as of 1/1/25. Interview on 11/20/25 at 8:30 PM with the ADM revealed he did not remember the DOR bringing up the problem he was having in obtaining a physician signed plan of care from hospice for Resident #1. He stated he also did not remember the PASARR representative emailing him about it but stated he called hospice today and they came right over and provided a signed plan of care. The ADM stated in talking with the DOR he realized the issue had been going on for about a year. He stated it should not have taken this long to complete the NFSS and it was Resident #1 who ultimately was at a disadvantage because she was not able to utilize the CMWC to assist her with positioning. Review of the facility's policy PASARR, dated 7/29/25 read in relevant part The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs. 4. Care Planning: Based on the findings of the Level II evaluation, a care plan is developed that may include specialized services or living arrangements tailored to the individual's needs. Collaboration with mental health professionals and Local Authority to ensure continuity of care.

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents for 1 of 8 Residents (Resident #3) reviewed for sanitary conditions. The facility failed to ensure the damaged linoleum tile was replaced, the walls were painted, the baseboard behind the bed was sanded and painted in Resident #3's room for a period of approximately 2 months. This deficient practice could place residents at risk of living in uncomfortable and unsanitary conditions. The findings were:Review of Resident #3's face sheet, dated 11/24/25, revealed he was admitted to the facility on [DATE] with diagnosis including unspecified Dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). Review of Resident #3's BIMS assessment dated [DATE] revealed his score was 7 of 15 reflective of moderate cognitive impairment. Observation on 11/20/25 at 5:12 PM in Resident #3's room revealed there were multiple holes covered with [NAME] on the far wall by the window. Under the window unit there was a piece of linoleum missing and the exposed area was black/brown color. The baseboard behind the head of the bed was chipped and splintered. In the bathroom, the floor tiles entering the shower stall were uneven. There was a shower curtain rod leaning against the tile inside the shower, there was a second shower curtain rod hanging on the back of the shower. Neither shower rod had a shower curtain. There was a shower chair in the shower. The top of the toilet seat on the shower chair was pealing. The back of the shower chair was wedged underneath the safety bar along the back of the shower. Observation and interview with the MS on 11/20/25 at 3:22 PM in Resident #3's room revealed the wall along the far back near the window needed painting. He stated the baseboard behind the bed was splintered and the wood needed sanding and painting. The MS stated rainwater would seep through the sewer lines in the walls and gathered under the AC unit causing a section of the linoleum to come off. He stated the brown/black area was the glue that was exposed. The MS stated the ADM had staff send him a work order of all areas needing repairs and areas needing painting when the new company bought the facility about 2 months ago. He stated the work orders were entered into their internal application program. The MS stated he started working for the facility for about 6 weeks and was working his way through the list. He stated he had an assistant, but the assistant was not experienced, and the facility was an old building and there were multiple rooms that needed repairs and painting. The MS stated Resident #3's restroom was ugly. He stated the floor was uneven leading to the shower stall and could be an accident hazard. He stated he did not know why there were multiple shower curtain rods in the stall but were not being used. He stated the shower chair was old and the seat was peeling. The MS stated Resident #3's room and shower room should be presentable, the resident equipment should be in good condition and the areas should be in good repair and homelike. The MS stated no resident should live in these conditions and commented he would not want a family member living under the same conditions. Interview on 11/20/25 at 3:35 PM with Resident #3 revealed he presented as being alert to person and place with confusion. He kept repeating the same information when questions were asked of him. Resident #3 stated the condition of the room and restroom did not bother him. He stated he showered in the shower even though staff told him he should use the main shower room. Interview on 11/24/25 at 5:00 PM with the ADM revealed the facility was an old building, there were multiple rooms, common areas which needed repairing and painting. He stated unfortunately he and most of the administrative staff were fairly new and a new company bought out the facility about 2 months ago. He stated he talked to the corporate staff and the buyer when they initially expressed interest in buying the facility and toured them through the facility. He stated everyone knew the condition of the facility and the plan was to complete repairs and paint areas which needed painting, but it would take time. He stated at this point there were other factors that took priority. The ADM stated he understood that some of the residents might not be happy with the environmental conditions, and they deserved better but again stated it would take time. Review of the facility's policy Maintenance Services, revised December 2009, read in relevant part Maintenance services shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance in federal, state and local laws, regulations and guidelines. b. maintaining the building in good repair and free from hazards. Review of the facility's policy, Resident Rights, revised February 2021, read in relevant part Employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence.

Based on observations, interviews, and record review the facility failed to ensure residents received adequate supervision, to the extent possible for 2 of 8 residents (Resident #48 and Resident #64) reviewed for safety. The facility failed to ensure Resident #48, and Resident #64 were provided adequate supervision as the residents walked out of the women's secure unit doors and out into the facility parking lot on 8/23/25, where Resident #64 fell in-between staff vehicles and obtained a laceration to the back of her head requiring 2 sutures. An IJ was identified on 08/28/2025. The IJ Template was provided to the facility on [DATE] at 05:02 PM. While the IJ was removed on 08/29/25, the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to complete repairs and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for avoidable accidents, injuries, and possible death. Findings included: Review of Resident #48's undated face sheet, reflected she was a [AGE] year-old female admitted [DATE] to the Secure Unit of the facility with diagnoses of Alzheimer's disease, anxiety disorder, and depression. Review of Resident #48's Quarterly MDS assessment dated [DATE] reflected in Section GG-Functional Abilities, for the task of walking 10 feet, she was coded as 88. Not attempted due to medical condition or safety concerns. Her BIMS was a 03, indicating she had severely impaired cognition. Review of Resident #48's comprehensive care plan dated last revised 8/25/2025 reflected the resident was care planned for following residents/staff around the unit, touches and grabs things that do not belong to her and pushing other residents in their wheelchairs. She also cared planned for being at risk for falls due to impulsive and unsafe behaviors and a new environment on the women's secure unit. Review of Resident #48's progress note dated 8/23/2025 at 7:47pm by LVN A revealed, At approximately 7:25 pm the resident was observed exiting through the back door that leads to the parking lot by staff. A staff member brought the resident back inside. Upon assessment, the resident's skin was intact, and no signs of distress were noted. The resident is alert and oriented to person and place, while the episode happened no alarms had been triggered. Family member, ADON were notified.Review of Resident# 48's Elopement Assessment updated on 8/25/25 reflected that resident had a history of leaving the facility without informing the staff. Review of Resident #64's undated face sheet, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included non-Alzheimer's dementia, anxiety, depression, and muscle weakness. Review of Resident #64's admission MDS assessment dated [DATE] reflected In Section GG-Functional Abilities, for the task of walking 10 feet, she was coded as '06. Independent - Resident completes the activity by themself with no assistance from a helper'. Her BIMS was a 05, indicating she had severely impaired cognition. Review of Resident #64's comprehensive care plan dated 8/27/25 revealed she was care planned for elopement. Review of Resident #64's secure unit evaluation dated 8/18/25 revealed she exhibited the following behaviors: wandering, physical aggression, verbal aggression, delusions, and paranoia. An updated elopement risk assessment was completed on 8/25/2025 indicating she had wandering behavior. Observation on 8/26/25 at 10:38 AM revealed Resident #48 on the Secure Unit and non-interview able due to low cognitive level. Observation on 8/26/25 at 10:47 AM revealed Resident #64 on the Secure Unit and non-interview able due to low cognitive level. Observation on 8/28/25 at 12:35 PM revealed the maintenance supervisor, MS, tested the door on the Women's Secure unit and after an initial push a loud egress alarm sounded for 15 seconds and then automatically turned off. 2nd alarm sounded when the door was completely separated from the frame. The 2nd alarm did not stop until a staff member used a key to disarm the alarm. Both alarms were loud enough to be heard at the farthest room at the end of the hall with a resident's room door open. When the resident's door was completely closed in the farthest room, the alarm could be heard but it was not loud. Observation on 8/29/25 at 12:13 PM revealed the rear door of the Women's Secure Unit had the 2nd alarm on the back door still. Observed the staff press on the door slightly and the initial egress alarm did sound. They did not fully open the door to set off the 2nd alarm. In an interview on 8/28/2025 at 11:00am with the ADM revealed Residents #48 and #64 were seen by staff outside in the parking lot on 8/23/25. Resident #64 had pushed the door long enough for the emergency egress to activate and allow them out. He said the alarm sounded and he tested it, and it was loud. The CNA and nurse who were working the floor told him they were in resident rooms and could not hear the door. The alarm turned off after 15 seconds. He stated that he was having the alarm permanently replaced to be an alarm that had to be deactivated manually. In the interim he had placed a red alarm that would continue to sound if the door was opened until staff reset it. He said he had already started that process to have the money approved for the work to be done on a permanent fix. In an interview on 8/28/2025 with CNA A she stated she was in the secure unit dining room assisting residents. CNA A thought CNA B was on the hall with Resident #64. CNA A was informed by another hall's staff, that 2 residents from the women's secure unit were outside. CNA A followed behind LVN A and found Resident #64 on the ground in the parking lot, close to the gate of the fence. CNA B stated that she was in a resident's room changing someone at the time of the elopement. CNA A stated she heard LVN A say she didn't hear the alarm sound. CNA A stated the incident could have been prevented. She stated a negative outcome was that a resident could have gotten killed and the residents were on a locked unit for a reason. In an interview on 8/28/2025 with CNA B, she stated that she was in a resident room with the door shut at the end of the hall in the secure unit changing a resident and did not hear the alarm go off. In an interview on 8/28/2025 with LVN A, she stated that she was going in and out of the secured unit courtyard/dining room assisting multiple residents and did not hear an alarm sound. She stated she was notified by other staff that the residents were outside. She stated she went outside and assessed the residents and called 911 for resident #64 who had fallen and hit her head which was bleeding. She stated resident #64 was taken to the emergency room. She stated resident #48 was unharmed and returned to the unit. In a confidential interview on 8/28/2025 it was revealed that Resident #64 was found in the parking lot on the ground between cars and the confidential interviewee had been informed by the facility that the resident had been attempting to climb a fence, when she fell and received a laceration to her head. In an interview with the ADM on 08/28/2025 at 4:20pm he stated that the door alarm on the secure unit was not fixed until 8/27/2025. Review of facility policy dated 2001 and last revised December 2021 titled, Emergency Procedure-Missing Resident reflected the following: Resident elopement resulting in a missing resident is considered a center emergency.Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety. Review of facility policy dated 4/22/25 titled, Wandering and Elopement reflected the following: The facility will ensure that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents. Adequate supervision will be provided to help prevent accidents or elopements. Review of hospital emergency room records for Resident #64 dated 8/23/25 reflect the following: Presented in emergency room (ER) on 8/23/25 at 9:15 Pm for Laceration Repair with staples. ER note indicates Resident 64 arrived at the ER by ambulance transport after she fell backwards on her head as she attempted to flee from the facility. Resident #64 was discharged back to the facility on the same day. The ADM was notified on 08/28/25 at 5:02 PM that an Immediate Jeopardy was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 08/29/25 at 11:44 AM: Plan of Removal Problem: F689 Free from Accidents/ Hazards On 08/28/2025 an abbreviated survey was initiated at the facility. On 08/28/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Resident #48 and Resident #64) reviewed for accidents.The facility failed to ensure [Resident #48] and [Resident #64] were provided adequate supervision as the residents walked out of the women's secure unit doors out into the facility parking lot, where [Resident #64] fell in between staff vehicles and obtained a laceration to the back of her head requiring 2 sutures.Immediate Action for Residents Affected:Action: [Residents #48 & #64] were assessed with Resident #48 showing unharmed and resident #64 having a head wound from falling. Responsible Party and Medical Director notified. [Resident #64] was sent to the ER for further evaluation and treatment. [Resident #64] returned with 2 staples to back of head with order to monitor daily and remove staples in 7-10 days ; no additional adverse physical findings and residents are behaving per their norm, not showing any signs of mental distress. Start Date: 8/28/2025Completion Date: 8/28/2025Responsible: Charge NurseIdentifying Additional Residents That Could be Affected: Action: Updated elopement assessments performed on all residents that reside in the facility, in and out of secured units, to include [Residents #48 and #64]. All new assessments consistent with previous assessment and care plans with no new findings. Start Date: 8/29/2025Completion Date: 8/29/2025Responsible: Charge Nurse, Assistant Director of Nursing, Director of Nursing, and/or DesigneeAction: The Administrator and Director of Nursing educated over Emergency Procedure- Missing Resident & Wandering/Elopement, on what to do when the alarm sounds-key takeaway: staff to perform a head count and search the premises/surrounding area for residents that have potentially eloped, and finally what to implement when a door is not functioning properly Start Date: 8/24/2025Completion Date: 8/28/2025Responsible: Senior [NAME] President of Clinical Operations and/or Designee Actions put in Place to Prevent Further OccurrenceAction: Education provided for all staff related to the facility's Emergency Procedure- Missing Resident & Wandering/Elopement. Staff will be educated on what to do when the alarm sounds such as the staff is to perform a head count and search the premises/surrounding area for residents that have potentially elopedAll staff, including temporary agency staff, PRN staff, new hires, will be educated prior to working their next shift. Start Date: 8/23/2025Completion Date: 8/28/2025Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee Action: Elopement drills performed for competency/education retention every shift/rotation with acknowledgement that they completed the elopement drill and comprehended the education provided. If any concerns are noted during drill, staff re-educated immediately. Start Date: 8/23/2025Completion Date: 8/28/2025Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or DesigneeAction: All doors checked for functionality. Noted door with issue was being monitored and resident head count every 15 minutes.Alarm placed on door that will alarm at a loud enough volume and will continue until manually disabled to alert staff that a resident potentially has exited the door and to follow policy based on the education noted above (head count and search the premises/surrounding area for residents that have potentially eloped). Start Date: 8/28/2025Completion Date: 8/28/2025Responsible: AdministratorQAPIAction: Ad hoc (Additional meeting for specific problem) QAPI performed to notify the Medical Director of the Immediate Jeopardy Template and the facility's plan to remove the immediacy. Start Date: 8/28/2025Completion Date: 8/28/2025Responsible: Administrator, Director of Nursing, and/or Designee The surveyors monitored the POR on 8/29/25 as follows: In an observation on 8/29/25 at 12:13 PM revealed the rear door of the Women's Secure Unit had a 2nd alarm on the back door which when the staff pressed on the door slightly, the initial egress alarm sounded. They did not fully open the door to set off the 2nd alarm. In interviews on 8/29/25 from 12:05 PM-2:00 PM with staff across both shifts (LVN A, LVN C, LVN D LVN F, MA A, CNA F, CNA K, CNA L, CNA O, CNA P, HK, MS) all stated they had been in-serviced before starting their shifts on the elopement binders that were kept at all the nurse's station, how to do a face to name audit on residents, and Code Pink for missing residents. They were told to try and redirect exit seeking residents as needed and to monitor the doors. MS stated the maintenance department was in-serviced on Code Pink, weekly door inspections and 15 second egress door alarms. Interviews with the ADM, DON, and ADON confirmed they had been in-serviced by regional staff on elopements and Code Pink. The ADM, DON, and ADON all stated they had given elopement drills already and QAPI had been completed on 8/28/25. Record review of an in-service titled Emergency Procedure - Missing Resident Elopements & Wandering Residents and dated 8/28/2025 was conducted by the Senior [NAME] President of Operations (SVPO)was given to the DON and the ADM and was signed by the SVPO, ADM, and DON. Record review of sampled Residents #2, #4, #6, #8, #10, #68 who did resided on a secured unit revealed they had Elopement Risk Assessments conducted on 8/29/2025 per the POR. Record review of an Ad hoc QAPI sign in sheet dated 8/28/25 revealed the signatures of the MD, AMD, DON, ADON, SW, MDSC, DM and included the POR. An IJ was identified on 08/28/2025. The IJ Template was provided to the facility on [DATE] at 05:02 PM. While the IJ was removed on 08/29/25, the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to complete repairs and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure the right to be free from abuse for 6 of 11 residents (Residents #4, #5, #7, #8, #10, and #11) reviewed for abuse as evidenced by: 1. Facility failed to address that Resident #3 sexually assaulted Resident #4 on [DATE]. 2. Facility failed to address that Resident #3 physically assaulted Resident #5 on [DATE]. 3. Facility failed to address that Resident #7 reported to CNA B that Resident #3 was sexual inappropriate with Resident #7 on [DATE]. 4. Facility failed to address that Resident #3 was sexually inappropriate with Resident #10 and reported to Social Worker A on [DATE]. 5. Facility failed to address that Resident #11 reported to Social Worker A that Resident #3 was being sexually inappropriate and moved out of Resident #3's room on [DATE]. 6. Facility failed to address that Resident #3 was sexually inappropriate with Resident #8 during the week of [DATE] - [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:10 p.m. The IJ template was provided to the facility on [DATE] at 7:24 p.m. While the IJ was removed on [DATE] at 3:18 p.m., the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of its plan of Removal (POR). This failure could place residents in the facility at risk for abuse or harm from other residents exhibiting aggressive behaviors. The findings were: 1. Record review of Resident #3's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included Vascular Dementia (a general term for impaired ability to remember, think, or make decisions), Type 2 Diabetes (a chronic condition that happens when your body can't use insulin properly), Schizoaffective Disorder, Bipolar Type (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), Anxiety Disorder (a feeling of worry, nervousness, or unease) and Depression (a mood disorder that causes persistent feelings of sadness and loss of interest). Record review of Resident #3's quarterly MDS assessment, dated [DATE], revealed Resident #3 had a BIMS score of 14, indicating no cognitive impairment. Record review of Resident #3's comprehensive care plan revealed the following care plans: 1) [Resident #3] has behaviors in the dining area, during meals, that agitates other residents' r/t he uses vulgar language, racial slurs and talks loudly, start date [DATE]. 2) [Resident # wants to express himself sexually and is cognitively intact to choose to have a sexual relationship(s), start date [DATE]. 3) [Resident #3] has behaviors while outside smoking that agitates other residents' r/t he uses vulgar language, racial slurs, and talks loudly, start date [DATE]. 4) Resident has physically abusive behavioral symptoms of physical aggression directed toward another resident, start date [DATE], end date [DATE]. 5) Resident has been heard calling his roommate 'my lover', which upsets the roommate. He stated he calls him that because he believes it to be funny, but he does not consider his roommate to be his lover, start date [DATE]. 6) Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by [Resident #3] talks in a loud voice and says inappropriate things to staff and other residents. [Resident #3] tells untrue stories such as the Administrator will buy him gifts. [Resident #3] stated his cigarettes were marijuana. [Resident #3] makes false allegations against staff, start date [DATE]. 7) Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by recent behaviors reported by nursing staff: argumentative, refusing to come inside late at night, yelling and cursing at staff, singing and talking loudly in the dining area during meal services, start date [DATE]. 8) [Resident #3] was observed engaging in a sexual act with another male resident, start date [DATE]. 9) Resident has potential for socially inappropriate/disruptive behavioral symptoms r/t bipolar disorder and anxiety, start date [DATE]. Record review of Resident #3's December MAR revealed Resident #3 had the following orders: 1) Clonazepam 1mg, 1 tablet, scheduled for 8:00 a.m. and 8:00 p.m. daily for bipolar disorder with a start date of [DATE]. 2) Benztropine 1mg, 1 tablet, scheduled for 8:00 a.m. daily for schizoaffective disorder with a start date of [DATE]. 3) Cymbalta delayed release 60mg, 1 capsule, scheduled for 7 a.m.-10 a.m. daily for major depression disorder with a start date of [DATE]. 4) Gabapentin 400mg, 2 tablets to equal 800 mg scheduled for 8:00 a.m., 2:00 p.m., and 8:00 p.m. for neuropathy pain with a start date of [DATE]. 5) Lyrica 50mg, 1 capsule scheduled for 8:00 a.m.-10:00 a.m. and 8:00 p.m.- 10:00 p.m. for pain with a start date of [DATE]. 6) Trazadone 150mg, ,d+[DATE] tab scheduled for 8:00 p.m. for insomnia. Record review of Resident #3 progress note, [DATE] at 11:50 a.m. by LVN A, stated, told in report that DON was not reached. Pt has been very argumentative with staff and other patients all day. Record review of Resident #3's progress note, [DATE] at 11:21 a.m. by LVN C, stated, Enter this shift this morning and observed resident very talkative, speaking with other residents and staff loudly, sometimes 15 minutes with kisses and hugs. Administered all medications including PRN Ativan 0.5mg. STAT labs CBC. CMP, UA with C&S. Resident attempted to go outside and sit on the porch but was redirected back inside. Resident required redirection to eat breakfast, sat down to eat 30 minutes later after food was placed on the table. While in dining room [Resident #3] called another resident a bitch because [Resident #3] says the other resident called him a prostitute. [Resident #3] was redirected and continued to eat his breakfast. After resident ate breakfast, he went to his room and laid down. Police here to speak with resident due to an incident that occurred yesterday. Resident is 1:1[supervision] until further notice. Record review of Resident #3 prescription order revealed an ordered received by LVN C on [DATE] for Ativan .5mg, 1 tablet, PRN. Record review of Resident #3's progress note, [DATE] at 11:53 a.m. by LVN C stated, [lab company] here to do STAT labs, resident refused blood draw d/t police here questioning him on complaint made by another resident. At this time resident is very upset and doesn't want to be bothered. UA was collected earlier today and was sent with tech. Attempted to do a skin assessment, resident refused that as well. Record review of Resident #3's progress note, [DATE] at 11:58 a.m. by Agency LVN L stated, This nurse observed resident arguing with another resident. This nurse did not hear what they were saying. This nurse redirected residents successfully. Record review of Resident #3's progress note, [DATE] at 1:15 p.m. by LVN C, stated, This nurse was informed resident threatened to kill 'whoever call the police on him.' This nurse called on call for [Resident #3 physician] and spoke with [Nurse Practitioner] and gave orders to send resident to psych hospital. Call placed to [hospital name] to give report, ER nurse made me aware that if resident doesn't meet criteria he will be sent right back. Call placed to EMS requesting resident to be sent out for a psych eval and treat. EMS dispatcher made me aware that since this is a psych transport police will come out first. The police came back inside and stated since resident didn't verbally name someone then they can't do much about it because the person would have to press charges. Record review of Resident #3's progress note, [DATE] at 1:36 p.m. by LVN C stated, Resident was sitting outside and came inside once he saw the other resident [representative] enter the building. As the [representative] was leaving with the resident for a oop stay, [Resident #3] began cursing at the resident and [resident representative] while they were leaving and tried walking toward them. Resident was blocked from trying to get the other resident. [Resident representative] exchanged words as well. Resident then proceeds to walk towards the dining room and states to another resident what are the fuck are you looking at mother fucker and hits him. The other resident gets up and attempt to hit him back but almost lost his balance. Residents were separated immediately. Call placed to the police. Record review of Resident #3's progress note, [DATE] at 2:55 p.m. by LVN C stated, Resident arrested due to physical assault to another resident and sent to [County Name], [case number]. Police informed this nurse its a Emergency protective order that last for 72 hours if judge approves. Call placed to [resident representative], message left requesting call back, NP on call, Administrator, ADON and DON was notified. Record review of a facility document titled 24-hour resident monitoring form used to document the 1:1 supervision for Resident #3, dated [DATE], listed 3 columns for each shift with column 1 -time, column 2-location/room, column 3- staff initials. The form revealed Resident #3 was documented as out front at 12:00 p.m., 12:blank, 12:blank and initialed with CNA A's initials. Resident #3 was documented DR (number) at 12: blank, 1:00 p.m., 1:blank, 1:blank, 1:blank, 2:00 p.m., 2:15, 2:30, 2:45 and initialed with CNA A's initials. Record review of a facility document titled Event Report for Resident #3, completion date [DATE] at 2:31 p.m. by LVN C, described the behavior exhibited by Resident #3 as, Resident was sitting outside and came inside once he saw the other resident [representative] enter the building. As the [representative] was leaving the resident for a oop stay [Resident #3] began cursing at the resident and [resident representative] while they were leaving and tried walking toward them. Resident then proceeds to walk towards the dining room and states another resident what are the fuck are you looking at mother fucker and hits him. The other resident gets up and attempt to hit him back but almost lost his balance. Residents were separated immediately. Call placed to the police. The event report revealed Resident #3 exhibited 'anger' and a 'desire to harm others'. The event report section titled Behavioral Symptoms stated Resident #3 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 4 to 6 days, but less than daily. The event report section of behavioral symptoms stated Resident #3 exhibited verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), 1 to 3 days in the last 7 days. The event report section of behavioral symptoms stated Resident #3 exhibited other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds, 1 to 3 days in the last 7 days. The event report stated Resident #3's behaviors put the resident at risk for significant risk for physical illness or injury, significantly interfered with resident care, put others at significant risk for physical injury, significantly intruded on the privacy and activities of others and significantly disrupted the care or living environment. The event report section for interventions for Resident #3 revealed medications were ineffective and non-pharmacological measures taken were redirection and 1:1. The outcome of the non-pharmacological measures used was coded as 'interventions ineffective'. 2. Record review of Resident #5's undated face sheet revealed he was an [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included Conversion Disorder with Seizures (a functional disorder that causes abnormal sensory experiences and movement problems during periods of high psychological stress), Congenital Malformations of Corpus Callosum-Birth Defect (a condition present at birth when parts of the nerve fibers that connect the right and left sides of the brain are missing), Dementia (a mood disorder that causes persistent feelings of sadness and loss of interest), Unspecified Intellectual Disabilities (a diagnosis for individuals when assessment of the degree of the intellectual disability by means of locally available procedures, is difficult or impossible because of sensory or physical impairments). Record review of Resident #5's MDS assessment, dated [DATE], revealed Resident #5 was coded as rarely/never understood on Section B- Hearing, Speech and Vision. Section C- Cognitive Patterns revealed Resident #5 had short term memory problems and Resident #5's cognitive skills for daily decision making were moderately impaired, defined on the MDS as decisions poor, cues/supervision required. Record review of Resident #5's comprehensive care plan revealed the following care plans, 1) [Resident #5] has been identified as having IDD PASRR positive status related to unspecified intellectual disabilities and conversion disorder, start date [DATE]. 2) Resident has difficulty understanding others R/T impaired cognition, start date [DATE]. 3) Resident has impaired cognition R/T Dementia and Congenital malformations of corpus callosum, start date [DATE]. Record review of Resident #5's progress note, [DATE] at 2:50 p.m. by Agency LVN L stated, Another resident [Resident #3] walked by [Resident #5] and said what the F*** are you looking at and hit [Resident #5] in the left forearm. This was Witness by [MA A]. Record review of Resident #5's progress note, [DATE] at 3:22 p.m. by Agency LVN L stated, [Physician name] returned call and was notified. Stat x-ray ordered. Record review of Resident #5's progress notes revealed a skin assessment was completed on [DATE] at 3:27 p.m. by Agency LVN L and there were no alterations in skin integrity noted. Record review of Resident #5's progress note, [DATE] at 9:14 p.m. by LVN F stated, x-ray came to take x-ray at 7:30 p.m. Resident is resting in his room. Record review of a document titled event report for Resident #5, completion date [DATE] at 2:59 p.m. by Agency LVN L, revealed Resident #5 was hit in the left forearm by Resident #3. The event report was checked 'yes' to a question of if the incident was witnessed. The location of the incident was marked as 'dining room'. Injury was described as no injury noted. Resident has a small dark green bruise. Treatment was marked 'x-ray ordered'. Action taken was marked 'police notified'. Immediate intervention to prevent reoccurrence stated keep [Resident #3] away from resident. The report revealed Resident #5's resident representative, physician and NP were notified of the incident. Record review of Resident #5's x-ray report, date of service [DATE] and faxed date [DATE], revealed no evidence of acute fracture or dislocation in forearm. 3. Record review of Resident #4's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Schizophrenia (a chronic mental illness characterized by delusions, hallucinations and disorganized thinking), End stage renal disease, and Conversion disorder with seizures (a functional disorder that causes abnormal sensory experiences and movement problems during periods of high psychological stress). Record review of Resident #4's quarterly MDS assessment, dated [DATE], revealed Resident #4 had a BIMS score of 15, indicating no cognitive impairment. Record review of Resident #4's progress notes, [DATE] at 11:50 a.m. by Agency LVN L stated, Residents [representative] called this morning asking to speak with someone about a grievance. This nurse stated that [Admission Coordinator name] the manager on duty was at lunch, that this nurse could take her number and have [Admission Coordinator name] call her back. This nurse stated that I was [Resident #4's] nurse today and if I could help her. [Resident representative] then stated that [Resident #4] was sexually assaulted last night. that [Resident #3 first name] asked [Resident #4] to come look at his Christmas tree last night and when [Resident #4] entered the room [Resident #3] shut the door and took his clothes off and started rubbing on [Resident #4]. This nurse took [resident representative] number and stated that [Admission Coordinator] would call her back. Record review of Resident #4's progress notes, [DATE] at 12:01 p.m. by Agency LVN L stated, police have arrived and are getting statements. Record review of Resident #4's progress notes, [DATE] at 2:05 p.m. by Agency LVN L stated, Resident left with [resident representative] for therapeutic leave. Record review of Resident #4's facility document titled event report, completion date [DATE] at 12:22 p.m. by ADON A, described the event as recipient of sexually inappropriate behavior and included a brief description of the incident that stated Resident was invited by another Resident to their room to look at the Christmas tree. Once they were in the room, the other resident then closed the door, pulls his pants down, blocks the entrance to his room door and begins to rub his genitals against [Resident #4]. The event report revealed there were no witnesses to the alleged event and no injuries were noted. Action taken was described as staff re-education, resident re-education, police notified, state notified, Administrator notified, DON notified and listed as immediate intervention implemented that the other resident was placed on 1:1 supervision. Record review of Resident #4's Social Service progress note, [DATE] at 4:38 p.m. by Social Worker A stated, [Resident #4] returned from [resident representative] outing in time to smoke outside. SW spoke to him 4: 38PM and he appeared to be doing well. SW expressed sorrow that [Resident #4] was assaulted in that way and that it was no way his fault. We talked about how shocking it is to be put in that situation. He said he was badly shaken up but going home with his [resident representative] really helped. They fed him well and talked to him and gave him his meds. He said he is not traumatized by it but felt that way when it happened. SW assured him that the Resident was arrested and taken to jail and will not be returning and that we are packing up his belongings. I told him [psychiatry company name] would be here to visit with him and I personally contacted them to be sure they were coming. He thanked me for coming to talk to him. I told him to reach out anytime he needed to talk. I also offered additional counseling if he needed it and he told me he was good. 4. Record review of Resident #7's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Myopathy (a muscle disease) and Atherosclerosis of coronary artery bypass graft (surgical operation to bypass arteries in the heart). Record review of Resident #7's MDS assessment, dated [DATE], revealed Resident #7 had a BIMS score of 15, indicating no cognitive impairment. 5. Record review of Resident #8's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Pulmonary Fibrosis (a disease in which the lungs become scarred and damaged causing difficulty in breathing), Anxiety (a feeling of worry, nervousness, or unease) and Depression (a mood disorder that causes persistent feelings of sadness and loss of interest). Record review of Resident #8's MDS assessment, dated [DATE], revealed Resident #8 had a BIMS score of 12, indicating moderate cognitive impairment. 6. Record review of Resident #10's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Hemiplegia (paralysis of one side of the body), Anxiety (a feeling of worry, nervousness, or unease), Depression (a mood disorder that causes persistent feelings of sadness and loss of interest), Schizoaffective Disorder, Bipolar Type (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), and Chronic Post-Traumatic Stress Disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress and anxiety). Record review of Resident #10's MDS assessment, dated [DATE], revealed Resident #10 had a BIMS score of 15, indicating no cognitive impairment. Record review of a facility document titled Safe Survey for Resident #10, dated [DATE] by Social Worker A, revealed a question Has any staff/resident approached you in a way that made you feel uncomfortable? Social Worker A wrote Friday-[Resident #3] came to my room the other day. He said he has a 'female part' down there (he pointed to his penis). He said his 'asshole is his pussy'. He told me I would like him better than [girl's name]. [Resident#10] told him 'I'm not doing that shit'. He bent over and showed me his butthole. He told me if I told anyone he has rights and the right to be gay. Last Monday he tried to give me a kiss (he walked into my room). That's sexual harassment. He is gay and he can be gay all he wants. He uses his gayness as a crutch. He ate all my cookies, he sat there and ate them. He offered my money. Can you keep him away from me? 7. Record review of Resident #11's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes (a chronic condition that happens when your body can't use insulin properly) and Mild Intellectual Disabilities (a neurodevelopmental condition that affects adaptive and cognitive potential). Record review of Resident #11's MDS assessment, dated [DATE], revealed Resident #11 had a BIMS score of 13, indicating no cognitive impairment. Record review of a facility document titled Safe Survey for Resident #11, dated [DATE] by Social Worker B, revealed a question Has any staff/resident approached you in a way that made you feel uncomfortable? Social Worker B wrote yes but I don't know if he is no longer here, from what I heard. Resident #11 told the head nurse/reported it when it happened. The survey also revealed a question has any staff/resident approached you about any sexual advances or remarks or anything that would cause you concern? and Social Worker B wrote yes, same as above. Happened last week then they moved me to a different room and then I heard he wet to jail. He told the head nurse when it happened. It was his former roommate, [Resident #3]. During an interview with the Administrator, [DATE] at 10:40 a.m., the Administrator stated Resident #3 and Resident #4 were not in the facility. The Administrator stated Resident #4 was out on pass with his resident representative and Resident #3 was in jail because Resident #3's behavior continued to escalate and there was another incident that resulted in Resident #3 being arrested. During an interview with the Administrator, [DATE] at 11:00 a.m., the Administrator stated he was notified on the morning of [DATE] around 9 a.m. by the Admissions Coordinator that Resident #4 reported to the Admissions Coordinator that Resident #3 allegedly asked Resident #4 to go to Resident #3's room to look at his Christmas tree on [DATE] at approximately 5 p.m. to 6 p.m. Resident #4 reported that he went to Resident #3's room and when he entered the room, Resident #3 closed the door to the room, dropped his pants, rubbed his bare bottom on him and made him uncomfortable and attempted to kiss him. The Administrator stated, when he was notified of the allegation, he began an investigation and reported the incident to HHSC and the police were notified by Resident #4's resident representative before the Administrator had a chance to contact them. The Administrator stated the police arrived around 10:14 a.m. on [DATE] to interview Resident #3 and Resident #4 and after the interviews, Resident #4's family took him out on pass from the facility. The Administrator stated after Resident #3 was interviewed by the officers, Resident #3 came out of his room and started threatening to beat people's asses and wanted to know who called the police on him and then looked at another resident and said, 'what are you looking at' and then hit the other resident. The Administrator stated the police were still outside at the time and came back in the facility and arrested Resident #3 and took him to jail. The Administrator also stated the police took an article of clothing from Resident #4 to see if there was any DNA from Resident #3. The Administrator stated Resident #3 had exhibited behaviors in the past and had a couple of reportable incidents after he admitted to the facility. The Administrator stated Resident #3 had a sexual encounter with a resident that was reported but both residents were consenting and after we investigated it, it was unsubstantiated. The Administrator stated Resident #3 had a resident-to-resident physical altercation right after he admitted last year, but there were no injuries. The Administrator stated Resident #3 had been on hospice services and was declining for part of the year but had recently improved and graduated off of hospice and said Resident #3 was on psychiatric services and his medication had been effective. During an interview with the Admissions Coordinator, [DATE] at 11:40 a.m., the Admissions Coordinator stated she arrived at the facility for manager of duty around 6:30 a.m. on [DATE]. The Admissions Coordinator stated Resident #3 asked her to go see his room and his decorations when she arrived and she went down to his room. Upon noticing that Resident #3 had decorated the whole room, the Admissions Coordinator stated she made a comment to him about how nice the room looked but if he gets assigned a roommate, he would have to take down the decorations on the other side of the room. The Admissions Coordinator said he got upset and poked me on the right upper arm and said 'no, you have to give me thirty days' notice first' in a real agitated voice. The Admissions Coordinator displayed a round dime size bruise on her right upper arm and stated that the bruise was from Resident #3. The Admissions Coordinator stated she tried to redirect Resident #3 to go to breakfast but he stated he was just going to stay in his room. The Admission Coordinator stated she took residents who smoke outside on a smoke break around 7 a.m. and Resident #4 was late to the smoke break and appeared tired and upset. The Admissions Coordinator stated she asked Resident #4 if he was ok and he stated he was tired and could not sleep the night before and agreed to go to her office to talk to her after the smoke break. The Admissions Coordinator stated around 8 a.m., Resident #4 went to her office and told her Resident #3, on [DATE] around 5 p.m., asked Resident #4 to go see his room and how he decorated it and to see his Christmas tree. Resident #4 said Resident #3 then shut the door behind him, dropped his pants, rubbed his naked ass on him and then tried kissing on him as he was trying to get out the door. Resident #4 said Resident #3 told Resident #4 that since Resident #4's family member had died 3 months ago, he did not need to be heterosexual. The Admissions Coordinator stated Resident #4 said he was able to get around Resident #3 and leave the room and stated he told a nurse what happened but could not describe the nurse and stated he did not know who it was. The Admissions Coordinator stated the 2 nurses that work the shift are his favorites so I don't know how he could not remember who it was, I think his times could be off because he knows the nurses. The Admissions Coordinator stated she notified the Administrator of the allegations made by Resident #4. The Admissions Coordinator stated between the hours of 8 a.m. and 9 a.m. on [DATE], Resident #3 was observed being agitated and being rude to residents and staff in the dining room, insulting people, and calling people fat. The Admissions Coordinator stated staff continued to redirect Resident #3 and he returned to his room and then the police arrived around 10:15 a.m. to talk to Resident #3 and Resident #4. The Admissions Coordinator stated 2 officers went to talk to Resident #3 and she could hear Resident #3 screaming and yelling in the room. Other officers went to talk to Resident #4 for about 30 minutes and took some articles of clothing. The Admissions Coordinator stated she asked an Officer what was going to happen once they leave from Resident #3's room because he was agitated, and they said they would investigate to see if they would issue a warrant for sexual assault. When the officers exited from Resident #3's room, the Admissions Coordinator witnessed Resident #3 walking behind the officers and yelling fuck you, you pigs. I used to be a male prostitute, I know my rights, I'm getting a lawyer. The Admissions Coordinator stated a CNA was assigned to sit with Resident #3 1:1. Resident #4's resident representative called and said they would be coming up to the facility to take Resident #4 out on pass and the nurse was notified and then Resident #3 was overheard yelling I will fucking kill whoever called the police on me at the nurses station. The Admissions Coordinator stated she notified the Administrator of the behavior and notified the police who were still outside of the facility. The police reentered the facility and told the Admissions Coordinator that Resident #3 could not be arrested for the statement since it was not directed toward a specific named individual. The Admissions Coordinator stated she told the CNA who was providing 1:1 with Resident #3 around 1:30 p.m. to take Resident #3 out front to get some air while the Admissions Coordinator was going to take the residents, including Resident #4, outside on the smoking patio for a smoke break. The Admissions Coordinator stated she was outside with the residents on a smoke break for about 5 - 10 minutes and was notified that Resident #3 physically hit Resident #5. The Admissions Coordinator stated she was told by a nurse that Resident #4's resident representative entered the facility and Resident #3 started calling Resident #4's representative a faggot or gay and Resident #5 laughed so Resident #3 hit him on the forearm. The Admissions Coordinator stated she notified the Administrator of the physical altercation; police were notified and she had to leave the facility for a personal appointment before the police arrived and arrested Resident #3. The Admissions Coordinator stated she was unsure how Resident #3 was able to physically assault Resident #5 while he was on 1:1 supervision and stated, I am not sure how Resident #3 was able to get close enough to Resident #5 to be able to hit him and stated I was upset when I got home and was afraid he was really going to hurt someone. During an observation and interview with Resident #5, [DATE] at 3:00 p.m., revealed Resident #5 sitting in a wheelchair in the dining room. Resident #5 smiled when greeted and was able to nod yes and no to basic questions. Resident #5 lifted the sleeve of his sweatshirt on his left forearm revealing a dime size bruise when asked if he felt safe at the facility. Resident #5 made a punching gesture with his right fist into his left forearm when asked what happened to cause the bruise. Resident #5 indicated he was not scared of anyone and that he was not in pain by nodding his head no. [TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 8 residents (Residents #1 and #2) reviewed for accidents hazards and supervision, in that: 1. On [DATE] at 8:54 a.m., Resident #1 was found outside the facility near a busy two way street near the facility. The facility did not investigate whether Resident #1 had received adequate supervision. Also, the facility did not have a mechanism in place for monitoring the front door to ensure resident supervision/monitoring resulting in Resident #1's elopement. 2. On [DATE] at 6:45 a.m., Resident #2 was found bleeding from the head from an unwitnessed fall in the Women's Secured Unit. Facility staff were not monitoring the resident's movements and were aware the resident was agitated. Facility's failure to provide adequate supervision resulted in the resident suffering a large subdural hematoma from a fall from a rolling stool in the dining room. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to establish a permanent alarm system for the monitoring of the front door. The failure could place residents at risk of experiencing accidents, injuries, and/or death. The findings included: 1. Record review of Resident#1's face sheet, dated [DATE] revealed, the resident was admitted on [DATE] with diagnoses that included: dementia, major depressive disorder, and anxiety. Resident was a male age 62. The RP was listed as a family member. Record review of Resident#1's quarterly MDS, dated [DATE], revealed: o BIMS Score was 5 (,d+[DATE]: severe cognitive impairment.) ADLs for transfer was supervision only. ROM listed no impairments. Record review of Resident #1's Care Plan dated [DATE], revealed the goals and interventions included: placement in the secured unit due to wandering and/or exit seeking behaviors. An approach documented in the said CP was for Frequent staff rounding and redirection when wandering/exit seeking observed. Record review of Resident#1's MAR (medication administration record), dated [DATE] revealed, Psychotropic medications included: Aricept 5 mg 1 tab daily (dementia) and Zoloft 25 mgs I tab daily (depression) and Depakote 125 mgs 1 tab twice per day (dementia). Record review of Resident#1's Skin Assessments revealed : (dated [DATE]) revealed: skin intact. Record review of Resident #1's Fall Risk Score (dated [DATE]) revealed, a rating of not at risk for elopement. Record review of Resident#1's Physician' Orders, dated [DATE] , revealed no specific order for the close monitoring of the resident. Record review of Resident #1's Nurse Notes revealed: [DATE] at 8:59 a.m., authored by LVN A revealed: the LVN was notified the resident had left the Men's Secured Unit. LVN A and CNA B went outside the facility and saw Resident #1 walking down the street. A visiting family member offered LVN A car transportation to bring Resident #1 back to the facility. The MD and RP were notified of the elopement. LVN A conducted a full assessment of the resident and no injuries found. [DATE] at 9:07 a.m. authored by LVN A revealed: Resident #1 put on 15 minute checks for elopement prevention. Record review or staff statements date [DATE] revealed: CNA B documented : staff became aware of resident missing between the hours of 8:00 am to 9:00 am. CNA B assisted LVN A in returning the resident back to the facility. Housekeeping Aide C documented she was in the front room and saw resident leaving to the front door and notified HR Aide D [no time listed]. HR Aide D reflected: at 8:56 am ([DATE]) she spoke to Housekeeping Aide C and was informed the resident [Resident #1] left through the front door; and notified LVN A. Record review of facility's internal investigation packet revealed: 5 day investigation report was completed and the finding was missing person confirmed. In-service on the topics of abuse and neglect and elopement were initiated on [DATE]. 72 hour monitoring sheet was present. During a telephone interview on [DATE] at 9:45 AM, a message was left for return call to surveyor. Called returned at 10:00 AM. Housekeeping Aide C stated that she saw Resident #1 leaving the facility and did not follow him or maintain eye contact. Housekeeping Aide C stated she informed HR Aide D about Resident #1 leaving through the front door. During an observation and interview on [DATE] at 9:00 a.m., Receptionist E stated in the month of February 2024 she was made receptionist for the front desk [day shift] with the duty to observe residents and visitor movements at the front door. Observation revealed that there was no bell or alarm on the front door that alerted staff when a person entered or left through the front door. Receptionist E stated the door was not monitored on weekends/nights or when she left the front desk. During an observation and interview on [DATE] at 10:30 a.m., revealed during while the path Resident #1 took when he was found to be a missing person on [DATE] was walked, with the Administrator, the resident had walked outside the facility's boundary for about 100 feet before being found at a local charity store. There was a busy street with traffic in both directions in the path the resident took on [DATE], and the Administrator stated the resident did not cross the busy street but continued to walk on the sidewalks parallel to the nursing facility. The Administrator stated, fortunately a family member and the former MDS Nurse saw the resident walking down the sidewalk while driving in their respective cars and immediately notified the facility of the resident walking away from the facility. The Administrator stated the facility when notified of the missing person dispatched nursing staff to convince the resident to return to the facility; the resident returned and was placed back in the Men's Secured Unit. The Administrator stated the preventative measures put in place after the incident on [DATE] included: in-service training on abuse/ neglect and missing persons, signs of the doors on the secured units advising all staff and visitors to use the door and check for piggy-backing (residents following visitors or staff), change of door codes, and verification of the census. Observation on [DATE] on [DATE] at 10:35 a.m. of Men's Secured Unit revealed there were two signs inside the unit which read: Stop .Please ask for assistance from staff when entering and exiting a secure unit .Please do not let unsupervised residents leave the secured unit unattended. The signs to the entrance of the Men's Secured Unit read: Please ask for assistance from staff when entering and exiting a secure unit. During an observation and interview on [DATE] at 11:34 a.m., Resident #1 was in bed in the Men's Secured Unit, alert and oriented to person and place; cleaned and groomed. The resident did not reveal signs of injury, bruises or skin tears, and the resident was ambulatory. The resident stated: I did leave .but do not remember .not sure whether someone saw me leaving .I walked alone when the door opened .no one stopped me .I was going to my house .I did not want to be here .they found me and brought me back .I probably was gone for five minutes .I feel safe here .but I want to be in my house .I have not tried to escape again .if taken to my house I will stay in my house .the door is now locked in the [unit] and I cannot leave .I have not tried to leave again .there is no abuse .no neglect .I just want to be home . During an interview with the Administrator and MDS Nurse G on [DATE] at 11:53 a.m., the Administrator and MDS Nurse G revealed the following timeline involving the missing person incident on [DATE]: 8:55 a.m.: from Nurse progress note authored by LVN A stated Resident #1 had completed eating breakfast and likely followed a visiting person outside the Men's Unit. 8:55 -8:56 a.m.: Housekeeping Aide C was sitting up front (from interview with the Administrator) and she saw the resident leaving the front door and reported to HR Aide D. [no process/procedure or elopement training was in place at the time of the incident] 8:56 a.m.: (from written statement authored by HR Aide D) statement made that HR Aide D called the Men's Unit and notified the nurse station and spoke to LVN A. 8:56 a.m.: (from interview with Administrator) a visitor and the MDS Nurse H (no longer an employee) alerted someone in the facility that the resident was seen away from the facility. 8:56 a.m.: LVN A and CNA B (no longer an employee) left the facility immediately to retrieve the resident. 8:57 a.m.: LVN A and CNA B met up with the resident about ,d+[DATE] feet and convinced the resident to return (in nurse notes) and accepted a visitor's offer to drive the resident and staff back to the facility. 8:59 a.m.: Nurse Note authored by LVN A stated that resident was back in the secured unit. During an interview with MDS Nurse G on [DATE] at 2:10 p.m., MDS Nurse G stated after the elopement of Resident #1 the 72-hour monitoring order was discontinued on [DATE]. MDS Nurse G stated the resident did not experience any other exit seeking behaviors after [DATE]. MDS Nurse G stated law enforcement was not notified; but the MD, and RP were notified of the elopement. During an interview with HR Aide D on [DATE] at 2:48 p.m., HR Aide D stated the statement written on [DATE] was correct. HR Aide D stated she did not maintain eye contact of Resident #1 because she was not sure the person identified by Housekeeping Aide C was a resident of the facility. HR Aide D stated after the training on missing persons the highlight was to follow the person until help arrived. During an interview with the ADON on [DATE] at 6:01 p.m , the ADON stated she was told by LVN A that Resident #1 had left the Men's Unit on [DATE]. The ADON stated the code to the Secured Men's Unit might have been given to a regular family member not related to Resident #1 who visited the Men's Unit and the resident had followed someone's family member on the day of the incident. The ADON stated the current practice was for only paid staff to have the secure units' codes and to educate agency nursing staff not to give the code out. The ADON stated, in-service was given and the codes were changed and a door bell was placed in the secured units to announce entering the secured units after the incident. Record review of facility's Emergency Procedure-Missing Resident dated revised [DATE] read, .Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety . Record review of the facility's Wandering and Elopements policy dated revised [DATE] read, .Adequate supervision will be provided to help prevent accidents or elopements . 2. Record review of Resident #2's face sheet, dated [DATE] revealed, the resident was admitted on [DATE] with diagnoses that included: dementia, osteoarthritis (weak bones), and agitation and restlessness. Resident was a female age 84. RP was listed as a family member. Record review of Resident#2's Care Plan revealed the goals and interventions included: [start date [DATE]] at risk for falls with interventions: assistance, re-direction, safety measures, and monitoring. [[DATE]] additional interventions: proper foot attire, and keep pathway free of obstacles. Record review of Resident #2's quarterly MDS dated ,d+[DATE] revealed: BIMS score was 99 (unable to answer questions), transfer was listed as supervision, bed Mobility was listed as supervision, and ROM was documented as no impairments. Record review of Resident #2's Fall Risk Score (dated [DATE] ) revealed a rating of high risk for falls. Record review of Resident #2's Nurse Note authored by LVN K, dated [DATE], revealed, resident did not sleep well and was agitated all night. At 6:15 a.m. the resident was in the dining area near the trash can and pick-up the trash can and carried it around. The resident was re-directed and sent to her room. Resident returned to dining room and LVN K and CNA J heard and noise and noted resident on the floor lying next to a rolling stool on her right side and blood was noted on the floor. Resident was bleeding from the forehead and pressure was applied to the site. Vitals taken (temp 98.0 (normal), pulse 54 (normal), respiration 18 (normal), Blood Pressure ,d+[DATE] (normal), O2 (95% room air-normal). 911 was called. LVN K notified Hospice, RP, and MD of the unwitnessed fall. Record review of Resident #2's clinical record revealed, Resident #2 was found on the dining room floor bleeding from the head from an unwitnessed fall on [DATE] at 6:45 AM. Staff members in the Women's Secured Unit were not monitoring the resident's movement in the dining room after the resident displayed agitation and left obstacles in her pathway. Resident #2 was taken by EMS to a local hospital where she was assessed and eventually underwent surgery for a large subdural hematoma with mid line shift (bleeding in the brain creating pressure on one side of the brain). Hospital status post finding revealed a craniotomy (a surgical procedure to remove the subdural hematoma) on [DATE]. Record review of Resident #2's hospital record dated [DATE] revealed: resident had a large subdural hematoma with mid line shift; placement in ICU; and physical restraint for aggression and behaviors. Status post craniotomy (a surgical procedure to remove the subdural hematoma) on [DATE]. Resident was discharged to another NF on [DATE]. Hospital diagnoses at discharge: SDH and Alzheimer's disease, HTN and history of falls. Record review of facility's discharge list dated [DATE] revealed Resident #2 was discharged [DATE] to hospital and did not return. Record review of Resident #2's Skin Assessments revealed: (dated [DATE]) laceration to the upper right side of the forehead; no measurements. Record review of Resident #2's Fall Risk Score (dated [DATE]) revealed, a rating of high risk for falls. Record review of Resident #2's Physician' Orders, dated [DATE] revealed, no specific order for more than routine monitoring the resident's movements in the secured unit. Record review of Resident #2's incident report dated [DATE] authored LVN K revealed: unwitnessed fall with injury from fall in dining room involving a rolling stool. Record review of facility's Provider Investigation Report dated [DATE] involving the incident on [DATE] revealed: Disciplinary action taken against CNA J, LVN K and NA L; all three employees were terminated. Rolling stools removed from the Unit. Investigation summary: Overall, the allegations did not prove [Resident #2] had an unwitnessed fall with significant injury. [Resident #2] had a laceration to the right side of forehead and was admitted to hospital with a diagnosis of brain bleed (some old and some new) .disciplinary action taken .rolling stools removed .education provided . 5 day report submitted; finding was inconclusive. Start of neuro checks pending EMS arrival from 6:45 AM-7:15 AM. Inservice on fall prevention [DATE] for 35 employees in the secured units. Record review of three terminated employees' written statements revealed: LVN K [hire date [DATE]]: at [DATE] at 6:45 a.m. when resident fell the LVN [K] was standing in front of the nurse's cart away from the resident. CNA J [hire date [DATE]]: not present in the dining room when fall occurred; location was at hall near Nurse station. CNA L [hire date [DATE]]: not present when fall occurred; location was at the Nurse Station. Record review of three terminated employee files revealed: they had received Abuse/Neglect Training and Fall Prevention Training at hiring and also on the day of the incident [DATE]. Record review of facility's employee list of dated [DATE] revealed: 13 dedicated staff assigned to the secured units. Record review of in-service training on fall prevention started [DATE] to [DATE] revealed 117 employees received the training (100 % completion rate). Record review of the facility's Wandering and Elopements policy, dated revised [DATE], read, .Adequate supervision will be provided to help prevent accidents or elopements . Record review of facility's Resident Rights policy, dated revised February 2021, read, .rights include the resident's right to .a dignified existence .be free from abuse, neglect, misappropriation of property, and exploitation . Record review of facility's Falls-Clinical Protocol policy, dated Revised [DATE], read, .The physician will help identify individuals with a history of falls and risk factors for falling .The staff and practitioner will review each resident's risk factors for falling and document in the medical record . During an interview on [DATE] at 11:58 a.m., NP stated she was informed of the unwitnessed fall involving Resident #2 from a rolling stool. The NP stated there were no orders other than routine monitoring of residents in the secured unit. During an interview on [DATE] at 12:36 p.m., the Administrator stated his investigation revealed the unwitnessed fall was actually witnessed by the staff hearing the fall. The Administrator stated he terminated all the 3 employees (CNA J, LVN K and NA L) because thy failed to monitor the dining room before breakfast meal which led to Resident #2 falling from a rolling stool. The Administrator stated post incident the interventions put in place included: no rolling stools in the secured unit, an in-service of staff, fall risk assessments for secured unit residents, and updated care plans if necessary. The Administrator stated the timeline of the incident on [DATE] was: unwitnessed fall at 6:45 a.m. EMS arrived at 7:15 a.m. During telephone call on [DATE] at 2:13 p.m., Hospice RN stated: hospice was contacted concerning the resident falling in dining room and suffering a laceration to the head requiring a visit to the ER. During a telephone interview on [DATE] at 2:21 p.m., the RP stated , .[the resident] was sent to the ER and had to undergo brain surgery .she was hospitalized for one week and put in ICU for the brain bleed .after the hospital stay [Resident #2] was transfer to another NF for three months and then died .I hold [the NF] responsible for the death of [Resident #2]. The RP stated that she was notified of the incident on [DATE]. In interviews on [DATE] from 10:00 a.m. to 10:30 a.m. with 5 day shift (6:00 a.m. to 6:00 p.m.) nursing staff (1 LVNs and 3 CNAs) and one other (Activity Tech) in the Men's Secured Unit; also, in the Women's Unit nursing staff (1 LVN and 2 CNAs); revealed: they had been in-serviced on fall prevention in the Secured Units with the highlights of: no rolling stools, no objects that could create hazards or accidents, no wet floors and maintaining supervision of the residents. Further interviews of 5 night staff (6:00 p.m. to 6:00 a.m.) (2 LVNs, 2 CNAs, and 1 MA) revealed they had the latter fall prevention training on maintaining safety in the secured units as well as throughout the facility. In interviews on [DATE] from 12:15 p.m. to 12:30 p.m. 15 with day shift (6:00 a.m. to 6:00 p.m.) nursing staff (1 LVN and 1 CNA), 9 therapy staff (day shift) (4 PTAs, 3 OTs, 1 SP, 1 Rehab Tech) and 3 night shift (6:00 p.m. to 6:00 a.m.) included (1 LVN and 1 MA) and 9 other staff (1 Maintenance, 2 HR, and 1 Housekeeping) staff nursing and; further interviews of 5 night staff (6:00 p.m. to 6:00 a.m.) (2 LVNs, 2 CNAs, and 1 MA) revealed they had been in-serviced on fall prevention in the Secured Units with the highlights of: no rolling stools, no objects that could create hazards or accidents, no wet floors and maintaining supervision of the residents; also no fall or accident hazards throughout the facility. The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]) 1. 100 percent completion rate for in-service of 117 paid staff on fall prevention (completed [DATE]). 2. Immediate Inservice on fall prevention on [DATE] for 35 employees assigned to the secured units. 3. Termination of the three employees (LVN K, CNA J, and NA L) for failing to provide supervision to Resident #2. 4. Assessment of resident #2 at time of fall and transferring the resident to the ER. 5. Neurology checks before the arrival of EMS from 6:45 a.m. to 7:15 a.m. 6. Assessing the scene of the fall and removing rolling stools. 7. Notifying the RP, Hospice, and MD of the fall. Observation of Women's and Men's Secured Units on [DATE] and [DATE] revealed no rolling stools present or equipment or objects that could create accidents and hazards and adequate supervision. During telephone interview on [DATE] at 4:10 p.m., LVN K stated the resident was agitated and moving in and out of resident rooms and eventually found a trash can she carried. LVN K stated the resident was redirected and sent back into her room in preparation for the breakfast meal. LVN K stated the resident was left unsupervised and returned to the dining hall where she found a rolling stool and tried to sit on it a fell . LVN K stated at the time of the incident she was preparing medications for morning dispensing. LVN K stated she was terminated because Resident #2 was left unsupervised. During a telephone interview on [DATE] at 4:51 p.m., CNA J stated that Resident #2 was highly agitated on [DATE] and wandered throughout the unit and eventually found a rolling stool where she fell from. At the time of the incident, CNA J stated she was at the nurse station doing documentation. CNA J stated she was terminated for not monitoring Resident #2 on the day of the fall. Attempted telephone calls to [DATE] at 3:55 p.m. and 4:00 p.m. to NA L revealed the phone was busy not accepting any calls or messages. Interviews with 33 day and night staff (8 LVNs, 9 CNAs, 3 MAs, 9 Rehab staff, 1 Housekeeping, 1 HR, 1 Maintenance, and 1 Activity) on [DATE] from 1:00 p.m. to 2:00 p.m. revealed they had received an in-service on fall prevention with the return demonstration highlights: check on obstacles in the secured units and throughout the facility that could create accidents and hazards. The Administrator was notified of an Immediate Jeopardy (IJ) on [DATE] at 6:35 p.m. The Administrator was provided with the IJ Template and a Plan of Removal was requested. The facility provided a Plan of Removal which reads as follows: Plan of Removal: 689: Accidents, Hazards, Supervision & Devices Date Initiated: [DATE] Today's Date: [DATE] The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 22 residents (Resident #1) reviewed for adequate supervision. All residents residing on the secured unit can be affected by this deficient practice. Immediate Action Performed: Action: Resident #1 was assisted back into the nursing home, resident was assessed, elopement assessment performed, and care plan updated. Resident was placed on 15 min checks until evaluated by the Psychology provider and medication review and adjustments completed. Notified the Administrator, Notified MD, and Responsible Party. Person(s) Responsible: Director of Nursing Date: [DATE] Action: - Resident head count performed with all residents residing at [the facility]. No other missing residents identified. - Elopement assessment performed on all residents at [the facility]. Any residents residing on the secured unit have elopement assessment, secured unit assessment, orders, consent and care plans in place. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: [DATE] Action: To prevent future occurrence the facility has- Placed signs on the inside and outside of the secured unit doors informing staff, vendors, and visitors to Please do not allow residents to follow you out. Secured unit doors codes have been changed, staff aware of the codes, doorbell installed and visitors/vendors will be let in by staff. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: [DATE] Steps to Achieve Compliance: Action: Resident #1 was assessed for and further exit seeking behaviors and elopement risk assessment performed. They resident care plan was updated. Person(s) Responsible: Director of Nursing Date: [DATE] Action: Place a staff member, continuously on all shifts at the front door until the Interdisciplinary Team (Including minimum Administrator, Director of Nursing, Assistant Director of Nursing, and Maintenance Director) can implement an alarm or a keypad that would alarm and/or require a code to exit the front door of the center. Person(s) Responsible: Administrator, Maintenance Director, and/or Designee Date: [DATE] Action: Elopement assessments reperformed on all residents. Elopement assessments and Secure Unit assessments will be repeated quarterly, annually and with significant change. The DON will review elopement assessments weekly to ensure they are completed timely. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: [DATE] Action: Missing Resident & Wandering/Elopement education provided to all staff to include: If you note a resident (with emphasis a resident on the secured unit) attempting to exit any door, stay with resident and ensure that they have signed out and/or have appropriate supervision. Elopement book has been verified as updated and staff education on location of the elopement book, which includes residents on the secured unit that are at risk for elopement. The Elopement Book will be updated daily with any changes by the Social Worker/designee. All employees, including new and temporary, to be educated prior to working their next shift. All newly hired employees will be education during orientation, prior to first scheduled shift The DON/designee will review the next days schedule daily to ensure that any staff scheduled to work on the oncoming shifts have been educated. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: [DATE] Action: Ad hoc QAPI performed with Medical Director to inform of the Immediate Jeopardy template and the facility's action to remove the immediacy. Person(s) Responsible: Administrator Date: [DATE] Verification of Plan of Removal: During an observation and interview on [DATE] at 10:30 a.m. the front door was locked and when opened by the Admissions Coordinator, a bell sounded. Observation further revealed that a reception desk was set up with a ledger near the entrance to control traffic and out of the facility. The Admissions stated that her assignment was to monitor traffic during her shift. She stated that the facility was working on a permanent alarm system for the front. Observation on [DATE] at 11:26 a.m. of Resident #1 revealed the resident was in the secured men's unit in the dining room socializing with other residents. Observation on [DATE] at 12:05 p.m. of Men's Secured Unit had two signs inside the unit that read: Stop .Please ask for assistance from staff when entering and exiting a secure unit .Please do not let unsupervised residents leave the secured unit unattended. The signs to the entrance of the Men's Secured Unit read: Please ask for assistance from staff when entering and exiting a secure unit. The Women's Secured Unit signs read: Please do not allow residents to follow you out .Ensure door is locked behind you . Observation also revealed that the doorbell are operating in both secured units. Observation on [DATE] from 2:45 p.m.-2:55 p.m. revealed the location of the elopement books at: station 1, station 2, Men's Secured Unit and the Women's Secured Unit. Record review of Resident's Nursing note dated [DATE] at 8:59 a.m. authored by, LVN A revealed the resident eloped from the facility and was missing for about 5 minutes; was assessed and returned to the facility. Record review of Resident #1's elopement evaluation on [DATE] revealed high risk for elopement. Record review of Resident #1's CP dated [DATE] revealed: the resident was an elopement risk. Record review of Resident #1's behavior monitoring dated [DATE] to [DATE] revealed monitoring done and completed; see attachment. Record review of Resident #1's Psychology evaluation on [DATE] by [psychiatric company] revealed: medications reviewed and follow-up visits. Record review of Resident #1's Medication review done by the NP dated [DATE] revealed: medications reviewed and new order for Aricept 5 mgs once per day at bedtime (dementia). Record review of Resident #1's Nurse Progress note dated [DATE] authored by LVN A revealed the MD was notified and the RP. Record review of facility's census audit on [DATE] revealed 124 residents were present and no other resident had eloped. Record review of sample residents (Residents #3 through #7) revealed elopement assessment was completed on [DATE]. Record review of Secured Units' census on [DATE] revealed: Men's was 34 and Women was 22. Record review of sample residents in the Men's Unit on [DATE] revealed Resident's clinical record contained the elopement assessment, secured unit assessment, orders, consent and care plan was in place. Record review of sample residents in the Women's Unit on [DATE] revealed Resident #8's clinical record contained the elopement assessment, secured unit assessment, orders, consent and care plan was in place. Record review of Resident #1's elopement assessment dated [DATE] authored by RN revealed the assessment was present; and resident assessed for high risk of elopement. Record review of Resident #1's CP dated [DATE] revealed: the CP was updated and to closely monitor the resident for wandering and elopement. Record review of facility's POR binder revealed 117 elopement assessments were present. Record review of training on Missing Residents for 117 staff members revealed: 117 signatures were present for 100% completion. Record review or email dated [DATE] to Medical Director revealed a discussion on the IJ and the POR. During an interview on [DATE] at 12:09 p.m. the DON stated the codes to the locked units had been changed and would be changed every three months unless compromised. The DON stated, Staff were made aware of the codes individually when she made rounds and during orientation. The DON stated that the codes are not given to agency staff or visitors. During an interview on [DATE] at 12:43 p.m., the Corporate Nurse stated that corporate headquarters is exploring a permanent solution for the front door monitoring to prevent elopement and tracking visitors. During an interview on [DATE] at 12:49 p.m., the DON stated, yes .117 elopement assessments were completed .the resident at risk for elopement resided in the secured units was a total of 51 residents .the scale for elopement was 'at risk' and 'not at risk' . In interviews on [DATE] from 1:00 p.m. with 10 day shift (6:00 a.m. to 6:00 p.m.) nursing staff (2 LVNs, 4 CNAs, 1 MAs) and 3 other staff (SW, admissions, and HR); and 10 night shift (6 p.m. to 6 a.m.) nursing staff (3 LVNs, 4 CNAs) and 3 Other

Based on interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for adequate supervision. 1. Resident #1 who required total assistance in eating and received a cup of coffee ,on 08/28/23, from CNA C that he spilled on himself which resulted in significant injury to the right torso region area. 2. CNA C did not check on Resident #1's MDS, care plan, or with the Charge Nurse as to the level of eating assistance Resident #1 required. 3. The facility did not investigate the accident for two days or put in place adequate supervision for other residents (R#6, #7, #8, #9, #10, and #11) with total assistance for eating. An IJ was identified on 12/01/23. The IJ template was provided to the facility on [DATE] at 12:35 PM. While the IJ was removed on 12/02/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy because of facility's need to monitor the implementation and effectiveness of its corrective systems. The failures could result in Residents requiring total assistance with feeding, experiencing a diminished quality of life, medical complications, and/or death. The findings included: Record review of Resident #1's face sheet, dated 11/30/23 and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: Alzheimer's disease (primary) (progressive mental deterioration), abnormal gait and mobility, lack of coordination, stroke affecting right side of face; and hospice. Further review revealed the resident was a male; age 64, Advanced Directive was DNR, and the resident's RP was listed as a family member. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS could not be conducted as the resident was rarely/never understood and could not answer questions. Further review of this MDS revealed Resident #1 total assistance for eating with one person assistance. Record review of Resident #1's Care Plan, initiation date 05/21/2021, revealed, Eating amount of assistance: One person assist. Further review revealed the resident's care plan did not state whether it was total or extensive assistance. Record review of Resident #1's Nurse Progress Note dated 8/28/23 at 5:43 AM, authored by LVN A read: Resident was in dining room being assisted with coffee but dropped the cup when taking a drink [sitting in wheelchair]. Redness to right side of abdomen and mid right arm. Record review of Resident #1's Nurse Progress Notes, from 8/28/23 at 5:43 AM to 8/31/23 at 5:32 AM, revealed no nursing staff provided an assessment or treatment to Resident #1's burn area, the MD and RP were not notified of the incident; and facility nursing management was not told about the incident by LVN A. Record review of Resident #1's Nurse Note dated 8/31/23 at 5:32 AM authored by LVN A read: Post coffee burn to right flank now with 2 open areas. Large open area measures 4 cm x 3 cm and smaller one measures 1.5 cm diameter .Will make wound care aware of changes. Record review of facility's temperature liquid reading for the date of 8/28/23 read 140 degrees Fahrenheit for coffee. Record review of Resident #1's skin assessment dated [DATE] revealed: right flank big one [burn near right kidney] 4 cm X 3 cm; small [burn near right kidney] 1.5 cm in diameter. Record review of Resident #1's Skin Observation on 09/02/23 at 1:13 PM note authored by LVN G read: Coffee spilled causing burn. 2 open blister like areas measuring 4 x 3 cm and 1.5 x 1.5 cm. Partial thickness [NAME]. Redness surrounding areas . Record review of Resident #1's physician assessment on 09/05/23 read: Skin .2nd degree burn healing . Record review of Resident #1's rehab notes from 06/27/23 to 07/26/23 revealed no SP assessment was completed or a change recommended to Resident #1's assistance with eating. During an interview on 11/08/23 at 1:08 PM, LVN A stated CNA C told her that Resident #1 spilled coffee on himself, LVN A stated, Resident #1's skin was red. The spill occurred at the resident's right side, flank area. LVN A stated, I didn't put anything on it at the time, so I just washed the coffee off and changed his shirt. It was just pink, so I just washed the area. We put him back in the dining room, and I gave report to the day nurse. LVN A stated she did a skin assessment two days later and discovered the resident had developed a blister. LVN A stated on 8/31/23 she called the MD's office to report on Resident #1's skin blister. During an interview on 11/09/23 at 9:11 AM, CNA C stated: she made a coffee cup for R#1 and he went to pick it up and it spilled on him. She reported the incident to LVN A. CNA stated: I don't know how he dropped it. He picked up cup off the table, took it to his mouth, was going to take a drink and spilled it. During an interview on 11/30/23 at 11:10 AM, the Administrator stated the timeline was as follows: - 5/31/21 Resident #1's care plan for ADL reflected, Eating amount of assist: One Person Assist. - 7/06/23 Resident #1's MDS (quarterly) reflected, one person total assistance for eating. - 8/28/23 in the morning Resident #1 spilled coffee on self not being assisted by CNA C. - 8/30/23 Resident #1's MDS (significant change) reflected extensive assistance X1 (one person) - 8/31/23 Resident #1 discovered with blisters: MD, RP, and Hospice notified. HHS report submitted. - 9/06/23 Resident #1's care plan was revised to read, Eating assist with meals as needed. During an interview on 11/30/23 at 11:50 AM, the Administrator stated that the report submitted to HHS on 9/7/23 was accurate and he had nothing to add to the internal investigation summary. The Administrator stated, Overall, the investigation did prove that [Resident #1] spilled coffee on himself and that resulted in a significant burn injury that [was] treated by nursing staff per doctors' orders . The Administrator stated: the coffee temperature on 8/28/23 was at 140 degrees F. The Administrator stated the standard of serving hot coffee was 140 degrees F. During an interview on 11/30/23 at 12:23 PM, RN K (ADON) stated total assistance was defined as the person doing the feeding assistance, they provided 100 % of weight bearing, meaning the resident was not involved in the weight bearing. RN K (ADON ) stated prior to the incident on 08/28/23, Resident #1 was total assistance in eating. RN K stated that extensive assistance meant that the staff provided the assistance in 50-75% of the weight bearing. Resident #1 was changed to extensive after the incident on 8/28/23. RN K stated Resident #1's care plan prior to the incident reflected Resident #1 was helped with eating/drinking. RN K further stated after the incident Resident #1's care plan was revised for eating was assist with meals as needed versus the MDS, dated [DATE], which documented for Resident #1 as extensive. RN K stated Resident #1's record contained no evidence or information which indicated the resident was independent in eating at the time of the incident. RN K stated the total number of residents requiring total feeding was six (Residents #6, #7, #8, #9, #10, and #11). During an interview on 11/30/23 at 12:30 PM, the FSS stated he monitored coffee temperatures, and the acceptable highest temperature limit was 140 degrees F. During an interview on 11/30/23 at 1:00 PM, the Rehab Director stated that a review of Rehab notes for Resident #1 for the past year revealed no referrals to rehab involving feeding assistance; nor a referral for PT, OT, or SP. During an interview on 11/30/23 at 1:30 PM, the Administrator stated staff were in-service on the topics of incidents and accidents, investigating, burns, change of condition; safety and supervision of residents [8/31/23-09/05/23; total signatures were 71; 100%]. The Administrator stated any new nursing staff or PRN staff would be trained on the latter topics. The Administrator further stated a QAPI meeting was held on 8/31/23 to address the incident involving Resident #1. [No training on checking a resident's feeding status before the resident was assisted or not assisted with feeding was conducted]. During an interview on 11/30/23 at 2:16 PM, LVN G (MDS) stated Resident #1's MDS dated [DATE] was coded that the resident was total dependence one person for eating. LVN G stated there was a coding error in the resident's MDS and the code for Resident #1 should have been extensive assistance with one person assistance. During an interview on 11/30/23 at 2:57 PM, the ADON stated that an audit was completed to ensure the MDS and care plan for six residents (Residents #6, #7, #8, #9, #10, and #11) needing total assistance were accurate [Audit was requested by surveyor]. The ADON stated the audit revealed that Resident #10's MDS and care plan on eating were not matching. Resident #10's MDS ADL, dated 11/23/23, for eating read: Dependent-Helper does all of the effort. Resident does none of the effort to complete the activity. OR the assistance of 2 or more helpers is required for the resident to complete the activity. The care plan, dated 11/13/23, read: Provide extensive assistance X1 for meals. During an interview on 11/30/23 at 4:00 PM, the DON stated the topic of knowing the eating assistance status for residents that required total, extensive, limited, and cuing was not covered in the in-service from 08/31/23 to 09/05/23. During an interview on 11/30/23 at 4:24 PM, CNA C stated Resident #1 feed himself and she had worked with the resident for over one year. CNA C stated the resident's eating requirement was extensive which meant that he was able to do some eating tasks with staff assistance. CNA C did not respond to the question as to whether she knew Resident #1's eating code by checking the resident's MDS, care plane, or checking with the charge nurse. CNA C stated in-service training was conducted on various topics after the incident, but she did not know whether checking the eating requirements of a resident was part of the training. CNA C stated on the day of Resident #1's injury she placed the coffee on the coffee table, provided no assistance to Resident #1, and the resident reached for and grabbed the cup of coffee spilling it on his abdomen. CNA C stated she notified LVN A about the incident. During an interview with the Administrator and the ADON on 11/30/23 at 5:10 PM, the Administrator stated that no specific in-service training was done on staff knowing the eating requirement of residents and where to find the information. The ADON stated that no specific training was done after the incident involving knowing the ADL for eating and where to find the eating code of a resident. During an interview on 12/01/23 at 10:25 AM, the DON stated: On the day of the incident, 8/28/23, Resident #1 was sitting in a wheelchair and CNA C placed the coffee cup on the coffee table. The resident reached for the coffee and spilled it on his torso. The resident did not bump the coffee table with his wheelchair. Record review of facility's internal investigation dated 8/31/23 revealed: [8/28/23] 5:43 am Resident [Resident #1] spilled coffee on himself when coffee was placed on the dining table. 8/31/2023 6 am Wound on residents [Resident #1] rt flank was reported to ADON .Employee suspended .Orders obtained for treatment . Record review of facility's Employee memorandum, authored by the DON dated 8/31/23, involving LVN A revealed the facility violation was that: LVN A failed to report a change of condition [for two days involving Resident #1] to the MD, RP and facility management. Record review of facility's temperature food and liquid reading for the date of 8/28/23 read 140 degrees F. Record review of the facility's Safety and Supervision of Residents policy, revised 2017, read: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Record review of the facility's Accidents and Incidents-Investigating and Reporting, revised July 2017, read: The Nurse Supervisor (DON)/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident (Burns -Notify-Administrator as well) . Record review of facility's Care Area Assessments policy, revised November 2019, read: . Document interventions on the care plan. Record review of facility's Care Plans policy, dated December 2020, read: . care plans are revised as information about the residents and the residents 'conditions change . Record review of the facility's Abuse, Neglect, and Exploitation policy, undated, read: . Possible indicators of abuse include .Failure to provide care needs such as comfort, safety, feeding . The Administrator was given the IJ template and was notified of the Immediate Jeopardy (IJ) on 12/01/23 at 12:35 PM and a plan of removal (POR) was requested. On 12/01/23 at 6:38 PM the POR was accepted. It was documented as follows: [Facility] Plan of Removal: 689: Free of Accidents Hazards/Supervision/Devices Action: Resident #1 no longer resides at [Facility]. Date: 9/13/2023 Action: Residents that require staff assistance with consuming food and/or liquids can be affected by this deficient practice. --Audited all residents most recent MDS against their documentation and the resident care plan/resident profile located in the point of care for their needs for supervision while consuming food and/or liquids. MDS audit will be verified by the Regional Reimbursement Nurse. Person(s) Responsible: MDS Coordinators and/or Designee; Regional Reimbursement Nurse Date: 12/1/2023 Action: To prevent future occurrence the facility has educated the following staff over: Staff (including facility staff and temporary staff- agency and/or mobile clinical) that may assist a resident while eating or drinking have been educated on where to pull supervision information (within the point of care-resident profile). All staff will be educated on notifying the abuse coordinator on any incidents/accidents resulting in resident harm such as a skin alteration as a result of warm liquids. All staff, facility and/or temporary, that this action item applies to will be educated prior to working their next shift. Improved Processes: When there was a change in resident assistance for eating and drinking, the clinical team (Director of Nursing, Assistant Director of Nursing, MDS Coordinator) will discuss and update the care plans/resident profile to reflect the resident's current needs, as needed, during the daily clinical meetings, x 5 days (Monday-Friday), weekly. The MDS will be updated per the RAI manual to Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, MDS Coordinator and/or Designee. Date: 12/1/2023 Action: Monitoring to include: --A minimum of 5 staff members per week will be observed by nursing administration on how to pull a resident's eating assistance from the point of care or resident profile for 4 weeks. --Event reports for incidents/accidents will be reviewed 5 days weekly (Monday to encompass Friday-Sunday), x 4 weeks, to ensure proper notifications were made and adequate supervision/proper interventions were provided timely following an incident. --Weekly audits of the POC profiles vs Care Plans will be completed, x 4 weeks, by the MDS Coordinator to ensure accurate eating/drinking assistance information is available for staff. Person(s) Responsible: Director of Nursing, Administrator, MDS Coordinator, and/or Designee Date: 12/1/2023 Action: Ad Hoc [unplanned] QAPI performed with Medical Director to inform him of the Immediate Jeopardy Template and the Facility's Plan to Remove the immediacy. Person(s) Responsible: Administrator Date: 12/1/2023 Verification of the Plan of Removal: Record review of the Resident Roster dated 12/02/2023 revealed Resident #1 no longer resided in the facility. In an interview on 12/02/2023 from 8:48 a.m. to 8:58 a.m., MDS Nurse LVN G stated all the residents' charts had been audited by her, MDS Nurse RN H, and the Regional Reimbursement Nurse to ensure the residents' care plan matched the residents' ADL level of assistance for eating as indicated on the residents' MDS assessment. MDS Nurse LVN G stated residents' whose care plans did not reflect their ADL level of assistance for eating were updated. MDS Nurse LVN G said the CNAs have access to the updated care plans on the POC (Point of Care) system which are mounted on the walls throughout the facility. MDS Nurse LVN G stated she was in-serviced on compliance with MDS plans, and another in-service was held on where to find resident's care plan information on the POC. MDS Nurse LVN G stated residents completed MDS's would be monitored weekly by the Regional Reimbursement Nurse to verify the residents' care plans had been completed and updated. In interviews on 12/02/2023 from 10:13 a.m. to 2:42 p.m. with 10 day shift (6 a.m. to 6 p.m.) nursing staff (7 LVNs, 1 RN, 8 CNAs, 2 MAs), 4 night shift (6 p.m. to 6 a.m.) nursing staff (2 LVNs, 2 CNAs) and 4 day shift agency CNAs revealed they had been in-serviced on how to access the residents' care plans through the POC system, to notify the abuse coordinator of any accidents/incidents resulting sin skin alterations such hot liquid spills, and on abuse and neglect. The Medical Director was called on 12/02/2023 at 1:15 p.m. for an interview but he did not answer his phone or return the surveyor's call before the surveyor exited the facility on 12/02/2023. In an interview on 12/02/2023 at 2:46 p.m. the Administrator stated the Regional Reimbursement Nurse had completed an audit of all the residents' MDS and care plans as part of the POR. In an interview on 12/02/2023 at 3:07 p.m. the DON stated the nursing staff were in-serviced in person or on the phone on where to find the resident's level of assistance either in the resident's care plan in the POC, or through the charge nurse, or the resident's MDS. The DON stated when CNAs started their shift, they did a hands-on demonstration with the CNA on where to find the resident's care plan in the POC system. The DON stated staff were also in-service on abuse and who the abuse coordinator which was the administrator. In an interview on 12/02/2023 at 3:11 p.m. the DON stated the ADONs would monitor 5 nursing staff each week on their knowledge of where to find the resident's care plans in the POC system. The DON stated an ad hoc QAPI meeting was held at 6:30 p.m. on 12/01/2023 by telephone with the Medical Director and the Medical Director's NP (NP I). The DON stated the Medical Director was informed of the facility's IJ and the facility's POR. The DON stated facility's QAPI meetings were held monthly, and they would be monitoring the changes in the resident's level of care in the QAPI meetings. In an interview on 12/02/2023 at 3:22 p.m. the Administrator stated the Regional Reimbursement Nurse educated the MDS nurses, conducted an audit of all the residents' MDS and Care plans to ensure the resident's MDS matched their care plans. The Administrator stated staff were in-serviced on where to find the resident's ADL level by asking the nurse and/or through the POC system. He stated any new agency staff would be educated by the ADONs before they started their shift on where to find a resident's level of care in the POC system. The Administrator stated staff was also in-serviced on reporting abuse neglect, who the abuse coordinator was, and reporting change of condition. The Administrator stated he was randomly asking 5 CNAs on their knowledge of where to find the resident's level of care. He stated the regional MDS nurse was auditing at least 4 residents' charts to ensure the resident's MDS matched their care plans. The Administrator said the QAPI Ad hoc meeting was held on 12/01/2023 with the Medical Director and his NP I. The Administrator stated the IJ template, the facility's POR was reviewed with the Medical Director at the ad hoc QAPI meeting and the facility's POR would be monitored monthly in the QAPI meetings for the next three months. Record review of Resident #4's undated face sheet revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (decline in cognitive abilities that affects an individual's ability to perform everyday activities), schizoaffective disorder (mental disorder characterized by abnormal thought processes and unstable mood) and extrapyramidal movement disorder (involuntary, uncontrollable movements caused by medications). Record review of Resident #4's most recent MDS dated [DATE] revealed under Section GG it was coded for the resident to feed himself independently. Record review of Resident #4's care plan for ADL self-care deficit related to impaired strength, revised 12/01/2023, revealed the resident was independent with eating and only needed assistance with set up. Observation on 12/02/2023 at 5:10 p.m. in the main dining room revealed Resident #4 was able to feed himself independently after the tray was set up for him. Record review of Resident #3's undated face sheet revealed he was admitted to the facility on [DATE] with diagnoses which included dementia (decline in cognitive abilities that affects an individual's ability to perform everyday activities), high blood pressure, and hemiplegia (partial paralysis affecting one side of the body). Record review of Resident #3's most recent MDS dated [DATE] revealed under Section GG it was coded for the resident to feed himself independently. Record review of Resident #3's care plan for Self-Care deficits related to left sided hemiplegia, revised on 08/28/2023, revealed the resident was independent with eating after assistance with tray set up. Observation on 12/02/2023 at 5:17 p.m. in the main dining room revealed Resident #3 was able to feed himself independently after a CNA assisted him with seasoning his food. Record review of Resident #5's undated face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (decline in cognitive abilities that affects an individual's ability to perform everyday activities), high blood pressure, and heart failure. Record review of Resident #5's most recent MDS dated [DATE] revealed under Section GG it was coded the resident needed Supervision or touching assistance which included verbal cues intermittently during the activity or assistance with set up. Record review of Resident #5's care plan for problem area of ADL function revealed it was revised on 12/02/2023 and indicated the resident needed supervision with set up. Observation on 12/02/2023 at 5:24 p.m. in the women's secured unit dining room revealed Resident #5 was able to feed herself after the CNA set the tray up for the resident and provided verbal cues. Record review of the facility's POR binder for F689 revealed under the tab titled MDS verses Care Plan Audit revealed beside each resident's name had a letter beside their name to indicate who audited the resident's clinical record and all residents who resided in the facility had been audited. Record review of the facility's POR binder revealed under the Education tab, the Regional Reimbursement Nurse had sent an email to the Administrator on 11/30/2023 which indicated she had in-serviced MDS Nurse LVN G and MDS Nurse RN H on timely completion of the MDS, accurate coding of the MDS which included if the POC coding was not a true reflection of the resident, the MDS Nurse was to educate the CNAs on the accurate coding, and to add a note to the MDS and a Progress Note to the resident's chart. The in-service also included updating the care plans within 7 days of the RN signature and to code at the level of staff assistance the resident needed, and CNAs were to chart the level of assistance performed each shift. Also under the Education tab was a list of nursing staff and in-service sign-in sheets that revealed 57 of 61 nursing staff (27 of 30 CNAs, 21 of 22 LVNs, 5 of 5 RNs, and 4 of 4 MAs), and 6 of 6 Agency CNAs had been in-serviced on how to access residents' eating assistance in POC, notification to the Abuse Coordinator of accidents/incidents that result in skin altercation such as a warm liquid, and the facility's abuse policy. Record review of the facility's POR binder revealed under the Monitoring tab was a list of 14 employees who had been asked where they would be able to access a resident's level of assistance in the POC system and when to notify the abuse coordinator of any accident/incident that result in skin altercations such as warm liquids. Record review of the facility's POR binder revealed under the QAPI tab was the signature page of the QAPI meeting held on 12/01/2023 which was attended by the Administrator, the Medical Director by phone, the Medical Director's NP I by phone and the DON. On 12/02/2023 at 6:15 p.m. the Administrator was informed the POR was validated and immediacy was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal.

Based on interview and record review, the facility failed to ensure residents are free of significant medication errors for 1 (Resident #1) of 5 residents reviewed for safe administration of medications, in that: Resident #1's order for levothyroxine was not entered by nursing staff during her initial admittance and upon readmission to the facility. Resident #1 was not given twenty-four doses of levothyroxine for her diagnosis of hypothyroidism as ordered by a physician, as a result, Resident #1 was hospitalized with a myxedema coma. This failure resulted in identification of an Immediate Jeopardy (IJ) situation; an IJ was identified on 03/30/2023. The IJ template was provided to the facility on [DATE] at 10:48 a.m. While the IJ was removed on 03/31/2023 at 2:37 p.m., the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope of a pattern until interventions were put in place to ensure residents' physician orders were accurately entered into the medical records system. This deficient practice could affect all residents who receive medication from the facility and place them at risk for adverse reactions, decline in physical health, hospitalization , or death. The findings were: Record review of Resident #1's face sheet, dated 03/31/2023, revealed the resident was initially admitted the facility on 02/09/2023 with diagnoses including: hypothyroidism, unspecified dementia, and hyperkalemia. Record review of Resident #1's admission MDS, dated [DATE], revealed a staff assessment of memory was completed with short-term and long-term memory problems. Record review of Resident #1's care plan as of 03/31/2023, revealed goals: Resident's needs/wants will be met at all times and Resident will experience no complications. Record review of Resident #1's hospital discharge orders, dated 02/06/2023, revealed levothyroxine (a drug to treat hypothyroidism) 200 micrograms daily was prescribed. Record review of Resident #1's clinical record from the facility revealed the resident was re-hospitalized from 02/13/2023 to 02/20/2023. Record review of Resident #1's hospital discharge orders, dated 02/20/2023, revealed the resident received levothyroxine during her hospital stay and was prescribed levothyroxine 100 micrograms daily upon discharge. Record review of Resident #1's order summary, dated 03/31/2023, revealed the physician order for levothyroxine was not included in her list of medications upon admission on 02/09/2023 and was not included in her re-admission medication list on 02/20/2023. Record review of Resident #1's medication administration record, dated 03/31/2023, revealed the resident was not administered levothyroxine while in the facility from 02/09/2023 to 02/13/2023, and was not administered levothyroxine while in the facility from 02/20/2023 to 03/13/2023. Further review of Resident #1's clinical record from the facility, dated 03/13/2023, revealed .resident was put on [an oxygen] mask at 2 [liters] due to residents [oxygen saturation at 70%] .resident was observed moaning as if in pain, her skin was yellowish in color, increased lethargy, and unable to communicate with staff. [Nurse Practitioner] stated to send to [emergency room ] to be evaluated for possible [pneumonia]. Further review of Resident #1's clinical record from the facility revealed the resident was re-hospitalized again from 03/13/2023 to 03/20/2023. Record review of Resident #1's hospital records from 03/13/2023 to 03/20/2023 revealed the resident was diagnosed as having a myxedema coma, defined by the National Institute of Health as, a rare life-threatening clinical condition in patients with longstanding severe untreated hypothyroidism (ncbi.nlm.nih.gov/books/NBK279007 updated 04/25/2018, accessed 04/05/2023). Further review revealed the resident had a TSH (thyroid stimulating hormone) level of 139 with approximately 5 being the upper range of an acceptable level. During an interview with LVN A on 03/29/2023, LVN A stated she was new to the facility at the time of Resident #1's admission and had inadvertently left out the resident's physician order for levothyroxine while entering Resident #1's admission orders from the hospital. During the same interview, ADON B stated the facility protocol for new admissions was for an ADON to check the admissions entries the day after an admission had occurred and stated he did not perform this check following Resident #1's admission because he did not have time. LVN A and ADON B confirmed that all of Resident #1's hospital discharge orders should have been added to the resident's facility medical record and were not added due to an oversight. LVN A confirmed she had not been directed by a physician or nurse practitioner to exclude levothyroxine from Resident #1's medication list. During an interview with LVN A on 03/29/2023, LVN A confirmed she had completed Resident #1's readmission on 02/20/2023 and had restarted the original, incomplete medication list from the time of the resident's admission which left out the discharge order for levothyroxine. LVN A confirmed she had not been directed by a physician or nurse practitioner to exclude levothyroxine from Resident #1's medication list. During an interview with the Nurse Practitioner on 03/29/2023 at 4:20 p.m., the Nurse Practitioner stated she had reviewed a clinical record for Resident #1 which indicated that the resident was being treated with the medication hydrocortisone for the condition of adrenal insufficiency and she believed this course of treatment was related to the resident's thyroid condition. The Nurse Practitioner stated she did not recall which record she had reviewed. The Nurse Practitioner further stated she had not seen any of Resident #1's clinical records from the resident's two hospitalization s and if she has known that the resident was being treated in the hospital with levothyroxine for hypothyroidism, she would have continued with that treatment in consultation with the hospital. The Nurse Practitioner stated she relies on the information entered in the facility medical records system to know what hospital discharge orders are given for each resident. The Nurse Practitioner further stated she had referred Resident #1 to an endocrinologist, a thyroid specialist. During an interview with the facility's consultant Pharmacist on 03/29/2023 at 4:36 p.m., the consultant Pharmacist stated the potential harm of a resident not receiving levothyroxine as prescribed was not having the medication at a therapeutic level, and confirmed that a myxedema coma could be the result of not having received levothyroxine as prescribed. During an interview with the DON on 03/29/2023 at 4:45 p.m., the DON stated she had spoken with the Nurse Practitioner regarding Resident #1's treatment and stated it was her belief that the Nurse Practitioner chose not to continue the hospital order of levothyroxine for hypothyroidism and instead was pursuing hydrocortisone for adrenal insufficiency as the course of treatment. Record review of Resident #1 facility medication list as of 03/21/2023 revealed the resident was prescribed levothyroxine 100 mcg daily. Record review of Resident #1's clinical record from the facility revealed labratory results, dated 03/29/2023, which indicated the resident's TSH level was 42.761 with a desired range of .450-5.3. On 03/30/2023 at 10:48 a.m. the Administrator was notified of the Immediate Jeopardy (IJ) situation for the above failure, a completed IJ template was provided, and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 03/30/2023 9:09 p.m. and included: Colonial Manor respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on 03/30/2023 for F760. Plan submitted on 03/30/2023 at 3:15pm. Immediate action taken for resident affected: Resident #1 was readmitted from the hospital on 03/20/2023 and discharge orders were received and transcribe to the admitting orders for Levothyroxine 100mcg per gastric tube QD. This order was verified with the nurse practitioner by the admitting nurse. The DON notified the physician of the medication error on 3/29/2023 at 3:05 pm and labs were ordered for a CBC, CMP, TSH and Lipids. These were drawn by the lab at 8:11pm. The facility is waiting on results. Resident identified to have been affected by the alleged deficient practice: The Director of Nursing and Clinical Resource Nurse immediately completed a review of all residents that have been admitted or readmitted in the last 90 days to ensure that hospital discharge records are available in the Documents tab in Matrix and that all discharged orders have been transcribed correctly on the orders and the hospital discharge orders and the admitting orders have been reviewed with the physician. Completed 03/30/23 Residents with the potential to be affected by the alleged deficient practice: During the above thorough review the facility identified 27 residents who were admitted /readmitted in the last 90 days. The facility found no other medication omissions on the admission orders. Systemic Measures: 1. The Director of Nursing/designee including the ADON/Weekend RN Supervisor will review new admissions/readmissions on a daily basis to ensure that hospital discharge orders are available in the Documents tab in Matrix and that the discharge orders are transcribed accurately in the admission orders and the hospital discharge orders and the admitting orders have been reviewed with the physician. The results of these daily reviews will [sic] reported to the QAPI committee for no less than 90 days 2. Training: Will be completed as follows: a. All licensed nurses will be trained by the Director of Nursing/designee including the ADON/Weekend RN Supervisor on reviewing hospital discharge orders in the Documents tab of Matrix, transcribing orders to the admission orders in Matrix and reviewing these with the attending physician for approval prior to their next scheduled shift. Completed 03/30/2023. b. All licensed nurses will be trained by the Director of Nursing/designee including the ADON/Weekend RN Supervisor to document the review of these orders and approval by the physician in the progress notes prior to their next scheduled shift. Completed 03/30/2023 c. The Director of Nursing/designee including the ADON/Weekend RN Supervisor will train all newly hired nurses upon hire on reviewing hospital discharge orders in the Documents tab of Matrix, transcribing orders to the admission orders in Matrix and reviewing these with the attending physician for approval prior to their next scheduled shift. Completed 03/30/2023. d. The Director of Nursing/designee including the ADON/Weekend RN Supervisor will review the schedule daily and will train any agency nurses prior to the start of their shift on reviewing hospital discharge orders in the Documents tab of Matrix, transcribing orders to the admission orders in Matrix and reviewing these with the attending physician for approval. Completed 03/30/2023. e. The Director of Nursing/designee including the ADON/Weekend RN Supervisor will be trained by the Clinical Resource Nurse on the Clinical Morning Meeting and review of new admissions/readmissions to ensure hospital discharge orders are uploaded into the Documents tab, admitting orders are transcribed accurately and the physician has reviewed these and approved the orders. Completed 03/30/2023. f. The facility Medical Director and their providers will be trained by the Administrator on location of hospital discharge records in Matrix. Completed 03/30/2023. Quality Assurance Performance Improvement: On 03/30/2023 the Quality Assessment and Performance Improvement committee members to include, the Medical Director, Administrator, and Director of Nursing, Clinical Resource Nurse and Clinical Company Leader met to review and approve this plan. The Committee will meet weekly until the findings of immediate jeopardy are abated. The results of the Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Date of Correction: 03/30/2023. Plan of Removal verification included the following: Record review of facility training document, Staff Re-education, dated 03/30/2023, revealed, The charge nurse will review the orders with the physician on new and readmits. The charge nurse will enter the medications ordered by the physician in the electronic medical record. The ADON or designee will review previous medications for readmissions, hospital orders, and medication list to review that all medications ordered are listed . During an interview with ADON B on 03/30/2023 at 4:02 p.m., ADON B stated he had worked at the facility for four years, confirmed the facility provided an in-service training regarding medications and the admission/readmission process. ADON B stated that a nurse manager will double check all new admissions and readmits to ensure all hospital orders are entered correctly, the physician is notified, and that lab orders entered into the electronic medical records. As a nurse manager, ADON B stated he had given his personal phone number to all members of nursing staff and encouraged them to call him in the event they had a question with admissions or any other facility procedure. During interviews with fifteen members of nursing staff between 03/30/2023 at 4:36 p.m. and 03/31/2023 at 11:23 a.m., including agency staff, facility staff, LVNs, RNs, and nurse managers, all nursing staff members confirmed they had received the in-service training and were able to verbalize understanding of the training materials. The Administrator was informed the Immediate Jeopardy was removed on 03/31/2023 2:37 p.m. The facility remained out of compliance at actual harm that is not immediate jeopardy with a scope of a pattern until interventions were put in place to ensure residents' physician orders were accurately entered into the medical records system.

Based on observation, interview, and record review the facility failed to ensure licensed nursing staff had the appropriate competencies and skills set to provide nursing and related services to assure safety for 1 (Resident #1) of 3 residents reviewed catheterization. The facility did not ensure LVNs A and LVN B were trained to accurately read orders for catheterization prior to completing care. This failure could place residents who require catheterization at risk for infection, injury, or psychosocial harm. Findings included: Review of Resident #1's Face Sheet, dated 06/24/2022, revealed [AGE] year-old-male admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Order to Admit Patient to Hope Hospice dated 6/16/2022 revealed: Catheter Orders; 1. Patient to perform self-catheterization via navel w/ moderate assistance from staff 3x daily using aseptic technique. Interview on 06/24/2022 at 9:45 AM, Director of Nursing (DON) stated Resident #1 was admitted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON confirmed the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated he immediately started in-serving all nursing staff and ensured the order was correct and in place. DON stated he understands that the incorrect routing of a catheter could pose a health or safety risk to a resident due to improper care met. Interview on 06/24/2022 at 12:00 PM, LVN A stated she completed catheterization of Resident #1 via the penis during her day shift on 6/19/2022. LVN A said she was told by LVN B that there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A stated she did not question LVN B because she did not see a stoma (an opening in your belly's wall that a surgeon makes in order for waste to leave your body) and therefore assumed the route was via the penis. LVN A stated she had seen an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A stated she had been trained to review orders in the facility's computer program and she did prior to completing the catheterization however, she took the verbal directive of LVN B due to her saying there was an order and that she did not see a stoma. Interview on 06/24/2022 at 12:20 PM, LVN B stated she had completed catheterization of Resident #1 while working her shift on 6/19/2022. LVN B stated she routed the catheter through the resident's penis. LVN B said she checked the resident's orders prior to completing the catheterization and read order to use a 16 French catheter which is always routed through the male's penis. LVN B said she did not see the order requesting the routing to be within the resident's navel. LVN B stated she instructed LVN A to complete catheterization of Resident #1 through the penis due to the order calling for a 16 French catheter. Interview on 06/24/2022 at 12:40 PM, RN A stated she was preparing to complete catheterization on Resident #1 when she re-checked his orders against the Hospice orders and found it to be written wrong in their system. RN A stated she corrected the order in the system and completed the catheterization as ordered for Resident #1. RN A stated the incorrect order was entered by LVN C on 6/16/2022. Interview on 06/24/2022 at 1:00 PM, LVN C stated he entered the order for Resident #1's catheter based on verbal communication from Hospice RN (HRN) on 6/16/2022 the day he was admitted . LVN C stated the HRN told him the catheter was suprapubic (catheter inserted through a hole in the abdomen) so that it how he entered it. LVN C stated he did not write the order as being via the navel due to the lack of information provided by HRN. Review of facility in-service sign-in sheet for In & Out Catheterization - via navel dated 6/20/2022 revealed: All nursing staff have been trained on requirements for checking orders prior to implementation of catheterization. Review of Witness Statement dated 6/23/2022 revealed, LVN A stated, I had tried twice on Saturday evening @ around 530/pm to get urine output from resident. Attempted to obtain output threw [sic] the penis. Review of Witness Statement dated 6/24/2022 revealed, LVN B wrote, I knew he had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I perform in & out cath @ 103/am through the penis. Review of Witness Statement dated 6/24/2022 revealed, LVN C wrote. I wrote the order for suprapubic 16 FR Dx CKD, asst Res with S/P PRN. I did witness hospice nurse do in & out cath through stoma, suprapubic. Review of facility policy Suprapubic Catheter Care dated October 2010 revealed: Preparation. 1. Review the resident's care plan to assess for any special needs of the resident.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 24 (Resident # 20, 79, 115) reviewed for mitigation of Covid 19. Facility failed to isolate COVID-19 positive resident # 79 and #115 after they tested positive for COVID-19 and continued to cohort with 22 other negative residents on the women's secure unit. Resident # 79 (positive) and resident #20 (negative) were cohorting in the same room on the women's secure unit. Facility failed to change PPE in between working with COVID positive residents and COVID negative residents on the women's secure unit. An Immediate Jeopardy was identified on 01/19/22 while the IJ was removed on 1/21/22, the facility remained out of compliance at a severity level of potential for more than minimum harm and a scope of pattern because the facility was still monitoring the effectiveness of their plan of removal. These failures place residents at risk for exposure to COVID-19 which could result in serious illness, hospitalization , and or death. Findings included: During an interview on 01/19/22 at 10:32 AM with DON, he said they had 2 individuals (Resident #79, 115) that tested Covid positive on the women's secure unit. The residents were not moved because they were elopement risk, very aggressive, combative, and would barge through staff. He said they instead quarantined the entire unit. During an interview 01/19/22 at 1:18 PM LVN F of the women's secure unit stated There were two residents diagnosed with COVID on January 16th. Resident# 79 did have a roommate (Resident #20) who was negative. Record review of Resident #20 Admission MDS dated [DATE] revealed: A [AGE] year-old female admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . BIMS score of 4 meaning severe cognitive impairment. Record review of Resident #20 Progress Notes from 01/01/22 through 01/21/22 revealed no indication of resident testing positive for Covid 19. Record review of Resident #79 Quarterly MDS dated [DATE] revealed: A [AGE] year-old female admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . BIMS score of 3 meaning severe cognitive impairment. Record review of Resident #79 Progress Notes dated 01/16/22 revealed: Resident tested positive on rapid COVID-19, no emergency contact or family on file to notify. Safety precautions taken. Record review of Resident #115 Quarterly MDS dated [DATE] revealed: An [AGE] year-old female admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No BIMS score to identify cognition. Record review of Resident #115 Progress Notes dated 01/16/22 revealed: Resident tested positive on rapid COVID-19 test, called and informed emergency contact. Safety precautions taken. During observation 01/19/2022 at 9:01 AM of the women's secure unit, LVN F at med cart wearing KN95 mask, isolation gown and eye protection glasses distributing medication to residents. During observation 01/19/2022 at 9:02 AM of the women's secure unit, there were no residents wearing masks or social distancing. During an interview 01/19/2022 at 09:05, LVN F of the women's secure unit, states Resident #79 and Resident #115 were diagnosed with positive COVID and were allowed to come out of quarantine in the hallways as well as in the dining area. She also stated, although testing positive with 22 other negative residents, there was no way to keep them in their rooms. During observation 01/19/2022 at 09:30 AM of the women's secure unit, there were 14 residents(negative) in dining room with Resident #115(positive) sitting within 2 feet from other residents at the same table. During an observation 01/19/22 at 09:57 AM of the women's secure unit, CNA A and CNA E were doffing isolation gowns and gloves into overflowing trash of women's secure unit before entering door on hallway of co-ed secure unit with dining cart. During an interview on 01/19/22 at 10:32 AM with DON, he said they had 2 individuals (Resident #79, 115) that tested Covid positive on the women's secure unit. The residents were not moved because they were elopement risk, very aggressive, combative, and would barge through staff. He said they instead quarantined the entire unit. He said the residents didn't dig in the trash, but he expected that if the trash were full it should go right out to the dumpster because there was 1 nurse and 2 aides on that unit. He said that all the residents on the women's secure unit were being monitored for signs/symptoms of Covid 19, 1 time a day. The facility was not testing for Covid 19 at that time due to emergency shortage of testing supplies. DON said they had letter from their local health department to only test symptomatic residents and staff at that time. They had just received an emergency supply of testing supplies from TX HHSC and were continuing to use the recommendation of testing only if symptomatic. During an observation on 01/19/22 at 1:10 PM of the women's secure unit, Resident# 115 (positive) walking from dining area, walking up and down hallway looking for her room. During an observation on 01/19/22 at 1:15 PM of the women's secure unit, Resident #20(negative) leaving room [ROOM NUMBER] while Resident #79 (positive) walking from dining hall to the same room. During an interview 01/19/22 at 1:18 PM LVN F of the women's secure unit stated There were two residents diagnosed with COVID on January 16th. Resident# 79 did have a roommate (Resident #20) who was negative, they kind of stay apart. I am waiting till the COVID goes back to zero and will then change residents around. During observation 01/19/2022 at 1:37 PM of the women's secure unit, LVN F wearing KN95, isolation gown, protection glasses and walked into Rm 32, where Resident# 79 (positive) was located, to answer call light. There was no change of PPE, or hand hygiene done. There was no hand sanitizer inside the resident's room. During observation 01/19/22 at 2:10 PM signage on door to the women's secure unit states quarantine area. During an interview on 01/19/22 at 02:55 PM with the DON, Asst adm, the Assistant ADM said they did not have the staffing to do get private sitters for the 2 women (Resident #79, 115) that tested positive on the women's secure unit at that time. DON said they had been treating the entire women's secure unit as Covid positive, wearing the same ppe, letting them all have their time with activities and dining. Asst ADM said if they would have made the 2 positives(Resident #79, 115) roommates then they would have been fighting and then that would have caused facility to have self-reports for hitting each other, so they had to keep in mind their safety and rights. Record review of facility policy labeled Infection Prevention and Control Program revised 10/2020 revealed: An Infection Prevention and Control Program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Each center should refer to and follow CDC guidance and their state guidance for Infection Prevention and Control. Texas Health and Human Services, COVID-19 Response for Nursing Facilities most current version, should be referred to and followed by centers located in the state of Texas .The program is based on accepted national infection prevention and control standards. The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of infection prevention and control program consists of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety . Outbreak management is a process that consists of: determining the presence of an outbreak; managing the affected residents; preventing the spread to other residents; documenting information about the outbreak; reporting the information to the appropriate public health authorities; educating the staff and the public; monitoring for reoccurrences; reviewing the care after the outbreak has subsided; and recommending newer revised policies to handle similar events in the future . The medical staff will help the facility comply with pertinent state and local Regulations concerning the reporting and management of those with reportable communicable diseases. Prevention of Infection. Important facets of infection prevention include: identifying possible infection or potential complications of existing infections; instituting measures to avoid complications or dissemination; educating staff and ensuring they adhere to proper techniques and procedures; communicating the importance of standard precautions and cough etiquette to visitors and family members; enhancing screening for possible significant pathogens; immunizing residents and staff to try to prevent illness; implementing appropriate isolation precautions when necessary; and following established general and disease specific guidelines such as those of the Centers for Disease control. Record review of CDC guidance labeled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2(Covid 19) Spread in Nursing Homes accessed on 02/03/22 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed: Even as nursing homes resume normal practices, they must sustain core IPC practices and remain vigilant for [CONDITION(S)]-CoV 2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death . Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom . Only patients with the same respiratory pathogen should be housed in the same room . Limit transport and movement of the patient outside of the room to medically essential purposes . HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The Administrator was notified on 01/19/22 at 3:16 PM an IJ situation was identified due to the above failures and an IJ template was provided. The Plan of Removal was accepted on 01/19/22 at 5:35 PM and reflected: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on January 19th, 2022. Definitions: Cold rooms/areas: Residents that have not been exposed to COVID-19, testing negative on outbreak testing, and are not symptomatic. Warm rooms/areas: Residents with an unknown COVID status (new admissions that are not vaccinated), residents that have been exposed to COVID but are testing negative, symptomatic residents that are continuing to test negative. Hot rooms/areas: Confirmed COVID-19 positive. Identified Concern: The facility's failure to isolate positive and follow recommended infection control practices placed 22 negative residents at risk of contracting the COVID19 virus which could result in serious illness, hospitalization , and/or death. The facility has been granted permission from the Local Health Department and DSHS to only test those residents that exhibit signs and symptoms due to the shortage in testing kits across the nation. In the event, that a patient test positive soon we will immediately isolate the resident to avoid further infection of residents. 1. Immediate Action: COVID positive residents will be identified through outbreak testing. The facility has been granted permission from the Local Health Department and DSHS to only test those residents that exhibit signs and symptom. (Please see attachment) Staff continues to check patients' temps and assess patients for signs and symptoms daily for COVID-19. 2 residents that tested positive have been isolated to our hot zone and will be rooming together in room [ROOM NUMBER]. Patients were moved at 3:46pm on 01/19/2022. Facility staff and a local sitter agency will provide 1-1 monitoring as patients are an elopement risk and suffer from severe cognitive impairment. 2. Immediate Action: Designated hot, warm, and cold zones, in which will be labeled with the signage in which is outlined below. Staff will redirect residents to their perspective areas that coincide with their COVID-19 status. COVID-19 positive residents will not be in common areas, they will reside in the hot unit/hot rooms, with meaningful separation from the warm and cold residents. Warm residents will have meaningful separation from cold residents, as well. All COVID positive residents will be moved to the designated hot zone. o Completed 01/19/2022 by Director of Nurses and QAPI Nurse Manager 3. Immediate Action: Current available staff does not allow for dedicated staff for the hot, warm, cold areas. Center is attempting to recruit staff, has reached out to staffing agencies, and is filling out the appropriate forms to request HHSC's assistance with staffing. Facility staff and a local sitter agency will provide 1-1 monitoring as patients are an elopement risk and suffer from severe cognitive impairment. In the event, that the facility and local sitter agency is unable to provide staffing the facility will designate a portion of the secured women's unit as hot, and have designated staff for those residents. Completed 01/19/2022 by Administrator, Director of Nurses, QAPI Nurse Manager 4. Immediate Action: Ensure there is proper PPE to include: gowns, N-95, surgical masks, and eye protection outside of the hot and warm rooms/unit. Ensure there are receptacles in each warm room so employees can doff between caring for warm residents. Ensure there are receptacles available for doffing outside hot unit and hot rooms. o Administrator, DON, and/or designee will observe PPE bins outside of residents in warm and hot areas to ensure proper PPE is available every shift. o Completed: (01/19/2022) 6. Immediate Action: Ensure proper CDC signage is outside of each hot and warm room regarding the PPE donning and doffing and appropriate PPE attire, which includes: gown, N-95, and eye protection. Ensure door/COVID positive area is indicated via signage and floor tape. o Administrator, DON, and/or designee to round center once a day to ensure appropriate signage is in place to indicate warm and hot areas. o Completed: (01/19/2022) 7. Immediate Action: Ensure staff is educated prior to working their next shift on: cohorting/separating COVID positive, COVID unknown, and COVID negative residents. Ensure staff is educated on proper PPE, when to don and doff and how to properly don and doff. Ensure staff is educated on physical distancing. Initiated on 01/19/2022 and will be completed on 01/25/2022 due to rotating shifts with nursing, dietary, therapy, and housekeeping staff. Staff responsible for completing education is Director of Nurses, QAPI Nurse Manager, and Nurse Management Team. o Staff will show return demonstration regarding proper hand hygiene - o Staff will show return demonstration regarding donning and doffing o Staff will show competency by completing a test o Staff currently in house completed (01/19/2022) and will continue prior to employee's shifts until 100% compliant. 8. Immediate Action: Ensure staff working in COVID positive area/rooms are doffing PPE before leaving room/area to work with residents in warm or cold areas. Ensure staff is donning and doffing PPE after working with each warm resident, for their status is unknown, in the receptacles in the warm/hot residents' rooms which will prevent other residents from coming into contact with the discarded PPE. o Random rounds to be completed by DON, administrator or designee in warm/hot zones to ensure staff is properly doffing when exiting area, to be completed every shift for 5 days to ensure substantial compliance. o DON, administrator or designee in warm/hot zones to ensure staff is performing proper hand hygiene when exiting area, to be completed every shift for 5 days to ensure substantial compliance. o Completed: (01/19/2022) and continued monitoring to ensure compliance. Staff responsible for ensuring compliance is Director of Nurses, QAPI Nurse Manager, and Nurse Management Team. 9. Immediate Action: Educate residents on physical distancing, encourage residents to stay in their rooms, and redirect residents regarding physical distancing (staff responsible for education will be Director of Nurses, QAPI Nurse Manager, Nurse Management Team and Social Services). MDS coordinators have updated all residents care plans to reflect the importance of physical distancing, encourage residents to stay in their rooms, and redirect residents regarding physical distancing. Facility staff is aware that attempting to educate dementia and Alzheimer's residents on the importance of social distancing may be unsuccessful due to our residents exhibiting severe cognitive impairment. Facility will supplement education, with activities that promotes and allows for social distancing. Facility will promote and provide small group activities where residents who participate can be equally spaced 6 feet apart. Facility will also promote and provide individualized activities that allows residents to complete in their rooms to promote social distancing. o Initiated on 01/19/2022 and continued monitoring to ensure compliance. Staff responsible to ensure compliance is Director of Nursing, QAPI Nurse Manager, Nurse Management Team, and Social Services. 10. Immediate Action: ADHOC QAPI meeting performed with medical director, completed 01/19/2022. Informed medical director of immediate jeopardy and read through POR. Medical director has no other suggestions at this time. 11. Center will review education, competencies, test results, PPE and signage rounds, during their upcoming QAPI meeting, and as needed thereafter. Should facility see failures in our efforts noted above, the facility will provide ongoing education to staff, residents, family members, and visitors. In addition, facility will conduct ADHOC meetings to assess, identify, and correct areas of deficiency and failures. Staff responsible for review of education, competencies, test results, PPE and signage rounds is the Director of Nurses, QAPI Nurse Manager, Nurse Management Team, Administration. Our next QAPI meeting is scheduled for February 10, 2022. Verification During an observation on 01/19/22 at 3:45PM, Resident #79 and #115 were moved to the Covid unit hot zone by DON and CNA E. Both residents were wearing surgical masks and isolation gowns during the transfer from the women's secure unit to the Covid unit. During an interview on 01/19/22 at 03:55 PM ADM wanted to verify that they moved both resident #79 and #115 from the women's locked unit to the Covid unit. During an observation on 01/19/22 at 4:10PM of the women's secure unit, all remaining 22 residents were tested with a negative result. During an observation on 01/19/22 at 4:45PM, the Covid unit had double doors that were closed that had signage to Stop See Nurse's Station, through the double doors there is an area with red tape on the floor with PPE storage unit that housed face shields, N95 masks, isolation gowns, vinyl gloves and ABHR. Signage on wall indicated the PPE used and steps for donning/doffing PPE. The exit door at end of hallway had a trash can with lid operated by foot with signage to discard used PPE with signage of how to doff steps on it and a table with ABHR. During an interview on 01/20/2022 at 8:50 AM with CMA A, she stated, We had in-services this morning for hand hygiene, COVID residents, Call lights, locking med carts, donning, and doffing PPE. During an interview on 01/20/22 at 8:55 AM with CNA A, she stated, I had in-service yesterday on PPE, COVID, hand hygiene, and COVID unit. During an interview on 01/20/22 at 9:00 AM with LVN B, she stated, I had in-services yesterday before I left on hand washing, PPE, donning and doffing of PPE, Isolation hall on what can go in and out of that hall. During an interview on 01/20/22 at 2:30 PM with CNA D she stated, I had in-services on donning and doffing PPE, COVID unit and hand hygiene. I have 2 residents that are COVID positive and they are in a room together with a sitter. When I go in there, I wear n95 mask, gown gloves and face shield. I take my gown and gloves off in the room and place them in yellow bag in a box in the room as I leave. During an observation on 01/20/22 at 06:28 PM, there were 2 COVID 19 positive residents on men's unit, residents in room together with a sitter in the room. Stop see nurse sign is on the door along with instructions on how to don and doff PPE. During an interview on 01/21/22 at 08:20 AM with CNA B, she stated, We had ab out 5 in-services. Infection Control, donning and doffing PPE, Safety in isolation area, Resident Rights, and hand hygiene. we do not have any COVID positive residents on this unit (CO_ED HALL). I wear n95 mask every day. During an interview on 01/21/22 at 08:22 AM with CMA B, she stated, I had in-service on hand hygiene, PPE, COVID. We have extra mask and gowns in the office. During an interview on 01/21/22 at 08:35 AM with LVN E, she stated, Had in-service on hand hygiene, call lights, PPE and I know more but can't think right now. Observed LVN E reminding resident to put on mask when in hallway. During an interview on 01/21/22 at 08:40 AM with CNA C, she stated, I have had in-services on hand hygiene, PPE, call lights, can't remember others. When I go on the COVID unit I wear gloves, gown, goggles, n95 mask. I take off my gown and gloves before I leave the room and put them in the box. During an observation/interview on 01/21/22 at 09:13 AM, the PPE cart prior to the entrance of COVID unit was fully stocked . PPE was also in 3 small carts located down the hall outside of resident rooms fully stocked. There were 2 closets with PPE located on the COVID unit, 2 small carts with PPE located outside of residents room on the men's unit fully stocked, PPE in treatment nurse office, PPE at front desk, PPE in QA nurse office, and shed in back with PPE. QA nurse says that she keeps PPE in her office also. She goes to the shed every morning and restocks the entire building. During an observation/interview on 01/21/22 at 09:15 AM, RN B was donning PPE and entering the COVID unit appropriately. Nurse rolled cart to each room and passed out meds. Observed DON sanitizing handrails in the COVID unit. 1 resident (no longer positive) leaving COVID unit going back to her room. Observed DON sanitized her wheelchair and her medications where in a plastic bag. Resident was wheeled to the line by the DON then the QA nurse took her off the unit. Resident had mask on. Observed DON doffing and exiting the back door. RN B states that she was in-serviced on proper PPE, donning and doffing, locking med carts, and hand hygiene on Wednesday 01/19/2022. During an observation/interview on 01/21/22 at 09:20 AM CNA C donning PPE to enter COVID unit appropriately. She said she was in-serviced on donning and doffing PPE and hand hygiene on Wednesday 01/19/2022. During an interview on 01/21/22 at 09:29 AM RN A said that she was in-serviced on handwashing, donning, and doffing on Wednesday 01/19/2022. Record review of resident testing of women's secure unit dated 01/19/22 revealed: 22 residents tested negative for Covid 19. Record review of resident Care Plans for residents of the women's secure unit dated 01/20/22 revealed updated Covid 19 risk factors with goals and interventions that included monitoring for signs/symptoms, social distancing, isolating as needed, following CDC/federal/state/local health department guidelines. Record review of inservice labeled How to Properly Don and Doff Infection Control dated 01/19/22 revealed numerous staff signatures verifying comprehension from many different departments, shifts. Record review of facility inservice labeled Importance of Charting/Separating Covid positive, Covid unknown, Covid negative residents dated 01/19/22 revealed numerous staff signatures verifying comprehension from many different departments, shifts. Record review of facility inservice labeled Importance of Social Distancing-Everyone must continue to social distance-best practice for staff/residents dated 01/19/22 revealed numerous staff signatures verifying comprehension from many different departments, shifts. Record review of facility inservice labeled Covid hall/Hand hygiene-Clean side before the [NAME] on B hall-once you cross over red line you can only exit through back door-flows like a river in direction-make sure you perform hand hygiene before and after dated 01/20/22 revealed numerous staff signatures verifying comprehension from many different departments, shifts. Record review of facility inservice labeled Social Distancing-Promote social distancing, Promote small group activities, Promote individualized activities dated 01/21/22 revealed numerous staff signatures verifying comprehension from many different departments, shifts. Record review of facility inservice labeled Infection Control-One to One presentation/demonstrate/return demonstration dated 01/20/22 revealed numerous staff signatures verifying comprehension from many different departments. Record review of facility electronic mail (email) communication with Public Health Department dated 01/11/22 revealed local Public health epidemiologist recommendation that they go to testing only symptomatic residents and staff with the few that they have left. Record review of facility communication LTCR form 2198 dated 01/07/22 revealed an emergency request for Binax card testing supplies to Texas Health and Human Resources with a request of 460 cards per week for 3 weeks. Record review of facility communication dated 01/10/22 revealed Please be aware that STRAC has currently dispensed all the Binax COVID tests in our inventory. Due to supply chain issues and ongoing federal purchases, Texas is unable to get resupplied. The Administrator was informed the IJ was removed on 01/21/22 at 12:50 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal.

Based on observations, interviews and record reviews the facility failed to ensure that 1 of 3 residents (Resident #1) whose care was reviewed received treatment and care in accordance with professional standards of practice in that: LVN A did not consult with the physician when Resident #1 was having emesis, profusely sweating refused to eat and remained in bed for two days (when he usually was an active person), Resident # 1 became unresponsive the following day, required cardiopulmonary resuscitation and expired at the hospital. This deficient practice could affect and place residents at risk of not receiving necessary medical intervention from their physician. The findings were: Review of Resident #1's Face Sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Annual MDS dated [DATE] revealed Resident #1 had a BIMS of 3 (severe cognitive impairment). Further review of MDS revealed no wandering behavior exhibited. Resident #1 was able to perform own Activities of Daily Living required supervision with dressing, eating and personal hygiene. Review of Resident #1's care plan revised [DATE] revealed Resident #1 had behavior symptoms as evidenced by wandering related to dementia. Resides in secure unit and is at risk for falls and injury due to unawareness of safety. Observe my location with visual checks at least every two hours and record percentage of breakfast, lunch and dinner eaten. Further review of care plan revealed Resident #1 was on antibiotics for UTI and was at risk for adverse reactions with interventions to monitor for increased temp, dehydration, pain, discomfort, etc.- report to physician. Care plan further revealed Resident #1 was at nutritional risk and dehydration due to advanced age and confusion, increase energy expenditure secondary to frequent ambulation. Monitor for changes in nutritional status (changes in intake, ability to feed self ) and report to physician. Review of Resident #1's physician progress notes [REDACTED].#1 resided on the secured unit for exit seeking, wandering and safety concerns. Resident #1 was ambulatory, confused and was observed during this visit outside with two pairs of pants on and a brief stuffed up the leg. Nursing reported Resident #1 was becoming more incontinent of bowel and bladder getting urinalysis and culture and sensitivity. Nursing further reports more agitation. Review of Resident #1's nursing progress note dated [DATE] at 1:39 pm revealed Resident #1 continued on antibiotics for urinary tract infection no signs and symptoms of distress, even unlabored respirations. Review of Resident #1's nursing progress note dated [DATE] at 5:04 am revealed Resident #1 continues on antibiotics twice a day for urinary tract infection. Today is day 10 of 10 with no adverse reactions. Taking fluids but not as much as he should. Review of Resident #1's facility activity report dated [DATE]-[DATE] revealed: No documentation of breakfast or lunch consumed on [DATE] On [DATE] at 9:14 pm ate ,[DATE]% of dinner On [DATE] at 9:15 pm Resident #1 did not have a bedtime snack. No documentation of meal intakes noted for [DATE]. Review of the hospital admission report revealed Resident #1 was admitted on [DATE] at 5:09 pm. He had no pulse and Emergency Medical Services (EMS) was called and Cardiopulmonary Resuscitation (CPR) was started. Resident #1 was down for about 2 minutes and was intubated by EMS. CPR was performed for 20 minutes. It was unclear if Resident #1 experienced a Cardiac event or [MEDICAL CONDITIONS]. The family withdrew care and the pressors were stopped and patient was terminally extubated on (MONTH) 19, 2019 at 7:01 pm. Interview with CNA C on [DATE] at 10:00 am revealed she was on break between 9:00 am and 10:00 am on [DATE]. CNA C stated Resident #1 routinely walked outside to the locked patio attached to the secured unit and he always wore his [NAME]et. CNA C stated she could not recall if she had informed the agency nurse that she was on break between ,[DATE] am on [DATE]. CNA C stated Resident #1 would walk out into the patio daily and re-enter the facility on his own. Resident #1 was among the residents who were monitored because he liked to walk around. During further interview CNA C stated she returned after her break on [DATE] and assisted CNA B with changing Resident #1's clothing and was asked if she knew how long Resident #1 had been outside. CNA C replied she was on break and did not know how long Resident #1 had been outside. CNA C stated Resident #1 remained in his room and had a large bowel movement that required her to bed bath the resident. Resident #1 remained in bed and had lunch delivered to his room. CNA C further revealed she could not recall the time of his bed bath and was not monitoring Resident #1 between 9:00 a.m. and 10:00 a.m. because she was on break. CNA C stated Resident #1 did not go to the dining room for his lunch on [DATE]. He ate his lunch in his room. CNA C stated she could not recall if she had documented the intake for Resident #1 and further stated she left at 2:00 pm and Resident #1 remained in bed. Interview with CNA B on [DATE] at 1:44 pm revealed Resident #1 was observed to be sitting outside in the patio of the secured unit between 9:00 am and 10:00 am on [DATE]. Resident #1 was not supervised and was observed from the window located in the dining area in the secure unit. CNA B stated she looked for CNA C and did not find her. She went outside and found Resident #1 was sitting outside with a [NAME]et on and was slightly slanted to one side. CNA B further revealed she was not aware of how long Resident #1 had been sitting outside. During further interview CNA B stated she went outside to help and re-direct Resident #1 back into the unit when she discovered Resident #1 had vomited. Resident #1 was sweating and having difficulty standing. CNA B stated LVN A directed her to take him to his room and have him cleaned up. CNA B stated she removed his [NAME]et, provided drinking water and changed out his clothes. LVN A assessed him, and CNA B went to the kitchen and requested a sandwich and fruit drink for Resident #1. He ate in his room. She could not recall the amount of his intake and could not recall if she had documented the snack meal. CNA B stated she did not know if Resident #1 ate dinner on [DATE]. CNA B stated she did not know if his dinner meal was delivered to his room. He remained in bed when she left at 6:00 pm. CNA B stated that on [DATE], Resident #1 wanted to stay in bed and LVN A asked they get him up for breakfast. Resident #1 refused breakfast and the agency nurse asked the kitchen to provide Resident #1 with warm soup and other fluids that she could not recall. CNA B stated a wheelchair was used to take Resident #1 to the dining room. CNA B stated that she was not in the facility when Resident #1 was taken by EMS to the hospital. She took her lunch break from 2:00 pm to 3:00 pm. CNA B stated the agency nurse assisted Resident #1 with his soup. Resident #1 did not require assistance with his meals, but LVN A wanted to encourage him to eat. Interview with LVN A on [DATE] at 2:14 pm revealed CNA B informed her Resident #1 had been sitting outside on the patio. CNA B informed her, Resident #1 had thrown up and did not know how long he had been outside. LVN A stated Resident #1 was ambulatory and paced throughout the unit and outside patio. During further interview LVN A stated Resident #1 was moved into his room and she requested CNA B to change out his clothes. LVN A stated Resident #1 was wearing a [NAME]et, was sweating heavily, appeared confused and unsteady on his feet. LVN A stated Resident #1 was assessed and he was warm to the touch. LVN A helped CNA B get him to his room and assessed him. Resident #1 complained about pain to his stomach, cramping and experienced episodes of loose stools. Bowel movement was everywhere. CNA C gave Resident #1 a bed bath. CNA B went to the kitchen and got him a sandwich and cranberry juice. His fluid intake was encouraged with assistance from staff throughout the day. Resident #1 stayed in his room for lunch. Resident #1 declined dinner on [DATE]. LVN A stated on [DATE] Resident #1 did not want to get up from bed and have breakfast in the dining room. She asked the CNAs to help him up with the use of a wheel chair and bring him to the dining room. LVN A stated she asked the kitchen to prepare soup for Resident #1, LVN A assisted him with his meal. LVN A stated Resident #1 was observed starting to slump over in the wheel chair. LVN A stated she found a faint pulse in the carotid artery. Resident #1 was rolled into his room in the wheel chair. Resident #1 was unresponsive and laid on the floor when LVN A found no pulse. Resident #1 was a full code and LVN A started CPR. The charge nurse called EMS. LVN A stated Resident # 1 was transported by EMS and later expired in the hospital. The surveyor asked if LVN A had contacted Resident #1's physician at any time to inform him of the resident's change to condition. LVN A confirmed she had not notified the physician, because she felt she was treating him accordingly. Interview with the Weekend Supervisor on [DATE] at 10:51 am revealed LVN A did not inform him of Resident #1's condition. The Weekend Supervisor further revealed LVN A should have called to report Resident #1 was found outside, sweating profusely with unsteadiness to standing to the physician and confirmed there was a change to condition in Resident #1 that should have been communicated to his physician when he remained in bed and continued to refuse his meals. Interview attempted with the physician for Resident #1 on [DATE] at 5:44 pm and [DATE] at 11:34 am regarding Resident #1's change of condition. The physician did not return the phone call. Review of Resident #1's nursing progress notes from [DATE] and [DATE] revealed no documentation of Resident #1 being found outside in the patio, vomiting and slumped over on [DATE]. Review of weather history for that area revealed temperature on [DATE] at 8:56 am was 78 degrees 87% humidity overcast and at 9:56 am temperature was 81 degrees 79% humidity mostly cloudy retrieved from https://www.timeanddate.com/weather/@ 1/historic?month=5&year=2019. Review of the facility policy titled: Change in a Resident's Condition or Status revealed the nurse will notify the resident's attending physician or physician on call when 4. (b). there a significant change in the resident's physical, mental, or psychosocial status; .(e) it is necessary to transfer the resident to a hospital/treatment center 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted . Record review of Texas Board of Nurses Standard of Nursing Practice Rule 217.11 revealed (1) Standard applicable to all Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and confirm to the Texas Nursing Practice Act and the board's rules and regulations as well as federal, state or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices . (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications. retrieved from http://www.bon.texas.gov/rr_current/,[DATE].asp.

Based on interview and record review, the facility failed to consult the physician when 1 of 3 residents (Resident #1) experienced a significant change in the resident's physical, mental, or psychosocial status : LVN A did not consult with the physician when Resident #1 was having emesis, profusely sweating, refused to eat and remained in bed for two days (when he usually was an active person.) Resident #1 became unresponsive the following day, required cardiopulmonary resuscitiation and expired at the hospital. This deficient practice could affect and place residents at risk of not receiving necessary medical intervention from their physician. The findings were: Review of Resident #1's Face Sheet dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Annual MDS dated [DATE] revealed Resident #1 had a BIMS of 3 (severe cognitive impairment). Further review of MDS revealed no wandering behavior exhibited. Resident #1 was able to perform own Activities of Daily Living required supervision with dressing, eating and personal hygiene. Review of Resident #1's care plan revised [DATE] revealed Resident #1 had behavior symptoms as evidenced by wandering related to dementia. Resides in secure unit and is at risk for falls and injury due to unawareness of safety. Observe my location with visual checks at least every two hours and record percentage of breakfast, lunch and dinner eaten. Further review of care plan revealed Resident #1 was on antibiotics for UTI and was at risk for adverse reactions with interventions to monitor for increased temp, dehydration, pain, discomfort, etc.- report to physician. Care plan further revealed Resident #1 was at nutritional risk and dehydration due to advanced age and confusion, increase energy expenditure secondary to frequent ambulation. Monitor for changes in nutritional status (changes in intake, ability to feed self ) and report to physician. Review of Resident #1's physician progress notes [REDACTED].#1 resided on the secured unit for exit seeking, wandering and safety concerns. Resident #1 was ambulatory, confused and was observed during this visit outside with two pairs of pants on and a brief stuffed up the leg. Nursing reported Resident #1 was becoming more incontinent of bowel and bladder getting urinalysis and culture and sensitivity. Nursing further reports more agitation. Review of Resident #1's nursing progress note dated [DATE] at 1:39 pm revealed Resident #1 continued on antibiotics for urinary tract infection no signs and symptoms of distress, even unlabored respirations. Review of Resident #1's nursing progress note dated [DATE] at 5:04 am revealed Resident #1 continues on antibiotics twice a day for urinary tract infection. Today is day 10 of 10 with no adverse reactions. Taking fluids but not as much as he should. Review of Resident #1's facility activity report dated [DATE]-[DATE] revealed: No documentation of breakfast or lunch consumed on [DATE]. On [DATE] at 9:14 pm ate ,[DATE]% of dinner. On [DATE] at 9:15 pm Resident #1 did not have a bedtime snack. No documentation of meal intakes noted for [DATE]. Review of the hospital admission report revealed Resident #1 was admitted on [DATE] at 5:09 pm. He had no pulse and Emergency Medical Services (EMS) was called and Cardiopulmonary Resuscitation (CPR) was started. Resident #1 was down for about 2 minutes and was intubated by EMS. CPR was performed for 20 minutes. It was unclear if Resident #1 experienced a Cardiac event or [MEDICAL CONDITIONS]. The family withdrew care and the pressors were stopped and patient was terminally extubated on (MONTH) 19, 2019 at 7:01 pm. Interview with CNA C on [DATE] at 10:00 am revealed she was on break between 9:00 am and 10:00 am on [DATE]. CNA C stated Resident #1 routinely walked outside to the locked patio attached to the secured unit and he always wore his [NAME]et. CNA C stated she could not recall if she had informed the agency nurse that she was on break between ,[DATE] am on [DATE]. CNA C stated Resident #1 would walk out into the patio daily and re-enter the facility on his own. Resident #1 was among the residents who were monitored because he liked to walk around. During further interview CNA C stated she returned after her break on [DATE] and assisted CNA B with changing Resident #1's clothing and was asked if she knew how long Resident #1 had been outside. CNA C replied she was on break and did not know how long Resident #1 had been outside. CNA C stated Resident #1 remained in his room and had a large bowel movement that required her to bed bath the resident. Resident #1 remained in bed and had lunch delivered to his room. CNA C further revealed she could not recall the time of his bed bath and was not monitoring Resident #1 between 9:00 a.m. and 10:00 a.m. because she was on break. CNA C stated Resident #1 did not go to the dining room for his lunch on [DATE]. He ate his lunch in his room. CNA C stated she could not recall if she had documented the intake for Resident #1 and further stated she left at 2:00 pm and Resident #1 remained in bed. Interview with CNA B on [DATE] at 1:44 pm revealed Resident #1 was observed to be sitting outside in the patio of the secured unit between 9:00 am and 10:00 am on [DATE]. Resident #1 was not supervised and was observed from the window located in the dining area in the secure unit. CNA B stated she looked for CNA C and did not find her. She went outside and found Resident #1 was sitting outside with a [NAME]et on and was slightly slanted to one side. CNA B further revealed she was not aware of how long Resident #1 had been sitting outside. During further interview CNA B stated she went outside to help and re-direct Resident #1 back into the unit when she discovered Resident #1 had vomitted. Resident #1 was sweating and having difficulty standing. CNA B stated LVN A directed her to take him to his room and have him cleaned up. CNA B stated she removed his [NAME]et, provided drinking water and changed out his clothes. LVN A assessed him, and CNA B went to the kitchen and requested a sandwich and fruit drink for Resident #1. He ate in his room. She could not recall the amount of his intake and could not recall if she had documented the snack meal. CNA B stated she did not know if Resident #1 ate dinner on [DATE]. CNA B stated she did not know if his dinner meal was delivered to his room. He remained in bed when she left at 6:00 pm. CNA B stated that on [DATE], Resident #1 wanted to stay in bed and LVN A asked they get him up for breakfast. Resident #1 refused breakfast and the agency nurse asked the kitchen to provide Resident #1 with warm soup and other fluids that she could not recall. CNA B stated a wheelchair was used to take Resident #1 to the dining room. CNA B stated that she was not in the facility when Resident #1 was taken by EMS to the hospital. She took her lunch break from 2:00 pm to 3:00 pm. CNA B stated the agency nurse assisted Resident #1 with his soup. Resident #1 did not require assistance with his meals, but LVN A wanted to encourage him to eat. Interview with LVN A on [DATE] at 2:14 pm revealed CNA B informed her Resident #1 had been sitting outside on the patio. CNA B informed her, Resident #1 had thrown up and did not know how long he had been outside. LVN A stated Resident #1 was ambulatory and paced throughout the unit and outside patio. During further interview LVN A stated Resident #1 was moved into his room and she requested CNA B to change out his clothes. LVN A stated Resident #1 was wearing a [NAME]et, was sweating heavily, appeared confused and unsteady on his feet. LVN A stated Resident #1 was assessed and he was warm to the touch. LVN A helped CNA B get him to his room and assessed him. Resident #1 complained about pain to his stomach, cramping and experienced episodes of loose stools. Bowel movement was everywhere. CNA C gave Resident #1 a bed bath. CNA B went to the kitchen and got him a sandwich and cranberry juice. His fluid intake was encouraged with assistance from staff throughout the day. Resident #1 stayed in his room for lunch. Resident #1 declined dinner on [DATE]. LVN A stated on [DATE] Resident #1 did not want to get up from bed and have breakfast in the dining room. She asked the CNAs to help him up with the use of a wheel chair and bring him to the dining room. LVN A stated she asked the kitchen to prepare soup for Resident #1, LVN A assisted him with his meal. LVN A stated Resident #1 was observed starting to slump over in the wheel chair. LVN A stated found a faint pulse in the carotid artery. Resident #1 was rolled into his room in the wheel chair. Resident #1 was unresponsive and laid on the floor when LVN A found no pulse. Resident #1 was a full code and LVN A started CPR. The charge nurse called EMS. LVN A stated Resident # 1 was transported by EMS and later expired in the hospital. The surveyor asked if LVN A had contacted Resident #1's physician at any time to inform him of the resident's change to condition. LVN A confirmed she had not notified the physician, because she felt she was treating him accordingly. Interview with the Weekend Supervisor on [DATE] at 10:51 am revealed LVN A did not inform him of Resident #1's condition. Weekend Supervisor further revealed LVN A should have called to report Resident #1 was found outside, sweating profusely with unsteadiness to standing to the physician and confirmed there was a change to condition in Resident #1 that should have been communicated to his physician when he remained in bed and continued to refuse his meals. Interview attempted with the physician for Resident #1 on [DATE] at 5:44 pm and [DATE] at 11:34 am regarding Resident #1's change of condition. The physician did not return the phone call. Review of Resident #1's nursing progress notes from [DATE] and [DATE] revealed no documentation of Resident #1 being found outside in the patio, vomiting and slumped over on [DATE]. Review of weather history for that area revealed temperature on [DATE] at 8:56 am was 78 degrees 87% humidity overcast and at 9:56 am temperature was 81 degrees 79% humidity mostly cloudy retrieved from https://www.timeanddate.com/weather/@ 1/historic?month=5&year=2019. Review of the facility policy titled: Change in a Resident's Condition or Status revealed the nurse will notify the resident's attending physician or physician on call when 4. (b). there is a significant change in the resident's physical, mental, or psychosocial status; .(e) it is necessary to transfer the resident to a hospital/treatment center 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted .

Based on observation, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to make sure the walk-in refrigerator was maintaining a temperature at 41 degrees Fahrenheit or below for over 3 hours. The facility continued to store and use food in the malfunctioning walk-in during the time that it was not maintaining the appropriate temperature. The facility's Dietary District Manager wanted food items that had been in the malfunctioning walk-in for 3 hours that registered at above 50 degrees Fahrenheit kept and put on ice. Record review of the Texas Food Establishment Rules, (MONTH) (YEAR), §228.75(f)(1)(B) Except during preparation, cooking 2. The facility failed to take a temperature of milk before serving to residents to make sure it was at an appropriate temperature. 3. The Maintenance Director failed to monitor monthly the functioning and performance of the walk-in refrigerator as per facility policy. 4. The walk-in refrigerator had a container with lid of peaches stored without an opened or use-by date and opened clear plastic bag of meatballs in walk-in refrigerator without label or use-by or opened date. 5. Opened package of sausage in freezer was not air-tight. 6. The facility failed to ensure the sanitizer dispenser on the dishwasher was working properly to sanitize the dishes. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:16 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of widespread because the facility was still monitoring the Plan of Removal. These deficient practices could place residents, who received meals from the main kitchen, at risk for foodborne illness. The findings were: 1. Observation with the FSS on [DATE] at 9:40 a.m., revealed the thermometer inside the walk-in refrigerator registered at 52 degrees Fahrenheit. Interview with the FSS on [DATE] at 9:40 a.m., confirmed the thermometer inside of the walk-in refrigerator was at 52 degrees Fahrenheit, but revealed that they got in a shipment today at 6:30 a.m., that took them a while to put up and may have affected the temperature inside the walk-in. The FSS revealed that the staff took the temperature of the walk-in refrigerator when they came in before the shipment arrived and it was at 38 degrees Fahrenheit. Record review of the facility Walk-In Refrigerator Temperature Log revealed the temperature of the unit is taken in the AM and PM. The record also revealed the temperatures recorded revealed the walk-in refrigerator was 41 degrees or below for [DATE]- [DATE]. Observation and interview on [DATE] at 10:05 a.m., revealed in the Walk-in fridge there were two thermometers that read 52 degrees Fahrenheit. The District Manager confirmed that both thermometers read 52 degrees Fahrenheit. The District Manager revealed the thermometer on the outside of the fridge is not reading high and that the surveyor should come back and read the thermometer in 30 minutes when the fridge has been closed for a while because the staff have been in and out of the fridge. The district manager then said to the FSS to leave the fridge door closed for 30 minutes to get the temp down. Observation and interview on [DATE] at 10:40 a.m., revealed the thermometer gauge outside the walk-in refrigerator that is built into the unit read 58 degrees Fahrenheit. Further observation inside the walk-in refrigerator revealed two hanging thermometers which both read at 54 degrees Fahrenheit. The District Manager moved a thermometer that was inside a separate reach-in refrigerator that read at 40 degrees Fahrenheit into the walk-in and that one changed to 52 degrees Fahrenheit. The District Manager confirmed the thermometers inside the walk-in refrigerator read at 52 degrees Fahrenheit. The District Manager took the temperature of food items in the walk-in including left-over cream-based soup, peaches in syrup that was stored in a plastic container and egg whites in a carton, all the items registered at ,[DATE] degrees Fahrenheit. The District Manager confirmed the temperature of the soup, egg whites and peaches were ,[DATE] degrees Fahrenheit and that they should be 41 degrees Fahrenheit or below. The District Manager threw those items in the trash. The District Manager revealed that he would call the Maintenance in for the machine. Interview with the District Manager on [DATE] at 11:05 a.m., revealed that once the kitchen opens in the morning their staff are in and out of the walk-in refrigerator all day. Observation and photographic evidence on [DATE] at 11:06 am to 11:07 a.m., revealed 3 thermometers inside the walk-in refrigerator that read at over 50 degrees Fahrenheit. The observation of the walk-in revealed there were boxes of egg white cartons, fresh pasteurized eggs, jugs of milk, thawing meats, butter, mayonnaise, cinnamon apples, peaches, and butter spread. Interview with the District Manager on [DATE] at 11:06 a.m., the surveyors informed the District Manager that the three thermometers inside the refrigerator were at above 50 degrees Fahrenheit. The District Manager revealed that they had 4 hours to get the food items in the walk-in to 41 degrees or below. Observation of the walk-in refrigerator with the FSS on [DATE] at 1:53 p.m., revealed on the thermometer gauge outside the walk-in refrigerator that is built into the unit and the three thermometers hanging inside the walk-in registered at 54 degrees Fahrenheit. Further observation revealed the walk-in still had the boxes of egg white cartons, fresh pasteurized eggs, jugs of milk, thawing meats, butter, mayonnaise, cinnamon apples, peaches, and butter spread from the 11:07 am observation. One of the egg white boxes was dated [DATE]. Moreover, the observation revealed while in the refrigerator a food service worker came in and labeled 3 trays of pre-portioned milks and juices and revealed that she just poured up the drinks for dinner service and was coming to label them. During an interview on [DATE] at 1:53 p.m., the FSS confirmed the three thermometers inside the walk-in refrigerator read at 54 degrees Fahrenheit. The FSS confirmed that the boxes of egg white, milks, health shakes, produce and fresh eggs are all products that have been in the walk-in refrigerator since this morning. The FSS confirmed that the staff have been using food items from the walk-in refrigerator for the meal service today. Observation on [DATE] at 1:55 p.m., the FSS took the temperature of milk inside the walk-in refrigerator by pouring the milk from the jug into a cup while inside the -walk and the temperature registered at 53 degrees Fahrenheit. During an interview on [DATE] at 1:55 p.m., the FSS confirmed the temperature of the milk poured straight from the milk jug inside the walk-in registered at 53 degrees Fahrenheit. The FSS revealed that he would open the freezer that is inside the walk- in refrigerator to try to decrease the temperature of the refrigerator. During an interview on [DATE] at 2:02 p.m., the FSS revealed he was going to move as much of the food items in the walk-in refrigerator to the other reach-in refrigerators. The surveyor questioned the FSS about moving the items to the reach-in refrigerators because these items have been stored at a temperature of above 50 degrees Fahrenheit for the past 3 hours. The FSS then revealed that he would have to throw everything out. The FSS revealed the District Manager told him to just move the items from the walk-in to the reach-in refrigerators. During an interview with the District Manager on [DATE] at 2:12 p.m., the surveyors informed the District Manager the thermometers inside the walk-in refrigerator were still reading at above 50 degrees Fahrenheit and that milk tested from a jug inside the walk-in registered at 53 degrees Fahrenheit. The District Manager revealed that he would just move the food items out of the walk-in and put them on ice. The surveyor questioned the District Manager about having to wait 4 hours to get the temperature down and he replied that he had four hours to cool items down. The surveyor reminded the District Manager that 4-hour time frame dealt with cooling cooked food items and not all the food items were cooked such as the milk and egg whites. The District Manager then wanted the surveyor to tell him what to do, and then the surveyor revealed that she could not give recommendations or suggestions. As a result, the District Manager revealed that he would just put the food items in the walk-in refrigerator on ice. During an interview with the District Manager on [DATE] at 3:10 p.m., the District Manger confirmed that they were keeping the food items from the walk-in refrigerator and that they were putting the milk in the freezer. The District Manager also revealed the food was on ice. The District Manager confirmed again that the temperatures inside the walk-in refrigerator have been higher than 41 degrees Fahrenheit. Furthermore, he revealed maintenance was looking at the refrigerator right now. During an interview on [DATE] at 3:40 p.m., the District Manager revealed Maintenance had taken off the bottom pan on the condensing unit, thawed it out, replaced the PVC on the wall, and added freon to the unit. The District Manager revealed that they had done a similar repair to the walk-in refrigerator last year, but he could not remember the exact date. During an interview on [DATE] at 4:08 p.m., the FSS revealed the walk-in refrigerator read at 40 degrees Fahrenheit. During an interview on [DATE] at 4:40 p.m., the District Manager confirmed that there was a faulty part inside the walk-in refrigerator, it was ordered today and should be in tomorrow. Observation of the walk-in refrigerator on [DATE] at 4:59 p.m., revealed the the inside thermometers read at 40 degrees Fahrenheit and the walk-in refrigerator was empty of food products. 2. Record review of the facility's [DATE] dinner temperature log, did not reveal a temperature for the milk that was to be served for dinner. During an interview on [DATE] at 5:41 p.m., the District Manager and the FSS confirmed that they do not take the temperature of the milks before service to the residents. Observation on [DATE] at 5:42 p.m., the District Manager took the temperature of a pre-portioned milk place in 2 bins on the tray-line for dinner meal service. The temperature on two milks in one of the bins were 43.5 and 44 degrees Fahrenheit. Observation on [DATE] at 5:44 p.m., the District Manager took the temperature of second bin had a milk tested at 38 degrees Fahrenheit. During an interview on [DATE] at 5:44 p.m. the District Manager confirmed that the milks in the first bin need to be colder and add more ice. 3. Interview with the Maintenance Director on [DATE] at 4:32 p.m., the Maintenance Director revealed that there was a repair on the walk-in a year ago and they did something similar. Asking for the part/invoices. Confirmed he does not do monthly checks on the refrigerator. Interview with the Maintenance Director on [DATE] at 11:03 a.m., the Maintenance Director revealed that he has a maintenance schedule that shows him when to service, check, and clean the condensing unit in the fridges and that he was supposed to do this every month. The Maintenance Director revealed that he does not have time to check the fridge monthly and that he was not checking the temperatures on the fridges. When asked by surveyor if he has a maintenance log for the walk-in refrigerator, he revealed that he does not have any to provide. 4. Observation of the walk-in refrigerator on [DATE] at 9:24 a.m. revealed a container with lid of peaches and opened clear plastic bag meatballs stored without an opened or use-by date. Interview with the FSS on [DATE] at 9:24 a.m. confirmed the container with lid of peaches and opened meatballs was stored without an opened or use-by date and removed them from the refrigerator. Record review of the Texas Food Establishment Rules, (MONTH) (YEAR), §228.75(g) Ready-to eat, time/temperature controlled for safety food, date marking. (1) Refrigerated, ready-to-eat, time/temperature controlled for safety, food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicated the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees F or less for a maximum of 7 days. (2) Refrigerated, ready-to-eat, time/temperature controlled for safety food prepared and packaged by a food processing plant shall be clearly be marked at the time the original container is opened in a food establishment and held at a temperature of 41 degrees Fahrenheit or less if the food is held for more than twenty-four hours. 5. Observation of the walk-in freezer on [DATE] between 9:24 am and 9:33 a.m. revealed an opened package of Kielbasa sausage in freezer was not air-tight. Interview with the FSS on [DATE] between 9:24 am and 9:33 a.m. confirmed the package of Kielbasa sausage in freezer was opened but was not air-tight and the FSS confirmed it should have been. The FSS removed the Kielbasa sausage from the freezer. 6. Observation in the kitchen on [DATE] at 9:56 a.m., revealed a low-temperature chemical sanitizing dishwasher was running and the surveyor asked the FFS to test the sanitizer concentration level the dishwasher was providing. The dishwasher rinse cycle registered at 122 degrees Fahrenheit. The FFS got the test strips and opened the dishwasher and tested the sanitizer on the plate cover domes. The sanitizer strip did not change color. During an interview on [DATE] at 9:56 a.m., the FFS confirmed the test strip did not change color. The FFS revealed that the dishwasher sanitizer concentration should register at 50 ppm. The FSS revealed that he was going to run it again. The FFS revealed that maybe he had the wrong test strips for this sanitizer and got another set of test strips. Observation in the kitchen on [DATE] at 9:58 a.m., revealed the dishwasher cycle registered at 122 degrees Fahrenheit. The FFS got the test strips and opened the dishwasher and tested the sanitizer on the plate cover domes and rubbed it all over the dome. The sanitizer strip registered at 10 ppm. During an interview on [DATE] at 9:58 a.m., the FFS confirmed the test strip registered at 10 ppm and that was not strong enough. The FFS revealed that maybe he had the wrong test strips for this sanitizer and got another set of test strips. During an interview on [DATE] at 9:59 a.m., the FSS returned with another set of strips. The FSS revealed the other test strips were labeled that they expired as of (YEAR) and the new strips he found were not expired. The FFS revealed he was going to send some bowls through the dishwasher instead of the plate domes. The surveyor then suggested to turn the bowls upward, so the sanitizer solution dispensed on the bowls would be caught and the FSS could test a larger amount of the solution. Observation on [DATE] at 10:04 a.m., revealed the FSS sent some bowls turned upward through the dishwasher. The observation further revealed the dishwasher cycle registered at 124 degrees Fahrenheit. The FFS got the test strips and opened the dishwasher and tested the sanitizer solution held inside one of the bowls. The sanitizer strip registered at 10 ppm. During an interview on [DATE] at 10:04 a.m., the FFS confirmed the test strip registered at 10 ppm and that was not strong enough. The FSS revealed that they were currently running the dishwasher before we started testing the concentration and that they would have to wash all the dishes in their 3-compartment sink, until they could have the company that maintains the dishwasher to look at the machine. During an interview and observation in the facility conference room on [DATE] 10:29 a.m., the FSS brought in a test strip that was over 50 ppm and revealed the company told him he had to prime the sanitizer concentration to get the appropriate level of concentration. Record review of the facility policy titled, Warewashing, dated ,[DATE], revealed all dishware, serviceware, and utensils will be cleaned and sanitized after each use. 1. Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. Record review of the TFER, p. 70, §228.75(f)(,[DATE])(B), revealed except during preparation, cooking, or cooling, or when time is used as the public health control as specified under subsection (i) of this section, an except as specified in paragraphs (2) and (3) of this subsection, time/temperature controlled for safety food shall be maintained (at) 5 degrees Celsius (41 degrees Fahrenheit) or less. Record review of the facility policy titled, Equipment, dated ,[DATE], revealed all Foodservice equipment will be clean, sanitary, and in proper working order. Record review of the facility policy titled, Food Storage: Cold Foods, dated ,[DATE], revealed 2. All perishable foods will be maintained at a temperature of 41 degrees Fahrenheit or below except during necessary periods of preparation and service. ( ) 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. 5. All foods will be stored wrapped or covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Record review of the Food and Drug Administration's article titled, Food Safety for Older Adults, dated (MONTH) 2006, revealed By the age of 65 many of us have been diagnosed with [REDACTED]. The side effects of some medications or the chronic disease process may weaken the immune system, causing older adults to be more susceptible to contracting a foodborne illness. Essentially, as we age, our immune system and other organs in our bodies have become a bit sluggish in recognizing and ridding the body of harmful bacteria and other pathogens that cause infections, such as foodborne illness. Should older adults contract a foodborne illness, you are more likely to have a lengthier illness, undergo hospitalization , or even die. To avoid contracting a foodborne illness, older adults must be especially vigilant when handling, preparing, and consuming foods. (article PDF: https://www.fda.gov/downloads/Food/FoodborneIllnessContaminants/UCM 0.pdf) Record review of the United States Department of Agriculture Food Safety and Inspection Services' website titled Danger Zone (40 °F - 140 °F), dated last modified [DATE], revealed Leaving food out too long at room temperature can cause bacteria (such as Staphylococcus aureus, Salmonella Enteritidis, Escherichia coli O157:H7, and Campylobacter) to grow to dangerous levels that can cause illness. Bacteria grow most rapidly in the range of temperatures between 40 °F and 140 °F, doubling in number in as little as 20 minutes. This range of temperatures is often called the Danger Zone.(web address: https://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-food-handling/danger-zone-40-f-140-f/ct_index/!ut/p/a1/jZFva8IwEMa_ir7QNxITVxUdyOjKRN1sp2Wz9o3E9voHbNIlcXV--qX2jRu6mUDg7p7jd88F-9jDPqOfaUxVyhndlbHf35AF6XeGFpk5w86YTO33hfNsWWTg9rRg_YfANm7sv3JM8l__7AbAnZhb8xj7OVUJSlnEsReDQpTJAoTEXsR5iCSNQH2hiAYKyQRA6UKZQ6dqQlm4S1mMvZCyGAQ6cgaoS1CEOuWLvUBtUhbCAa-w_3Mm0tF3ahtudzKzDeJ0fwsuLK0SXN-Kth3v-Pb0Q2uTbY2B9icgAgGivRc6nSiVy_sGaZCiKNpbPXs74FmDSKAiSB4-RkEYtBRkOQiq9gJalbFWaawpRTCaPiH3pH3khbYWc51xl0a9iViwqXC3jnokqpC51TQTC9X82tn_FrFr5V8nGdv3vHFnJD0NVsNVG9t1uvf1OM9CQ!!/#1) An Immediate Jeopardy (IJ) was identified on [DATE] at 4:16 p.m. The Administrator, District Manager, Corporate RN HH and DON were notified, and a plan of removal was requested at that time. The plan of removal was accepted, and immediacy lifted on [DATE] at 2:45 p.m. and included: -Maintenance Supervisor examined walk in refrigerator unit and additional repairs invoiced. Equipment was taken out of service and Thermal Expansion valve was ordered for walk in refrigerator repair; started on [DATE] and completed [DATE]. -Administrator obtained 2 refrigeration units from Universal City Appliance company [DATE]; started on [DATE] and completed [DATE]. -Existing unit placed out of service [DATE]. Repairs were made at 3:30 PM [DATE] by local repair representative. Thermal Expansion Valve required to make unit operational; started on [DATE] and completed [DATE]. -Registered Dietitian training for dietary staff regarding prevention of food borne illnesses and on procedure on what to do and how to report in the event refrigerator is below 41 degrees to dietary staff; started on [DATE] and completed [DATE]. -Maintenance Supervisor TELS (Preventative Maintenance Program) program to include kitchen equipment weekly instead of the monthly checks; started on [DATE] and completed [DATE]. -Nursing Staff to assess residents for S/S nausea/vomiting and /or Signs/symptoms of ingesting product from affected faulty equipment every shift for the next 24 hours; started on [DATE] and completed [DATE]. -Dietary Staff to document internal refrigerator temperatures before beginning to prepare meal service, after meal service to ensure new equipment is holding required temperatures; started on [DATE] and completed [DATE]. -Beverage temperatures to be documented prior to meal service; started on [DATE] and completed [DATE]. -Any potentially hazardous foods were discarded from the kitchen on [DATE]. Potentially hazardous items were replaced on [DATE]; started on [DATE] and completed [DATE]. -Facility Medical Director notified of the Immediate Jeopardy by the DON on [DATE]; started on [DATE] and completed [DATE]. -Out-of-cycle QAPI with Interdisciplinary Team (IDT) to review issue and reviewed plan to prevent re-occurrence; started on [DATE] and completed [DATE]. -QAPI Audit tool for Kitchen/Food Service observation was completed on [DATE] to ensure no food borne illness potentials exit; started and completed on [DATE]. -Regional Supervisor for Health Care Services Group (HCSG) notified of Immediate Jeopardy and reported to the facility for additional over-sight in the Dietary Department [DATE]; started on [DATE] and completed [DATE]. Monitoring of Accepted Plan of Removal began on [DATE] revealed: Observation on [DATE] at 7:45 a.m., revealed the thermometer inside the purchased white fridge had a temperature of 42 degrees Fahrenheit and the milk was test in that refrigerator and it read at 41 degrees Fahrenheit. Observation on [DATE] at 12:30 p.m., revealed Cook II taking temperatures of the milk in glasses on the lunch which read at 39 degrees Fahrenheit. Record review of Refrigerator/Freezer Temperature Log, Dated [DATE] revealed that the facility started recording the temperatures in the refrigerators and freezers were being recorded 6 times a day. Record review of Meal Service food temperature log, dated [DATE], revealed that all the food and beverages had temperatures record that were at the appropriate temperature. During interview on [DATE] at 11:04 a.m., Regional District Manager, the District Manager, Dietitian, Administrator and the Corporate RN HH revealed documentation of completed Plan of Removal: -Note from maintenance direction on inspection of refrigerator repairs dated [DATE] -Receipts provided and dated [DATE]. -Invoice for repairs was provided and verbal confirmation that signs were posted on the walk-in refrigerator. -Inservice training roster provided for dietary staff dated [DATE]. -Maintenance in-serviced for weekly check everything in kitchen and document findings dated [DATE]. -Nursing notes on resident nausea or vomiting documentation provided with dates on [DATE] and [DATE]. -Temperature checks completed 6 times a day on [DATE] completed and provided on [DATE]. -Temperature logs of food before meal service provided dated [DATE]/19. -Inventory email and picture of food items discarded were provided on [DATE]. -Note provided signed on [DATE] revealed the Medical Director's Nurse Practitioner was notified on [DATE]. -Notes from QAPI meeting provided and dated [DATE]. -QAPI Audit tool for Kitchen/Food Service observation was provided and dated [DATE]. -Notification for Regional Supervisor for Health Care Services Group (HCSG) provided and dated [DATE].

Based on record review, interview, and observation, the facility failed to employ competent staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. 1. The facility did not ensure the FSS and the District Manager were knowledgeable about maintaining proper food temperatures in a walk-in refrigerator and put resident's health at risk. An Immediate Jeopardy (IJ) was identified on 02/06/19 at 4:16 p.m. While the IJ was removed on 2/07/19, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of widespread because the facility was still monitoring the Plan of Removal. Other failures: 2. The facility did not ensure the District Manager was knowledgeable about sanitizing food contact surfaces. This deficient practice could place the residents who consumed food prepared from the kitchen at increased risk of food borne illness. The findings were: 1. Record view of facility policy, dated 9/2017 on Department Staffing reveals that the dining services department will employ sufficient staff, with appropriate competencies and skill sets to carry out the functions of food and nutrition services in a manner that is safe and effective. Observation with the FSS on 2/05/19 at 9:40 a.m., revealed the thermometer inside the walk-in refrigerator registered at 52 degrees Fahrenheit. Interview with the FSS on 2/05/19 at 9:40 a.m., confirmed the thermometer inside of the walk-in refrigerator was at 52 degrees Fahrenheit, but revealed that they got in a shipment today at 6:30 a.m., that took them a while to put up and may have affected the temperature inside the walk-in. The FSS revealed that the staff took the temperature of the walk-in refrigerator when they came in before the shipment arrived and it was at 38 degrees Fahrenheit. Record review of the facility Walk-In Refrigerator Temperature Log revealed the temperature of the unit is taken in the AM and PM. The record also revealed the temperatures recorded revealed the walk-in refrigerator was 41 degrees or below for 2/1/19- 2/5/19. Observation and interview on 2/06/19 at 10:05 a.m., revealed in the walk-in fridge there were two thermometers that read 52 degrees Fahrenheit. The District Manager confirmed that both thermometers read 52 degrees Fahrenheit. The District Manager revealed the thermometer on the outside of the fridge is not reading high and that the surveyor should come back and read the thermometer in 30 minutes when the fridge has been closed for a while because the staff have been in and out of the fridge. The district manager then said to the Dietary Manager to leave the fridge door closed for 30 minutes to get the temp down. Observation and interview on 2/06/19 at 10:40 a.m., revealed the thermometer gauge outside the walk-in refrigerator that is built into the unit read 58 degrees Fahrenheit. Further observation inside the walk-in refrigerator revealed two hanging thermometers which read at 54 degrees Fahrenheit. The District Manager moved a thermometer that was inside a separate reach-in refrigerator that read at 40 degrees Fahrenheit into the walk-in and that one changed to 52 degrees Fahrenheit. The District Manager confirmed the thermometers inside the walk-in refrigerator read at 52 degrees Fahrenheit. The District Manager took the temperature of food items in the walk-in including left-over cream-based soup, peaches in syrup that was stored in a plastic container and egg whites in a carton, all the items registered at 52-54 degrees Fahrenheit. The District Manager confirmed the temperature of the soup, egg whites and peaches were 52-54 degrees Fahrenheit and that they should be 41 degrees Fahrenheit or below. The District Manager threw those items in the trash. The District Manager revealed that he would call the Maintenance in for the machine. Interview with the District Manager on 2/6/19 at 11:05 a.m., revealed that once the kitchen opens in the morning our staff are in and out of the walk-in refrigerator all day. Observation and photographic evidence on 2/6/19 at 11:06 am to 11:07 a.m., revealed 3 thermometers inside the walk-in refrigerator that read at over 50 degrees Fahrenheit. The observation of the walk-in revealed there were boxes of egg white cartons, fresh pasteurized eggs, jugs of milk, thawing meats, butter, mayonnaise, cinnamon apples, peaches, and butter spread. Interview with the District Manager on 2/6/19 at 11:06 a.m., the surveyors informed the District Manager that the three thermometers inside the refrigerator were at above 50 degrees Fahrenheit. The District Manager revealed that they had 4 hours to get the food items in the walk-in to 41 degrees or below. Observation of the walk-in refrigerator with the FSS on 2/06/19 at 1:53 p.m., revealed on the thermometer gauge outside the walk-in refrigerator that is built into the unit and the three thermometers hanging inside the walk-in registered at 54 degrees Fahrenheit. Further observation inside the walk-in refrigerator revealed two hanging thermometers which read at 54 degrees Fahrenheit. Further observation revealed the walk-in still had the boxes of egg white cartons, fresh pasteurized eggs, jugs of milk, thawing meats, butter, mayonnaise, cinnamon apples, peaches, and butter spread from the 11:07 am observation. One of the egg white boxes was dated 2/2/19. Moreover, the observation revealed while in the refrigerator a food service worker came in and labeled 3 trays of pre-portioned milks and juices and revealed that she just poured up the drinks for dinner service and was coming to label them. During an interview on 2/06/19 at 1:53 p.m., the FSS confirmed the three thermometers inside the walk-in refrigerator read at 54 degrees Fahrenheit. The FSS confirmed that the boxes of egg white, milks, health shakes, produce and fresh eggs are all products that have been in the walk-in refrigerator since this morning. The FSS confirmed that the staff have been using food items from the walk-in refrigerator for the meal service today. Observation on 2/06/19 at 1:55 p.m., the FSS took the temperature of milk inside the walk-in refrigerator by pouring the milk from the jug into a cup while inside the -walk and the temperature registered at 53 degrees Fahrenheit. During an interview on 2/06/19 at 1:55 p.m., the FSS confirmed the temperature of the milk poured straight from the milk jug while inside the walk-in registered at 53 degrees Fahrenheit. The FSS revealed that he would open the freezer that is inside the walk- in refrigerator to try to decrease the temperature of the refrigerator. During an interview on 2/06/19 at 2:02 p.m., the FSS revealed he was going to move as much of the food items in the walk-in refrigerator to the other reach-in refrigerators. The surveyor questioned the FSS about moving the items to the reach-in refrigerators because these items have been stored at a temperature of above 50 degrees Fahrenheit for the past 3 hours. The FSS then revealed that he would have to throw everything out. The Dietary Manager revealed the District Manager told him to just move the items from the walk-in to the reach-in refrigerators. During an interview with the District Manager on 2/06/19 at 2:12 p.m., the surveyors informed the District Manager the thermometers inside the walk-in refrigerator were still reading at above 50 degrees Fahrenheit and that milk tested from a jug inside the walk-in registered at 53 degrees Fahrenheit. The District Manager revealed that he would just move the food items out of the walk-in and put them on ice. The surveyor questioned the District Manager about having to wait 4 hours to get the temperature down and he replied that he had four hours to cool items down. The surveyor reminded the District Manager that 4-hour time frame dealt with cooling cooked food items and not all the food items were cooked such as the milk and egg whites. The District Manager then wanted the surveyor to tell him what to do, and then the surveyor revealed that she could not give recommendations or suggestions. As a result, the District Manager revealed that he would just put the food items in the walk-in refrigerator on ice. During an interview with the District Manager on 2/06/19 at 3:10 p.m., the District Manger confirmed that they were keeping the food items from the walk-in refrigerator and that they were putting the milk in the freezer. The District Manager also revealed the food was on ice. The District Manager confirmed again that the temperatures inside the walk-in refrigerator have been higher than 41 degrees Fahrenheit. Furthermore, he revealed maintenance was looking at the refrigerator right now. During an interview on 2/06/19 at 3:40 p.m., the District Manager revealed Maintenance had taken off the bottom pan on the condensing unit, thawed it out, replaced the PVC on the wall, and added freon to the unit. The District Manager revealed that they had done a similar repair to the walk-in refrigerator last year, but he could not remember the exact date. During an interview on 2/06/19 at 4:08 p.m., the FSS revealed the walk-in refrigerator read at 40 degrees Fahrenheit. During an interview on 2/06/19 at 4:40 p.m., the District Manager confirmed that there was a faulty part inside the walk-in refrigerator, it was ordered today and should be in tomorrow. Observation of the walk-in refrigerator on 2/06/19 at 4:59 p.m., revealed the the inside thermometers read at 40 degrees Fahrenheit and the walk-in refrigerator was empty of food products. Review of the Texas Food Establishment Rules (TFER) (YEAR), section §228. 32 (3)(G) The Person in charge shall demonstrate this knowledge by responding correctly to the inspector's questions as they relate to the specific food operation. The areas of knowledge include: stating the required temperatures and times for the safe refrigerated storage, hot holding, cooling, and reheating of time/temperature controlled for safety (TCS) food; Review of the Texas Food Establishment Rules (TFER) (YEAR), section §228. 32 (3)(J)(ii) The Person in charge shall demonstrate this knowledge by responding correctly to the inspector's questions as they relate to the specific food operation. The areas of knowledge include: explaining the relationship between food safety and providing equipment that is: properly designed, constructed, located, installed, operated, maintained, and cleaned; Review of the Texas Food Establishment Rules (TFER) (YEAR), section §228. 75 (d)(3) Except as specified in paragraph (4) of this subsection, a time/temperature controlled for safety food received in compliance with laws allowing a temperature above 5 degrees Celsius (41 degrees Fahrenheit) during shipment from the supplier as specified in section 228.63 (a) (2) of this title, shall be cooled within four hours to 5 degrees Celsius (41 degrees Fahrenheit) or less. Record review of the TFER, p. 70, §228.75(f)(1-3)(B), revealed except during preparation, cooking, or cooling, or when time is used as the public health control as specified under subsection (i) of this section, an except as specified in paragraphs (2) and (3) of this subsection, time/temperature controlled for safety food shall be maintained (at) 5 degrees Celsius (41 degrees Fahrenheit) or less. Record review of the facility policy titled, Food Storage: Cold Foods, dated 4/2018, revealed 2. All perishable foods will be maintained at a temperature of 41 degrees Fahrenheit or below except during necessary periods of preparation and service. ( ) 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. 5. All foods will be stored wrapped or covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Record review of the Food and Drug Administration's article titled, Food Safety for Older Adults, dated (MONTH) 2006, revealed By the age of 65 many of us have been diagnosed with [REDACTED]. The side effects of some medications or the chronic disease process may weaken the immune system, causing older adults to be more susceptible to contracting a foodborne illness. Essentially, as we age, our immune system and other organs in our bodies have become a bit sluggish in recognizing and ridding the body of harmful bacteria and other pathogens that cause infections, such as foodborne illness. Should older adults contract a foodborne illness, you are more likely to have a lengthier illness, undergo hospitalization , or even die. To avoid contracting a foodborne illness, older adults must be especially vigilant when handling, preparing, and consuming foods. (article PDF: https://www.fda.gov/downloads/Food/FoodborneIllnessContaminants/UCM 0.pdf) Record review of the United States Department of Agriculture Food Safety and Inspection Services' website titled Danger Zone (40 °F - 140 °F), dated last modified 6/28/17, revealed Leaving food out too long at room temperature can cause bacteria (such as Staphylococcus aureus, Salmonella Enteritidis, Escherichia coli O157:H7, and Campylobacter) to grow to dangerous levels that can cause illness. Bacteria grow most rapidly in the range of temperatures between 40 °F and 140 °F, doubling in number in as little as 20 minutes. This range of temperatures is often called the Danger Zone.(web address: https://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-food-handling/danger-zone-40-f-140-f/ct_index/!ut/p/a1/jZFva8IwEMa_ir7QNxITVxUdyOjKRN1sp2Wz9o3E9voHbNIlcXV--qX2jRu6mUDg7p7jd88F-9jDPqOfaUxVyhndlbHf35AF6XeGFpk5w86YTO33hfNsWWTg9rRg_YfANm7sv3JM8l__7AbAnZhb8xj7OVUJSlnEsReDQpTJAoTEXsR5iCSNQH2hiAYKyQRA6UKZQ6dqQlm4S1mMvZCyGAQ6cgaoS1CEOuWLvUBtUhbCAa-w_3Mm0tF3ahtudzKzDeJ0fwsuLK0SXN-Kth3v-Pb0Q2uTbY2B9icgAgGivRc6nSiVy_sGaZCiKNpbPXs74FmDSKAiSB4-RkEYtBRkOQiq9gJalbFWaawpRTCaPiH3pH3khbYWc51xl0a9iViwqXC3jnokqpC51TQTC9X82tn_FrFr5V8nGdv3vHFnJD0NVsNVG9t1uvf1OM9CQ!!/#1) An Immediate Jeopardy (IJ) was identified on 2/06/19 at 4:16 p.m. The Administrator, District Manager, Corporate RN HH and DON were notified, and a plan of removal was requested at that time. The plan of removal was accepted, and immediacy lifted on 2/07/19 at 2:45 p.m. and included: -Maintenance Supervisor examined walk in refrigerator unit and additional repairs invoiced. Equipment was taken out of service and Thermal Expansion valve was ordered for walk in refrigerator repair; started on 2/06/19 and completed 2/07/19. -Administrator obtained 2 refrigeration units from Universal City Appliance company 02-06-19; started on 2/06/19 and completed 2/07/19. -Existing unit placed out of service 02-06-19. Repairs were made at 3:30 PM 02-06-19 by local repair representative. Thermal Expansion Valve required to make unit operational; started on 2/06/19 and completed 2/07/19. -Registered Dietician training for dietary staff regarding prevention of food borne illnesses and on procedure on what to do and how to report in the event refrigerator is below 41 degrees to dietary staff; started on 2/06/19 and completed 2/07/19. -Maintenance Supervisor TELS (Preventative Maintenance Program) program to include kitchen equipment weekly instead of the monthly checks; started on 2/06/19 and completed 2/07/19. -Nursing Staff to assess residents for S/S nausea/vomiting and /or Signs/symptoms of ingesting product from affected faulty equipment every shift for the next 24 hours; started on 2/06/19 and completed 2/07/19. -Dietary Staff to document internal refrigerator temperatures before beginning to prepare meal service, after meal service to ensure new equipment is holding required temperatures; started on 2/06/19 and completed 2/07/19. -Beverage temperatures to be documented prior to meal service; started on 2/06/19 and completed 2/07/19. -Any potentially hazardous foods were discarded from the kitchen on 02-06-19. Potentially hazardous items were replaced on 02-06-19; started on 2/06/19 and completed 2/07/19. -Facility Medical Director notified of the Immediate Jeopardy by the DON on 02-06-19; started on 2/06/19 and completed 2/07/19. -Out-of-cycle QAPI with Interdisciplinary Team (IDT) to review issue and reviewed plan to prevent re-occurrence; started on 2/06/19 and completed 2/07/19. -QAPI Audit tool for Kitchen/Food Service observation was completed on 02-06-19 to ensure no food borne illness potentials exit; started and completed on 2/06/19. -Regional Supervisor for Health Care Services Group (HCSG) notified of Immediate Jeopardy and reported to the facility for additional over-sight in the Dietary Department 02-06-19; started on 2/06/19 and completed 2/07/19. Monitoring of Accepted Plan of Removal began on 2/07/19 revealed: Observation on 2/7/19 at 7:45 a.m., revealed the thermometer inside the purchased white fridge had a temperature of 42 degrees Fahrenheit and the milk was test in that refrigerator and it read at 41 degrees Fahrenheit. Observation on 2/07/19 at 12:30 p.m., revealed Cook II taking temperatures of the milk in glasses on the lunch which read at 39 degrees Fahrenheit. Interview with the Maintenance Director on 2/07/19 at 4:32 p.m., the Maintenance Director revealed that there was a repair on the walk-in a year ago and they did something similar. Asking for the part/invoices. Confirmed he does not do monthly checks on the refrigerator. Interview with the Maintenance Director on 2/8/19 at 11:03 a.m., the Maintenance Director revealed that he has a maintenance schedule that shows him when to service, check, and clean the condensing unit in the fridges and that he was supposed to do this every month. The Maintenance Director revealed that he does not have time to check the fridge monthly and that he was not checking the temperatures on the fridges. When asked by surveyor if he has a maintenance log, he revealed that he does not. Record review of Refrigerator/Freezer Temperature Log, Dated [DATE] revealed that the facility started recording the temperatures in the refrigerators and freezers were being recorded 6 times a day. Record review of Meal Service food temperature log, dated 2/8/19, revealed that all the food and beverages had temperatures record that were at the appropriate temperature. During interview on 2/08/19 at 11:04 a.m., Regional District Manager, the District Manager, Dietitian, Administrator and the Corporate RN HH revealed documentation of completed Plan of Removal: -Note from maintenance direction on inspection of refrigerator repairs dated 2/6/19 -Receipts provided and dated 2/6/19. -Invoice for repairs was provided and verbal confirmation that signs were posted on the walk-in refrigerator. -Inservice training roster provided for dietary staff dated 2/7/19. -Maintenance in-serviced for weekly check everything in kitchen and document findings dated 2/7/19. -Nursing notes on resident nausea or vomiting documentation provided with dates on 2/6/19 and 2/7/19. -Temperature checks completed 6 times a day on 2/7/19 completed and provided on 2/8/19. -Temperature logs of food before meal service provided dated 2/2/7/19. -Inventory email and picture of food items discarded were provided on 2/8/19. -Note provided signed on 2/8/19 revealed the Medical Director's Nurse Practitioner was notified on 2/6/19. -Notes from QAPI meeting provided and dated 2/6/19. -QAPI Audit tool for Kitchen/Food Service observation was provided and dated 2/6/19. -Notification for Regional Supervisor for Health Care Services Group (HCSG) provided and dated 2/8/19. 2. Observation in the kitchen on 2/7/19 at 10:23 a.m., revealed a sanitizer bucket under the work table next to the steam table with rag inside the bucket. Interview on 2/7/19 at 10:23 a.m., the District Manager reveals that the sanitizer bucket had been changed right after breakfast. When asked to measure the concentration of the solution in the sanitizer bucket he got a sanitizer strip stored above the three-compartment sink. The concentration measured at 0 parts per million and confirmed this verbally. The district manager revealed that the concentration of the sanitizing solution should be 50 parts per million. Interview on 2/7/19 at 10:26 a.m., the District Manager revealed that the concentration must be taken before putting the rag into the bucket. When asked by the surveyor, why is that?, he stated, because the rag will suck up all the product and cause the number to be screwed. Review of the Texas Food Establishment Rules (TFER) (YEAR), section §228. 68 (d)(2)(A) Wiping cloths, use limitation. Cloths in-use for wiping counters and other equipment surfaces shall be: held between uses in a chemical sanitizer solution at a concentration specified under 228.111(n) of this title.

Based on interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice about aspects of his or her life in the facility that are significant to the resident for 1 of 26 residents (#14) whose records were reviewed for resident rights. The SW did not follow up with the psychiatric NP to ensure that Resident #14 completed the necessary assessment for discharge planning. Resident #14 experienced prolonged emotional distress when she wanted to seek community placement but was led to believe she could not, due to a NP's order indicating the resident would be considered leaving against medical advice if she sought discharge from the facility. This deficient practice could affect residents that want to discharge to the community and could contribute to the delay in discharge planning for residents. The findings were: Review of Resident #14's face sheet, undated, revealed she was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] revealed Resident #14 scored 15 of 15 on her BIMS; she did not have memory deficits, did not exhibit signs of [MEDICAL CONDITION], mood or behavior problems. Furthermore, she was independent with all ADL's and only required staff supervision (oversight); was continent of bowel and bladder; did not have any skin conditions and received an anti-depressant for Depression. Review of Resident #14's consolidated physician orders [REDACTED].#14 leave it would be against medical advice. Interview on 02/06/19 at 09:39 AM with Resident #14 revealed she was admitted into the facility over 1 year ago and was ready to transition back into the community. She stated the psychiatrist told her she had to stay because she had a memory problem and he needed to complete memory testing. Resident #14 stated she had scheduled 5 different appointments with him and he had failed to keep them and had not called her back. Resident #14 stated the SW had also given her the run around and further stated the SW gave her an extensive test and she passed all the questions. Then the SW turned around and said she was not qualified to give the test. Resident #14 stated the SW had not assisted in helping her to plan to transition back into the community and told her that if she left she would be leaving against medical advice and would lose her insurance benefits. Resident #14 stated she would not qualify for services and financial aid through her insurance plan. She stated she felt angry and believed she was taking a spot someone else could use. Resident #14 stated she was receiving rehabilitation services per her request so she could get exercise because she laid around the facility. She stated she was independent with her ADL's; was Diabetic, but took cinnamon to control her sugars and also received 40 units of [MEDICATION NAME] every day and multi-vitamins. Resident #14 stated she did not have any mental health problems or a mental illness that would prevent her from living independently. Furthermore, she stated she went out on pass; would check herself out and would self-administer all her medications while on pass. Resident #14 became emotional and teary eyed during the interview and commented she was ready to move on. Interview on 02/07/19 at 01:16 PM with the SW revealed she had worked at the facility for about 15 months. She stated she was in charge of ensuring residents received ancillary services and she assisted with discharge planning. The SW stated Resident #14 had wanted to move into the community for about 6 months. The SW confirmed that Resident #14 was independent with all ADL's; participated in planning for her care; that she went out on pass ad lib and took her medications with her and that her BIMS was 15. She stated there was a standing order that if Resident #14 left the facility it would be against medical advice. Her current insurance provider would not provide her with a home voucher or monies with the AMA order in place. The SW stated that all parties (nursing staff and the Psychiatric NP) understood Resident #14 wanted to transition back into community and could not until she completed further testing because of the AMA order. The SW stated at one point Resident #14 was using memory loss as a crutch which was the reason why the plan to complete an evaluation for memory came about. Resident #14 agreed to complete testing and the SW stated the NP agreed to meet with Resident #14 a few weeks ago. He did not meet with the Resident on the scheduled date and was supposed to see the Resident this past Monday (2/4/19), but the NP did not meet with the resident again. Resident #14 thought the appointment was Friday and waited but was not scheduled for an appointment that date. The SW stated the NP visited the facility weekly but had not seen him in the building. The SW stated she had not called the NP to find out what happened and commented, she forgot. Interview on 02/08/19 at 11:28 AM with Psychiatric NP confirmed he understood Resident #14 wanted to transition back into the community. He stated he completed a Mini Mental Exam about 6 months ago and noted cognitive deficits/change of cognitive status at that time. He stated she scored 24 out of 30 indicating mild cognitive deficits. The NP stated he started Resident #14 on [MEDICATION NAME] used for Dementia and was going to come back to follow up with another assessment (WHO Disability Assessment Schedule 2.0) to determine whether Resident #14 actually had Dementia. NP stated, however, since the initial testing Resident #14 appeared more clear minded. He stated he had not completed further testing because he had not been able to find the Resident when he came to the facility. He stated they had 2 missed scheduled appointments. The NP stated the AMA order was meant to be temporary; at the time of the order he did not believe it was safe for Resident #14 to return to the community. The NP stated he had not called back to discontinue the order and stated he thought the SW had not implemented a discharge plan due to the insurance provider not approving the discharge. The NP commented he hoped it had not held the process up because really she could leave whenever she wanted; it would be between her and her PCP. The NP stated he could call the facility today and discontinue the AMA order. The NP stated he did not have a copy of the Mini Mental Exam and stated he would have filed it in the Resident's chart after completing the exam. Review of Resident #14's paper chart and e-chart revealed a copy of the Mini Mental Exam was not available. Interview on 02/25/19 at 01:59 PM with RN K confirmed she talked with the NP on 2/8/19 and he said he discontinued the AMA order for Resident #14 on that same date. NP told her he talked with LVN about discontinuing the AMA order. RN K confirmed they discussed it on 2/8/19. She further revealed she either missed the call or she forgot to write the order on 2/8/19. Interview on 02/25/19 at 02:10 PM with the NP revealed he wrote the AMA order because at the time Resident #14 wanted to re-locate to New Mexico. She wanted to get on a bus and travel on her own. The NP stated staff wanted him to say that she was safe to travel on her own across the country and re-locate. NP stated he did not believe she was able to do that at the time. He confirmed he called on the same date he spoke with this Surveyor and called LVN U and discontinued the AMA order. Again, NP re-iterated that Resident #14 and her PCP could agree to her leaving at any time and she did not need approval from him. NP stated he did not understand the AMA order was holding her discharge planning with her insurance provider prior to the Surveyors entrance. The NP stated Resident #14 told her she wanted to discharge into the community about 1 to 2 weeks prior to Surveyor's entering. NP stated he returned on 2/12/19, completed a 2nd Mini Mental Status. The NP stated the assessment took about 10 minutes to completed. NP stated another order was written and signed on 2/12/19. Then he stated he signed the order on this date, 2/25/19. The NP stated there was no particular reason the AMA order was open ended and it did not have a specific time frame. Interview on 02/25/19 at 02:45 PM with LVN U confirmed she remembered talking with the NP about the AMA order on 2/8/19, but could not remember him telling her with all certainty to discontinue the order. LVN U stated she was pre-occupied with getting Surveyors all the documentation requested. She stated she normally she would have written the order down or entered it as a progress note then entered it on triplicate form and told the nurse about the order. Interview on 02/25/19 03:15 PM with RN K revealed the NP came in on this date (2/25/19) and she, LVN U and the NP were looking for the AMA order. LVN U confirmed the NP called her but she could not find a written order. RN K stated she discontinued the AMA order on this date (2/25/19) and dated it 2/12/19 reflecting when she believed the NP gave the verbal order to discontinue the AMA order. Upon further discussion it was determined the verbal order was actually provided on 2/8/19, exit date for the survey. RN K stated then it would be a transcription error and it actually should have been written as a clarification order, timed and dated on this date (2/25/19). Interview on 02/26/19 at 09:40 AM with Resident #14 revealed she had been cleared and stated she completed the testing and had done everything they wanted me to do. She further stated the NP had lifted the AMA order and commented I'm so excited I can't hardly contain myself. Resident #14 shared her plans to return to the community. Interview on 02/26/19 at 10:00 AM with LVN J stated seeing an AMA was not the norm and stated she had never seen this in place before. LVN J stated she thought it would be like a restraint but then stated they would actually not be able to keep a resident from leaving. LVN J stated she would contact the physician, educate the resident about their choices and get upper management involved. Interview on 02/26/19 at 10:30 AM with LVN U confirmed the NP wrote the AMA order because during a Care Plan meeting the last part of (YEAR), Resident #14 wanted to go to New Mexico (NM) via bus or however else she could get there. It did not matter to the Resident how she got to NM. LVN U stated they were concerned about her safety. Interview on 02/26/19 at 10:42 AM with the SW revealed Resident #14 initially approached her about discharging at the beginning of the new year of (YEAR). At the time she had a different insurance provider and there were concerns regarding her mental state of mind at the time. She had been back into the facility a short time since her previous unsuccessful attempt to move back into the community. The SW stated Resident #14 had accessed financial assistance from the program known as Money follows the Person at that time. The assistance provided included a housing voucher; furnishings, making necessary improvements needed to rental establishment and groceries. The SW stated the previous case manager through the insurance provider told her the assistance provided through the program was a one time benefit. The SW stated Resident #14 would for sure need subsidized housing assistance because she used the housing voucher. The SW stated she was not sure when the AMA was implemented. However, stated they re-wrote an entered the order when they implemented a new software program used at the time during 11/1/18. The order was already a standing order in place. Resident #14 changed insurance providers and when she talked with current case manager, she said Resident #14 would not qualify for the MFP program and would not qualify for MCD benefits due to the AMA order. The SW stated Resident #14 approached her multiple times about discharging back into the community since the AMA order was implemented. She was aware the Resident was also talking with the case manager about discharging. The SW stated they would both re-educated Resident #14 about the AMA order and benefit restrictions because of it. The SW stated she approached the NP at least once about Resident #14 wanting to discharge prior to the Survey and he told her he did not believe it was safe for her to leave because of her psychological state. The SW stated she did not remember talking with the NP about how the AMA order would affect the Resident's insurance benefits. The SW stated she was aware of 2 times for sure that the NP and Resident #14 missed each other for further assessment. She confirmed the NP completed the assessment on 2/12/19. She stated there was a conference call scheduled tomorrow (2/27/19) to include Resident #14, the Ombudsman and the case manager. They would be discussing the Resident's options for discharge and the funding and services available for her through her insurance and other programs. Interview on 02/26/19 at 2:22 PM with Resident #14 insurance case manager (CM) revealed that the SW called her today to let her know that the AMA letter was lifted and confirmed the conference call scheduled for 2/27/19. The CM stated that the AMA order prevented them from assisting with Resident #14 with any discharge planning including referring her for subsidized housing and accessing benefits with the Money Follows the Person program and with a referral for services through the COIL program. She stated the benefits through the Money Follows the Person program was a one time benefit so she would have to find out what benefits the Resident accessed during her first discharge and determine what benefits were still available for her. The CM stated the Resident would still qualify for a housing voucher and whatever other services COIL provided and any other benefits through MCD/MICR; medical, home health etc. Review of a facility policy titled, Resident Rights revised during (MONTH) (YEAR) read in part: 1. Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident's right to: e. self-determination.

Based on observation, interview and record review the facility failed to ensure that residents received medically-related social services to attain or maintain the highest practicable physical well-being for 1 of 26 Residents (Resident # 14) whose records were reviewed for medically-related social services in that: The facility did not follow up with the psychiatric NP to ensure that Resident #14 completed the necessary assessment for discharge planning. These deficient practices could result decisions being made that do not take the resident's wishes into account. The findings were: Review of Resident #14's face sheet, undated, revealed she was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] revealed Resident #14 scored 15 of 15 on her BIMS; she did not have memory deficits, did not exhibit signs of [MEDICAL CONDITION], mood or behavior problems. Furthermore, she was independent with all ADL's and only required staff supervision (oversight); was continent of bowel and bladder; did not have any skin conditions and received an anti-depressant for Depression. In addition, she had an active discharge plan to return to the community. Review of Resident #14's consolidated physician orders [REDACTED].#14 leave it would be against medical advice. Interview on 02/06/19 at 09:39 AM with Resident #14 revealed she was admitted into the facility over 1 year ago and was ready to transition back into the community. She stated the psychiatrist told her she had to stay because she had a memory problem and he needed to complete memory testing. Resident #14 stated she had scheduled 5 different appointments with him and he had failed to keep them and had not called her back. Resident #14 stated the SW had also given her the run around and further stated the SW gave her an extensive test and she passed all the questions. Then the SW turned around and said she was not qualified to give the test. Resident #14 stated the SW had not assisted in helping her to plan to transition back into the community and told her that if she left she would be leaving against medical advice and would lose her MCD benefits. Resident #14 stated she would not qualify for services and financial aid through her insurance plan. She stated she felt angry and believed she was taking a spot someone else could use. Resident #14 stated she was receiving rehabilitation services per her request so she could get exercise because she laid around the facility. She stated she was independent with her ADL's; was Diabetic, but took cinnamon to control her sugars and also received 40 units of [MEDICATION NAME] every day and multi-vitamins. Resident #14 stated she did not have any mental health problems or a mental illness that would prevent her from living independently. Furthermore, she stated she went out on pass at lib; would check herself out and would self-administer all her medications while on pass. Resident #14 became emotional and teary eyed during the interview and commented she was ready to move on. Interview on 02/07/19 at 01:16 PM with the SW revealed she had worked at the facility for about 15 months. She stated she was in charge of ensuring residents received ancillary services and she assisted with discharge planning. The SW stated Resident #14 had wanted to move into the community for about 6 months. The SW confirmed that Resident #14 was independent with all ADL's; participated in planning for her care; that she went out on pass at lib and took her medications with her and that her BIMS was 15. She stated there was a standing order that if Resident #14 left the facility it would be against medical advice. Her current insurance provider would not provide her with a home voucher or monies with the AMA order in place. The SW stated that all parties (nursing staff and the Psychiatric NP) understood Resident #14 wanted to transition back into community and could not until she completed further testing because of the AMA order. The SW stated at one point Resident #14 was using memory loss as manipulation for her behaviors which was the reason why the plan to complete an evaluation for memory came about. Resident #14 agreed to complete testing and the SW stated the NP agreed to meet with Resident #14 a few weeks ago. He did not meet with the Resident on the scheduled date and was supposed to see the Resident this past Monday (2/4/19), but the NP did not meet with the resident again. Resident #14 thought the appointment was Friday and waited but was she was not scheduled for an appointment that date. The SW stated the NP visited the facility weekly but had not seen him in the building. The SW stated she had not called the NP to find out what happened and commented, she forgot. Interview on 02/08/19 at 11:28 AM with Psychiatric NP confirmed he understood Resident #14 wanted to transition back into the community. He stated he completed a Mini Mental Exam about 6 months ago and noted cognitive deficits/change of cognitive status at that time. He stated she scored 24 out of 30 indicating mild cognitive deficits. The NP stated he started Resident #14 on [MEDICATION NAME] used for Dementia and was going to come back to follow up with another assessment (WHO Disability Assessment Schedule 2.0) to determine whether Resident #14 actually had Dementia. However, stated since the initial testing Resident #14 appeared more clear minded. He stated he had not completed further testing because he had not been able to find the Resident when he came to the facility. He stated they had 2 missed scheduled appointment. The NP stated the AMA order was meant to be temporary; at the time of the order he did not believe it was safe for Resident #14 to return to the community. The NP stated he had not called back to discontinue the order and stated he thought the SW had not implemented a discharge plan due to the insurance provider not approving the discharge. The NP commented he hoped it had not held the process up because really she could leave whenever she wanted; it would be between her and her PCP. The NP stated he could call the facility today and discontinue the AMA order. The NP stated he did not have a copy of the Mini Mental Exam and stated he would have filed it in the Resident's chart after completing the exam. Review of Resident #14's paper chart and e-chart revealed a copy of the Mini Mental Exam was not available. Interview on 02/25/19 at 01:59 PM RN K confirmed she talked with the NP on 2/8/19 and he said he discontinued the AMA order for Resident #14 on that same date. He told her he talked with LVN about discontinuing the AMA order. Confirmed we discussed it on 2/8/19. Stated remembered thought missed the call or she forgot to write the order. She called him to clarify what was going on. Interview on 02/25/19 at 02:10 PM with the NP revealed he wrote the AMA order because at the time Resident #14 wanted to re-locate to New Mexico. She wanted to get on a bus and travel on her own. The NP stated staff wanted him to say that she was safe to travel on her own across the country and re-locate. He stated he did not believe she was able to do that at the time. He confirmed he called on the same date he spoke with this Surveyor and called LVN U and discontinued the AMA order. Again, he re-iterated that Resident #14 and her PCP could agree to her leaving at any time and she did not need approval from him. He stated he did not understand the AMA order was holding her discharge planning with her insurance provider prior to the Surveyors entrance. The NP stated Resident #14 told her she wanted to discharge into the community about 1 to 2 weeks prior to Surveyor's entering. He stated he returned on 2/12/19, completed a 2nd Mini Mental instead of the WHODAS (mental assessment tool) because he had already conducted a Mini Mental. The NP stated the assessment took about 10 minutes to complete. He stated on that same dated, 2/12/19, they could not find a written order for the AMA dated 2/8/19 so another order was written and signed on 2/12/19. Then he stated he signed the order on this date, 2/25/19. The NP stated there was no particular reason the AMA order was open ended and it did not have a specific time frame. Interview on 02/25/19 at 02:45 PM with LVN U confirmed she remembered talking with the NP about the AMA order on 2/8/19, but could not remember him telling her with all certainty to discharge the order. LVN U stated she was focused and pre-occupied with getting Surveyors all the documentation requested. She stated normally she would have written the order down or entered it as a progress note then entered it on triplicate form and told the nurse about the order. Upon further discussion, LVN U remembered the exact documents Surveyor requested for Resident #14 including the fact that she was unable to locate the initial Mini Mental Exam in the Resident's chart. Interview on 02/25/19 03:15 PM with RN K revealed the NP came in on this date (2/25/19) and she, LVN U and the NP were looking for the AMA order. LVN U confirmed the NP called her but she could not find a written order. RN K stated she discontinued the AMA order on this date (2/25/19) and dated it 2/12/19 reflecting when she believed the NP gave the verbal order to discontinue the AMA order. Upon further discussion it was determined the verbal order was actually provided on 2/8/19, exit date for the survey. RN K stated then it would be a transcription error and it actually should have been written as a clarification order, timed and dated on this date (2/25/19). Interview on 02/26/19 at 09:40 AM with Resident #14 revealed she had been cleared and stated she completed the testing and had done everything they wanted me to do. She further stated the NP had lifted the AMA order and commented I'm so excited I can't hardly contain myself. Resident #14 shared her plans to return to the community. Interview on 02/26/19 at 10:00 AM with LVN J stated seeing an AMA was not the norm and stated she had never seen this in place before. LVN J stated she thought it would be like a restraint but then stated they would actually not be able to keep a resident from leaving. LVN J stated she would contact the physician, educate the resident about their choices and get upper management involved. Interview on 02/26/19 at 10:30 AM with LVN U confirmed the NP wrote the AMA order because during a Care Plan meeting the last part of (YEAR), Resident #14 wanted to go to New Mexico (NM) via bus or however else she could get there. It did not matter to the Resident how she got to NM. LVN U stated they were concerned about her safety. Interview on 02/26/19 at 10:42 AM with the SW revealed Resident #14 initially approached her about discharging at the beginning of the new year of (YEAR). At the time she had a different insurance provider and there were concerns regarding her mental state of mind at the time. She had been back into the facility a short time since her previous unsuccessful attempt to move back into the community. The SW stated Resident #14 had accessed financial assistance from the program known as Money follows the Person at that time. The assistance provided included a housing vochure; furnishings, making necessary improvements needed to rental establishment and groceries. The SW stated the previous case manager through the insurance provider told her the assistance provided through the program was a one time benefit. The SW stated Resident #14 would for sure need subsidized housing assistance because she used the housing vochure. The SW stated she was not sure when the AMA was implemented. However, stated they re-wrote an entered the order when they implemented a new software program used at the time during 11/1/18. The order was already a standing order in place. Resident #14 changed insurance providers and when she talked with current case manager, she said Resident #14 would not qualify for the MFP program and would not qualify for MCD benefits due to the AMA order. The SW stated Resident #14 approached her multiple times about discharging back into the community since the AMA order was implemented. She was aware the Resident was also talking with the case manager about discharging. The SW stated they would both re-educated Resident #14 about the AMA order and benefit restrictions because of it. The SW stated she approached the NP at least once about Resident #14 wanting to discharge prior to the Survey and he told her he did not believe it was safe for her to leave because of her psychological state. The SW stated she did not remember talking with the NP about how the AMA order would affect the Resident's insurance benefits. The SW stated she was aware of 2 times for sure that the NP and Resident #14 missed each other for further assessment. She confirmed the NP completed the assessment on 2/12/19. She stated there was a conference call scheduled tomorrow (2/27/19) to include Resident #14, the Ombudsman and the case manager. They would be discussing the Resident's options for discharge and the funding and services available for her through her insurance and other programs. Interview on 02/26/19 at 02:22 PM with Resident #14 insurance case manager (CM) revealed that the SW called her today to let her know that the AMA letter was lifted and confirmed the conference call scheduled for 2/27/19. The CM stated that the AMA order prevented them from assisting with Resident #14 with any discharge planning including referring her for subsidized housing and accessing benefits with the Money Follows the Person program and with a referral for services through the COIL program. She stated the benefits through the Money Follows the Person program was a one time benefit so she would have to find out what benefits the Resident accessed during her first discharge and determine what benefits were still available for her. The CM stated the Resident would still qualify for a housing vochure and whatever other services COIL provided and any other benefits through MCD/MICR; medical, home health etc. Review of a facility policy titled, Resident Rights revised during (MONTH) (YEAR) read in part: 1. Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident's right to: e. self-determination. Review of a facility policy titled, Quality of Life-Dignity read in part as follows: Each resident shall be cared for inn a manner that promotes and enhances quality of life, dignity, respect and individuality. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on interviews, observations and record reviews the facility failed to ensure residents were free from neglect for 6 of 6 residents (#2, #3, #4, #5, #6 and #7) whose care was reviewed for neglect, in that: The facility's structure to prevent abuse were not implemented when: 1. The facility failed to put interventions in place to manage Resident #1's aggressive behaviors to protect the resident and other residents from incidents of abuse. 2. The failure of not having interventions in place for Resident #1's aggressive behaviors led to an incident where resident #1 seriously injured Resident #3, resulting in Resident # 3 not wanting to come out of his room to avoid Resident #1. 3. The facility failed to protect Residents #2, #4, #5, #6 and #7 from abuse after they revealed they were afraid of Resident #1's aggressive behaviors and did not feel safe and free from abuse in the facility. These failures resulted in identification of an Immediate Jeopardy (IJ) on 02/19/2019. While the IJ was removed on 02/22/2019, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place to protect residents from Resident #1's repeated incidents of aggressive behavior and staff were trained on behavior strategies (dealing with residents with agitation and those with inappropriate behavior/suspicious paranoia and agitation) and abuse and neglect. This deficient practice could affect the residents at the facility and place them at risk for physical and/or psychosocial harm. The findings were: 1. Record review of Resident #1's face sheet revealed an admission date of [DATE] and readmitted on 02/01/2019 with [DIAGNOSES REDACTED]. Observation on 02/20/19 at 10:08 AM revealed Resident # 1 was sitting in his wheelchair in the day area with Resident #7, no staff were present monitoring residents in day area. Observation on 2/20/19 at 1:38 PM revealed Resident #1 was sitting in the hallway on Station 2, no staff were present monitoring residents in hallway. During an interview on 2/20/19 at 1:38 PM with Resident #1 he revealed he was given a 30-day notice. He further revealed it was because he asked a nurse for the time and when he asked her a second time she began to yell at him and they blame him for it. He then revealed he had another incident with another resident after that resident tried to grab an ice pack from his friend Resident #7's leg. Observation on 2/22/19 at 8:55 AM revealed Resident # 1 was walking in the hallway, pushing his wheelchair and AD (assigned on 1:1) was approximately three feet away from Resident #1. Record review of Resident #1's care plan revised 12/6/18 revealed resident had the potential to demonstrate physical behavioral symptoms toward others related to ineffective coping skills, such as poor anger management and poor impulse control due to [DIAGNOSES REDACTED]. Resident is known to stand from his wheelchair and charge towards others with intention, not easily redirected when agitated. No additional interventions were added to the care plan after the last MDS revision on 12/6/18. During an interview on 2/20/19 at 1:49 PM with the MDS Coordinator she confirmed they did not have any new interventions in place after the physical altercations on 2/6/19 and 2/15/19. She further confirmed she updated the care plan today and added Crisis line completed safety plan and resident on 1:1 supervision on 2/16/19, medication adjustments on 2/18/19. MDS Coordinator further confirmed Resident #1 is not currently on 1:1, he was just placed on 1:1 for 2/16/19. The MDS Coordinator further reveled she had seen Resident #1 stand up from his wheelchair and charge at other residents. It takes more than one staff member to redirect him. Sometimes he will walk out of the building to the parking lot and it takes 3-4 staff to bring him back into the building. The MDS Coordinator further revealed three residents had informed her they did not feel safe with Resident #1 at facility, Residents #4, #5 and #8. Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 13 (cognition intact), further review of MDS revealed resident had verbal behavior symptoms directed toward others. Record review of Resident #1's nursing progress note dated 1/20/19 at 1:52 PM written by LVN A revealed due to behavioral and psychological circumstances it is recommended that this resident get transferred to a facility that can manage both. During an interview on 02/21/19 at 2:40 PM with LVN A, LVN A revealed the recommendations for Resident #1 were made by the Psychiatric Nurse Practitioner (NP). LVN A further revealed she had not received any training on how to manage Resident #1's behavior. She further revealed Resident #1 was very difficult to de-escalate and redirect and had been verbally aggressive towards her. Record review of Resident #1's nursing progress note dated 1/20/19 at 6:23 PM revealed resident sent to psychiatric hospital for an evaluation and medication adjustment. Resident was witnessed in a verbal altercation with two other residents. The resident was then asked to remove himself from the dining room, in which, he did but continued to verbally accost the RN Supervisor. Police Department was notified report of harassment was filed. Responsible party convinced Resident to go to an inpatient psychiatric facility to be evaluated and treated. Record review of Resident #1's Crisis Assessment and Recommendation for Treatment dated 1/21/19 revealed Resident #1 has been increasing in his agitation towards staff and other residents. Resident has begun to attack others verbally and physically. He has stuck his arm out of his wheelchair to hurt others as they walk by, he has stood out of his wheelchair and charged others. Staff at facility stated that they cannot keep him safe and that he is a danger to others. History of present illness: Resident #1 has a history of mental health treatment including extensive hospitalization in a psych unit and [DIAGNOSES REDACTED]. Recommendations hospitalization . Record review of Resident #1's nursing progress note dated 1/21/19 at 6:30 PM revealed Resident returned to facility after AMA discharge from Hospital, MCOT (mobile crisis outreach team) assessed Resident met criteria. Resident continued to be easily agitated. Record review of Resident#1's nursing progress note dated 1/22/19 at 3:23 PM revealed Resident continues 1:1 since initial return from hospital. ED (emergency detention) was successfully initiated, and resident transported to Hospital via police escort. Record review of Resident #1's consolidated physician orders [REDACTED]. Record review of Resident #1's MAR for (MONTH) 2019 did not reveal any monitoring for behaviors or monitoring for side effects of medications. Further review of MAR indicated [REDACTED]. Record review of Resident #1's nursing progress note dated 2/1/19 at 6:31 PM revealed resident was readmitted to facility from the hospital. Record review of Resident #1's social services progress note dated 2/6/19 at 7:00 PM revealed LBSW informed sister of incident with another resident. Record review of Resident #1's social services progress note dated 2/16/19 at 6:14 AM revealed LBSW was made aware of resident to resident altercation from 2/15/19. MHMR Crisis Line contacted for MCOT evaluation. Record review of Resident #1's Crisis Assessment and Recommendation for Treatment dated 2/16/19 revealed Facility nurses reported that resident was in an altercation with another resident last night at the facility. Resident became physical with the other resident which led to the other resident being sent to the hospital. The other resident had multiple scratch marks, a laceration to his left ear, and a contusion on the left hip. Resident was restless throughout the night. This morning he asked the nurse repeatedly what time it was. After telling him several times the time, the nurse reminded resident that he had a watch on his wrist. Resident became angry and yelled at the nurse to just tell him the time. He would not calm down, so the nurse called the DON and the administrator, resident became angry and started coming towards the nurse. The nurse became afraid and started to walk away from him and he began to chase her. She ran down to the lock down unit and he began banging on the door and trying to get to her. Police were called and came to talk to resident. Police advised resident to stay away from the nurse that he was chasing. Further review of the Crisis Assessment revealed Resident #1 has become more aggressive recently and now is assaulting other residents. He is having more outbursts and increased agitation. Recommendations: A safety plan was developed between Resident #1 and MCOT. Resident will use coping strategies deep breaths-close my mouth, go find my buddy, smoking when he has warning signs developing such as loud, stand up on the chair, spit on self because I'm talking fast, being told I can't do something. Record review of Resident #1's social services progress note dated 2/19/19 at 3:16 PM revealed LBSW met with resident today to provide involuntary notice of discharge due to continued documented behavior of aggressiveness toward staff and other residents. Resident became extremely angry at beginning of conversation. AD present as witness attempted to calm resident with no success. Maintenance Supervisor came in and assisted with keeping resident calm. Resident continued to yell throughout conversation but took notice. Record review of Resident #1's social services progress note dated 2/16/19 at 5:44 PM revealed MCOT (mobile Crisis Outreach Team) assessed resident determined resident was not a threat to self or others. Safety plan was completed by MCOT. During an interview on 02/20/19 at 4:55 PM with Psychiatric NP, he revealed that he believed the facility does not meet Resident #1's needs due to [MEDICAL CONDITION] violent behaviors. He further revealed Resident #1 residing in the nursing facility was unsafe and inappropriate. NP stated he recently adjusted the dosages on Resident #1's psychiatric medications about two weeks ago and Resident #1 needs a more suiting long-term care living arrangement. During an interview on 02/21/19 at 8:22 AM the Administrator confirmed there was no documentation of any interventions for Resident#1's behavior. The Administrator further confirmed there was no behavior monitoring. During an interview on 02/21/19 at 8:58 AM with LVN B, she revealed Resident #1 continued with aggressive behaviors during the time after the physical altercation between Resident #1 and Resident #3 and was screaming loudly and using vulgar language. LVN B further revealed she attempted to verbally redirect Resident #1 then he proceeded to charge towards her even after she went behind closed doors in the secured unit, he banged on the doors and continued to try to reach her. She further revealed she never received any training on how to manage aggressive residents and that staff was not recording/monitoring Resident #1's behaviors. During an interview on 2/21/19 at 10:34 AM with the Social Worker, she confirmed the safety plan from MCOT should have been implemented. She further revealed they went over the safety plan and nursing received a copy. Social worker further revealed herself the Administrator and the BOM met informally the day after the incident and were made available to the resident if he needed to talk. During further interview the social worker revealed the safety plan could have been better communicated and added to the care plan. During an interview on 02/20/19 at 2:54 PM with LVN C (nurse assigned to resident), she stated Resident #1 only had a MAR, and that there was no treatment record or behavioral logs. She further stated Resident #1 is regularly verbally aggressive and outspoken and that staff are not tracking any of his behaviors. During an interview on 02/20/19 at 3:40 PM with CNA D, she revealed Resident #1 is regularly outspoken, he acts out if he doesn't get his way and gets jealous when staff are with other residents and not paying attention to him. She further stated she is not recording any of his behaviors and has not been trained to record or monitor his behaviors. Record review of facility's Policy on Abuse Prevention revision dated 5/29/18 revealed the facility creates a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. The facility will identify, assess, care-plan and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents with self-injurious behaviors, residents with communication disorders, and those that require heavy nursing care or are totally dependent on staff. Monitor the residents for early warning signs or any changes that would trigger abuse behavior and reassess strategies on a regular basis. 2. Record review of Resident # 3's face sheet revealed an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's 60-day MDS dated [DATE] revealed a BIMS of 15 (cognition intact). Record review of facility's incident report dated 2/15/19 revealed Resident # 3 was sent to the hospital for multiple injuries including scratch marks, a laceration to his left ear requiring skin glue for treatment, and a contusion on the left hip. During an interview with Resident #3 on 2/20/19 at 9:42 AM, Resident # 3 revealed he was recently involved in a verbal altercation that turned physical with Resident #1. He further revealed he was seriously injured from Resident #'1 attack and had to be taken to an ER by a family member to get treated for [REDACTED]. Resident # 3 stated the altercation started after Resident # 1 saw him talking to a mutual friend and feeling left out. Resident # 1 then started verbally abusing Resident # 3 and it escalated to physical aggression. Resident # 3 stated that he and his daughters have told the administrator about Resident # 1 starting fights with him and the administrator stated she would look into the matter. Resident #3 further stated Resident #1 calls him names, starts arguments and tries to fight him. Resident #3 stated he just tries to stay in his room to avoid any interaction with Resident #1 which makes him feel like he is missing out on doing other activities. 3. a. Record review of Resident #2's face sheet revealed an admission date of [DATE] and readmission on 11/07/18 with [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS of 15 (cognition intact). During an interview on 2/20/19 at 9:48 AM with Resident # 2 she revealed she witnessed Resident #1 instigate a verbal and physical attack towards Resident #6. During further interview with Resident # 2 she revealed Resident #1's behaviors make her feel unsafe. b. Record review of Resident #4's face sheet revealed an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 4's Quarterly MDS dated [DATE] revealed a BIMS of 10 (cognition moderately impaired). During an interview on 02/20/19 at 2:44 PM with Resident #4, he revealed Resident #1 is regularly pushing and instigating arguments with him by talking badly to him, verbally attacking him and testing him. He further stated that Resident #1 is always wanting to fight and is aggressive, and he does not feel safe at the facility because of Resident #1. c. Record review of Resident #5's face sheet revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS of 08 (cognition moderately impaired). During an interview on 02/20/19 at 1:32 PM Resident #5 revealed Resident #1 hit her two times last week and she had informed the nurse. She further revealed Resident #1 gets agitated, uses profanity (Specifically the F word) and does not feel safe when Resident #1 is around her. Resident #5 stated these attacks from Resident #1 have occurred in the hallways and dining room areas. d. Record review of Resident #6's face sheet revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. During an interview on 02/20/19 at 10:46 AM with alert and oriented Resident #6, he revealed Resident #1 pushes his buttons and that he starts verbal confrontations that have resulted in physical altercations. Resident #6 further revealed he did not feel safe around Resident #1. e. Record review of Resident #7's face sheet revealed an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 7's Admission MDS dated [DATE] revealed a BIMS of 15 (cognition intact). During an interview on 2/20/19 at 5:50 PM with Resident #7, he revealed Resident #1 starts verbal fights with him and regularly gets loud and starts yelling. He further revealed he continues to be his friend to avoid any conflicts. Resident #7 further revealed he did not feel safe in the facility with Resident #1 residing here. The DON was notified of the IJ on 2/20/19 at 4:50 PM and a Plan of Removal was requested. The Plan of Removal was requested. During an interview on 2/20/19 at 5:05 PM with the DON she revealed she believed the cause of the immediate jeopardy was Resident #1's aggressive behavior. She further revealed they had tried to find placement for him and consulted psychosocial services, but he refuses. After he returned from the hospital his medications were adjusted and he seemed to be doing better. She further revealed they had been meeting with other regional nurses and corporate management to discuss resident. They made the mistake of accepting the resident. They tried finding a place for him, but no one will accept him. They had to take him back from the hospital otherwise they would be dumping the resident on them. The DON further confirmed Resident #1's verbal aggressiveness led to the physical aggression. DON revealed she was not aware that other residents were afraid of him. The DON further revealed staff had received training on how to identify aggressive behavior and de-escalating situations. The DON further confirmed Resident #1's care plan was not updated, they were not doing any behavior monitoring, and staff did not receive additional training on Resident #1's behaviors. Plan of Removal- 02/20/19 1. On 02/20/19 the facility has placed Resident #1 on 1:1 24/7 until alternate placement is made. 2. On 02/19/19 an involuntary discharge was submitted to Resident #1's representative and the resident. 3. Beginning on 02/20/19 Safe Surveys conducted for Interviewable residents to determine if like residents are in the facility by social services and department managers. 4. Medical Director notified of facility Immediate Jeopardy by the DON on 02/20/19. On 02/21/19 Medical Director Recommends; no secure unit, medication review today 02/21/19, continue 1:1 monitoring until alternate placement can be arranged, continue safety plan and continue psychiatric services. 5. Out-of-cycle QAPI regarding protection of residents in the facility was held on 02/21/19 at 11:30 AM, the VPO, Regional Clinical Manager held the facility QAPI regarding the neglect of residents in the facility. 6. Senior Living Properties Policy and Procedure for Abuse/Neglect/Exploitation prevention training initiated on 02/20/19 with facility staff. Facility staff were trained on definition of abuse and neglect with emphasizes on the protection of residents during resident to resident altercations. An employee roster was obtained for all departments and the IDT was responsible for training their subordinates 1:1 and/or by phone to ensure 100% of active employees have received the training. Signatures were cross-referenced to ensure compliance of active employees. Staff members were given a hand out entitled Understanding why difficult behaviors occur; Problem solving strategies obtained from the SLP current behavioral manual. A copy of this literature is placed at the nurses' station for a quick reference. 7. Beginning on 02/20/19 Behavior Strategies training for Staff members. Detail: The SLP behavior manual implemented in (YEAR) by the former VP of clinical services pages 7-10 identify behaviors, potential causes or antecedents and management strategies, including but limited to; dealing with residents with agitation and those with inappropriate behavior/suspicious paranoia and agitation. 8. Health Care Plan update/review for Resident #1 updated 2/21/19 by Clinical Case Manager and reviewed by the Regional Clinical Manager, at 10:00 am. Goal: Resident # 1 will not exhibit any threatening behaviors towards other residents and/or staff members in the next 28 days. New Interventions added to protect other residents include the following; Attempt to predict impulsive unsafe behaviors based on body language and tone of voice. Continue 1:1 - 24/7 until alternate placement. Follow the safety plan established by the local mental health specialist on 2/16/19. (behavior skills training to assist the individual in reducing stress and managing symptoms, problem solving, provide instruction and structure to the individual in adapting to and copying with stressors-allow the resident to smoke at any time to relieve identified stressors regardless of the facility smoking schedule. If a psychotic episode occurs; the social worker or nursing staff will be notified and Mental Health Crisis Hotline and continue 1:1. Resident care plans are available 24/7 on the Point of Care Kiosk in which employees with Matrix access (direct care staff) can visualize care plans. Also available in Matrix is the Daily Activity report which serves as an alert for resident change in conditions and changes in treatment plan. Plan of correction date is 2/21/19. Verification of Plan of Removal- 02/22/19 1. Observations on 02/20/19 at 7:55 PM, 02/21/19 at 9:15 AM and 2/22/19 at 8:55 AM Resident #1 was on 1:1 supervision. Record review of telephone order dated 2/21/19 revealed orders for 1:1 continuously until alternate placement is arranged. Record review of facility's 1 to 1 Monitoring for Resident # 1 dated 2/20/19 revealed 1:1 started on 2/20/19- 2/21/19 at 6:30 PM- 6:00 PM. Record review of facility's 1:1 Monitoring for Resident # 1 dated 2/22/19 revealed 1:1 continued at 6:00 PM - current. 2. Involuntary Discharge - Notice of Involuntary Transfer or Discharge and Opportunity for Appeal was given to Resident on 2/19/19. Further review revealed effective date of Transfer or Discharge is 3/20/19. Discharge or transfer necessary for Resident #1's welfare because facility cannot meet his needs, as documented in the clinical record and by physician. The safety of individuals in the facility is endangered, as documented in the clinical record. 3. Record review of Safe Surveys provided by the facility revealed 10 Interviewable residents were surveyed to determine if like residents are in the facility. On 2/22/19 at 9:18 AM 3 of the 10 residents were interviewed and confirmed they had been surveyed by facility staff on if they were afraid of any specific resident and why. 4. Facility provided a signed letter by Medical Doctor dated 2/21/19 with recommendations for Resident #1: 1. Medication review 2/21/19. 2. No Secure unit placement 3. Continue the 1:1 monitoring 4. Continue the MHMR Safety Plan until alternate placement is arranged. 5. Continue psychiatric services 5. Record review of facility's QAPI sign in sheet dated 2/21/19 revealed topic was on Abuse Neglect Prevention, Behavior Strategies for Residents with agitation/physical altercations. Department heads, Medical Director, Administrator, Corporate Nurse and VPO attended. Copy of behavioral management strategies, SLP Operations, LLC Abuse Prevention Process and Abuse Prevention attached. 6. Record review and interview of staff in-services revealed Staff LVN E, LVN F, CNA G, CNA H, Restorative Aide I, and Restorative Aide J were trained on either 2/21/19 or 2/22/19 on facility procedure for Abuse/Neglect/Exploitation, some staff demonstrated handouts that were provided to them by the facility. 7. Record review and interview of staff in-services revealed Staff LVN E, LVN F, CNA G, CNA H, Restorative Aide I, and Restorative Aide J were trained on either 2/21/19 or 2/22/19 on Behavior Strategies, some of the staff demonstrated handouts that were provided to them by the facility. Review of facility's in-service sign in sheets revealed 63% of facility staff were in-serviced on abuse/neglect/exploitation and on Behavior Strategies. 100% of contracted staff were in-serviced. The remaining 27% of staff were called three times and messages were left. 8. Record review of Resident #1's Care Plan revealed a revision date of 2/21/19. Further review of care plan revealed new interventions were added: Attempt to predict impulsive unsafe behaviors based on body language and tone of voice. Continue 1:1 -24/7 until alternate placement. Follow the safety plan established by the local mental health specialist on 2/16/19. If a psychotic episode occurs; the social worker or nursing staff will be notified and Mental Health Crisis Hotline and continue 1:1. During an observation and interview with LVN E on 2/22/19 at 9:45 AM he was not able to locate the resident's care plan on the computer system. He asked for assistance from regional nurse who coached him through the process to locate the care plan on the computer system. Regarding the daily activity report, the nurse explained the report is printed by night staff in preparation to give report to day staff. He was able to provide a hard copy of the daily activity report for the residents he was caring for. During interview and observation with LVN F on 2/22/19 at 10:07 AM, she was able to locate a resident's care plan and daily activity report on the computer through the facility's computer system. POR was amended on 02/22/19; 63% of the staff training was completed, the remainder 27% will receive the training upon returning to work. While the IJ was removed on 02/22/2019 at 1:25 PM, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place to protect residents from Resident #1's aggressive behavior and staff were trained on behavior strategies (dealing with residents with agitation and those with inappropriate behavior/suspicious paranoia and agitation) and abuse and neglect.

Based on interviews, observations, and record reviews, the facility failed to implement written policies and procedures to ensure residents were free from abuse for 6 of 6 residents ( #2, #3, #4, #5, #6 and #7) whose care was reviewed for abuse, in that: The facility did not prohibit or prevent residents from abuse when: 1. The facility failed to put interventions in place to manage Resident #1's aggressive behaviors to protect the resident and other residents from incidents of abuse. 2. The failure of not having interventions in place for Resident #1's aggressive behaviors led to an incident where resident #1 seriously injured Resident #3, resulting in Resident # 3 not wanting to come out of his room to avoid Resident #1. 3. The facility failed to protect Residents #2, #4, #5, #6 and #7 from abuse after they revealed they were afraid of Resident #1's aggressive behaviors and did not feel safe and free from abuse in the facility. These failures resulted in identification of an Immediate Jeopardy (IJ) on 02/19/2019. While the IJ was removed on 02/22/2019, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place to protect residents from Resident #1's aggressive behavior and staff were trained on behavior strategies (dealing with residents with agitation and those with inappropriate behavior/suspicious paranoia and agitation) and abuse and neglect. This deficient practice could affect the residents at the facility and place them at risk for physical or psychosocial harm. The findings were: Record review of facility's Policy on Abuse Prevention revision dated 5/29/18 revealed the facility creates a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. The facility will identify, assess, care-plan and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents with self-injurious behaviors, residents with communication disorders, and those that require heavy nursing care or are totally dependent on staff. Monitor the residents for early warning signs or any changes that would trigger abuse behavior and reassess strategies on a regular basis. 1. Record review of Resident #1's face sheet revealed an admission date of [DATE] and readmitted on 02/01/2019 with [DIAGNOSES REDACTED]. Observation on 02/20/19 at 10:08 AM revealed Resident # 1 was sitting in his wheelchair in the day area with Resident #7, no staff were present monitoring residents in day area. Observation on 2/20/19 at 1:38 PM revealed Resident #1 was sitting in the hallway on Station 2, no staff were present monitoring residents in hallway. During an interview on 2/20/19 at 1:38 PM with Resident #1 he revealed he was given a 30-day notice. He further revealed it was because he asked a nurse for the time and when he asked her a second time she began to yell at him and they blame him for it. He then revealed he had another incident with another resident after that resident tried to grab an ice pack from his friend Resident #7's leg. Observation on 2/22/19 at 8:55 AM revealed Resident # 1 was walking in the hallway, pushing his wheelchair and AD (assigned on 1:1) was approximately three feet away from Resident #1. Record review of Resident #1's care plan revised 12/6/18 revealed resident had the potential to demonstrate physical behavioral symptoms toward others related to ineffective coping skills, such as poor anger management and poor impulse control due to [DIAGNOSES REDACTED]. Resident is known to stand from his wheelchair and charge towards others with intention, not easily redirected when agitated. No additional interventions were added to the care plan after the last MDS revision on 12/6/18. During an interview on 2/20/19 at 1:49 PM with the MDS Coordinator she confirmed they did not have any new interventions in place after the physical altercations on 2/6/19 and 2/15/19. She further confirmed she updated the care plan today and added Crisis line completed safety plan and resident on 1:1 supervision on 2/16/19, medication adjustments on 2/18/19. MDS Coordinator further confirmed Resident #1 is not currently on 1:1, he was just placed on 1:1 for 2/16/19. The MDS Coordinator further reveled she had seen Resident #1 stand up from his wheelchair and charge at other residents. It takes more than one staff member to redirect him. Sometimes he will walk out of the building to the parking lot and it takes 3-4 staff to bring him back into the building. The MDS Coordinator further revealed three residents had informed her they did not feel safe with Resident #1 at facility, Residents #4, #5 and #8. Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 13 (cognition intact), further review of MDS revealed resident had verbal behavior symptoms directed toward others. Record review of Resident #1's nursing progress note dated 1/20/19 at 1:52 PM written by LVN A revealed due to behavioral and psychological circumstances it is recommended that this resident get transferred to a facility that can manage both. During an interview on 02/21/19 at 2:40 PM with LVN A, LVN A revealed the recommendations for Resident #1 were made by the Psychiatric Nurse Practitioner (NP). LVN A further revealed she had not received any training on how to manage Resident #1's behavior. She further revealed Resident #1 was very difficult to de-escalate and redirect and had been verbally aggressive towards her. Record review of Resident #1's nursing progress note dated 1/20/19 at 6:23 PM revealed resident sent to psychiatric hospital for an evaluation and medication adjustment. Resident was witnessed in a verbal altercation with two other residents. The resident was then asked to remove himself from the dining room, in which, he did but continued to verbally accost the RN Supervisor. Police Department was notified report of harassment was filed. Responsible party convinced Resident to go to an inpatient psychiatric facility to be evaluated and treated. Record review of Resident #1's Crisis Assessment and Recommendation for Treatment dated 1/21/19 revealed Resident #1 has been increasing in his agitation towards staff and other residents. Resident has begun to attack others verbally and physically. He has stuck his arm out of his wheelchair to hurt others as they walk by, he has stood out of his wheelchair and charged others. Staff at facility stated that they cannot keep him safe and that he is a danger to others. History of present illness: Resident #1 has a history of mental health treatment including extensive hospitalization in a psych unit and [DIAGNOSES REDACTED]. Recommendations hospitalization . Record review of Resident #1's nursing progress note dated 1/21/19 at 6:30 PM revealed Resident returned to facility after AMA discharge from Hospital, MCOT (mobile crisis outreach team) assessed Resident met criteria. Resident continued to be easily agitated. Record review of Resident#1's nursing progress note dated 1/22/19 at 3:23 PM revealed Resident continues 1:1 since initial return from hospital. ED (emergency detention) was successfully initiated, and resident transported to Hospital via police escort. Record review of Resident #1's consolidated physician orders [REDACTED]. Record review of Resident #1's MAR for (MONTH) 2019 did not reveal any monitoring for behaviors or monitoring for side effects of medications. Further review of MAR indicated [REDACTED]. Record review of Resident #1's nursing progress note dated 2/1/19 at 6:31 PM revealed resident was readmitted to facility from the hospital. Record review of Resident #1's social services progress note dated 2/6/19 at 7:00 PM revealed LBSW informed sister of incident with another resident. Record review of Resident #1's social services progress note dated 2/16/19 at 6:14 AM revealed LBSW was made aware of resident to resident altercation from 2/15/19. MHMR Crisis Line contacted for MCOT evaluation. Record review of Resident #1's Crisis Assessment and Recommendation for Treatment dated 2/16/19 revealed Facility nurses reported that resident was in an altercation with another resident last night at the facility. Resident became physical with the other resident which led to the other resident being sent to the hospital. The other resident had multiple scratch marks, a laceration to his left ear, and a contusion on the left hip. Resident was restless throughout the night. This morning he asked the nurse repeatedly what time it was. After telling him several times the time, the nurse reminded resident that he had a watch on his wrist. Resident became angry and yelled at the nurse to just tell him the time. He would not calm down, so the nurse called the DON and the administrator, resident became angry and started coming towards the nurse. The nurse became afraid and started to walk away from him and he began to chase her. She ran down to the lock down unit and he began banging on the door and trying to get to her. Police were called and came to talk to resident. Police advised resident to stay away from the nurse that he was chasing. Further review of the Crisis Assessment revealed Resident #1 has become more aggressive recently and now is assaulting other residents. He is having more outbursts and increased agitation. Recommendations: A safety plan was developed between Resident #1 and MCOT. Resident will use coping strategies deep breaths-close my mouth, go find my buddy, smoking when he has warning signs developing such as loud, stand up on the chair, spit on self because I'm talking fast, being told I can't do something. Record review of Resident #1's social services progress note dated 2/19/19 at 3:16 PM revealed LBSW met with resident today to provide involuntary notice of discharge due to continued documented behavior of aggressiveness toward staff and other residents. Resident became extremely angry at beginning of conversation. AD present as witness attempted to calm resident with no success. Maintenance Supervisor came in and assisted with keeping resident calm. Resident continued to yell throughout conversation but took notice. Record review of Resident #1's social services progress note dated 2/16/19 at 5:44 PM revealed MCOT (mobile Crisis Outreach Team) assessed resident determined resident was not a threat to self or others. Safety plan was completed by MCOT. During an interview on 02/20/19 at 4:55 PM with Psychiatric NP, he revealed that he believed the facility does not meet Resident #1's needs due to [MEDICAL CONDITION] violent behaviors. He further revealed Resident #1 residing in the nursing facility was unsafe and inappropriate. NP stated he recently adjusted the dosages on Resident #1's psychiatric medications about two weeks ago and Resident #1 needs a more suiting long-term care living arrangement. During an interview on 02/21/19 at 8:22 AM the Administrator confirmed there was no documentation of any interventions for Resident#1's behavior. The Administrator further confirmed there was no behavior monitoring. During an interview on 02/21/19 at 8:58 AM with LVN B, she revealed Resident #1 continued with aggressive behaviors during the time after the physical altercation between Resident #1 and Resident #3 and was screaming loudly and using vulgar language. LVN B further revealed she attempted to verbally redirect Resident #1 then he proceeded to charge towards her even after she went behind closed doors in the secured unit, he banged on the doors and continued to try to reach her. She further revealed she never received any training on how to manage aggressive residents and that staff was not recording/monitoring Resident #1's behaviors. During an interview on 2/21/19 at 10:34 AM with the Social Worker, she confirmed the safety plan from MCOT should have been implemented. She further revealed they went over the safety plan and nursing received a copy. Social worker further revealed herself the Administrator and the BOM met informally the day after the incident and were made available to the resident if he needed to talk. During further interview the social worker revealed the safety plan could have been better communicated and added to the care plan. During an interview on 02/20/19 at 2:54 PM with LVN C (nurse assigned to resident), she stated Resident #1 only had a MAR, and that there was no treatment record or behavioral logs. She further stated Resident #1 is regularly verbally aggressive and outspoken and that staff are not tracking any of his behaviors. During an interview on 02/20/19 at 3:40 PM with CNA D, she revealed Resident #1 is regularly outspoken, he acts out if he doesn't get his way and gets jealous when staff are with other residents and not paying attention to him. She further stated she is not recording any of his behaviors and has not been trained to record or monitor his behaviors. 2. Record review of Resident # 3's face sheet revealed an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's 60-day MDS dated [DATE] revealed a BIMS of 15 (cognition intact). Record review of facility's incident report dated 2/15/19 revealed Resident # 3 was sent to the hospital for multiple injuries including scratch marks, a laceration to his left ear requiring skin glue for treatment, and a contusion on the left hip. During an interview with Resident #3 on 2/20/19 at 9:42 AM, Resident # 3 revealed he was recently involved in a verbal altercation that turned physical with Resident #1. He further revealed he was seriously injured from Resident #'1 attack and had to be taken to an ER by a family member to get treated for [REDACTED]. Resident # 3 stated the altercation started after Resident # 1 saw him talking to a mutual friend and feeling left out. Resident # 1 then started verbally abusing Resident # 3 and it escalated to physical aggression. Resident # 3 stated that he and his daughters have told the administrator about Resident # 1 starting fights with him and the administrator stated she would look into the matter. Resident #3 further stated Resident #1 calls him names, starts arguments and tries to fight him. Resident #3 stated he just tries to stay in his room to avoid any interaction with Resident #1 which makes him feel like he is missing out on doing other activities. 3. a. Record review of Resident #2's face sheet revealed an admission date of [DATE] and readmission on 11/07/18 with [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS of 15 (cognition intact). During an interview on 2/20/19 at 9:48 AM with Resident # 2 she revealed she witnessed Resident #1 instigate a verbal and physical attack towards Resident #6. During further interview with Resident # 2 she revealed Resident #1's behaviors make her feel unsafe. b. Record review of Resident #4's face sheet revealed an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 4's Quarterly MDS dated [DATE] revealed a BIMS of 10 (cognition moderately impaired). During an interview on 02/20/19 at 2:44 PM with Resident #4, he revealed Resident #1 is regularly pushing and instigating arguments with him by talking badly to him, verbally attacking him and testing him. He further stated that Resident #1 is always wanting to fight and is aggressive, and he does not feel safe at the facility because of Resident #1. c. Record review of Resident #5's face sheet revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS of 08 (cognition moderately impaired). During an interview on 02/20/19 at 1:32 PM Resident #5 revealed Resident #1 hit her two times last week and she had informed the nurse. She further revealed Resident #1 gets agitated, uses profanity (Specifically the F word) and does not feel safe when Resident #1 is around her. Resident #5 stated these attacks from Resident #1 have occurred in the hallways and dining room areas. d. Record review of Resident #6's face sheet revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. During an interview on 02/20/19 at 10:46 AM with alert and oriented Resident #6, he revealed Resident #1 pushes his buttons and that he starts verbal confrontations that have resulted in physical altercations. Resident #6 further revealed he did not feel safe around Resident #1. e. Record review of Resident #7's face sheet revealed an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 7's Admission MDS dated [DATE] revealed a BIMS of 15 (cognition intact). During an interview on 2/20/19 at 5:50 PM with Resident #7, he revealed Resident #1 starts verbal fights with him and regularly gets loud and starts yelling. He further revealed he continues to be his friend to avoid any conflicts. Resident #7 further revealed he did not feel safe in the facility with Resident #1 residing here. The DON was notified of the IJ on 2/20/19 at 4:50 PM and a Plan of Removal was requested. The Plan of Removal was requested. During an interview on 2/20/19 at 5:05 PM with the DON she revealed she believed the cause of the immediate jeopardy was Resident #1's aggressive behavior. She further revealed they had tried to find placement for him and consulted psychosocial services, but he refuses. After he returned from the hospital his medications were adjusted and he seemed to be doing better. She further revealed they had been meeting with other regional nurses and corporate management to discuss resident. They made the mistake of accepting the resident. They tried finding a place for him, but no one will accept him. They had to take him back from the hospital otherwise they would be dumping the resident on them. The DON further confirmed Resident #1's verbal aggressiveness led to the physical aggression. DON revealed she was not aware that other residents were afraid of him. The DON further revealed staff had received training on how to identify aggressive behavior and de-escalating situations. The DON further confirmed Resident #1's care plan was not updated, they were not doing any behavior monitoring, and staff did not receive additional training on Resident #1's behaviors. Plan of Removal- 02/20/19 1. On 02/20/19 the facility has placed Resident #1 on 1:1 24/7 until alternate placement is made. 2. On 02/19/19 an involuntary discharge was submitted to Resident #1's representative and the resident. 3. Beginning on 02/20/19 Safe Surveys conducted for Interviewable residents to determine if like residents are in the facility by social services and department managers. 4. Medical Director notified of facility Immediate Jeopardy by the DON on 02/20/19. On 02/21/19 Medical Director Recommends; no secure unit, medication review today 02/21/19, continue 1:1 monitoring until alternate placement can be arranged, continue safety plan and continue psychiatric services. 5. Out-of-cycle QAPI regarding protection of residents in the facility was held on 02/21/19 at 11:30 AM, the VPO, Regional Clinical Manager held the facility QAPI regarding the neglect of residents in the facility. 6. Senior Living Properties Policy and Procedure for Abuse/Neglect/Exploitation prevention training initiated on 02/20/19 with facility staff. Facility staff were trained on definition of abuse and neglect with emphasizes on the protection of residents during resident to resident altercations. An employee roster was obtained for all departments and the IDT was responsible for training their subordinates 1:1 and/or by phone to ensure 100% of active employees have received the training. Signatures were cross-referenced to ensure compliance of active employees. Staff members were given a hand out entitled Understanding why difficult behaviors occur; Problem solving strategies obtained from the SLP current behavioral manual. A copy of this literature is placed at the nurses' station for a quick reference. 7. Beginning on 02/20/19 Behavior Strategies training for Staff members. Detail: The SLP behavior manual implemented in (YEAR) by the former VP of clinical services pages 7-10 identify behaviors, potential causes or antecedents and management strategies, including but limited to; dealing with residents with agitation and those with inappropriate behavior/suspicious paranoia and agitation. 8. Health Care Plan update/review for Resident #1 updated 2/21/19 by Clinical Case Manager and reviewed by the Regional Clinical Manager, at 10:00 am. Goal: Resident # 1 will not exhibit any threatening behaviors towards other residents and/or staff members in the next 28 days. New Interventions added to protect other residents include the following; Attempt to predict impulsive unsafe behaviors based on body language and tone of voice. Continue 1:1 - 24/7 until alternate placement. Follow the safety plan established by the local mental health specialist on 2/16/19. (behavior skills training to assist the individual in reducing stress and managing symptoms, problem solving, provide instruction and structure to the individual in adapting to and copying with stressors-allow the resident to smoke at any time to relieve identified stressors regardless of the facility smoking schedule. If a psychotic episode occurs; the social worker or nursing staff will be notified and Mental Health Crisis Hotline and continue 1:1. Resident care plans are available 24/7 on the Point of Care Kiosk in which employees with Matrix access (direct care staff) can visualize care plans. Also available in Matrix is the Daily Activity report which serves as an alert for resident change in conditions and changes in treatment plan. Plan of correction date is 2/21/19. Verification of Plan of Removal- 02/22/19 1. Observations on 02/20/19 at 7:55 PM, 02/21/19 at 9:15 AM and 2/22/19 at 8:55 AM Resident #1 was on 1:1 supervision. Record review of telephone order dated 2/21/19 revealed orders for 1:1 continuously until alternate placement is arranged. Record review of facility's 1 to 1 Monitoring for Resident # 1 dated 2/20/19 revealed 1:1 started on 2/20/19- 2/21/19 at 6:30 PM- 6:00 PM. Record review of facility's 1:1 Monitoring for Resident # 1 dated 2/22/19 revealed 1:1 continued at 6:00 PM - current. 2. Involuntary Discharge - Notice of Involuntary Transfer or Discharge and Opportunity for Appeal was given to Resident on 2/19/19. Further review revealed effective date of Transfer or Discharge is 3/20/19. Discharge or transfer necessary for Resident #1's welfare because facility cannot meet his needs, as documented in the clinical record and by physician. The safety of individuals in the facility is endangered, as documented in the clinical record. 3. Record review of Safe Surveys provided by the facility revealed 10 Interviewable residents were surveyed to determine if like residents are in the facility. On 2/22/19 at 9:18 AM 3 of the 10 residents were interviewed and confirmed they had been surveyed by facility staff on if they were afraid of any specific resident and why. 4. Facility provided a signed letter by Medical Doctor dated 2/21/19 with recommendations for Resident #1: 1. Medication review 2/21/19. 2. No Secure unit placement 3. Continue the 1:1 monitoring 4. Continue the MHMR Safety Plan until alternate placement is arranged. 5. Continue psychiatric services 5. Record review of facility's QAPI sign in sheet dated 2/21/19 revealed topic was on Abuse Neglect Prevention, Behavior Strategies for Residents with agitation/physical altercations. Department heads, Medical Director, Administrator, Corporate Nurse and VPO attended. Copy of behavioral management strategies, SLP Operations, LLC Abuse Prevention Process and Abuse Prevention attached. 6. Record review and interview of staff in-services revealed Staff LVN E, LVN F, CNA G, CNA H, Restorative Aide I, and Restorative Aide J were trained on either 2/21/19 or 2/22/19 on facility procedure for Abuse/Neglect/Exploitation, some staff demonstrated handouts that were provided to them by the facility. 7. Record review and interview of staff in-services revealed Staff LVN E, LVN F, CNA G, CNA H, Restorative Aide I, and Restorative Aide J were trained on either 2/21/19 or 2/22/19 on Behavior Strategies, some of the staff demonstrated handouts that were provided to them by the facility. Review of facility's in-service sign in sheets revealed 63% of facility staff were in-serviced on abuse/neglect/exploitation and on Behavior Strategies. 100% of contracted staff were in-serviced. The remaining 27% of staff were called three times and messages were left. 8. Record review of Resident #1's Care Plan revealed a revision date of 2/21/19. Further review of care plan revealed new interventions were added: Attempt to predict impulsive unsafe behaviors based on body language and tone of voice. Continue 1:1 -24/7 until alternate placement. Follow the safety plan established by the local mental health specialist on 2/16/19. If a psychotic episode occurs; the social worker or nursing staff will be notified and Mental Health Crisis Hotline and continue 1:1. During an observation and interview with LVN E on 2/22/19 at 9:45 AM he was not able to locate the resident's care plan on the computer system. He asked for assistance from regional nurse who coached him through the process to locate the care plan on the computer system. Regarding the daily activity report, the nurse explained the report is printed by night staff in preparation to give report to day staff. He was able to provide a hard copy of the daily activity report for the residents he was caring for. During interview and observation with LVN F on 2/22/19 at 10:07 AM, she was able to locate a resident's care plan and daily activity report on the computer through the facility's computer system. POR was amended on 02/22/19; 63% of the staff training was completed, the remainder 27% will receive the training upon returning to work. While the IJ was removed on 02/22/2019 at 1:25 PM, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place to protect residents from Resident #1's aggressive behavior and staff were trained on behavior strategies (dealing with residents with agitation and those with inappropriate behavior/suspicious paranoia and agitation) and abuse and neglect.

Based on observations, record reviews and interviews, the facility failed to ensure treatment and care was provided in accordance with the comprehensive assessment and professional standards of practice that met the physical, mental and psychological needs for 1 of 6 residents (#1) reviewed for falls in that: The facility failed to obtain a STAT x-ray of Resident #1's right leg in accordance with the physician's orders [REDACTED]. The resident was sent to the emergency room for evaluation and treatment 5 days after the x-ray results were reported to the facility and 13 days after the fall. This deficient practice could affect 6 residents in the facility and put them at risk for falls and injury. The findings were: Review of Resident #1's admission record dated 9/21/15 revealed the resident was admitted on [DATE] with a past medical history of [REDACTED]. Review of an annual MDS dated [DATE] and a quarterly MDS dated [DATE] revealed an assessment of BIMS that could not be determined due to severe cognitive and memory deficit. The resident's functional status was assessed as totally dependent on staff for all ADLs and used a wheelchair to ambulate. Review of a care plan dated 4/17/16 to 10/28/17 stipulated that the resident was at risk for falls due to cognitive loss, lack of safety awareness and a history of falls. Review of an Event Summary Report (incident report) dated 12/27/17 revealed that Resident #1 had a fall from her wheelchair in the dining room at 12:30 p.m. Two nurse aides lifted the resident off the floor into the wheelchair and reported the incident to the charge nurse. The resident was incompliant during the skin assessment for injuries and the resident was taken to her room to lie down. Review of an incident report dated 12/27/17 revealed the RP (daughter) and physician had been informed of the fall at 12:40 p.m. on 12/27/17. Review of a nursing progress note dated 12/31/17 revealed the nursing staff had noticed a latent bruising to the right side of the leg and hip from a recent fall of 12/27/17. The progress note documented notifying the Medical Director (MD) and DON. Review of a physician's orders [REDACTED]. A second ordered dated 1/3/18 revealed the order was discontinued at 3:27 p.m. by the attending physician. Review of a progress note dated 1/2/18 revealed that the facility social worker had attempted to contact the RP to discuss the option for hospice services and left a voice message to return her call. Review of a nursing progress note dated 1/3/18 revealed that the x-ray ordered on [DATE] had been cancelled at the request of the admitting hospice nurse, RN D because the daughter had felt that the x-ray would cause the resident discomfort. Review of the hospice admission note by RN D dated 1/3/18 revealed that the a large bruise to the right upper leg was swollen and measured 42 cm right and 37 cm left. X-ray was ordered but per daughter request canceled. During an interview at 2:49 p.m. on 1/12/18, the RP reported that when she was informed of Resident #1's fall on 12/27/17 she asked the staff member, LVN A, to have the resident seen by a physician. She stated that although the facility later reported that the resident had fallen twice on 12/27/17, she received only one call and was not aware of the second fall. The RP denied refusing an x-ray of the resident's right leg on 1/3/18 and stated that she had been informed by the RN D that the injury was to the lower leg. Review of a facility nursing progress note dated 1/3/18 revealed that the resident was alert but unable to verbalize needs or wants and was dependent upon staff for all aspects of care. Discoloration remained to the right leg and hip. Resident unable to verbalize pain. No facial grimacing. Review of NP G's progress report dated 1/3/18 revealed that the resident had a fall on 12/27/17 and was presenting with a bruise in her right inner thigh area. X-ray ordered yesterday still pending. Review of a nursing progress note dated 1/4/18 at 1:24 p.m. revealed that the facility staff had reviewed Resident #1's progress during a risk management meeting and concluded that the current plan of care could be continued until the following week. Review of a nursing progress note dated 1/5/18 at 6:11 p.m. revealed the right upper leg had increased in swelling, tenderness and pain. RN D was contacted at 9:40 a.m. on 1/5/18 and the facility was instructed to contact and inform the RP. The RP was contacted and requested that an x-ray be done. The facility then received a STAT order for an x-ray at 9:48 a.m. from NP G. Review of a nursing progress note dated 1/5/18 revealed that the STAT x-ray placed at 9:48 a.m. on 1/5/18 could not be done until the following day, 1/6/18 at 1:30 p.m. The facility did not attempt to transport the resident to the ER at this time. Review of a nursing progress note dated 1/6/18 at 6:33 p.m. revealed that the x-ray was positive for a fracture. The report revealed an acute open significantly displaced distal right femoral diaphyseal fracture (a bone break that occurs along the shaft of a long bone like the femur in the thigh). At 10:30 p.m. on 1/6/18 the resident was medicated with 1 ml of [MEDICATION NAME] SL. The dressing to the right knee was changed due to tint red drainage. Review of RN D's progress note for 1/7/18 revealed that she had changed Resident #1's dressing with the help of facility LVN M. A small amount of serosanguinous drainage was noted. The wound was recovered. During an interview at approximately 4:00 p.m. on 1/22/18, facility LVN M stated that he had assisted Hospice RN D with the dressing change of Resident #1's right leg on 1/7/18 and noted the protruding bone from the open wound. He stated since he was unfamiliar with Resident #1 he did not report the observation to the charge nurse, or to the weekend supervisor. Review of RN D's progress note for 1/8/18 revealed that she had encouraged the CN, LVN B to obtain an orthopedic consult as soon as possible as the resident was at risk for infection. RN D documented updating the Hospice Medical Director, who responded that another day (in facility) would not matter. Review of the nursing progress note from the night charge nurse on 1/9/18 at 3:11 a.m. revealed that the right leg bruising had different stages of healing. The ACE wrap had pushed down to under the knee and was soiled with blood and yellowish drainage. The Ace wrap was removed and revealed a jagged bone sticking out of slightly above the knee approximately 2 cm out. When the resident moved her leg, the bone protruded out more with movement. The wound was redressed. The daughter was present during the observation. Review of the Administrator's morning meeting note dated 1/9/18 revealed that the night observation had been discussed and the resident was transferred to the ER at 10:15 a.m. During an interview on 1/10/18 at 10:45 a.m., the Administrator reported that on Friday, 1/5/18, she had conducted clinical rounds with her staff and noted that Resident #1's right leg was still swollen. She stated that she instructed the nursing staff to order an x-ray. A STAT order was given by the facility's NP. Due to a delay on the part of the x-ray company, the x-ray was not conducted until 1:30 p.m. on 1/6/18 and the x-ray was positive for a displaced [MEDICAL CONDITION] femur. The Administrator stated that she reported the fracture to the Regulatory Agency, but was not aware of a protruding fracture until 1/9/18 when she had the resident transported out of the facility to an emergency room . During an interview at 4:17 p.m. on 1/19/18, NP G reported that it was customary to order an x-ray when a resident fell . She stated that Resident #1 was being co-managed with the hospice agency and that she had not seen the protruding bone, but saw the bruising in different stages of healing. She stated that the cancelation of her original x-ray order was the fault of the hospice agency admitting the resident to their service. NP G stated that she was not informed of the fall on 12/27/17 until 12/31/17, although she was in the building on 12/29/17. NP G stated that STAT was regarded as within 4 hours. During an interview at 11:56 a.m. on 1/22/18, LVN I, Staffing Coordinator, reported that she had seen Resident #1's leg on 1/1/18, New Year's Day, because CNA L wanted her to notice the swelling to the right leg, as the charge nurse was an agency nurse and was unfamiliar with the residents. LVN I stated that she noticed the swelling and redness and called NP G. On 1/2/18, LVN I reported that she noticed that the x-ray had not been done due to an issue related to the x-ray company. Two other residents with x-ray orders had also not been done. On 1/3/18, LVN I stated that the order had been cancelled due to Hospice RN D speaking with the daughter on 1/3/18. As far as she knew, no one on the staff had spoken to the daughter. During an observation at 4:50 p.m. on 1/19/18, Resident #1 was observed lying in bed with an undressed sutured wound above the right knee approximately 2 to 3 inches long. A long bandage was noted extending from the right hip to the middle of the thigh. The right foot was protected in a foam boot and the skin was intact. During an interview at 5:30 p.m. on 1/19/18, RN D was asked why she didn't order an x-ray after noticing the swelling to the right leg. RN D reported that she did not order an x-ray of the right leg during admission of Resident #1, because there was an order for [REDACTED].>During an interview at 5:40 p.m. on 1/19/18, the Hospice Medical Director reported that the x-ray should have been done prior to the admission and stated that she had been emphatic that an x-ray be performed. She stated that she felt uncomfortable having Resident #1 on her service without the x-ray being performed, although she had tried to honor the daughter's refusal for the x-ray. She stated that she was informed on Thursday, 1/4/18, that the daughter had declined the x-ray. During an interview at 11:45 a.m. on 1/22/18, CNA L reported that she had been off for a few days after helping Resident #1 to bed on 12/27/17 and had first saw the swelling to the right leg on 1/5/18. She stated that she immediately reported it to LVN B. During an interview by phone at approximately 5:00 pm on 11/25/18, the facility's attending physician for Resident #1 at the facility reported that he was not available for consult from 1/4/18 to 1/10/18 and was vaguely familiar with the circumstances that transpired. He reported that he had not spoken to the hospice medical director and indicated that there might have been some miscommunication between the hospice agency and his NP and that he was not involved in the decisions of care. The facility's CMS Form 672 date 1/10/18 reported 6 residents at risk for falls and injury.

Based on observations, interviews, and record reviews, the facility failed to be administered in a manner than enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 7 of 17 residents (Resident #s 14, 5, 6, 1, 3, 7, and 2) whose care was reviewed in that: 1. The administrator and DON failed to identify recurrent falls for Resident #s 1, 14, 2, and others and to address these falls. Resident #s 1, 14, 2, and others continued to fall without effective interventions. 2. The administrator and DON failed to provide staffing on the women's unit that was sufficient to meet Resident #14's needs. 3. The administrator admitted residents to the facility whose needs could not be met by facility staff. 4. The administrator failed to create an environment in which staff felt free to voice concerns. 5. The administrator and DON failed to monitor staff to ensure that MDS assessments were being completed for Resident #s 5, 6, 1, 3, and 7. 6. The administrator and DON failed to ensure that the QAPI process was utilized to fix identified problem areas. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 10/27/17. While the IJ was removed on 11/2/17, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all residents were assessed and all staff were in-serviced. This deficient practice could affect all 139 residents at the facility by contributing to inadequate care, more falls and resident-to-resident altercations, and injury. The findings were: Record review of the DON's job description (revised 6/16/17) revealed Responsibilities/Accountabilities: Clinical Excellence: . 2. Determines the workforce/staffing model for the nursing department necessary to meet the nursing needs of the patients 3. Oversees implementation and evaluation of the staffing model to assure high quality, cost-effective care . 5. Collaborates and coordinates with other departments and professionals to provide timely, safe, and effective care consistent with individuals' needs, choices, and preferences . Business Excellence: . 6. Provides oversight and approves nursing department schedules to include position control and pay practices . 8. Implements and assures adherence to the organization's policies and procedures . Administrative: . 1.3 Manages staffing 1.3.1. Determines the staffing needs of the nursing department necessary to meet the nursing needs of the patients 1.3.2 Recruits, interviews, hires, on-boards, and orients professional nursing staff . Clinical Leadership: . 2.11 Ensures a process is in place for communication between licensed nursing staff and CNAs during and between shifts 2.12 Ensures a process is in place to provide shift-to-shift communication between incoming and outgoing nursing staff 2.13 Ensures timely and accurate compliance of the MDS process and that it reflects the patient's plan of care 2.14 Reviews prospective admissions in relation to existing nursing capabilities and ensures readiness to treat . Quality Improvement: . 3.5 Ensures that the patients' care plans are implemented and periodically reviewed and modified as necessary 3.6 Ensures that physician orders [REDACTED]. 3.8 Ensures that patient's accident/incident, adverse event and grievances/concerns are fully documented, investigated, reported and addressed in accordance with (the corporation's) policies and procedures and the federal/state rules and regulations. During an interview with the DON at 5:53 p.m. on 10/30/17, when asked how she thought the Immediate Jeopardy (IJ) situation came about, she stated We have a lot of demented and psychotic residents that we can't stop from falling. Even if we try our best, they will keep falling. (Resident #14) - It's a behavior - We can't stop her falls - We just have to keep her safe. The DON reported that the facility's problems came with the evacuees and stated The people who are falling are (sister facility's) residents. When asked if the type of residents at the facility needed more staff, the DON responded with silence and then stated It depends on the unit. Station 2 has 3 CNAs and 2 nurses - that's fine. Station 1 has 2 CNAs, a nurse, and a medication aide - that's fine. The men's unit - not heavy - 1 CNA and a nurse is enough. The women's unit - (sister facility) walkie/talkies affected our residents. Before we got the evacuees, we added a medication aide - 2 CNAs, a medication aide, and a nurse. Now, with the evacuees, depending on the behavior of the residents on the women's unit, we need more staff sometimes. They're (the staff on the women's unit) asking for more, but I don't decide that. When asked who decided that, the DON stated We follow guidelines - the state ratio - 1 CNA to 12 residents on the day shift. The DON was unaware that Texas did not have a staffing ratio and that staffing was determined by resident need. Record review of the administrator's job description (effective 1/1/16) revealed Position Summary: Create an environment where staff members are highly engaged and focused on providing the highest level of clinical care and [MEDICATION NAME] to patients, residents, and families . responsible for planning and is accountable for all activities and departments of the center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents . administers, directs, and coordinates all activities of the center to assure that the highest degree of quality of care is consistently provided to residents . Essential Functions: Business Excellence: 1. Assures that the QAPI process is understood and utilized by all members of the center leadership team to continually improve all aspects of center performance as measured by the center performance scorecard 2. Oversees and assures an efficient Refer to Admit Process which maximizes center occupancy . Clinical Excellence: 1. Is highly visible throughout the center on all shifts and days of the week to develop positive relationships with residents, patients, family members and staff to assure that the needs of all are being met . 3. Assures that staffing levels in all departments are appropriate to meet the needs of all patients and residents 4. Confers with consultants to various departments concerning problem areas and utilizes the QAPI process to improve performance 5. Creates an environment that is focused on patient and staff safety . Compliance: . 7. Provides open lines of communication regarding compliance issues within management area and access to the integrity line, and ensures that retaliation against staff who report suspected incidences of noncompliance does not occur . 8. Participates in education, monitoring and auditing activities and investigations, and implementing quality assurance and performance improvement processes, as required. During an interview with the administrator at 2:12 p.m. on 11/1/17, when asked how she thought the Immediate Jeopardy (IJ) situation came about, she stated Lack of accurate observation and clinical assessment by charge nurse. I think she lied. I cornered her in a lie by interviewing her and others. The surveyor then clarified herself with That's the incident. What brought about the system breakdown? The administrator responded with I don't know because I disagree with the IJ because your RD/PM/whatever does not believe residents have the right to fall and believes that all falls can be prevented. I don't agree with that in a nursing home environment. That's an impossible expectation. When asked if she believed that her facility had issues with falls, the administrator stated No. The number of falls I have given the population of residents I take care of, I don't think it's excessive. When asked if she was aware of the situation that caused the IJ, the administrator stated Yes. We have a high number of falls. The administrator reported that she and the DON had looked at staffing on the women's unit and added a medication aide in June. The administrator reported that the addition of the medication aide helped and that the incidents on the unit seemed to slow down until the facility got the hurricane evacuees. When asked if, with the addition of the evacuees, another staff member of the unit would help, the administrator stated I don't know. If you get too many staff, they get lax. When asked what resources were available to her and her staff, the administrator reported that the corporation's policies and procedures were online and stated Staff wouldn't even know where to look for them. We talk about policies and procedures during in-services as needed. When asked how she ensured the competency of her staff and evaluated the facility's policies and procedures to ensure the effectiveness of facility processes, the administrator reported that she did not evaluate the facility's policies and procedures. The administrator stated I don't. Corporate does this. I follow the corporate policies and procedures. If I have issues with the policies and procedures, I inform (Corporate Nurse H) or (Vice President of Operations). The administrator reported that she used citations, weekly monitoring meetings, CASPER reports, and Quality Measures to evaluate the effectiveness of facility processes. 1. a. Record review of Resident #1's facesheet (dated 10/25/17) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS assessment (ARD 8/30/17) revealed that she could sometimes be understood and could sometimes understand. Her vision was assessed as being adequate without lenses. There were dashes for all areas of cognition, mood, behavior, and functional status (exceptions were balance - noted as not steady but able to stabilize without staff assistance - and ROM - no impairment). She was assessed to have had falls in the last month prior to admission and one fall without injury since admission. In the 7-day look back period, she was administered an antipsychotic 4 days, an antianxiety medication 6 days, and an antidepressant 6 days. Record review of Resident #1's care plan (provided to the investigator on 10/25/17) revealed that her fall risk was addressed with interventions of orthostatic blood pressures every shift for 72 hours (initiated 9/22/17), medication evaluation as needed (initiated 8/27/17), assist resident getting in and out of bed with 1-2 assistance (initiated 8/27/17), provide verbal cues for safety and sequencing when needed (initiated 8/27/17), provide verbal cues for proper pacing and energy conservation techniques (initiated 8/27/17), provide resident/caregiver education for safe techniques (initiated 9/18/17), place call light within reach while in bed or close proximity to bed (initiated 8/27/17), remind resident to use call light when attempting to ambulate or transfer (initiated 8/27/17), maintain a clutter-free environment in the resident's room and consistent furniture arrangement (initiated 8/27/17), when resident is in bed place all necessary personal items within reach (initiated 8/27/17), monitor for and assist with toileting needs (initiated 8/27/17), and resident to be screened by therapy (initiated 8/29/17). Record review of the facility's incident/accident reports revealed: 8/25/17 11:30 a.m. - Resident #1 was found on the floor in the dining room. She attempted to stand without assistance. It was noted that Resident #1 was not able to ambulate without assistance and was limited to her wheelchair. The brakes on her wheelchair were documented as not being locked. Interventions were monitoring for adjustment to the facility (Resident #1 was an evacuee), a therapy screen, and x-rays. There were no other documented interventions. During an interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that therapy screened Resident #1 on 8/29/17 and determined that she was appropriate for services. However, Resident #1's family declined therapy at this time because 1) they didn't know how long Resident #1 would be at the facility and 2) they thought she may be having adjustment issues and wanted to give her time to adjust. Further record review of the facility's incident/accident reports revealed: 9/12/17 11:30 a.m. - Resident #1 had a witnessed fall in the hallway. She attempted to sit in her wheelchair, missed the chair, and fell on her back side. There was no documentation pertaining to whether or not her wheelchair brakes were locked. Interventions were resident education on safe technique and continued PT/OT for gait/strengthening. During an interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that Resident #1 was not picked up for therapy after her 8/25/17 fall because the family declined it. At the time of her 9/12/17 fall, Resident #1 was not receiving therapy services During an interview with the DON at 8:44 a.m. on 10/27/17, when asked about Resident #1 being educated on safe technique, she stated We can educate at that time, but residents on the unit especially forget. During continued interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that physical therapy picked Resident #1 up for services on 9/13/17 because she was falling and because her family agreed to it. PT K stated Her main thing was wandering. My point of view . she had the [MEDICAL CONDITION] symptoms of dementia - slow movement, decreased step length, and instability while walking. Antipsychotic medications are given for dementia, and they usually cause the [MEDICAL CONDITION] stuff. We try to increase movement, joint movement, and postural stability. We do gait training and walking, the lower extremity bike to improve endurance and lower extremity strength and rhythm. When asked if Resident #1 was cooperative with therapy, PT K stated It was more about the dementia - a lot of anxiety and confusion. She'd have a crying spat - we'd work - and then she'd cry again. Overall, she did participate with verbal and tactile cueing and encouragement. Further record review of the facility's incident/accident reports revealed: 9/21/17 - Resident #1 lost her footing in the dining room and sat down on the floor. Intervention was to monitor orthostatic blood pressure for 3 days. Record review of Resident #1's 9/22/17 physician order [REDACTED]. Two times a day for 3 days - Evaluate both recording for potential orthostatic [MEDICAL CONDITION] indicated systolic drops by 20 units or diastolic drops by 10 units - Document occurrence and action taken in progress note was included in order summary. During an interview with the DON at 12:23 p.m. on 10/27/17, when asked why the facility decided to do blood pressure checks on Resident #1 after her 9/21/17 fall, she stated To rule out orthostatic [MEDICAL CONDITION]. Staff noticed she would stand up, get dizzy, and then sit back down. The DON, at this time, reported that Resident #1's blood pressures were normal (120/70) when checked for 3 days. Record review of Resident #1's Medication/Treatment Administrator Records for September of 2017 revealed that her blood pressures were as follows: 9/22/17 7:00 p.m. - sitting 118/62, standing 127/74 9/23/17 7:00 a.m. - sitting 145/76, standing 108/76 9/23/17 7:00 p.m. - sitting 114/74, standing 88/61 9/24/17 7:00 a.m. - sitting 126/72, standing 116/64 9/24/17 7:00 p.m. - sitting 112/62, standing 98/43 9/25/17 7:00 a.m. - sitting 125/75, standing (not documented) During an interview with the DON and Corporate Nurse H at 1:18 p.m. on 10/27/17, the DON confirmed that Resident #1's diastolic and systolic blood pressures had dropped significantly during the 3 days of monitoring after her 9/21/17 fall. When asked if the medication aide/nurse who took the abnormal blood pressures notified the doctor according to his order, the DON reviewed the progress notes and said that there was no indication that the doctor had been notified. During an interview with the DON at 3:00 p.m. on 10/27/17, the investigator asked So if blood pressure checks after Resident #1's 9/21/17 fall to rule out orthostatic [MEDICAL CONDITION] were done and were abnormal and it doesn't look like nurse notified the doctor . The DON intervened with The doctor normally says just to monitor if the resident is not on blood pressure medications. The investigator continued with But we don't know that he would say that. The orders say document occurrence and action taken in progress notes. There's no documentation in progress notes. So what was the point of the intervention if nothing was done when the blood pressures were abnormal? The DON did not respond at first. She then stated They were still within normal range. The investigator then stated But orthostatic [MEDICAL CONDITION] is a drop and there was a drop. Further record review of the facility's incident/accident reports revealed: 9/26/17 - Resident #1 was found on the floor in the dining room. She attempted to stand from her wheelchair without assistance and fractured her right hip. There was no documentation pertaining to whether or not her wheelchair brakes were locked. Intervention (post readmission after hip surgery) was PT/OT/ST. During an interview with the DON at 8:45 a.m. on 10/12/17, she reported that the facility terminated and referred LVN D to the Board of Nursing because she did not report Resident #1's 9/26/17 fall or assess Resident #1 for injury after her 9/26/17 fall. They determined this through interviews when doing their own investigation of Resident #1's [MEDICAL CONDITION]. During an interview with Medication Aide C at 1:03 p.m. on 10/24/17, she reported that she was coming back to the unit on the early afternoon of 9/26/17 and heard a yell from another resident. She reported that she ran to the dining room (where the yell came from) and found Resident #1 on her back. There were no staff in the dining room at the time. Medication Aide C reported that she got LVN D and that LVN D told her and CNA E to get Resident #1 in her wheelchair. Medication Aide C reported that LVN D did not do any kind of assessment on Resident #1 while she was on the floor. During an interview with CNA E at 1:50 p.m. on 10/24/17, she reported that she showered Resident #1 with CNA F's assistance around 2:30 p.m. on 9/26/17 and then put her in the dining room. She stated I did some other things. I was asking (LVN D) for something, and one of the residents yelled. She was in the dining room with (Resident #1) at the time. The nurse, me and the medication aide went to the dining room. (Resident #1) was on her back on the floor. CNA E reported that Resident #1 complained of pain and cried a bit. She normally cries when she talks. We put her in her chair and the nurse told (CNA F) to lay her down. When asked if LVN D assessed Resident #1 before putting her in the chair, CNA E stated I believe she just took her blood pressure. CNA E reported that Resident #1 did not cry out when they put her back in her chair. She reported that Resident #1 was wearing nonskid socks at the time of her fall. CNA E stated She had a habit of standing up from her chair. We were aware of her fall risk. We thought putting her in a wheelchair would stop her from getting up so much. CNA E reported that no staff were in the dining room with Resident #1 at the time of her fall. She reported that Resident #1 was in the dining room without staff supervision for about 10 minutes. Knowing her fall risk and that she had been getting up, she shouldn't have been left alone in the dining room. We all misjudged how severe her fall risk was. CNA E reported that Resident #1 fell in the dining room on a Tuesday and that she was off on Wednesday. She stated When I came back on Thursday, they told me she was in the hospital. I said 'It must have been from the fall'. They said 'What fall?' They didn't know about the fall because it wasn't documented. An attempt to interview LVN D by phone was made at 9:04 a.m. on 10/25/17. There was no answer. A message with a callback number was left. LVN D did not return the call. During an interview with CNA F at 2:45 p.m. on 10/25/17, she reported that she was working on 9/26/17 and went to the dining room around 3:30/4:00 p.m. because all of the staff were there. CNA F reported that Resident #1 was in her wheelchair and that LVN D was pushing her wheelchair. CNA F reported that she offered to help LVN D and pushed Resident #1's wheelchair into her room. CNA F reported that she found out Resident #1 fell when another resident told her after the fact. CNA F reported that she assisted CNA E with showering Resident #1 around 2:30 p.m. CNA F stated that she did not see LVN D assess Resident #1. She reported that, 2 days later, she noticed that Resident #1's crying was different and that she was crying real tears. She informed her charge nurse (LVN J) of the crying. LVN J assessed Resident #1. CNA F reported that she told LVN J Do you think this could be from her fall? and that LVN J was unaware of Resident #1 falling because there was no incident report or documentation of it. CNA F reported that, once she was made aware of Resident #1's fall, LVN J ordered x-rays that found a [MEDICAL CONDITION]. CNA F reported that, in the days prior to Resident #1's 9/26/17 fall, she had been up without assistance and stated We had to watch her closely. She was in a wheelchair. We try to have one CNA on the hall and one CNA in the dining room at all times. During an interview with the DON at 8:44 a.m. on 10/27/17, when asked what the facility's corrective actions for Resident #1's fall with fracture were (besides terminating LVN D), she reported that staff were offering redirection for residents with frequent falls and stated When you tell staff what to do, they do it. We provide redirection and encouragement on the unit. If you guide them to the dining room, they follow. Staff try to guide them to a safe place. We can educate at that time, but residents on the unit especially forget. During an interview with the DON and the administrator at 8:45 a.m. on 10/27/17, they reported that they did an in-service on abuse/neglect and an in-service on the fall care delivery process for nurses and direct care staff after Resident #1's 9/26/17 fall. During continued interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that, after hospitalization for fracture surgery, Resident #1 was maximum assist for everything. He reported that she could walk 100-200 feet with minimal assist 2-3 weeks after readmission. PT K reported that Resident #1 still tried to get up unassisted and that he tried not to leave her alone. When asked if he thought Resident #1 needed constant supervision, PT K stated Mmm hmm and nodded his head. He stated She gets up when there is a need that needs to be fulfilled - she needs to be changed, is hungry, etc. She's not one of those who just gets up without reason. I like to keep my eyes on her. The investigator attempted to find Resident #1 at 9:41 a.m. on 10/27/17 and didn't see her. She asked the staff (there was a CNA, a medication aide, and a nurse at the medication cart in the dining room) where Resident #1 was. CNA L said that Resident #1 was in her room and guided the investigator there. Observation of Resident #1 at 9:43 a.m. on 10/27/17 revealed that she was sitting on the edge of her bed and trying to stand up without assistance. CNA L confirmed this. During an interview with CNA M at 2:10 p.m. on 10/27/17, she reported that Resident #1 was always walking around prior to her fall with fracture. When asked if Resident #1 required 1:1 supervision, CNA M stated A lot of times, yes. She was a fall risk, and we had to help her to sit. We kept her in eyesight. b. Record review of Resident #14's significant change MDS assessment (ARD 10/5/17) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She could rarely understand or be understood, had impaired vision without corrective lenses, had severely-impaired cognition with inattention and disorganized thinking, wandered 1-3 days during the 7-day look back period and had no other documented behaviors, needed supervision with walking in the room and in the corridor, and needed the extensive assistance of one staff for transfers. Her balance was noted as being steady at all times (exception was turning around - not steady but able to stabilize without staff assistance). There were no documented range of motion impairments or mobility devices, and she was assessed to be incontinent of bowel and bladder. She was assessed to have had 3 falls since the prior assessment - 2 without injury and 1 with minor injury. In the 7-day look back period, she was administered an antianxiety medication 7 days and an antidepressant 6 days. 167 minutes of occupational therapy and 316 minutes of physical therapy were documented. Record review of Resident #14's care plan (last reviewed 10/16/17) revealed address of physical behaviors (grabbing other residents' hair and using items to hold other residents down, biting, and sitting on the floor) with interventions of monitor medications (initiated 9/27/17), evaluate the nature and circumstances and adjust care delivery appropriately (initiated 9/27/17), evaluate need for psych/behavioral health consult (initiated 8/29/17), observe for non-verbal signs of physical aggression (initiated 9/27/17), provide a calm well-lit environment (initiated 9/27/17), and social services to provide support as needed (initiated 9/27/17). Level of supervision needed was not care-planned. Continued record review of Resident #14's care plan (last reviewed 10/16/17) revealed that her fall risk was addressed with interventions of orthostatic blood pressures every shift for 72 hours (initiated 10/10/17), medication evaluation as needed (initiated 8/27/17), assist resident getting in and out of bed with 1 staff assistance (initiated 8/27/17), provide verbal cues for safety and sequencing when needed (initiated 8/27/17), provide verbal cues for proper pacing and energy conservation techniques (initiated 8/27/17), provide resident/caregiver education for safe techniques (initiated 9/18/17), place call light within reach while in bed or close proximity to bed (initiated 8/27/17), remind resident to use call light when attempting to ambulate or transfer (initiated 8/27/17), maintain a clutter-free environment in the resident's room and consistent furniture arrangement (initiated 8/27/17), when resident is in bed place all necessary personal items within reach (initiated 8/27/17), monitor for and assist with toileting needs (initiated 8/27/17), resident to be evaluated by therapy post fall (initiated 9/22/17), utilize low bed with floor mat (initiated 10/15/17), resident to be screened by therapy (initiated 9/13/17), encourage resident to attend activities that maximize their full potential while meeting their need to socialize (initiated 10/5/17), and will allow resident to sit on the floor and provide cushion for protection if she chooses to and staff to monitor (initiated 10/23/17). Level of supervision needed was not care-planned. Record review of the facility's incident/accident reports revealed: 8/26/17 - Resident #14 walked over to another resident in the dining room, grabbed her hair, and pulled it. A CNA immediately intervened and took Resident #14 to her room. Patient teaching was unsuccessful due to her mental status. Intervention was continued monitoring. 8/27/17 - Resident #14 wandered into another resident's room. The other resident became aggressive and pinched her on the arm with a grab stick. The other resident called for help, and staff separated them. A psych eval was ordered, and residents were to be monitored. Record review of Resident #14's progress notes revealed that she had a fall on 8/29/17 from which she sustained a laceration requiring stitches. There was no incident/accident report for this fall. 9/13/17 - Resident #14 was found on her back on the floor in the hall. Intervention was a therapy screen. 9/21/17 - Resident #14 attempted to stand up from her wheelchair in the dining room and fell . Three staff were in the dining room at the time, and her wheelchair brakes were locked. Intervention was a physical therapy evaluation. Further record review of Resident #14's progress notes revealed that she started physical therapy services on 9/28/17. 10/4/17 - Resident #14 was found on her back on the floor in the dining room. Interventions were to encourage all activities to meet need to socialize and keep her busy and continue physical therapy services. 10/10/17 - Resident #14 lost her balance when standing behind a chair in the dining room and fell . A CNA witnessed the fall. Interventions were continued physical therapy and orthostatic blood pressure checks for 3 days. 10/16/17 - Resident #14 wandered into another resident's room. The other resident kicked her. Resident #14 was immediately removed from the situation and encouraged not to enter the other resident's room again though she does not follow commands. There were no other interventions. 10/21/17 - Resident #14 fell in the dining room. A CNA witnessed the fall. Intervention was a referral to physical therapy for evaluation and treatment. 10/24/17 - Resident #14 entered into another resident's room and sat on her bed. The other resident struck her on the back. Resident #14 was redirected out of the room. A housekeeper witnessed the altercation. Observations of Resident #14 at 9:13 a.m. on 10/25/17 and at 1:38 p.m. on 10/27/17 revealed that she was not being supervised and was ambulating up and down the hall. At 9:13 a.m. on 10/25/17, a nurse, a medication aide, and 2 CNAs were in the dining room with residents. The social worker was in the clinical records closet (door open) between the dining room and the hall. There were 5 residents on the hall - 3 of whom were arguing with each other - 2 pushing the other one out of their room. No staff were on the hall supervising. At 1:38 p.m. on 10/27/17, there were at least 3 residents in bed on the hall and residents in the dining room. There was one CNA, a medication aide, and a nurse in the dining room talking. There were no staff observed on the hall. During an interview with MA C at 1:40 p.m. on 10/27/17, she reported that Resident #14 needed constant supervision because she wandered into other residents' rooms, instigating fights with other residents. MA C defined constant supervision as within eyesight - in the same room. During an interview with CNA E at 1:45 p.m. on 10/27/17, she defined closely monitor as within vision - so we can see and hear. CNA E defined constant supervision as closely - check on every minute or 2. During an interview with CNA M at 2:10 p.m. on 10/27/17, she reported that Resident #14 needed to be within eyesight secondary to her fall risk and wandering behaviors. CNA M reported that there were 7 residents (identified by name) on the women's unit that required constant supervision due to fall risk. When asked how she knew which residents were at risk for falls, CNA M reported that the charge nurse told them. During an interview with CNA E at 2:18 p.m. on 10/27/17, she reported that staff had to keep an eye on Resident #14 even though she was ambulatory because she fell often. CNA E reported that there were 4 residents on the women's unit who were at high risk for falls and required close monitoring. When asked how she knew which residents were at risk for falls, CN (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to ensure that 3 of 17 residents (Resident #s 1, 14, and 2) whose care was reviewed received adequate supervision and assistance devices to prevent accidents in that: 1. Resident #1 had a history of [REDACTED].#1 to prevent further falls. She sustained 4 falls within 2 months, the last fall resulting in a right hip fracture. 2. Resident #14 had a history of [REDACTED].#14 to prevent further falls and wandering into other resident rooms. Resident #14 sustained 5 falls, one resulting in a laceration with stitches, and was involved in 4 resident-to-resident altercations within 2 months. 3. The facility failed to implement individualized interventions for and identify Resident #2 as a fall risk to prevent further falls. Resident #2 had 2 falls within 15 days. Staff providing care for Resident #2 were unaware of his fall risk and had no knowledge of a rib fracture that may have resulted from a 2nd fall. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 10/27/17. While the IJ was removed on 11/2/17, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all residents were assessed and all staff were in-serviced. This deficient practice had the potential to affect 25 residents with recurrent falls by contributing to injury. The findings were: 1. Record review of Resident #1's facesheet (dated 10/25/17) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS assessment (ARD 8/30/17) revealed that she could sometimes be understood and could sometimes understand. Her vision was assessed as being adequate without lenses. There were dashes for all areas of cognition, mood, behavior, and functional status (exceptions were balance - noted as not steady but able to stabilize without staff assistance - and ROM - no impairment). She was assessed to have had falls in the last month prior to admission and one fall without injury since admission. In the 7-day lookback period, she was administered an antipsychotic 4 days, an antianxiety medication 6 days, and an antidepressant 6 days. Record review of Resident #1's care plan (provided to the investigator on 10/25/17) revealed that her fall risk was addressed with interventions of orthostatic blood pressures every shift for 72 hours (initiated 9/22/17), medication evaluation as needed (initiated 8/27/17), assist resident getting in and out of bed with 1-2 assistance (initiated 8/27/17), provide verbal cues for safety and sequencing when needed (initiated 8/27/17), provide verbal cues for proper pacing and energy conservation techniques (initiated 8/27/17), provide resident/caregiver education for safe techniques (initiated 9/18/17), place call light within reach while in bed or close proximity to bed (initiated 8/27/17), remind resident to use call light when attempting to ambulate or transfer (initiated 8/27/17), maintain a clutter-free environment in the resident's room and consistent furniture arrangement (initiated 8/27/17), when resident is in bed place all necessary personal items within reach (initiated 8/27/17), monitor for and assist with toileting needs (initiated 8/27/17), and resident to be screened by therapy (initiated 8/29/17). Record review of the facility's incident/accident reports revealed: 8/25/17 11:30 a.m. - Resident #1 was found on the floor in the dining room. She attempted to stand without assistance. It was noted that Resident #1 was not able to ambulate without assistance and was limited to her wheelchair. The brakes on her wheelchair were documented as not being locked. Interventions were monitoring for adjustment to the facility (Resident #1 was an evacuee), a therapy screen, and x-rays. There were no other documented interventions. During an interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that therapy screened Resident #1 on 8/29/17 and determined that she was appropriate for services. However, Resident #1's family declined therapy at this time because 1) they didn't know how long Resident #1 would be at the facility and 2) they thought she may be having adjustment issues and wanted to give her time to adjust. Further record review of the facility's incident/accident reports revealed: 9/12/17 11:30 a.m. - Resident #1 had a witnessed fall in the hallway. She attempted to sit in her wheelchair, missed the chair, and fell on her back side. There was no documentation pertaining to whether or not her wheelchair brakes were locked. Interventions were resident education on safe technique and continued PT/OT for gait/strengthening. During an interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that Resident #1 was not picked up for therapy after her 8/25/17 fall because the family declined it. At the time of her 9/12/17 fall, Resident #1 was not receiving therapy services During an interview with the DON at 8:44 a.m. on 10/27/17, when asked about Resident #1 being educated on safe technique, she stated We can educate at that time, but residents on the unit especially forget. During continued interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that physical therapy picked Resident #1 up for services on 9/13/17 because she was falling and because her family agreed to it. PT K stated Her main thing was wandering. My point of view . she had the Parkinson's symptoms of dementia - slow movement, decreased step length, and instability while walking. Antipsychotic medications are given for dementia, and they usually cause the Parkinson's stuff. We try to increase movement, joint movement, postural stability. We do gait training and walking, the lower extremity bike to improve endurance and lower extremity strength and rhythm. When asked if Resident #1 was cooperative with therapy, PT K stated It was more about the dementia - a lot of anxiety and confusion. She'd have a crying spat - we'd work - and then she'd cry again. Overall, she did participate with verbal and tactile cueing and encouragement. Further record review of the facility's incident/accident reports revealed: 9/21/17 - Resident #1 lost her footing in the dining room and sat down on the floor. Intervention was to monitor orthostatic blood pressure for 3 days. Record review of Resident #1's 9/22/17 physician order [REDACTED]. Two times a day for 3 days - Evaluate both recording for potential orthostatic hypotension indicated systolic drops by 20 units or diastolic drops by 10 units - Document occurrence and action taken in progress note was included in order summary. During an interview with the DON at 12:23 p.m. on 10/27/17, when asked why the facility decided to do blood pressure checks on Resident #1 after her 9/21/17 fall, she stated To rule out orthostatic hypotension. Staff noticed she would stand up, get dizzy, and then sit back down. The DON, at this time, reported that Resident #1's blood pressures were normal (120/70) when checked for 3 days. Record review of Resident #1's Medication/Treatment Administrator Records for September of 2017 revealed that her blood pressures were as follows: 9/22/17 7:00 p.m. - sitting 118/62, standing 127/74 9/23/17 7:00 a.m. - sitting 145/76, standing 108/76 9/23/17 7:00 p.m. - sitting 114/74, standing 88/61 9/24/17 7:00 a.m. - sitting 126/72, standing 116/64 9/24/17 7:00 p.m. - sitting 112/62, standing 98/43 9/25/17 7:00 a.m. - sitting 125/75, standing (not documented) During an interview with the DON and Corporate Nurse H at 1:18 p.m. on 10/27/17, the DON confirmed that Resident #1's diastolic and systolic blood pressures had dropped significantly during the 3 days of monitoring after her 9/21/17 fall. When asked if the medication aide/nurse who took the abnormal blood pressures notified the doctor according to his order, the DON reviewed the progress notes and said that there was no indication that the doctor had been notified. During an interview with the DON at 3:00 p.m. on 10/27/17, the investigator asked So if blood pressure checks after Resident #1's 9/21/17 fall to rule out orthostatic hypotension were done and were abnormal and it doesn't look like nurse notified the doctor . The DON intervened with The doctor normally says just to monitor if the resident is not on blood pressure medications. The investigator continued with But we don't know that he would say that. The orders say document occurrence and action taken in progress notes. There's no documentation in progress notes. So what was the point of the intervention if nothing was done when the blood pressures were abnormal? The DON did not respond at first. She then stated They were still within normal range. The investigator then stated But orthostatic hypotension is a drop and there was a drop. Further record review of the facility's incident/accident reports revealed: 9/26/17 - Resident #1 was found on the floor in the dining room. She attempted to stand from her wheelchair without assistance and fractured her right hip. There was no documentation pertaining to whether or not her wheelchair brakes were locked. Intervention (post readmission after hip surgery) was PT/OT/ST. During an interview with the DON at 8:45 a.m. on 10/12/17, she reported that the facility terminated and referred LVN D to the Board of Nursing because she did not report Resident #1's 9/26/17 fall or assess Resident #1 for injury after her 9/26/17 fall. They determined this through interviews when doing their own investigation of Resident #1's fractured hip. During an interview with Medication Aide C at 1:03 p.m. on 10/24/17, she reported that she was coming back to the unit on the early afternoon of 9/26/17 and heard a yell from another resident. She reported that she ran to the dining room (where the yell came from) and found Resident #1 on her back. There were no staff in the dining room at the time. Medication Aide C reported that she got LVN D and that LVN D told her and CNA E to get Resident #1 in her wheelchair. Medication Aide C reported that LVN D did not do any kind of assessment on Resident #1 while she was on the floor. During an interview with CNA E at 1:50 p.m. on 10/24/17, she reported that she showered Resident #1 with CNA F's assistance around 2:30 p.m. on 9/26/17 and then put her in the dining room. She stated I did some other things. I was asking (LVN D) for something, and one of the residents yelled. She was in the dining room with (Resident #1) at the time. The nurse, me and the medication aide went to the dining room. (Resident #1) was on her back on the floor. CNA E reported that Resident #1 complained of pain and cried a bit. She normally cries when she talks. We put her in her chair and the nurse told (CNA F) to lay her down. When asked if LVN D assessed Resident #1 before putting her in the chair, CNA E stated I believe she just took her blood pressure. CNA E reported that Resident #1 did not cry out when they put her back in her chair. She reported that Resident #1 was wearing nonskid socks at the time of her fall. CNA E stated She had a habit of standing up from her chair. We were aware of her fall risk. We thought putting her in a wheelchair would stop her from getting up so much. CNA E reported that no staff were in the dining room with Resident #1 at the time of her fall. She reported that Resident #1 was in the dining room without staff supervision for about 10 minutes. Knowing her fall risk and that she had been getting up, she shouldn't have been left alone in the dining room. We all misjudged how severe her fall risk was. CNA E reported that Resident #1 fell in the dining room on a Tuesday and that she was off on Wednesday. She stated When I came back on Thursday, they told me she was in the hospital. I said 'It must have been from the fall'. They said 'What fall?' They didn't know about the fall because it wasn't documented. An attempt to interview LVN D by phone was made at 9:04 a.m. on 10/25/17. There was no answer. A message with a callback number was left. LVN D did not return the call. During an interview with CNA F at 2:45 p.m. on 10/25/17, she reported that she was working on 9/26/17 and went to the dining room around 3:30/4:00 p.m. because all of the staff were there. CNA F reported that Resident #1 was in her wheelchair and that LVN D was pushing her wheelchair. CNA F reported that she offered to help LVN D and pushed Resident #1's wheelchair into her room. CNA F reported that she found out Resident #1 fell when another resident told her after the fact. CNA F reported that she assisted CNA E with showering Resident #1 around 2:30 p.m. CNA F stated that she did not see LVN D assess Resident #1. She reported that, 2 days later, she noticed that Resident #1's crying was different and that she was crying real tears. She informed her charge nurse (LVN J) of the crying. LVN J assessed Resident #1. CNA F reported that she told LVN J Do you think this could be from her fall? and that LVN J was unaware of Resident #1 falling because there was no incident report or documentation of it. CNA F reported that, once she was made aware of Resident #1's fall, LVN J ordered x-rays that found a hip fracture. CNA F reported that, in the days prior to Resident #1's 9/26/17 fall, she had been up without assistance and stated We had to watch her closely. She was in a wheelchair. We try to have one CNA on the hall and one CNA in the dining room at all times. During an interview with the DON at 8:44 a.m. on 10/27/17, when asked what the facility's corrective actions for Resident #1's fall with fracture were (besides terminating LVN D), she reported that staff were offering redirection for residents with frequent falls and stated When you tell staff what to do, they do it. We provide redirection and encouragement on the unit. If you guide them to the dining room, they follow. Staff try to guide them to a safe place. We can educate at that time, but residents on the unit especially forget. During an interview with the DON and the administrator at 8:45 a.m. on 10/27/17, they reported that they did an in-service on abuse/neglect and an in-service on the fall care delivery process for nurses and direct care staff after Resident #1's 9/26/17 fall. During continued interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that, after hospitalization for fracture surgery, Resident #1 was maximum assist for everything. He reported that she could walk 100-200 feet with minimal assist 2-3 weeks after readmission. PT K reported that Resident #1 still tried to get up unassisted and that he tried not to leave her alone. When asked if he thought Resident #1 needed constant supervision, PT K stated Mmm hmm and nodded his head. He stated She gets up when there is a need that needs to be fulfilled - she needs to be changed, is hungry, etc. She's not one of those who just gets up without reason. I like to keep my eyes on her. The investigator attempted to find Resident #1 at 9:41 a.m. on 10/27/17 and didn't see her. She asked the staff (there was a CNA, a medication aide, and a nurse at the medication cart in the dining room) where Resident #1 was. CNA L said that Resident #1 was in her room and guided the investigator there. Observation of Resident #1 at 9:43 a.m. on 10/27/17 revealed that she was sitting on the edge of her bed and trying to stand up without assistance. CNA L confirmed this. During an interview with CNA M at 2:10 p.m. on 10/27/17, she reported that Resident #1 was always walking around prior to her fall with fracture. When asked if Resident #1 required 1:1 supervision, CNA M stated A lot of times, yes. She was a fall risk, and we had to help her to sit. We kept her in eyesight. 2. Record review of Resident #14's significant change MDS assessment (ARD 10/5/17) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She could rarely understand or be understood, had impaired vision without corrective lenses, had severely-impaired cognition with inattention and disorganized thinking, wandered 1-3 days during the 7-day lookback period and had no other documented behaviors, needed supervision with walking in the room and in the corridor, and needed the extensive assistance of one staff for transfers. Her balance was noted as being steady at all times (exception was turning around - not steady but able to stabilize without staff assistance). There were no documented range of motion impairments or mobility devices, and she was assessed to be incontinent of bowel and bladder. She was assessed to have had 3 falls since the prior assessment - 2 without injury and 1 with minor injury. In the 7-day lookback period, she was administered an antianxiety medication 7 days and an antidepressant 6 days. 167 minutes of occupational therapy and 316 minutes of physical therapy were documented. Record review of Resident #14's care plan (last reviewed 10/16/17) revealed address of physical behaviors (grabbing other residents' hair and using items to hold other residents down, biting, and sitting on the floor) with interventions of monitor medications (initiated 9/27/17), evaluate the nature and circumstances and adjust care delivery appropriately (initiated 9/27/17), evaluate need for psych/behavioral health consult (initiated 8/29/17), observe for non-verbal signs of physical aggression (initiated 9/27/17), provide a calm well-lit environment (initiated 9/27/17), and social services to provide support as needed (initiated 9/27/17). Level of supervision needed was not care-planned. Continued record review of Resident #14's care plan (last reviewed 10/16/17) revealed that her fall risk was addressed with interventions of orthostatic blood pressures every shift for 72 hours (initiated 10/10/17), medication evaluation as needed (initiated 8/27/17), assist resident getting in and out of bed with 1 staff assistance (initiated 8/27/17), provide verbal cues for safety and sequencing when needed (initiated 8/27/17), provide verbal cues for proper pacing and energy conservation techniques (initiated 8/27/17), provide resident/caregiver education for safe techniques (initiated 9/18/17), place call light within reach while in bed or close proximity to bed (initiated 8/27/17), remind resident to use call light when attempting to ambulate or transfer (initiated 8/27/17), maintain a clutter-free environment in the resident's room and consistent furniture arrangement (initiated 8/27/17), when resident is in bed place all necessary personal items within reach (initiated 8/27/17), monitor for and assist with toileting needs (initiated 8/27/17), resident to be evaluated by therapy post fall (initiated 9/22/17), utilize low bed with floor mat (initiated 10/15/17), resident to be screened by therapy (initiated 9/13/17), encourage resident to attend activities that maximize their full potential while meeting their need to socialize (initiated 10/5/17), and will allow resident to sit on the floor and provide cushion for protection if she chooses to and staff to monitor (initiated 10/23/17). Level of supervision needed was not care-planned. Record review of the facility's incident/accident reports revealed: 8/26/17 - Resident #14 walked over to another resident in the dining room, grabbed her hair, and pulled it. A CNA immediately intervened and took Resident #14 to her room. Patient teaching was unsuccessful due to her mental status. Intervention was continued monitoring. 8/27/17 - Resident #14 wandered into another resident's room. The other resident became aggressive and pinched her on the arm with a grab stick. The other resident called for help, and staff separated them. A psych eval was ordered, and residents were to be monitored. Record review of Resident #14's progress notes revealed that she had a fall on 8/29/17 from which she sustained a laceration requiring stitches. There was no incident/accident report for this fall. 9/13/17 - Resident #14 was found on her back on the floor in the hall. Intervention was a therapy screen. 9/21/17 - Resident #14 attempted to stand up from her wheelchair in the dining room and fell . Three staff were in the dining room at the time, and her wheelchair brakes were locked. Intervention was a physical therapy evaluation. Further record review of Resident #14's progress notes revealed that she started physical therapy services on 9/28/17. 10/4/17 - Resident #14 was found on her back on the floor in the dining room. Interventions were to encourage all activities to meet need to socialize and keep her busy and continue physical therapy services. 10/10/17 - Resident #14 lost her balance when standing behind a chair in the dining room and fell . A CNA witnessed the fall. Interventions were continued physical therapy and orthostatic blood pressure checks for 3 days. 10/16/17 - Resident #14 wandered into another resident's room. The other resident kicked her. Resident #14 was immediately removed from the situation and encouraged not to enter the other resident's room again though she does not follow commands. There were no other interventions. 10/21/17 - Resident #14 fell in the dining room. A CNA witnessed the fall. Intervention was a referral to physical therapy for evaluation and treatment. 10/24/17 - Resident #14 entered into another resident's room and sat on her bed. The other resident struck her on the back. Resident #14 was redirected out of the room. A housekeeper witnessed the altercation. Observations of Resident #14 at 9:13 a.m. on 10/25/17 and at 1:38 p.m. on 10/27/17 revealed that she was not being supervised and was ambulating up and down the hall. At 9:13 a.m. on 10/25/17, a nurse, a medication aide, and 2 CNAs were in the dining room with residents. The social worker was in the clinical records closet (door open) between the dining room and the hall. There were 5 residents on the hall - 3 of whom were arguing with each other - 2 pushing the other one out of their room. No staff were on the hall supervising. At 1:38 p.m. on 10/27/17, there were at least 3 residents in bed on the hall and residents in the dining room. There was one CNA, a medication aide, and a nurse in the dining room talking. There were no staff observed on the hall. During an interview with MA C at 1:40 p.m. on 10/27/17, she reported that Resident #14 needed constant supervision because she wandered into other residents' rooms, instigating fights with other residents. MA C defined constant supervision as within eyesight - in the same room. During an interview with CNA E at 1:45 p.m. on 10/27/17, she defined closely monitor as within vision - so we can see and hear. CNA E defined constant supervision as closely - check on every minute or 2. During an interview with CNA M at 2:10 p.m. on 10/27/17, she reported that Resident #14 needed to be within eyesight secondary to her fall risk and wandering behaviors. CNA M reported that there were 7 residents (identified by name) on the women's unit that required constant supervision due to fall risk. When asked how she knew which residents were at risk for falls, CNA M reported that the charge nurse told them. During an interview with CNA E at 2:18 p.m. on 10/27/17, she reported that staff had to keep an eye on Resident #14 even though she was ambulatory because she fell often. CNA E reported that there were 4 residents on the women's unit who were at high risk for falls and required close monitoring. When asked how she knew which residents were at risk for falls, CNA E stated We just monitor and know. It's common sense - what we believe. When asked how she determined which residents needed more supervision, CNA E stated Active seekers to get up - try to walk more than the rest. She reported that there was no list of residents at risk for falls or any type of fall risk identification system in place. Record review of the facility's incident/accident reports from 8/24/17 through 10/27/17 revealed that Resident #14 had 5 falls and 4 resident-to-resident altercations, 3 of which resulted from her wandering into other residents' rooms. 3. Record review of Resident #2's electronic facesheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's 8/23/17 progress note revealed a history of falls. Record review of Resident #2's 9/15/17 incident/accident report revealed that he was found on the floor in his room. He reported that he was walking to the bathroom and slipped, fell , and hit the back of his head. He was assessed for injury, and there were no complaints of pain. Corrective action was Post void bladder ultrasound for urinary retention. Record review of Resident #2's 9/15/17 progress note revealed that he sustained a right side back of head abrasion measuring 2.6 x 0.9 from the fall. Record review of Resident #2's progress notes after 9/15/17 revealed no documentation pertaining to the post void bladder ultrasound results and/or action taken once the ultrasound was obtained. Record review of Resident #2's 9/29/17 incident/accident report revealed that he was found sitting on his buttocks on the floor in his bathroom. He reported that he lost his balance and fell . He was assessed for injury, and there were no complaints of pain. He was referred to occupational therapy for toileting training and his medications were adjusted for better pain management. Record review of Resident #2's 10/1/17 progress note revealed that he complained of right side pain. X-rays revealed a right rib fracture. Observation of the men's unit at 9:30 a.m. on 10/25/17 revealed Resident #2 in his wheelchair in the hallway sleeping. During an interview with LVN G, the charge nurse for the men's unit, at 9:32 a.m. on 10/25/17, she reported that she had been on the unit for 4 days. She reported that she was unaware of Resident #2 having a recent fall or fracture. However, she reported that she would find out his fall history. During an interview with LVN G at 9:40 a.m. on 10/25/17, she reported that Resident #2 had a fall on 9/29/17 and fractured his rib. She reported that he ambulated and used the bathroom on his own. When asked if Resident #2 was on any fall precautions, LVN G stated We monitor and encourage him to use his walker. During an interview LVN N at 3:33 p.m. on 10/27/17, when asked how she knew which residents were at risk for falls, stated Go through the charts and review their medications. We communicate with direct care staff by letting the nurses/aides know by word of mouth/in-services. LVN N reported that the facility did not utilize any sort of falling leaf/star program to identify residents at risk for falls and that the facility did not have lists of residents at risk for falls. She stated Everybody here has the perception that the resident has the right to fall. We are a nonrestraint facility. It's hard to change that perception in their heads. Record review of the facility's fall management policy (revised 3/15/16) revealed Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause. Practice Standards: 1. Identify patient's fall risk by reviewing the following. 1.1 Electronic Medical Record Systems - Nursing Assessment 1.2 Non-electronic Medical Record Systems - Fall Risk Evaluation 2. Communicate patient's fall risk status to caregivers. 3. Develop individualized plan of care. 4. Review and revise care plan regularly. 5. If patient falls: 5.1 Following Guidelines for Managing a Fall (refer to Falls Care Delivery Process) if staff member is present when the fall occurs. 5.2 Utilize the Fall Response Protocol (refer to Falls Care Delivery Process) for both witnessed and unwitnessed falls. 5.3 Document accident/incident: 5.3.1 As a new event in the Risk Management System (RMS); 5.3.2 On a Change of Condition Note; 5.3.3 On the 24-Hour Report; 5.3.4 Investigation using the Fall Investigation/QA and other appropriate tools in RMS. 5.4 Update care plan to reflect new interventions. 5.5 Conduct interdisciplinary team meeting within 72 hours of fall 5.6 The Center Executive Director and Center Nurse Executive will conduct a post fall review. At 5:52 p.m. on 10/27/17, Corporate Nurse H, the DON, and the administrator were notified of the Immediate Jeopardy (IJ) situation for the above failures and a Plan of Removal was requested. The facility began corrective actions on 10/27/17 after 6:00 p.m. and continued to in-service and monitor staff and residents to ensure resident safety and prevention of falls. Observation of the women's unit at 2:45 p.m. on 10/28/17 revealed that Resident #14 was ambulating in the hallway and not within staff eyesight. Another resident was leaning forward in her wheelchair. CNA F was showering a resident. MA C was in the dining room with 8 residents. CNA Q was laying a resident down. During an interview with MA C at 2:52 p.m. on 10/28/17, she reported that the charge nurse was on break and that she and the 2 CNAs were the only staff on the unit at the time. Observation of Resident #1 in the dining room at 3:16 p.m. on 10/28/17 revealed that her eyes were closing and that she was dozing off in her wheelchair. She was sitting at a table with a drink in front of her. CNA S was at her side - providing 1:1 supervision. During an interview with the administrator, the DON, MDS Nurse I, NPE S, and LVN N at 3:51 p.m. on 10/29/17, the administrator reported that she did not plan on making staffing changes and stated Why? No more staff are needed. When asked if the facility had looked at activities for Resident #1, the administrator stated She has a BIMS of 0 - Why would we look at activities to engage her? LVN N stated that facility interventions after Resident #1's hip surgery were moving her to another unit because of familiar faces there and stated I don't think she will be mobile again. She's scared of falling again. The fall really affected her - scared her. Observation of Resident #1 in the dining room at 4:59 p.m. on 10/29/17 revealed that she was supervised by staff. Observations of Resident #14 in the hall of the women's unit at 5:10 p.m. and 5:18 p.m. on 10/29/17 revealed that she was attempting to open closet doors at the facility's entrance and rocking back and forth. There were no staff supervising. During an interview with MA C and LVN R at 5:12 p.m. on 10/29/17, they reported that the residents on the women's unit had been active that day and that, earlier in the shift, Resident #14 had walked out of another resident's room with a broken picture frame. During an interview with LVN S on the women's unit at 3:50 p.m. on 10/30/17, she reported that Resident #1 had a history of [REDACTED]. LVN S stated We have a lot of ladies who do (need constant supervision). Yes, more staff are needed. (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to implement its written policies and procedures that prohibited neglect related to falls for 3 of 17 residents (Resident #s 1, 14, and 2) whose care was reviewed in that: 1. Resident #1 had a history of [REDACTED].#1 to prevent further falls. She sustained 4 falls within 2 months, the last fall resulting in a right [MEDICAL CONDITION]. 2. Resident #14 had a history of [REDACTED].#14 to prevent further falls and wandering into other resident rooms. Resident #14 sustained 5 falls, one resulting in a laceration with stitches, and was involved in 4 resident-to-resident altercations within 2 months. 3. The facility failed to implement individualized interventions for and identify Resident #2 as a fall risk to prevent further falls. Resident #2 had 2 falls within 15 days. Staff providing care for Resident #2 were unaware of his fall risk and had no knowledge of a rib fracture that may have resulted from a 2nd fall. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 10/27/17. While the IJ was removed on 11/2/17, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all residents were assessed and all staff were in-serviced. This deficient practice had the potential to affect 25 residents with recurrent falls by contributing to injury. The findings were: Record review of the facility's abuse policy (revised 4/7/17) revealed Neglect is defined as the failure of the center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility's fall management policy (revised 3/15/16) revealed Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause. Practice Standards: 1. Identify patient's fall risk by reviewing the following. 1.1 Electronic Medical Record Systems - Nursing Assessment 1.2 Non-electronic Medical Record Systems - Fall Risk Evaluation 2. Communicate patient's fall risk status to caregivers. 3. Develop individualized plan of care. 4. Review and revise care plan regularly. 5. If patient falls: 5.1 Following Guidelines for Managing a Fall (refer to Falls Care Delivery Process) if staff member is present when the fall occurs. 5.2 Utilize the Fall Response Protocol (refer to Falls Care Delivery Process) for both witnessed and unwitnessed falls. 5.3 Document accident/incident: 5.3.1 As a new event in the Risk Management System (RMS); 5.3.2 On a Change of Condition Note; 5.3.3 On the 24-Hour Report; 5.3.4 Investigation using the Fall Investigation/QA and other appropriate tools in RMS. 5.4 Update care plan to reflect new interventions. 5.5 Conduct interdisciplinary team meeting within 72 hours of fall 5.6 The Center Executive Director and Center Nurse Executive will conduct a post fall review. 1. Record review of Resident #1's facesheet (dated 10/25/17) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS assessment (ARD 8/30/17) revealed that she could sometimes be understood and could sometimes understand. Her vision was assessed as being adequate without lenses. There were dashes for all areas of cognition, mood, behavior, and functional status (exceptions were balance - noted as not steady but able to stabilize without staff assistance - and ROM - no impairment). She was assessed to have had falls in the last month prior to admission and one fall without injury since admission. In the 7-day lookback period, she was administered an antipsychotic 4 days, an antianxiety medication 6 days, and an antidepressant 6 days. Record review of Resident #1's care plan (provided to the investigator on 10/25/17) revealed that her fall risk was addressed with interventions of orthostatic blood pressures every shift for 72 hours (initiated 9/22/17), medication evaluation as needed (initiated 8/27/17), assist resident getting in and out of bed with 1-2 assistance (initiated 8/27/17), provide verbal cues for safety and sequencing when needed (initiated 8/27/17), provide verbal cues for proper pacing and energy conservation techniques (initiated 8/27/17), provide resident/caregiver education for safe techniques (initiated 9/18/17), place call light within reach while in bed or close proximity to bed (initiated 8/27/17), remind resident to use call light when attempting to ambulate or transfer (initiated 8/27/17), maintain a clutter-free environment in the resident's room and consistent furniture arrangement (initiated 8/27/17), when resident is in bed place all necessary personal items within reach (initiated 8/27/17), monitor for and assist with toileting needs (initiated 8/27/17), and resident to be screened by therapy (initiated 8/29/17). Record review of the facility's incident/accident reports revealed: 8/25/17 11:30 a.m. - Resident #1 was found on the floor in the dining room. She attempted to stand without assistance. It was noted that Resident #1 was not able to ambulate without assistance and was limited to her wheelchair. The brakes on her wheelchair were documented as not being locked. Interventions were monitoring for adjustment to the facility (Resident #1 was an evacuee), a therapy screen, and x-rays. There were no other documented interventions. During an interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that therapy screened Resident #1 on 8/29/17 and determined that she was appropriate for services. However, Resident #1's family declined therapy at this time because 1) they didn't know how long Resident #1 would be at the facility and 2) they thought she may be having adjustment issues and wanted to give her time to adjust. Further record review of the facility's incident/accident reports revealed: 9/12/17 11:30 a.m. - Resident #1 had a witnessed fall in the hallway. She attempted to sit in her wheelchair, missed the chair, and fell on her back side. There was no documentation pertaining to whether or not her wheelchair brakes were locked. Interventions were resident education on safe technique and continued PT/OT for gait/strengthening. During an interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that Resident #1 was not picked up for therapy after her 8/25/17 fall because the family declined it. At the time of her 9/12/17 fall, Resident #1 was not receiving therapy services During an interview with the DON at 8:44 a.m. on 10/27/17, when asked about Resident #1 being educated on safe technique, she stated We can educate at that time, but residents on the unit especially forget. During continued interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that physical therapy picked Resident #1 up for services on 9/13/17 because she was falling and because her family agreed to it. PT K stated Her main thing was wandering. My point of view . she had the [MEDICAL CONDITION] symptoms of dementia - slow movement, decreased step length, and instability while walking. Antipsychotic medications are given for dementia, and they usually cause the [MEDICAL CONDITION] stuff. We try to increase movement, joint movement, postural stability. We do gait training and walking, the lower extremity bike to improve endurance and lower extremity strength and rhythm. When asked if Resident #1 was cooperative with therapy, PT K stated It was more about the dementia - a lot of anxiety and confusion. She'd have a crying spat - we'd work - and then she'd cry again. Overall, she did participate with verbal and tactile cueing and encouragement. Further record review of the facility's incident/accident reports revealed: 9/21/17 - Resident #1 lost her footing in the dining room and sat down on the floor. Intervention was to monitor orthostatic blood pressure for 3 days. Record review of Resident #1's 9/22/17 physician order [REDACTED]. Two times a day for 3 days - Evaluate both recording for potential orthostatic [MEDICAL CONDITION] indicated systolic drops by 20 units or diastolic drops by 10 units - Document occurrence and action taken in progress note was included in order summary. During an interview with the DON at 12:23 p.m. on 10/27/17, when asked why the facility decided to do blood pressure checks on Resident #1 after her 9/21/17 fall, she stated To rule out orthostatic [MEDICAL CONDITION]. Staff noticed she would stand up, get dizzy, and then sit back down. The DON, at this time, reported that Resident #1's blood pressures were normal (120/70) when checked for 3 days. Record review of Resident #1's Medication/Treatment Administrator Records for September of 2017 revealed that her blood pressures were as follows: 9/22/17 7:00 p.m. - sitting 118/62, standing 127/74 9/23/17 7:00 a.m. - sitting 145/76, standing 108/76 9/23/17 7:00 p.m. - sitting 114/74, standing 88/61 9/24/17 7:00 a.m. - sitting 126/72, standing 116/64 9/24/17 7:00 p.m. - sitting 112/62, standing 98/43 9/25/17 7:00 a.m. - sitting 125/75, standing (not documented) During an interview with the DON and Corporate Nurse H at 1:18 p.m. on 10/27/17, the DON confirmed that Resident #1's diastolic and systolic blood pressures had dropped significantly during the 3 days of monitoring after her 9/21/17 fall. When asked if the medication aide/nurse who took the abnormal blood pressures notified the doctor according to his order, the DON reviewed the progress notes and said that there was no indication that the doctor had been notified. During an interview with the DON at 3:00 p.m. on 10/27/17, the investigator asked So if blood pressure checks after Resident #1's 9/21/17 fall to rule out orthostatic [MEDICAL CONDITION] were done and were abnormal and it doesn't look like nurse notified the doctor . The DON intervened with The doctor normally says just to monitor if the resident is not on blood pressure medications. The investigator continued with But we don't know that he would say that. The orders say document occurrence and action taken in progress notes. There's no documentation in progress notes. So what was the point of the intervention if nothing was done when the blood pressures were abnormal? The DON did not respond at first. She then stated They were still within normal range. The investigator then stated But orthostatic [MEDICAL CONDITION] is a drop and there was a drop. Further record review of the facility's incident/accident reports revealed: 9/26/17 - Resident #1 was found on the floor in the dining room. She attempted to stand from her wheelchair without assistance and fractured her right hip. There was no documentation pertaining to whether or not her wheelchair brakes were locked. Intervention (post readmission after hip surgery) was PT/OT/ST. During an interview with the DON at 8:45 a.m. on 10/12/17, she reported that the facility terminated and referred LVN D to the Board of Nursing because she did not report Resident #1's 9/26/17 fall or assess Resident #1 for injury after her 9/26/17 fall. They determined this through interviews when doing their own investigation of Resident #1's [MEDICAL CONDITION]. During an interview with Medication Aide C at 1:03 p.m. on 10/24/17, she reported that she was coming back to the unit on the early afternoon of 9/26/17 and heard a yell from another resident. She reported that she ran to the dining room (where the yell came from) and found Resident #1 on her back. There were no staff in the dining room at the time. Medication Aide C reported that she got LVN D and that LVN D told her and CNA E to get Resident #1 in her wheelchair. Medication Aide C reported that LVN D did not do any kind of assessment on Resident #1 while she was on the floor. During an interview with CNA E at 1:50 p.m. on 10/24/17, she reported that she showered Resident #1 with CNA F's assistance around 2:30 p.m. on 9/26/17 and then put her in the dining room. She stated I did some other things. I was asking (LVN D) for something, and one of the residents yelled. She was in the dining room with (Resident #1) at the time. The nurse, me and the medication aide went to the dining room. (Resident #1) was on her back on the floor. CNA E reported that Resident #1 complained of pain and cried a bit. She normally cries when she talks. We put her in her chair and the nurse told (CNA F) to lay her down. When asked if LVN D assessed Resident #1 before putting her in the chair, CNA E stated I believe she just took her blood pressure. CNA E reported that Resident #1 did not cry out when they put her back in her chair. She reported that Resident #1 was wearing nonskid socks at the time of her fall. CNA E stated She had a habit of standing up from her chair. We were aware of her fall risk. We thought putting her in a wheelchair would stop her from getting up so much. CNA E reported that no staff were in the dining room with Resident #1 at the time of her fall. She reported that Resident #1 was in the dining room without staff supervision for about 10 minutes. Knowing her fall risk and that she had been getting up, she shouldn't have been left alone in the dining room. We all misjudged how severe her fall risk was. CNA E reported that Resident #1 fell in the dining room on a Tuesday and that she was off on Wednesday. She stated When I came back on Thursday, they told me she was in the hospital. I said 'It must have been from the fall'. They said 'What fall?' They didn't know about the fall because it wasn't documented. An attempt to interview LVN D by phone was made at 9:04 a.m. on 10/25/17. There was no answer. A message with a callback number was left. LVN D did not return the call. During an interview with CNA F at 2:45 p.m. on 10/25/17, she reported that she was working on 9/26/17 and went to the dining room around 3:30/4:00 p.m. because all of the staff were there. CNA F reported that Resident #1 was in her wheelchair and that LVN D was pushing her wheelchair. CNA F reported that she offered to help LVN D and pushed Resident #1's wheelchair into her room. CNA F reported that she found out Resident #1 fell when another resident told her after the fact. CNA F reported that she assisted CNA E with showering Resident #1 around 2:30 p.m. CNA F stated that she did not see LVN D assess Resident #1. She reported that, 2 days later, she noticed that Resident #1's crying was different and that she was crying real tears. She informed her charge nurse (LVN J) of the crying. LVN J assessed Resident #1. CNA F reported that she told LVN J Do you think this could be from her fall? and that LVN J was unaware of Resident #1 falling because there was no incident report or documentation of it. CNA F reported that, once she was made aware of Resident #1's fall, LVN J ordered x-rays that found a [MEDICAL CONDITION]. CNA F reported that, in the days prior to Resident #1's 9/26/17 fall, she had been up without assistance and stated We had to watch her closely. She was in a wheelchair. We try to have one CNA on the hall and one CNA in the dining room at all times. During an interview with the DON at 8:44 a.m. on 10/27/17, when asked what the facility's corrective actions for Resident #1's fall with fracture were (besides terminating LVN D), she reported that staff were offering redirection for residents with frequent falls and stated When you tell staff what to do, they do it. We provide redirection and encouragement on the unit. If you guide them to the dining room, they follow. Staff try to guide them to a safe place. We can educate at that time, but residents on the unit especially forget. During an interview with the DON and the administrator at 8:45 a.m. on 10/27/17, they reported that they did an in-service on abuse/neglect and an in-service on the fall care delivery process for nurses and direct care staff after Resident #1's 9/26/17 fall. During continued interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that, after hospitalization for fracture surgery, Resident #1 was maximum assist for everything. He reported that she could walk 100-200 feet with minimal assist 2-3 weeks after readmission. PT K reported that Resident #1 still tried to get up unassisted and that he tried not to leave her alone. When asked if he thought Resident #1 needed constant supervision, PT K stated Mmm hmm and nodded his head. He stated She gets up when there is a need that needs to be fulfilled - she needs to be changed, is hungry, etc. She's not one of those who just gets up without reason. I like to keep my eyes on her. The investigator attempted to find Resident #1 at 9:41 a.m. on 10/27/17 and didn't see her. She asked the staff (there was a CNA, a medication aide, and a nurse at the medication cart in the dining room) where Resident #1 was. CNA L said that Resident #1 was in her room and guided the investigator there. Observation of Resident #1 at 9:43 a.m. on 10/27/17 revealed that she was sitting on the edge of her bed and trying to stand up without assistance. CNA L confirmed this. During an interview with CNA M at 2:10 p.m. on 10/27/17, she reported that Resident #1 was always walking around prior to her fall with fracture. When asked if Resident #1 required 1:1 supervision, CNA M stated A lot of times, yes. She was a fall risk, and we had to help her to sit. We kept her in eyesight. 2. Record review of Resident #14's significant change MDS assessment (ARD 10/5/17) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She could rarely understand or be understood, had impaired vision without corrective lenses, had severely-impaired cognition with inattention and disorganized thinking, wandered 1-3 days during the 7-day lookback period and had no other documented behaviors, needed supervision with walking in the room and in the corridor, and needed the extensive assistance of one staff for transfers. Her balance was noted as being steady at all times (exception was turning around - not steady but able to stabilize without staff assistance). There were no documented range of motion impairments or mobility devices, and she was assessed to be incontinent of bowel and bladder. She was assessed to have had 3 falls since the prior assessment - 2 without injury and 1 with minor injury. In the 7-day lookback period, she was administered an antianxiety medication 7 days and an antidepressant 6 days. 167 minutes of occupational therapy and 316 minutes of physical therapy were documented. Record review of Resident #14's care plan (last reviewed 10/16/17) revealed address of physical behaviors (grabbing other residents' hair and using items to hold other residents down, biting, and sitting on the floor) with interventions of monitor medications (initiated 9/27/17), evaluate the nature and circumstances and adjust care delivery appropriately (initiated 9/27/17), evaluate need for psych/behavioral health consult (initiated 8/29/17), observe for non-verbal signs of physical aggression (initiated 9/27/17), provide a calm well-lit environment (initiated 9/27/17), and social services to provide support as needed (initiated 9/27/17). Level of supervision needed was not care-planned. Continued record review of Resident #14's care plan (last reviewed 10/16/17) revealed that her fall risk was addressed with interventions of orthostatic blood pressures every shift for 72 hours (initiated 10/10/17), medication evaluation as needed (initiated 8/27/17), assist resident getting in and out of bed with 1 staff assistance (initiated 8/27/17), provide verbal cues for safety and sequencing when needed (initiated 8/27/17), provide verbal cues for proper pacing and energy conservation techniques (initiated 8/27/17), provide resident/caregiver education for safe techniques (initiated 9/18/17), place call light within reach while in bed or close proximity to bed (initiated 8/27/17), remind resident to use call light when attempting to ambulate or transfer (initiated 8/27/17), maintain a clutter-free environment in the resident's room and consistent furniture arrangement (initiated 8/27/17), when resident is in bed place all necessary personal items within reach (initiated 8/27/17), monitor for and assist with toileting needs (initiated 8/27/17), resident to be evaluated by therapy post fall (initiated 9/22/17), utilize low bed with floor mat (initiated 10/15/17), resident to be screened by therapy (initiated 9/13/17), encourage resident to attend activities that maximize their full potential while meeting their need to socialize (initiated 10/5/17), and will allow resident to sit on the floor and provide cushion for protection if she chooses to and staff to monitor (initiated 10/23/17). Level of supervision needed was not care-planned. Record review of the facility's incident/accident reports revealed: 8/26/17 - Resident #14 walked over to another resident in the dining room, grabbed her hair, and pulled it. A CNA immediately intervened and took Resident #14 to her room. Patient teaching was unsuccessful due to her mental status. Intervention was continued monitoring. 8/27/17 - Resident #14 wandered into another resident's room. The other resident became aggressive and pinched her on the arm with a grab stick. The other resident called for help, and staff separated them. A psych eval was ordered, and residents were to be monitored. Record review of Resident #14's progress notes revealed that she had a fall on 8/29/17 from which she sustained a laceration requiring stitches. There was no incident/accident report for this fall. 9/13/17 - Resident #14 was found on her back on the floor in the hall. Intervention was a therapy screen. 9/21/17 - Resident #14 attempted to stand up from her wheelchair in the dining room and fell . Three staff were in the dining room at the time, and her wheelchair brakes were locked. Intervention was a physical therapy evaluation. Further record review of Resident #14's progress notes revealed that she started physical therapy services on 9/28/17. 10/4/17 - Resident #14 was found on her back on the floor in the dining room. Interventions were to encourage all activities to meet need to socialize and keep her busy and continue physical therapy services. 10/10/17 - Resident #14 lost her balance when standing behind a chair in the dining room and fell . A CNA witnessed the fall. Interventions were continued physical therapy and orthostatic blood pressure checks for 3 days. 10/16/17 - Resident #14 wandered into another resident's room. The other resident kicked her. Resident #14 was immediately removed from the situation and encouraged not to enter the other resident's room again though she does not follow commands. There were no other interventions. 10/21/17 - Resident #14 fell in the dining room. A CNA witnessed the fall. Intervention was a referral to physical therapy for evaluation and treatment. 10/24/17 - Resident #14 entered into another resident's room and sat on her bed. The other resident struck her on the back. Resident #14 was redirected out of the room. A housekeeper witnessed the altercation. Observations of Resident #14 at 9:13 a.m. on 10/25/17 and at 1:38 p.m. on 10/27/17 revealed that she was not being supervised and was ambulating up and down the hall. At 9:13 a.m. on 10/25/17, a nurse, a medication aide, and 2 CNAs were in the dining room with residents. The social worker was in the clinical records closet (door open) between the dining room and the hall. There were 5 residents on the hall - 3 of whom were arguing with each other - 2 pushing the other one out of their room. No staff were on the hall supervising. At 1:38 p.m. on 10/27/17, there were at least 3 residents in bed on the hall and residents in the dining room. There was one CNA, a medication aide, and a nurse in the dining room talking. There were no staff observed on the hall. During an interview with MA C at 1:40 p.m. on 10/27/17, she reported that Resident #14 needed constant supervision because she wandered into other residents' rooms, instigating fights with other residents. MA C defined constant supervision as within eyesight - in the same room. During an interview with CNA E at 1:45 p.m. on 10/27/17, she defined closely monitor as within vision - so we can see and hear. CNA E defined constant supervision as closely - check on every minute or 2. During an interview with CNA M at 2:10 p.m. on 10/27/17, she reported that Resident #14 needed to be within eyesight secondary to her fall risk and wandering behaviors. CNA M reported that there were 7 residents (identified by name) on the women's unit that required constant supervision due to fall risk. When asked how she knew which residents were at risk for falls, CNA M reported that the charge nurse told them. During an interview with CNA E at 2:18 p.m. on 10/27/17, she reported that staff had to keep an eye on Resident #14 even though she was ambulatory because she fell often. CNA E reported that there were 4 residents on the women's unit who were at high risk for falls and required close monitoring. When asked how she knew which residents were at risk for falls, CNA E stated We just monitor and know. It's common sense - what we believe. When asked how she determined which residents needed more supervision, CNA E stated Active seekers to get up - try to walk more than the rest. She reported that there was no list of residents at risk for falls or any type of fall risk identification system in place. Record review of the facility's incident/accident reports from 8/24/17 through 10/27/17 revealed that Resident #14 had 5 falls and 4 resident-to-resident altercations, 3 of which resulted from her wandering into other residents' rooms. 3. Record review of Resident #2's electronic facesheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's 8/23/17 progress note revealed a history of falls. Record review of Resident #2's 9/15/17 incident/accident report revealed that he was found on the floor in his room. He reported that he was walking to the bathroom and slipped, fell , and hit the back of his head. He was assessed for injury, and there were no complaints of pain. Corrective action was Post void bladder ultrasound for [MEDICAL CONDITION]. Record review of Resident #2's 9/15/17 progress note revealed that he sustained a right side back of head abrasion measuring 2.6 x 0.9 from the fall. Record review of Resident #2's progress notes after 9/15/17 revealed no documentation pertaining to the post void bladder ultrasound results and/or action taken once the ultrasound was obtained. Record review of Resident #2's 9/29/17 incident/accident report revealed that he was found sitting on his buttocks on the floor in his bathroom. He reported that he lost his balance and fell . He was assessed for injury, and there were no complaints of pain. He was referred to occupational therapy for toileting training and his medications were adjusted for better pain management. Record review of Resident #2's 10/1/17 progress note revealed that he complained of right side pain. X-rays revealed a right rib fracture. Observation of the men's unit at 9:30 a.m. on 10/25/17 revealed Resident #2 in his wheelchair in the hallway sleeping. During an interview with LVN G, the charge nurse for the men's unit, at 9:32 a.m. on 10/25/17, she reported that she had been on the unit for 4 days. She reported that she was unaware of Resident #2 having a recent fall or fracture. However, she reported that she would find out his fall history. During an interview with LVN G at 9:40 a.m. on 10/25/17, she reported that Resident #2 had a fall on 9/29/17 and fractured his rib. She reported that he ambulated and used the bathroom on his own. When asked if Resident #2 was on any fall precautions, LVN G stated We monitor and encourage him to use his walker. During an interview LVN N at 3:33 p.m. on 10/27/17, when asked how she knew which residents were at risk for falls, stated Go through the charts and review their medications. We communicate with direct care staff by letting the nurses/aides know by word of mouth/in-services. LVN N reported that the facility did not utilize any sort of falling leaf/star program to identify residents at risk for falls and that the facility did not have lists of residents at risk for falls. She stated Everybody here has the perception that the resident has the right to fall. We are a nonrestraint facility. It's hard to change that perception in their heads. At 5:52 p.m. on 10/27/17, Corporate Nurse H, the DON, and the administrator were notified of the Immediate Jeopardy (IJ) situation for the above failures and a Plan of Removal was requested. The facility began corrective actions on 10/27/17 after 6:00 p.m. and continued to in-service and monitor staff and residents to ensure resident safety and prevention of falls. Observation of the women's unit at 2:45 p.m. on 10/28/17 revealed that Resident #14 was ambulating in the hallway and not within staff eyesight. Another resident was leaning forward in her wheelchair. CNA F was showering a resident. MA C was in the dining room with 8 residents. CNA Q was laying a resident down. During an interview with MA C at 2:52 p.m. on 10/28/17, she reported that the charge nurse was on break and that she and the 2 CNAs were the only staff on the unit at the time. Observation of Resident #1 in the dining room at 3:16 p.m. on 10/28/17 revealed that her eyes were closing and that she was dozing off in her wheelchair. She was sitting at a table with a drink in front of her. CNA S was at her side - providing 1:1 supervision. During an interview with the administrator, the DON, MDS Nurse I, NPE S, and LVN N at 3:51 p.m. on 10/29/17, the administrator reported that she did not plan on making staffing changes and stated Why? No more staff are needed. When asked if the facility had looked at activities for Resident #1, the administrator stated She has a BIMS of 0 - Why would we look at activities to engage her? LVN N stated that facility interventions after Resident #1's hip surgery were moving her to another unit because of familiar faces there and stated I don't think she will be mobile again. She's scared of falling again. The fall really affected her - scared her. Observation of Resident #1 in the dining room at 4:59 p.m. on 10/29/17 revealed that she was supervised by staff. Observations of Resident #14 in the hall of the women's unit at 5:10 p.m. and 5:18 p.m. on 10/29/17 revealed that she was attempting to open closet doors at the facility's entrance and rocking back and forth. There were no staff supervising. During an interview with MA C and LVN R at 5:12 p.m. on 10/29/17, they reported that the residents on the women's unit had been active that day and that, earlier in the shift, Resident #14 had walked out of another resident's room with a broken picture frame.<br (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to ensure that 3 of 17 residents (Resident #s 1, 14, and 2) whose care was reviewed had the right to be free from neglect related to falls in that: 1. Resident #1 had a history of [REDACTED].#1 to prevent further falls. She sustained 4 falls within 2 months, the last fall resulting in a right [MEDICAL CONDITION]. 2. Resident #14 had a history of [REDACTED].#14 to prevent further falls and wandering into other resident rooms. Resident #14 sustained 5 falls, one resulting in a laceration with stitches, and was involved in 4 resident-to-resident altercations within 2 months. 3. The facility failed to implement individualized interventions for and identify Resident #2 as a fall risk to prevent further falls. Resident #2 had 2 falls within 15 days. Staff providing care for Resident #2 were unaware of his fall risk and had no knowledge of a rib fracture that may have resulted from a 2nd fall. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 10/27/17. While the IJ was removed on 11/2/17, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all residents were assessed and all staff were in-serviced. This deficient practice had the potential to affect 25 residents with recurrent falls by contributing to injury. The findings were: 1. Record review of Resident #1's facesheet (dated 10/25/17) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS assessment (ARD 8/30/17) revealed that she could sometimes be understood and could sometimes understand. Her vision was assessed as being adequate without lenses. There were dashes for all areas of cognition, mood, behavior, and functional status (exceptions were balance - noted as not steady but able to stabilize without staff assistance - and ROM - no impairment). She was assessed to have had falls in the last month prior to admission and one fall without injury since admission. In the 7-day lookback period, she was administered an antipsychotic 4 days, an antianxiety medication 6 days, and an antidepressant 6 days. Record review of Resident #1's care plan (provided to the investigator on 10/25/17) revealed that her fall risk was addressed with interventions of orthostatic blood pressures every shift for 72 hours (initiated 9/22/17), medication evaluation as needed (initiated 8/27/17), assist resident getting in and out of bed with 1-2 assistance (initiated 8/27/17), provide verbal cues for safety and sequencing when needed (initiated 8/27/17), provide verbal cues for proper pacing and energy conservation techniques (initiated 8/27/17), provide resident/caregiver education for safe techniques (initiated 9/18/17), place call light within reach while in bed or close proximity to bed (initiated 8/27/17), remind resident to use call light when attempting to ambulate or transfer (initiated 8/27/17), maintain a clutter-free environment in the resident's room and consistent furniture arrangement (initiated 8/27/17), when resident is in bed place all necessary personal items within reach (initiated 8/27/17), monitor for and assist with toileting needs (initiated 8/27/17), and resident to be screened by therapy (initiated 8/29/17). Record review of the facility's incident/accident reports revealed: 8/25/17 11:30 a.m. - Resident #1 was found on the floor in the dining room. She attempted to stand without assistance. It was noted that Resident #1 was not able to ambulate without assistance and was limited to her wheelchair. The brakes on her wheelchair were documented as not being locked. Interventions were monitoring for adjustment to the facility (Resident #1 was an evacuee), a therapy screen, and x-rays. There were no other documented interventions. During an interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that therapy screened Resident #1 on 8/29/17 and determined that she was appropriate for services. However, Resident #1's family declined therapy at this time because 1) they didn't know how long Resident #1 would be at the facility and 2) they thought she may be having adjustment issues and wanted to give her time to adjust. Further record review of the facility's incident/accident reports revealed: 9/12/17 11:30 a.m. - Resident #1 had a witnessed fall in the hallway. She attempted to sit in her wheelchair, missed the chair, and fell on her back side. There was no documentation pertaining to whether or not her wheelchair brakes were locked. Interventions were resident education on safe technique and continued PT/OT for gait/strengthening. During an interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that Resident #1 was not picked up for therapy after her 8/25/17 fall because the family declined it. At the time of her 9/12/17 fall, Resident #1 was not receiving therapy services During an interview with the DON at 8:44 a.m. on 10/27/17, when asked about Resident #1 being educated on safe technique, she stated We can educate at that time, but residents on the unit especially forget. During continued interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that physical therapy picked Resident #1 up for services on 9/13/17 because she was falling and because her family agreed to it. PT K stated Her main thing was wandering. My point of view . she had the [MEDICAL CONDITION] symptoms of dementia - slow movement, decreased step length, and instability while walking. Antipsychotic medications are given for dementia, and they usually cause the [MEDICAL CONDITION] stuff. We try to increase movement, joint movement, postural stability. We do gait training and walking, the lower extremity bike to improve endurance and lower extremity strength and rhythm. When asked if Resident #1 was cooperative with therapy, PT K stated It was more about the dementia - a lot of anxiety and confusion. She'd have a crying spat - we'd work - and then she'd cry again. Overall, she did participate with verbal and tactile cueing and encouragement. Further record review of the facility's incident/accident reports revealed: 9/21/17 - Resident #1 lost her footing in the dining room and sat down on the floor. Intervention was to monitor orthostatic blood pressure for 3 days. Record review of Resident #1's 9/22/17 physician order [REDACTED]. Two times a day for 3 days - Evaluate both recording for potential orthostatic [MEDICAL CONDITION] indicated systolic drops by 20 units or diastolic drops by 10 units - Document occurrence and action taken in progress note was included in order summary. During an interview with the DON at 12:23 p.m. on 10/27/17, when asked why the facility decided to do blood pressure checks on Resident #1 after her 9/21/17 fall, she stated To rule out orthostatic [MEDICAL CONDITION]. Staff noticed she would stand up, get dizzy, and then sit back down. The DON, at this time, reported that Resident #1's blood pressures were normal (120/70) when checked for 3 days. Record review of Resident #1's Medication/Treatment Administrator Records for September of 2017 revealed that her blood pressures were as follows: 9/22/17 7:00 p.m. - sitting 118/62, standing 127/74 9/23/17 7:00 a.m. - sitting 145/76, standing 108/76 9/23/17 7:00 p.m. - sitting 114/74, standing 88/61 9/24/17 7:00 a.m. - sitting 126/72, standing 116/64 9/24/17 7:00 p.m. - sitting 112/62, standing 98/43 9/25/17 7:00 a.m. - sitting 125/75, standing (not documented) During an interview with the DON and Corporate Nurse H at 1:18 p.m. on 10/27/17, the DON confirmed that Resident #1's diastolic and systolic blood pressures had dropped significantly during the 3 days of monitoring after her 9/21/17 fall. When asked if the medication aide/nurse who took the abnormal blood pressures notified the doctor according to his order, the DON reviewed the progress notes and said that there was no indication that the doctor had been notified. During an interview with the DON at 3:00 p.m. on 10/27/17, the investigator asked So if blood pressure checks after Resident #1's 9/21/17 fall to rule out orthostatic [MEDICAL CONDITION] were done and were abnormal and it doesn't look like nurse notified the doctor . The DON intervened with The doctor normally says just to monitor if the resident is not on blood pressure medications. The investigator continued with But we don't know that he would say that. The orders say document occurrence and action taken in progress notes. There's no documentation in progress notes. So what was the point of the intervention if nothing was done when the blood pressures were abnormal? The DON did not respond at first. She then stated They were still within normal range. The investigator then stated But orthostatic [MEDICAL CONDITION] is a drop and there was a drop. Further record review of the facility's incident/accident reports revealed: 9/26/17 - Resident #1 was found on the floor in the dining room. She attempted to stand from her wheelchair without assistance and fractured her right hip. There was no documentation pertaining to whether or not her wheelchair brakes were locked. Intervention (post readmission after hip surgery) was PT/OT/ST. During an interview with the DON at 8:45 a.m. on 10/12/17, she reported that the facility terminated and referred LVN D to the Board of Nursing because she did not report Resident #1's 9/26/17 fall or assess Resident #1 for injury after her 9/26/17 fall. They determined this through interviews when doing their own investigation of Resident #1's [MEDICAL CONDITION]. During an interview with Medication Aide C at 1:03 p.m. on 10/24/17, she reported that she was coming back to the unit on the early afternoon of 9/26/17 and heard a yell from another resident. She reported that she ran to the dining room (where the yell came from) and found Resident #1 on her back. There were no staff in the dining room at the time. Medication Aide C reported that she got LVN D and that LVN D told her and CNA E to get Resident #1 in her wheelchair. Medication Aide C reported that LVN D did not do any kind of assessment on Resident #1 while she was on the floor. During an interview with CNA E at 1:50 p.m. on 10/24/17, she reported that she showered Resident #1 with CNA F's assistance around 2:30 p.m. on 9/26/17 and then put her in the dining room. She stated I did some other things. I was asking (LVN D) for something, and one of the residents yelled. She was in the dining room with (Resident #1) at the time. The nurse, me and the medication aide went to the dining room. (Resident #1) was on her back on the floor. CNA E reported that Resident #1 complained of pain and cried a bit. She normally cries when she talks. We put her in her chair and the nurse told (CNA F) to lay her down. When asked if LVN D assessed Resident #1 before putting her in the chair, CNA E stated I believe she just took her blood pressure. CNA E reported that Resident #1 did not cry out when they put her back in her chair. She reported that Resident #1 was wearing nonskid socks at the time of her fall. CNA E stated She had a habit of standing up from her chair. We were aware of her fall risk. We thought putting her in a wheelchair would stop her from getting up so much. CNA E reported that no staff were in the dining room with Resident #1 at the time of her fall. She reported that Resident #1 was in the dining room without staff supervision for about 10 minutes. Knowing her fall risk and that she had been getting up, she shouldn't have been left alone in the dining room. We all misjudged how severe her fall risk was. CNA E reported that Resident #1 fell in the dining room on a Tuesday and that she was off on Wednesday. She stated When I came back on Thursday, they told me she was in the hospital. I said 'It must have been from the fall'. They said 'What fall?' They didn't know about the fall because it wasn't documented. An attempt to interview LVN D by phone was made at 9:04 a.m. on 10/25/17. There was no answer. A message with a callback number was left. LVN D did not return the call. During an interview with CNA F at 2:45 p.m. on 10/25/17, she reported that she was working on 9/26/17 and went to the dining room around 3:30/4:00 p.m. because all of the staff were there. CNA F reported that Resident #1 was in her wheelchair and that LVN D was pushing her wheelchair. CNA F reported that she offered to help LVN D and pushed Resident #1's wheelchair into her room. CNA F reported that she found out Resident #1 fell when another resident told her after the fact. CNA F reported that she assisted CNA E with showering Resident #1 around 2:30 p.m. CNA F stated that she did not see LVN D assess Resident #1. She reported that, 2 days later, she noticed that Resident #1's crying was different and that she was crying real tears. She informed her charge nurse (LVN J) of the crying. LVN J assessed Resident #1. CNA F reported that she told LVN J Do you think this could be from her fall? and that LVN J was unaware of Resident #1 falling because there was no incident report or documentation of it. CNA F reported that, once she was made aware of Resident #1's fall, LVN J ordered x-rays that found a [MEDICAL CONDITION]. CNA F reported that, in the days prior to Resident #1's 9/26/17 fall, she had been up without assistance and stated We had to watch her closely. She was in a wheelchair. We try to have one CNA on the hall and one CNA in the dining room at all times. During an interview with the DON at 8:44 a.m. on 10/27/17, when asked what the facility's corrective actions for Resident #1's fall with fracture were (besides terminating LVN D), she reported that staff were offering redirection for residents with frequent falls and stated When you tell staff what to do, they do it. We provide redirection and encouragement on the unit. If you guide them to the dining room, they follow. Staff try to guide them to a safe place. We can educate at that time, but residents on the unit especially forget. During an interview with the DON and the administrator at 8:45 a.m. on 10/27/17, they reported that they did an in-service on abuse/neglect and an in-service on the fall care delivery process for nurses and direct care staff after Resident #1's 9/26/17 fall. During continued interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that, after hospitalization for fracture surgery, Resident #1 was maximum assist for everything. He reported that she could walk 100-200 feet with minimal assist 2-3 weeks after readmission. PT K reported that Resident #1 still tried to get up unassisted and that he tried not to leave her alone. When asked if he thought Resident #1 needed constant supervision, PT K stated Mmm hmm and nodded his head. He stated She gets up when there is a need that needs to be fulfilled - she needs to be changed, is hungry, etc. She's not one of those who just gets up without reason. I like to keep my eyes on her. The investigator attempted to find Resident #1 at 9:41 a.m. on 10/27/17 and didn't see her. She asked the staff (there was a CNA, a medication aide, and a nurse at the medication cart in the dining room) where Resident #1 was. CNA L said that Resident #1 was in her room and guided the investigator there. Observation of Resident #1 at 9:43 a.m. on 10/27/17 revealed that she was sitting on the edge of her bed and trying to stand up without assistance. CNA L confirmed this. During an interview with CNA M at 2:10 p.m. on 10/27/17, she reported that Resident #1 was always walking around prior to her fall with fracture. When asked if Resident #1 required 1:1 supervision, CNA M stated A lot of times, yes. She was a fall risk, and we had to help her to sit. We kept her in eyesight. 2. Record review of Resident #14's significant change MDS assessment (ARD 10/5/17) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She could rarely understand or be understood, had impaired vision without corrective lenses, had severely-impaired cognition with inattention and disorganized thinking, wandered 1-3 days during the 7-day lookback period and had no other documented behaviors, needed supervision with walking in the room and in the corridor, and needed the extensive assistance of one staff for transfers. Her balance was noted as being steady at all times (exception was turning around - not steady but able to stabilize without staff assistance). There were no documented range of motion impairments or mobility devices, and she was assessed to be incontinent of bowel and bladder. She was assessed to have had 3 falls since the prior assessment - 2 without injury and 1 with minor injury. In the 7-day lookback period, she was administered an antianxiety medication 7 days and an antidepressant 6 days. 167 minutes of occupational therapy and 316 minutes of physical therapy were documented. Record review of Resident #14's care plan (last reviewed 10/16/17) revealed address of physical behaviors (grabbing other residents' hair and using items to hold other residents down, biting, and sitting on the floor) with interventions of monitor medications (initiated 9/27/17), evaluate the nature and circumstances and adjust care delivery appropriately (initiated 9/27/17), evaluate need for psych/behavioral health consult (initiated 8/29/17), observe for non-verbal signs of physical aggression (initiated 9/27/17), provide a calm well-lit environment (initiated 9/27/17), and social services to provide support as needed (initiated 9/27/17). Level of supervision needed was not care-planned. Continued record review of Resident #14's care plan (last reviewed 10/16/17) revealed that her fall risk was addressed with interventions of orthostatic blood pressures every shift for 72 hours (initiated 10/10/17), medication evaluation as needed (initiated 8/27/17), assist resident getting in and out of bed with 1 staff assistance (initiated 8/27/17), provide verbal cues for safety and sequencing when needed (initiated 8/27/17), provide verbal cues for proper pacing and energy conservation techniques (initiated 8/27/17), provide resident/caregiver education for safe techniques (initiated 9/18/17), place call light within reach while in bed or close proximity to bed (initiated 8/27/17), remind resident to use call light when attempting to ambulate or transfer (initiated 8/27/17), maintain a clutter-free environment in the resident's room and consistent furniture arrangement (initiated 8/27/17), when resident is in bed place all necessary personal items within reach (initiated 8/27/17), monitor for and assist with toileting needs (initiated 8/27/17), resident to be evaluated by therapy post fall (initiated 9/22/17), utilize low bed with floor mat (initiated 10/15/17), resident to be screened by therapy (initiated 9/13/17), encourage resident to attend activities that maximize their full potential while meeting their need to socialize (initiated 10/5/17), and will allow resident to sit on the floor and provide cushion for protection if she chooses to and staff to monitor (initiated 10/23/17). Level of supervision needed was not care-planned. Record review of the facility's incident/accident reports revealed: 8/26/17 - Resident #14 walked over to another resident in the dining room, grabbed her hair, and pulled it. A CNA immediately intervened and took Resident #14 to her room. Patient teaching was unsuccessful due to her mental status. Intervention was continued monitoring. 8/27/17 - Resident #14 wandered into another resident's room. The other resident became aggressive and pinched her on the arm with a grab stick. The other resident called for help, and staff separated them. A psych eval was ordered, and residents were to be monitored. Record review of Resident #14's progress notes revealed that she had a fall on 8/29/17 from which she sustained a laceration requiring stitches. There was no incident/accident report for this fall. 9/13/17 - Resident #14 was found on her back on the floor in the hall. Intervention was a therapy screen. 9/21/17 - Resident #14 attempted to stand up from her wheelchair in the dining room and fell . Three staff were in the dining room at the time, and her wheelchair brakes were locked. Intervention was a physical therapy evaluation. Further record review of Resident #14's progress notes revealed that she started physical therapy services on 9/28/17. 10/4/17 - Resident #14 was found on her back on the floor in the dining room. Interventions were to encourage all activities to meet need to socialize and keep her busy and continue physical therapy services. 10/10/17 - Resident #14 lost her balance when standing behind a chair in the dining room and fell . A CNA witnessed the fall. Interventions were continued physical therapy and orthostatic blood pressure checks for 3 days. 10/16/17 - Resident #14 wandered into another resident's room. The other resident kicked her. Resident #14 was immediately removed from the situation and encouraged not to enter the other resident's room again though she does not follow commands. There were no other interventions. 10/21/17 - Resident #14 fell in the dining room. A CNA witnessed the fall. Intervention was a referral to physical therapy for evaluation and treatment. 10/24/17 - Resident #14 entered into another resident's room and sat on her bed. The other resident struck her on the back. Resident #14 was redirected out of the room. A housekeeper witnessed the altercation. Observations of Resident #14 at 9:13 a.m. on 10/25/17 and at 1:38 p.m. on 10/27/17 revealed that she was not being supervised and was ambulating up and down the hall. At 9:13 a.m. on 10/25/17, a nurse, a medication aide, and 2 CNAs were in the dining room with residents. The social worker was in the clinical records closet (door open) between the dining room and the hall. There were 5 residents on the hall - 3 of whom were arguing with each other - 2 pushing the other one out of their room. No staff were on the hall supervising. At 1:38 p.m. on 10/27/17, there were at least 3 residents in bed on the hall and residents in the dining room. There was one CNA, a medication aide, and a nurse in the dining room talking. There were no staff observed on the hall. During an interview with MA C at 1:40 p.m. on 10/27/17, she reported that Resident #14 needed constant supervision because she wandered into other residents' rooms, instigating fights with other residents. MA C defined constant supervision as within eyesight - in the same room. During an interview with CNA E at 1:45 p.m. on 10/27/17, she defined closely monitor as within vision - so we can see and hear. CNA E defined constant supervision as closely - check on every minute or 2. During an interview with CNA M at 2:10 p.m. on 10/27/17, she reported that Resident #14 needed to be within eyesight secondary to her fall risk and wandering behaviors. CNA M reported that there were 7 residents (identified by name) on the women's unit that required constant supervision due to fall risk. When asked how she knew which residents were at risk for falls, CNA M reported that the charge nurse told them. During an interview with CNA E at 2:18 p.m. on 10/27/17, she reported that staff had to keep an eye on Resident #14 even though she was ambulatory because she fell often. CNA E reported that there were 4 residents on the women's unit who were at high risk for falls and required close monitoring. When asked how she knew which residents were at risk for falls, CNA E stated We just monitor and know. It's common sense - what we believe. When asked how she determined which residents needed more supervision, CNA E stated Active seekers to get up - try to walk more than the rest. She reported that there was no list of residents at risk for falls or any type of fall risk identification system in place. Record review of the facility's incident/accident reports from 8/24/17 through 10/27/17 revealed that Resident #14 had 5 falls and 4 resident-to-resident altercations, 3 of which resulted from her wandering into other residents' rooms. 3. Record review of Resident #2's electronic facesheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's 8/23/17 progress note revealed a history of falls. Record review of Resident #2's 9/15/17 incident/accident report revealed that he was found on the floor in his room. He reported that he was walking to the bathroom and slipped, fell , and hit the back of his head. He was assessed for injury, and there were no complaints of pain. Corrective action was Post void bladder ultrasound for [MEDICAL CONDITION]. Record review of Resident #2's 9/15/17 progress note revealed that he sustained a right side back of head abrasion measuring 2.6 x 0.9 from the fall. Record review of Resident #2's progress notes after 9/15/17 revealed no documentation pertaining to the post void bladder ultrasound results and/or action taken once the ultrasound was obtained. Record review of Resident #2's 9/29/17 incident/accident report revealed that he was found sitting on his buttocks on the floor in his bathroom. He reported that he lost his balance and fell . He was assessed for injury, and there were no complaints of pain. He was referred to occupational therapy for toileting training and his medications were adjusted for better pain management. Record review of Resident #2's 10/1/17 progress note revealed that he complained of right side pain. X-rays revealed a right rib fracture. Observation of the men's unit at 9:30 a.m. on 10/25/17 revealed Resident #2 in his wheelchair in the hallway sleeping. During an interview with LVN G, the charge nurse for the men's unit, at 9:32 a.m. on 10/25/17, she reported that she had been on the unit for 4 days. She reported that she was unaware of Resident #2 having a recent fall or fracture. However, she reported that she would find out his fall history. During an interview with LVN G at 9:40 a.m. on 10/25/17, she reported that Resident #2 had a fall on 9/29/17 and fractured his rib. She reported that he ambulated and used the bathroom on his own. When asked if Resident #2 was on any fall precautions, LVN G stated We monitor and encourage him to use his walker. During an interview LVN N at 3:33 p.m. on 10/27/17, when asked how she knew which residents were at risk for falls, stated Go through the charts and review their medications. We communicate with direct care staff by letting the nurses/aides know by word of mouth/in-services. LVN N reported that the facility did not utilize any sort of falling leaf/star program to identify residents at risk for falls and that the facility did not have lists of residents at risk for falls. She stated Everybody here has the perception that the resident has the right to fall. We are a nonrestraint facility. It's hard to change that perception in their heads. Record review of the facility's fall management policy (revised 3/15/16) revealed Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause. Practice Standards: 1. Identify patient's fall risk by reviewing the following. 1.1 Electronic Medical Record Systems - Nursing Assessment 1.2 Non-electronic Medical Record Systems - Fall Risk Evaluation 2. Communicate patient's fall risk status to caregivers. 3. Develop individualized plan of care. 4. Review and revise care plan regularly. 5. If patient falls: 5.1 Following Guidelines for Managing a Fall (refer to Falls Care Delivery Process) if staff member is present when the fall occurs. 5.2 Utilize the Fall Response Protocol (refer to Falls Care Delivery Process) for both witnessed and unwitnessed falls. 5.3 Document accident/incident: 5.3.1 As a new event in the Risk Management System (RMS); 5.3.2 On a Change of Condition Note; 5.3.3 On the 24-Hour Report; 5.3.4 Investigation using the Fall Investigation/QA and other appropriate tools in RMS. 5.4 Update care plan to reflect new interventions. 5.5 Conduct interdisciplinary team meeting within 72 hours of fall 5.6 The Center Executive Director and Center Nurse Executive will conduct a post fall review. Record review of the facility's abuse policy (revised 4/7/17) revealed Neglect is defined as the failure of the center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. At 5:52 p.m. on 10/27/17, Corporate Nurse H, the DON, and the administrator were notified of the Immediate Jeopardy (IJ) situation for the above failures and a Plan of Removal was requested. The facility began corrective actions on 10/27/17 after 6:00 p.m. and continued to in-service and monitor staff and residents to ensure resident safety and prevention of falls. Observation of the women's unit at 2:45 p.m. on 10/28/17 revealed that Resident #14 was ambulating in the hallway and not within staff eyesight. Another resident was leaning forward in her wheelchair. CNA F was showering a resident. MA C was in the dining room with 8 residents. CNA Q was laying a resident down. During an interview with MA C at 2:52 p.m. on 10/28/17, she reported that the charge nurse was on break and that she and the 2 CNAs were the only staff on the unit at the time. Observation of Resident #1 in the dining room at 3:16 p.m. on 10/28/17 revealed that her eyes were closing and that she was dozing off in her wheelchair. She was sitting at a table with a drink in front of her. CNA S was at her side - providing 1:1 supervision. During an interview with the administrator, the DON, MDS Nurse I, NPE S, and LVN N at 3:51 p.m. on 10/29/17, the administrator reported that she did not plan on making staffing changes and stated Why? No more staff are needed. When asked if the facility had looked at activities for Resident #1, the administrator stated She has a BIMS of 0 - Why would we look at activities to engage her? LVN N stated that facility interventions after Resident #1's hip surgery were moving her to another unit because of familiar faces there and stated I don't think she will be mobile again. She's scared of falling again. The fall really affected her - scared her. Observation of Resident #1 in the dining room at 4:59 p.m. on 10/29/17 revealed that she was supervised by staff. Observations of Resident #14 in the hall of the women's unit at 5:10 p.m. and 5:18 p.m. on 10/29/17 revealed that she was attempting to open closet doors at the facility's entrance and rocking back and forth. There were no staff supervising. During an interview with MA C and LVN R at 5:12 p.m. on 10/29/17, they reported that the residents on the women's unit had been active that day and that, earlier in the shift, Resident #14 had walked out of another resident's room with a broken picture frame. During an interview (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to ensure that the quality assessment and assurance committee met as needed and developed and implemented appropriate plans of action to correct identified quality deficiencies in that: Residents were having recurrent falls with and without injury. The facility had identified falls as a problem but had not developed and implemented appropriate plans of action to correct identified quality deficiencies. Incident/accident reports were not being completed and appropriate interventions were not implemented after resident falls. 1. Resident #1 had a history of [REDACTED].#1 to prevent further falls. She sustained 4 falls within 2 months, the last fall resulting in a right [MEDICAL CONDITION]. 2. Resident #14 had a history of [REDACTED].#14 to prevent further falls and wandering into other resident rooms. Resident #14 sustained 5 falls, one resulting in a laceration with stitches, and was involved in 4 resident-to-resident altercations within 2 months. 3. The facility failed to implement individualized interventions for and identify Resident #2 as a fall risk to prevent further falls. Resident #2 had 2 falls within 15 days. Staff providing care for Resident #2 were unaware of his fall risk and had no knowledge of a rib fracture that may have resulted from a 2nd fall. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 10/27/17. While the IJ was removed on 11/2/17, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all residents were assessed and all staff were in-serviced. This deficient practice had the potential to affect 25 residents with recurrent falls by contributing to injury. The findings were: 1. Record review of Resident #1's facesheet (dated 10/25/17) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's admission MDS assessment (ARD 8/30/17) revealed that she could sometimes be understood and could sometimes understand. Her vision was assessed as being adequate without lenses. There were dashes for all areas of cognition, mood, behavior, and functional status (exceptions were balance - noted as not steady but able to stabilize without staff assistance - and ROM - no impairment). She was assessed to have had falls in the last month prior to admission and one fall without injury since admission. In the 7-day lookback period, she was administered an antipsychotic 4 days, an antianxiety medication 6 days, and an antidepressant 6 days. Record review of Resident #1's care plan (provided to the investigator on 10/25/17) revealed that her fall risk was addressed with interventions of orthostatic blood pressures every shift for 72 hours (initiated 9/22/17), medication evaluation as needed (initiated 8/27/17), assist resident getting in and out of bed with 1-2 assistance (initiated 8/27/17), provide verbal cues for safety and sequencing when needed (initiated 8/27/17), provide verbal cues for proper pacing and energy conservation techniques (initiated 8/27/17), provide resident/caregiver education for safe techniques (initiated 9/18/17), place call light within reach while in bed or close proximity to bed (initiated 8/27/17), remind resident to use call light when attempting to ambulate or transfer (initiated 8/27/17), maintain a clutter-free environment in the resident's room and consistent furniture arrangement (initiated 8/27/17), when resident is in bed place all necessary personal items within reach (initiated 8/27/17), monitor for and assist with toileting needs (initiated 8/27/17), and resident to be screened by therapy (initiated 8/29/17). Record review of the facility's incident/accident reports revealed: 8/25/17 11:30 a.m. - Resident #1 was found on the floor in the dining room. She attempted to stand without assistance. It was noted that Resident #1 was not able to ambulate without assistance and was limited to her wheelchair. The brakes on her wheelchair were documented as not being locked. Interventions were monitoring for adjustment to the facility (Resident #1 was an evacuee), a therapy screen, and x-rays. There were no other documented interventions. During an interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that therapy screened Resident #1 on 8/29/17 and determined that she was appropriate for services. However, Resident #1's family declined therapy at this time because 1) they didn't know how long Resident #1 would be at the facility and 2) they thought she may be having adjustment issues and wanted to give her time to adjust. Further record review of the facility's incident/accident reports revealed: 9/12/17 11:30 a.m. - Resident #1 had a witnessed fall in the hallway. She attempted to sit in her wheelchair, missed the chair, and fell on her back side. There was no documentation pertaining to whether or not her wheelchair brakes were locked. Interventions were resident education on safe technique and continued PT/OT for gait/strengthening. During an interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that Resident #1 was not picked up for therapy after her 8/25/17 fall because the family declined it. At the time of her 9/12/17 fall, Resident #1 was not receiving therapy services During an interview with the DON at 8:44 a.m. on 10/27/17, when asked about Resident #1 being educated on safe technique, she stated We can educate at that time, but residents on the unit especially forget. During continued interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that physical therapy picked Resident #1 up for services on 9/13/17 because she was falling and because her family agreed to it. PT K stated Her main thing was wandering. My point of view . she had the [MEDICAL CONDITION] symptoms of dementia - slow movement, decreased step length, and instability while walking. Antipsychotic medications are given for dementia, and they usually cause the [MEDICAL CONDITION] stuff. We try to increase movement, joint movement, postural stability. We do gait training and walking, the lower extremity bike to improve endurance and lower extremity strength and rhythm. When asked if Resident #1 was cooperative with therapy, PT K stated It was more about the dementia - a lot of anxiety and confusion. She'd have a crying spat - we'd work - and then she'd cry again. Overall, she did participate with verbal and tactile cueing and encouragement. Further record review of the facility's incident/accident reports revealed: 9/21/17 - Resident #1 lost her footing in the dining room and sat down on the floor. Intervention was to monitor orthostatic blood pressure for 3 days. Record review of Resident #1's 9/22/17 physician order [REDACTED]. Two times a day for 3 days - Evaluate both recording for potential orthostatic [MEDICAL CONDITION] indicated systolic drops by 20 units or diastolic drops by 10 units - Document occurrence and action taken in progress note was included in order summary. During an interview with the DON at 12:23 p.m. on 10/27/17, when asked why the facility decided to do blood pressure checks on Resident #1 after her 9/21/17 fall, she stated To rule out orthostatic [MEDICAL CONDITION]. Staff noticed she would stand up, get dizzy, and then sit back down. The DON, at this time, reported that Resident #1's blood pressures were normal (120/70) when checked for 3 days. Record review of Resident #1's Medication/Treatment Administrator Records for September of 2017 revealed that her blood pressures were as follows: 9/22/17 7:00 p.m. - sitting 118/62, standing 127/74 9/23/17 7:00 a.m. - sitting 145/76, standing 108/76 9/23/17 7:00 p.m. - sitting 114/74, standing 88/61 9/24/17 7:00 a.m. - sitting 126/72, standing 116/64 9/24/17 7:00 p.m. - sitting 112/62, standing 98/43 9/25/17 7:00 a.m. - sitting 125/75, standing (not documented) During an interview with the DON and Corporate Nurse H at 1:18 p.m. on 10/27/17, the DON confirmed that Resident #1's diastolic and systolic blood pressures had dropped significantly during the 3 days of monitoring after her 9/21/17 fall. When asked if the medication aide/nurse who took the abnormal blood pressures notified the doctor according to his order, the DON reviewed the progress notes and said that there was no indication that the doctor had been notified. During an interview with the DON at 3:00 p.m. on 10/27/17, the investigator asked So if blood pressure checks after Resident #1's 9/21/17 fall to rule out orthostatic [MEDICAL CONDITION] were done and were abnormal and it doesn't look like nurse notified the doctor . The DON intervened with The doctor normally says just to monitor if the resident is not on blood pressure medications. The investigator continued with But we don't know that he would say that. The orders say document occurrence and action taken in progress notes. There's no documentation in progress notes. So what was the point of the intervention if nothing was done when the blood pressures were abnormal? The DON did not respond at first. She then stated They were still within normal range. The investigator then stated But orthostatic [MEDICAL CONDITION] is a drop and there was a drop. Further record review of the facility's incident/accident reports revealed: 9/26/17 - Resident #1 was found on the floor in the dining room. She attempted to stand from her wheelchair without assistance and fractured her right hip. There was no documentation pertaining to whether or not her wheelchair brakes were locked. Intervention (post readmission after hip surgery) was PT/OT/ST. During an interview with the DON at 8:45 a.m. on 10/12/17, she reported that the facility terminated and referred LVN D to the Board of Nursing because she did not report Resident #1's 9/26/17 fall or assess Resident #1 for injury after her 9/26/17 fall. They determined this through interviews when doing their own investigation of Resident #1's [MEDICAL CONDITION]. During an interview with Medication Aide C at 1:03 p.m. on 10/24/17, she reported that she was coming back to the unit on the early afternoon of 9/26/17 and heard a yell from another resident. She reported that she ran to the dining room (where the yell came from) and found Resident #1 on her back. There were no staff in the dining room at the time. Medication Aide C reported that she got LVN D and that LVN D told her and CNA E to get Resident #1 in her wheelchair. Medication Aide C reported that LVN D did not do any kind of assessment on Resident #1 while she was on the floor. During an interview with CNA E at 1:50 p.m. on 10/24/17, she reported that she showered Resident #1 with CNA F's assistance around 2:30 p.m. on 9/26/17 and then put her in the dining room. She stated I did some other things. I was asking (LVN D) for something, and one of the residents yelled. She was in the dining room with (Resident #1) at the time. The nurse, me and the medication aide went to the dining room. (Resident #1) was on her back on the floor. CNA E reported that Resident #1 complained of pain and cried a bit. She normally cries when she talks. We put her in her chair and the nurse told (CNA F) to lay her down. When asked if LVN D assessed Resident #1 before putting her in the chair, CNA E stated I believe she just took her blood pressure. CNA E reported that Resident #1 did not cry out when they put her back in her chair. She reported that Resident #1 was wearing nonskid socks at the time of her fall. CNA E stated She had a habit of standing up from her chair. We were aware of her fall risk. We thought putting her in a wheelchair would stop her from getting up so much. CNA E reported that no staff were in the dining room with Resident #1 at the time of her fall. She reported that Resident #1 was in the dining room without staff supervision for about 10 minutes. Knowing her fall risk and that she had been getting up, she shouldn't have been left alone in the dining room. We all misjudged how severe her fall risk was. CNA E reported that Resident #1 fell in the dining room on a Tuesday and that she was off on Wednesday. She stated When I came back on Thursday, they told me she was in the hospital. I said 'It must have been from the fall'. They said 'What fall?' They didn't know about the fall because it wasn't documented. An attempt to interview LVN D by phone was made at 9:04 a.m. on 10/25/17. There was no answer. A message with a callback number was left. LVN D did not return the call. During an interview with CNA F at 2:45 p.m. on 10/25/17, she reported that she was working on 9/26/17 and went to the dining room around 3:30/4:00 p.m. because all of the staff were there. CNA F reported that Resident #1 was in her wheelchair and that LVN D was pushing her wheelchair. CNA F reported that she offered to help LVN D and pushed Resident #1's wheelchair into her room. CNA F reported that she found out Resident #1 fell when another resident told her after the fact. CNA F reported that she assisted CNA E with showering Resident #1 around 2:30 p.m. CNA F stated that she did not see LVN D assess Resident #1. She reported that, 2 days later, she noticed that Resident #1's crying was different and that she was crying real tears. She informed her charge nurse (LVN J) of the crying. LVN J assessed Resident #1. CNA F reported that she told LVN J Do you think this could be from her fall? and that LVN J was unaware of Resident #1 falling because there was no incident report or documentation of it. CNA F reported that, once she was made aware of Resident #1's fall, LVN J ordered x-rays that found a [MEDICAL CONDITION]. CNA F reported that, in the days prior to Resident #1's 9/26/17 fall, she had been up without assistance and stated We had to watch her closely. She was in a wheelchair. We try to have one CNA on the hall and one CNA in the dining room at all times. During an interview with the DON at 8:44 a.m. on 10/27/17, when asked what the facility's corrective actions for Resident #1's fall with fracture were (besides terminating LVN D), she reported that staff were offering redirection for residents with frequent falls and stated When you tell staff what to do, they do it. We provide redirection and encouragement on the unit. If you guide them to the dining room, they follow. Staff try to guide them to a safe place. We can educate at that time, but residents on the unit especially forget. During an interview with the DON and the administrator at 8:45 a.m. on 10/27/17, they reported that they did an in-service on abuse/neglect and an in-service on the fall care delivery process for nurses and direct care staff after Resident #1's 9/26/17 fall. During continued interview with Physical Therapist K at 9:06 a.m. on 10/27/17, he reported that, after hospitalization for fracture surgery, Resident #1 was maximum assist for everything. He reported that she could walk 100-200 feet with minimal assist 2-3 weeks after readmission. PT K reported that Resident #1 still tried to get up unassisted and that he tried not to leave her alone. When asked if he thought Resident #1 needed constant supervision, PT K stated Mmm hmm and nodded his head. He stated She gets up when there is a need that needs to be fulfilled - she needs to be changed, is hungry, etc. She's not one of those who just gets up without reason. I like to keep my eyes on her. The investigator attempted to find Resident #1 at 9:41 a.m. on 10/27/17 and didn't see her. She asked the staff (there was a CNA, a medication aide, and a nurse at the medication cart in the dining room) where Resident #1 was. CNA L said that Resident #1 was in her room and guided the investigator there. Observation of Resident #1 at 9:43 a.m. on 10/27/17 revealed that she was sitting on the edge of her bed and trying to stand up without assistance. CNA L confirmed this. During an interview with CNA M at 2:10 p.m. on 10/27/17, she reported that Resident #1 was always walking around prior to her fall with fracture. When asked if Resident #1 required 1:1 supervision, CNA M stated A lot of times, yes. She was a fall risk, and we had to help her to sit. We kept her in eyesight. 2. Record review of Resident #14's significant change MDS assessment (ARD 10/5/17) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She could rarely understand or be understood, had impaired vision without corrective lenses, had severely-impaired cognition with inattention and disorganized thinking, wandered 1-3 days during the 7-day lookback period and had no other documented behaviors, needed supervision with walking in the room and in the corridor, and needed the extensive assistance of one staff for transfers. Her balance was noted as being steady at all times (exception was turning around - not steady but able to stabilize without staff assistance). There were no documented range of motion impairments or mobility devices, and she was assessed to be incontinent of bowel and bladder. She was assessed to have had 3 falls since the prior assessment - 2 without injury and 1 with minor injury. In the 7-day lookback period, she was administered an antianxiety medication 7 days and an antidepressant 6 days. 167 minutes of occupational therapy and 316 minutes of physical therapy were documented. Record review of Resident #14's care plan (last reviewed 10/16/17) revealed address of physical behaviors (grabbing other residents' hair and using items to hold other residents down, biting, and sitting on the floor) with interventions of monitor medications (initiated 9/27/17), evaluate the nature and circumstances and adjust care delivery appropriately (initiated 9/27/17), evaluate need for psych/behavioral health consult (initiated 8/29/17), observe for non-verbal signs of physical aggression (initiated 9/27/17), provide a calm well-lit environment (initiated 9/27/17), and social services to provide support as needed (initiated 9/27/17). Level of supervision needed was not care-planned. Continued record review of Resident #14's care plan (last reviewed 10/16/17) revealed that her fall risk was addressed with interventions of orthostatic blood pressures every shift for 72 hours (initiated 10/10/17), medication evaluation as needed (initiated 8/27/17), assist resident getting in and out of bed with 1 staff assistance (initiated 8/27/17), provide verbal cues for safety and sequencing when needed (initiated 8/27/17), provide verbal cues for proper pacing and energy conservation techniques (initiated 8/27/17), provide resident/caregiver education for safe techniques (initiated 9/18/17), place call light within reach while in bed or close proximity to bed (initiated 8/27/17), remind resident to use call light when attempting to ambulate or transfer (initiated 8/27/17), maintain a clutter-free environment in the resident's room and consistent furniture arrangement (initiated 8/27/17), when resident is in bed place all necessary personal items within reach (initiated 8/27/17), monitor for and assist with toileting needs (initiated 8/27/17), resident to be evaluated by therapy post fall (initiated 9/22/17), utilize low bed with floor mat (initiated 10/15/17), resident to be screened by therapy (initiated 9/13/17), encourage resident to attend activities that maximize their full potential while meeting their need to socialize (initiated 10/5/17), and will allow resident to sit on the floor and provide cushion for protection if she chooses to and staff to monitor (initiated 10/23/17). Level of supervision needed was not care-planned. Record review of the facility's incident/accident reports revealed: 8/26/17 - Resident #14 walked over to another resident in the dining room, grabbed her hair, and pulled it. A CNA immediately intervened and took Resident #14 to her room. Patient teaching was unsuccessful due to her mental status. Intervention was continued monitoring. 8/27/17 - Resident #14 wandered into another resident's room. The other resident became aggressive and pinched her on the arm with a grab stick. The other resident called for help, and staff separated them. A psych eval was ordered, and residents were to be monitored. Record review of Resident #14's progress notes revealed that she had a fall on 8/29/17 from which she sustained a laceration requiring stitches. There was no incident/accident report for this fall. 9/13/17 - Resident #14 was found on her back on the floor in the hall. Intervention was a therapy screen. 9/21/17 - Resident #14 attempted to stand up from her wheelchair in the dining room and fell . Three staff were in the dining room at the time, and her wheelchair brakes were locked. Intervention was a physical therapy evaluation. Further record review of Resident #14's progress notes revealed that she started physical therapy services on 9/28/17. 10/4/17 - Resident #14 was found on her back on the floor in the dining room. Interventions were to encourage all activities to meet need to socialize and keep her busy and continue physical therapy services. 10/10/17 - Resident #14 lost her balance when standing behind a chair in the dining room and fell . A CNA witnessed the fall. Interventions were continued physical therapy and orthostatic blood pressure checks for 3 days. 10/16/17 - Resident #14 wandered into another resident's room. The other resident kicked her. Resident #14 was immediately removed from the situation and encouraged not to enter the other resident's room again though she does not follow commands. There were no other interventions. 10/21/17 - Resident #14 fell in the dining room. A CNA witnessed the fall. Intervention was a referral to physical therapy for evaluation and treatment. 10/24/17 - Resident #14 entered into another resident's room and sat on her bed. The other resident struck her on the back. Resident #14 was redirected out of the room. A housekeeper witnessed the altercation. Observations of Resident #14 at 9:13 a.m. on 10/25/17 and at 1:38 p.m. on 10/27/17 revealed that she was not being supervised and was ambulating up and down the hall. At 9:13 a.m. on 10/25/17, a nurse, a medication aide, and 2 CNAs were in the dining room with residents. The social worker was in the clinical records closet (door open) between the dining room and the hall. There were 5 residents on the hall - 3 of whom were arguing with each other - 2 pushing the other one out of their room. No staff were on the hall supervising. At 1:38 p.m. on 10/27/17, there were at least 3 residents in bed on the hall and residents in the dining room. There was one CNA, a medication aide, and a nurse in the dining room talking. There were no staff observed on the hall. During an interview with MA C at 1:40 p.m. on 10/27/17, she reported that Resident #14 needed constant supervision because she wandered into other residents' rooms, instigating fights with other residents. MA C defined constant supervision as within eyesight - in the same room. During an interview with CNA E at 1:45 p.m. on 10/27/17, she defined closely monitor as within vision - so we can see and hear. CNA E defined constant supervision as closely - check on every minute or 2. During an interview with CNA M at 2:10 p.m. on 10/27/17, she reported that Resident #14 needed to be within eyesight secondary to her fall risk and wandering behaviors. CNA M reported that there were 7 residents (identified by name) on the women's unit that required constant supervision due to fall risk. When asked how she knew which residents were at risk for falls, CNA M reported that the charge nurse told them. During an interview with CNA E at 2:18 p.m. on 10/27/17, she reported that staff had to keep an eye on Resident #14 even though she was ambulatory because she fell often. CNA E reported that there were 4 residents on the women's unit who were at high risk for falls and required close monitoring. When asked how she knew which residents were at risk for falls, CNA E stated We just monitor and know. It's common sense - what we believe. When asked how she determined which residents needed more supervision, CNA E stated Active seekers to get up - try to walk more than the rest. She reported that there was no list of residents at risk for falls or any type of fall risk identification system in place. Record review of the facility's incident/accident reports from 8/24/17 through 10/27/17 revealed that Resident #14 had 5 falls and 4 resident-to-resident altercations, 3 of which resulted from her wandering into other residents' rooms. 3. Record review of Resident #2's electronic facesheet (not dated) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's 8/23/17 progress note revealed a history of falls. Record review of Resident #2's 9/15/17 incident/accident report revealed that he was found on the floor in his room. He reported that he was walking to the bathroom and slipped, fell , and hit the back of his head. He was assessed for injury, and there were no complaints of pain. Corrective action was Post void bladder ultrasound for [MEDICAL CONDITION]. Record review of Resident #2's 9/15/17 progress note revealed that he sustained a right side back of head abrasion measuring 2.6 x 0.9 from the fall. Record review of Resident #2's progress notes after 9/15/17 revealed no documentation pertaining to the post void bladder ultrasound results and/or action taken once the ultrasound was obtained. Record review of Resident #2's 9/29/17 incident/accident report revealed that he was found sitting on his buttocks on the floor in his bathroom. He reported that he lost his balance and fell . He was assessed for injury, and there were no complaints of pain. He was referred to occupational therapy for toileting training and his medications were adjusted for better pain management. Record review of Resident #2's 10/1/17 progress note revealed that he complained of right side pain. X-rays revealed a right rib fracture. Observation of the men's unit at 9:30 a.m. on 10/25/17 revealed Resident #2 in his wheelchair in the hallway sleeping. During an interview with LVN G, the charge nurse for the men's unit, at 9:32 a.m. on 10/25/17, she reported that she had been on the unit for 4 days. She reported that she was unaware of Resident #2 having a recent fall or fracture. However, she reported that she would find out his fall history. During an interview with LVN G at 9:40 a.m. on 10/25/17, she reported that Resident #2 had a fall on 9/29/17 and fractured his rib. She reported that he ambulated and used the bathroom on his own. When asked if Resident #2 was on any fall precautions, LVN G stated We monitor and encourage him to use his walker. During an interview LVN N at 3:33 p.m. on 10/27/17, when asked how she knew which residents were at risk for falls, stated Go through the charts and review their medications. We communicate with direct care staff by letting the nurses/aides know by word of mouth/in-services. LVN N reported that the facility did not utilize any sort of falling leaf/star program to identify residents at risk for falls and that the facility did not have lists of residents at risk for falls. She stated Everybody here has the perception that the resident has the right to fall. We are a nonrestraint facility. It's hard to change that perception in their heads. Record review of the facility's fall management policy (revised 3/15/16) revealed Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause. Practice Standards: 1. Identify patient's fall risk by reviewing the following. 1.1 Electronic Medical Record Systems - Nursing Assessment 1.2 Non-electronic Medical Record Systems - Fall Risk Evaluation 2. Communicate patient's fall risk status to caregivers. 3. Develop individualized plan of care. 4. Review and revise care plan regularly. 5. If patient falls: 5.1 Following Guidelines for Managing a Fall (refer to Falls Care Delivery Process) if staff member is present when the fall occurs. 5.2 Utilize the Fall Response Protocol (refer to Falls Care Delivery Process) for both witnessed and unwitnessed falls. 5.3 Document accident/incident: 5.3.1 As a new event in the Risk Management System (RMS); 5.3.2 On a Change of Condition Note; 5.3.3 On the 24-Hour Report; 5.3.4 Investigation using the Fall Investigation/QA and other appropriate tools in RMS. 5.4 Update care plan to reflect new interventions. 5.5 Conduct interdisciplinary team meeting within 72 hours of fall 5.6 The Center Executive Director and Center Nurse Executive will conduct a post fall review. At 5:52 p.m. on 10/27/17, Corporate Nurse H, the DON, and the administrator were notified of the Immediate Jeopardy (IJ) situation for the above failures and a Plan of Removal was requested. The facility began corrective actions on 10/27/17 after 6:00 p.m. and continued to in-service and monitor staff and residents to ensure resident safety and prevention of falls. Observation of the women's unit at 2:45 p.m. on 10/28/17 revealed that Resident #14 was ambulating in the hallway and not within staff eyesight. Another resident was leaning forward in her wheelchair. CNA F was showering a resident. MA C was in the dining room with 8 residents. CNA Q was laying a resident down. During an interview with MA C at 2:52 p.m. on 10/28/17, she reported that the charge nurse was on break and that she and the 2 CNAs were the only staff on the unit at the time. Observation of Resident #1 in the dining room at 3:16 p.m. on 10/28/17 revealed that her eyes were closing and that she was dozing off in her wheelchair. She was sitting at a table with a drink in front of her. CNA S was at her side - providing 1:1 supervision. During an interview with the administrator, the DON, MDS Nurse I, NPE S, and LVN N at 3:51 p.m. on 10/29/17, the administrator reported that she did not plan on making staffing changes and stated Why? No more staff are needed. When asked if the facility had looked at activities for Resident #1, the administrator stated She has a BIMS of 0 - Why would we look at activities to engage her? LVN N stated that facility interventions after Resident #1's hip surgery were moving her to another unit because of familiar faces there and stated I don't think she will be mobile again. She's scared of falling again. The fall really affected her - scared her. Observation of Resident #1 in the dining room at 4:59 p.m. on 10/29/17 revealed that she was supervised by staff. Observations of Resident #14 in the hall of the women's unit at 5:10 p.m. and 5:18 p.m. on 10/29/17 revealed that she was attempting to open closet doors at the facility's entrance and rocking back and forth. There were no staff supervising. During an interview with MA C and LVN R at 5:12 p.m. on 10/29/17, they reported that the residents on the women's unit had been active that day and that, earlier in the shift, Resident #14 ha (TRUNCATED)