Every finding on record at Avir at Overton

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse 1 of 4 residents (Resident #1) reviewed for developing and implementing abuse and neglect policies. 1. The facility failed to report to the state and thoroughly investigate an allegation of abuse reported on 5/3/26 after the hospitality aide reported to the ADM, DON, and ADON that CNA B was being rough with Resident #1 in the shower. 2.The facility failed to report to the state and thoroughly investigate an allegation of abuse on 5/3/26 after a housekeeper observed CNA B forcefully push Resident #1 down into a dining room chair while Resident #1 stated no, no, no.These failures resulted in an identification of an Immediate Jeopardy (IJ) on 5/19/26 at 2:41 p.m. While the IJ was removed on 5/20/26, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of psychosocial harm and injury.Findings include: 1. Record review of the face sheet dated 5/19/26 indicated Resident #1 was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including schizoaffective disorder (mix of schizophrenia and mood disorder symptoms), dementia (altered cognition), muscle wasting, and difficulty walking. Record review of a quarterly MDS assessment dated [DATE] indicated a BIMS was not conducted due to resident being rarely or never understood. She required setup or cleanup assistance with eating, upper body dressing, and personal hygiene. She required supervision with oral hygiene, shower/bathing self, and lower body dressing. She required partial/moderate assistance with toileting hygiene. She had not exhibited physical, verbal, or other behavioral symptoms directed toward others. Record review of the care plan revised on 4/28/26 indicated Resident #1 resided on the women's secured unit related to elopement risk, inappropriate sexual behaviors with male residents, and poor safety awareness. Record review of the care plan revised on 4/16/26 indicated Resident #1 had impaired cognitive function/dementia or impaired thought processes. Interventions in place included providing the resident with necessary cues, and stopping and return if agitated. During an observation and interview on 5/18/26 at 11:00 a.m., Resident #1 said there was an incident with a CNA who caused her to fall. Resident #1 said she remembered there was more than one staff member in the room, but could not recall how many. Resident #1 said she could not recall any details of the event or names of staff involved. Resident #1's arms and shoulders were observed with no noted marks, skin tears, or bruising. During an interview on 5/19/26 at 9:30 a.m., Housekeeper A said she worked on 5/3/26 and was making her rounds on hall c when she noted CNA B walking with Resident #1 down the hall toward the dining room. Housekeeper A said it appeared CNA B was redirecting Resident #1 from entering another resident's room. Housekeeper A said when they arrived at the dining room, CNA B placed both hands on Resident #1's shoulders and pushed her down into a chair. Housekeeper A said she didn't report the incident immediately because she didn't feel it was abusive, but stated the action was forceful and Resident #1 was saying no, no, no. Housekeeper A said she did write a statement detailing the same information she told this surveyor and slid the note under the ADM's office door because LVN C instructed her to. Housekeeper A said ADM interviewed her about the incident the previous day, 5/18/26. During an interview on 5/19/26 at 10:00 a.m., Hospitality aid said she worked on 5/3/26 and was assigned to C hall with CNA B. Hospitality aid said Resident #1 had a large bowel movement and CNA B asked for help to clean her up. Hospitality aid said CNA B told her you have to be rough with Resident #1 sometimes and pulled her off the bed by the arms causing her to fall. Hospitality aid said Resident #1 fell twice. Hospitality aid said when CNA B got Resident #1 to the shower, she placed her hands on Resident #1's shoulders and pushed her down into the shower chair. Hospitality aid said she reported the incident immediately to LVN C who told CNA B about the allegation. Hospitality aid said she then called the DON who told her to call the ADON who did not answer. Hospitality aid said she then texted the ADM, DON, and ADON letting them know about the allegation and that she was quitting due to what she had witnessed. Hospitality aid said she texted them that CNA B had been rough with Resident #1 in the shower. Hospitality aid said she did not save the text messages.`During an interview on 5/18/26 at 12:00 p.m., CNA B said she worked on 5/3/26 and worked on the women's secured unit. CNA B said around 10:00 a.m. Resident #1 had a large bowel movement. CNA B said wipes would not be able to clean her up so she asked Hospitality aid for assistance to take her to the shower. CNA B said resident was combative with staff initially but calmed down and allowed CNA B to shower resident without incident. CNA B said she and Hospitality aid walked resident to the shower together, each holding one hand. CNA B said she completed the shower, walked Resident #1 back to her room, and sat her on the bed while she helped her get dressed. CNA B said she didn't report the combative behavior because Resident #1 was not hitting or swinging at them. CNA B could not verbalize exactly what aggressive behavior Resident #1 had exhibited. CNA B said Resident #1 was known to be combative. During an interview on 5/18/26 at 3:30 p.m., the DON said she did receive a call from hospitality aid on Sunday. The DON said she was at church so she didn't follow up with Hospitality aid and told her to call the ADON. The DON denied speaking to hospitality aid and said she was unaware there had been an allegation of abuse made in the facility. The DON said if she had known about the allegation she would have immediately reported it to the ADM. During an interview on 5/18/26 at 3:40 p.m., the ADON said she had a missed call from Hospitality aid and was unable to reach Hospitality aid when she called back. The ADON said there had been no complaints of similar nature regarding CNA B. The ADON said she had attended training on ANE and said she would report any allegations of abuse to the ADM immediately. During an interview on 5/18/26 at 4:00 p.m., LVN C said she worked 5/3/26 as the shift charge nurse. LVN C said Hospitality aid did not report any abuse allegations to her on that shift. LVN C said she was told by LVN P who overheard hospitality aid talking on the phone around 10:00 a.m. and reported it to her. LVN C said she performed a head-to-toe assessment on Resident #1 and noted no injuries or emotional distress. LVN C said she failed to chart the assessment. LVN C said she then asked Housekeeper A to write a statement since she had been on the hall during the time of the allegation. LVN C said housekeeper A wrote a statement and slipped it under the ADM's door. Interviews were attempted with LVN P on 5/19/26 at 4:14 p.m. and on 5/20/26 at 11:07 a.m. and 12:11 p.m. During an interview on 5/19/26 at 11:00 a.m., the ADM said she first learned about the incident on 5/3/26 when Hospitality aid texted her that CNA B was being rough with Resident #1 in the shower. The ADM said she investigated the incident which included interviews with staff working the hall that shift and none reported seeing any mistreatment of Resident #1, and the resident had a head-to-toe assessment of Resident #1. The ADM said the assessment found no injuries and did not identify any psychosocial harm for Resident #1. The ADM said there were no in-services completed and CNA B was not suspended. The ADM said she did not believe hospitality aid was credible, because she was reportedly upset about being asked to switch hallway assignments, and did not believe the incident was reportable to the state because she found no credible allegation had been made. The ADM said she didn't recall receiving the note from housekeeper A was slipped under her office door, but would continue looking. The ADM said housekeeper A also never mentioned the second incident with her during interviews. Record review of a witness statement dated 5/3/26 by Housekeeper A indicated I [housekeeper A] was on C hall and noticed [CNA B] guided [Resident #1] to the dining room chair, and [Resident #1] was resisting. There was no abuse. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy last revised April 2021 indicated: .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:Develop and implement policies and protocols to prevent and identify:Abuse or mistreatment of residents. Record review of the facility's policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating last revised September 2022 indicated: .All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Record review of facility policy Identifying Types of Abuse last revised September 2022 indicated: .Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. The Administrator was notified that an Immediate Jeopardy situation was identified due to the above failure and provided with the Immediate Jeopardy template on 5/19/26 at 2:41 PM. The facility's Plan of Removal was accepted on 5/20/26 8:02 AM and included: Plan of Removal:607: Develop/Implement Abuse/Neglect, etc. PoliciesThe facility failed to implement their abuse policies on 5/3/26 when staff alleged that CNA B was rough and mistreated Resident #1 on 2 separate incidents.The facility failed to report allegations of abuse within the required time frames.The facility failed to implement their abuse policy when they did not identify and investigate allegations of abuse or mistreatment of residents.The facility failed to develop and implement their abuse policy when they did not put measures in place to protect residents during allegation investigations.IJ Called: 5/19/2026POR Submitted: 5/19/2026Action: Resident #1 was assessed for negative findings both physically and psychosocially on 5/19/2026. No concerns noted. Person(s) Responsible: Director of Nursing, Social Services, and/or DesigneeDate: 5/19/2026 at 3:56PMAction: CNA B has been suspended pending investigation. Person(s) Responsible: Administrator Date: 5/19/2026 at 3:44PM. Action: All residents that have been under CNA B's care since 5/3/2026 (employee has consistent scheduling on the female secured unit) had a skin assessed performed in an attempt to identify any additional concerns with being rough or abuse, no additional concerns noted. Attempt to complete safe surveys with residents in the secured unit, under CNA B's care, to look for signs or symptoms of abuse or staff being rough with residents. No additional concerns noted. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 5/19/2026 by 430PM. *Action: The following policies were reviewed Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Abuse Reporting and Investigating, and Identifying Types of Abuse were confirmed appropriate for utilization per state and federal regulation. Person(s) Responsible: Regional [NAME] President, Regional Nurse Consultant, Administrator, Director of Nursing, and/or Designee Date: 5/19/2026 by 5:45PM Action: Administrator, Director of Nursing, and Assistant Director of Nursing educated on the Provider Letter 2024-14 as it relates to allegations and reporting. Additionally, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Abuse Reporting and Investigating, and Identifying Types of Abuse were educated on for training the trainer and to confirm understanding with the facility's abuse policy. Administrator, Director of Nursing, and Assistant Director of Nursing confirm understanding the criteria of a self-report and the timeframes required in reporting, abuse allegations should be reported to the State in accordance with state and federal regulations within 2 hours. Education included that the alleged perpetrator will be removed from the building and suspended until the investigation can be completed. If investigation confirms abuse, the perpetrator will be terminated. Person(s) Responsible: Regional Nurse Consultant Date: 5/19/2026 by 715PM Action: All staff educated on the facility's policy for, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Abuse Reporting and Investigating, and Identifying Types of Abuse & The Provider Letter 2024-14. Staff will understand what abuse is, when to report abuse (immediately), and who to report abuse to (abuse coordinator), protecting the residents after witnessing abuse, and if staff feel as if their concerns are not being followed up on by the abuse coordinator they should call the compliance line. Education will additionally include to ensure resident safety which would include staying with the alleged perpetrator or ensure perpetrator does not harm any additional residents until they are out of the building. *Finally, staff will be educated on, If you must re-direct a resident or guide them, please re-direct gently, don't force the resident to do anything they don't want to do, making eye contact with the resident, ensuring that they understand what you are doing. Give them extra time to process your guidance. If they refuse care, please ensure their safety and return a little later to attempt the care process again.A test for competency on abuse and neglect will be completed by staff. If a staff member does not pass the test, they will be reeducated until staff retains the educated information. Staff currently working educated by 4PM. All staff will be educated prior to working their next shift. No agency is being utilized at the facility at this time. New hires will be educated prior to working their first shift. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 5/19/2026 Action: Allegations made by hospitality aide and housekeeper are being reported to the state, employee suspended, police notified, and investigation being conducted. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 5/19/2026 by 5:45PM Action: 5 staff members and 5 residents will be interviewed on abuse and reporting weekly, x4 weeks. If any concerns with abuse arise, they will be reported in accordance with state and federal regulation as well as facility policy. Person(s) Responsible: Administrator and/or Designee Date: 5/19/2026 Action: Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy Template, root cause the deficient practice, and review the facility's plan of removal. At this time, the Medical Director has no further recommendations and is agreeable with the facility's plan. Person(s) Responsible: AdministratorDate: 5/19/2026 by 4PMAdministrator is responsible for initiating, monitoring, and completion of the Plan of Removal. On 5/20/26 at 11:37 AM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:Review of skin assessment for Resident #1 dated 5/20/26 indicated there were no alterations to skin integrity.Record review of In-service dated 5/19/26 covering topic Abuse/Neglect Policy attended by 43 staff membersRecord review of In-service dated 5/19/26 covering topic redirecting/guiding residents gently attended by 40 staff members.Record review of In-service dated 5/19/26 covering topic Abuse and Neglect Reporting Policy attended by 3 staff members.Record review of In-service dated 5/19/26 covering topic Identifying Types of Abuse and Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating attended by 40 staff members.Record review of In-service dated 5/19/26 covering topic Provider Letter on Reportable Event attended by 3 staff members.Record review of Abuse and Neglect post-tests completed by 43 staff in-serviced all staff passed.Record review of resident safe surveys indicated 7/8 residents felt safe with staff, had not seen staff being physically aggressive toward someone, felt safe around all staff, and would be comfortable notifying charge nurse, social worker, or a manager if they became fearful of someone. 1/8 residents interviewed did not respond to questions. Record review of QAPI minutes from 5/19/26 meeting indicated corrective action and identification, systematic measures, quality assurance and monitoring were implemented.Staff interviewed on 5/20/26 between 9:00 AM and 11:37 PM (LVN D, CNA E, Housekeeper F, CNA G, CNA H, DM, LVN I, CNA J, CNA K, CMA L, CNA M, OTA, Housekeeper M, Activity Director, Dietary Aide, LVN O, ADM, DON) were able to identify types of abuse, signs and symptoms of abuse in a resident, and verbalized to immediately report any witnessed or suspected abuse to the ADM who was the facility abuse coordinator.During an interview on 5/20/26 at 10:30 AM, the DON said the facility had begun in-servicing staff on abuse and neglect, abuse reporting requirements, and how to handle a resident that was resistant to care. The DON said all staff would attend these in-services before being able to work. The DON said, additionally, the facility did skin sweeps on the women's secured unit where CNA B worked. The DON said notifications were made to the MD, RP, and local police, and a psychiatric visit was scheduled for Resident #1. The DON said the facility planned to monitor Resident #1 over the next 72 hours to identify any distress. The DON said post-testing was also completed on abuse and neglect for all in-serviced staff. During an interview on 5/20/26 at 11:31 a.m., the ADM said the facility took corrective action including conducting in-services on abuse and neglect, guiding and redirecting residents, and reporting abuse/neglect. The ADM said all staff would attend the in-services before returning to work and had to successfully complete a post-test on abuse and neglect. The ADM said skin sweeps and safe surveys were conducted on all residents on the women's secure hall where CNA B worked with no negative findings. The ADM said the facility held an Ad hoc QAPI meeting in which the MD attended. The ADM said the facility would implement monitoring by interviewing 5 staff members and 5 residents weekly for 4 weeks to identify any concerns. The ADM said CNA B was suspended pending the investigation outcome. While the IJ was removed on 5/20/26, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 3 of 3 months (October, November, and December 2025) reviewed for Quarter 1 of the fiscal year 2026.The facility did not have RN coverage for 3 days in October 2025.The facility did not have RN coverage for 4 days in November 2025.The facility did not have RN coverage for 5 days in December 2025.This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters.Findings included:Record review of the RN punch detail hour report for October 2025 indicated there were no RN hours worked on the following dates: October 12, 2025, October 25, 2025, and October 26, 2025.Record review of the RN punch detail hour report for November 2025 indicated there were no RN hours worked on the following dates: November 8. 2025, November 9, 2025, and November 27, 2025.Record review of the RN punch detail hour report for December 2025 indicated there were no RN hours worked on the following dates: December 1, 2025, December 2, 2025, December 5, 2025, and December 7, 2025.Record review of the CMS Payroll Based Journal (PBJ) report for the first quarter of 2026 (October 1, 2025 - December 31, 2025) indicated there were no RN hours for the following dates:10/12 (SU); 10/25 (SA); 10/26 (SU)11/08 (SA); 11/09 (SU); 11/26 (WE); 11/27 (TH)12/01 (MO); 12/02 (TU); 12/05 (FR); 12/06 (SA); 12/07 (SU)During a joint interview on 4/27/2026 at 1:40 pm, the Administrator and HR both said the previous DON's last day worked in the facility was 11/23/2025 and she was terminated 11/24/2025. She said the facility currently had an RN that worked every weekend and she started 12/19/2025 to 4/12/2026. She said the facility did not have consistent RN coverage from October 2025 to December 2025. She said in December 2025 they hired a full time DON for the facility.During an interview on 4/29/2026 at 10:31 am, the ADON said she had been at the facility for 2 -3 weeks and was responsible for doing the schedules for the nurses and nurse aides. She said RN coverage should be 8 hours each day and the DON was at the facility Monday-Friday and another RN worked the weekends and if no RN were available then the DON would work that weekend. She said she was not aware the facility did not have RN coverage back in October 2025-December 2025. She said having an RN in the facility was mandatory per regulatory guidelines.During a follow up interview on 4/29/2026 at 11:17 am, the Administrator said during October 2025 to December 2025 the facility had RN coverage, but it was not consistent. She said an RN was needed in the facility as a ranking clinician due to scope of practice. She said going forward she planned to have RN coverage 8 hours a day 7 days a week. She said if a LVN had an issue beyond their scope then they would not have an RN available. She said she was aware of the facility not having RN hours for the first quarter of 2026. She said the facility hired the new DON December 8, 2025.Record review of a facility policy titled Staffing revised September 2023 indicated, .Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety. 4. The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .

Based on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable, environment with 2 of 6 halls (Hall A and Hall F) reviewed for environment.The facility failed to ensure ceiling tiles were secure on Halls A and F on 4/27/2026.This failure could place the residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included:During an observation on 4/27/2026 at 10:34 am, Hall F had multiple ceiling tiles that were detached from the ceiling. One ceiling tile was located by a sprinkler head that had approximately a 2-inch gap that exposed the attic space. Hall F was occupied by residents who resided on the hall.Record review of a Resident List Report dated 4/27/2026 indicated Hall F had 13 residents on the hall.During an observation on 4/27/2026 at 10:48 am, Hall A had multiple ceiling tiles that were detached from the ceiling. Hall A was occupied by residents who resided on the hall.Record review of a Resident List Report dated 4/27/2026 indicated Hall A had 14 residents on the hall.During an observation on 4/28/2026 at 9:20 am, the ceiling tiles on Hall A and F were repaired.During an interview on 4/29/2026 at 10:37 am, the Maintenance Supervisor said he had been at the facility since October 2025. He said when he started, he saw issues with ceiling tiles and would repair them as he saw them. He said the facility was old and had a lot of issues and when the foundation settled the ceiling tiles would shift. He said a request was entered in the online portal on 4/27/2026 to repair the ceiling tiles and they were repaired. He said if they did not repair the ceiling tiles they could fall and make a mess or fall and create discomfort for the residents.During an interview on 4/29/2026 at 11:17 am, the Administrator said everyone was responsible for reporting issues to maintenance that needed repair. She said they reported issues verbally, via text messages, and through the online portal (TELS). She said the facility has had a lot of issues since she started in August 2025. She said ceiling tiles might have been moved by a contractor at some point and not put back in place. She said there could be a risk of falling and potentially hurting residents in the facility if they were attached.Record review of a facility policy titled Maintenance Service revised December 2009 indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment. 2. Functions of maintenance personnel include, but are not limited to: b. maintaining the building in good repair and free from hazards .

Based on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for residents for 3 of 15 residents (Resident #9, Resident #13, and Resident #43) observed for resident environment. The facility failed to ensure the floor in Resident #9 and Resident #13's room did not have damaged and missing bathroom flooring and base of toilet was free of a soiled appearance on 4/27/2026-4/29/2026. The facility failed to ensure the blinds in Resident #43's room were not broken and bent on 4/27/2026-4/29/2026. These failures could place residents at risk for an unsanitary and comfortable environment. Findings included:1.Record review of an admission Record for Resident #9 dated 4/28/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (a group of symptoms that affects memory, thinking and interfers with daily life), hypertension (high blood pressure), paranoid schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), anorexia (eating disorder in which people have a low body weight based on personal weight history), and dysphasia (A condition with difficulty in swallowing food or liquid).Record review of a Significant Change MDS Assessment for Resident #9 dated 1/25/2026 indicated she had severe impairment in thinking with a BIMS score of 3. She was dependent on staff to transfer from chair to bed. Record review of a care plan for Resident #9 revised 11/12/2025 indicated she had impaired functional abilities related to weakness and dementia. She has communication problems related to dementia. During an observation and interview on 4/27/2026 at 10:00 am, Resident #9 was sitting up in a wheelchair. She was clean and dressed appropriately. She was not able to respond appropriately to questions concerning the bathroom floor. Record review of an admission Record for Resident #13 dated 4/28/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of hypertension (high blood pressure). Generalized anxiety (fear characterized by behavioral disturbances), repeated falls, dementia (a group of symptoms that affects memory, thinking and interfers with daily life), and difficulty walking. Record review of a quarterly MDS assessment for Resident #13 dated 2/2/2026 indicated she had severe impairment in thinking with a BIMS score of 3. She was dependent on staff to transfer from chair to bed. Record review of a care plan for Resident #13 revised 01/22/2026 indicated she had impaired cognitive functional abilities related to dementia. She has communication problems related to dementia. During an observation and interview on 4/27/2026 at 10:08 am, Resident #9 was lying in her bed. She was clean and dressed appropriately. She was not able to respond appropriately to questions concerning the bathroom floor. During an observation on 4/27/2026 at 10:00 am, the room of Resident #9 and Resident #13 had a piece of flooring missing in at the entrance of the bathroom approximately 4.5 inches by 1.5 inches. Flooring was noted to be damaged under the sink. The area surrounding the base of the toilet appeared to be soiled with a dark yellow and black appearance. 2. Record review of an admission Record of Resident #43 dated 4/28/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of hemiplegia and hemiparesis affecting right dominant side (a symptom that involves one-sided paralysis), Type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel), hypertension (high blood pressure), and intellectual disabilities (a lifelong neurodevelopmental condition that affects a person's intellectual and adaptive functioning). Record review of a quarterly MDS assessment for Resident #43 dated 4/19/2026 indicated he had severe impairment in thinking with a BIMS score of 07. He was dependent on staff for activities of daily living. Record review of a care plan for Resident #43 revised 4/27/2026 indicated he had impaired thought processes related to intellectual disability and impaired communication related to unclear speech. During an observation and interview on 4/27/2026 at 10:20 am, Resident #43 was lying in his bed. He was clean and dressed appropriately. He was not able to respond appropriately to questions concerning the blinds covering the window located next to his bed. During an observation on 4/27/2026 at 10:20 AM, the blinds covering the window located next to Resident #43 bed were bent and broken. Noted broken pieces of the binds lying on the windowsill. Resident #43 bed was positioned next to window with no space between the bed and the window. Observation of broken areas of blinds revealed irregular edges. During an interview on 4/29/2026 at 9:30 am, the Maintenance Supervisor said all staff were responsible for reporting any repairs or maintenance issues in the building. He said staff used the TELS program, a maintenance reporting system, to report any maintenance repairs needed. He said he received a notification through the system when any reports were generated by staff. He stated he also checked the system daily for any reports that may have been made through the workday. He indicated that no reports of damaged bathroom flooring for Resident #9 and Resident #13 or damage to Resident #43's blinds had been made. He said he was responsible for building repairs or replacing broken blinds. He stated if he was not able to make repairs, he worked with contractors that were able to carry out any repairs needed. He said he was made aware of the damaged flooring to Resident #9 and Resident #13 bathroom during on 4/28/2026. He said that a flooring contractor would be needed to replace the flooring. He said that he was made aware of the damaged blinds in Resident #43 room on 4/29/2026. He stated he has replaced the blinds in Resident #43's room several times due to the resident causing damage to the blinds. He said he would be working with the administrator and corporate office to make sure necessary repairs were completed. During an interview on 4/29/2026 at 11:36 AM, the Administrator said all staff are responsible for reporting any repairs needed in the facility. She was not aware the flooring in Resident #9 and Resident #13 was damaged or that the blinds in Resident #43's room were broken and bent. She said staff were supposed to report maintenance issues to the maintenance supervisor by placing the request in TELS. She said if she were a resident she would expect repairs to be fixed. Record review of a facility policy titled Maintenance Service revised December 2009 indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment. 2. Functions of maintenance personnel include, but are not limited to: b. maintaining the building in good repair and free from hazards .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen reviewed for pest control. The facility failed to ensure the kitchen remained free from roaches on 04/28/2026, during the lunch meal, when a roach was observed crawling on the wall. This failure could place residents at risk for reduced quality of life and poor sanitary environment. Findings:During an observation on 4/28/2026 at 11:03 am, there was a roach crawling on the kitchen wall behind the handwashing station. During an interview on 4/28/2026 at 11:05 am, the Dietary Aide said that she had not seen any roaches in the kitchen recently but in the past if there were roaches, she reported it to the administrator. She said that roaches can spread disease and were unsanitary.During an interview on 4/28/2026 at 11:25 am, the [NAME] said that she had seen roaches on and off in the kitchen and they were usually near the sink areas. She said they kill them and tell the dietary manager. She said roaches spread germs. During an interview on 4/28/2026 at 2:23 pm, the service manager for the pest control company said that the technician serviced the facility monthly and on that visit the facility common areas like the kitchen, dining room, break room and laundry areas were treated. He said they used a log form in their book for the technician to know of any sightings of pest. He said they did not come for an extra visit unless there were multiple sightings or infestation. He said they have not changed their treatment plan in the last few months, but the technician was scheduled to come today for treatment. During an interview on 4/29/2026 at 9:19 am, the Maintenance Supervisor said he was responsible for the pest control program, and they treated the facility monthly and as needed. He said the staff report verbally to him or write issues on the pest control log. He said when the technician came, he would check the log and treat any areas on the log. He said no staff had reported roaches in the kitchen but once he was aware he called to have the area treated again. He said an ineffective pest control program could lead to the spread of diseases. During an interview on 4/29/2026 at 9:31 am, the Administrator said she and the maintenance supervisor were responsible for the pest control program. She said she was aware that the kitchen had roaches on and off but thought the monthly treatment was working. She said that an ineffective pest control program could potentially cause contamination of food products. She said she planned to discuss with the pest control company a new plan for treatment. Record review of a pest control log form revealed staff had recorded sightings of roaches in the facility on 1/08/2026, 2/10/2026, 4/01/2026, 4/20/2026, and 4/24/2026.Record review of pest control invoices dated from 4/15/2026 to 10/15/2026 revealed the facility had monthly service. There was no invoice indicating any extra services for pest sightings. Record review of a facility policy titled Pest Control dated May 2008 indicated, .our facility shall maintain an effective pest control program .

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 2 smoking areas (outside dining room) reviewed for smoking safety.The facility failed to ensure paper was not discarded into the ashtrays and cigarettes butts were not placed in the trash can on 4/27/2026.This failure could place residents at risk of injury, burns, and an unsafe smoking environment.Findings included:During an observation on 4/27/2026 at 11:46 am, the smoking area outside of the dining room had three ashtrays present. Two of the three ashtrays had paper trash. The trash can had a plastic liner with cigarettes butts inside.During an interview on 4/29/2026 at 10:37 am, the Maintenance Supervisor said he had been at the facility since October 2025. He said he and housekeeping staff checked the smoking areas every day for trash and made sure trash and butts were in the right spots. He said trash should be in the trash receptables and butts should be in the ashtray and or in the red cans. He said butts should never be placed in the trash. He said there should not be any trash in the ashtrays. He said there could be a risk of fire. He said the smoking area by the dining room was checked Monday (4/27/2026) afternoon and the trash and butts were placed in the appropriate receptacles.During an interview on 4/29/2026 at 11:17 am, the Administrator said the smoking areas were the responsibility of housekeeping and Maintenance daily. She said the smoking area outside of the dining room was for everyone that smoked and staff should empty the ashtrays into the cans after each smoke break. She said trash should not be in the ashtrays. She said there was a risk of potential fires. She said she reeducated the staff on Monday (4/27/2026) per policy after being made aware of the issues with the smoking area outside of the dining room.Record review of a facility policy titled Smoking Policy-Residents dated October 2022 indicated, .This facility shall establish and maintain safe resident smoking practices. 6. Ashtrays are emptied only into designated receptacles .

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative where there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly for 1 of 2 residents (Resident #1) reviewed for falls. The facility failed to notify Resident #1's responsible party when he fell on 6/22/26 resulting in a laceration to the bridge of his nose.The facility failed to notify Resident #1's attending physician and responsible party when he fell on 6/27/26. These failures could place residents at risk for delayed treatment, not receiving necessary treatments and medications, and a decreased quality of life.Findings included:Record review of a facility face sheet dated 3/11/26 for Resident #1 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Senile degeneration of brain (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia).Record review of a comprehensive MDS dated [DATE] for Resident #1 indicated a BIMS score of 99, which indicated he was unable to complete the interview. He had severely impaired cognition. He had a history of falls prior to admission and had experienced falls while in facility. Record review of a comprehensive care plan dated 6/22/25 for Resident #1 indicated he was at risk for falls.Record review of incident report dated 6/22/25 at 5:16 am indicated that Resident #1 had sustained a witnessed fall on 6/22/25. Notifications section of incident report reads: .Resident Representative Notified: No. and incident report was signed by LVN A.Record review of an incident report dated 6/27/25 at 1:51 am indicated that Resident #1 had sustained an un-witnessed fall on 6/27/25. Notifications section of incident report read: .Attending faxed: No.; .Physician Notified: No.; and .Resident Representative Notified: No. and incident report was signed by LVN A.Record review of a nursing progress note dated 6/22/25 at 5:18 am for Resident #1 read: .Resident ran into door facing, fell to floor, laceration noted to bridge of nose 1x05 cm. Area cleaned, tao applied. and was signed by LVN A. No documentation of notification or an attempted notification to responsible party was indicated for fall sustained on 6/22/25 at 5:18 am.Record review of a nursing progress note dated 6/27/25 at 1:52 am and signed by LVN A for Resident #1 indicated no documentation of notification to responsible party or physician. There was no documentation for physician or responsible party notifications or attempted notifications for fall sustained on 6/27/25 at 1:52 am.During a telephone interview on 3/10/26 at 9:49 am with Resident #1's Responsible Party said he had fallen that first night and cut his nose. She said facility staff did not call and notify her nor the hospice agency. She said she did not find out about the fall until she came back to the facility on 6/23/25 and saw his nose. She said she believed he also had other falls at the facility that she was not notified of.A telephone interview was attempted with LVN A on 3/11/26 at 7:40 am, there was no answer, phone call went straight to voicemail. A message was left requesting a return phone call. No return call was received before exiting facility on 3/11/26 at 11:30 am.During an interview on 3/11/26 at 9:38 am LVN B said if she completed an incident report for a resident fall, she would indicate whether or not family and physician notifications were made on the report. She said if the report indicated notifications were not made, that meant the physician or responsible party were not notified. She said if she was not able to reach them, she would at least document the attempt and document later in a progress note when notifications were made. She said residents' families may not know what was going on with the residents if appropriate notifications were not made, or residents could be at risk of infections if treatments were needed and no orders were obtained. During an interview on 3/11/26 at 10:00 am DON said family and physicians should be notified of any resident falls and they may not know what was going on with the residents if proper notifications were not made. She said the nurse completing the incident report was responsible for making the notifications. She said if a resident needed treatment or evaluation and the physician was not notified; they could be at risk of infections. She said this incident occurred before she started employment as the DON at the facility so she could not comment on what happened. She said that going forward, they would do audits to ensure notifications were being handled appropriately. During an interview on 3/11/26 at 10:18 am administrator said she expected her staff to make notifications to MD, family, and administrator, after a resident fall. She said she and the DON reviewed incident reports and signed off on them and would continue to do so, ensuring appropriate notifications were made going forward. She said this incident occurred before she was employed at the facility. She said if notifications were not made appropriately, residents could develop an infection or anxiety. Record review of a facility policy titled Change in a Resident's Condition or Status dated April 2025 read: .The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident. and .a nurse will notify the resident's representative when: a. the resident is involved in an accident or incident that results in an injury including injuries of an unknown source.Record review of information given to resident's upon admission titled Your Rights and Protections as a Nursing Home Resident undated, read: .You have the right to: .Have your representative notified: The nursing home must notify your doctor and, if known, your legal representative or an interested family member when the following occurs: .You're involved in an accident and are injured and/or need to see a doctor.

Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered careof the residents that meet professional standards of quality care for 1 of 6 residents (Resident #1) reviewed for baseline care plans.The facility failed to ensure Resident #1's baseline care plan was completed within 48 hours of admission on [DATE]. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome.Findings included:Record review of a facility face sheet dated 3/11/26 for Resident #1 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Senile degeneration of brain (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia).Record review of a comprehensive MDS dated [DATE] for Resident #1 indicated a BIMS score of 99, which indicated he was unable to complete the interview. He had severely impaired cognition. He had a history of falls prior to admission and had experienced falls while in facility.Record review of an electronic medical record for Resident #1 on 3/11/26 indicated there was no baseline care plan completed.Record review of a comprehensive care plan initiated on 6/22/25 for Resident #1 indicated it only addressed falls and behavioral symptoms.During an interview on 3/11/26 at 9:45 am the MDS nurse said baseline care plans should be initiated within 24 to 48 hours. She said if a comprehensive care plan was initiated in place of the baseline, it should include ADLs, transfers, social needs, orders, etc. She said staff may not know how to care for the residents if the baseline care plan was not initiated. During an interview on 3/11/26 at 10:00 am the DON said baseline care plans should be initiated within 48 hours or as soon as possible after admission. She said if a resident was admitted on the weekend, the RN supervisor was responsible for initiating it. She said during the week, responsibility would fall on her or any other RN that was in the facility. She said that going forward, they would do audits to ensure care plans were being initiated appropriately. She said this incident occurred before she was employed at the facility and she could not comment on why it was not completed. She said staff could not properly care for the residents without an appropriate care plan in place. During an interview on 3/11/26 at 10:18 am the administrator said she expected her staff to initiate care plans appropriately. She said she and the DON would be reviewing admissions to ensure care plans were done appropriately going forward. She said staff may not be able to meet the needs of the residents if care plans were not put into place because staff would not be aware of their needs. Record review of a facility policy titled Care Plans - Baseline dated 2001 read: .A baseline care plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. and .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy Orders; e. Social Services; and f. PASARR recommendation, if applicable.

Based on interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 2 of 5 residents (Resident #1 and Resident #2) reviewed for quality of care.The facility failed to ensure Resident #1 and Resident #2 were assessed for injury following a motor vehicle accident on 12/19/2025 in the facility transport van.This failure could place residents at risk for not receiving appropriate care and treatment and/or decline in their health.Findings included:1. Record review of an admission Record for Resident #1, dated 1/12/2026, indicated he was an [AGE] year-old male, admitted [DATE], readmitted [DATE], with diagnoses that included focal traumatic brain injury with loss of consciousness (brain injury), dementia with other behavioral disturbance (decline in thinking, memory and reasoning), and fusion of spine, thoracic region (permanent connects two or more vertebrae).Record review of an Annual MDS Assessment for Resident #1, dated 11/10/2025, indicated he had a BIMS score of 12 which indicated mild cognitive impairment. He required substantial/maximal assistance with transfers. He required the use of a manual wheelchair for mobility. Record review of a care plan for Resident #1, revised 9/09/2025, indicated ADLs functional status/rehabilitation potential with interventions that included, Transfers amount of assist: 1 staff member assist, some days I may require more assistance than others. Record review of Resident #1's EMS Patient Care Record, dated 12/19/2025 at 12:58 p.m., indicated, No visible injuries were noted upon observation. Pt denied LOC, denied head strike and taking blood thinners. Record review of a facility nursing progress note for Resident #1, dated 12/19/2025 at 5:45 p.m. written by LVN A, indicated, While transporting back to facility, transport van rear ended by another vehicle. Police and EMS called at that time. EMS eval and tx resident, no injuries occurred and was released by EMS to be transported back to facility. No pain or discomfort verbalized. RP notified of incident. NP also notified and aware at this time. Record review of a facility nursing progress note for Resident #1, dated 12/20/2025 at 12:09 p.m. written by LVN B indicated, Resident is s/p MVA with complaints of back pain and bilateral hip pain. Resident is alert and oriented x4. Respirations are even and unlabored with no signs of acute distress. Medication given per MAR and NP was notified. New orders were given for Xrays of L-spine, C-spine and bilateral hips. RP notified of COC and new orders. Record review of a facility nursing progress note, dated 12/21/2025 at 12:09 p.m. written by the ADON, indicated, X-ray results sent to NP. No acute injuries noted. Continue to c/o stiffness and mild pain. Routine pain meds given qid. Record review of x-rays of the cervical spine, bilateral hips, and lumbar spine, dated 12/20/2025, indicated no acute changes noted. Record review of facility skin assessment of Resident #1 not completed due to no skin assessment was completed after the accident on 12/19/2025. 2. Record review of an admission Record for Resident #2, dated 1/12/2026, indicated he admitted [DATE] and was [AGE] years old with diagnoses that included malignant neoplasm of the colon (colon cancer), history of transient ischemic attack and cerebral infarction (stroke), and age-related cognitive decline (problem thinking).Record review of a Significant change MDS Assessment for Resident #2, dated 11/11/2025, indicated he had severe impairment in thinking with a BIMS score of 3. He required supervision/touching assistance with walking.Record review of a care plan for Resident #2, revised 9/24/2025, indicated ADLs functional status/rehabilitation potential with interventions that included, Ambulation/Transferring amount of assist: supervision, assist x 1-2. Record review of EMS Patient Care Record, dated 12/19/2025 at 12:58 p.m., for Resident #2 indicated, No visible injuries were noted upon observation. Pt denied LOC. Denied head strike and taking blood thinners. Record review of a facility nursing progress note for Resident #2, dated 12/19/2025 at 5:42 p.m. written by LVN A, indicated, While transporting back to facility, transport van rear ended by another vehicle. Police and EMS called at that time. EMS eval and tx resident, no injuries occurred and was released by EMS to be transported back to facility. RP notified of incident. No pain or discomfort verbalized. NP notified and aware at this time. Record review of facility skin assessment for Resident #2, dated 12/24/2025 completed by ADON, indicated Resident #2 did not have any skin issues. During an interview on 1/12/2026 at 10:10 a.m., Resident #1's family member said they felt like after the accident Resident #1 should have been sent to the hospital to be evaluated. Resident #1's family member said when Resident #1 arrived back to the facility after the accident he had to crawl out of the side of the van to exit the vehicle due to the wheelchair ramp not working on the van. Resident #1's family member said the day after the accident Resident #1 had bruising noted to his right-hand index finger and to the left cheek and eye area. During an interview on 1/12/2026 at 12:00 p.m., LVN A said on the day of the accident (12/19/25) there were two residents on the van, Resident #1 and Resident #2., LVN A said the transporter told her she was rear ended in the van by another vehicle. She said the transporter told her EMS checked Resident #1 and Resident #2 out and said they were ok to go. She said when they returned to the facility Resident #1 rolled himself into the dining room and did not complain of any pain. She said CNA C helped Resident #1 out of the van due to the wheelchair ramp not working after the accident. She said she did not assess Resident #1 or Resident #2 for injury upon return to the facility because she thought EMS evaluated the residents and they were cleared at the scene of the accident. During an interview on 1/12/2026 at 12:14 p.m., the ADON said she received a call from LVN A regarding the wreck involving the facility van and Resident #1 and Resident #2. She said they had called the police and EMS to the scene. The ADON said she asked if LVN A had checked on the residents and if they were ok. She said she told the transporter to call EMS. She said the next day Resident #1 was complaining of pain and stiffness, so she notified the NP to get an order for x-rays. The ADON said Resident #1 told her he crawled over the seat to get out of the van. During an interview on 1/12/2026 at 12:47 p.m., Resident #1 said he went to a doctor's appointment on the day of the accident 12/19/2025. He said on their way back to the facility someone hit them from behind, on the side where he was seated in his wheelchair. He said EMS arrived and stood at the front driver's door and asked him if he was alright. He said he told EMS he felt fine. He said no one asked him if he wanted to go the hospital. He said he probably would not have wanted to go get checked out. He said he could not get out of the van because the ramp would not work. He said when he got to the facility, he had to crawl over the seat to get out of the van. He said the next day his neck and back were hurting him, so they x-rayed him at the facility. He said the pain went away in a few days. Resident #1 said the pain went away but he had chronic pain due to rods and pins in his back and knee. During an interview on 1/12/2026 at 1:25 p.m., Resident #2 said on the day of the accident they were sitting at a stop sign and got hit from behind. He said that no one checked him at the scene of the accident. He said no one checked him when he got back to the facility. He said he was sore for a few days after the wreck but other than that he did not have any other injuries. During an interview on 1/12/2026 at 1:29 p.m., CNA C said he was asked to help get Resident #1 out of the van. He said he let the back seats down and got him out of the wheelchair and then got his wheelchair out and then he picked up Resident #1 and put him in his wheelchair. During an interview on 1/12/2026 at 1:40 p.m., the transporter said she was a CNA and the backup driver for a sister facility and was helping out this facility because they did not have a transporter. She said she was returning from the doctor's appointment and was stopped at the yield sign when the on-coming car hit them. She said neither of the residents were hurt. She said police and EMS came to the scene of the accident. She said she was talking with the police at the scene and could not see from where she was if EMS evaluated the residents on the van. She said she notified the administrator and the DON and was told to let the residents get checked out by EMS. She said EMS told her they were free to go, and they drove to the facility. She said the back of the van would not open so her and CNA C had to get Resident #1 out of the van through the side door. During an interview on 1/13/2026 at 1:00 p.m., the DON said the ADON received a call about the residents being in a wreck and was told they were ok. She said the Administrator handled the situation. During an interview on 1/13/2026 at 1:10 p.m., the Administrator said as far as she knew the residents were evaluated at the scene of the accident and were cleared with no injuries to return to the facility. She said she found skin assessments done on Resident #1 upon returning to the facility, but none were provided prior to surveyor exit. Record review of the facility's policy, Transportation Policy undated, indicated, To outline procedures for safe, dignified, and compliant transportation for residents to medical appointments. Record review of the facility Driver Checklist undated indicated, .in the event of an emergency, dial 911 then facility at [phone number] and follow instructions. Record review of the facility policy Change in a Resident's Condition or Status, dated April 2025, indicated, .3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the interact SBAR communication form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observations, interviews, and records review the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from physical abuse on 10/19/25 at approximately 5:46 p.m. when Resident #2 stomped on Resident #1's foot. This failure could place residents at risk of pain, injury, hospitalization, and diminished quality of life. Findings included: 1. Review of an admission Record for Resident #1 dated 10/21/25 indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of schizoaffective disorder bipolar type (schizophrenia symptoms combined with episodes of mania and/or depression), autistic disorder, and cognitive communication deficit (difficulty communicating due to cognition). Review of a quarterly MDS for Resident #1 dated 9/12/2025 indicated he had moderately impaired cognition with a BIMS of 12. He had not exhibited any physical, verbal, or other behavioral symptoms directed toward others. Review of the care plan for Resident #1 dated 8/14/25 indicated Resident #1 wandered due to diagnosis of Autism and required secure unit placement. Review of an admission Record for Resident #2 dated 10/21/25 indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of unspecified intellectual disability, cognitive communication deficit (difficulty communicating), and bipolar disorder (fluctuations between manic and depressive episodes). Review of a significant change of status MDS for Resident #2 dated 8/13/25 indicated he had severely impaired cognition with a BIMS of 7. He had not exhibited any physical, verbal, or other behavioral symptoms directed toward others. Review of the care plan for Resident #2 dated 7/12/25 indicated he had behavioral symptoms directed at other residents including telling other residents to shut up and leave him alone when no residents were talking to him. Appropriate interventions were in place including monitoring for behaviors, redirection, and referral to psychiatric services. Review of the care plan for Resident #2 dated 7/14/25 indicated Resident #2 required secure unit placement due to inappropriate touching of females, wandering, and poor safety awareness. Review of an event report by RN A dated 10/19/25 at 5:46 p.m. indicated Resident #1 had a bruise to his right foot, purple and black in color after Resident #2 kicked or stomped resident's foot. Resident #1 denied pain or discomfort. Review of an event report by RN A dated 10/19/25 at 5:58 p.m. indicated Resident #2 exhibited aggressive behavior evidenced by kicking another resident's (Resident #1) foot. During an interview on 10/20/25 at 10:30 a.m., CNA B said he was assigned to work on the men's secured unit on 10/19/25. CNA B said he observed Resident #2 kick or stomp on Resident #1's foot in the dining room. CNA B said Resident #1 moved his feet away from Resident #2. CNA B said Resident #2 attempted to kick or stomp on Resident #1's feet several times more before he could separate the residents. During an interview on 10/20/25 at 10:40 a.m., Resident #2 said he stomped on Resident #1's foot. Resident #2 said I did it out of meanness, I won't do it again. Resident #2 said he was upset because he missed his parents and wanted to leave the facility. During an observation and interview on 10/20/25 at 10:50 a.m., Resident #1 was observed in the dining room, sitting at a table with other residents. There were no visible marks, bruises, or skin tears. Resident #1 appeared to show no signs of fear while interacting with other residents. Resident #1 said he could not remember the altercation with Resident #2. Resident #1 said he felt safe in the facility, and he had no pain. During an interview on 10/20/25 at 11:00 a.m., the Hospitality Aide said Resident #2 had exhibited verbal behaviors which included yelling and cursing at other residents. She said she had not seen Resident #2 exhibit any physical behaviors. She said she had received training on resident-to-resident altercations and would separate the residents to ensure safety and then report the incident to the ADM. During an interview on 10/20/25 at 12:15 p.m., RN A said CNA B reported that Resident #2 had stomped or kicked Resident #1's foot. RN A said she conducted a head-to-toe assessment of Resident #1 and noted a light bruise on the side of his right foot. RN A said Resident #1 denied pain and showed no signs of behavioral changes post-incident. RN A said staff are expected to intervene in resident-to-resident altercations, separate residents, and notify the ADM of the incident. During an interview on 10/22/25 at 12:55 p.m., the DON said Resident #2 was having difficulty adjusting to the facility and he was receiving psychiatric services, and his medications had recently been adjusted to address the behaviors. The DON said all staff received training on abuse and neglect and resident-to-resident altercations. The DON said additional abuse and neglect in-service training for all staff was being conducted that began on 10/20/25. During an interview on 10/22/25 at 1:10 p.m., the ADM said Resident #2 was placed on 1-to-1 observation after the incident. The ADM said Resident #2 was receiving psychiatric services and was seen by a provider on 10/20/25 who determined he was safely placed on the secure men's unit and discontinued 1-to-1 observation. The ADM said they were seeking a referral to a behavioral health facility for Resident #2 and would re-evaluate his placement on the secured unit pending provider recommendations. The ADM said all staff would be receiving additional training in abuse and neglect including resident-to-resident altercations. A facility policy titled Abuse, Neglect, and Exploitation last revised 10/2023 indicated .The facility will develop and implement written policies and procedures that.Prohibit and prevent abuse, neglect, and exploitation of residents.

Based on observations, interviews, and records review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours, for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to ensure RN A and CNA B reported an allegation of abuse to the ADM immediately when Resident #2 stomped Resident #1's foot on 12/19/25. This failure could place residents at risk of continued abuse which could lead to risk of pain, injury, hospitalization, and diminished quality of life. Findings included: 1. Review of an admission Record for Resident #1 dated 10/21/25 indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of schizoaffective disorder bipolar type (schizophrenia symptoms combined with episodes of mania and/or depression), autistic disorder, and cognitive communication deficit (difficulty communicating due to cognition). Review of a quarterly MDS for Resident #1 dated 9/12/2025 indicated he had moderately impaired cognition with a BIMS of 12. He had not exhibited any physical, verbal, or other behavioral symptoms directed toward others. Review of the care plan for Resident #1 dated 8/14/25 indicated Resident #1 wandered due to diagnosis of autism and required secure unit placement. Review of an admission Record for Resident #2 dated 10/21/25 indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of unspecified intellectual disability, cognitive communication deficit (difficulty communicating), and bipolar disorder (fluctuations between manic and depressive episodes). Review of a significant change of status MDS for Resident #2 dated 8/13/25 indicated he had severely impaired cognition with a BIMS of 7. He had not exhibited any physical, verbal, or other behavioral symptoms directed toward others. Review of the care plan for Resident #2 dated 7/12/25 indicated he had behavioral symptoms directed at other residents including telling other residents to shut up and leave him alone when no residents were talking to him. Appropriate interventions were in place including monitoring for behaviors, redirection, and referral to psychiatric services. Review of the care plan for Resident #2 dated 7/14/25 indicated Resident #2 required secure unit placement due to inappropriate touching of females, wandering, and poor safety awareness. Review of a psychotherapy visit note dated 10/20/25 for Resident #2 indicated .referred to [provider] for adjustment difficulty, physically and verbal aggression.No medication changes today. Review of an event report by RN A dated 10/19/25 at 5:46 p.m. indicated Resident #1 had a bruise to his right foot, purple and black in color after Resident #2 kicked or stomped the resident's foot. Resident #1 denied pain or discomfort. Review of an event report by RN A dated 10/19/25 at 5:58 p.m. indicated Resident #2 exhibited aggressive behavior evidenced by kicking another resident's (Resident #1) foot. During an interview on 10/20/25 at 10:30 a.m., CNA B said he was assigned to work on the men's secured unit on 10/19/25. CNA B said he observed Resident #2 kick or stomp on Resident #1's foot in the dining room. CNA B said Resident #1 moved his feet away from Resident #2. CNA B said Resident #2 attempted to kick or stomp on Resident #1's feet several times more before he could separate the residents. CNA B said he reported the incident to RN A after it happened but did not report it to the ADM. During an interview on 10/20/25 at 10:40 a.m., Resident #2 said he stomped on Resident #1's foot. Resident #2 said I did it out of meanness, I won't do it again. Resident #2 said he was upset because he missed his parents and wanted to leave the facility. During an observation and interview on 10/20/25 at 10:50 a.m., Resident #1 was observed in the dining room, sitting at a table with other residents. There were no visible marks, bruises, or skin tears. Resident #1 appeared to show no signs of fear while interacting with other residents. Resident #1 said he could not remember the altercation with Resident #2. Resident #1 said he felt safe in the facility, and he was not having any pain. During an interview on 10/20/25 at 11:00 a.m., the Hospitality Aide said Resident #2 had exhibited verbal behaviors which included yelling and cursing at other residents. She said she had not seen Resident #2 exhibit any physical behaviors. She said she had received training on abuse and would report any witnessed or suspected abuse to the nurse and the ADM immediately. During an interview on 10/20/25 at 12:15 p.m., RN A said CNA B reported that Resident #2 had stomped or kicked Resident #1's foot. RN A said she conducted a head-to-toe assessment of Resident #1 and noted a light bruise on the side of his right foot. RN A said she notified Resident #1's provider and family members but did not notify the ADM of the incident. RN A said she had not received training on abuse when she was hired and did not know she was supposed to notify the ADM. During an interview on 10/22/25 at 12:55 p.m., the DON said Resident #2 was having difficulty adjusting to the facility and he was receiving psychiatric services, and his medications had recently been adjusted to address the behaviors. The DON said no staff reported any other instances of suspected abuse to her concerning Resident #2. The DON said all staff received training on abuse and neglect and reporting immediately any alleged or suspected abuse. The DON said additional abuse and neglect in-service training for all staff was being conducted that began on 10/20/25. During an interview on 10/22/25 at 1:10 p.m., the ADM said she was first notified on 10/20/25 at 9:00 a.m. that Resident #2 stomped on Resident #1's foot on 10/19/25 in the evening at an unknown time. The ADM said she reported the incident to the state upon learning of the incident. The ADM said she had not been notified of any other incidents involving Resident #2. The ADM said Resident #2 was receiving psychiatric services and had been seen by a provider on 10/20/25 who determined he was safely placed on the secure men's unit. The ADM said they were seeking a referral to a behavioral health facility for Resident #2 and would re-evaluate his placement on the secured unit pending provider recommendations. The ADM said all staff would be receiving additional training in abuse and neglect and reporting requirements. Review of a training record dated 9/29/25 indicated RN A received all required training including abuse and neglect training. Review of Abuse, Neglect, and Exploitation Statement dated 10/9/25 indicated .Residents of the facility shall not be subject to abuse. RN A signed the form on 10/9/25. Review of staff personnel files (Medication Aide, ADON, LVN, RN A)_revealed required abuse training had been completed by 4 of 4 staff members reviewed. A facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating last revised September 2022 indicated .If Resident abuse, neglect, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines.

Based on observations, interviews, and records review, the facility failed to ensure residents' right to a dignified existence for 1 of 5 residents (Resident #1) reviewed for Resident Rights. The facility failed to ensure CNA A provided privacy for Resident #1 on 11/12/25 at approximately 2:15 p.m. during incontinent care when she left the room without closing the privacy curtain or covering the resident for privacy. This failure could place residents who require incontinent care at risk of psychosocial harm and diminished quality of life.Findings included: 1.Review of an admission Record for Resident #1 dated 11/12/2025 indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of dementia (altered cognition) and muscle wasting and atrophy (weakness from disuse). Review of a quarterly MDS for Resident #1 dated 9/26/2025 indicated he had severely impaired cognition with a BIMS of 3. He required maximal assistance with toileting hygiene and showering/bathing; he required moderate assistance with oral hygiene, upper and lower body dressing, putting on and taking off footwear, and personal hygiene; he required setup/cleanup assistance with eating. Review of the care plan for Resident #1 dated 9/24/25 Resident #1 had a self-care deficit related to impaired cognition and impaired judgement. Appropriate interventions were in place including providing dressing, grooming, bathing, and hygiene assistance. During an observation on 11/12/25 at 2:15 p.m., CNA A exited Resident #1's room and entered the hallway. Resident #1 was clearly visible through the open door as CNA A exited the room. Resident #1 was lying on his bed, naked from the waist down. The privacy curtain in the room had not been closed and Resident #1 was uncovered leaving him exposed to the hallway. During an interview on 11/12/25 at 2:30 p.m., CNA A said she forgot to pull the privacy curtain and to cover Resident #1 when she went into the hallway to get additional supplies. CNA A said she had annual skills checks, which included incontinent care, and was expected to provide privacy for residents during incontinent care by closing the privacy curtain and covering the resident up if she had to leave the room for additional supplies. During an attempted interview on 11/12/25 at 2:40 p.m., Resident #1 was unable to respond coherently to interview questions due to severely impaired cognition. During an interview on 11/12/25 at 3:00 p.m., the ADON said she was responsible for supervision of nursing staff. The ADON said CNAs were expected to provide privacy to residents during incontinent care by pulling the privacy curtain, closing the drapes/blinds, and covering the residents if they had to leave the room for supplies. During an interview on 11/12/25 at 3:15 p.m., the ADM said the DON and ADON were responsible for supervision of the nursing staff and ensuring all skills checks were completed. The ADM said CNAs were expected to provide privacy to residents while providing incontinent care by closing the privacy curtain, closing the blinds, and closing the door. The ADM said if the CNA left the room for supplies the resident should be covered up first. Review of a Perineal Care Return Demonstration checklist, dated 7/15/25, indicated CNA A correctly completed all procedure steps including providing privacy for residents. Review of a facility policy titled Perineal Care revised in February 2018 indicated .Provide privacy as appropriate, such as closing doors/curtains, drape resident.

Based on observation, interview, and record review, the facility failed to ensure residents remained free from physical abuse for 1 of 8 residents (Resident #1) reviewed for physical abuse.The facility failed to protect Resident #1 from resident-to-resident physical abuse on 7/16/25 when Resident #2 hit Resident #1 with a television cord, a nightstand drawer, and a wheelchair footrest causing injuries including facial and scalp lacerations, a fractured globe of the left eye, and a nasal fracture.An Immediate Jeopardy (IJ) situation was determined to have begun on 7/16/2025 and ended on 7/18/25. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey.This failure could place all residents at risk for serious injury and hospitalization.Findings included: Record review of Resident #1's admission record, dated 8/12/25, indicated he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included vascular dementia (decline in cognitive function), muscle wasting (atrophy), muscle weakness, and unspecified lack of coordination. Record review of Resident #1's significant change MDS, dated [DATE], indicated he had severely impaired thinking with a BIMS of 7. He required moderate assistance with personal hygiene, putting on/taking off footwear, lower body dressing, and showering/bathing; he required supervision assistance with toileting hygiene and upper body dressing; he required setup or cleanup assistance with oral hygiene and eating. He was frequently incontinent of bowel and bladder.Record review of Resident #1's comprehensive care plan, revised 7/15/25, indicated he had limited ability to walk related to impaired gait. Appropriate interventions were in place including providing dependent assistance for walking, instruct in use of a rolling walker, and remind resident not to walk without assistance. Record review of Resident #2's admission record, dated 8/12/25, indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of vascular dementia, mood disorder, unspecified symptoms involving cognitive functions and awareness. Record review of Resident #2's optional state assessment MDS dated [DATE] indicated he had severely impaired cognition with a BIMS of 5. He required supervision for most ADLs. Record review of Resident #2's comprehensive care plan dated 9/04/24 indicated he had exhibited socially inappropriate and disruptive behaviors including aggression and verbal aggression towards others. Appropriate interventions were in place including avoid over-stimulating environments, intervene early if resident behavior endangers the resident or others, and maintain a calm, slow, understandable approach with resident. During an interview on 8/12/25 at 9:10 a.m., the ADM said Resident #2 was admitted to the facility from a state facility and was required to be housed in a nursing facility as a condition of his release. The ADM said Resident #2 had no history of physical aggression towards other residents but had been verbally aggressive at times. The ADM said the facility acted immediately upon learning of the resident-to-resident altercation. The ADM said the facility performed all appropriate notifications and Resident #2 was placed under arrest by city police department. The ADM said Resident #1 was transported to the ER for evaluation and treatment and later returned to the facility. During an interview and observation on 8/12/25 at 3:30 p.m., Resident #1 was observed in his room, lying in bed. He appeared clean and well-groomed with no offensive odors detected. His left eye was closed, and he showed no fear interacting with staff or other residents. Resident #1 said on the night of the resident-to-resident altercation he woke up to use the bathroom. Resident #1 said he was sitting on the side of his bed using a hand-held urinal when Resident #2 told him to quit shaking my dick at him. Resident #1 said he told Resident #2 to stop staring at him, finished using the urinal, and laid back down in bed. Resident #1 said Resident #2 came over to his bed and started hitting him in the face and head with an electrical cord, which he believed was from the television in the room. Resident #1 said he tried to get up from bed but fell onto the floor. Resident #1 said Resident #2 picked up the television and threw it on top of him. Resident #1 said Resident #2 removed the metal footrest from Resident #1's wheelchair and began hitting him in the legs with it. Resident #1 said Resident #2 then pulled a drawer out of the bedside table and hit him in the left side of his face/head with it. Resident #1 said he was unable to get up or defend himself and yelled for help. Resident #1 said he still has pain in his left eye and can not see out of it well. Resident #1 said he had to have surgery, and it would be a few weeks before he could see well.Record review of a witness statement dated 7/17/25 by CNA Q indicated .On July 16, 2025, around midnight I just finished rounds.I heard the ice machine drop ice then another boom then 3 more [NAME].When I got about halfway down c hall, about where the wooden phone booth is, [Resident #2] met me in the hall coming out of his room and said, He attacked me. I asked who attacked him and he said his roommate.I continued to their room where I saw [Resident #1] lying face down in the floor.he was still in his gown with a brief on and bleeding.I kneeled beside [Resident #1] and asked him if he was okay and he said No, he beat me. I started yelling for [LVN L]. [Resident #1]'s nightstand drawer was pulled out and busted up, the chest of drawers pulled out and busted up on the floor.The TV cord was laying across the back of [Resident #1]'s thighs.During an interview on 8/13/25 at 1:15 p.m., LVN L said she worked 7/16/25 and was assigned to Resident #1's hallway. She said she was working at the nurse's station when she was called to the secured men's unit. She said she entered the secured unit and saw Resident #2 walking in the hallway and directed him to go sit in the dining room away from other residents. LVN L said she went into Resident #1's room and noted him lying face down with blood on his head and a pool of blood under him. LVN L said she completed an assessment noting facial lacerations, swelling and bleeding to his left cheek and eye, and redness to his legs and abdomen. LVN L said 911 was called and resident was transported to the ER. LVN L said local police were also notified. LVN L said local police came to the facility and investigated which resulted in Resident #2 being placed under arrest for aggravated assault and transported to the ER for clearance to be transported to the county justice center.Record review of a progress note dated 7/16/25 at 2:14 a.m. by the LVN L, indicated she was called to Resident #1's room and noted him lying in front of his roommate's bed, face down. LVN L noted a large amount of blood on the floor and on his head. LVN L noted resident was slow to respond to verbal stimuli but responsive to physical stimuli. Resident #1 was noted with swelling to his left eye and left side of his head, skin tears to both arms, redness noted to upper legs and abdomen. EMS was called to transport Resident #1 to the ER for evaluation and treatment. Record review of an arrest report dated 7/16/25 at 12:09 a.m. indicated an officer was dispatched to the nursing facility in reference to an assault. The arrest report indicated the following .[Officer] began examining the room where the assault had occurred.There appeared to be a large puddle of blood next to the bed where [Resident #2] sleeps. There were also 3 broken wooden drawers from the furniture inside the room and a broken TV that was across the room from it's original location.There was blood spatter on the drawers next to the bathroom door, as well as on the floor with a blood belt buckle.Based on the evidence I observed on scene, I determined [Resident #2] was the aggressor the assault. I placed [NAME] under arrest for Aggravated Assault Causes Serious Bodily Injury. Record review of an ER admission record form dated 7/16/25 indicated Resident #1 was admitted to the ER with the chief complaint of assault victim and primary findings of rupture of globe of left eye following blunt trauma. A physical exam in the ER revealed resident had multiple small facial and scalp lacerations, significant swelling around his left eye. Imaging revealed Resident #1 had a nasal fracture, a hematoma (abnormal collection of blood) to his left cheek, and additional findings of ruptured globe of left eye which required surgical intervention. Resident #1 said his pain was well controlled with his current pain medications. Record review of an after-visit summary dated 7/17/25 from a local emergency room indicated Resident #1 was diagnosed with blunt head trauma, rupture of globe of eye, nasal bone fracture, and scalp laceration. He was discharged back to the facility. Record review of a progress note on 7/17/25 at 5:59 p.m. by LVN K indicated Resident #1 was readmitted to the facility. A head-to-toe assessment was conducted and noted Resident #1's left eye swollen shut, covered by an eye patch. Resident #1 had skin tears to his forehead, right eyebrow, and on both ears. Resident #1 had 4 staples on the left side of his head near the front of his hairline, swollen nose, swollen left cheek, swollen bottom lip with a purple bruise, and scratches to both shins. Resident #1 complained of pain at 9 on a 0-10 numerical scale. New orders were received for pain medication three times daily as needed. During an interview on 8/13/25 at 2:45 p.m., the DON said changes were made to the facilities staffing which included adding a second staff member to the secured men's and women's units. The DON said the facility is utilizing a hospitality aid who functions as a sitter and monitor. The DON said the hospitality aid's job duties include monitoring residents so the CNA can enter resident rooms and provide care without the resident's being unsupervised. The DON said administration review the schedule every weekday with Friday encompassing the weekend shift reviews. The DON said there was a monitoring log which is to be signed daily by the administrative staff who reviewed staffing. The DON said an on-call rotation was established to cover for callouts. The DON said additional corrective actions included staff education on resident-to-resident altercations, staffing requirements, de-escalation techniques and managing aggressive behaviors, weekly random abuse/neglect interviews with staff and residents. The DON said all residents on the men's secure unit were given safe surveys and skin assessments were conducted on residents who could not respond to interview questions to identify potential abuse. The DON said residents with similar behaviors were also reviewed to ensure they were properly placed and there was no risk to resident safety. The DON said an ad hoc QAPI meeting was held to discuss further changes or corrective action if needed. Record review of a facility policy titled Resident-to-Resident Altercations revised in December 2016 indicated .Facility staff will monitor residents for aggressiveness/inappropriate behavior towards other residents. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. It was determined these failures placed residents in an IJ situation on 7/16/25 to 7/18/25. The facility corrected the noncompliance on 7/18/25 by the following: Review of minutes from an ad hoc QAPI meeting held on 7/16/25 indicated the following actions had been taken: Residents were already separated. Nurse assessed both residents and ambulance contacted due to extent of non-aggressors injuries.Skin assessments and Safe Surveys to be completed on Male Secure Unit.Notifications to RP, MD, NP, Mental Health NP, Ombudsman, and [NAME] County Judges office completed.[Local] Police Department notified and entered facility resulting in [Resident #2] being arrested. ([Resident #2] will not be returning.Care Plan reviewed and updated.In-services planned: AN&E, Managing residents with Behaviors, and de-escalation tactics, Supervision.Review of in-service titled Secure Unit Staffing Plan conducted on 7/17/25 was attended by all staff and indicated Both male and female secure unit will be staff with two staff members and the charge nurse/designee will cover staff member on the unit breaks.Review of in-service titled Abuse and Neglect, Res to Res Altercation, De-escalation, COC (Reporting) conducted on 7/17/25 was attended by all staff.Skin assessments were completed on all residents residing on men's secure hall who were unable to be interviewed. Review of monitoring document dated 7/19/25 - 8/12/25 titled 5 staff members to be interviewed over abuse policy and education provided indicated ongoing staff interviews were being conducted weekly. Review of monitoring document dated 7/24/25 - 8/12/25 titled Staffing Reviews indicated ongoing staff reviews were being conducted daily. Review of monitoring document dated 7/18/25 - 8/12/25 titled 5 staff members to be interviewed over abuse policy and education provided indicated ongoing staff interviews were being conducted. Record review of a psychiatric visit summary dated 7/18/25 indicated Resident #1's was evaluated by psychiatric services following the resident-to-resident altercation. Record review of document Identification of residents with prior incidents. Review with MD and psych provider. Indicated residents residing on secured men's halls with similar behaviors were reviewed for placement on 7/18/25. Record review of facility staffing assignment sheets revealed two staff members were assigned to both men's and women's secured units. Observations at various times throughout the investigation revealed two staff members were always on both men's and women's secured units. During staff interviews on multiple shifts at various times and of varying disciplines throughout the investigation indicated all Staff interviewed 5 LVNs (LVN B, LVN J, LVN K, LVN L, LVN O), 4 CNAs (CNA C, CNA E, CNA H, CNA M), 1 Sitter (Sitter D), 1 LCSW, 1 ADON, 1 DA, 1 DON. said they received in-service training following Resident #1's resident-to-resident altercation which included resident-to-resident altercations, managing aggressive resident behaviors, and protecting residents from harm. All staff said they were trained in resident-to-resident altercations and dealing with aggressive resident behaviors. All staff said they were trained to separate residents and to use de-escalation techniques including physical and verbal redirection. All staff verbalized to report any instances of abuse to the facility administrator who is the abuse coordinator. All staff members interviewed said the secure units were to be staffed with two staff members at all times and staff must be relieved before going on break or leaving the unit.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 8 residents (Resident #3) reviewed for accidents.The facility failed to keep Resident #3 in a safe environment to prevent an elopement on 7/27/2025 when he followed visitors out of the facility.An Immediate Jeopardy (IJ) situation was determined to have begun on 07/27/2025 and ended on 08/01/2025. It was determined to be past non-compliance due to the facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury and accidentsFindings included: Review of an undated admission record for Resident #3 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive cognitive decline) and schizoaffective disorder, bipolar type (combines schizophrenia and bipolar features). Review of a quarterly MDS dated [DATE] indicated he had a BIMS of 0 which indicated severe cognitive impairment. He required total assistance with toileting and personal hygiene; he required substantial assistance with showering/bathing; he required moderate assist putting on/taking off footwear, and with upper and lower body dressing; he required setup or cleanup assistance eating and with oral hygiene. Review of the comprehensive care plan dated 9/4/25 indicated Resident #3 was at risk for elopement related to diagnoses of Alzheimer's disease, dementia (cognitive decline), and schizoaffective disorder. Appropriate interventions were in place including wearing a Wander Guard bracelet (device that alarms if wearer was close to the facility exit doors), checking placement and function every shift, and quarterly or as needed elopement assessments to be completed.During an interview on 8/12/25 at 9:05 a.m., the DON said Resident #3 followed visitors out of the facility on 7/27/25. The DON said Resident #3 had a wander guard bracelet in place at the time of the elopement, but the alarm did not activate. The DON said when a resident had interventions to wear a wander guard the nursing staff checked the device every shift for placement and functionality and signed the wander guard logbook to indicate the checks were completed. The DON said she was not sure why the wander guard alarm system did not activate, but repairs were made to the system. The DON said the maintenance man had begun checking all alarms and door locks daily in addition to continuing the scheduled weekly maintenance checks. During an interview on 8/12/25 at 9:10 a.m., the ADM said at the time of the elopement on 7/27/25, Resident #3 was being housed on Hall A and was wearing a wander guard bracelet. The ADM said the wander guard alarm system was tested daily by the nursing staff when a resident was wearing one in the facility, and the door locks and alarms were checked weekly by the maintenance man. The ADM said he was unsure why the wander guard alarm did not activate. The ADM said he had service technicians come to the facility on 7/31/25 and make repairs to the alarm system. The ADM said Resident #3 was moved onto the secure men's unit following the elopement.Review of a witness statement dated 7/28/25 at 1:21 p.m., indicated at approximately 6:20 p.m. a woman visiting the facility rang the doorbell and asked LVN A if the man in the parking lot was a resident. LVN A said she immediately went outside and located Resident #3 walking by the dumpsters. LVN A said she led Resident #3 back inside the building. Review of a witness statement dated 7/30/25 by a visitor indicated on 7/27/25 she and several other visitors exited the facility through the front door. She said Resident #3 was near the nurse's station when they were walking up the hall to the lobby. She said after they exited the facility another visitor noted Resident #3 in the parking lot and went back inside the facility to alert facility staff. Review of an Elopement Event Report dated 7/31/25 at 2:16 p.m., completed by the DON indicated Resident #3 eloped from the facility on 7/27/25 at approximately 6:31 p.m. and was located in the front parking area. The report indicated there had been no recent changes in mental status, no recent traumatic events, new diagnosis, new stressors, or medication changes prior to the elopement. The report indicated Resident #3 was assessed for secure unit placement and moved to the men's secure unit.During an observation and interview on 8/12/25 at 10:52 a.m., Resident #3 was in sitting in the dining room of the men's secured unit. He appeared clean and well-groomed with no offensive odors; he had no visible skin tears, marks, or bruising. Resident #3 said he went outside the facility but could not provide any detail as to when, why or how. During an interview on 8/12/25 at 10:30 a.m., LVN B said Resident #3 was the only resident in the facility care planned for a wander guard. LVN B said nurses were responsible for checking the placement and function of wander guards every shift and signing the wander guard book to indicate checks were completed. LVN B said she was not aware of any problems with the wander guard alarm system prior to the elopement on 7/27/25. During an interview on 8/13/25 at 10:45 a.m., the maintenance man said prior to the elopement he was responsible for checking the door locks and all alarm systems weekly. He said he had not identified any problems with the alarm system or door locks prior to the elopement. He said following the elopement a service technician came to the facility and completed repairs. He said he verified all door locks and alarms were functioning following the repairs. He said following the elopement he was now responsible for completing daily checks of door locks and alarms in addition to the scheduled weekly checks. He said he was logging these checks on paper but was now logging the checks in the facility electronic maintenance system.Review of logbook report dated 8/12/25for Task Name: Doors, Locks, Gates & Alarms: Test operation of doors and locks for the last 6 months indicated all weekly checks had been completed and no problems were identified.Review of wander guard logbook from 3/1/2025 to 7/27/25 indicated all daily wander guard alarm tests were completed with no problems identified.Review of facility policy revised on 9/1/23 titled Wandering and Elopements indicated .The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.Review of facility policy revised in December of 2021 titled Emergency Procedure - Missing Resident indicated .Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. It was determined these failures placed residents in an IJ situation on 7/27/25 to 8/1/25.The facility corrected the noncompliance on 8/1/25 by the following: An observation on 8/12/25 at 9:00 a.m., revealed a sign hung on the facility exit door at eye level which stated .Visitors and staff please be cautious of our residents who may be in the foyer or following you to the front entrance/exit door. Notify staff to redirect residents away from the door if needed.During an observation on 8/13/25 from 11:00 a.m. - 11:45 a.m., the maintenance man checked all door magnetic locks and alarms; the locks functioned properly, and alarms were audible. The maintenance man checked wander guard alarm system by holding a wander guard bracelet and walking toward the facility exit; the alarm system sounded audibly. Review of a resident headcount conducted on 7/27/25 indicated all 49 residents in-house were accounted for. Review of Facility Observation Summary Report dated 7/28/25 indicated all residents in the facility received updated elopement assessments. Review of minutes from an all-staff meeting on 7/30/25 indicated all staff received education on exiting doors (be sure that residents were not following them through exit or secure unit doors), Code Pink (staff response to a missing resident), Wandering and Elopement, and Caring for Residents Exhibiting Behavior.Review of an invoice dated 7/30/25 from a service call indicated Roam Alert front door alarm system and two push-bars were repaired/replaced.Review of Code Pink Drill for missing resident dated 7/30/25 indicated a drill took place at 3:30 p.m.Review of Code Pink Drill for missing resident dated 7/30/25 a drill took place at 6:44 p.m. Review of an in-service dated 8/1/25 titled Exit Doors instructed staff to make sure exit doors were closed when exiting the facility and do not block exit doors.Review of document titled Door Alarms Records indicated daily checks were performed on all door locks and alarms from 8/5/25 to 8/9/25.Review of electronic logbook report indicated daily checks were performed on all door locks and alarms on 8/11/25 and 8/12/25.Interviews with staff of various disciplines and shifts were conducted during the investigation and were all able to verbalize signs of exit seeking behavior and appropriate interventions. All staff were able to verbalize appropriate action to take in the event of a missing resident. Staff interviews included 5 LVNs (LVN B, LVN J, LVN K, LVN L, LVN O), 4 CNAs (CNA C, CNA E, CNA H, CNA M), 1 Sitter (Sitter D), 1 LCSW, 1 ADON, 1 DA, 1 DON.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 2 of 3 months (July 2024 and August 2024) reviewed for Quarter 4 of the fiscal year 2024. The facility did not have RN coverage for 4 days in July 2024. The facility did not have RN coverage for 1 day in August 2024. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings included: Record review of the RN punch detail hour report for July 2024 indicated there were no RN hours worked on the following dates: July 6, 2024, July 7, 2024, July 13, 2024, and July 21, 2024. Record review of the RN punch detail hour report for August 2024 indicated there were no RN hours worked on the following day: August 4, 2024. Record review of the CMS Payroll Based Journal (PBJ) report for the fourth quarter of 2024 (July 1, 2024, through September 30, 2024) indicated there were no RN hours for the following dates: 07/06 (SA); 07/07 (SU); 07/13 (SA); 07/21 (SU); 08/04 (SU). During an interview on 2/18/2025 at 2:48 PM, the ADON said she and the DON were responsible for doing the schedules for the nurses and nurse aides. She said they currently had a weekend RN who worked every other weekend. She said a RN should be in the facility 8 hours every day. She said most of the time if a LVN could not handle the situation, then the RN would help them for changes in condition or a death and should be in the facility daily. She said she was not aware there were some days in July or August 2024 when there was not a RN in the facility. During an interview on 2/18/2025 at 3:19 PM, the DON said the ADON was responsible for staffing the nurse and nurse aides in the facility. She said the facility had staffing issues since she hired July 2023 and the facility recently hired 2 RNs at the end of November of 2024. She said back in July and August 2024, she was working a lot of days as nurse aides and charge nurses in the facility and was told her hours would not count toward the RN 8 hours that was required daily. She said the facility should have an RN in the facility 8 hours a day. She said there could be a delay in response times and assessing the patient when there was a change in condition if a RN was not in the facility. During an interview on 2/18/2025 at 3:35 PM, the Administrator said he was aware of the facility not having RN hours for the fourth quarter of 2024 and at that time they went through a lot of needed staff turnover and in turn some days were missed. He knew there was a requirement for a RN, and they should be in the facility 8 hours daily. He said the facility currently had a RN covering every other weekend now and the other weekends the DON would be covering. Record review of a facility policy titled Staffing revised September 2023 indicated, .Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety. 4. The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in one of one kitchen reviewed for dietary services. The facility did not ensure the dish machine was working properly on 02/17/2025. The facility did not ensure that raw foods were thawed appropriately on 02/17/2025. These failures could place residents who eat from the kitchen at risk of foodborne illnesses. Findings included: During an observation on 02/17/25 at 9:08 am the dish machine was tested with Dietary Aide. The dish machine wash temperature was 120 degrees Fahrenheit and rinse temperature was 125 degrees Fahrenheit, but the sanitizer did not register on the test strip. The Dietary Aide was not sure what to do and went to get her dietary manager. During an interview on 02/17/2025 at 9:10 am the Dietary Aide said she was trained on the sanitizer testing but did not always use the strips and watched for the solution to drop in the water. She said the Dietary Manager tested the machine herself this morning and it was working correctly. She said the dish machine temperature and sanitation should be checked every day. She said if the dishes were not properly sanitized it could cause infections. During an interview on 02/17/2025 at 9:14 am the Dietary Manager said she had tested the dishwasher this morning and there were no issues. She said she tested the machines herself to ensure it was done but the Dietary Aide had been trained on the dishwasher temperature checks and proper sanitizer numbers. She said she would contact the dishwasher company to have it inspected. She said if dishes weren't properly sanitized it could cause infections. During an observation on 02/17/2025 at 9:35am there were bags of frozen food items thawing in the kitchen sink. The items included 3 bags of peas and carrots, 1 bag mashed potatoes, 2 bags of gravy mix and 3 bags of chicken breast. During an interview on 02/17/2025 at 9:37 am the [NAME] said that when frozen foods were pulled to thaw, they should be in the refrigerator or in a sink with cold running water running continuously. She said raw meat should not be thawing with other items and by not properly thawing food it could cause bacteria growth and residents could become sick. She said she had been trained on the proper method of thawing foods and was in a hurry this morning. During an observation and interview on 02/17/2025 at 12:00 pm a dish machine repair worker was present and checking the dishwasher. He said the tubing for the sanitizer had come unattached from the container and the tubing was reapplied and cycle complete with sanitizer at 100-200 ppm. He said he provided retraining with the dietary aide and dietary manager. During an interview on 02/17/2025 at 1:03 pm The Dietary Manager said that she had seen the food thawing in the sink and should have said something to the cook. She said the cook had been trained on the proper thawing process of foods and would retrain all staff. She said that she was responsible for the kitchen and its staff and if the staff were not correctly preparing food it could cause residents to become sick. During an interview on 02/17/2025 at 1:45 pm the Administrator said the Dietary Manager was responsible for the kitchen and expected all staff knew and followed the proper process for cleaning and sanitizing dishes and thawing foods. He said all the staff have had many hours of training and he would oversee that they were retrained. He said that he expected the staff to follow the kitchen sanitation in all areas and by not doing so it could cause illness. Record review of temperature/sanitizer log for dish machine dated February 2025 indicated the dish machine had been tested and working properly 17 of 17 days of the month. Record review of an undated facility policy titled Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment indicated, .The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 2. Make sure that the automatic detergent dispenser and/or liquid sanitizer injector is working properly. f. A test kit or other device that accurately measures the parts per million concentrations of the solution must be available and used . Record review of an undated facility policy titled Food Storage indicated, .To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines . i. Once frozen food has been thawed, it must be maintained at 41 Fahrenheit or less prior to cooking .

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and sanitary environment for residents on hallway B (Women's locked Unit, Resident #8) and C (men's locked unit), 1 of 3 dining rooms (main dining room) and main dining room patio reviewed for physical environment. The facility failed to provide Resident #8 a safe, clean and sanitary environment on 02/17/25 to 2/18/25 when the mattress on her bed was stained with a brown substance, the wall next to her bed was smeared with a dirty yellow, red and brown substance and had exposed sheetrock. The facility failed to maintain the wall in Resident #8's bathroom leaving the sheetrock exposed at the sink and non- working soap dispenser in the bathroom. The facility failed to maintain walls, doors, doorways, and floors to residents residing on Hallways A and B. The facility failed to maintain the main dining room ceiling and vents. The facility failed to maintain tiles covering the dining room patio. These failures could place residents and visitors at risk for exposure to an unclean, unsanitary environment, risk of falls and other injuries due to an unsafe environment. Findings included: Record review of a face sheet for Resident #8 dated 2/18/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (disorganized thoughts) and anxiety disorder (feeling of nervousness). Record review of an Annual MDS Assessment for Resident #8 dated 02/09/2025 indicated she had severe impairment in thinking with a BIMS score of 3 and ambulated independently. During an observation and interview on 2/17/2025 at 09:55 am, Resident #8 resides on the B hall (Women's locked unit) in room [ROOM NUMBER]. Resident #8 was dressed, sitting on her unmade bed, her mattress had a 2 x 2-foot brown stain that was wet. On the wall beside Resident #8's bed there was an area 3 feet wide and 2 feet tall that the paint was chipped and was covered with yellow, red, and brown smeared substance. Resident #8 said she sometimes vomits at night, and she wipes it there. Resident #8's bathroom soap dispenser is torn off the wall exposing sheetrock. The soap dispenser was sitting on top of the paper towel dispenser, making it unusable. During an observation and interview on 2/17/2025 at 10:10 am hallway B (Women's locked unit), rooms [ROOM NUMBERS] doors and doorways in the hallway are gouged, marred and paint is missing. room [ROOM NUMBER] has floor tile missing. CNA B said she had worked at the facility for about 7 months and received training on infection control and safety. She said housekeeping cleans the women's unit every day and she cleans up spills and messes made by the residents on the unit when needed. She said she didn't know when the wall in Resident #8's room had been cleaned. She said the resident #8 wipes body substances on the wall beside her bed. CNA B said the staff should log any items that need to be repaired in the maintenance request book at the nurse's station. She said that living in an unsanitary environment could cause sickness and spread infection. During an observation on 2/17/2025 at 12:00 pm the patio used for smoking area, beside the dining room. The patio had 5 missing ceramic tiles with a tile not adhered, sitting cross ways, and creating a trip slip hazard. The dining room ceiling was sagging, and the sheetrock ceiling had cracks, the top layer is pulling away from the sheetrock. The ceiling had three large areas that appeared to have old water damage. The areas were sagging and crumbling. The dining room was open to the public and residents. There were dried water rings near a dirty vent. The filter inside the air vent was layered with dust and dirt. Multiple vents in the dining area are covered with layers of dust. During an interview on 2/17/2025 at 12:45 pm the Maintenance Man said it was his responsibility to maintain the facility. He said he had worked at the facility for over 2 years. He said he cleans the air vents when needed and changes out vent filters usually monthly. He said the staff log maintenance needs in a book at the nurses' station and he checks it daily for issues. During an observation and interview on 2/18/2025 at 8:30 am the substances on Resident #8 wall beside her bed area were 3 feet wide and 2 feet tall that the paint was chipped and was covered with yellow, red, and brown smeared substance unchanged from 2/17/2025. CNA C said she had worked at the facility for 7 months and she doesn't know how often Resident #8's wall gets cleaned, she said housekeeping cleans it once a week or so. During an interview on 2/18/2025 at 8:45 am Housekeeper A said if the wall looks real bad bedside resident #8's bed she would scrub it down. Housekeeper A said the wall looked bad beside Resident #8 bed and needed to be scrubbed and repainted. During an observation 02/18/2025 at 2:30 pm Hallway C (men's locked unit) room [ROOM NUMBER] and room [ROOM NUMBER] doors and doorways in the hallway are gouged, marred and paint was missing. The vinyl flooring in room [ROOM NUMBER] has tears and was pulling apart from the concrete underneath which was a trip slip hazard. The sheetrock was exposed in areas on the hallway C with paint missing. During an interview on 2/18/2025 at 2:45 pm the Administrator said it was the policy of the facility to maintain a clean, sanitary, and orderly environment. He said that not maintaining the environment could lead to decreased quality of life, infections, and hazards. The Administrator said he had bids for replacement of flooring but had not received funds from corporate for replacement. Record Review of a maintenance work order book, requests for maintenance dated 2/18/2025 to 07/01/2024 indicated no requests for doors, hallways, ceilings, vents, or resident rooms to be repaired. Record Review of a facility policy, Homelike Environment dated 2/2021 indicated: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible . Policy Interpretation and Implementation 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 reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment. b. comfortable (minimum glare) yet adequate (suitable to the task) lighting; c. inviting colors and decor; d. personalized furniture and room arrangements; e. clean bed and bath linens that are in good condition;

Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 8 residents (Resident #21) reviewed for accidents/hazards. The facility failed to remove a worn and damaged mechanical lift sling from service on 2/17/2025 and 2/18/2025. This deficient practice could place residents at risk of a loss of quality of life due to injuries. Findings included: Record review of a face sheet for Resident #21 dated 2/18/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of diffuse traumatic brain injury (an injury caused by a forceful bump, blow, or jolt to the head), hemiplegia and hemiparesis following cerebral infarction (paralyzed on one side of the body), and aphasia following cerebral infarction (difficulty speaking following a stroke). Record review of a Quarterly MDS Assessment for Resident #21 dated 11/22/2024 indicated he had moderate impairment in thinking with a BIMS score of 12. He was dependent on staff with chair/bed to chair transfers. Record review of a care plan for Resident #21 dated 12/23/2024 indicated he required a Hoyer lift for transfers with interventions to transfer him via Hoyer lift with staff member x2. During an observation and interview on 2/17/2025 at 9:20 AM, Resident #21 was in his room sitting up in a wheelchair. He was alert and oriented to person, place, and time. He was dressed and said he had been at the facility for 6 months. He was sitting on a mechanical lift sling in the wheelchair that was faded in color. He said the staff used a mechanical lift to transfer him with two people. During an observation on 2/17/2025 at 3:21 PM, Resident #21 was sitting in a wheelchair in the dining room on a mechanical lift sling that was faded in color. During an observation on 2/18/2025 at 8:34 AM, Resident #21 was sitting in a wheelchair in the dining room on a mechanical lift sling that was faded in color. During an interview on 2/18/2025 at 3:02 PM, CNA D was on the hall where Resident #21 resided. She said she had been employed at the facility for 2 years and worked the day shift from 6 am-6 pm. She said when she arrived to work on 2/18/2025, staff had Resident #21 up in his wheelchair and the night shift staff were responsible for getting residents up before they left for their shift. She said Resident #21 was a 2-person transfer with using the mechanical lift. She said the staff were to check the lift slings before use to make sure there were not any tears, rips, or strings, and it they found it was not sturdy they were told to take it to the Administrator. She said they also checked to make sure the colors were correct and not faded in color. During an observation and interview on 2/18/2025 at 3:06 PM, Resident #21 was in the dining room still sitting on the lift sling that was faded in color. CNA D looked at the sling and said it was faded in color but sturdy. She said she was not sure if it could be used or not because it was still sturdy, and tags were not visible with any writing. During an observation and interview on 2/18/2025 at 3:08 PM, the Laundry Supervisor observed the sling that was underneath Resident #21 in the dining room. She said the tag was frayed and one of the labels said it was an Invacare brand. She said they washed the slings on cycle-regular #3, no bleach and they were hung to air dry. She said it was faded and was probably bleached. She said they should not be bleached, and the sling should not be in use. She said the sling should not be bleached according to the manufacturer label. She said there was a risk for tears, and she usually checked for tears when she washed them and could also be a hazard to the resident resulting in a fall. She said she thought that the sling was an old one and they had newer ones in the facility. She said she would inform the DON. During an interview on 2/18/2025 at 3:15 PM, the DON said she was not aware of Resident #21 having a faded sling. She said she was not sure how they washed the slings in the facility or if they used bleach. She said if the staff could not tell the color of the rings on the sling, they could put the wrong color of the ring on the lift and cause it to become unbalanced which might cause a fall. During an interview on 2/18/2025 at 3:43 PM, the Administrator said he was made aware of the sling for Resident #21 being faded in color by staff that day. He said they had new ones in the facility. He said he was not sure how they washed them. He assumed they used the chemicals that were supplied. He said they would probably need to get rid of the sling. He said staff were to ensure they were using the right sling for the right resident. Record review of a facility policy titled mechanical lift sling guidelines dated 3/11/2024 indicated, .2. Regular inspections of lifting slings must be carried out in accordance with the manufacturer's instructions, with a minimum of every 6 months 5. Wash and sanitize according to manufacturer's instructions . Record review of the Owner's Operator and Maintenance Manual for patient slings for Invacare undated indicated, .Care: Note: laundering should always be done with dark colors. Do not bleach. Refer to tagged washing instructions on the sling. Warning: after each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken sling are unsafe and could result in injury. Discard immediately .

Based on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (2/17/2025 and 2/18/2025) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 2/17/2025 and 2/18/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included: During an observation on 2/17/2025 at 10:01 AM, the daily staff posting was not in or around the front entrance. The daily staff posting was dated 2/16/2025 and on a wall by the nurse station partially blocked by two medication carts that was not clearly visible to see. During an observation 02/17/25 3:33 PM, the daily staff posting was dated 2/17/2025 and on a wall by the nurse station partially blocked by two medication carts that was not clearly visible to see. During an observation on 2/18/2025 at 10:55 AM, the daily staff posting was dated 2/18/2025 on a wall by the nurse station partially blocked by two medication carts that was not clearly visible to see. During an interview on 2/18/2025 at 2:48 PM, the ADON said she was responsible for completing the schedules for the nurses and nurse aides. She said the night nurse put up the daily staff positing and would get the information from the schedule. She said the daily posting was on the wall by the medication carts. She said it had always been on that wall. She said where it was placed visitors would not be able to see the information. During an interview on 2/18/2025 at 3:19 PM, the DON said the ADON was responsible for staffing in the facility for the nurses and nurse aides. She said the daily staff posting was the responsibility of the night charge nurse. She said the posting was to be placed in the plastic sleeve on the wall by the fire alarm and by the medication carts. She said the location was where it had always been. She said she did not see anything wrong with the location the posting was located, and it could be seen by anyone in the facility. During an interview on 2/18/2025 at 3:35 PM, the Administrator said the night nurse or ADON was responsible for putting out the daily staff posting. He said the current location on the wall by the medication carts, someone entering the facility would not know to look for it there and it was not in a good location. He said it was moved by front entrance that day. He said the purpose of the staff posting was so anyone would be able to see how many staff were in the facility. Record review of a facility policy titled Staffing revised September 2023 indicated, .Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety. 8. Staffing levels for direct care staffing are updated each shift and posted in a public area .

Based on interview and record review, the facility failed to ensure all residents were free from neglect for 1 of 5 residents (Resident #1) reviewed for neglect. RN A did not call 911 for emergency services for Resident #1 until approximately 29 minutes after discovering Resident #1 unresponsive on [DATE]. CPR was not initiated on Resident #1 on [DATE] until approximately 9:52 PM when Fire Department arrived and began resuscitation attempts. Resident #1 was pronounced deceased at approximately 10:27 PM after Justice of the Peace arrived. The facility staff failed to provide life saving measures to Resident #1 who was identified as being full code after he was found unresponsive in his room. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:50 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for neglect due to not receiving necessary life-saving measures, decline in health, and death. Findings include: 1. Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease (movement disorder of the nervous system that worsens over time), hypertension (elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The face sheet indicated Resident #1 was a full code (in the event of cardiac arrest, CPR will be initiated). Record review of MDS dated [DATE] indicated Resident #1 was rarely understood by others and rarely understood others. The MDS indicated Resident #1 BIMS was not conducted due to resident being rarely/never understood. The MDS did not indicate Resident #1 had a DNR advanced directive in place. Record review of the care plan revised on [DATE] indicated Resident #1's code status as .[resident] is a Full Code. He wishes to be resuscitated if he should stop breathing. Record review of physician orders reflected an order of Code Status: Full Code with starting date of [DATE] with no end date. Record review of the nursing progress note dated [DATE] written by RN A indicated that RN A found Resident #1 unresponsive at approximately 9:00 PM on [DATE]. The progress note indicated RN A assessed Resident #1 and he was without pulse or respirations. The progress note indicated RN A called the facility ADM, DON, and ADON but did not initiate CPR or call 911. The progress note indicated RN A called NP at 9:29 and was directed to call 911 due to resident Full Code status. The progress note indicated Emergency Services arrived at 9:50 PM and initiated CPR at 9:52 PM. The progress note indicated Justice of the Peace arrived at 10:20 PM and CPR was stopped at 10:27 PM and Resident #1 was pronounced deceased . During a telephone interview on [DATE] at 12:30 PM, RN A said on [DATE] she discovered Resident #1 lying in his bed and he did not respond to her voice. RN A said she assessed Resident #1, and he had no palpable pulse, no respirations, pupils were fixed, dilated, and nonreactive to light, and resident's lips and fingertips were cold to the touch. RN A said she did not start CPR because Resident #1 was already deceased . RN A said she called the facility ADM, ADON, and DON for guidance on funeral home notification but only the ADON responded, and she did not know the policy. RN A said she called NP for further guidance and NP directed her to call 911 due to Resident #1 Full Code status. RN A said the 911 operator asked her to start CPR on Resident #1, but she declined to do so because he was already gone. RN A said she was familiar with Resident #1's code status because she was responsible for updating the resident code status book nightly at midnight. RN A said she had never received any training from the facility regarding Emergency Procedures or CPR. Record Review of an in-service education form dated [DATE] included topics Code Status Guidelines and Advanced Directives and Code Blue reflected RN A was in attendance. Record review of a National CPR Foundation Provider Card indicated RN A was certified in Standard - CPR / AED issued [DATE] and expiring [DATE] . During an interview on [DATE] at 1:00 PM the ADON said she remembered Resident #1 expiring. The ADON said RN A called her that night and told her Resident #1 was deceased and asked what Justice of the Peace and funeral home to notify. The ADON said if there was no preference in Resident #1's chart she was unsure and would call her back. The ADON said she assumed RN A had initiated CPR for Resident #1 due to his Full Code status and did not ask for clarification. During a telephone interview on [DATE] at 2:30 PM, NP said she first learned that Resident #1 was deceased on the morning of [DATE] when she received a message left with her answering service. She said RN A never called her on the night of [DATE] and she did not give RN A any directions or guidance. She said CPR should have been initiated immediately on a nonresponsive resident who is a full code. During an interview on [DATE] at 3:00 PM the ADM said he remembered Resident #1 expiring. The ADM said he was not at the facility but was given report regarding Resident #1's death. The ADM said he had been informed CPR was not initiated on Resident #1. The ADM said staff are expected to follow facility policy and initiate CPR for any resident who is Full Code. He said an RN may pronounce death if there are obvious signs of irreversible death . (e.g., rigor mortis, decomposition, decapitation) The ADM said the facility had begun disciplinary action with RN A for failing to follow policy when she self-terminated her employment at the facility. He said all staff receive education in Abuse, Neglect, and Exploitation on hire and the facility has frequent in-services to reinforce training. During a telephone interview on [DATE] at 4:00 PM . CNA B said she worked the overnight shift on [DATE]. CNA A said she checked on Resident #1 at approximately 8:00 PM and assisted him to the restroom and he did not appear to be in distress. She said RN A was Resident #1's nurse that night. Record review of the facility's Abuse, Neglect, and Exploitation policy last revised [DATE] indicated: .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents . Record review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation policy last revised February 2018 indicated: .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) . The Administrator was notified that an Immediate Jeopardy situation was identified due to the above failure and provided with the Immediate Jeopardy template on [DATE] at 5:22 PM. A Plan of Removal was requested. The facility's Plan of Removal was accepted on [DATE] 8:23 AM and included: Plan of Removal: 600: Free from Abuse & Neglect Ensure staff performed CPR for Resident #1 until emergency services arrived. Utilize the AED when Resident #1 was found unresponsive. Immediately call 911 when the resident was found unresponsive - waited approximately 29 minutes until calling emergency services. 1. Immediate Actions Taken for Those Residents Identified: What immediate/direct action was taken for the staff involved? Action: Charge Nurse no longer works for [facility] as of [DATE]. Nurse self-termed themself. Action: Resident #1 was noted as unresponsive, CPR initiated by emergency services, Resident #1 was pronounced as deceased . Person(s) Responsible: Charge Nurse Date: [DATE] 2. How the Facility Identified Other Possibly Affected Residents:? Action: Completed a DNR and Full Code audit:? Reviewed Physician orders, vs the face sheet, vs the care plan, vs the Out of Hospital DNR (if applicable) to ensure all are matching and correct. ? Person(s) Responsible: Regional Nurse Consultant, Director of Nursing, and/or Designee ? Date: [DATE] 8AM Action: Audit staff CPR cards to ensure proper number of certified employees present each shift. ? Person(s) Responsible: Human Resources, Administrator, and/or Designee ? Date: [DATE]? 10AM 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred:? Action: Ensured the crash cart has an updated list of full code and DNR residents. ? Person(s) Responsible: Administrator and/or Designee ? Date: [DATE] 10PM Action: ?Education- All Nurses educated regarding Emergency Management Code Procedure Policy to include the following, in which would be the response in an emergency situation for a full code resident requiring CPR: 1. If an individual is found unresponsive, the nurse to first arrive to the resident will briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: The first responding nurse will- Instruct a staff member to activate the emergency response system (code) and call 911. The first responding nurse will- Instruct a staff member to retrieve the automatic external defibrillator. The first responding nurse will- Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. Chest compressions: Following initial assessment, begin CPR with chest compressions. Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute; Allow full chest recoil after each compression; and Minimize interruptions in chest compressions. 4. Airway: Tilt head back and lift chin to clear airway. 5. Breathing: After 30 chest compressions provide 2 breaths via ambu bag or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 7. When the AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency medical personnel arrive. All above-mentioned staff will be educated prior to working their next shift. ? Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, &/or Designee Date: [DATE] 10AM Action: All direct care staff educated over the abuse and neglect policy. All above-mentioned staff will be educated prior to working their next shift. ? Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, &/or Designee Date: [DATE] 10AM 4. How the Corrective Actions Will be Monitored, by whom and for how long:? - Action: 1 mock code drill to be performed once a shift, for each Charge Nurse shift, to ensure proper reaction and that staff are following protocols educated on above. Charge Nurses work 12-hour shifts. Person(s) Responsible: Administrator, Director of Nurses, and/or Designee Date: [DATE] 10AM QAPI- Action: Ad hoc QAPI performed with Medical Director to review the IJ Template and the facility's plan to lower the immediacy. ? Person(s) Responsible: Administrator ? Date: [DATE]? 10PM On [DATE] at 12:50 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a random selection of staff CPR certifications indicated 8 of 8 staff reviewed had a current and appropriate CPR certification, sample included 3 RN, 2 LVN, 3 CNA. Record review of a random selection of resident charts indicated 15 of 15 residents reviewed had code status that matched on the face sheet and orders and had DNR's on file for residents who had chosen to be a DNR. Record review of AED/Crash Cart checklist sheet for the month of [DATE] indicated the crash cart had been checked daily. Record review of AED Competency Check Lists, DDU-100 Life Line Semi-Automatic External Defibrillator Post Tests. Record review of mock Code Blue drill sheet dated [DATE] including both overnight and day shift staff. Review of Ad Hoc QAPI meeting minutes. Attendees: ADM, DON, Medical Director, topics discussed included IJ templates and Plan of Removal. Review of In-service Education Form titled Abuse, Neglect, and Misappropriation (Other Occurrences That Are Reportable to HHSC/DADS) dated [DATE] 14 staff members of varying departments attended including nursing, human resources, and housekeeping. Observed mock code blue drill performed on [DATE] at 12:30 PM. During an interview on [DATE] at 9:20 AM, the DON said nurses and direct care certified in CPR had been in-serviced on CPR and AED use, she had run mock code blue (unresponsive resident) drills with both overnight and day shift staff, and they had a QAPI (Quality Assurance and Performance Improvement) meeting where the topics of emergency procedures and CPR were discussed. She said all staff has received additional in-service training in Abuse, Neglect, and Misappropriation. During an interview on [DATE] at 9:25 AM. the Administrator said the facility had audited all resident code statuses and verified all were correct in code status binder, audited crash cart check-off, audited direct care staff CPR cards, conducted training with nurses and direct care staff regarding emergency procedures, AED, CPR, and Abuse and Neglect training. He said the facility also ran mock code blue drills with both overnight and day shift staff. He said not all staff had been trained due to being unavailable but those who have not been would not be allowed to work until completing training. He said he held an ad hoc QAPI meeting with ADON and Medical Director to review IJ templates and discuss plan of removal. Staff interviewed on [DATE] between 10:30 AM and 12:30 PM (CNA B, CNA C, LVN D, CNA E, CNA F, RN G, CNA H, LVN J, CNA K, LVN L) were able to name where to find the code status for a resident. Staff interviewed said they should call for help and initiate CPR immediately for an unresponsive resident who is Full Code and not breathing normally. CPR certified staff were able to verbalize correct usage for AED. Staff interviewed were able to define neglect and who to report witnessed incidents to. ADM was notified of IJ removal on [DATE] at 12:50 PM. While the IJ was removed on [DATE] , the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 (Resident #1) residents reviewed for CPR. The facility failed to ensure staff performed CPR on [DATE] for Resident #1 who was identified as a full code . CPR was not initiated prior to emergency services arrival. The facility failed to ensure staff utilized the AED on [DATE] when Resident #1 was found unresponsive. The facility failed to follow their policy and procedure for Emergency Procedure - Cardiopulmonary Resuscitation. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:50 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings include: 1. Record review of an undated facesheet indicated Resident #1 was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease (movement disorder of the nervous system that worsens over time), hypertension (elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The face sheet indicated Resident #1 was a full code (in the event of cardiac arrest, CPR will be initiated). Record review of MDS dated [DATE] indicated Resident #1 was rarely understood by others and rarely understood others. The MDS indicated Resident #1 BIMS was not conducted due to resident being rarely/never understood. The MDS did not indicate Resident #1 had a DNR advanced directive in place. Record review of the care plan last revised [DATE] indicated Resident #1's code as .[resident] is a Full Code. He wishes to be resuscitated if he should stop breathing. Record review of the physician orders reflected order of Code Status: Full Code with starting date of [DATE] with no end date. Record review of the nursing progress note dated [DATE] written by RN A indicated that RN A found Resident #1 unresponsive at approximately 9:00 PM on [DATE] . The progress note indicated RN A assessed Resident #1 and he was without pulse or respirations. The progress note indicated RN A called the facility ADM, DON, and ADON but did not initiate CPR or call 911. The progress note indicated RN A called the facility NP at 9:29 and was directed to call 911 due to resident Full Code status. The progress note indicated Emergency Services arrived at 9:50 PM and initiated CPR at 9:52 PM. The progress note indicated Justice of the Peace arrived at 10:20 PM and CPR was stopped at 10:27 PM and Resident #1 was pronounced deceased . During a telephone interview on [DATE] at 12:30 PM, RN A said on [DATE] she discovered Resident #1 lying in his bed and he did not respond to her voice. RN A said she assessed Resident #1, and he had no palpable pulse, no respirations, pupils were fixed, dilated, and nonreactive to light, and resident's lips and fingertips were cold to the touch. RN A said she did not start CPR because Resident #1 was already deceased . RN A said she called the facility ADM, ADON, and DON for guidance on funeral home notification but only the ADON responded, and she did not know the policy. RN A said she called NP for further guidance and NP directed her to call 911 due to Resident #1 Full Code status. RN A said the 911 operator asked her to start CPR on Resident #1, but she declined to do so because he was already gone. RN A said she was familiar with Resident #1's code status because she was responsible for updating the resident code status book nightly at midnight. RN A said she had never received any training from the facility regarding Emergency Procedures or CPR. Record Review of an in-service education form dated [DATE] included topics Code Status Guidelines and Advanced Directives and Code Blue reflected RN A was in attendance. Record review of a National CPR Foundation Provider Card indicated RN A was certified in Standard - CPR / AED issued [DATE] and expiring [DATE]. During an interview on [DATE] at 1:00 PM the ADON said she remembered Resident #1 expiring. The ADON said RN A called her that night and told her Resident #1 was deceased and asked what Justice of the Peace and funeral home to notify. The ADON said she assumed RN A had initiated CPR for Resident #1 due to his Full Code status and did not clarify. During a telephone interview on [DATE] at 2:30 PM, She said RN A never called her on the night of [DATE] and she did not give RN A any directions or guidance. The NP said CPR should have been initiated immediately on a nonresponsive resident who is full code. During an interview on [DATE] at 3:00 PM the ADM said he remembered Resident #1 expiring. The ADM said he was not at the facility but was given report regarding Resident #1's death. The ADM said he had been informed CPR was not initiated on Resident #1. The ADM said staff are expected to follow facility policy and initiate CPR for any resident who is Full Code unless there are obvious signs of irreversible death. During a telephone interview on [DATE] at 4:00 PM. CNA B said she worked the overnight shift on [DATE]. CNA A said she checked on Resident #1 at approximately 8:00 PM and assisted him to the restroom and he did not appear to be in distress. She said RN A was Resident #1's nurse that night. Record review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation policy last revised February 2018 indicated: .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) . The Administrator was notified that an Immediate Jeopardy situation was identified due to the above failure and provided with the Immediate Jeopardy template on [DATE] at 5:22 PM. A Plan of Removal was requested. The facility's Plan of Removal was accepted on [DATE] 8:23 AM and included: Plan of Removal: 678: Cardio-Pulmonary Resuscitation (CPR)? The facility failed to: Ensure staff performed CPR for Resident #1 until emergency services arrived. Utilize the AED when Resident #1 was found unresponsive. Immediately call 911 when the resident was found unresponsive - waited approximately 29 minutes until calling emergency services. Follow their policy and procedures to immediately initiate CPR. 1. Immediate Actions Taken for Those Residents Identified:? What immediate/direct action was taken for the staff involved? Action: Charge Nurse no longer works for [facility] as of [DATE]. Nurse self-termed themself. Action: Resident #1 was noted as unresponsive, CPR initiated by emergency services, Resident #1 was pronounced as deceased . Person(s) Responsible: Charge Nurse Date: [DATE] 2. How the Facility Identified Other Possibly Affected Residents:? Action: Completed a DNR and Full Code audit:? Reviewed Physician orders, vs the face sheet, vs the care plan, vs the Out of Hospital DNR (if applicable) to ensure all are matching and correct. ? Person(s) Responsible: Regional Nurse Consultant, Director of Nursing, and/or Designee ? Date: [DATE] 8AM Action: Audit staff CPR cards to ensure proper number of certified employees present each shift. ? Person(s) Responsible: Human Resources, Administrator, and/or Designee ? Date: [DATE]? 10AM 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred:? Action: Ensured the crash cart has an updated list of full code and DNR residents. ? Person(s) Responsible: Administrator and/or Designee ? Date: [DATE] 10PM Action: ?Education- All Nurses educated regarding Emergency Management Code Procedure Policy to include the following, in which would be the response in an emergency situation for a full code resident requiring CPR: 1. If an individual is found unresponsive, the nurse to first arrive to the resident will briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: The first responding nurse will- Instruct a staff member to activate the emergency response system (code) and call 911. The first responding nurse will- Instruct a staff member to retrieve the automatic external defibrillator. The first responding nurse will- Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. Chest compressions: Following initial assessment, begin CPR with chest compressions. Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute; Allow full chest recoil after each compression; and Minimize interruptions in chest compressions. 4. Airway: Tilt head back and lift chin to clear airway. 5. Breathing: After 30 chest compressions provide 2 breaths via ambu bag or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 7. When the AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency medical personnel arrive. All above-mentioned staff will be educated prior to working their next shift. ? Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, &/or Designee Date: [DATE] 10AM 4. How the Corrective Actions Will be Monitored, by whom and for how long:? - Action: 1 mock code drill to be performed once a shift, for each Charge Nurse shift, to ensure proper reaction and that staff are following protocols educated on above. Charge Nurses work 12-hour shifts. Person(s) Responsible: Administrator, Director of Nurses, and/or Designee Date: [DATE] 10AM QAPI- Action: Ad hoc QAPI performed with Medical Director to review the IJ Template and the facility's plan to lower the immediacy. ? Person(s) Responsible: Administrator ? Date: [DATE] 10PM On [DATE] at 12:50 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a random selection of staff CPR certifications indicated 8 of 8 staff reviewed had a current and appropriate CPR certification, sample included 3 RN, 2 LVN, 3 CNA. Record review of a random selection of resident charts indicated 15 of 15 residents reviewed had code status that matched on the face sheet and orders and had DNR's on file for residents who had chosen to be a DNR. Record review of AED/Crash Cart checklist sheet for the month of [DATE]. Record review of AED Competency Check Lists, DDU-100 Life Line Semi-Automatic External Defibrillator Post Tests. Record review of mock Code Blue drill sheet dated [DATE] including both overnight and day shift staff. Review of Ad Hoc QAPI meeting minutes. Attendees: ADM, DON, Medical Director, topics discussed included IJ templates and Plan of Removal. Review of In-service Education Form titled Abuse, Neglect, and Misappropriation (Other Occurrences That Are Reportable to HHSC/DADS dated [DATE] Observed mock code blue drill performed on [DATE] at 12:30 PM. Staff interviewed on [DATE] between 10:30 AM and 12:30 PM (CNA B, CNA C, LVN D, CNA E, CNA F, RN G, CNA H, LVN J, CNA K, LVN L) were able to name where to find the code status for a resident. Staff interviewed said they should call for help and initiate CPR immediately for an unresponsive resident who is Full Code and not breathing normally. CPR certified staff were able to verbalize correct usage for AED. Staff interviewed were able to define neglect and who to report witnessed incidents to. During an interview on [DATE] at 9:20 AM, the DON said nurses and direct care certified in CPR had been in-serviced on CPR and AED use, she had run mock code blue (unresponsive resident) drills with both overnight and day shift staff, and they had a QAPI (Quality Assurance and Performance Improvement) meeting where the topics of emergency procedures and CPR were discussed. During an interview on [DATE] at 9:25 AM. the Administrator said the facility had audited all resident code statuses and verified all were correct in code status binder, audited crash cart check-off, audited direct care staff CPR cards, conducted training with nurses and direct care staff regarding emergency procedures, AED, CPR, and Abuse and Neglect training. He said the facility also ran mock code blue drills with both overnight and day shift staff. He said not all staff had been trained due to being unavailable but those who have not been would not be allowed to work until completing training. He said he held an ad hoc QAPI meeting with ADON and Medical Director to review IJ templates and discuss plan of removal. ADM was notified of IJ removal on [DATE] at 12:50 PM. While the IJ was removed on [DATE] , the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure residents were free from abuse for 5 of 6 residents (Resident #3, Resident #20, Resident #21, Resident #23, and Resident #24) reviewed for Resident Abuse. 1. The facility failed to protect Resident #3 from abuse by Resident #20. On [DATE] Resident #20 tried to choke Resident #3. 2. The facility failed to protect Resident #21 from abuse by Resident #20. On [DATE] Resident #20 attempted to strike Resident #21 and both fell to floor. 3. The facility failed to protect Resident #3 from abuse by Resident #20. On [DATE] Resident #20 bit Resident #3 on the thumb causing a skin tear, leading to an infection requiring treatment. 4. The facility failed to protect Resident #20 from abuse by Resident #23. On [DATE] Resident #20 was involved in an altercation with Resident #23 and Resident #23 hit Resident #20 causing him to fall. 5. The facility failed to protect Resident #20 from abuse by Resident #25. On [DATE] Resident #20 wandered into Resident #25's room and Resident #25 hit Resident #20 on the head. 6. The facility failed to protect Resident #24 from abuse by Resident #20. On [DATE] Resident #20 wandered into Resident # 24's room on the male secured unit of the facility and hit him in the face. An IJ (immediate jeopardy) was identified on [DATE] at 5:52 pm. While the IJ was removed on [DATE] at 2:45 pm, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. These failures placed all residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: 1. Record review of facility face sheet dated [DATE] indicated Resident #3 was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with a primary diagnosis of malignant neoplasm of oropharynx (type of cancer that affects the tonsils, back of the throat, tongue, or roof of the mouth), hypertension (high blood pressure), and tracheostomy status (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). Record review of a quarterly MDS dated [DATE] indicated Resident #3 was unable to complete interview for BIMS status due to rarely/never being understood. Section C for cognition indicated Resident #3 had inattention and disorganized thinking. Section E for behaviors indicated Resident #3 had no verbal or physical behaviors directed toward others. Record review of care plan dated [DATE] indicated Resident #3 required psychotropic medications for diagnosis of mood disorder and anxiety. Resident #3 had impaired cognitive function and dementia and required the secured unit due to wandering and poor safety awareness. Record review of facility incident report dated [DATE] revealed a resident-to-resident altercation that occurred between Resident #3 and Resident #20. Resident #3 was observed pushing and hitting Resident #20. Resident #3 was redirected by staff. Resident #3 then demonstrated to charge nurse that Resident #20 had tried to choke him by putting his hands around his throat. Record review of a witness statement, undated, signed by ADON J for incident on [DATE] read I, [name], entered into men's secure unit. Staff immediately stated that she had observed the two residents having an altercation. Resident [name Resident #3] began demonstrating that the other resident attempted to choke him. The other resident began calling him [Resident #3] a terrorist. Record review of a witness statement dated [DATE], signed by CNA H read I, [name], CNA was coming down the hall, saw resident going into another resident room. Staff observed Resident [name - Resident #20] guarding self from other resident. Resident [name - Resident #3] was striking the head, body blows. I separated them and redirected Resident [name - Resident #3] to room and I then pressed call light and ADON entered the unit and spoke with resident in room. Record review of a facility progress note dated [DATE] at 4:46 pm SW stated Resident #20 initiated incident and referral to Behavioral Hospital was pending. Record review of a facility progress note dated [DATE] at 3:36 am indicated that Resident #3 was bitten on the thumb by another resident when the other resident tried to enter his room and Resident #3 held up his hand to stop the other resident. The bite caused a skin tear, and the area was cleansed with wound cleanser, patted dry and bandage was applied. Record review of a facility progress note dated [DATE] at 11:48 am indicated that Resident #3's thumb was swollen, warm to touch. New order was received for Levaquin 750mg by mouth daily for 7 days. Record review of a facility progress note dated [DATE] at 4:03 pm indicated that nurse practitioner changed the order from Levaquin to Bactrim DS one tab by mouth twice daily for 7 days. Responsible party was notified. Record review of a facility progress note dated [DATE] at 9:00 pm indicated that initial dose of Bactrim DS was given at this time. Record review of a facility progress note dated [DATE] at 2:48 pm indicated that Resident #3 had completed antibiotic treatment for infection in skin/soft tissue. 2. Record review of facility face sheet dated [DATE] indicated Resident #20 was a [AGE] year-old male admitted to the facility [DATE] with the diagnosis of Alzheimer's disease. Record review of quarterly MDS dated [DATE] indicated Resident #20 had a BIMS of 9 indicating Resident #20 had moderate cognitive impairment. Section E for behaviors indicated Resident #20 wandered 1 to 3 days of previous 7 days and that he exhibited physical behaviors directed toward others 4 to 6 days but less than daily. Record review of comprehensive care plan dated [DATE] indicated that Resident #20 had physically abusive behavioral symptoms evidenced by him becoming agitated and hitting others. Also indicated that resident was not easily re-directed related to dementia/bipolar disorder. Care plan interventions included increased supervision for safety of self and others if needed. Record review of a facility incident report dated [DATE] read .The resident across the hall from [name - Resident #25] continuously goes into his room and [name - Resident #25] him [name - Resident #20] on the side of his head. [Name - Resident #25] also was screaming and cussing at the resident. Two CNAs and a nurse had to intervene . Record review of a facility progress note dated [DATE] at 10:19 pm stated .Resident across the hall wandered into another [name - Resident #25]'s room, and [name - Resident #25] got very upset and was screaming and cussing and hit the other resident (Resident #20) upside the head. When I got to the room the other resident (Resident #20) was sitting on the floor and was attempting to defend himself but did not make contact. No injuries . signed by LVN G. 3.Record review of facility face sheet dated [DATE] indicated Resident #21 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dementia. Record review of a comprehensive MDS dated [DATE] indicated Resident #21 had a BIMS of 3 indicating Resident #21 had severe cognitive impairment. Section E for behaviors indicated no behaviors directed towards others during previous 7 days. Record review of comprehensive care plan dated [DATE] indicated Resident #21 had a potential to demonstrate physical behaviors such as increased agitation and hitting/pushing others. Record review of a facility incident report dated [DATE] for Resident #21 indicated that Resident #21 attempted to block his roommate (Resident #20) from getting into their room. Resident #20 continued to try to enter room and Resident #21 attempted to forcefully move Resident #20 out from path of door. This caused both resident to exchange punches and Resident #21 fell on top of Resident #20. Record review of a facility progress note dated [DATE] at 9:30 pm indicated that Resident #20 was involved in an altercation with his roommate where he pushed his roommate (Resident #21) away from the door and Resident #21 then struck Resident #20. Both sat in the floor and Resident #20 was noted to have a 6cm (centimeter) discolored area to right elbow and a small, opened area to right wrist. 4. Record review of facility face sheet dated [DATE] indicated Resident #23 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS dated [DATE] indicated Resident #23 had a BIMS of 3 indicating severe cognitive deficit. Section E for behaviors indicated no physical behavioral symptoms directed towards others during the previous 7 days. Record review of comprehensive care plan dated [DATE] indicated Resident #23 required secured unit and was an elopement risk for wandering. Record review of a facility incident report dated [DATE] for Resident #23 indicated that resident became angry at another resident and hit him in his left side. Record review of a facility progress note dated [DATE] at 1:48 pm for Resident #20 indicated that Resident #20 was on the secured unit when he was hit in his left side by another resident (Resident #23). Record review of a witness statement dated [DATE] and signed by CNA F read .I, [name], CNA, was working C hall today and I was making Mr. [name - Resident #23]'s bed. And as I was making Mr. [name - Resident #20] came to talk to me. He didn't come in the room. He was just standing outside the door. Mr. [name - Resident #23] came up to Mr. [name - Resident #20] and cold cock him in the side and knock him to his knees. And then started to grab his arm and tried to drag him. I to Mr. [name - Resident #23] to stop and went and got the nurse from the nursing station. Ms. [name] the nurse came and got Mr. [name - Resident #20] and brung (brought) him to the nursing station. Everything I stated is true to my knowledge . 5. Record review of facility face sheet dated [DATE] indicated Resident #25 was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS dated [DATE] indicated Resident #25 had a BIMS score of 3, indicating severe cognitive impairment. Section E for behaviors indicated no physical or verbal behaviors directed at others in the previous 7 days. Record review of comprehensive care plan dated [DATE] and edited on [DATE] indicated Resident #25 had a diagnosis of schizophrenia and it could possibly alter his mood, resulting in violent behaviors towards himself, peers, or others. Care plan also indicated that Resident #25 had a history of hitting another resident for repeatedly coming in and out of his room and he was easily agitated. Record review of a facility incident report dated [DATE] for Resident #25 indicated that the resident across the hall from Resident #25 continuously went into his room and Resident #25 hit him (Resident #20) on the side of his head. Resident #25 also was screaming and cussing at the resident. Two CNAs and a nurse had to intervene. During an observation on [DATE] at 12:00 pm of male secured unit, multiple residents were gathered in common area of unit. No altercations or behaviors seen at this time. During an observation on [DATE] at 11:00 am Resident #20 was sitting in a wheelchair at nurses' station, 1:1 sitter observed standing next to him. No aggressive behaviors observed at this time. Resident remains on 1:1 supervision due to agitation, aggressive behaviors and exit-seeking. During an observation on [DATE] at 10:20 am Resident #25 was observed lying in bed watching TV. He said that he was treated well and said that no one had ever been mean to him. During an observation on [DATE] at 10:25 am Resident #21 was observed ambulating in men's secure unit. He said that he was treated well. Denied anyone having ever been mean to him and did not remember any incidents. During an observation on [DATE] at 10:35 am Resident #23 was observed lying in bed, pleasantly confused. He said that he was treated well. He said that no one had ever been mean to him. He said that he had been here for years, and he cannot remember how long. During an observation on [DATE] at 10:42 am, Resident #24 was observed lying in bed. He denied that he was Resident #24. Staff (CNA E) confirmed that he was indeed Resident #24. He was unable to answer questions appropriately. Resident #3 was not observed during investigation due to being discharged from the facility on [DATE] and expired in the hospital due to an unrelated condition. During an interview with DON on [DATE] at 02:00 pm she stated that she had been employed as the DON since [DATE], and could not comment on any altercations that had occurred before that date. She said that Resident #20 now had an around the clock 1 on 1 sitter with him to prevent his wandering and any resident-to-resident altercations. 1 on 1 monitoring began on [DATE] during the day shift and on [DATE] was increased to round the clock. During an interview with Administrator on [DATE] at 1:15 pm she said that their plan now if the sitter needs to take a break was for the sitter to call the nurses station using a phone or the call light and another staff member must come to sit with resident until sitter can return. She said that Resident #20 had been put on 1:1 on day shift on [DATE] and it was increased to 24 hours a day on [DATE]. Attempted a telephone interview with CNA D on [DATE] at 3:07 pm, who was the 1:1 sitter who was on duty [DATE], the night of the altercation between Resident #20 and Resident #24. Received a message saying that the mailbox was full and was unable to leave a voicemail. A text message was sent asking for a return phone call to surveyor's state phone number. No return call was received before exiting the facility on [DATE]. During a telephone interview on [DATE] at 3:10 pm, CNA A said that on [DATE] she had just finished a round in the male secure unit, and when she came out into the hall, she heard a clapping noise and when she went into Resident #24's room, she saw Resident #20 standing over him, hitting him in the face and upper body area. She said that she was not told that Resident #20 required 1:1 monitoring until after the incident occurred. Record review of a facility policy titled Wandering and Elopements dated [DATE] read .The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care . Record review of a facility policy titled Abuse Prevention Program revised on [DATE] read .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Record review of a facility policy titled Resident Rights dated 2001 and revised February 2021 read .Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect. misappropriation of property, and exploitation . The facility Administrator was notified on [DATE] at 5:52 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on [DATE] at 10:54 AM and included: (Immediate) Action: Resident #20 has been put on continuous 1:1 on [DATE] and has remained on 1:1, without fail, since the [DATE] incident. Resident #3 no longer resides at [name] Healthcare Center. Residents #21, #24, and #25 have received a safe survey or skin assessment (if unable to verbalize concerns). The sitter that brought Resident #20 to the secured unit on the night of [DATE] was a temporary staff member (agency) and have been placed on the do not return list and has not worked since [DATE]. The facility is actively seeking alternate placement for Resident #20. Resident #20 will remain on 1:1 until deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. The discontinuation of the 1:1 will be documented in the resident's medical record. (See below action item) Person(s) Responsible: Administrator and Director of Nursing Date: [DATE]; [DATE] by 5:00PM (Identification) Action: Cognitive residents have received a safe survey to include: 1. Do you enjoy living at [name] Healthcare? 2. Do you feel safe at [name] Healthcare? 3. Are you afraid of any residents or staff? 4. Have you ever been hit, slapped, kicked, pinched, etc. by anyone at [name] Healthcare? If so, who and how long ago? Resident Education: Your abuse coordinator is your administrator; you should report any abuse or neglect immediately to your Abuse Coordinator. Her phone number is posted if she is not present. You can also report any abuse or wrong treatment to any staff, and they will let the Abuse Coordinator immediately know. Any residents unable to answer due to level of cognition received head-to-toe skin assessments (no concerns identified) Person(s) Responsible: Social Services, Director of Nursing, and/or Designee Date: Started/Finished [DATE] by 5PM-[DATE] by 3:15PM (Prevention) Action: All staff educated over the following: Following a Resident-to-Resident Altercation the aggressor will immediately be placed on 1:1. When you are assigned to 1:1 you will remain with the resident 1:1 until you are relieved, and someone takes over for you. You cannot leave a resident requiring 1:1 alone, no exceptions. If you require a break, you must find someone to 1:1 the resident until you return. 1:1 can be defined as within arm's length from the resident when residents are in common areas and within eyesight when residents are in their rooms. 1:1 is in place to ensure overall safety for the resident and other residents residing in [name] Healthcare Center. At no time is it appropriate to place a resident on the secured unit that has not been deemed appropriate by the IDT. Resident can only come off 1:1 when deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. Key Takeaway: Employees will understand 1:1, what it entails, and the expectations of 1:1 observation/intervention. Abuse & Neglect Key Takeaway: Employees will understand resident to resident altercations can be considered abuse and must be reported to the abuse coordinator immediately to ensure timely response to the allegation. Resident to Resident Altercations Key Takeaway: Employees will understand the steps to follow as a result of a resident-to-resident altercation (immediately separate, ensure resident safety, notify the abuse coordinator, Charge Nurse- notify the MD or MD extender-follow orders given, put interventions in place/ensure they are care planned). All staff shall be educated prior to working their next scheduled shift. All temporary and new staff will be educated prior to working their first/next shift. Person(s) Responsible: Director of Nursing, Administrator, and/or Designee Date: Started [DATE]-Completed [DATE] @ 5PM (Monitoring) Action: Clinical Meeting to include Event Report Review x5 days, Monday-Friday, Monday to encompass Friday-Sunday events. Date: Event Reports Review: Any Resident-to-Resident Altercations? Any other reportable events? **Has this been reported to HHSC & an investigation initiated?** 1.MD Notified? 2. RP Notified? 3. Documentation/Follow-Up? 1. What interventions have been initiated? 2. Care Plan updated? 3. Assessments Completed? This action will ensure that events are investigated, reported (if applicable), prevented (to the best of our abilities), and corrected. Person(s) Responsible: Director of Nursing and/or Designee Date/Time: Initiated [DATE] by 10AM and will continue to be documented x4 weeks Action: The facility has established a 1:1 policy following each resident to resident altercation in which can only be discontinued by 1 of the following options: Resident can only come off 1:1 when deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. The discontinuation of the 1:1 will be documented in the resident's medical record. This action item has been discussed with the Medical Director and he is agreeable with the policy change. Person(s) Responsible: [NAME] President of Clinical Services and/or Administrator Date/Time: [DATE] @ 10PM Action: Ad Hoc QAPI performed with Medical Director to notify him/her of the IJ Template and to share the Plan of Removal. MD has no additional steps to perform at this time. Person(s) Responsible: Administrator, Director of Nursing, and Medical Director Date: [DATE] by 6:45PM On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: 1. Residents #21, #24, and #25 have received a safe survey or skin assessment (if unable to verbalize concerns). - 2 safe and 1 skin assessment reviewed on [DATE]. 2. The facility was actively seeking alternate placement for Resident #20. - SW notes reviewed on [DATE]. 3. Resident #20 will remain on 1:1 until deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. - Attestation reviewed on [DATE]. 4. Cognitive residents have received a safe survey. - X38 safe surveys or skin assessments reviewed on [DATE] 5. Staff In-services: a. Following a Resident-to-Resident Altercation the aggressor will immediately be placed on 1:1. - x43 signatures reviewed on [DATE]. b. When you are assigned to 1:1 you will remain with the resident 1:1 until you are relieved, and someone takes over for you. - X44 signatures reviewed on [DATE]. c. You cannot leave a resident requiring 1:1 alone, no exceptions. - X44 signatures on [DATE]. d. If you require a break, you must find someone to 1:1 the resident until you return. - X44 signatures reviewed on [DATE]. e. 1:1 can be defined as within arm's length from the resident when residents are in common areas and within eyesight when residents are in their rooms. - X44 signatures reviewed on [DATE]. f. 1:1 is in place to ensure overall safety for the resident and other residents residing in [name] Healthcare Center. - X44 signatures reviewed on [DATE]. g. At no time is it appropriate to place a resident on the secured unit that has not been deemed appropriate by the IDT. - X44 signatures reviewed on [DATE]. h. Resident can only come off 1:1 when deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. - x43 signatures reviewed on [DATE]. 6. Clinical Meeting to include Event Report Review x5 days, Monday-Friday, Monday to encompass Friday-Sunday events. - Monitoring tool reviewed on [DATE]. 7. The facility has established a 1:1 policy following each resident to resident altercation in which can only be discontinued by 1 of the following options: Resident can only come off 1:1 when deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. Resident to resident altercation policy revised [DATE] reviewed on [DATE]. 8. Ad Hoc QAPI performed with Medical Director to notify him/her of the IJ Template and to share the Plan of Removal. [DATE] at 6:33pm including medical director; reviewed on [DATE]. During interviews on [DATE] between the times of 1:00 pm and 2:30 pm, the following staff were able to appropriately voice understanding resident to resident altercations, when to report, and 1:1 monitoring. Nurses- 4-LVN's and 2-RN's (LVN B, LVN K, RN L, LVN M, ADON, and DON); CNA's- 4-CNA's (CNA E, CNA N, CNA O, and CNA P); MA's - 1 MA (MA Q); and Other- 3 (DA R, Activity Director, and BOM/HR). The Administrator was informed that the Immediate Jeopardy was removed on [DATE] at 2:45 pm.; however, the facility remained out of compliance at a severity level of actual harm that is not an immediate jeopardy and scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 5 of 6 residents (Resident #3, Resident #20, Resident #21, Resident #23, and Resident #24) reviewed for incidents. The facility failed to implement their abuse policy and program to prevent abuse when: 1. On 6/5/23 Resident #20 tried to choke Resident #3. 2 On 6/14/23 Resident #20 attempted to strike Resident #21 and both fell to floor. 3.On 6/14/23 Resident #20 bit Resident #3 on the thumb causing a skin tear, leading to an infection requiring treatment. This incident was not investigated or reported. 4.On 6/20/23 Resident #20 was involved in an altercation with Resident #23 and Resident #23 hit Resident #20 causing him to fall. 5. On 8/21/23 Resident #20 wandered into Resident #25's room and Resident #25 hit Resident #20 on the head. 6. On 9/18/23 Resident #20 wandered into Resident # 24's room on the male secured unit of the facility and hit him in the face. An IJ (immediate jeopardy) was identified on 10/24/2023 at 5:52 pm. While the IJ was removed on 10/25/2023 at 2:45 pm, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. These deficient practices affected all residents and contributed to further abuse. Findings included: 1. Record review of facility face sheet dated 10/20/23 indicated Resident #3 was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with a primary diagnosis of malignant neoplasm of oropharynx (type of cancer that affects the tonsils, back of the throat, tongue, or roof of the mouth), hypertension (high blood pressure), and tracheostomy status (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). Record review of a quarterly MDS dated [DATE] indicated Resident #3 was unable to complete interview for BIMS status due to rarely/never being understood. Section C for cognition indicated Resident #3 had inattention and disorganized thinking. Section E for behaviors indicated Resident #3 had no verbal or physical behaviors directed toward others. Record review of care plan dated 05/10/2023 indicated Resident #3 required psychotropic medications for diagnosis of mood disorder and anxiety. Resident #3 had impaired cognitive function and dementia and required the secured unit due to wandering and poor safety awareness. Record review of facility incident report dated 06/05/2023 revealed a resident-to-resident altercation that occurred between Resident #3 and Resident #20. Resident #3 was observed pushing and hitting Resident #20. Resident #3 was redirected by staff. Resident #3 then demonstrated to charge nurse that Resident #20 had tried to choke him by putting his hands around his throat. Record review of a witness statement, undated, signed by ADON J for incident on 6/5/23 read I, [name], entered into men's secure unit. Staff immediately stated that she had observed the two residents having an altercation. Resident [name Resident #3] began demonstrating that the other resident attempted to choke him. The other resident began calling him [Resident #3] a terrorist. Record review of a witness statement dated 6/5/23, signed by CNA H read I, [name], CNA was coming down the hall, saw resident going into another resident room. Staff observed Resident [name - Resident #20] guarding self from other resident. Resident [name - Resident #3] was striking the head, body blows. I separated them and redirected Resident [name - Resident #3] to room and I then pressed call light and ADON entered the unit and spoke with resident in room. Record review of a facility progress note dated 6/5/23 at 4:46 pm SW stated Resident #20 initiated incident and referral to Behavioral Hospital was pending. Record review of a facility progress note dated 6/15/23 at 3:36 am indicated that Resident #3 was bitten on the thumb by another resident when the other resident tried to enter his room and Resident #3 held up his hand to stop the other resident. The bite caused a skin tear, and the area was cleansed with wound cleanser, patted dry and bandage was applied. Record review of a facility progress note dated 6/18/23 at 11:48 am indicated that Resident #3's thumb was swollen, warm to touch. New order was received for Levaquin 750mg by mouth daily for 7 days. Record review of a facility progress note dated 6/18/23 at 4:03 pm indicated that nurse practitioner changed the order from Levaquin to Bactrim DS one tab by mouth twice daily for 7 days. Responsible party was notified. Record review of a facility progress note dated 6/18/23 at 9:00 pm indicated that initial dose of Bactrim DS was given at this time. Record review of a facility progress note dated 6/25/23 at 2:48 pm indicated that Resident #3 had completed antibiotic treatment for infection in skin/soft tissue. 2. Record review of facility face sheet dated 7/11/2023 indicated Resident #20 was a [AGE] year-old male admitted to the facility 05/24/23 with the diagnosis of Alzheimer's disease. Record review of quarterly MDS dated [DATE] indicated Resident #20 had a BIMS of 9 indicating Resident #20 had moderate cognitive impairment. Section E for behaviors indicated Resident #20 wandered 1 to 3 days of previous 7 days and that he exhibited physical behaviors directed toward others 4 to 6 days but less than daily. Record review of comprehensive care plan dated 10/17/2023 indicated that Resident #20 had physically abusive behavioral symptoms evidenced by him becoming agitated and hitting others. Also indicated that resident was not easily re-directed related to dementia/bipolar disorder. Care plan interventions included increased supervision for safety of self and others if needed. Record review of a facility incident report dated 8/21/23 read .The resident across the hall from [name - Resident #25] continuously goes into his room and [name - Resident #25] him [name - Resident #20] on the side of his head. [Name - Resident #25] also was screaming and cussing at the resident. Two CNAs and a nurse had to intervene . Record review of a facility progress note dated 8/21/23 at 10:19 pm stated .Resident across the hall wandered into another [name - Resident #25]'s room, and [name - Resident #25] got very upset and was screaming and cussing and hit the other resident (Resident #20) upside the head. When I got to the room the other resident (Resident #20) was sitting on the floor and was attempting to defend himself but did not make contact. No injuries . signed by LVN G. 3.Record review of facility face sheet dated 10/25/2023 indicated Resident #21 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dementia. Record review of a comprehensive MDS dated [DATE] indicated Resident #21 had a BIMS of 3 indicating Resident #21 had severe cognitive impairment. Section E for behaviors indicated no behaviors directed towards others during previous 7 days. Record review of comprehensive care plan dated 10/24/2023 indicated Resident #21 had a potential to demonstrate physical behaviors such as increased agitation and hitting/pushing others. Record review of a facility incident report dated 6/14/23 for Resident #21 indicated that Resident #21 attempted to block his roommate (Resident #20) from getting into their room. Resident #20 continued to try to enter room and Resident #21 attempted to forcefully move Resident #20 out from path of door. This caused both resident to exchange punches and Resident #21 fell on top of Resident #20. Record review of a facility progress note dated 6/14/23 at 9:30 pm indicated that Resident #20 was involved in an altercation with his roommate where he pushed his roommate (Resident #21) away from the door and Resident #21 then struck Resident #20. Both sat in the floor and Resident #20 was noted to have a 6cm (centimeter) discolored area to right elbow and a small, opened area to right wrist. 4. Record review of facility face sheet dated 10/25/2023 indicated Resident #23 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS dated [DATE] indicated Resident #23 had a BIMS of 3 indicating severe cognitive deficit. Section E for behaviors indicated no physical behavioral symptoms directed towards others during the previous 7 days. Record review of comprehensive care plan dated 10/18/2023 indicated Resident #23 required secured unit and was an elopement risk for wandering. Record review of a facility incident report dated 6/20/23 for Resident #23 indicated that resident became angry at another resident and hit him in the left side. Record review of a facility progress note dated 6/20/23 at 1:48 pm for Resident #20 indicated that Resident #20 was on the secured unit when he was hit in his left side by another resident (Resident #23). Record review of a witness statement dated 6/20/23 and signed by CNA F read .I, [name], CNA, was working C hall today and I was making Mr. [name - Resident #23]'s bed. And as I was making Mr. [name - Resident #20] came to talk to me. He didn't come in the room. He was just standing outside the door. Mr. [name - Resident #23] came up to Mr. [name - Resident #20] and cold cock him in the side and knock him to his knees. And then started to grab his arm and tried to drag him. I to Mr. [name - Resident #23] to stop and went and got the nurse from the nursing station. Ms. [name] the nurse came and got Mr. [name - Resident #20] and brung (brought) him to the nursing station. Everything I stated is true to my knowledge . 5. Record review of facility face sheet dated 10/25/2023 indicated Resident #25 was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS dated [DATE] indicated Resident #25 had a BIMS score of 3, indicating severe cognitive impairment. Section E for behaviors indicated no physical or verbal behaviors directed at others in the previous 7 days. Record review of comprehensive care plan dated 8/23/23 and edited on 10/24/2023 indicated Resident #25 had a diagnosis of schizophrenia and it could possibly alter his mood, resulting in violent behaviors towards himself, peers, or others. Care plan also indicated that Resident #25 had a history of hitting another resident for repeatedly coming in and out of his room and he was easily agitated. Record review of a facility incident report dated 8/21/23 for Resident #25 indicated that the resident across the hall from Resident #25 continuously went into his room and Resident #25 hit him (Resident #20) on the side of his head. Resident #25 also was screaming and cussing at the resident. Two CNAs and a nurse had to intervene. Record review of Resident #20's electronic medical record revealed that he was not transferred to a behavioral hospital until 7/5/23. Resident #20 was not put on 1 on 1 monitoring until 9/8/23 on a 24-hour continuous basis. During an observation on 10/17/23 at 12:00 pm of male secured unit, multiple residents were gathered in common area of unit. No altercations or behaviors seen at this time. During an observation on 10/17/23 at 11:00 am Resident #20 was sitting in a wheelchair at nurses' station, 1:1 sitter observed standing next to him. No aggressive behaviors observed at this time. Resident remains on 1:1 supervision due to agitation, aggressive behaviors and exit-seeking. During an observation on 10/26/23 at 10:20 am Resident #25 was observed lying in bed watching TV. He said that he was treated well and said that no one had ever been mean to him. During an observation on 10/26/23 at 10:25 am Resident #21 was observed ambulating in men's secure unit. He said that he was treated well. Denied anyone having ever been mean to him and did not remember any incidents. During an observation on 10/26/23 at 10:35 am Resident #23 was observed lying in bed, pleasantly confused. He said that he was treated well. He said that no one had ever been mean to him. He said that he had been here for years, and he cannot remember how long. During an observation on 10/26/23 at 10:42 am, Resident #24 was observed lying in bed. He denied that he was Resident #24. Staff (CNA E) confirmed that he was indeed Resident #24. He was unable to answer questions appropriately. Resident #3 was not observed during investigation due to being discharged from the facility on 9/2/23 and expiring in the hospital. During an interview with DON on 10/18/23 at 02:00 pm she stated that she had been employed as the DON since July 11, 2023, and could not comment on any altercations that had occurred before that date. She said that Resident #20 now had an around the clock 1 on 1 sitter with him to prevent his wandering and any resident-to-resident altercations. Resident had 1 on 1 monitoring initiated on 9/7/23 during the day shift and 1 on 1 monitoring was increased to 24 hours on 9/8/23. During an interview with Administrator on 10/24/23 at 1:15 pm she said that their plan now if the sitter needs to take a break was for the sitter to call the nurses station using a phone or the call light and another staff member must come to sit with resident until sitter can return. She said that Resident #20 had been put on 1:1 on day shift on 9/7/23 and on 9/8/23 it was increased to 24 hours a day. She said regarding the biting incident with Resident #20 and Resident #3, that it had not been reported to her until the next day in stand-up meeting at approximately 9am. The incident had happened at 1:50 am on 6/15/23. She said that she thought she had reported the incident but apparently had only reported another incident that occurred that same day. She said that she had now reported the incident and would do an investigation. She said that risks to residents could include that they may need to go out or get first aid if incidents are not reported. She verbalized no other possible risks regarding failure to report abuse timely or do an investigation. Attempted a telephone interview with CNA D on 10/24/23 at 3:07 pm, who was the 1:1 sitter who was on duty 9/18/21, the night of the altercation between Resident #20 and Resident #24. Received a message saying that the mailbox was full and was unable to leave a voicemail. A text message was sent asking for a return phone call to surveyor's state phone number. No return call was received before exiting the facility on 10/26/2023. During a telephone interview on 10/24/2023 at 3:10 pm, CNA A said that on 9/18/2023 she had just finished a round in the male secure unit, and when she came out into the hall, she heard a clapping noise and when she went into Resident #24's room, she saw Resident #20 standing over him, hitting him in the face and upper body area. She said that she was not told that Resident #20 required 1:1 monitoring until after the incident occurred. Record review of a facility policy titled Wandering and Elopements dated 9/1/23 read .The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care . Record review of a facility policy titled Abuse Prevention Program revised on 1/9/23 read .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . and .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and /or injuries of unknown origin source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by Center management. Findings of abuse will also be reported . and .the administration will: 6. Investigate and report any allegations of abuse within timeframes as required by federal requirements . Record review of a facility policy titled Resident Rights dated 2001 and revised February 2021 read .Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect. misappropriation of property, and exploitation . The facility Administrator was notified on 10/24/23 at 5:52 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 10/25/23 at 10:54 AM and included: 1. (Immediate) Action: The facility initiated a self-report and investigation for a resident-to-resident incident of abuse that occurred on 6/15/2023 for Resident #20 biting Resident #3's thumb. Intake has been received and worked. 2. Review all Resident-to-Resident incidents that have occurred in the previous 90-days to ensure the MD and RP were notified, that interventions were placed in the care plan, that the documentation shows the interventions that have been put into place are effective, and that the incidents were reported to HHSC/investigated. Any concerns noted will be updated, added, and/or notified immediately. 3. Educate Administrator and Director of Nursing: Self Reports will be submitted per the Provider Letter 19-17 & SOM Appendix PP 5 Day Investigations will be thorough & all supporting documentation will be documented/submitted Review all incidents daily x5 days (Monday-Friday) Everything is completed and documented that facility said would be completed. 4. Educated IDT regarding: (Department Heads) Appropriate interventions following events Care Plan Updates Notification of MD, RP, and psych services (if applicable) Documentation Review- Event Report Review, Progress Note Review, CP, and Additional Documentation (i.e.- increased supervision). 5. Educated all nurses regarding: Aggressive behaviors initiated or Received Contact the DON (Director of Nursing) if you are unsure an event needs to be completed If you complete an event or document a problem, you must complete the notification of the RP and the physician. Notify the DON to ensure the event is not reportable. If you document a problem or behavior, you must document an intervention. If you are unsure of what intervention, you must contact the DON (Director of Nursing). Ad Hoc QAPI with the Medical Director performed to inform him/her of the IJ template and our plan of action to remove the immediacy and correct the deficient practice. On 10/25/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: 1. (Immediate) Action: The facility initiated a self report and investigation for a resident-to-resident incident of abuse that occurred on 6/15/2023 for Resident #20 biting Resident #3's thumb. Intake has been received and worked. 2. Review all Resident-to-Resident incidents that have occurred in the previous 90-days to ensure the MD and RP were notified, that interventions were placed in the care plan, that the documentation shows the interventions that have been put into place are effective, and that the incidents were reported to HHSC/investigated. Any concerns noted will be updated, added, and/or notified immediately. Incidents reviewed from 7/23/-10/24/23. 3. Educate Administrator and Director of Nursing: Self Reports will be submitted per the Provider Letter 19-17 & SOM Appendix PP 5 Day Investigations will be thorough & all supporting documentation will be documented/submitted Review all incidents daily x5 days (Monday-Friday) Everything is completed and documented the facility said would be completed. Reviewed in-service signed by admin and DON. 4. Educated IDT regarding: (Department Heads) Appropriate interventions following events Care Plan Updates Notification of MD, RP, and psych services (if applicable) Documentation Review- Event Report Review, Progress Note Review, CP, and Additional Documentation (ie- increased supervision). X11 signatures 5. Educated all nurses regarding: Aggressive behaviors initiated or Received Contact the DON (Director of Nursing) if you are unsure an event needs to be completed If you complete an event or document a problem, you must complete the notification of the RP and the physician. Notify the DON to ensure the event is not a reportable. If you document a problem or behavior, you must document an intervention. If you are unsure of what intervention, you must contact the DON (Director of Nursing). X13 signatures 6. Ad Hoc QAPI with the Medical Director performed to inform him/her of the IJ template and our plan of action to remove the immediacy and correct the deficient practice. 10/24/23 at 6:33pm including medical director. During interviews on 10/25/23 during the times of 1:00 pm to 2:30 pm, the following staff were able to appropriately voice understanding resident to resident altercations, when to report, and 1:1 monitoring. Nurses- 4-LVN's and 2-RN's (LVN B, LVN K, RN L, LVN M, ADON, and DON); CNA's- 4-CNA's (CNA E, CNA N, CNA O, and CNA P); MA's - 1 MA (MA Q); and Other- 3 (DA R, Activity Director, and BOM/HR). The Administrator was informed that the Immediate Jeopardy was removed on 10/25/23 at 2:45 pm; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility Quality Assurance and Performance Improvement committee (QAPI) failed to develop and implement appropriate plans of action to correct and identify quality deficiencies for 1 of 1 facility. The facility QAPI failed to identify and implement an action plan to address multiple, resident to resident altercations, that occurred on 6/5/23, 6/14/23, 6/20/23, 8/21/23 and 9/18/23. The facility QAPI failed to identify and implement an action plan to address an elopement that occurred on 6/6/23. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 10/25/23 at 3:49 PM. While the IJ was removed on 10/26/23 at 11:45 AM, the facility remained out of compliance at a severity level of the potential for more than minimal harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for physical, mental, and psychosocial harm and at risk for not receiving appropriate care and services to prevent harm. Findings include: 1.Record review of Resident #20's face sheet undated revealed Resident #20 was a [AGE] year-old male that originally admitted to the facility on [DATE] with the most recent readmission on 7/21/23. Resident #20's diagnoses included Alzheimer's disease (progressive disease that destroys memory), bipolar disorder (mood swings and depression), and metabolic encephalopathy (a problem in the brain). Record review of Resident #20's care plan dated 10/17/23 indicated Resident #20 had behavioral symptoms and interventions included were assess whether the behavior endangers the resident and or others, when resident becomes physically abusive keep distance between resident and others. Resident #20 is at risk for elopement with interventions were to equip resident with a device that alarms when resident wanders. 2.Record review of Resident #3's face sheet undated revealed Resident #3 was a [AGE] year-old male that originally admitted to the facility on [DATE] with the most recent readmission on 8/31/23. Resident #3's diagnoses included malignant neoplasm of the oropharynx (throat cancer), major depressive disorder, tracheostomy (tube to keep airway open). Record review of Resident #3's care plan dated 1/6/23 indicated Resident #3 had behavioral symptoms and interventions included assess whether the behavior endangers the resident and or others, remove resident from other residents' rooms and unsafe situations. 3.Record review of Resident #25's face sheet undated revealed Resident #25 was an [AGE] year-old male that admitted to the facility on [DATE]. Resident #25's diagnoses included dementia with behaviors (problem with thinking), cerebral infarction (stroke), and bipolar disorder (mood swings and depression). Record review of Resident #25's care plan dated 8/23/23 revealed Resident #25 had a problem with mood and interventions included staff will monitor Resident #25's mood and interactions with peers and others to intervene when indicated and notify psych services for med reviews to assist in managing his mood and behaviors. 4. Record review of Resident #24's face sheet undated revealed Resident #24 was a [AGE] year-old male that originally admitted to the facility on [DATE] with the most recent readmission on 5/17/23. Resident #24's diagnoses included Schizophrenia (affects a person's ability to think, feel, and behave clearly), dementia with behaviors (problem with thinking). Record review of Resident #24's care plan dated 5/21/23 revealed Resident #24 had behavioral symptoms and interventions included assess whether the behavior endangers the resident and or others. Intervene if necessary. 5. Record review of Resident #21's face sheet undated revealed Resident #21 was a [AGE] year-old male that admitted to the facility on [DATE]. Resident #21's diagnoses included dementia with behaviors (problem with thinking), impulse disorder, and anxiety. Record review of Resident #21's care plan dated 5/21/23 revealed Resident #24 had behavioral symptoms and interventions included staff will monitor me and report changes in exit seeking behaviors to the facility Administrator, Director of Nursing, Physician, and responsible party. Record review of event report dated 6/5/23 indicated Resident #20 attempted to choke Resident #3. Record review of event report dated 6/6/23 indicated Resident #20 eloped from the male secured unit. Record review of event report dated 6/14/23 indicated Resident #20 attempted to strike Resident #21 and both fell to the floor. Record review of event report dated 6/14/23 indicated Resident #20 bit Resident #3 on the thumb. Record review of event report dated 6/20/23 indicated Resident #21 hit Resident #20 causing him to fall. Record review of event report dated 8/21/23 indicated Resident #25 hit Resident #20. Record review of event report dated 9/18/23 indicated Resident #20 hit Resident #24. Review of the monthly QAPI meeting minutes provided by the facility indicated a QAPI meeting was held on 7/3/23 which covered the month of June 2023. Further review of the QAPI minutes revealed no issues or care area concerns were identified related to resident elopement. Two self-reports for resident-to-resident abuse were identified with no plan of action to address resident to resident altercations. Review of the monthly QAPI meeting minutes provided by the facility indicated a QAPI meeting was held on 9/1/23 which covered the month of August 2023. Further review of the QAPI minutes revealed no issues or care area concerns were identified related to resident elopement. No issues or care area concerns were identified related to resident-to-resident abuse, and no plan of action to address resident to resident altercations. Review of the monthly QAPI meeting minutes provided by the facility indicated a QAPI meeting was held on 10/3/23 which covered the month of September 2023. Further review of the QAPI minutes revealed no issues or care area concerns were identified related to resident elopement. No issues or care area concerns were identified related to resident-to-resident abuse, and no plan of action to address resident to resident altercations. Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revised February 2023, indicated, The facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents .The objectives of the QAPI Program are to: Provide a means to measure current and potential indicators for outcomes of care and quality of life .Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators .establish systems through which to monitor and evaluate corrective actions. Implementation: The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process included A. Tracking and measuring performance. B. Establishing goals and thresholds for performance measurement. C. Identifying and prioritizing quality deficiencies. D. Systematically analyzing underlying causes of systemic quality deficiencies. E. Developing and implementing corrective action or performance improvement activities. F. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. During an interview on 10/24/23 at 10:54 AM, the DON said she had worked at the facility since July 2023, and said she is part of the QAPI process. She said the QAPI meeting is held monthly and as needed. The DON said they have discussed resident to resident altercations in QAPI meetings. She said Resident #20 had been a topic and discussed alternated placement for him. She said since she has worked at the facility Resident #20 had been the only resident to resident altercation that had been discussed. The DON said they had not discussed elopement since she has worked at the facility. She said she was not aware of any performance improvement plans but if there were any the Administrator would have them in her office. During an interview on 10/24/23 at 11:15 AM, the Administrator said during QAPI meetings each department head brought up topics they felt needed to be addressed. This was the facility's process for identifying areas of concern. She said if any new issues or concerns were identified they come up with a performance improvement plan. She said they discuss any resident-to-resident altercations if there are any reports. She said they discussed finding alternate placement for Resident #20, and Resident #3. The Administrator said they had not discussed any elopements in the QAPI meetings. She said they had not done any performance improvement plans on resident-to-resident altercations or elopement. The facility Administrator was notified on 10/25/23 at 3:49 PM, that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 10/26/23 at 10:29 AM and included: 1. Resident #20 has been put on continuous 1:1 on 9/18/2023 and has remained on 1:1, without fail, since the 9/18/2023 incident. Resident #3 no longer resides at [NAME] Healthcare Center. Residents #21, #24, and #25 have received a safe survey or skin assessment (if unable to verbalize concerns). The sitter that brought resident #20 was a temporary staff member (agency) and have been placed on the do not return list and has not worked since 9/18/2023. The facility is actively seeking alternate placement for Resident #20. Resident #20 will remain on 1:1 until deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. The discontinuation of the 1:1 will be documented in the resident's medical record. (See below action item) 2. Administrator and Director of Nurses provided a copy of the State Operations Manual, Appendix PP for 867 lining out the regulations, expectations, and elements of non-compliance. 3. The Interdisciplinary Committee IDT, including the Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Human Resources, Maintenance Director, Dietary Manager, Director of Rehab, and Activity Director, educated regarding the Quality Assurance Performance Improvement QAPI Policy. The IDT should understand that issues, concerns, problems, patterns, and non-compliance identified throughout their departments, and the entirety of the nursing home, should be brought to the QAPI meeting, at minimum monthly. At this time, the IDT as a whole will develop an action plan to correct the issue, concern, problem, patterns, and non-compliance. 4. At minimum, the Director of Nursing and/or Administrator, will identify issues such as resident to resident altercations and elopements through the daily meeting process/clinical meeting and will implement interventions/ensure interventions are implemented, to assist in the reduction or elimination of these incidents occurring/reoccurring. These interventions will be documented in the resident's medical record. Clinical Meeting to include Event Report Review x5 days, Monday-Friday, Monday to encompass Friday-Sunday events. Event Reports Review: Any Resident-to-Resident Altercations? Any other reportable events? **Has this been reported to HHSC & an investigation initiated? ** 1.MD Notified? 2. RP Notified? 3. Documentation/Follow-Up? 1.What interventions have been initiated? 2. Care Plan updated? 3. Assessments Completed? This action will ensure that events are investigated, reported (if applicable), prevented (to the best of our abilities), and corrected. Person(s) Responsible: Director of Nursing and/or Designee Date/Time: Initiated 10/23/2023 by 10AM and will continue to be documented x4 weeks. 5. Ad Hoc QAPI meeting performed with Medical Director regarding the template and plan of removal for the immediate jeopardy called for F-867: QAPI/QAA Improvement Activities. On 10/26/23 between 10:29 AM and 11:45 AM, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Record review of in-service dated 10/25/23 titled I have received a copy of the SOM appendix PP for 867 lining out the regulations/key elements for noncompliance signed by the Administrator and DON. Record review of in-service dated 10/25/23 titled QAPI: it is the IDT's responsibility to identify and provide interventions with incidents and deficient practices signed by the Administrator, DON, HR, Maintenance Director, Social Worker, ADON, DOR, Housekeeping Supervisor, Dietary Manager, and Activity Director. Record review of daily monitoring tool titled Event Report Review to be used in the daily clinical meeting 5 days a week. Record review of Ad Hoc QAPI meeting performed 10/25/23 with the following attendees: Administrator, Social Worker, DON, Medical Director, Housekeeping Supervisor, Dietary Manager, and ADON. During interviews on 10/26/23 between 10:29 AM and 11:45 AM the following members of the IDT were able to appropriately verbalize understanding of the QAPI process: Administrator, DON, ADON, Social Worker, Dietary Manager, HR, Maintenance Director, Housekeeping Supervisor, and DOR. On 10/26/23 at 11:45 AM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of the potential for more than minimal harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for one (Resident #3) of nine residents reviewed for a change of condition. The facility failed to notify the physician of a change in condition for Resident #3 after he had thick hardened secretions that could not be removed from his tracheostomy on [DATE] at 10:51 PM. Resident #3 was transported to the hospital in cardiac arrest and later passed away. An Immediate Jeopardy was identified on [DATE] at 7:11 PM. While the Immediate Jeopardy was removed on [DATE] at 5:31 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition, and ultimately death. Findings included: Record review of Resident #3's face sheet undated revealed Resident #3 was a [AGE] year-old male that originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #3's diagnosis included malignant neoplasm of the oropharynx (throat cancer), major depressive disorder, tracheostomy (tube to keep airway open). Record review of Resident #3's quarterly MDS dated [DATE] indicated Resident #3 was rarely/never understood and a BIMS summary score was not obtained. Section O of the MDS revealed Resident #3 had received trach care within the last 14 days while a resident at the facility. Record review of Resident #3's care plan dated [DATE] indicated tracheostomy supplies are to be kept at resident's bedside for immediate access in locked cart. The goal was to maintain airway patency. The approach was medication cart to consist of trach tube (one size smaller), one set of trach ties, ambu bag (artificial breathing device), suctioning kit, sterile yankers. Record review of Resident #3's medication administration record for [DATE] through [DATE], revealed Resident #3 had a physician's order for Ipratropium Albuterol sol solution; 1XXX,d+[DATE].5mg/milliliters by halation to be given as needed every 4 hours. On [DATE] the medication record indicated the medication had not been given. Record review of nurse progress note dated [DATE] at 10:51 PM written by LVN C revealed Resident #3 allowed nurse to suction trach and was very hard to insert the suction tube, the nurse educated Resident #3 that he had to take the breathing treatments and allow other nurses to do trach care so the trach will not be clogged up. LVN C indicated that the DON was updated on the matter. Record review of nurse progress note dated [DATE] at 6:21 PM written by RN D: Resident was lying on the floor on the unit. The aid on the unit stated that he purposely laid down. Observed stridor (high-pitched respiratory sound) in resident. Attempted to clear mucus plug from resident's trach without success. Resident became unconscious and CPR was started while another nurse called 911. 1st responders arrived in minutes and assisted with CPR while the ambulance was in route. CPR was continued and resident was sent to the hospital at 7:25 PM. Contacted resident EC and left message to call the facility. Also contacted NP, DON, Administrator. Resident's EC returned call and was notified of resident's event and that he is in route to the hospital. Record review of hospital records dated [DATE] at 1:04 PM written by Hospital MD revealed Resident #3 admitted with out-of-hospital arrest, asystolic arrest, and etiology is likely hypoxic arrest. Resident #3 was noted with mucous plug, which has previously been prone to mucous plug noted in 2022. This would have resulted in hypoxic arrest which usually presents as PEA arrest, but after prolonged hypoxia/anoxia, would result in asystolic arrest. True downtime is unclear at this time. Record review of nurse progress note dated [DATE] at 8:10 AM indicated the case manager at the hospital called and spoke with nurse with disposition on resident. Family had a meeting with physician and decided to stop all life sustaining measures on [DATE]. Case Manager went on to state, Resident with no brain activity @ 1:40pm, and at 5:10pm was pronounced with no cardiac activity. During an interview on [DATE] at 9:15 AM the RP said she had received a call from the facility stating that Resident #3 had a mucus plug in his tracheostomy that the nurse was unable to remove. She said Resident #3 was very good at taking care of his tracheostomy himself and would suction himself. She said Resident #3 would let you know when he needed to by suctioned and tracheostomy care was needed. During an interview on [DATE] at 2:03 PM LVN C said she worked with Resident #3 2 to 3 nights a week. She said Resident #3 was hard to suction on [DATE] due to hard mucus in his trach. She said Resident #3 had a lot of buildup due to Resident #3 not allowing anyone to suction his trach. LVN C said she had to use a new suction tip each time she suctioned him due to the amount of buildup of mucus in his trach. She said she used 2 suction tips and then Resident #3 did not want her to suction him anymore. LVN C said she did not administer any as needed breathing treatments. She said she did notify the DON that Resident #3 was harder to suction but that she did not notify anyone else, and said she just charted it. LVN C said Resident #3 would let you know if he felt like he couldn't breathe. During an interview on [DATE] at 2:22 PM RN AC said on [DATE] she was not the nurse taking care of Resident #3, she said it was an agency nurse that was responsible for Resident #3's care, and it was her first time at the facility, so she was helping her out by doing the nursing progress note for the incident. RN AC said she walked into the secured unit and observed Resident #3 lying on the floor and Resident #3 was in stridor (high-pitched respiratory sound). She said they got Resident #3 back to his room and she attempted to suction his trach and Resident #3 passed out. RN AC said Resident #3's secretions were very hard, and she was not able to clear them. RN AC said she began CPR on Resident #3 while another nurse called 911. During an interview on [DATE] at 4:10 PM the NP said she remembered Resident #3 and that Resident #3 refused care frequently. She said she could not recall if the nurse had called and notified her of being unable to clear thick hardened secretions from Resident #3's trach on [DATE]. Said if she had been notified, she would have given an order for a nebulizer treatment to attempt to loosen secretions and attempt 1 more suction pass to clear secretions and if unsuccessful then she would have given an order to send to the emergency room . She said she was unsure if it would have made a difference in resulting in Resident #'s death. She said that Resident #3 had significantly declined over the previous 6 months with his cancer and felt like resident would have died soon. She said she was aware that resident frequently refused care and was not complainant with his diet and peg tube. During an interview on [DATE] at 4:48 PM the Medical Director said he did not recall being called on [DATE] and notified regarding the thick hardened secretions of Resident #3's trach. He said if he would have been notified, he would have given an order for Resident #3 to be sent out to the emergency room . He said that he was aware that Resident #3 had refused care in the past. He said he could not say if being sent out to the emergency room would have made a difference in the ultimate demise of Resident #3. During an interview on [DATE] at 8:35 AM the DON said she had worked at the facility since [DATE]. She said she was not in the facility when Resident #3 went out to the hospital. She said the only notification that she received was that Resident #3 had refused to let the nurse suction him. She said that he would refuse trach care and suctioning from time to time but would later let the nurse clean and suction his trach. The DON said that the NP was aware that Resident #3 refused care at times. She said that Resident #3 never suctioned himself or cleaned his trach himself, and said it was always a nurse. The DON said she was not notified of resident's secretions being hard to suction or that there was anything wrong with his trach. Record review of facility policy dated [DATE] titled Change in a Resident's Condition or Status revealed Our facility promptly notifies the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights etc.). The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a (an): D. significant change in the resident's physical/emotional/mental condition; E. need to alter the resident's medical treatment significantly; F. refusal of treatment or medications G. need to transfer the resident to a hospital/treatment center;. 2. A significant change of condition is major decline or improvement in the resident's status that: A. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). Record review of the facility policy dated [DATE] titled Tracheostomy Care The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. General Guidelines 4. Tracheostomy tubes should be changed as ordered and as needed (at least monthly). 5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. 7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 7:11 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on [DATE] at 2:34 PM and reflected the following: Resident #3 no longer resides at the facility (discharged : [DATE]) and will not return. Action: No residents residing at the facility at this time require suctioning. Person(s) Responsible: Director of Nursing Date: [DATE] Action: Nurses educated regarding change in condition and physician notification. The charge nurse should report all signs & symptoms, obtain vital signs if possible, and give a report of assessment findings. With respiratory residents, the charge nurse should assess respirations, observe for signs of cyanosis, listen to lung sounds, note any SOB or dyspnea, check the resident's SPO2, and provide oxygen if the airway is possibly obstructed. If the resident appears to be in respiratory distress, apply oxygen and send the resident out [DATE] to be evaluated and receive treatment at the emergency department. After the resident has been transported to the ED, notify the physician and responsible party/POA of the emergent transfer secondary to the change in condition. When caring for residents with a trach, notify the physician when there are changes in the respirations, difficulty with suctioning the trach, difficulty in removing thick secretions/mucus plugs, or shortness of breath or dyspnea. Do not force the suctioning catheter into the trach during suctioning and gently rotate the catheter when withdrawing. With any issues with suctioning a resident's trach, assess the SPO2, apply oxygen if SPO2 is less than 95%, and activate [DATE] for transport to the ED for treatment. **Key Takeaway: Nurses will understand the importance of notifying and when to notify the physician immediately following the change in condition/when residents have a thick hardened secretions that are unable to be cleared with suctioning. All current nurses will be educated prior to working their next shift. All temporary and new nurses will be educated prior to working their first/next shift. Person(s) Responsible: Director of Nursing Date: [DATE] by 10AM Action: Ad Hoc QAPI performed with Medical Director to notify him/her of the IJ Template and to share the Plan of Removal. MD has no additional steps to perform at this time. Person(s) Responsible: Administrator, Director of Nursing, and Medical Director Date: [DATE] by 11:30AM On [DATE] between 2:34 PM and 5:31 PM, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Record review of in-service dated [DATE] titled Change in condition and Physician Notification revealed 19 signatures with a change in condition quiz. Record review of Ad Hoc QAPI completed on [DATE] at 10:30 AM revealed 8 signatures including the Medical Director. During interviews on [DATE] between 2:34 PM and 5:31 PM the following nurses were able to verbalize understanding of change of condition and physician notification: DON, ADON, LVN S, and RN L. On [DATE] at 5:31 pm, the Administrator, DON and corporate representatives was informed the IJ was removed; however, the facility remained out of compliance at a severity of actual harm with harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions.

Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance to prevent accidents for 3 of 3 residents reviewed for accidents/supervision (Resident #3, Resident #20, and Resident #26) in that: 1. The facility failed to provide adequate supervision to prevent resident #3's exit from the secured unit on 8/18/23 and 9/2/23. Resident #3 was able to get out of a side door when opened from other side by other staff/residents on 8/18/23 and 9/2/23. 2. The facility failed to provide adequate supervision to prevent resident #20's exit from the secured unit on 5/27/23, 6/1/23, and 6/6/23. Resident #20 was able to get out of side door to secured unit when opened from other side by staff or other residents on 5/27/23 and 6/1/23. The facility failed to ensure emergency exit doorway at end of secured unit was locked when Resident #20 eloped on 6/6/23 and was able to get outside the facility. 3. The facility failed to provide adequate supervision to prevent resident #26's exit from the secured unit on 5/28/23. Resident #26 was able to get out of a side door when opened from other side by other staff/residents on 5/28/23. 4. The facility failed to ensure a resident environment was free of accidents/hazards as possible due to not ensuring the locks were engaged on the secure unit and not ensuring that residents were adequately supervised to prevent elopements from the secured unit. An IJ (immediate jeopardy) was identified on 10/18/2023 at 7:11 pm. While the IJ was removed on 10/19/2023 at 05:31 pm, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. This failure could place all residents at risk of eloping which could lead to severe injuries or death. Findings included: During an observation of male secured unit on 10/17/23 at 12:00 pm, multiple residents were observed gathered in the common area of unit. No altercations or behaviors seen at this time. One CNA was present on the unit at this time, she was observed entering unit through side door from hallway before secured glass doorways. Side door was observed to open freely from hallway into the common area where residents were gathered but locked from inside so as not to allow residents to exit unassisted. 1. Record review of facility face sheet dated 10/20/23 indicated Resident #3 was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with a primary diagnosis of malignant neoplasm of oropharynx (type of cancer that affects the tonsils, back of the throat, tongue, or roof of the mouth), hypertension (high blood pressure), and tracheostomy status (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). Record review of a quarterly MDS dated [DATE] indicated Resident #3 was unable to complete interview for BIMS status due to rarely/never being understood. Section C for cognition indicated Resident #3 had inattention and disorganized thinking. Section E for behaviors indicated Resident #3 had no verbal or physical behaviors directed toward others. Record review of care plan dated 05/10/2023 indicated Resident #3 required psychotropic medications for diagnosis of mood disorder and anxiety. Resident #3 had impaired cognitive function and dementia and required the secured unit due to wandering and poor safety awareness. Record review of a facility progress note dated 8/18/23 at 9:22 am for Resident #3 indicated that resident got out of secured unit and went into dining room, poured himself a cup of regular coffee and ran back into the unit through the side door. Record review of a facility progress note dated 9/2/23 at 6:10 pm for Resident #3 indicated that he snuck out of unit as another resident opened the door to enter the unit. Resident #3 then went to dining room seeking food and soda, and refused to go back to the secured unit. 3 staff members tried explaining to him that he was not allowed to eat or drink anything by mouth per doctors orders because he could not swallow. He aggressively tried to get to soda machine, he became physically combative to the CN and the DON, he tried to throw an object at another resident but was stopped by the CN and DON. The resident left the dining room, went to nurses station and begain picking up objects to throw at others, began exit seeking to the front door and hallway emergency exits. Law enforcement was called by administrator. An officer responded and tried to reason with resident and was successful getting resident back to secured unit. Record review of a secured unit evaluation dated 9/1/23 for Resident #3 read .Resident remains on the secure unit due to displaying elopement behaviors. He is ambulatory and attempts to get out of the exit and secure unit doors . 2. Record review of facility face sheet dated 7/11/2023 indicated Resident #20 was a [AGE] year-old male admitted to the facility 05/24/23 with the diagnosis of Alzheimer's disease. Record review of quarterly MDS dated [DATE] indicated Resident #20 had a BIMS of 9 indicating Resident #20 had moderate cognitive impairment. Section E for behaviors indicated Resident #20 wandered 1 to 3 days of previous 7 days. Record review of comprehensive care plan dated 10/17/2023 indicated that Resident #20 wandered and was not easily re-directed related to dementia/bipolar disorder. Care plan interventions included increased supervision for safety of self and others if needed. Record review of a facility progress note dated 5/27/23 at 8:25 am for Resident #20 indicated that he had walked out of the exit door to the unit twice that morning. Record review of a facility progress note dated 6/1/23 at 8:56 am for Resident #20 indicated that he had walked off of secured mens unit and was safely redirected back to mens unit without issues. Record review of a facility progress note dated 6/6/23 at 9:43 pm for Resident #20 read .nurse notified by gesture to come to unit by other resident, other resident opens the emergency door to outside, pointing at this resident walking outside away from the facility passing the brown fence, nurse and staff rushed to resident to redirect resident back to facility, resident safely redirected, without hesitation to facility and back inside C unit. This resident previously noted to push on emergency door . signed LVN AB. Record review of a facility incident report dated 6/6/23 for Resident #20 indicated that he had gotten out the fire-exit door at the end of C-Hall and was found in the driveway outside the facility. 3. Record review of a facility face sheet dated 10/23/23 for Resident #26 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hallucinations (hearing or seeing things that are not there) and dementia. Record review of a comprehensive MDS dated [DATE] for Resident #26 indicated that he had a BIMS score of 8, which indicated that he had moderate cognitive impairment. Section E for behaviors indicated that he exhibited wandering which could place the resident at significant risk of getting to a potentially dangerous place. Record review of a comprehensive care plan dated 5/31/23 for Resident #26 indicated that he exhibited behavioral symptoms as evidenced by eloping. Interventions were to praise appropriate behavior and maintain a calm environment. Record review of a facility progress note dated 5/28/23 at 7:51 am for Resident #26 indicated that he somehow exited the secure unit with all his clothing. Skilled nursing staff attempted to redirect him, and he became combative. He insisted that staff let him go home. No documentation of how staff was able to get resident back on unit. During an attempted telephone interview on 10/18/23 at 9:09 with CNA AA who was working the night of Resident #20's elopement from facility there was no answer and no option to leave a voicemail. During a telephone interview on 10/18/23 at 10:03 am LVN AB said that Resident #20 got out the end emergency door. She said when she entered the unit the alarm was sounding on the unit, but she could not hear the alarm at the nurse's station. She said that she did not recall seeing any other staff on the unit, but they may have been in a room. She said that this resident had been trying to get out for some time. She did not remember any interventions that were put into place. She said that she has not worked here in about 2 months and does not remember any other residents being able to get off unit while she was there. She said that this was the only time that a resident had gotten outside facility while she was there. She cannot remember if she was the nurse assigned to the unit that night, or if she just happened to be the one to notice the other resident gesturing for help. During an interview with DON on 10/18/23 at 10:20 am, she said she had been employed since July 11, 2023, as the DON. She said that she cannot comment on any specifics in this incident since it was before her employment, but she did say that she only considers it an elopement if the resident gets outside of the facility. She was not here when the elopement occurred. She said that he was not a resident at the time that she started as he was out to a behavioral hospital at that time. She said that normal procedures for an elopement would be that they would call the code, start searching, maintenance would usually go out and sweep the premises, including cars and parking lot, and if unable to find the missing resident, they would widen the search area. Once they found the resident, they would notify physician, responsible party, and DON, then do a reportable for state. They would check to make sure all systems were in place and functioning properly. During an observation and interview on 10/18/23 at 11:00 am the male secure unit end door revealed that it did not open with a 15 second delayed egress. The door did not alarm as it was pushed on. The DON had to go find the code to open the door, it took her about 5 minutes to go and find the code and come back to open the door. She did not know the code previously. She said that it had recently been changed and she did not know it. When she entered the code, the door unlocked and when opened, there was only a single door chime, like a doorbell chime, that could only be heard on C hall, not in entire facility. CNA Y on male unit also did not know the code to open the door. Patio door inside C hall dining room for male secured unit also did not open with a 15 second egress and had to have code entered, DON entered code. During an interview on 10/18/23 at 12:20 pm Administrator said that she did not remember exactly how Resident #20 got out but does remember it being reported to her that he got out of the facility. During a telephone interview on 10/18/23 at 12:40 pm, Maintenance Director said that he had been employed for a little over a year. He said that he checked the doors once a week. He said after the elopement, he came to look at the door and it had already been re-magnetized or reset and was locked. He said that he just changed the code at that time and made sure that the door was locked and shut completely. He said that the C hall emergency door does not have a delayed egress. He was unsure how Resident #20 got out of that door unless a staff member had used it and not ensure that it had been completely closed back and shut properly. During an interview on 10/18/23 at 1:00 pm, Administrator said that after the elopement incident, Resident #20 was referred to psych services (which he had already been receiving) and they had discontinued his Buspar and Effexor. She said that she was unsure of how he got out of the end door and assumed maybe a staff member had used it and not closed it completely, but there was no investigation afterward to find out how he eloped out of that doorway. She did not verbalize any risks to residents who were able to elope. Record review of facility policy titled Wandering and Elopements dated 9/1/23 read .The facility will ensure that resident who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care . and defines elopement as .when a resident leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so . and .adequate supervision will be provided to help prevent accidents or elopements . The facility Administrator was notified on 10/18/23 at 7:11 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 10/19/23 at 4:41 PM and included: Resident #3 no longer resides at [name] Healthcare Center (discharged : 9/3/23) and will not return. Resident #20 is on 1:1 observation (initiated on 9/5/23, prior to surveyor entry) Resident #26 no longer resides at [name] Healthcare Center (discharged : 6/30/23). Action: -Educated all staff on Elopement Policy: **Key takeaway procedures to follow in the event of an elopement. Search for resident, call code pink, notify and administrator and police department in the event we cannot find the resident as soon as possible but within 30 minutes if the search of the home and grounds are unsuccessful. -Educated all staff on residents that reside on the secured unit should remain on the secured unit at all times (with an exception of appointments, out on pass with family, hospital visits, or other emergencies requiring such). Meals, activities, and smoking should occur in the resident's unit. -Educated all staff on ensuring residents do not come out of the unit when entering or exiting the unit. All staff shall be educated prior to working their next scheduled shift. All temporary and new staff will be educated prior to working their first/next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 10/19/2023 by 10AM Action: Placed signs on the inside and outside of the secured unit doors letting staff and visitors know to ensure residents do not leave the unit while they are entering and exiting. Person(s) Responsible: Administrator Date: 10/18/2023 by 10AM Action: Placed a lock on the outside of the unit dining room/common area. This still allows for entrance and exit through the hallway doors and is not impeding an emergency exit/altering the required egress. Person(s) Responsible: Administrator Date: 10/18/2023 by 2PM Action: Emergency Exit Only sign placed at the end of the secured unit doors leading outside. Continuous alarm has been activated and will sound when the emergency exit door, leading to an unenclosed outside area, is opened alerting staff that the door is ajar. Person(s) Responsible: Maintenance Director Date: 10/19/2023 by 4:25PM Action: Ad Hoc QAPI performed with Medical Director to notify him/her of the IJ Template and to share the Plan of Removal. MD has no additional steps to perform at this time. Person(s) Responsible: Administrator, Director of Nursing, and Medical Director Date: 10/19/2023 by 11:30AM On 10/19/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: 1. Educated all staff on Elopement Policy. Inservice dated 10/18/23 with 37 signatures. 2. Educated all staff on residents that reside on the secured unit should remain on the secured unit at all times. Inservice dated 10/18/23 with 37 signatures. 3. Educated all staff on ensuring residents do not come out of the unit when entering or exiting the unit. Inservice dated 10/19/23 with 25 signatures. 4. Placed signs on the inside and outside of the secured unit doors letting staff and visitors know to ensure residents do not leave the unit while they are entering and exiting. Observed signs on the glass entering the secured unit on 10/19/23 at 4:00pm 5. Placed a lock on the outside of the unit dining room/common area. Observation of door on 10/19/23 at 4:00pm, door handle has been removed and door has been permanently locked. 6. Emergency Exit Only sign placed at the end of the secured unit doors leading outside. Continuous alarm has been activated and will sound when the emergency exit door, leading to an unenclosed outside area, is opened alerting staff that the door is ajar. Observed 10/19/23 at 4:47pm door alarming when opened. 7. Ad Hoc QAPI. Verified with ad hoc qapi dated 10/19/23 at 11:30am with Administrator, DON and Medical director. Staff Interviews: During interviews on 10/19/23 between 4:50 pm and 5:15 pm, the following staff were able to appropriately verbalize understanding of education received during in-services. Nurses- 2-LVNS, 2-RN's (4:50pm DON, 5:01pm LVN S, 5:04pm ADON, 5:09pm RN L); CNA's- 5 CNA's (5:08pm CNA T, 5:12pm CNA O, 5:19pm CNA U, 5:06pm CNA P, 5:28pm CNA E); MA's- 1-MA's (4:57pm MA Q); and Other- 9 (4:53pm HSK SUP, 4:55pm COTA V, 4:59pm activity director, 5:00pm BOM/HR, 5:03pm HSK W, 5:08pm Maintenance Man, 5:11pm ST X, 5:13pm Administrator, and 5:15pm Dietary Supervisor). The Administrator was informed that the Immediate Jeopardy was removed on 10/19/23 at 5:31 pm; however, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure each resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #3) of 9 residents reviewed for assistive devices. The facility failed to promptly identify and intervene when Resident #3 had thick hardened secretions in his tracheostomy. Resident #3 was transported to the hospital in cardiac arrest and later died . An Immediate Jeopardy was identified on [DATE] at 7:11 p.m. While the Immediate Jeopardy was removed on [DATE] at 5:31 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate threat due to the facility's need to evaulate the effectiveness of the corrective systems. This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition, and ultimately death. Findings included: Record review of Resident #3's face sheet undated revealed Resident #3 was a [AGE] year-old male that originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #3's diagnosis included malignant neoplasm of the oropharynx (throat cancer), major depressive disorder, tracheostomy (tube to keep airway open). Record review of Resident #3's quarterly MDS dated [DATE] indicated Resident #3 resident is rarely/never understood and a BIMS summary score was not obtained. Section O of the MDS revealed Resident #3 had received trach care within the last 14 days while a resident at the facility. Record review of Resident #3's care plan dated [DATE] indicated tracheostomy supplies are to be kept at resident's bedside for immediate access in locked cart. The goal was to maintain airway patency. The approach was medication cart to consist of trach tube (one size smaller), one set of trach ties, ambu bag, suctioning kit, sterile yankers. Record review of Resident #3's medication administration record for [DATE] through [DATE], revealed Resident #3 had a physician's order for Ipratropium Albuterol sol solution; 1XXX,d+[DATE].5mg/ml via inhalation to be given as needed every 4 hours. On [DATE] the medication record indicated the medication had not been given. Record review of nurse progress note dated [DATE] at 10:51 PM written by LVN C revealed Resident #3 allowed nurse to suction trach and was very hard to insert the suction tube, the nurse educated Resident #3 that he had to take the breathing treatments and allow other nurses to do trach care so the trach will not be clogged up. LVN C indicated that the DON was updated on the matter. Record review of nurse progress note dated [DATE] at 6:21 PM written by RN D: Resident was lying on the floor on the unit. The aid on the unit stated that he purposely laid down. Observed stridor in resident. Attempted to clear mucus plug from resident's trach without success. Resident became unconscious and CPR was started while another nurse called 911. 1st responders arrived in minutes and assisted with CPR while the ambulance was in route. CPR was continued and resident was sent to the hospital at 7:25 PM. Contacted resident EC and left message to call the facility. Also contacted NP, DON, Administrator. Resident's EC returned call and was notified of resident's event and that he is in route to the hospital. Record review of hospital records dated [DATE] at 1:04 PM, written by Hospital MD revealed Resident #3 admitted with out-of-hospital arrest, asystolic arrest, and etiology is likely hypoxic arrest. Resident #3 was noted with mucous plug, which has previously been prone to mucous plug noted in 2022. This would have resulted in hypoxic arrest which usually presents as PEA arrest, but after prolonged hypoxia/anoxia, would result in asystolic arrest. True downtime is unclear at this time. Record review of nurse progress note dated [DATE] at 8:10 AM, indicated the case manager at the hospital called and spoke with nurse with disposition on resident. Family had a meeting with physician and decided to stop all life sustaining measures on [DATE]. Case Manager went on to state, Resident with no brain activity @ 1340, and at 1710 was pronounced with no cardiac activity. During an interview on [DATE] at 9:15 AM the RP said she had received a call from the facility stating that Resident #3 had a mucus plug in his tracheostomy that the nurse was unable to remove. She said Resident #3 was very good at taking care of his tracheostomy himself and would suction himself. She said Resident #3 would let you know when he needed to by suctioned and tracheostomy care was needed. During an interview on [DATE] at 2:03 PM, LVN C said she worked with Resident #3, ,d+[DATE] nights a week. She said Resident #3 was hard to suction on [DATE] due to hard mucus in his trach. She said Resident #3 had a lot of buildup due to Resident #3 not allowing anyone to suction his trach. LVN C said she had to use a new suction tip each time she suctioned him due to the amount of buildup of mucus in his trach. She said she used 2 suction tips and then Resident #3 did not want her to suction him anymore. LVN C said she did not administer any as needed breathing treatments. She said she did notify the DON that Resident #3 was harder to suction but that she did not notify anyone else, and said she just charted it. LVN C said Resident #3 would let you know if he felt like he couldn't breathe. During an interview on [DATE] at 2:22 PM, RN AC said on [DATE] she was not the nurse taking care of Resident #3, she said it was an agency nurse and it was her first time at the facility, so she was helping her out by doing the nursing progress note for the incident. RN AC said she walked into the secured unit and observed Resident #3 lying on the floor and Resident #3 was in stridor (high-pitched respiratory sound). She said they got Resident #3 back to his room and she attempted to suction his trach and Resident #3 passed out. RN AC said Resident #3's secretions were very hard, and she was not able to clear them. She said they began CPR on Resident #3 while another nurse called 911. During an interview on [DATE] at 4:10 PM, the NP said she remembered Resident #3 and that Resident #3 refused care frequently. She said she could not recall if the nurse had called and notified her of being unable to clear thick hardened secretions from Resident #3's trach on [DATE]. Said if she had been notified, she would have given an order for a nebulizer treatment to attempt to loosen secretions and attempt 1 more suction pass to clear secretions and if unsuccessful then she would have given an order to send to the emergency room . She said she was unsure if it would have made a difference in resulting in Resident #'s death. She said that Resident #3 had significantly declined over the previous 6 months with his cancer and felt like resident would have died soon. She said she was aware that resident frequently refused care and was not complainant with his diet and peg tube. During an interview on [DATE] at 4:48 PM, the Medical Director said he did not recall being called on [DATE] and notified regarding the thick hardened secretions of Resident #3's trach. He said if he would have been notified, he would have given an order for Resident #3 to be sent out to the emergency room . He said that he was aware that Resident #3 had refused care in the past. He said he could not say if being sent out to the emergency room would have made a difference in the ultimate demise of Resident #3. During an interview on [DATE] at 8:35 AM, the DON said she had worked at the facility since [DATE]. She said she was not in the facility when Resident #3 went out to the hospital. She said the only notification that she received was that Resident #3 had refused to let the nurse suction him. She said that he would refuse trach care and suctioning from time to time but would later let the nurse clean and suction his trach. She said the NP was aware that Resident #3 refused care at times. She said that Resident #3 never suctioned himself or cleaned his trach himself, and said it was always a nurse. The DON said she was not notified of resident's secretions being hard to suction or that there was anything wrong with his trach. Record review of facility policy dated [DATE] titled Change in a Resident's Condition or Status revealed Our facility promptly notifies the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights etc.). The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a (an): D. significant change in the resident's physical/emotional/mental condition; E. need to alter the resident's medical treatment significantly; F. refusal of treatment or medications G. need to transfer the resident to a hospital/treatment center;. 2. A significant change of condition is major decline or improvement in the resident's status that: A. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). Record review of the facility policy dated [DATE] titled Tracheostomy Care The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. General Guidelines 4. Tracheostomy tubes should be changed as ordered and as needed (at least monthly). 5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. 7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. An Immediate Jeopardy was identified on [DATE] at 7:11 PM. The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 7:11 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on [DATE] at 2:34 PM and reflected the following: Resident #3 no longer resides at [NAME] Healthcare Center (discharged : [DATE]) and will not return. Action: No residents residing at [NAME] Healthcare Center have a Tracheostomy. Person(s) Responsible: Director of Nursing Date: [DATE] Action: Nurses have been educated over the Tracheostomy Policy and suctioning/techniques. *Key Takeaways: Nurses will understand the need to promptly identify and intervene for thick hardened secretions, if suctioning is unsuccessful, notify the MD immediately/as soon as possible, and follow orders given. All Nurses will be educated prior to working their next shift. All new and temporary nurses will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: [DATE] by 10AM Action: Any future admissions with tracheostomies will be reviewed prior to admission to ensure proper equipment is present and proper training has been completed with staff. Orders will be reviewed and put in place to ensure proper care is given to ensure residents receive treatment and care in accordance with professional standards of practice. Care plans will be person centered and reflect residents' choices/preferences. In future situations nurses will be trained prior to working with a tracheostomy resident. Person(s) Responsible: Director of Nursing and/or Assistant Director of Nursing Date: [DATE] by 11:30AM Action: Ad Hoc QAPI performed with Medical Director to notify him/her of the IJ Template and to share the Plan of Removal. MD has no additional steps to perform at this time. Person(s) Responsible: Administrator, Director of Nursing, and Medical Director Date: [DATE] by 11:30AM On [DATE] between 2:34 PM and 5:31 PM, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Record review of in-service dated [DATE] titled Oxygen Administration, Tracheostomy, Nebulizer, Inhaler revealed 7 nurse signatures. Record review of Ad Hoc QAPI completed on [DATE] at 10:30 AM with 8 signatures including the Medical Director. During interviews on [DATE] between 2:34 PM and 5:31 PM the following nurses were able to verbalize understanding of Oxygen Administration, tracheostomy care, Nebulizers, and Inhalers: DON, ADON, LVN S, and RN L. On [DATE] at 5:31 pm, the facility was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate threat due to the facility's need to evaulate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free form neglect for 1 (Resident #1) of 5 residents reviewed for neglect. The facility failed to ensure Resident #1's care plan was followed, and interventions were in place. The facility failed to ensure Resident #1 received weekly skin assessments The facility failed to ensure the system they had in place with the podiatrist was in functional in providing Resident #1 with the care needed. The facility failed to ensure aides were assessing skin, and feet when providing care. The facility failed to document and assess Resident #1 when concerns were reported from therapy of Residents #1 being in pain and his feet were bleeding. The failures caused Resident #1 to have part of his foot/toes amputated. An Immediate Jeopardy (IJ) situation was identified 08/15/23 at 3:42 p.m. While the IJ was removed on 08/16/23 at 4:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #1's undated face sheet indicted his current admitted was 5/25/23. He was a [AGE] year-old male with diagnoses of vascular dementia, with behavioral disturbances, diabetes mellitus, muscle wasting to the right and left lower leg, lack of coordination, and muscle weakness. Record review of Resident #1's admission MDS dated [DATE] indicated he was severely cognitively impaired. He had inattention and disorganized thinking behaviors present that came and went and changed in severity. The MDS indicated Resident # 1 required extensive assist of two people for bed mobility and transfers. He required extensive assist with dressing, toilet use, and personal hygiene of one person. He used a wheelchair for mobility. Resident #1 was totally dependent for putting on or taking off footwear. He was at risk for developing pressure ulcers but did not have any wounds listed. Record review of Resident #1's care plan with a start date of 10/20/21 and last updated 7/27/23 indicated a problem of at risk for diabetic complications, frequent infections, pressure/venous/status ulcers, vision impairment, hyper/hypoglycemia, kidney failure, cognitive/physical impairment. Skin desensitized to pain or pressure related to diabetes mellitus. Some of the approaches were to assist with repositioning routinely and as needed with pillows for comfort, support and to keep feet elevated of the bed as the resident will allow, and weekly skin assessments. Resident #1 was at risk for skin break down related to impaired mobility, diabetes mellitus, and incontinence. One of the approaches was weekly skin assessments. Resident #1 had self-care deficits due to impaired cognition, impaired memories, impaired daily decision making, occasional refusal of care and impaired mobility. Some of the approaches were bathing, personally hygiene, transfers required one to 2 people assist, if he refused, reapproach, notify the nurse. The resident required 1 to 2 people assist with bed mobility, use of pillows for comfort and support. And to keep the feet elevated off the bed. He required 1 to 2 people assist with dressing, offer clothing choices and encourage the resident to participate. Record review of Resident #1's computerized physician's orders indicated an order dated 5/27/23 for Tylenol Extra Strength 500 mg, 2 tablets, every 6 hours as needed for pain. An order dated 4/9/23 reflected to admit to the secure unit due to exit seeking secondary to dementia. An order dated 3/13/23 for a podiatry consult as needed. An order dated 10/2/21 indicated to assess for pain every shift. Record review of Resident #1's social services note dated 6/13/23 indicated his family member expressed several requests that she would like Resident #1 to be seen by a podiatrist due to his toes needing attention and he was a diabetic. Record review of Resident #1's nursing notes dated 6/14/23 indicated the podiatrist to see Resident #1 and they would be at the facility on 6/29/23. Written by LVN D. Record review of Resident #1's Braden scale for predicting pressure sore risk dated 6/15/23 indicated the resident had very limited responses to a sensory perception, his skin was moist constantly, he was chair fast with his ability to was walk severely limited or nonexistence. The resident's ability to change or control body position was very limited but made occasional slight changes. The resident's nutrition was he ate most of his meals every day. Friction and shear were a problem due to the resident required moderate to maximum assist with moving his. The Braden scale score was listed as a 12 which indicated high risk for pressure sores. There were no interventions checked as for preventive measures listed on the form. Record Review of Resident #1's Physical Therapy notes indicated the resident received therapy between 6/15/23 and 6/26/23. Therapy notes dates 6/19/23 indicated Resident #1 complained of not feeling well and said his foot hurt bad on this day. The LVN was notified. The resident was unwilling to participate secondary to pain. Therapy notes dated 6/22/23 indicated observation of blood to the right great toe through his sock. The nursing staff were made aware of observation and complaints of pain on this day. Therapy notes dated 6/26/23 indicated Resident #1 had difficulty with shifting onto his right lower extremity secondary to pain. All notes written by PTA. During an interview on 8/16/23 at 11:18 p.m. the PTA said she had voiced her concerns she had written in her therapy notes to the nursing staff about Resident #1. She said she was not sure exactly who she talked to, but they were made aware of Resident #1' complaints of pain and the blood on his sock for at least two occasions. Record review of Resident #1's Podiatry report dated 6/29/23 indicated. [The patient was unable to answer questions appropriately and was confined to a wheelchair. The chief complaint was diabetes, lesions at risk for poor circulation, and diseased toenails. The impression was cutaneous abscess (localized collection of pus in the skin and may occur on any skin surface. Symptoms and signs are pain and tender, firm or swelling.) to the right foot, cellulitis (bacterial skin infection) of right toe, onychogryphosis (nail disorder resulting from slow nail plate growth. Yellow brown thickening of the nail plate.), and peripheral vascular disease. The plan was due to the patient's pain tolerance. The medial right first nail border and all loose nail distally was freed from its soft tissue attachments and avulsed the offending border with nail nippers, care being taken to remove and excise all nonviable (dead) tissue. All corners were inspected for spicules (hard tissue) as best as possible. The abscess was drained from the nail bed noting malodorous (unpleasant smelling) red, brow, rust colored moderate amount of drainage approximately 1cc in total. All noted drainage and dicrotic tissue was removed with manual pressure to right toe and mechanical debridement (removal of damaged tissue from a wound) and nail nippers revealing clean, moist nail bed. The nail margins and nail bed were cleansed with Techni care and treated with triple antibiotic and dressed with a 2x2 and paper tape. Discussed with nurse the patient's right hallux(big toe) nail. Verbally recommended continued wound care consisting of daily cleaning and application of betadine and bandage until dry. Discussed possible by mouth antibiotic for the patient, nurse said she would confirm with attending NP for antibiotic. If deterioration of nail bed or eschar( dry, dark scab) on right hallux please bring patient to clinic. As soon as possible or if the patient develops systemic signs of infection including fever, chills, increased warmth to right toe/foot.] Record review of the facility 24-hour report dated 6/29/23 to 6/30/23 did not indicate any mention of Resident #1. During a telephone interview on 8/10/23 at 4:12 p.m. the Podiatrist said she remembered Resident #1. She said on 6/29/22 she had debrided his toe, bandaged his toe with triple antibiotic ointment, gauze and paper tape. The Podiatrist said when she was ready to leave there were several people at the nurse's station. She said she talked to a nurse and did not get a name or remember who she was. The Podiatrist said she asked for an order form to write her order for treatment of Resident #1's toe down but was told by the nurse she could give a verbal order. The Podiatrist said had given her verbal order to cleanse Resident #1's toe and apply betadine daily until healed. The unknown nurse said she would relay the information to the NP. She said Resident #1's wound did not appear to be tunneling and she felt if they had kept it cleaned and changed the bandage daily it would have healed in about two weeks. The Podiatrist said they did not need to wait until she came to the facility for Resident #1 to be seen, they could have brought him to her office. The Podiatrist said the only person she remembered at the nurse's station was the BOM. During an interview on 8/10/23 at 4:16 p.m. the BOM said she saw the Podiatrist at the nurse's station on 6/29/23 during her last visit. The BOM said she was talking to someone. However, she did not remember who she was talking to or hear what was said. Record review of Resident #1's nursing notes from 6/14/23 to 8/7/32 revealed no documented evidence of the Podiatrist recommendations, foot, pain, bleeding, bandage, or toe. Record review of Resident #1's weekly skin assessments indicated: On 5/29/23 no skin problems- completed by LVN J On 6/5/23- no skin problems On 6/12/23- no assessment was found On 6/19/23 - no skin problems-completed by RN K On 6/26/23 - no skin problems On 7/3/23- no assessment found On 7/10/23- no skin problems-LVN L On 7/17/23 no assessment found On 7/24/23 no assessment found On 7/31/23 - no skin problems On 8/7/23 - no skin problems (the day before hospitalization ) Record review of Resident #1's June 2023, July 2023 and August 2023 MARs and TARs indicated he did not receive any thing for pain and his pain assessment indicated no pain for those months. There was not documented evidence of treatments provided to his foot or toe. Record review of Resident #1's nutritional assessment dated [DATE] indicated the resident required supervision and oversite, encouragement or cueing for eating. He did not have any skin conditions or no recent labs. Record review of Resident #1's Physician's Progress note dated 7/5/23 indicated the resident was seen face to face with the nurse at bedside. There were no new complaints or concerns reported at the time. Review of systems indicated a general review. The resident was an unreliable historian, and the information was provided by staff. There were no changes in skin reported. Record review of Resident #1's ADL sheets for August 3023 indicated the resident was given a shower or bed bath each day from 8/2/23 through 8/7/23. Record review of Resident #1's nursing note dated 8/8/23 at 3:45 p.m. indicated Resident #1's family member came to the nurse's station asking to have the bandage on the resident's foot changed. The nurse went to do an assessment and changed the bandage. It was noted the entire right great toe was dark in color and dry. The DON and the NP were notified. New orders were received to send the resident to the ER for possible osteomyelitis (inflammation of the bone cause by infection). Record review of a Wound Information sheet dated 8/8/23 and created on 8/9/23 at 10:34 a.m. indicated Resident #1 had a wound type other, entire right great toe, not present on admission, the length was 4 cm and the with 3 cm and it was declining. The entire right great toe was dark in color and dry to touch. Record review of Resident #1's hospital History and Physical dated 8/9/23 at 2:29 a.m. indicated the Resident#1 received services on 8/8/23 at 7:43 p.m. Records indicated Resident #1 was assessed and determined to have chronic, worsening dry gangrene likely due to severe PVD. The right foot x ray showed gas within the soft tissue of the first digit of the right foot. Consult podiatry for possible amputation of the first digit. The radial pulses were 2+ on the right side and 2+ on the left side (blood flow was normal). The dorsalis pedis pulse was 0 on the right side (foot indicated vascular disease) and detected without doppler( Used to evaluate blood flow through the major arteries and veins of the feet.) on the left side. Posterior tibial pulses was detected without doppler on the right and left side. The skin integrity was positive for ulcer great, black discoloration of first digit, with skin breakdown, callus and dry. Ulcer located dorsal aspect of foot. Record review of Resident #1's Internal Medicine daily progress note dated 8/17/2023 at 8:42 a.m. indicated Resident #1 presented to the hospital on 8/8/23 from the nursing home with the chief complaint of right big toe pain with a chronic wound present. Resident #1 was at baseline with orientation to self only and used the wheelchair for mobility. The family member was at bedside and unsure how long the wound had been present but said at least a few months. An x-ray of the right foot indicated gas was shown within the soft tissue of the 1st digit with signs of arterial atherosclerosis (thickening or hardening of the arteries caused by buildup of plaque in the inner lining of the artery) and osteopenia (loss of bone mass and bone gets weaker), concerning for gas gangrene (dead tissue caused by and infection or loss of blood flow.). Podiatry preformed a right trans metatarsal amputation (surgery to remove part of the foot, one or more toes) and medial planner artery( supplies muscles of the big toe) based rotation flap 5cm (provides similar tissue with sensation and reaches the posterior most part of the weightbearing surface of the heal with ease.) on 8/12/23. Recommended daily bandage changes to the right foot. Due to poor healing. Cardiology recommended possible physical therapy involvement with wound care. A bone cultures preliminary results showed gram positive coli impairs and a few gram-positive rods. There was a recommendation was for a continued intravenous vancomycin( medication used to treat infections caused by bacteria) and cefepime ( medication antibiotic to treat bacterial infection) . The bone margarine biopsy was negative. Dry gangrene resolved as of 8/16/2023. Chronic worsening likely due to severe PVD. Podiatry performed the right trans metatarsal amputation and a medial plantar artery-based rotation flap 5 centimeters on 8/12/23 physical deconditioning chronic. The nursing home indicated the resident was totally dependent for care, bed bound, and needed assistance to wheelchair and to be pushed. During an interview on 8/10/23 at 11:37 a.m. said Resident #1's family member said Resident #1 was still in the hospital due to poor circulation in his foot and gangrene. The family member said they had not seen him for two weeks. The family member said when they arrived on 8/8/23 Resident #1 was complaining of foot pain. When the family member took off his sock, it was obvious the sock had been on a while. The sock was filled with dried dead skin and dust. The family member said they had asked the ADON to come and look at his foot. The family member said there was gauze wrapped around Resident #1's big toe. The bandage was dirty and looked like it had been on Resident #1's foot for a while. The family member said they knew the Podiatrist had put a bandage on the foot. The way the bandage looked it could have been the same one. The family member said they could not be sure, but it was obvious it was not changed daily, if at all. The family member said the whole top of the right foot was black, the big toe was black. During an interview on 8/10/23 at 2:18 p.m. the DON said the NP gave an order on 8/8/23 to send Resident #1 to the ER for possible osteomyelitis to the great toe. The DON said the ADON had called her to the room to look at Resident #1's foot. It was dark in color and there was no drainage, no smell. The Administrator called in the incident into the State. She said Resident #1 was not on the wound care log, they had no records of him was receiving treatments. She said they checked, and he did not have a physician's order for wound care. The DON said they also checked the shower sheets and the assessments and there was no indication of a wound on Resident #1's foot. The DON said she began work at the facility in the middle of July and was not present when the Podiatrist had visited. She said she had checked the assessments, the TARS, physician orders, and shower sheets because she expected those things to give some indication of what was going on with Resident #1's foot. However, those records did not reveal anything. During an interview on 8/10/23 at 3:05 p.m. the Administrator said she learned about Resident #1's right foot from the DON. She said a family member came and asked to put another bandage on his foot. The DON went down on to look at his foot and called her to look as well. The Administrator said the big toe on his right was dark in color. She said the NP was notified and said to send Resident #1 out due to possible osteomyelitis. The Administrator said she reported the incident to the state because assessments, and treatments had not been done to the wound. She said as best their investigation could determine no one was aware he had any issues with his foot. She said she called the allegation in due to possible neglect in providing care to Resident #1. During an interview on 8/10/23 at 3:15 p.m. the ADON said she was called to Resident #1's room by a family member. She said she observed a bandage on Resident #1's toe, the bandage may have been on Resident #1's foot for a few days, it did not look new. The bandage had no date, and no initials on it. She said the bandage was tan in color. The ADON said Resident #1's foot was dark and dry, no drainage, and no smell. LVN D told the doctor, and she said send to the hospital to rule out osteomyelitis. The ADON said Resident #1 did not complain of pain. Record review of the facility Provider Investigation Report dated 8/9/23 at 5:00 p.m. indicated they had first learned of the incident on 8/9/23 at 2:30 p.m. The narrative indicated Resident #1 had poor circulation to his bilateral feet and experienced pain. The family member asked the nurse to remove his bandage on Resident #1's foot. The ADON removed the bandage and noted the entire right toe was dark in color and dry. She then notified the DON. The DON notified the NP and received orders to transfer the Resident #1 to the ER for possible osteomyelitis. The nursing staff was educated starting with the facility policy and procedures for reporting skin issues, making weekly rounds, and abuse and neglect. The allegation was Resident Neglect. During an interview on 8/10/23 at 1:00 p.m. CNA A said sometime in June 2023 Resident #1 had an area on his foot, and she notified LVN D. She said Resident #1 had something on the top of his big toe, and she showed LVN D. She said LVN D cleaned Resident #1's foot and the Podiatrist was contracted. CNA A said she was off for a couple of days, but she gave the resident a bed bath on 8/7/23. She said had not seen his foot; the foot had a dressing on the toe. CNA A said Resident #1 got baths MWF and she could not say the last time she had seen his foot even though she said he received his bath regularly and did not refuse. CNA A was asked several different times and several different ways when the last time she saw Resident #1's foot. She could not say the last time she had seen Resident #1's foot. She would refer to the day she showed the area to the LVN D and when the Podiatrist came on 6/29/23. During an interview on 8/10/23 at 1:30 p.m. LVN D said Resident #1 came back from another facility and the aide showed her his nails were long and needed attention. She said she thought it was 6/14/23 that she observed the resident's feet. His right foot looked like it had athlete's feet. His skin was flakey, he was diabetic, and his toes were long and thick. She notified the NP and did a referral for the Podiatrist. She said she had never conducted a treatment on Resident #1. She said that he did not have any orders so there was no need to provide wound care. She said she had not seen his foot since the day she did the podiatry referral. She had not conducted a skin assessment. She said she as a floor nurse and had worked at the facility for about 3 months. During a telephone interview on at 8/10/23 at 3:32 p.m. RN E said she did not provide any treatments to Resident #1. RN E said she had never seen his feet and did not know anything about a podiatrist visit. Record review of a nursing note dated 6/29/23 at 9:12 a.m. indicated Resident #1 was up in his chair with no problems during a day 3 of 3 post fall assessments. His vital signs were within normal limits, and he had no pain reported. Signed by RN E During a telephone interview on at 3:34 p.m. RN F said she has never been in the building when Podiatry was there. She said no one had given her a verbal order. RN F said that she was not aware of any wound on Resident #1's toe. She said she had never put a bandage on foot or seen his feet. During a telephone interview on at 3:43 p.m. RN G said she did not remember Resident #1 but if he had a treatment order, she would have provided treatment as needed. During an interview on 8/10/23 at 4:26 p.m. the DON said she started working at the facility on Monday, 7/10/23 She said when first started working she asked for wound report and Resident #1 had never been on any wound reports. The DON said it looked like nurses or aide had not assessed Resident #1's skin. The DON said she could not find any treatment orders or treatments for Resident #1. During an interview on 8/10/3 at 5:34 p.m. LVN H said she had never completed a skin assessment on Resident #1 or provided any treatment. During a telephone interview on 8/10/23 at 5:55 p.m. CNA A said she was there when the Podiatrist treated Resident #1's foot. She said Resident #1 was sitting in the chair and Resident#1 kept saying oh, oh, oh and the Podiatrist kept on doing what she was doing telling him it was ok. CNA A said the Podiatrist used clippers and a grinder. She did not see her put a bandage on Resident #1's toe; she left before the Podiatrist finished the process. She said she had not seen Resident #1's foot lately because he had a bandage on his toe, and they were not to take off bandages. She said she was aware of what abuse was, who to report abuse to. She said neglect was failure to provide goods and services to a resident. During an interview on 8/10/23 at 6:00 p.m. LVN D said she cleaned Resident #1' right foot on 6/14/23 and alerted therapy that his foot was tender. She said the aides put socks on Resident #1's feet. She said he did complain of a little pain when she cleaned his foot. However, after podiatry came Resident #1 had no more complaints of pain. During an interview on 8/10/23 at 6:09 p.m. CNA B said she gave Resident #1 a bath and she had cleaned him up because he had a BM but never saw his foot. She said she did not remember ever seeing his feet. She said she was aware of what abuse was, who to report abuse to. She said neglect was failure to provide goods and services to a resident. During an interview and observation on 8/14/23 at 3:15 p.m. Resident #1 was observed in the hospital bed. He was sitting up and alert but confused. He said he had sprained his ankle and that was what was wrong with is foot. He said he had never been to the nursing facility. He said the hospital had cut off his foot. Observation of his right foot revealed it was heavily bandaged, but it was still there. During an interview on 8/15/23 at 8:12 a.m. the Administrator said they had QA meetings on the first Monday of the month. She said they had not taken the incident with Resident #1 to QA yet, she was waiting to finish her investigation into the incident and the 3615(Provider Investigation Report to the State) was not due until tomorrow. She said after that was completed; they would conduct an impromptu QA meeting. She said they had finished some of the in-services on skin assessments, documentation, and shower sheets being completed correctly Sunday, 8/13/23, and they had conducted skin assessments on all residents and finished on 8/11/23 During a telephone interview on 8/15/23 at 8:20 a.m. the NP said Resident #1 had been in the hospital before and had diagnoses of stoke and high blood. She was not aware he had a diagnosis of PVD. The NP said she knew he was referred to podiatry but had not received any recommendations from podiatry. She was not made aware of any orders from the podiatrist. The NP said on 8/8/23 the nursed called her to discuss Resident #1's foot. They compared it to another resident she had looked at the day before and it was worse than that resident. She said the staff told her Resident #1's foot was black and there was a question of circulation. She said they said it was dry and they could not tell how deep the injury was. She told the staff to send the resident to the hospital for possible osteomyelitis. The NP said she had never saw Resident #1's feet. She was not aware of any issues with Resident #1's feet. During an interview on 8/15/23 at 9:12 a.m. LVN I said she worked at the facility for 4.5 years. She said she completed skin assessments when they populated in the computer. Resident #1 was readmitted to the facility on [DATE] by LVN J who was out on leave. LVN I said she never provided any care to Resident #1. She said she had gone to Resident #1's room on 8/8/23 with the ADON. She had seen the bandage and it was beige in color. During an interview on 8/15/23 at 10:16 a.m. the Corporate Nurse and DON said they had a system with the Podiatrist. The procedure was the podiatrists leave a census sheet and if there were any orders associated with the visit they would be noted on that sheet. The Corporate Nurse said in most facilities the Podiatrist asked for who they could see and who they could not related to payor source. The DON said the Podiatrist had not been to the facility since she had been working there. They did not have a DON during the last Podiatrist visit. The Corporate Nurse said the Podiatrist was to meet with the DON or the Administrator prior to exit. They said there was a failure of the Podiatrist to communicate the order or write the order down. The Corporate Nurse said she did not know why a nurse would have told her not to write the order down. There were plenty of physician order forms at the nurses station. The DON said they could not determine who the order was given to or why the order did not get transcribed. The Corporate Nurse said they were going to have some communication with the Podiatrist. During a record review and interview on 8/15/23 at 11:00 a.m. the Corporate Nurse said they had an issue with the Podiatrist. Review of the Podiatrist's notes indicated all residents had the same diagnoses of poor circulation, diseased toenails, on left and right feet like she copied and pasted, the only difference were the medications. Review of records revealed Resident#1 was the only resident on 6/29/23 with an order. Review of the note's indicated the residents were educated even the confused ones, and all had debridement. Review of the notes for 36 residents indicated they all reflected similar information. There was one code used on all the records code 11721- debridement of nails. Review of the 2/3/23 podiatrist consult notes indicated the same code and the same similarities in the records. The Corporate Nurse said perhaps the 11721 was a pay code they used to bill for services. The Corporate Nurse said they had a computer system Plan of Care (POC) that triggered when to do the skin assessments. She was checking that system to determine why assessments were not completed as they should have been. She could not tell if the system did not trigger the need to do the assessments or if staff had just no completed them as required. During an interview on 8/15/23 at 12:40 p.m. the DON said she could not determine who put the bandage on Resident #1's foot that was discovered on 8/8/23. During an interview on 8/15/23 at 2:00 p.m. with RN K and the Corporate Nurse, RN K said she saw Resident #1's foot but it had been a while, about 6 weeks. She said she had not seen a bandage on his foot and did not remember what the foot looked like. Corporate Nurse said RN K completed a skin assessment on Resident #1 on 6/19/23 (the day the PTA said Resident #1 was complaining of foot pain) RN K said she could not remember what the foot looked like. She said all diabetic residents had the thick toenails with fungus. She did not remember anything different about Resident #1's feet. During an interview on 8/16/23 at 3:38 p.m. LVN L said she never saw Resident #1's foot. (She completed Resident #1's a skin assessment on 7/10/23.) Record review of the facility's skin management documentation workflow dated 5/23/22 indicated to complete skin assessments on admission observation. Document all skin alterations to include abrasions, bruises, burn, dermatitis, laceration, rash, skin graft, skin tear, surgical incision, and ostomies and other areas. Complete a weekly Braden Scale observation each week post admission for three weeks. Complete weekly head to toe skin inspections. These are to be competed and documented in the POC computer system as they are scheduled. Record review of an in-service dated 8/10/23 indicated Nursing Care of the Older Adult with Diabetes indicated Skin and Foot Care: Skin should be kept as dry and clean as possible apply lotion to dry skin as needed unless contraindicated. Use antiseptic technique in caring for any lacerations, abrasions of or breaks in skin integrity, and report the condition immediately to your supervisor. Bathe the feet in warm hot water as necessary to keep clean. Keep the feet dry, especially between the toes. Encourage the use of non-constricting, well-fitting shoes, slippers, and hose. Keep the feet warm without the use of external heat sources Record review of the facility's in-service conducted on 8/10/23 the in-service indicated CNAs reporting and documenting skin injuries on weekly shower sheets and PRN notifications. The in-service indicated CNAs should report all skin injuries, discoloration, skin tears, lacerations, blisters, pressure injuries, open areas, to the charge nurse immediately. The area should be indicated on the CNA shower sheets when turned into the nurse, after notification to the charge nurse. Resident skin should be checked during showers/ bed baths, turning and repositioning, dressing, and toileting. CNAs should be moisturizing resident skin daily, and using moisture barrier to resident buttocks, peri-area, and groins after performing incontinent care. If there was a dressing without nursing initials or dates are found to be in place, notify the charge nurse immediately. If dressings become dislodged, or solided, notify the charge nurse so that the dressing can be changed. Check for breaks and skin and pressure ulcers to the external portions of the ear. When giving bed baths remove residence clothing, undergarments and socks, and check between toes. Inspects ankles and heels for pressure areas, blisters, or non-blanchable redness. Is very important to dry our diabetic residents' feet and between their toes well. Wash residents' hands with soap and water and moisturize their hands, especially those with contractures be gentle and respect the decreased range of motion strengthening the digits that are severel [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure a resident received proper treatment and care to maintain good foot health for 1 of 5 residents reviewed for foot care. (Resident #1) The facility failed to ensure Resident #1 who had diagnosis of diabetes and was at risk for issues with his feet, received assessments, and treatments. The facility failed to ensure accurate, timely skin assessments. Resident #1 had 7 weekly skin assessments from 5/29/23 through 8/7/23 by 7 different nurses and none of those assessments revealed any foot issues. The facility failed to ensure assessments of Resident #1's feet were completed during baths. Resident #1 had bed baths from 8/4/23 through 8/7/23 from 2 different aides. Those aides did not assess his feet during care. The resident was seen by the Podiatrist on 6/29/23, his toenails were cut, and his right big toe was debrided. A bandage was placed on his toe. The facility failed to ensure podiatry recommendations were followed for Resident #1. The facility failed to ensure Resident #1 received wound care, cleaning of the wound, treatment, and possible antibiotics for the wound on the toe. On 8/8/23 Resident #1 was found with a discolored bandage on his right big toe. He was sent to the hospital with a diagnosis of PVD, gangrene, and had to have surgery to remove part of the foot, one or more toes. An Immediate Jeopardy (IJ) situation was identified 08/15/23 at 3:42 p.m. While the IJ was removed on 08/16/23 at 4:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #1's undated face sheet indicted his current admitted was 5/25/23. He was a [AGE] year-old male with diagnoses of vascular dementia, with behavioral disturbances, diabetes mellitus, muscle wasting to the right and left lower leg, lack of coordination, and muscle weakness. Record review of Resident #1's admission MDS dated [DATE] indicated he was severely cognitively impaired. He had inattention and disorganized thinking behaviors present that came and went and changed in severity. The MDS indicated Resident # 1 required extensive assist of two people for bed mobility and transfers. He required extensive assist with dressing, toilet use, and personal hygiene of one person. He used a wheelchair for mobility. Resident #1 was totally dependent for putting on or taking off footwear. He was at risk for developing pressure ulcers but did not have any wounds listed. Record review of Resident #1's care plan with a start date of 10/20/21 and last updated 7/27/23 indicated a problem of at risk for diabetic complications, frequent infections, pressure/venous/status ulcers, vision impairment, hyper/hypoglycemia, kidney failure, cognitive/physical impairment. Skin desensitized to pain or pressure related to diabetes mellitus. Some of the approaches were to assist with repositioning routinely and as needed with pillows for comfort, support and to keep feet elevated of the bed as the resident will allow, and weekly skin assessments. Resident #1 was at risk for skin break down related to impaired mobility, diabetes mellitus, and incontinence. One of the approaches was weekly skin assessments. Resident #1 had self-care deficits due to impaired cognition, impaired memories, impaired daily decision making, occasional refusal of care and impaired mobility. Some of the approaches were bathing, personally hygiene, transfers required one to 2 people assist, if he refused, reapproach, notify the nurse. The resident required 1 to 2 people assist with bed mobility, use of pillows for comfort and support. And to keep the feet elevated off the bed. He required 1 to 2 people assist with dressing, offer clothing choices, and encourage the resident to participate. Record review of Resident #1's computerized physician's orders indicated an order dated 5/27/23 for Tylenol Extra Strength 500 mg, 2 tablets, every 6 hours as needed for pain. An order dated 4/9/23 reflected to admit to the secure unit due to exit seeking secondary to dementia. An order dated 3/13/23 for a podiatry consult as needed. An order dated 10/2/21 indicated to assess for pain every shift. Record review of Resident #1's social services note dated 6/13/23 indicated his family member expressed several requests that she would like Resident #1 to be seen by a podiatrist due to his toes needing attention and he was a diabetic. Record review of Resident #1's nursing notes dated 6/14/23 indicated the podiatrist to see Resident #1 and they would be at the facility on 6/29/23. Written by LVN D. Record review of Resident #1's Braden scale for predicting pressure sore risk dated 6/15/23 indicated the resident had very limited responses to a sensory perception, his skin was moist constantly, he was chair fast with his ability to was walk severely limited or nonexistence. The resident's ability to change or control body position was very limited but made occasional slight changes. The resident's nutrition was he ate most of his meals every day. Friction and shear were a problem due to the resident required moderate to maximum assist with moving his. The Braden scale score was listed as a 12 which indicated high risk for pressure sores. There were no interventions checked as for preventive measures listed on the form. Record Review of Resident #1's Physical Therapy notes indicated the resident received therapy between 6/15/23 and 6/26/23. Therapy notes dates 6/19/23 indicated Resident #1 complained of not feeling well and said his foot hurt bad on this day. The LVN was notified. The resident was unwilling to participate secondary to pain. Therapy notes dated 6/22/23 indicated observation of blood to the right great toe through his sock. The nursing staff were made aware of observation and complaints of pain on this day. Therapy notes dated 6/26/23 indicated Resident #1 had difficulty with shifting onto his right lower extremity secondary to pain. All notes written by PTA. During an interview on 8/16/23 at 11:18 p.m. the PTA said she had voiced her concerns she had written in her therapy notes to the nursing staff about Resident #1. She said she was not sure exactly who she talked to, but they were made aware of Resident #1' complaints of pain and the blood on his sock for at least two occasions. Record review of Resident #1's Podiatry report dated 6/29/23 indicated. [The patient was unable to answer questions appropriately and was confined to a wheelchair. The chief complaint was diabetes, lesions at risk for poor circulation, and diseased toenails. The impression was cutaneous abscess (localized collection of pus in the skin and may occur on any skin surface. Symptoms and signs are pain and tender, firm or swelling.) to the right foot, cellulitis (bacterial skin infection) of right toe, onychogryphosis (nail disorder resulting from slow nail plate growth. Yellow brown thickening of the nail plate.), and peripheral vascular disease. The plan was due to the patient's pain tolerance. The medial right first nail border and all loose nail distally was freed from its soft tissue attachments and avulsed the offending border with nail nippers, care being taken to remove and excise all nonviable (dead) tissue. All corners were inspected for spicules (hard tissue) as best as possible. The abscess was drained from the nail bed noting malodorous (unpleasant smelling) red, brow, rust colored moderate amount of drainage approximately 1cc in total. All noted drainage and dicrotic tissue was removed with manual pressure to right toe and mechanical debridement (removal of damaged tissue from a wound) and nail nippers revealing clean, moist nail bed. The nail margins and nail bed were cleansed with Techni care and treated with triple antibiotic and dressed with a 2x2 and paper tape. Discussed with nurse the patient's right hallux(big toe) nail. Verbally recommended continued wound care consisting of daily cleaning and application of betadine and bandage until dry. Discussed possible by mouth antibiotic for the patient, nurse said she would confirm with attending NP for antibiotic. If deterioration of nail bed or eschar( dry, dark scab) on right hallux please bring patient to clinic. As soon as possible or if the patient develops systemic signs of infection including fever, chills, increased warmth to right toe/foot.] Record review of the facility 24-hour report dated 6/29/23 to 6/30/23 did not indicate any mention of Resident #1. During a telephone interview on 8/10/23 at 4:12 p.m. the Podiatrist said she remembered Resident #1. She said on 6/29/22 she had debrided his toe, bandaged his toe with triple antibiotic ointment, gauze and paper tape. The Podiatrist said when she was ready to leave there were several people at the nurse's station. She said she talked to a nurse and did not get a name or remember who she was. The Podiatrist said she asked for an order form to write her order for treatment of Resident #1's toe down but was told by the nurse she could give a verbal order. The Podiatrist said had given her verbal order to cleanse Resident #1's toe and apply betadine daily until healed. The unknown nurse said she would relay the information to the NP. She said Resident #1's wound did not appear to be tunneling and she felt if they had kept it cleaned and changed the bandage daily it would have healed in about two weeks. The Podiatrist said they did not need to wait until she came to the facility for Resident #1 to be seen, they could have brought him to her office. The Podiatrist said the only person she remembered at the nurse's station was the BOM. During an interview on 8/10/23 at 4:16 p.m. the BOM said she saw the Podiatrist at the nurse's station on 6/29/23 during her last visit. The BOM said she was talking to someone. However, she did not remember who she was talking to or hear what was said. Record review of Resident #1's nursing notes from 6/14/23 to 8/7/32 revealed no documented evidence of the Podiatrist recommendations, foot, pain, bleeding, bandage, or toe. Record review of Resident #1's weekly skin assessments indicated: On 5/29/23 no skin problems- completed by LVN J On 6/5/23- no skin problems On 6/12/23- no assessment was found On 6/19/23 - no skin problems-completed by RN K On 6/26/23 - no skin problems On 7/3/23- no assessment found On 7/10/23- no skin problems-LVN L On 7/17/23 no assessment found On 7/24/23 no assessment found On 7/31/23 - no skin problems On 8/7/23 - no skin problems (the day before hospitalization ) Record review of Resident #1's June 2023, July 2023 and August 2023 MARs and TARs indicated he did not receive any thing for pain and his pain assessment indicated no pain for those months. There was not documented evidence of treatments provided to his foot or toe. Record review of Resident #1's nutritional assessment dated [DATE] indicated the resident required supervision and oversite, encouragement or cueing for eating. He did not have any skin conditions or no recent labs. Record review of Resident #1's Physician's Progress note dated 7/5/23 indicated the resident was seen face to face with the nurse at bedside. There were no new complaints or concerns reported at the time. Review of systems indicated a general review. The resident was an unreliable historian, and the information was provided by staff. There were no changes in skin reported. Record review of Resident #1's ADL sheets for August 3023 indicated the resident was given a shower or bed bath each day from 8/2/23 through 8/7/23. Record review of Resident #1's nursing note dated 8/8/23 at 3:45 p.m. indicated Resident #1's family member came to the nurse's station asking to have the bandage on the resident's foot changed. The nurse went to do an assessment and changed the bandage. It was noted the entire right great toe was dark in color and dry. The DON and the NP were notified. New orders were received to send the resident to the ER for possible osteomyelitis (inflammation of the bone cause by infection). Record review of a Wound Information sheet dated 8/8/23 and created on 8/9/23 at 10:34 a.m. indicated Resident #1 had a wound type other, entire right great toe, not present on admission, the length was 4 cm and the with 3 cm and it was declining. The entire right great toe was dark in color and dry to touch. Record review of Resident #1's hospital History and Physical dated 8/9/23 at 2:29 a.m. indicated the Resident#1 received services on 8/8/23 at 7:43 p.m. Records indicated Resident #1 was assessed and determined to have chronic, worsening dry gangrene likely due to severe PVD. The right foot x ray showed gas within the soft tissue of the first digit of the right foot. Consult podiatry for possible amputation of the first digit. The radial pulses were 2+ on the right side and 2+ on the left side (blood flow was normal). The dorsalis pedis pulse was 0 on the right side (foot indicated vascular disease) and detected without doppler(Used to evaluate blood flow through the major arteries and veins of the feet.) on the left side. Posterior tibial pulses was detected without doppler on the right and left side. The skin integrity was positive for ulcer great, black discoloration of first digit, with skin breakdown, callus and dry. Ulcer located dorsal aspect of foot. Record review of Resident #1's Internal Medicine daily progress note dated 8/17/2023 at 8:42 a.m. indicated Resident #1 presented to the hospital on 8/8/23 from the nursing home with the chief complaint of right big toe pain with a chronic wound present. Resident #1 was at baseline with orientation to self only and used the wheelchair for mobility. The family member was at bedside and unsure how long the wound had been present but said at least a few months. An x-ray of the right foot indicated gas was shown within the soft tissue of the 1st digit with signs of arterial atherosclerosis (thickening or hardening of the arteries caused by buildup of plaque in the inner lining of the artery) and osteopenia (loss of bone mass and bone gets weaker), concerning for gas gangrene (dead tissue caused by and infection or loss of blood flow.). Podiatry preformed a right trans metatarsal amputation (surgery to remove part of the foot, one or more toes) and medial planner artery(supplies muscles of the big toe) based rotation flap 5cm (provides similar tissue with sensation and reaches the posterior most part of the weightbearing surface of the heal with ease.) on 8/12/23. Recommended daily bandage changes to the right foot. Due to poor healing. Cardiology recommended possible physical therapy involvement with wound care. A bone cultures preliminary results showed gram positive coli impairs and a few gram-positive rods. There was a recommendation was for a continued intravenous vancomycin(medication used to treat infections caused by bacteria) and cefepime ( medication antibiotic to treat bacterial infection) . The bone margarine biopsy was negative. Dry gangrene resolved as of 8/16/2023. Chronic worsening likely due to severe PVD. Podiatry performed the right trans metatarsal amputation and a medial plantar artery-based rotation flap 5 centimeters on 8/12/23 physical deconditioning chronic. The nursing home indicated the resident was totally dependent for care, bed bound, and needed assistance to wheelchair and to be pushed. During an interview on 8/10/23 at 11:37 a.m. said Resident #1's family member said Resident #1 was still in the hospital due to poor circulation in his foot and gangrene. The family member said they had not seen him for two weeks. The family member said when they arrived on 8/8/23 Resident #1 was complaining of foot pain. When the family member took off his sock, it was obvious the sock had been on a while. The sock was filled with dried dead skin and dust. The family member said they had asked the ADON to come and look at his foot. The family member said there was gauze wrapped around Resident #1's big toe. The bandage was dirty and looked like it had been on Resident #1's foot for a while. The family member said they knew the Podiatrist had put a bandage on the foot. The way the bandage looked it could have been the same one. The family member said they could not be sure, but it was obvious it was not changed daily, if at all. The family member said the whole top of the right foot was black, the big toe was black. During an interview on 8/10/23 at 2:18 p.m. the DON said the NP gave an order on 8/8/23 to send Resident #1 to the ER for possible osteomyelitis to the great toe. The DON said the ADON had called her to the room to look at Resident #1's foot. It was dark in color and there was no drainage, no smell. The Administrator called in the incident into the State. She said Resident #1 was not on the wound care log, they had no records of him was receiving treatments. She said they checked, and he did not have a physician's order for wound care. The DON said they also checked the shower sheets and the assessments and there was no indication of a wound on Resident #1's foot. The DON said she began work at the facility in the middle of July and was not present when the Podiatrist had visited. She said she had checked the assessments, the TARS, physician orders, and shower sheets because she expected those things to give some indication of what was going on with Resident #1's foot. However, those records did not reveal anything. During an interview on 8/10/23 at 3:05 p.m. the Administrator said she learned about Resident #1's right foot from the DON. She said a family member came and asked to put another bandage on his foot. The DON went down on to look at his foot and called her to look as well. The Administrator said the big toe on his right was dark in color. She said the NP was notified and said to send Resident #1 out due to possible osteomyelitis. The Administrator said she reported the incident to the state because assessments, and treatments had not been done to the wound. She said as best their investigation could determine no one was aware he had any issues with his foot. She said she called the allegation in due to possible neglect in providing care to Resident #1. During an interview on 8/10/23 at 3:15 p.m. the ADON said she was called to Resident #1's room by a family member. She said she observed a bandage on Resident #1's toe, the bandage may have been on Resident #1's foot for a few days, it did not look new. The bandage had no date, and no initials on it. She said the bandage was tan in color. The ADON said Resident #1's foot was dark and dry, no drainage, and no smell. LVN D told the doctor, and she said send to the hospital to rule out osteomyelitis. The ADON said Resident #1 did not complain of pain. Record review of the facility Provider Investigation Report dated 8/9/23 at 5:00 p.m. indicated they had first learned of the incident on 8/9/23 at 2:30 p.m. The narrative indicated Resident #1 had poor circulation to his bilateral feet and experienced pain. The family member asked the nurse to remove his bandage on Resident #1's foot. The ADON removed the bandage and noted the entire right toe was dark in color and dry. She then notified the DON. The DON notified the NP and received orders to transfer the Resident #1 to the ER for possible osteomyelitis. The nursing staff was educated starting with the facility policy and procedures for reporting skin issues, making weekly rounds, and abuse and neglect. The allegation was Resident Neglect. During an interview on 8/10/23 at 1:00 p.m. CNA A said sometime in June 2023 Resident #1 had an area on his foot, and she notified LVN D. She said Resident #1 had something on the top of his big toe, and she showed LVN D. She said LVN D cleaned Resident #1's foot and the Podiatrist was contracted. CNA A said she was off for a couple of days, but she gave the resident a bed bath on 8/7/23. She said had not seen his foot; the foot had a dressing on the toe. CNA A said Resident #1 got baths MWF and she could not say the last time she had seen his foot even though she said he received his bath regularly and did not refuse. CNA A was asked several different times and several different ways when the last time she saw Resident #1's foot. She could not say the last time she had seen Resident #1's foot. She would refer to the day she showed the area to the LVN D and when the Podiatrist came on 6/29/23. During an interview on 8/10/23 at 1:30 p.m. LVN D said Resident #1 came back from another facility and the aide showed her his nails were long and needed attention. She said she thought it was 6/14/23 that she observed the resident's feet. His right foot looked like it had athlete's feet. His skin was flakey, he was diabetic, and his toes were long and thick. She notified the NP and did a referral for the Podiatrist. She said she had never conducted a treatment on Resident #1. She said that he did not have any orders so there was no need to provide wound care. She said she had not seen his foot since the day she did the podiatry referral. She had not conducted a skin assessment. She said she as a floor nurse and had worked at the facility for about 3 months. During a telephone interview on at 8/10/23 at 3:32 p.m. RN E said she did not provide any treatments to Resident #1. RN E said she had never seen his feet and did not know anything about a podiatrist visit. Record review of a nursing note dated 6/29/23 at 9:12 a.m. indicated Resident #1 was up in his chair with no problems during a day 3 of 3 post fall assessments. His vital signs were within normal limits, and he had no pain reported. Signed by RN E During a telephone interview on at 3:34 p.m. RN F said she has never been in the building when Podiatry was there. She said no one had given her a verbal order. RN F said that she was not aware of any wound on Resident #1's toe. She said she had never put a bandage on foot or seen his feet. During a telephone interview on at 3:43 p.m. RN G said she did not remember Resident #1 but if he had a treatment order, she would have provided treatment as needed. During an interview on 8/10/23 at 4:26 p.m. the DON said she started working at the facility on Monday, 7/10/23 She said when first started working she asked for wound report and Resident #1 had never been on any wound reports. The DON said it looked like nurses or aide had not assessed Resident #1's skin. The DON said she could not find any treatment orders or treatments for Resident #1. During an interview on 8/10/3 at 5:34 p.m. LVN H said she had never completed a skin assessment on Resident #1 or provided any treatment. During a telephone interview on 8/10/23 at 5:55 p.m. CNA A said she was there when the Podiatrist treated Resident #1's foot. She said Resident #1 was sitting in the chair and Resident#1 kept saying oh, oh, oh and the Podiatrist kept on doing what she was doing telling him it was ok. CNA A said the Podiatrist used clippers and a grinder. She did not see her put a bandage on Resident #1's toe; she left before the Podiatrist finished the process. She said she had not seen Resident #1's foot lately because he had a bandage on his toe, and they were not to take off bandages. She said she was aware of what abuse was, who to report abuse to. She said neglect was failure to provide goods and services to a resident. During an interview on 8/10/23 at 6:00 p.m. LVN D said she cleaned Resident #1' right foot on 6/14/23 and alerted therapy that his foot was tender. She said the aides put socks on Resident #1's feet. She said he did complain of a little pain when she cleaned his foot. However, after podiatry came Resident #1 had no more complaints of pain. During an interview on 8/10/23 at 6:09 p.m. CNA B said she gave Resident #1 a bath and she had cleaned him up because he had a BM but never saw his foot. She said she did not remember ever seeing his feet. She said she was aware of what abuse was, who to report abuse to. She said neglect was failure to provide goods and services to a resident. During an interview and observation on 8/14/23 at 3:15 p.m. Resident #1 was observed in the hospital bed. He was sitting up and alert but confused. He said he had sprained his ankle and that was what was wrong with is foot. He said he had never been to the nursing facility. He said the hospital had cut off his foot. Observation of his right foot revealed it was heavily bandaged, but it was still there. During an interview on 8/15/23 at 8:12 a.m. the Administrator said they had QA meetings on the first Monday of the month. She said they had not taken the incident with Resident #1 to QA yet, she was waiting to finish her investigation into the incident and the 3615(Provider Investigation Report to the State) was not due until tomorrow. She said after that was completed; they would conduct an impromptu QA meeting. She said they had finished some of the in-services on skin assessments, documentation, and shower sheets being completed correctly Sunday, 8/13/23, and they had conducted skin assessments on all residents and finished on 8/11/23 During a telephone interview on 8/15/23 at 8:20 a.m. the NP said Resident #1 had been in the hospital before and had diagnoses of stoke and high blood. She was not aware he had a diagnosis of PVD. The NP said she knew he was referred to podiatry but had not received any recommendations from podiatry. She was not made aware of any orders from the podiatrist. The NP said on 8/8/23 the nursed called her to discuss Resident #1's foot. They compared it to another resident she had looked at the day before and it was worse than that resident. She said the staff told her Resident #1's foot was black and there was a question of circulation. She said they said it was dry and they could not tell how deep the injury was. She told the staff to send the resident to the hospital for possible osteomyelitis. The NP said she had never saw Resident #1's feet. She was not aware of any issues with Resident #1's feet. During an interview on 8/15/23 at 9:12 a.m. LVN I said she worked at the facility for 4.5 years. She said she completed skin assessments when they populated in the computer. Resident #1 was readmitted to the facility on [DATE] by LVN J who was out on leave. LVN I said she never provided any care to Resident #1. She said she had gone to Resident #1's room on 8/8/23 with the ADON. She had seen the bandage and it was beige in color. During an interview on 8/15/23 at 10:16 a.m. the Corporate Nurse and DON said they had a system with the Podiatrist. The procedure was the podiatrists was to leave a census sheet and if there were any orders associated with the visit they would be noted on that sheet. The Corporate Nurse said in most facilities the Podiatrist asked for who they could see and who they could not related to payor source. The DON said the Podiatrist had not been to the facility since she had been working there. They did not have a DON during the last Podiatrist visit. The Corporate Nurse said the Podiatrist was to meet with the DON or the Administrator prior to exit. They said there was a failure of the Podiatrist to communicate the order or write the order down. The Corporate Nurse said she did not know why a nurse would have told her not to write the order down. There were plenty of physician order forms at the nurse's station. The DON said they could not determine who the order was given to or why the order did not get transcribed. The Corporate Nurse said they were going to have some communication with the Podiatrist. During a record review and interview on 8/15/23 at 11:00 a.m. the Corporate Nurse said they had an issue with the Podiatrist. Review of the Podiatrist's notes indicated all residents had the same diagnoses of poor circulation, diseased toenails, on left and right feet like she copied and pasted, the only difference were the medications. Review of records revealed Resident#1 was the only resident on 6/29/23 with an order. Review of the note's indicated the residents were educated even the confused ones, and all had debridement. Review of the notes for 36 residents indicated they all reflected similar information. There was one code used on all the records code 11721- debridement of nails. Review of the 2/3/23 podiatrist consult notes indicated the same code and the same similarities in the records. The Corporate Nurse said perhaps the 11721 was a pay code they used to bill for services. The Corporate Nurse said they had a computer system Plan of Care (POC) that triggered when to do the skin assessments. She was checking that system to determine why assessments were not completed as they should have been. She could not tell if the system did not trigger the need to do the assessments or if staff had just no completed them as required. During an interview on 8/15/23 at 12:40 p.m. the DON said she could not determine who put the bandage on Resident #1's foot that was discovered on 8/8/23. During an interview on 8/15/23 at 2:00 p.m. with RN K and the Corporate Nurse, RN K said she saw Resident #1's foot but it had been a while, about 6 weeks. She said she had not seen a bandage on his foot and did not remember what the foot looked like. Corporate Nurse said RN K completed a skin assessment on Resident #1 on 6/19/23 (the day the PTA said Resident #1 was complaining of foot pain) RN K said she could not remember what the foot looked like. She said all diabetic residents had the thick toenails with fungus. She did not remember anything different about Resident #1's feet. During an interview on 8/16/23 at 3:38 p.m. LVN L said she never saw Resident #1's foot. (She completed Resident #1's a skin assessment on 7/10/23.) Record review of the facility's skin management documentation workflow dated 5/23/22 indicated to complete skin assessments on admission observation. Document all skin alterations to include abrasions, bruises, burn, dermatitis, laceration, rash, skin graft, skin tear, surgical incision, and ostomies and other areas. Complete a weekly Braden Scale observation each week post admission for three weeks. Complete weekly head to toe skin inspections. These are to be competed and documented in the POC computer system as they are scheduled. Record review of an in-service dated 8/10/23 indicated Nursing Care of the Older Adult with Diabetes indicated Skin and Foot Care: Skin should be kept as dry and clean as possible apply lotion to dry skin as needed unless contraindicated. Use antiseptic technique in caring for any lacerations, abrasions of or breaks in skin integrity, and report the condition immediately to your supervisor. Bathe the feet in warm hot water as necessary to keep clean. Keep the feet dry, especially between the toes. Encourage the use of non-constricting, well-fitting shoes, slippers, and hose. Keep the feet warm without the use of external heat sources Record review of the facility's in-service conducted on 8/10/23 the in-service indicated CNAs reporting and documenting skin injuries on weekly shower sheets and PRN notifications. The in-service indicated CNAs should report all skin injuries, discoloration, skin tears, lacerations, blisters, pressure injuries, open areas, to the charge nurse immediately. The area should be indicated on the CNA shower sheets when turned into the nurse, after notification to the charge nurse. Resident skin should be checked during showers/ bed baths, turning and repositioning, dressing, and toileting. CNAs should be moisturizing resident skin daily, and using moisture barrier to resident buttocks, peri-area, and groins after performing incontinent care. If there was a dressing without nursing initials or dates are found to be in place, notify the charge nurse immediately. If dressings become dislodged, or soiled, notify the charge n [TRUNCATED]

Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent an elopement for 1 of 6 residents reviewed for elopement. (Resident #1) The facility did not develop interventions to address Resident #1's preoccupation with going home which lead to her eloping. The psychologist failed to communicate a change in the resident's behavior regarding a desire to go home during 2 visits. Resident #1 was missing from the facility for approximately 6 hours before staff were aware she was not in the facility. The resident was found in a nearby city 12 miles from the facility approximately 20 hours after she was determined to be missing. This was determined to be past non-compliance immediate jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of elopement, severe injury, or death. Findings included: Physician order [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated to monitor sleep patterns at night. The MDS dated [DATE] indicated Resident #1 had moderately impaired cognition and required supervision and set-up help with bed mobility, transfer, walking, dressing, eating, toilet use and personal hygiene. The resident had behavioral symptoms that were not directed towards others, she rejected care, and her behaviors were worsening. A care plan dated 02/12/19 did not address Resident #1 being an elopement risk, discharge plan, or problems with sleep patterns at night. A care plan revised 4/15/19 indicated a problem with a start date of 2/2/18 regarding Resident #1 requiring limited assistance of 1 staff for bed mobility, transfers, toileting, eating, and bathing due to cognitive loss. An approach was to have the call light near and answer promptly. A care plan revised 4/15/19 indicated a problem with a start date of 10/12/18 regarding Resident #1 having behaviors of self-isolation. Approaches included monitoring her for behaviors and report to the physician as needed and refer to psychological services. A care plan revised 4/15/19 indicated a problem with a start date of 2/2/18 regarding Resident #1 having a [DIAGNOSES REDACTED]. Approaches included administer [MEDICAL CONDITION] medications as ordered 30 minutes prior to morning meal. An undated Elopement Risk Evaluation indicated Resident #1 was not exit seeking at that time. A progress note dated 3/21/19 by Psychologist E indicated Resident #1 strongly wanted to go home. A progress note dated 4/4/19 by Ph.D. E indicated Resident #1 had become preoccupied with going home. An incident report dated 04/11/19 at 5:40 a.m. completed by LVN B indicated when the nurse completed her last rounds Resident #1 was not where the nurse had last seen her, so she checked Resident #1's room. Resident #1 was not in her room either. The staff was alerted and searched for Resident #1. The DON, administrator, and police department were notified. A nurse's note dated 04/11/19 at 7:16 a.m. indicated when the nurse was checking on residents, she saw Resident #1 was not in the same place she had last seen her. The nurse checked Resident #1's room, and she was not there either. The staff were alerted and started a search for Resident #1. The resident was last seen at 2:40 a.m. in the dining room on the couch watching television. The search for Resident #1 was started at 5:40 a.m. The DON and police department were notified along with Resident #1's parents. The police department started a search for Resident #1 also. A nurse's note dated 04/11/19 at 7:00 p.m., indicated Resident #1's mother called the facility, said Resident #1 was at her house, and the facility needed to come get her. A nurse's note dated 04/11/19 at 7:30 p.m., indicated Resident #1 returned to the facility accompanied by the DON and ADON. The policed talked to Resident #1, and she was moved to the locked unit. An undated signed statement completed by LVN A indicated she was informed by LVN B Resident #1 was not in her room and could not be found. The statement indicated she was told by CNA H Resident #1 was last seen in the television room about 2:30 a.m. An undated signed statement completed by LVN B said she did her last rounds and did not see Resident #1 where she had last seen her. She said she checked Resident #1's room, and she was not in their either. She said she alerted the staff that Resident #1 was missing and started a search for her. She said she saw Resident #1 in the dining room on the couch watching television at 2:40 a.m. She said the search was started at 5:40 a.m., and the DON, administrator, and police were notified thereafter. An undated signed statement completed by CNA H indicated she last saw Resident #1 at 2:04 a.m. sitting in the dining room watching television. An undated signed statement completed by CNA J indicated she did her last rounds around 5:45 a.m. on 04/11/19. She said her and LVN B noticed Resident #1 was not in her room. She said she had last seen Resident #1 around 2:10 a.m. in the kitchen area on the couch. She said they searched all the closets, bathrooms, and rooms. She said she walked around the building, but still did not find her. An incident report from the local police department dated 04/11/19 at 6:44 a.m. indicated Resident #1 was last seen at 2:45 a.m. wearing jeans and a dark colored hoodie. At 6:58 a.m. Officer K needed help searching for Resident #1. At 11:00 a.m. a region alert was put out, and Resident #1 was listed as a missing person. Officer K's narrative indicated on 04/11/19 at about 6:30 a.m. the police department was notified Resident #1 was missing by the facility. The narrative indicated he requested assistance from two other officers and the fire department to help with the search. The narrative indicated a nearby County Sheriff's Department called and told them one of their deputies had contact with Resident #1 about 11:40 p.m. on 04/10/19 on a nearby highway. He said Resident #1 told the deputy she was walking to her house in another city, so he gave her a ride to a restaurant in the city. Officer K said he returned to the nursing home and asked the administrator what time Resident #1 was last seen. He said the administrator said she had two signed statements which indicated Resident #1 had last been seen at 2:04 a.m. He told the administrator he was concerned about that information because Resident #1 had been given a ride at 11:40 p.m. by a sheriff deputy. He said, it appeared that the employees that gave her those statements had not been truthful about their times on their statements. Officer K said, Even if she had been seen at 2:40 like they said, it still took them over four hours to notify the police that she was missing. He said the search was called off in the local area about 11:30 a.m. He said at about 6:30 p.m. the administrator called the police and told them Resident #1's minister had seen her at a friend's house in Kilgore and took her to her mother's house. During an observation on 04/17/19 at 5:30 a.m. the facility's parking lot in the front of the facility was dark. There was a minimal amount of light from businesses across the highway. On the back part of the facility, there were large trees separating the property from a train track. It was very dark on the backside of the facility. The facility's property was in a curve on the highway and did not have a street light. During an interview on 04/16/19 at 9:30 a.m., the administrator said Resident #1's elopement happened 4/10/19 on the 10 p.m. to 6 a.m. shift. She said she was originally told by a staff member she was seen during the 2 a.m. hour. She said during her investigation, she found out Resident #1 had not been seen since 10 p.m. on 04/10/19 and she was not found until 4/11/19. She said the nurse assigned to Resident #1 made rounds at midnight, she said the nurse said it looked like the resident was in the bed, but she did not pull the covers back to visually see Resident #1. She said it was not abnormal for Resident #1 to be up walking around the facility in the middle of the night. She said Resident #1 walked around the exterior of the building for exercise. The administrator said about 5:45 a.m. on 04/11/19 was when the staff realized Resident #1 was missing. She said the staff started looking for Resident #1 in the building and on the grounds. She said the local police department was contacted and they started a search for the resident. The administrator said at 10 p.m., people could exit through the front, but nobody could come in the front because it was locked. The administrator said several of the employees said they saw Resident #1 sitting on the couch in the lobby at the 10 p.m. shift change. She said the family was notified Resident #1 was missing from the facility on 4/11/19. The administrator said she found out the local Sheriff's Department saw the resident walking on the nearby highway. The administrator said Resident #1 was stopped by a deputy who drove her to a restaurant in another city and left her. The administrator said the resident's parents had two houses a short distance from the restaurant and that was where the resident was found. The administrator said Resident #1 was found by her parents in one of the houses watching television, she said Resident #1 said she just wanted to go home. During an interview on 04/17/19 at 11:11 a.m., Resident #1 nodded yes indicating she wanted to go home. Resident #1 would not verbally speak or answer any other questions. During an interview on 04/17/19 at 5:35 a.m., LVN A said she worked 4/10/19 the night Resident #1 was missing. She said she was not her assigned nurse, nor did she remember seeing her throughout the shift. She said she was told Resident #1 was missing by LVN B. She said LVN B was told by an aide who was doing her final round around 4:00 a.m. LVN A said all the employees searched the entire building looking for Resident #1. She said LVN B called the DON to report Resident #1 missing around 5:40 a.m. She said she thought the administrator called the police department. She said since Resident #1 eloped, the staff must make complete and more frequent rounds of checking on the residents. She said the front door must be locked at 10:00 p.m. During an interview on 04/17/19 at 5:40 a.m., CNA C said she worked the night of 04/10/19 when Resident #1 was missing, she said she did not see Resident #1 during her shift because she was assigned to another unit. She said when she came out of the locked unit to help the aides do their final rounds LVN B told her Resident #1 was missing. She said the staff looked everywhere and could not find Resident #1. She said they were supposed to check on residents at least every 2 hours. She said one of the aides that worked the 2 p.m. to 10 p.m. shift the day Resident #1 eloped said the facility was short staffed that day, she said that could be a reason Resident #1 could have eloped. During an interview on 04/17/19 at 9:48 a.m., CNA D said she worked the day Resident #1 was missing on 04/11/19. She said the administrator came into the facility, called a code, and all the staff searched for Resident #1. She said since the incident Resident #1 was relocated to the locked unit. During an interview on 04/17/19 at 12:00 p.m., psychologist E said he had cared for Resident #1 for years. He said he saw her on 04/04/19, and Resident #1 told him she wanted to go home because she did not feel like she belonged at the facility. He said he did not tell the staff, but he felt they were aware of Resident #1's desire to go home. He said for about the last 6 months, Resident #1 had been telling him she wanted to go home. He said Resident #1 had resided at the facility for years and never expressed a desire to go home. He said he wrote a progress note on 4/4/19 that Resident #1 was preoccupied with going home. He said Resident #1 started having odd behaviors like hiding in her closet, but he did not think about her being at an increased risk of eloping. During an interview on 04/17/19 at 11:20 a.m., MA F said she arrived to work on the morning Resident #1 was missing (04/11/19) and saw police cars at the building. She said Resident #1 was still missing when she got off work at 2:00 p.m. She said Resident #1 missed medications the morning of 04/11/19. She said Resident #1 had not being interacting and being verbal with others as much as she had in the past. During an interview on 04/17/19 at 2:51 p.m. the DON said herself and the social worker reviewed progress notes written by psychologist E. She said they had not reviewed the psychologist's notes for Resident #1 prior to the resident eloping. She said psychologist E's progress notes were difficult to read due to his hand writing. During an interview on 04/17/19 at 3:28 p.m. the SW said she started working at the facility in (MONTH) (YEAR). She said she read the psychologist's progress notes if a resident with an issue was seen. She said Resident #1 started exhibiting odd behaviors like standing in front of the bathroom mirror in the dark and hiding in closets. She said Resident #1's behaviors were very abstract. She said she read parts of psychologist E's progress note from 04/04/19. She said she saw Resident #1 wanted to go home, and psychologist E recommended encouraging Resident #1 to eat and take her medications. She said she did not read the progress note until after Resident #1 had eloped. She said if she would have known Resident #1 wanted to go home, she would have arranged for a care plan meeting to discuss her going home. She said about 2 or 3 weeks ago Resident #1 was walking around the outside of the facility at night. She said she and the DON told Resident #1 she did not need to be doing that because it was not safe for her. She said Resident #1 wanted to go home, she knew eloping was not the way to do it. She said she had started making a list for psychologist E each week of which residents to see. She said Psychologist E was told to write more legible too. She said he was doing better with his penmanship. She said she could follow up with the residents better since she started making a list of which residents psychologist E needed to see. During an interview on 04/17/19 at 3:59 p.m. the DON said residents should be checked every 2 hours, but she could not find a policy that said residents needed to be checked on every 2 hours. An undated Missing Resident/Elopement policy indicated it was, the policy of this facility to provide a safe and secure environment for all residents. It was determined the above failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 04/10/19 through 4/11/19. The facility took the following actions to correct the non-compliance on 4/11/19: An in service on elopement and abuse/neglect dated 04/11/19 completed by the DON indicated residents were to be visually checked on every hour and were to specify where the resident was when they were seen. An employee memorandum signed by the DON on 4/11/19 indicated LVN B failed to do a sufficient midnight check to ensure Resident #1 was in the building. LVN B said, it seemed like Resident #1 was in bed when she checked on her, but she did not pull the covers back for a visual. The memorandum indicated LVN B was terminated on 4/15/19. An employee memorandum signed by the DON and administrator on 4/15/19 indicated CNA J said she saw Resident #1 in the building when she was going off another person's information and did not check on Resident #1 during the night. Resident #1 eloped at 10:30 p.m. on 04/11/19, and CNA J did not check and ensure Resident #1 was in the building. CNA J was suspended pending the investigation results and later terminated. On 04/17/19, the surveyor confirmed the non-compliance was removed by: The DON in-serviced and tested staff on 04/11/19 on locking the front door every night, how to conduct the midnight census, the abuse and neglect policy, elopements, and missing residents. 2 CNAs and a MA were interviewed and said they received training on 04/11/19 prior to the surveyor's entrance regarding locking the front door every night, abuse and neglect policy, elopements, and missing residents. 3 nurses were interviewed and said they received training on 04/11/19 prior to the surveyor's entrance regarding locking the front door every night, the midnight census, the abuse and neglect policy, elopements, and missing residents. An every 15 minute check form dated 4/11/19 indicated all residents were checked on hourly. Review of six resident charts indicated an elopement risk evaluation was completed on 04/11/19. The social worker said she would read all psychiatrist and pshychologist progress notes and make sure she followed up with each resident accordingly. On 04/12/19 a referral was made to several behavioral health centers, but Resident #1 refused in-patient treatment.

Based on observation, interview, and record review, the facility failed to implement interventions based on a comprehensive assessment to prevent development and worsening of pressure ulcers for 1 of 4 residents reviewed for pressure ulcers. (Resident #11) The facility did not provide pressure relieving interventions for Resident #11. The resident was admitted without any pressure ulcers and was identified to be at a mild risk for development of pressure ulcers. Resident #3 developed 2 facility acquired stage 2 pressure ulcers approximately 20 days after he was admitted . The pressure ulcers worsened and he developed 2 additional stage 2 pressure ulcers 5 days later. This failure could place 2 residents with pressure ulcers at risk for developing new pressure ulcers and a decline in existing pressure ulcers. Findings included: 1. Consolidated physician orders [REDACTED].#11 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. An admission evaluation dated 03/24/17 indicated Resident #11 was admitted with redness on his buttocks, but did not have any pressure ulcers. An admission Braden risk assessment dated [DATE] indicated Resident #11 was at mild risk for developing pressure ulcers. The most recent MDS dated [DATE] indicated Resident #11 had moderately impaired cognition, clear speech, made his needs known, and usually understood others. Resident #11 required supervision of one staff for bed mobility, limited assistance of one staff for transfers, and was frequently incontinent of bowel and bladder. The MDS indicated Resident #11 was at risk of developing pressure ulcers. The most recent care plan dated 04/14/17 indicated Resident #11 had a stage 2 pressure ulcer on his left inner buttock and a stage 2 pressure ulcer on his left lateral (outer) ankle. Interventions included he was to receive assistance with turning/repositioning every 2 hours and as needed, to be provided pressure relieving devices for his bed and wheelchair, padding to be used between pressure areas, and positioning devices provided for proper body alignment. The treatment for [REDACTED]. The treatment for [REDACTED]. The Daily Pressure Ulcer Documentation sheet indicated Resident #11 had a stage 2 pressure ulcer on his left inner buttock from 04/14/17 - 04/19/17. The treatment was moisture barrier. During an interview on 04/20/17 at 1:34 p.m., the ADON said the daily pressure ulcer documentation sheets dated 04/14/17 indicated Resident #11 was identified with a pressure ulcer on his left buttock; however, it was actually was the right buttock that developed the pressure ulcer. The ADON said the pressure ulcer on the resident's left buttock was not identified until 04/19/17. The Pressure Ulcer Scale for Healing (PUSH) Tool 3.0 for Resident #11 indicated the resident had a left buttock (should be right) pressure ulcer: *4/14/17- measuring 4cm x 0.5cm with no recorded depth. Granulation tissue in the wound bed of the left buttock. The Pressure Ulcer Scale for Healing (PUSH) Tool 3.0 for Resident #11 indicated the resident had a left lateral (outer) ankle pressure ulcer: *4/14/17- measuring 1cm x1cm with granulation tissue present in the wound bed. During an observation and interview on 4/18/17 at 8:10 a.m., Resident #11 was lying in bed on his back with the head of bed elevated greater than 30 degrees. The room smelled of urine. Resident #11 said he could not get out of the bed without assistance of a mechanical lift. He said he required assistance to turn in the bed. During an observation and interview on 4/19/17 at 9:30 a.m., Resident #11 was lying on his back in the bed. The head of bed was elevated greater than 30 degrees. During an observation on 4/19/17 at 12:35 a.m., Resident #11 remained on his back in bed, the head of bed elevated 45 degrees, eating lunch. During an interview 4/19/17 at 12:41 p.m., Resident #11 said the pressure ulcer on his buttock hurts. He said the nurse changed the dressing on his left ankle before breakfast and applied a treatment to his buttock. Resident #11 said he had not been repositioned off his back today. Resident #11 said he was not being turned every 2 hours and he had not refused to allow staff to reposition him. He said he would like to turn and change positions, but was unable to do it himself. During an observation on 04/19/17 at 2:50 p.m., Resident #11 remained on his back lying in bed. He had with a pillow under his feet that was not positioned to relieve pressure on his heels or right ankle. The resident had sheep skin booties on and his heels rested on the bed. The outer aspect of the right ankle over the boney prominence was lying against the pillow. During an interview on 4/19/17 at 3:40 p.m., CNA H said she turned Resident #11 every two hours and had just completed incontinence care. CNA H said Resident #11's pressure ulcer on his buttock looks about the same. CNA H said she had not seen the pressure ulcer on the left ankle because it is always was covered with a dressing. During an observation and interview on 4/19/17 at 3:41 p.m., Resident #11 was lying in bed with his legs elevated on a pillow; however, his heels were on the mattress. The resident's right foot was externally rotated where the boney prominence of the outer right ankle was lying against the pillow he was unable to bring his right foot upright to midline or move his lower extremity. Resident #11 said he had lost the function of his legs. Resident #11 had sheep skin booties on each foot. The ADON asked CNA H to remove the resident's sheep skin heel booties and off load his feet and ankles. The ADON she said the booties would not protect Resident #11 from pressure on his feet and ankles. The right outer ankle over the boney prominence had a quarter-sized reddened area that was slow to blanch. A [MEDICATION NAME] dressing was on the left outer ankle dated 4/19/17. CNA H turned Resident #11 on his right side without assistance of another staff, pulling on the draw sheet and pushing him with her hands on his back and buttocks. The ADON did not intervene and assist in the repositioning or request CNA H obtain other assistance. Resident #11 was unable to pull himself onto his right side or maintain position on his right side without staff support. Resident #11's buttocks had barrier cream on them and soft stool was noted on the anus. CNA H cleansed the barrier cream from the buttocks and bowel movement from the anus. Three open stage 2 pressure injuries were observed, one of the left inner buttocks; one on the right inner buttock, and one in the center of the right buttock to the right of the other. A large area of redness surrounded the stage 2 pressure injuries of the right and left buttocks and extended over the sacrum. During an interview on 4/19/17 at 3:50 p.m., CNA H said she should have had assistance of another staff when turning Resident #11. The ADON did not intervene to stop CNA H from performing turning without assist of another staff. During an interview on 4/19/17 at 3:53 p.m., the ADON said she routinely provided wound care and measured pressure ulcers weekly. The ADON said Resident #11 had a stage 2 pressure ulcer on his right buttock and a stage 2 pressure ulcer on his left ankle. She said they were treating the resident's buttock pressure injury with barrier cream and applied a [MEDICATION NAME] dressing to the pressure ulcer on his left outer ankle. During an observation on 4/19/17 at 4:00 p.m., the ADON measured Resident #11's pressure ulcers as follows: 1) Left buttock (new) - stage 2 measuring 3.0 cm x 1.0 cm x <0.1 cm with beefy red center. Surrounding skin intact, reddened and non blanchable. 2) Right buttock nearest the midline of buttock (developed 04/14/17) - stage 2 measuring 6 cm x 1.3 cm x < 0.1cm with beefy red center. Surrounding skin intact, reddened and non blanchable. 3) Mid-right buttock new - stage 2 measuring 0.5 cm x 0.5 cm x <0.1cm, beefy red wound bed; Surrounding skin intact, reddened and non blanchable. 4) Sacrum and buttocks area - stage 1 measuring 10 cm x 10 cm. The skin was dark pink and non-blanchable. It encompassed the pressure ulcers of the right and left buttocks. During an observation and interview on 4/19/17 at 4:10 p.m., the DON re-measured Resident #11's following pressure injuries #1 and #2, and measured pressure injury #5 the ADON stating she could not see and was unable to perform accurate measurements on the pressure injuries previously measured. 1) (Re measured) Left buttock near the midline of the buttock- measuring 3.0cm x 1.0cm x <0.1cm - 2) (Re measured) Right buttock nearest the midline of the buttock measuring 4.5 cm x 1.5 cm x <0.1cm. 5) Left outer ankle - unstageable measuring 1.5 cm x 1.5 cm x unknown; the wound bed was beefy red with 30% yellow slough in the center of the wound bed. The wound edges were clearly defined and could have been measured. The ADON said, Oh you see slough in it. During an observation and interview on 4/19/17 at 4:14 p.m., the DON said the open pressure ulcers on Resident #11's right buttock were stage 2s and the left buttock pressure ulcer was a stage 2. The DON said the pressure ulcer on his left ankle was unstageable due to the slough. The DON and ADON agreed the pressure ulcers had worsened or were not responding to the current treatment. During an interview on 04/20/17 at 1:25 p.m., the DON indicated Resident #11's moisture barrier treatment may not have been the proper treatment for [REDACTED]. The revised Skin System policy dated 08/23/10 indicated the following: 4. The Health Care Plan should be updated with treatment changes as well as with changes in the PU presentation. Each site requires a separate individualized care plan. 6. The weekly Documentation Flow Sheet form is completed weekly for residents regardless of the presence/absence of skin interruptions of any type. In no skin interruption is identified, the nurse assessor will document such weekly . 7. The facility DON is responsible for assignment of weekly shin assessments 8. The DON utilizes her nursing daily start-up tool to validate prior assigned assessments are completed timely. In the event that an assessment was not completed timely, the DON has a responsibility to re-teach the system to licensed nursing staff 10. The facility DON should visualize areas related to pressure weekly and be able to report observations to the Standards of Care Team members. The DON is also visually validating the accuracy of the description of the pressure ulcer documented on the weekly skin assessment form. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 05/05/17: .A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed . The CMS 672 dated 04/17/17 indicated 2 residents with pressure ulcers.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 8 residents reviewed for changes in condition and pain. (Resident # 3) The facility did not address Resident #3's complaints of pain, did not provide pain assessments, and did not provide interventions when the resident complained of pain. The facility did not recognize Resident #3's change in condition when he developed painful blister like rash on his buttocks. The facility did not assess Resident #3 for urine output, urine retention, or pain when the resident's [MEDICATION NAME] was stopped. Resident #3 had prostate problems and was ordered [MEDICATION NAME] after his [MEDICATION NAME] was discontinued on 3/13/17. The f the facility did not administer the [MEDICATION NAME]. The facility did not ensure Resident #2's indwelling urinary catheter tubing was cleaned during incontinent care and the drainage bag was not kept below the resident's bladder. This failure could place 19 residents receiving pain management at risk for injury and not receiving timely interventions to assess and treat pain. This failure could place 7 residents receiving preventive skin care at risk for the development and worsening of unidentified skin concerns. Findings included: 1. A physician consolidated orders dated 3/1/17 indicated Resident #3 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The orders included a head to toe skin assessment every week on Thursday (6-2 shift) and apply a moisture barrier to his buttocks every shift and as needed. The physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 had severe cognitive impairment, unclear speech, was sometimes understood, and usually understands others. Resident #3 required extensive assistance of one person for bed mobility, transfer, locomotion, dressing, and toileting, and was always incontinent of bowel and bladder. He had no impairment of range of motion to upper or lower extremities and required a wheelchair for mobility. The MDS indicated Resident #3 coughed and choked during meals and medication pass and had a significant weight loss. Resident #3 was at risk for the development of pressure ulcers based on a formal assessment instrument and clinical assessment with no identified skin concerns. A care plan dated 1/16/17 indicated Resident #3 was at risk for chest pain with interventions to observe for chest pain and abnormal pulse and report to the physician. There were no interventions to address Resident #3's limited verbal ability to express pain. A care plan dated 1/16/17 indicated Resident #3 had fragile skin with risk for breakdown, approaches included monitoring for signs and symptoms of skin breakdown or bruising and notification of the physician with changes related to skin breakdown. During an observation and interview on 4/17/17 at 1:22 p.m., Resident #3 was sitting in a Geri-chair in front of the nursing station, grimacing and trying to throw his feet over the side of the extended foot rest. He was moaning in pain and said his back and butt were hurting. Resident #3 was unable to relieve the pressure on his buttocks. Resident #3 did not have a pressure reducing device in the seat of the Geri-chair. Resident #3 had contractures of the fingers of his right hand. The ADON approached Resident #3 and encouraged him to be still until she could get staff to put him back to bed. The ADON said Resident #3 did not have skin breakdown. A Pain Management Flow sheet for April, 2017 for Resident #3 did not have any entries of identified pain, pain rating, or interventions, such as vital signs or comments or response to interventions through the 18th day of the month. A Treatment Flow sheet dated 4/1/17 indicated Resident #3 did not receive an assessment for pain every shift on shifts 6:00 a.m. to 2:00 p.m. and 2:00p.m. to 10:00p.m. on 4/17/17 and 4/18/17. A Treatment Flow sheet dated 4/1/17 indicated Resident #3 did not receive moisture barrier to his buttocks every shift as ordered. On 4/16/17 shift 2:00 p.m. to 10:00p.m., and 4/17/17 shifts 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. the barrier cream was not initialed. During an observation on 4/17/17 at 1:30 p.m., CNA B and CNA E transferred Resident #3 from his Geri-chair to his bed. Resident #3 did not have a pressure reducing cushion in the chair. Resident #3's brief was removed and wet with urine. CNA B performed incontinent care. There was no appearance of barrier cream on the buttocks or perineum. Resident #3 complained of pain and winced when CNA B wiped across his left buttock and under his right buttock. A cluster of fluid filled skin eruptions was on his left buttock, the approximate size of an orange in circumference, with redness and swelling. Multiple open red [MEDICAL CONDITION] were noted under the right buttock and in the fold between the leg and buttock. CNA E said she would report the blisters to the charge nurse. During an interview on 4/18/17 at 4:40 p.m., LVN J said she examined Resident #3's skin on 4/17/17 after the CNA E reported it to her. LVN J said she did not see any change in Resident #3's buttocks or identify a rash on the left buttock or under the right buttock. LVN J said all she saw was a red spot on the resident's tailbone that was being treated with barrier protective cream. LVN J said she did not notify the physician or document her findings. LVN J said Resident #3 complaints of pain in his lower back and buttocks were related to his being up in a Geri-chair or chair and staff usually put him back to bed when he complained. LVN J said there were no orders to treat pain. LVN J did not document an assessment or interventions to address Resident #3's complaint of pain or the newly identified fluid filled blisters of the buttocks. During an interview on 4/19/17 at 8:47 a.m., ADON/LVN F said LVN J said she would perform a skin assessment on Resident #3 on 4/17/17. The ADON said she expected LVN J to perform a thorough skin assessment and assess for pain. She said LVN J should have notified the physician of Resident #3's complaints of pain and rash and obtained treatment orders. During an observation on 4/17/17 at 5:30 p.m., Resident #3 was sitting in the Geri-chair. During an observation and interview on 4/18/17 at 8:19 a.m., CNAs E and A transferred Resident #3 from his wheelchair to the bed. Resident #3 complained of pain in his lower back and buttocks. CNA E said she first noticed the rash yesterday (4/17/17) on Resident #3's buttock and notified the ADON. The nursing notes for Resident #3 from March 13, 2017 to April 18, 2017 at 4:40 p.m. indicated the most recent nursing entry was dated 4/12/17. No nursing entries were made in follow-up to Resident #3's complaint of pain on 4/17/17 or 4/18/17 or the development of skin issues. During an observation on 4/19/17 at 8:22 a.m., Resident #3 complained of pain and attempted to reposition himself off his tailbone while sitting in a wheelchair on pummel cushion (wedge cushion). During an interview on 4/19/17 at 9:57 a.m. the DON said she recognized Resident #3 was in pain when she observed him in the Geri-chair and wheelchair on numerous occasions since she took the position of DON over the past week. She said Resident #3's facial expressions and body language evidenced significant pain whether he could verbalize it or not. The DON said she expected staff to respond to complaints of pain timely, perform a thorough assessment for pain and skin concerns, document findings, notify the physician of changes, and obtain treatment or medications as ordered. The DON did not have an explanation for the lack of follow up on Resident #3's complaints. 2. A Care Plan with a start date of 1/23/17 indicated Resident #3 had impaired urinary elimination related to an enlarged prostate and had lower urinary tract symptoms; Resident #3 was receiving [MEDICATION NAME] and [MEDICATION NAME]. The long term goal indicated Resident #3 would have complete bladder emptying and included approaches to assess urinary output, record the amount, type, color, and odor. A Consultant Pharmacist's Medication Regimen Review dated 3/8/17 indicated Resident #3 was receiving [MEDICATION NAME] to treat [MEDICAL CONDITION], a condition that restricted the flow of urine from the bladder to the urinary outlet. A recommendation was made to discontinue [MEDICATION NAME] due to increased risk of adverse effects such as blood pressure shifts if crushed or chewed. A recommendation to replace [MEDICATION NAME] with [MEDICATION NAME] was recommended if Resident #3 required his medications crushed. A physician progress notes [REDACTED].#3 had [MEDICAL CONDITION] and an enlarged prostate with lower urinary tract symptoms. A physician telephone order dated 3/13/17 indicated [MEDICATION NAME] was discontinued and an order to start [MEDICATION NAME] 2mg every night at bedtime was received for Resident #3. A Medications Flow sheet dated 4/1/17 indicated [MEDICATION NAME] was ordered 3/14/17 and the medication remained unavailable through 4/17/18. As of 3/14/17 [MEDICATION NAME] was no longer being given. Nursing notes for Resident #3 from March 13, 2017 to April18, 2017 at 4:40 p.m. did not provide any nursing entries since 4/12/17. There were no nursing entries on 3/13/17 that addressed the discontinuance of [MEDICATION NAME] and a new order to start [MEDICATION NAME]. The notes did not address the discontinuance of medication ([MEDICATION NAME]) or not having available ordered medication of ([MEDICATION NAME]) since order date of 3/13/17. Nursing notes for Resident #3 on 4/18/17 at 3:30 p.m. completed by LVN K indicated the medication [MEDICATION NAME] 2mg at bedtime ordered on [DATE] still had not been received. During an interview on 4/18/17 at 1:55 p.m., MA G said she told the prior DON and nurses Resident #3's [MEDICATION NAME] medication was not available. MA G said the medication needed prior approval before the pharmacy would fill it and the pharmacy notified the facility on several occasions, but nothing was ever done about it. MA G said it was the nurse's responsibility to follow up to assure the medication was delivered or the physician was notified. MA G said Resident #3 had not received [MEDICATION NAME] yet, since it was ordered on [DATE]. During an interview on 4/18/17 at 1:57 p.m., MA N said the charge nurses were notified the [MEDICATION NAME] was not available to administer to Resident #3. MA N said she remembered hearing MA G report the medication was not available. MA N said it was the nurses' responsibility to follow up with the physician and pharmacy. During an observation and interview on 4/18/17 at 2:05 p.m., LVN K said she did not know there was a change of orders for Resident #3's medication on 3/13/17. LVN K said there was no follow-up because the 24 hour report did not indicate a change in condition. LVN K notified the pharmacy per telephone concerning the [MEDICATION NAME]. LVN K said the pharmacy stated they notified the facility on 3/14/17, 3/15/17, 3/20/17, and 3/21/17 they were waiting for the physician's approval. LVN K said she would notify the physician now and said she would have normally forwarded the pharmacy request for a physician authorization and follow up as needed. During an interview on 4/18/17 at 4:40 p.m., LVN J said she was unaware Resident #3 had orders for [MEDICATION NAME] since 3/13/17 and had not received the medication. During an interview on 4/19/17 at 9:57 a.m., the DON said she expected staff to notify the physician of changes and obtain treatment or medications as ordered. 3. physician's orders [REDACTED].#2 admitted [DATE] and had [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 had severely impaired cognition, understood others and was understood by others. The MDS indicated Resident #2 required the extensive assistance of one staff for transfer the resident had an indwelling catheter. The most recent care plan revised 3/27/17 indicated Resident #2 had a problem of indwelling catheter and was at risk for infection. An approach was to observe catheter, and provide care every shift. A nursing note dated 3/23/17 indicated Resident #2 had a urine culture. The note indicated Resident #2 had a urinary tract infection and a new order for Bactrim (an antibiotic) was given to treat his urinary tract infection. During an observation on 4/17/17 at 12:04 p.m., Resident #2 was in the dining room with his catheter bag in his wheelchair seat beside his hip. During an observation on 4/17/17 at 5:06 p.m., Resident #2 was in the dining room with his catheter bag in his wheelchair seat beside his hip. During an interview on 4/17/17 at 11:59 a.m., the DON said Resident #2 went to the wound care center and the physician saw blood in his catheter bag and wrote an order for [REDACTED].>During an interview on 4/18/17 at 8:15 a.m., the DON said Resident #2's catheter bag should not be in the seat of the wheelchair. She said the catheter bag should be below the bladder at all times. She said when Resident #2 was in his wheelchair the catheter bag should below his bladder secured to the wheelchair. During an observation and interview on 4/19/17 at 9:20 a.m., CNA A did not wash his hands prior to performing catheter care. While CNA A performed catheter care he raised the catheter bag 3 times above Resident #2 while Resident #2 was lying in bed. After surveyor intervention CNA A said he did not know you could not raise the catheter bag above the bladder. During an interview on 4/19/17 at 9:50 a.m., LVN D said a catheter bag should always be below the bladder during incontinent care or while the resident was sitting in a wheelchair. During an interview on 4/19/17 at 9:52 a.m., the DON said staff should wash their hands before and after any care on a resident. The DON said staff may need more education regarding making sure the catheter bag was not above a resident's bladder. The website https://www.cdc.gov/hai/pdfs/cautiguideline2009final.pdf Guidelines for Prevention of Catheter-Associated Urinary Tract Infections 2009 accessed 4/21/17 at 11:27 a.m., indicated the proper techniques for urinary catheter maintenance included keeping the collecting bag below the level of the bladder at all time and using standard precautions during any manipulation of the catheter or collection system. A Pain Assessment and Management policy and procedure with a revision date 5/1/14 indicated the following: Residents residing in long term care facilities are likely to have multiple [DIAGNOSES REDACTED]. Optimizing pain assessment and management can alleviate many of these conditions and can improve quality of life . Fundamental Information: Pain refers to any type of physical pain or discomfort in any part of the body. Pain may be localized to one area, or may be more generalized. It may be acute or chronic, continuous or intermittent, or occur at rest or movement. The pain experience is very subjective; pain is whatever the resident says it is. A full assessment for pain includes: --Origin, Location, Severity, Alleviating, Exacerbating factors --Current treatment and response to treatment . Procedure: Ask if they have experienced any pain in the past 7 days. If they state they have pain, take their word for it. Pain is a subjective experience. Ask to describe the pain . Observe for indicators for pain: . Moaning, crying, and other vocalizations, wincing or frowning and other facial expressions. Body posture such as guarding or protecting an area of the body, or lying very still. Decrease in usual activities. If they have dementia and cannot verbalize that they are feeling pain, symptoms of pain can be manifested by particular behaviors. --Residents will be assessed for pain on Admission, Annually, Quarterly, and with any Significant Change of Condition. Residents with pain will be assessed and monitored daily. --Assessment for pain will be done anytime a resident complains of pain or indicates non-verbally that they are experiencing pain. --Institute non-pharmacologic measures to promote physical comfort such as positioning, turning, applications of heat or cold (per physician order). Administer [MEDICATION NAME] as ordered, on time and titrate the medication dosage I frequency within prescribed guidelines. --Provide measures for distraction- relaxation, diversional, activities, music therapy, etc. --Obtain referrals for physical therapy, or occupational therapy as needed. --Interventions for pain management in the Comprehensive Care Plan will include measures to promote adequate bowel and bladder function, and measures to include relaxation. --Pain Management will be documented on the back of the Pain Assessment Form. --The Pain Assessment Form includes the frequency and intensity of signs and symptoms of pain and can be used to identify indicators of pain as well as to monitor response to pain management interventions. It also attempts to target the site of pain. A Skin System protocol with a revision date 8/23/10 indicated the following: .8. The DON utilizer her Nursing Daily Start-Up tool to validate prior assigned assessments are completed timely. In the event that an assessment was not completed timely, The DON has a responsibility to re-teach the system to Licensed Nursing staff . 9. In the event that a resident does exhibit a skin interruption of any type: Each site has separate form for documentation purposes. The intent of the separate form per site is to quickly and correctly track the healing progression or decline o each specific identified area. Abrasions, skin tears, lacerations, excoriations, hematomas, bruises, surgical incisions, burns, incontinent associated [MEDICAL CONDITION], rashes, [MEDICAL CONDITION], venous and arterial ulcers as well as pressure ulcers/sores are the types of interruption Licensed Nursing staff assesses weekly utilizing form . An undated Change in Resident's Condition or Status policy and procedure provided by the DON 4/19/17 at 10:45 a.m. indicated the following: .1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: .d. a significant change in the resident's physical/emotional/mental conditions; e. A need to alter the resident's medical treatment significantly .5. The nurse supervisor /charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . The CMS 672 dated 4/17/17 indicated 19 residents were on a pain management program and 7 residents were receiving preventative skin care. The CMS-672 dated 4/17/17 indicated 2 residents had indwelling catheters.

Based on observation, interview, and record review, the facility failed to implement their policies and procedures to prohibit neglect for 1 of 14 residents reviewed for neglect. (Resident # 4) Resident #4 had a history of [REDACTED]. Resident #4 coughed and regurgitated his food. The facility did not provide Resident # 4 his ordered diet of pudding thickened liquids to prevent Resident #4 from aspirating on liquids. This failure created an Immediate Jeopardy situation identified on 7/22/14. The Immediate Jeopardy was removed on 7/23/14. The facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 6 residents who had diet orders for thickened liquids at risk for choking, aspiration, or death. Findings included: Physician orders [REDACTED].# 4 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #4 had severe cognitive impairment, and required assistance with eating. Resident #4 had an active [DIAGNOSES REDACTED]. Nursing care plans updated 6/24/14 indicated Resident #4's goal was to have no signs or symptoms of aspiration for 90 days as evidenced by "...no: coughing, shortness of breath, oxygen levels below 90%, gurgling lung sounds or elevated temperatures..." The care plan indicated Resident # 4 was to be served a pureed high calorie, high protein diet with large portions, magic cups, and pudding thick liquids with all meals three times a day. The interdisciplinary team care plan meeting notes for 6/24/14 indicated Resident # 4's diet was pureed with honey thick liquids. A swallow study report dated 02/05/14 indicated during the procedure, Resident # 4 was provided honey thick liquids and exhibited "silent aspiration." Recommendations listed were pureed solids and pudding thick liquids. These recommendations were "...determined to be the most appropriate for the patient..." During an interview on 07/21/14 at 3:31 p.m., the speech therapist said she recommended the pudding thick consistency because during the swallow study the resident had "silent aspiration" with honey thick liquids. She described "silent aspiration" as the resident was not observed coughing, but during the x-ray it was noted the resident had slight amounts of liquids going into his lungs. She said if the resident was being observed coughing during the consumption of honey thickened liquids, then the resident was aspirating large amount of liquids. She said the resident's swallowing function could have changed since her assessment, but if she recommended the pudding thickened liquids and the physician agreed and ordered them, then that was what the resident should receive. The speech therapist said the resident would have an increased risk for aspiration pneumonia if he was not getting the correct consistency. A physician evaluation and management report dated 02/05/14 indicated Resident # 4 was at high risk of aspiration due to decreased oral control and poor oral awareness. A nutritional quarterly assessment dated [DATE] indicated Resident # 4 had a swallow study that recommended the resident receive a pureed diet with pudding thick liquids. A communication form between the dietitian and the attending physician dated 02/28/14 indicated a recommendation to change Resident #4's diet to high calorie, high protein with pudding thick liquids. A diet order and communication sheet dated 03/10/14 indicated Resident # 4 had a diet change and his liquids were to be pudding consistency. The diet Order Reports dated 07/01/2014 through 07/31/2014 indicated the following liquid consistency for Resident #4: " ...Start Date: 07/30/2013; ...Diet-Liquids: Honey Thickened Liquids ... " " ...Start Date: 03/10/2014; ...Diet: Hi Cal, Hi Pro, Pureed with Pudding Thick Liquids... " An admission and annual screening assessment completed by the dietician on 04/08/14 indicated Resident # 4's diet order was for pureed, high calorie, high protein diet with large portions and PTL (pudding thick liquids). The physical assessment category for eating performance did not indicate the resident had any swallowing problems. Additional documentation notes for the dates of 05/15/14, 06/10/14 and 07/16/14 all indicated the resident received a pureed, high calorie, and high protein diet with pudding thick liquids. A nutritional progress note dated 05/11/14 by the dietary manager indicated there had been no changes to Resident # 4's diet of pureed diet with honey thick liquids. The note also indicated the resident diet would be provided as ordered by the physician. During an observation on 7/20/14 at 5:20 p.m., Resident # 4 was sitting in his wheelchair in the dining room of the male secure unit. The resident's dinner tray consisted of pureed tuna salad, pasta salad, fruit and crackers. Liquids on the resident's tray were a milk shake, tea and water with plastic wrap with an "H" written on top. The resident's tray card indicated the resident was on " honey thick liquids." During consumption of the liquids provided, Resident # 4 started coughing and regurgitated his meal. CNA A encouraged the resident to "slow down and try to take some slow breaths." CNA A told CNA C to notify the nurse Resident # 4 choked on his meal. During an observation on 07/21/14 at 10:26 a.m., cook G pointed to a poster hanging in the kitchen which indicated how much thickener to add to liquids to obtain nectar, honey, and pudding consistencies. The dry storage room only had nectar thick and honey thick liquids present. During an observation of the male unit lunch cart on 07/21/14 at 1:05 p.m., Resident #4's tray consisted of honey thick liquids and a chocolate pudding cup. During an observation on 07/21/14 at 1:13 p.m., the DON served Resident # 4 his lunch tray. The tray consisted of pureed pork steak, potatoes, broccoli, chocolate mousse and a magic cup with honey thickened juice, water, tea and a milk shake. All the liquids on Resident # 4's tray had plastic wrap with an "H" written on them except the milk shake. Resident # 4 started eating the magic cup, which appeared to have melted. The resident started coughing slightly while eating the magic cup. Resident # 4 then attempted to drink the thickened water, taking large gulps of the water and started coughing excessively and regurgitated the water. CNA E attempted to assist the resident with his meal and liquids. The resident took small sips of the milk shake, which appeared to be a thinner consistency than the tea or water, and started coughing excessively. The resident's tray card indicated he was on a pureed diet with honey thickened liquids. During an observation on 07/22/14 at 12:20 p.m., Resident # 4 was sitting in his wheelchair in the dining room of the male secure unit with his lunch tray in front of him. Resident # 4's tray ticket indicated he was on a pureed diet with honey thickened liquids. The resident had honey thickened liquids on his lunch tray. The resident started drinking the juice on his tray, began coughing excessively and regurgitated his meal. The CNA indicated the nurse should be notified the resident vomited during his meal. Nurse notes from 07/20/14 to 07/22/14 did not indicate Resident #4 coughed, choked or vomited during his meals. During an interview on 07/21/14 at 8:50 a.m., CNA I said Resident # 4 only ate his magic cup and drank his juice for breakfast (7/21/14). CNA I said the resident "spit his juice back up" during his meal. The CNA said the resident ' s appetite had decreased and he had an increase in swallowing problems for the past week. The CNA said the MDS coordinator was present during the lunch meal yesterday (07/20/14) and said she was going to set up another swallow study. She said Resident #4 received honey thickened liquids. During an interview on 07/21/14 at 9:40 a.m., CNA D said they kept Resident # 4's liquids and extra magic cups locked up in the refrigerator because they had to make sure he did not choke. She said the dietary staff provided his liquids pre-made to the consistency he required. CNA A said Resident #4's liquids were marked with an H on the plastic wrap indicating honey thick liquid. CNA D said someone had to be present while the resident was drinking because he had swallowing problems. She said they kept an eye on him because he would drink whatever he could find. She said Resident #4 received honey thickened liquids. During an interview on 7/21/14 at 10:40 a.m., LVN B said Resident #4 had episodes of aspiration during his meals, but the chest x-rays were always negative for aspiration pneumonia. She said the resident ' s appetite decreased significantly over the past week and he vomited after his meals. The charge nurse said she thought the resident vomited after he actually swallowed. LVN B said she knew Resident #4 received a pureed diet with thickened liquids, but was unsure what consistency the liquids were ordered. She said she did not even know what pudding thick liquids would be. LVN B said the dietary staff provided the liquids pre-made to the consistency the resident needed. She said she was told the Ensure and health shakes were already the correct consistency and did not need to be thickened any further. During an interview on 07/21/14 at 10:10 a.m., the MDS coordinator said she talked with the CNAs yesterday (07/20/14) during lunch. She said Resident # 4 was unable to get food into his mouth, such as mashed potatoes, because he did not open his mouth wide enough. She said she normally would tell the DON during the morning meeting, but they had not had one today. The MDS coordinator said she was going to discuss possibly scheduling another speech therapist evaluation. She said Resident #4 received honey thickened liquids. During an interview on 07/22/14 at 4:00 p.m., the MDS coordinator said she used the nursing notes and progress notes as her primary source of information. She said the nursing notes did not indicate Resident #4 had trouble swallowing. During an interview on 07/21/14 at 10:22 a.m., cook G said Resident #4 had not been eating or drinking his liquids. Cook G said Resident #4 received honey thick liquids with his meals. She said he was the only resident that received honey thickened liquids. Cook G said there were no residents with an order for [REDACTED]. During an interview on 07/21/14 at 10:30 a.m., the DM said Resident #4 received honey thick liquids. She said no residents received pudding thick consistency liquids. During an interview on 07/21/14 at 12:18 p.m., the DM reviewed the Order Report and said she did not know why Resident #4 was not receiving the pudding thick liquids. She said a Dietary Communication slip was not received and she was not aware of the pudding thick liquids order. During an interview on 07/21/14 at 1:45 p.m., CNA E said Resident # 4 choked because he was trying to drink too fast. She said she tried to get him to slow down and he would do a little better. CNA E said Resident #4 did better with his magic cup, and he did not eat any of the other foods anymore. During an interview on 07/21/14 at 3:45 p.m., CNA E said Resident #4 choked more on the liquids than the pureed foods. She said the resident was in too big of a hurry. During an interview on 07/21/14 at 3:59 p.m., CNA D said Resident #4 started choking approximately one month ago. She said it only happened occasionally, but had gotten worse over the past week. She said the nurses were aware the resident had swallowing problems during meals. During an interview on 07/21/14 at 2:10 p.m., the DON said Resident # 4 had problems during his meals. The DON said nurses were responsible for checking off the trays with the dietary roster before serving them to the residents. The DON said she checked the trays off during lunch. The DON said the resident was supposed to be on honey thickened liquids. After reviewing the dietary order initiated on 3/10/14, the DON said they were to follow the most recent order which would be the pudding thickened liquids. She said "the nurses should have caught that." She said the ADON reviewed the new physician's order [REDACTED]. She said she did not remember the resident having a diet change. The DON said if the resident did not receive the right ordered consistency for his fluids, he could choke. She said the Ensure and the health shakes were not honey thick consistency, but more of a "milk chocolate" consistency. An Abuse and Neglect policy dated 11/11/11defined neglect as " ...failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ... " The abuse and neglect policy also indicated " ...Our facility implements an effective system for the prevention of abuse and neglect ... the facility initiates a proactive approach to identify the events and occurrences that may constitute or contribute to abuse and neglect ... " and " ... the facility ensures timely, thorough, and objective investigations of all allegations of abuse and neglect, or mistreatment ... " The administrator and DON were notified on 7/22/14 at 2:14 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/22/14 at 7:10 p.m., and included: New diet order for Resident # 4 for high calorie, high protein pureed diet with pudding thick liquids implemented immediately. (Discontinued double portions) A diet communication form showing the new diet order for Resident # 4 was given to the dietary manager and placed in the dietary section of the residents chart. The dietary roster was updated to the new diet order for Resident #4. Review of all diet orders for thickened consistency completed with arm bands placed on the residents stating what type of consistency ordered. In-services conducted regarding arm bracelet for thickened liquids and which residents are on thickened liquids along with the consistency of liquid for each resident. Staff would be in-serviced prior to returning to working the floor. Physician and family notified of Resident #4's diet change, and episode of aspiration at breakfast. Order for a chest x-ray requested to rule out aspiration. Staff would be in-serviced regarding change of conditions, notification and documentation of change of condition prior to coming back to the floor. The CNAs would document change of condition and notification of the STOP form. The nurse and the CNAs would both sign the form. A copy of the form would be placed on a binder broken down by resident, taped to a page under the resident's name. A copy will be placed in the DON's door. Staff would be in-serviced regarding the implementation of this system prior to returning to the floor. Compare tray cards to current updated diet roster, verifying tray cards match the diet roster. In-service dietary staff on how to properly thicken the liquids, hot to compare the tray card to the diet roster in the kitchen, and process for diet changes. Staff will be in-serviced prior to returning to work. In-service nurses on validating the tray cards against the diet roster; and the trays being served. Staff will be in-serviced prior to returning to work. When a new diet order was received, the family would be notified; a diet communication form would be placed in the chart under the dietary section and handed to the dietary manager (if the dietary manager was not available, a copy would be provided to the cook and a copy would be placed under the dietary manager's door.) The nurse would change the diet roster in the dining room by hand to the new updated diet. A diet roster would be printed and changed out every Monday with every new diet order. The surveyors confirmed on 07/23/14 at 9:50 a.m., the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Five CNAs, four nurses and three dietary staff were interviewed and said they were in-serviced regarding new diet orders and validating the trays include the correct consistency of liquids and communication forms between the nursing staff and dietary staff. Four LVNs were interviewed and said they were in-serviced regarding how communicate to the dietary staff a new diet order had been received, how to validate the trays consist of the correct diet and documentation of change in a resident ' s status. During an observation on 07/22/14 at 5:00 p.m., Resident # 4 received pudding thickened liquids for his dinner meal. On 7/23/14 at 1:03 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however the facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A dietary roster dated 07/21/14 indicated 6 residents received thickened liquids.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures to prohibit neglect for 1 of 17 residents reviewed for neglect (Resident # 4). Resident #4 had a history of [REDACTED]. Resident #4 coughed and regurgitated his food. The facility did not provide Resident # 4 his ordered diet of pudding thickened liquids to prevent Resident #4 from aspirating on liquids. This failure created an Immediate Jeopardy situation identified on 7/22/14. The Immediate Jeopardy was removed on 7/23/14. The facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 6 residents who had diet orders for thickened liquids at risk for choking, aspiration, or death. Findings included: An Abuse and Neglect policy dated 11/11/11defined neglect as "...failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ..." The abuse and neglect policy also indicated " ...Our facility implements an effective system for the prevention of abuse and neglect ... the facility initiates a proactive approach to identify the events and occurrences that may constitute or contribute to abuse and neglect ..." and "... the facility ensures timely, thorough, and objective investigations of all allegations of abuse and neglect, or mistreatment ... " Physician orders [REDACTED].# 4 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #4 had severe cognitive impairment, and required assistance with eating. Resident #4 had an active [DIAGNOSES REDACTED]. Nursing care plans updated 6/24/14 indicated Resident #4's goal was to have no signs or symptoms of aspiration for 90 days as evidence by "...no: coughing, shortness of breath, oxygen levels below 90%, gurgling lung sounds or elevated temperatures..." The care plan indicated Resident # 4 was to be served a pureed high calorie, high protein diet with large portions, magic cups, and pudding thick liquids with all meals three times a day. The interdisciplinary team care plan meeting notes for 6/24/14 indicated Resident # 4's diet was pureed with honey thick liquids. A swallow study report dated 02/05/14 indicated during the procedure, Resident # 4 was provided honey thick liquids and exhibited " silent aspiration. " Recommendations listed were pureed solids and pudding thick liquids. These recommendations were "...determined to be the most appropriate for the patient..." During an interview on 07/21/14 at 3:31 p.m., the speech therapist said she recommended the pudding thick consistency because during the swallow study the resident had "silent aspiration" with honey thick liquids. She described silent aspiration" as the resident was not observed coughing, but during the x-ray it was noted the resident had slight amounts of liquids going into his lungs. She said if the resident was being observed coughing during the consumption of honey thickened liquids, then the resident was aspirating large amount of liquids. She said the resident's swallowing function could have changed since her assessment, but if she recommended the pudding thickened liquids and the physician agreed and ordered them, then that was what the resident should receive. The speech therapist said the resident would have an increased risk for aspiration pneumonia if he was not getting the correct consistency. A physician evaluation and management report dated 02/05/14 indicated Resident # 4 was at high risk of aspiration due to decreased oral control and poor oral awareness. A nutritional quarterly assessment dated [DATE] indicated Resident # 4 had a swallow study that recommended the resident receive a pureed diet with pudding thick liquids. A communication form between the dietitian and the attending physician dated 02/28/14 indicated a recommendation to change Resident #4 ' s diet to high calorie, high protein with pudding thick liquids. A diet order and communication sheet dated 03/10/14 indicated Resident # 4 had a diet change and his liquids were to be pudding consistency. The diet Order Reports dated 07/01/2014 through 07/31/2014 indicated the following liquid consistency for Resident #4: " ...Start Date: 07/30/2013; ...Diet-Liquids: Honey Thickened Liquids ... " " ...Start Date: 03/10/2014; ...Diet: Hi Cal, Hi Pro, Pureed with Pudding Thick Liquids... " An admission and annual screening assessment completed by the dietician on 04/08/14 indicated Resident # 4's diet order was for pureed, high calorie, high protein diet with large portions and PTL (pudding thick liquids). The physical assessment category for eating performance did not indicate the resident had any swallowing problems. Additional documentation notes for the dates of 05/15/14, 06/10/14 and 07/16/14 all indicated the resident received a pureed, high calorie, and high protein diet with pudding thick liquids. A nutritional progress note dated 05/11/14 by the dietary manager indicated there had been no changes to Resident # 4's diet of pureed diet with honey thick liquids. The note also indicated the resident diet would be provided as ordered by the physician. During an observation on 7/20/14 at 5:20 p.m., Resident # 4 was sitting in his wheelchair in the dining room of the male secure unit. The resident ' s dinner tray consisted of pureed tuna salad, pasta salad, fruit and crackers. Liquids on the resident's tray were a milk shake, tea and water with plastic wrap with an "H" written on top. The resident's tray card indicated the resident was on "honey thick liquids." During consumption of the liquids provided, Resident # 4 started coughing and regurgitated his meal. CNA A encouraged the resident to "slow down and try to take some slow breaths." CNA A told CNA C to notify the nurse Resident # 4 choked on his meal. During an observation on 07/21/14 at 10:26 a.m., cook G pointed to a poster hanging in the kitchen which indicated how much thickener to add to liquids to obtain nectar, honey, and pudding consistencies. The dry storage room only had nectar thick and honey thick liquids present. During an observation of the male unit lunch cart on 07/21/14 at 1:05 p.m., Resident #4's tray consisted of honey thick liquids and a chocolate pudding cup. During an observation on 07/21/14 at 1:13 p.m., the DON served Resident # 4 his lunch tray. The tray consisted of pureed pork steak, potatoes, broccoli, chocolate mousse and a magic cup with honey thickened juice, water, tea and a milk shake. All the liquids on Resident # 4's tray had plastic wrap with an "H" written on them except the milk shake. Resident # 4 started eating the magic cup, which appeared to have melted. The resident started coughing slightly while eating the magic cup. Resident # 4 then attempted to drink the thickened water, taking large gulps of the water and started coughing excessively and regurgitated the water. CNA E attempted to assist the resident with his meal and liquids. The resident took small sips of the milk shake, which appeared to be a thinner consistency than the tea or water, and started coughing excessively. The resident's tray card indicated he was on a pureed diet with honey thickened liquids. During an observation on 07/22/14 at 12:20 p.m., Resident # 4 was sitting in his wheelchair in the dining room of the male secure unit with his lunch tray in front of him. Resident # 4's tray ticket indicated he was on a pureed diet with honey thickened liquids. The resident had honey thickened liquids on his lunch tray. The resident started drinking the juice on his tray, began coughing excessively and regurgitated his meal. The CNA indicated the nurse should be notified the resident vomited during his meal. Nurse notes from 07/20/14 to 07/22/14 did not indicate Resident #4 coughed, choked or vomited during his meals. During an interview on 07/21/14 at 8:50 a.m., CNA I said Resident # 4 only ate his magic cup and drank his juice for breakfast (7/21/14). CNA I said the resident "spit his juice back up" during his meal. The CNA said the resident's appetite had decreased and he had an increase in swallowing problems for the past week. The CNA said the MDS coordinator was present during the lunch meal yesterday (07/20/14) and said she was going to set up another swallowing study. She said Resident #4 received honey thickened liquids. During an interview on 07/21/14 at 9:40 a.m., CNA D said they kept Resident #4's liquids and extra magic cups locked up in the refrigerator because they had to make sure he did not choke. She said the dietary staff provided his liquids pre-made to the consistency he required. CNA A said Resident #4's liquids were marked with an H on the plastic wrap indicating honey thick liquid. CNA D said someone had to be present while the resident was drinking because he had swallowing problems. She said they kept an eye on him because he would drink whatever he could find. She said Resident #4 received honey thickened liquids. During an interview on 7/21/14 at 10:40 a.m., LVN B said Resident #4 had episodes of aspiration during his meals, but the chest x-rays were always negative for aspiration pneumonia. She said the resident ' s appetite decreased significantly over the past week and he vomited after his meals. The charge nurse said she thought the resident vomited after he actually swallowed. LVN B said she knew Resident #4 received a pureed diet with thickened liquids, but was unsure what consistency the liquids were ordered. She said she did not even know what pudding thick liquids would be. LVN B said the dietary staff provided the liquids pre-made to the consistency the resident needed. She said she was told the Ensure and health shakes were already the correct consistency and did not need to be thickened any further. During an interview on 07/21/14 at 10:10 a.m., the MDS coordinator said she talked with the CNAs yesterday (07/20/14) during lunch. She said Resident # 4 was unable to get food into his mouth, such as mashed potatoes, because he did not open his mouth wide enough. She said she normally would tell the DON during the morning meeting, but they had not had one today. The MDS coordinator said she was going to discuss possibly scheduling another speech therapist evaluation. She said Resident #4 received honey thickened liquids. During an interview on 07/22/14 at 4:00 p.m., the MDS coordinator said she used the nursing notes and progress notes as her primary source of information. She said the nurse's notes did not indicate Resident #4 had trouble swallowing. During an interview on 07/21/14 at 10:22 a.m., cook G said Resident #4 had not been eating or drinking his liquids. Cook G said Resident #4 received honey thick liquids with his meals. She said he was the only resident that received honey thickened liquids. Cook G said there were no residents with an order for [REDACTED]. During an interview on 07/21/14 at 10:30 a.m., the DM said Resident #4 received honey thick liquids. She said no residents received pudding thick consistency liquids. During an interview on 07/21/14 at 12:18 p.m., the DM reviewed the Order Report and said she did not know why Resident #4 was not receiving the pudding thick liquids. She said a Dietary Communication slip was not received and she was not aware of the pudding thick liquids order. During an interview on 07/21/14 at 1:45 p.m., CNA E said Resident # 4 choked because he was trying to drink too fast. She said she tried to get him to slow down and he would do a little better. CNA E said Resident #4 did better with his magic cup, and he did not eat any of the other foods anymore. During an interview on 07/21/14 at 3:45 p.m., CNA E said he seemed to choke more on the liquids than the pureed foods. She said the resident was in too big of a hurry. During an interview on 07/21/14 at 3:59 p.m., CNA D said Resident #4 started choking approximately one month ago. She said it only happened occasionally, but had gotten worse over the past week. She said the nurses were aware the resident had swallowing problems during meals. During an interview on 07/21/14 at 2:10 p.m., the DON said Resident # 4 had problems during his meals. The DON said nurses were responsible for checking off the trays with the dietary roster before serving them to the residents. The DON said she checked the trays off during lunch. The DON said the resident was supposed to be on honey thickened liquids. After reviewing the dietary order initiated on 3/10/14, the DON said they were to follow the most recent order which would be the pudding thickened liquids. She said " the nurses should have caught that. " She said the ADON reviewed the new physician's order [REDACTED]. She said she did not remember the resident having a diet change. The DON said if the resident did not receive the right ordered consistency for his fluids, he could choke. She said the Ensure and the health shakes were not honey thick consistency, but more of a "milk chocolate" consistency. The administrator and DON were notified on 7/22/14 at 2:14 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/22/14 at 7:10 p.m., and included: New diet order for Resident # 4 for high calorie, high protein pureed diet with pudding thick liquids implemented immediately. (Discontinued double portions) A diet communication form showing the new diet order for Resident # 4 was given to the dietary manager and placed in the dietary section of the residents chart. The dietary roster was updated to the new diet order for Resident #4. Review of all diet orders for thickened consistency completed with arm bands placed on the residents stating what type of consistency ordered. In-services conducted regarding arm bracelet for thickened liquids and which residents are on thickened liquids along with the consistency of liquid for each resident. Staff would be in-serviced prior to returning to working the floor. Physician and family notified of Resident #4's diet change, and episode of aspiration at breakfast. Order for a chest x-ray requested to rule out aspiration. Staff would be in-serviced regarding change of conditions, notification and documentation of change of condition prior to coming back to the floor. The CNAs would document change of condition and notification of the STOP form. The nurse and the CNAs would both sign the form. A copy of the form would be placed on a binder broken down by resident, taped to a page under the resident's name. A copy will be placed in the DON's door. Staff would be in-serviced regarding the implementation of this system prior to returning to the floor. Compare tray cards to current updated diet roster, verifying tray cards match the diet roster. In-service dietary staff on how to properly thicken the liquids, hot to compare the tray card to the diet roster in the kitchen, and process for diet changes. Staff will be in-serviced prior to returning to work. In-service nurses on validating the tray cards against the diet roster; and the trays being served. Staff will be in-serviced prior to returning to work. When a new diet order was received, the family would be notified; a diet communication form would be placed in the chart under the dietary section and handed to the dietary manager (if the dietary manager was not available, a copy would be provided to the cook and a copy would be placed under the dietary manager's door.) The nurse would change the diet roster in the dining room by hand to the new updated diet. A diet roster would be printed and changed out every Monday with every new diet order. The surveyors confirmed on 07/23/14 at 9:50 a.m., the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Five CNAs, four nurses and three dietary staff were interviewed and said they were in-serviced regarding new diet orders and validating the trays include the correct consistency of liquids and communication forms between the nursing staff and dietary staff. Four LVNs were interviewed and said they were in-serviced regarding how communicate to the dietary staff a new diet order had been received, how to validate the trays consist of the correct diet and documentation of change in a resident's status. During an observation on 07/22/14 at 5:00 p.m., Resident # 4 received pudding thickened liquids for his dinner meal. On 7/23/14 at 1:03 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however the facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A dietary roster dated 07/21/14 indicated 6 residents received thickened liquids.

Based on observation, interview, and record review, the facility failed to ensure the plan of care was followed for 1 of 14 residents reviewed for physician orders. (Resident # 4) Resident #4 had a history of [REDACTED]. Resident #4 coughed and regurgitated his food. The facility did not provide Resident # 4's ordered diet of pudding thickened liquids to prevent Resident #4 from aspirating on liquids. This failure created an Immediate Jeopardy situation identified on 7/22/14. The Immediate Jeopardy was removed on 7/23/14. The facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 6 residents who had diet orders for specific thickened liquids at risk for choking, aspiration, and death. Findings included: Physician orders [REDACTED].# 4 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #4 had severe cognitive impairment, and required assistance with eating. Resident #4 had an active [DIAGNOSES REDACTED]. Nursing care plans updated 6/24/14 indicated Resident #4's goal was to have no signs or symptoms of aspiration for 90 days as evidence by "...no: coughing, shortness of breath, oxygen levels below 90%, gurgling lung sounds or elevated temperatures..." The care plan indicated Resident # 4 was to be served a pureed high calorie, high protein diet with large portions, magic cups and pudding thick liquids with all meals three times a day. The interdisciplinary team care plan meeting notes for 6/24/14 indicated Resident # 4's diet was pureed with honey thick liquids. A swallow study report dated 02/05/14 indicated during the procedure, Resident # 4 was provided honey thick liquids and exhibited "silent aspiration." Recommendations listed were pureed solids and pudding thick liquids. These recommendations were "...determined to be the most appropriate for the patient... " A physician evaluation and management report dated 02/05/14 indicated Resident # 4 was at high risk of aspiration due to decreased oral control and poor oral awareness. A nutritional quarterly assessment dated [DATE] indicated Resident # 4 had a swallow study that recommended the resident receive a pureed diet with pudding thick liquids. A communication form between the dietitian and the attending physician dated 02/28/14 indicated a recommendation to change Resident #4's diet to high calorie, high protein with pudding thick liquids. During an observation on 7/20/14 at 5:20 p.m., Resident # 4 was sitting in his wheelchair in the dining room of the male secure unit. The resident's dinner tray consisted of pureed tuna salad, pasta salad, fruit and crackers. Liquids on the resident's tray were a milk shake, tea and water with plastic wrap with an "H" written on top. The resident's tray card indicated the resident was on "honey thick liquids. " During consumption of the liquids provided, Resident # 4 started coughing and regurgitated his meal. CNA A encouraged the resident to "slow down and try to take some slow breaths." CNA A told CNA C to notify the nurse Resident # 4 choked on his meal. During an interview on 07/21/14 at 9:40 a.m., CNA D said they kept Resident # 4's liquids and extra magic cups locked up in the refrigerator because they had to make sure he did not choke. She said the dietary staff provided his liquids pre-made to the consistency he required. CNA D said Resident #4's liquids were marked with an H on the plastic wrap indicating honey thick liquid. CNA D said someone had to be present while the resident was drinking because he had swallowing problems. She said they kept an eye on him because he would drink whatever he could find. She said Resident #4 received honey thickened liquids. During an observation of the male unit lunch cart on 07/21/14 at 1:05 p.m., Resident #4's tray consisted of honey thick liquids and a chocolate pudding cup. During an observation on 07/21/14 at 1:13 p.m., the DON served Resident # 4 his lunch tray. The tray consisted of pureed pork steak, potatoes, broccoli, chocolate mousse, and a magic cup with honey thickened juice, water, tea and a milk shake. All the liquids on Resident # 4's tray had plastic wrap with an "H" written on them except the milk shake. Resident # 4 started eating the magic cup, which appeared to have melted. The resident started coughing slightly while eating the magic cup. Resident # 4 then attempted to drink the thickened water, taking large gulps of the water and started coughing excessively and regurgitated the water. CNA E attempted to assist the resident with his meal and liquids. The resident took small sips of the milk shake, which appeared to be a thinner consistency than the tea or water, and started coughing excessively. The resident's tray card indicated he was on a pureed diet with honey thickened liquids. During an observation on 07/22/14 at 12:20 p.m., Resident # 4 was sitting in his wheelchair in the dining room of the male secure unit with his lunch tray in front of him. Resident #4's tray ticket indicated he was on a pureed diet with honey thickened liquids. The resident had honey thickened liquids on his lunch tray. The resident started drinking the juice on his tray, began coughing excessively and regurgitated his meal. The CNA indicated the nurse should be notified the resident vomited during his meal. During an interview on 07/21/14 at 8:50 a.m., CNA I said Resident # 4 received honey thickened liquids. During an interview on 07/21/14 at 9:40 a.m., CNA D said the dietary staff provided Resident #4 liquids pre-made to the consistency he required. She said Resident #4 recieved honey thickend liquids. During an interview on 07/21/14 at 3:59 p.m., CNA D said Resident #4 started choking approximately one month ago. She said it only happened occasionally, but had gotten worse over the past week. She said the nurses were aware the resident had swallowing problems during meals. During an interview on 7/21/14 at 10:40 a.m., LVN B said Resident #4 received a pureed diet with thickened liquids, but was unsure what consistency the liquids were ordered. She said she did not even know what pudding thick liquids would be. LVN B said the dietary staff provided the liquids pre-made to the consistency the resident needed. She said she was told the Ensure and health shakes were already the correct consistency and did not need to be thickened any further. During an interview on 07/21/14 at 10:22 a.m., cook G said Resident #4 received honey thick liquids with his meals. She said he was the only resident that received honey thickened liquids. Cook G said there were no residents with an order for [REDACTED]. During an interview on 07/21/14 at 10:30 a.m., the DM said Resident #4 received honey thick liquids. She said no residents received pudding thick consistency liquids. During an interview on 07/21/14 at 12:18 p.m., the DM reviewed the Order Report and said she did not know why Resident #4 was not receiving the pudding thick liquids. She said a Dietary Communication slip was not received and she was not aware of the pudding thick liquids order. During an interview on 07/21/14 at 2:10 p.m., the DON said Resident # 4 had problems during his meals. The DON said nurses were responsible for checking off the trays with the dietary roster before serving them to the residents. The DON said she checked the trays off during lunch. The DON said the resident was supposed to be on honey thickened liquids. After reviewing the dietary order initiated on 3/10/14, the DON said they were to follow the most recent order which would be the pudding thickened liquids. She said "the nurses should have caught that" She said the ADON reviewed the new physician's order [REDACTED]. She said she did not remember the resident having a diet change. The DON said if the resident did not receive the right ordered consistency for his fluids, he could choke. She said the Ensure and the health shakes were not honey thick consistency, but more of a "milk chocolate" consistency. The administrator and DON were notified on 7/22/14 at 2:14 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/22/14 at 7:10 p.m., and included: New diet order for Resident # 4 for high calorie, high protein pureed diet with pudding thick liquids implemented immediately. (Discontinued double portions) A diet communication form showing the new diet order for Resident # 4 was given to the dietary manager and placed in the dietary section of the residents chart. The dietary roster was updated to the new diet order for Resident #4. Review of all diet orders for thickened consistency completed with arm bands placed on the residents stating what type of consistency ordered. In-services conducted regarding arm bracelet for thickened liquids and which residents are on thickened liquids along with the consistency of liquid for each resident. Staff would be in-serviced prior to returning to working the floor. Physician and family notified of Resident #4's diet change, and episode of aspiration at breakfast. Order for a chest x-ray requested to rule out aspiration. Staff would be in-serviced regarding change of conditions, notification and documentation of change of condition prior to coming back to the floor. The CNAs would document change of condition and notification of the STOP form. The nurse and the CNAs would both sign the form. A copy of the form would be placed on a binder broken down by resident, taped to a page under the resident ' s name. A copy will be placed in the DON ' s door. Staff would be in-serviced regarding the implementation of this system prior to returning to the floor. Compare tray cards to current updated diet roster, verifying tray cards match the diet roster. In-service dietary staff on how to properly thicken the liquids, hot to compare the tray card to the diet roster in the kitchen, and process for diet changes. Staff will be in-serviced prior to returning to work. In-service nurses on validating the tray cards against the diet roster; and the trays being served. Staff will be in-serviced prior to returning to work. When a new diet order was received, the family would be notified; a diet communication form would be placed in the chart under the dietary section and handed to the dietary manager (if the dietary manager was not available, a copy would be provided to the cook and a copy would be placed under the dietary manager ' s door.) The nurse would change the diet roster in the dining room by hand to the new updated diet. A diet roster would be printed and changed out every Monday with every new diet order. The surveyors confirmed on 07/23/14 at 9:50 a.m., the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Five CNAs, four nurses and three dietary staff were interviewed and said they were in-serviced regarding new diet orders and validating the trays include the correct consistency of liquids and communication forms between the nursing staff and dietary staff. Four LVNs were interviewed and said they were in-serviced regarding how communicate to the dietary staff a new diet order had been received, how to validate the trays consist of the correct diet and documentation of change in a resident ' s status. During an observation on 07/22/14 at 5:00 p.m., Resident # 4 received pudding thickened liquids for his dinner meal. On 7/23/14 at 1:03 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however the facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A dietary roster dated 07/21/14 indicated 6 residents received thickened liquids.

Based on observation, interview, and record review, the administrator and DON failed to manage the facility resources to ensure the highest practicable physical, mental and psychosocial well-being was maintained for 1 of 14 residents reviewed for neglect. (Resident # 4) The administrator and DON did not monitor and apprise care and services to ensure the following for Resident # 4: *diet was served per physician orders, *a new diet order was communicated to dietary, and *notify the physician of episodes of aspiration during meals. This failure created an Immediate Jeopardy situation identified on 7/22/14. The Immediate Jeopardy was removed on 7/23/14. The facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 6 residents who had diet orders for thickened liquids at risk for choking, aspiration, and death. Findings included: During an interview on 07/21/14 at 2:10 p.m., the DON said Resident # 4 had problems during his meals. The DON said nurses were responsible for checking off the trays with the dietary roster before serving them to the residents. The DON said she checked the trays off during lunch. The DON said the resident was supposed to be on honey thickened liquids. After reviewing the dietary order initiated on 3/10/14, the DON said they were to follow the most recent order which would be the pudding thickened liquids. She said "the nurses should have caught that". She said the ADON reviewed the new physician's orders [REDACTED]. She said she did not remember the resident having a diet change. The DON said if the resident did not receive the right ordered consistency for his fluids, he could choke. She said the Ensure and the health shakes were not honey thick consistency, but more of a "milk chocolate" consistency. During an interview on 07/22/14 at 2:20 p.m. the administrator and the DON said the immediate jeopardy was a result of Resident #4 being provided the wrong liquid consistency because staff was not following physician orders. They said dietary was responsible for ensuring the food prepared matched the dietary slips but ultimately nursing was responsible for ensuring the food and liquids on the residents' trays matched the physician orders [REDACTED]. Physician orders [REDACTED].# 4 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS assessment dated [DATE] noted Resident #4 had severe cognitive impairment, and required assistance with eating. Resident #4 had an active [DIAGNOSES REDACTED]. Nursing care plans updated 6/24/14 indicated Resident #4's goal was to have no signs or symptoms of aspiration for 90 days as evidence by "...no: coughing, shortness of breath, oxygen levels below 90%, gurgling lung sounds or elevated temperatures..." The care plan indicated Resident # 4 was to be served a pureed high calorie, high protein diet with large portions, magic cups and pudding thick liquids with all meals three times a day. The interdisciplinary team care plan meeting notes for 6/24/14 indicated Resident # 4's diet was pureed with honey thick liquids. A swallow study report dated 02/05/14 indicated during the procedure, Resident # 4 was provided honey thick liquids and exhibited "silent aspiration." Recommendations listed were pureed solids and pudding thick liquids. These recommendations were "...determined to be the most appropriate for the patient... " During an observation on 7/20/14 at 5:20 p.m., Resident # 4 was sitting in his wheelchair in the dining room of the male secure unit. The resident's dinner tray consisted of pureed tuna salad, pasta salad, fruit and crackers. Liquids on the resident's tray were a milk shake, tea and water with plastic wrap with an "H" written on top. The resident's tray card indicated the resident was on "honey thick liquids.. During consumption of the liquids provided, Resident # 4 started coughing and regurgitated his meal. CNA A encouraged the resident to "slow down and try to take some slow breaths." CNA A told CNA C to notify the nurse Resident # 4 choked on his meal. During an interview on 07/21/14 at 9:40 a.m., CNA D said they kept Resident # 4's liquids and extra magic cups locked up in the refrigerator because they had to make sure he did not choke. She said the dietary staff provided his liquids pre-made to the consistency he required. CNA D said Resident #4's liquids were marked with an H on the plastic wrap indicating honey thick liquid. CNA D said someone had to be present while the resident was drinking because he had swallowing problems. She said they kept an eye on him because he would drink whatever he could find. She said Resident #4 received honey thickened liquids. During an observation on 07/21/14 at 1:13 p.m., the DON served Resident # 4 his lunch tray. The tray consisted of pureed pork steak, potatoes, broccoli, chocolate mousse, and a magic cup with honey thickened juice, water, tea and a milk shake. All the liquids on Resident # 4's tray had plastic wrap with an "H" written on them except the milk shake. Resident # 4 started eating the magic cup, which appeared to have melted. The resident started coughing slightly while eating the magic cup. Resident # 4 then attempted to drink the thickened water, taking large gulps of the water and started coughing excessively and regurgitated the water. CNA E attempted to assist the resident with his meal and liquids. The resident took small sips of the milk shake, which appeared to be a thinner consistency than the tea or water, and started coughing excessively. The resident's tray card indicated he was on a pureed diet with honey thickened liquids. During an observation on 07/22/14 at 12:20 p.m., Resident # 4 was sitting in his wheelchair in the dining room of the male secure unit with his lunch tray in front of him. Resident #4's tray ticket indicated he was on a pureed diet with honey thickened liquids. The resident had honey thickened liquids on his lunch tray. The resident started drinking the juice on his tray, began coughing excessively and regurgitated his meal. The CNA indicated the nurse should be notified the resident vomited during his meal. During an interview on 07/21/14 at 8:50 a.m., CNA I said Resident # 4 received honey thickened liquids. During an interview on 07/21/14 at 9:40 a.m., CNA D said the dietary staff provided Resident #4 liquids pre-made to the consistency he required. She said Resident #4 received honey thickened liquids. During an interview on 7/21/14 at 10:40 a.m., LVN B said Resident #4 received a pureed diet with thickened liquids, but was unsure what consistency the liquids were ordered. She said she did not even know what pudding thick liquids would be. LVN B said the dietary staff provided the liquids pre-made to the consistency the resident needed. She said she was told the Ensure and health shakes were already the correct consistency and did not need to be thickened any further. During an interview on 07/21/14 at 10:22 a.m., cook G said Resident #4 received honey thick liquids with his meals. She said he was the only resident that received honey thickened liquids. Cook G said there were no residents with an order for [REDACTED]. During an interview on 07/21/14 at 10:30 a.m., the DM said Resident #4 received honey thick liquids. She said no residents received pudding thick consistency liquids. During an interview on 07/21/14 at 12:18 p.m., the DM reviewed the Order Report and said she did not know why Resident #4 was not receiving the pudding thick liquids. The administrator and DON were notified on 7/22/14 at 2:14 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/22/14 at 7:10 p.m., and included: New diet order for Resident # 4 for high calorie, high protein pureed diet with pudding thick liquids implemented immediately. (Discontinued double portions) A diet communication form showing the new diet order for Resident # 4 was given to the dietary manager and placed in the dietary section of the residents chart. The dietary roster was updated to the new diet order for Resident #4. Review of all diet orders for thickened consistency completed with arm bands placed on the residents stating what type of consistency ordered. In-services conducted regarding arm bracelet for thickened liquids and which residents are on thickened liquids along with the consistency of liquid for each resident. Staff would be in-serviced prior to returning to working the floor. Physician and family notified of Resident #4's diet change, and episode of aspiration at breakfast. Order for a chest x-ray requested to rule out aspiration. Staff would be in-serviced regarding change of conditions, notification and documentation of change of condition prior to coming back to the floor. The CNAs would document change of condition and notification of the STOP form. The nurse and the CNAs would both sign the form. A copy of the form would be placed on a binder broken down by resident, taped to a page under the resident's name. A copy will be placed in the DON's door. Staff would be in-serviced regarding the implementation of this system prior to returning to the floor. Compare tray cards to current updated diet roster, verifying tray cards match the diet roster. In-service dietary staff on how to properly thicken the liquids, hot to compare the tray card to the diet roster in the kitchen, and process for diet changes. Staff will be in-serviced prior to returning to work. In-service nurses on validating the tray cards against the diet roster; and the trays being served. Staff will be in-serviced prior to returning to work. When a new diet order was received, the family would be notified; a diet communication form would be placed in the chart under the dietary section and handed to the dietary manager (if the dietary manager was not available, a copy would be provided to the cook and a copy would be placed under the dietary manager's door.) The nurse would change the diet roster in the dining room by hand to the new updated diet. A diet roster would be printed and changed out every Monday with every new diet order. The surveyors confirmed on 07/23/14 at 9:50 a.m., the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Five CNAs, four nurses and three dietary staff were interviewed and said they were in-serviced regarding new diet orders and validating the trays include the correct consistency of liquids and communication forms between the nursing staff and dietary staff. Four LVNs were interviewed and said they were in-serviced regarding how communicate to the dietary staff a new diet order had been received, how to validate the trays consist of the correct diet and documentation of change in a resident's status. During an observation on 07/22/14 at 5:00 p.m., Resident # 4 received pudding thickened liquids for his dinner meal. On 7/23/14 at 1:03 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however the facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A dietary roster dated 07/21/14 indicated 6 residents received thickened liquids.

Based on interview and record review, the facility failed to provide supervision to prevent hot beverage burns for 1 of 5 residents reviewed for accidents. (Resident #2) Resident #2 was not assessed for his ability to manage hot beverages. Resident #2 sustained blisters to his legs while serving himself coffee. This failure could place 12 residents on the men ' s secure unit at risk for injury. Findings included: Physician orders [REDACTED].#2, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 had severely impaired cognitive skills for daily decision making, was unsteady, used a wheelchair and walker for mobility, and required supervision with setup help with eating. A comprehensive care plan revised 03/19/14 indicated Resident #2 was at risk for injury from wandering in an unsafe environment. Approaches included monitoring every hour and as needed to keep the resident ' s environment safe from possible hazards. The care plan indicated the resident required assistance with ADLs. The clinical record for Resident #2 did not have an evaluation to determine his ability to manage hot beverages. An Incident Report dated 04/25/14 indicated Resident #2 was assessed in his room with five blisters on his legs, three to both of his lower legs and one on each thigh. Resident #2 stated coffee when asked what happened. A Provider Investigation Report dated 4/29/14 indicated Resident #2 was discharged on [DATE]. A Provider Investigation Report dated 5/6/14 indicated Resident #2 received blisters to the right and left lower leg. The investigation summary indicated dietary staff saw Resident #2 " getting coffee all day in a large plastic cup. " During an interview on 05/14/14 at 2:00 p.m., LVN C said she assessed Resident #2 on 4/25/14 and discovered blisters on his legs. She said she was unsure of what occurred, but Resident #2 said " coffee " when she asked him how the blisters occurred. During an interview on 05/14/14 at 8:30 a.m., CNA A, said she worked the men ' s secure unit where Resident #2 resided. She said she was not aware Resident #2 spilled coffee on himself. She said residents continued to freely serve themselves coffee. She said 12 residents resided on the unit. CNA A said they all exhibit behaviors and required assistance with activities of daily living. She said the unit was staffed with one CNA. CNA A said one CNA could not provide the required care, supervision and monitor residents for behaviors. During an interview on 05/14/14 at 1:00 p.m., CNA B said he worked on the men ' s secure unit where Resident #2 resided. He said she was not aware Resident #2 spilled coffee on himself or if any preventative measures put into place. He said the unit had 12 residents who exhibited behaviors and required assistance with activities of daily living. He said the unit was staffed with one CNA. CNA B said one CNA could not provide the required care, supervision and monitor residents for behaviors. During interviews on 05/14/14 at 1:35 p.m., LVN D said she was assigned to the men ' s secure unit where Resident #2 resided. She said she was not aware Resident #2 spilled coffee on himself until today and was unsure if preventative measures were implemented. She said she did not remain on the hall because she was also assigned other halls. She said the unit had 12 residents who exhibited behaviors and required assistance with activities of daily living. LVN D said the unit was staffed with one CNA. LVN D said one CNA could not provide the required care, supervision and monitor residents for behaviors. During an interview on 05/14/14 at 3:00 p.m., the DON said Resident #2 was not evaluated for hot beverage safety. The DON said none of the residents in the facility had been assessed. She said most residents on the secured unit had a [DIAGNOSES REDACTED]. The DON said the facility identified a need for increased staff on the secure unit, but had not implemented additional staff. Facility policy titled "Resident Safety with Hot Beverages", dated 04/04/12, indicated " ...Skin on the arms and legs can suffer a burn before the danger is realized. The elderly who are immobilized in a wheelchair and confused residents are more susceptible. Because of this susceptibility follow the following safety precautions...residents should be supervised while drinking hot beverages, a staff member should pour the hot beverages. When serving hot liquids to residents with behavioral or medical conditions that put them at risk for spills, consider the following...evaluate resident's ability to independently manage hot beverages and provide appropriate assistance..." During an interview on 05/14/14 at 3:00 p.m., the DON said 12 residents resided on the male secured unit

Based on interview and record review, the facility failed to implement their abuse and neglect policy to prohibit neglect of 1 of 4 residents sampled for full code status. (Resident #1) Resident #1, who had a full code status, was found unresponsive, without a pulse or respirations on [DATE]. The resident was left alone and was not immediately provided CPR in accordance with facility policy. Resident #1 died in the facility on [DATE]. Two of two LVNs on duty at the time of the incident said they would leave a resident alone to call emergency services. This failure contributed to Resident #1's death. An Immediate Jeopardy identified [DATE] had existed since [DATE]. While the Immediate Jeopardy was removed [DATE], the facility remained out of compliance at a pattern of actual harm due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place 35 residents with full code status at risk of neglect due to a lack of nursing staff knowledge about emergency intervention. Findings included: Resident #1's [DATE] physician orders [REDACTED]. The resident had a full code status. Resident #1's quarterly MDS dated [DATE] documented she was independent with all ADLs and was continent of bowel and bladder. Resident #1's plan of care with a revision date of [DATE] documented she had a full code status. Nursing notes dated [DATE] indicated at 6:50 a.m., LVN A found Resident #1 in bed unresponsive, with no pulse or respirations. Her fingers were blue. LVN A said she started CPR and called for help. The LVN performed CPR until she "was physically unable to continue." A Record of Death form dated [DATE] noted Resident #1 died on [DATE]. During an interview on [DATE] at 12:42 p.m., LVN A said she entered Resident #1's room to check her blood sugar level on [DATE] at about 7:00 a.m. Resident #1 looked like she had been sitting on the side of the bed and fell backwards. LVN A said the resident was unresponsive and had no pulse. She said she left Resident #1's side to call 911. LVN A returned to Resident #1's room with CNA C and she (LVN A) initiated CPR. She said CNA C was in the room observing. LVN A said she did not obtain the crash cart and did not reposition before she started chest compressions. LVN A said she performed only chest compressions. She said she did not open or maintain Resident #1's airway or provide rescue breathing. She said she did chest compressions until she was exhausted. She stopped because she heard the paramedics arrive at the facility. She said she did not know to open the airway, or to perform rescue breathing during CPR. She said when she was hired, she informed the facility her CPR certification had expired and they assured her they would set up a class. Following the incident, LVN A attended a CPR class on [DATE]. LVN A said she had received no additional in-service training since this incident regarding facility required protocol for resident emergency situations. A Payroll Action form in LVN A's employee file documented she was hired [DATE]. A Job Description for LVNs signed by LVN A on [DATE] documented the following: *The LVN works under the supervision of the DON to provide nursing care to residents as prescribed by the physician and in accordance with standards of nursing practices and regulations, and supervises the CNA staff in the delivery of direct resident care. * The essential function of the LVN was to "participate in in-service training; assist in implementing orientation programs and job skills training; and maintain professional competence." * The LVN was to be capable of performing the essential functions and responsibilities of the job with or without reasonable accommodations. According to Mosby's 2009 Fundamentals of Nursing p. 960, if a client's [MEDICAL CONDITION] (low blood oxygen) is severe and prolonged, [MEDICAL CONDITION] will result. A [MEDICAL CONDITION] is a sudden cessation of cardiac output and circulation. When this occurs, oxygen is not delivered to tissues, carbon [MEDICATION NAME] is not transported from tissues....Permanent heart, brain, and other tissue damage occur within ,[DATE] minutes. During [MEDICAL CONDITION] there is an absence of pulse and respiration. ...The "ABCs" of cardiopulmonary resuscitation are to establish an airway, initiate breathing, and maintain circulation...The purpose of CPR is to circulate [MEDICATION NAME] blood to the brain to prevent permanent tissue damage. During an interview on [DATE] at 12:08 p.m., CNA C said she was responsible for Resident #1's care on [DATE]. At about 6:15 a.m., she went into the room to get Resident #1's roommate up for breakfast. Resident #1 was in bed on her back with her feet near the foot board. At about 6:50 a.m. she was told LVN A found Resident #1 unresponsive and without a pulse. CNA C said LVN A was providing CPR when she entered the resident's room (exact time unknown). She said LVN A did only chest compressions and did not open the resident's airway or administer rescue breathing. CNA C said LVN A performed CPR by herself and stopped once the paramedics arrived at the facility. LVN A "just stopped performing CPR" before the paramedics were in the resident's room. The CNA said she offered to continue compressions when LVN A was tired, and LVN A told her no. During an interview on [DATE] at 1:18 p.m., LVN B said a CNA told her LVN A found Resident #1 unresponsive without a pulse on [DATE]. LVN B said when she went to Resident #1's room, LVN A said she had already called 911. LVN A asked LVN B to get the paperwork ready because she was going to initiate CPR. LVN B said she prepared the paperwork and when she was finished, she saw the paramedics in the facility on the way to Resident #1's room (time unknown). LVN B said that if she found a resident unresponsive, she would also leave the resident alone to call a code over the intercom. LVN B said her CPR certification was current. The LVN was not able to explain the steps to follow regarding CPR and said, "I guess I need to update my reading on CPR." LVN B said she had received no additional in-service training since this incident regarding facility required protocol for resident emergency situations. During an interview on [DATE] at 1:54 p.m., the DON said she had been working at the facility since [DATE]. The DON said after speaking with LVN A on [DATE], she realized not all staff were knowledgeable regarding CPR. She said a CPR class was completed [DATE] and another class was scheduled for [DATE]. She said she gave the staff until [DATE] to have current CPR certification. The DON said LVN A incorrectly performed CPR because she stopped when she got tired. The DON said no one else performed CPR for the resident until the paramedics entered the resident's room. The DON said she was not aware LVN A did not follow the ABCs (airway, breathing, and circulation) of CPR or that the LVN left the resident alone to call 911. The DON said the nurse was supposed to stay with the resident and pull the call light or yell for help. The DON said they had not completed any training and there was no documentation staff were educated on how to handle an emergency situation involving an unresponsive resident. During an observation at the time of the interview on [DATE] at 1:54 p.m., the DON could not locate the facility policy regarding CPR. The ADON came into the office and the DON asked her where the policy was. Neither could locate the policy. They called corporate office for a copy. During an interview on [DATE] at 3:01 p.m., the administrator said no training had been completed and there was no documentation staff were educated on how to handle an emergency situation involving an unresponsive resident. He said an in-service was scheduled for [DATE] (16 days after the incident occurred) to educate the staff on how to handle emergency situations. On [DATE] at 3:01 p.m., the survey team determined the failure to ensure nursing staff were knowledgeable about how to properly handle emergency situations and how to perform CPR contributed to an Immediate Jeopardy situation that had existed since [DATE]. On [DATE] at 3:01 p.m., the surveyor notified the administrator and DON of the Immediate Jeopardy situation. On [DATE] at 5:53 p.m., the facility's Plan of Removal was accepted and included the following: "Issue: [DATE] Charge nurses not able to properly perform Emergency Medical Interventions during Code Situations. The DON/Designee is responsible for education of staff members. Correction: Target date [DATE] a. Licensed Nurses are currently actively receiving CPR training. b. Licensed Nurses trained in activation of the 911 system during a Medical Emergency. c. Licensed Nurses are being trained by the DON regarding sequence of duties required while responding to a Medical Emergency. Use of Ambu-bag for rescue breathing and proper use of back board to ensure compressions are beneficial for resuscitation. d. Licensed Nurses have received training regarding Presumptive signs of death and the LVN responsibility when residents are discovered with presumptive signs of death in accordance with Texas Board of Nursing 15.2 Role of the Licensed Vocational Nurse in Pronouncement of death. 1. Patient is unresponsive 2. Patient has no respirations 3. Patient has no pulse 4. Patient pupils are fixed and dilated, 5. The patient's body temperature indicates hypothermia 6. The patient has generalized cyanosis. 7. Conclusive Sign of death: There is a presence of livor mortis (venous pooling in dependent body parts causing purple discoloration of the skin which does not blanch with pressure). e. Licensed Nurses have received training in SLP Code Status System. (Code status of each resident is located on Emergency Cart). f. Licensed Nurses have been trained in working together as a team during a Code Situation whereas the resident is not left alone. The person running the Code assigns another staff member to notify 911 and prepare the transfer information for the Emergency Medical Team. The team leader also assigns another staff member to assist with CPR. g. Licensed Nurses are trained to continue CPR unless the resident is revived, until help arrives (911 EMT) or if physically unable to continue. h. New Licensed Nurses are provided Orientation which includes the location and use of the Emergency Cart. i. The facility will train Licensed Nurses on Change of Conditions and responsibility of physician notification. j. All nursing staff will be competent and knowledgeable in following policy and procedure in Cardio-Pulmonary Resuscitation. " Plan of Removal verification: As of [DATE], all nurses had received the in-service training. Four nurses were interviewed and provided correct responses about how to handle emergencies. The survey team determined the facility had implemented its plan of removal sufficiently to remove the Immediate Jeopardy, effective [DATE]. On [DATE] at 12:15 p.m., the administrator, DON, vice president of clinical operations and corporate nurse consultant were informed the Immediate Jeopardy was lifted. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete all proficiency audits, and monitor and evaluate the effectiveness of the corrective systems. The undated facility Abuse and Neglect policy and procedure defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The undated facility Nursing Guideline policy and procedure regarding CPR documented staff providing one-rescuer CPR were to do the following: -determine unresponsiveness -"call out for help" Airway -position yourself close to the resident, comfortably at the resident's shoulder level -open airway with head tilt/chin lift maneuver. Maintain open air way...... Circulation f.) once CPR is started do not discontinue unless qualified help arrives (paramedics), or unless a physician pronounces the resident dead and gives orders to discontinue CPR. A list dated [DATE] identified 35 residents with full code status. On [DATE], three days after the survey exit, the facility provided documentation that an inservice was conducted on [DATE], but was not attended by all staff.

Based on interview and record review, the facility failed to implement their written abuse and neglect policy to prohibit neglect of 1 of 4 residents sampled for full code status. (Resident #1) Resident #1, who had a full code status, was found unresponsive, without a pulse or respirations on [DATE]. The resident was left alone and was not immediately provided CPR in accordance with facility policy. Resident #1 died in the facility on [DATE]. Two of two LVNs on duty at the time of the incident said they would leave a resident alone to call emergency services. This failure contributed to Resident #1's death. An Immediate Jeopardy identified [DATE] had existed since [DATE]. While the Immediate Jeopardy was removed [DATE], the facility remained out of compliance at a pattern of actual harm due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place 35 residents with full code status at risk of neglect due to a lack of nursing staff knowledge about emergency intervention. Findings included: The undated facility Abuse and Neglect policy and procedure defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The undated facility Nursing Guideline policy and procedure regarding CPR documented staff providing one-rescuer CPR were to do the following: -determine unresponsiveness -"call out for help" Airway -position yourself close to the resident, comfortably at the resident's shoulder level -open airway with head tilt/chin lift maneuver. Maintain open air way...... Circulation f.) once CPR is started do not discontinue unless qualified help arrives (paramedics), or unless a physician pronounces the resident dead and gives orders to discontinue CPR. Resident #1's [DATE] physician orders [REDACTED]. The resident had a full code status. Resident #1's quarterly MDS dated [DATE] documented she was independent with all ADLs and was continent of bowel and bladder. Resident #1's plan of care with a revision date of [DATE] documented she had a full code status. Nursing notes dated [DATE] indicated at 6:50 a.m., LVN A found Resident #1 in bed unresponsive, with no pulse or respirations. Her fingers were blue. LVN A said she started CPR and called for help. The LVN performed CPR until she "was physically unable to continue." A Record of Death form dated [DATE] noted Resident #1 died on [DATE]. During an interview on [DATE] at 12:42 p.m., LVN A said she entered Resident #1's room to check her blood sugar level on [DATE] at about 7:00 a.m. Resident #1 looked like she had been sitting on the side of the bed and fell backwards. LVN A said the resident was unresponsive and had no pulse. She said she left Resident #1's side to call 911. LVN A returned to Resident #1's room with CNA C and she (LVN A) initiated CPR. She said CNA C was in the room observing. LVN A said she did not obtain the crash cart and did not reposition before she started chest compressions. LVN A said she performed only chest compressions. She said she did not open or maintain Resident #1's airway or provide rescue breathing. She said she did chest compressions until she was exhausted. She stopped because she heard the paramedics arrive at the facility. She said she did not know to open the airway, or to perform rescue breathing during CPR. She said when she was hired, she informed the facility her CPR certification had expired and they assured her they would set up a class. Following the incident, LVN A attended a CPR class on [DATE]. LVN A said she had received no additional in-service training since this incident regarding facility required protocol for resident emergency situations. A Payroll Action form in LVN A's employee file documented she was hired [DATE]. A Job Description for LVNs signed by LVN A on [DATE] documented the following: *The LVN works under the supervision of the DON to provide nursing care to residents as prescribed by the physician and in accordance with standards of nursing practices and regulations, and supervises the CNA staff in the delivery of direct resident care. * The essential function of the LVN was to "participate in in-service training; assist in implementing orientation programs and job skills training; and maintain professional competence." * The LVN was to be capable of performing the essential functions and responsibilities of the job with or without reasonable accommodations. According to Mosby's 2009 Fundamentals of Nursing p. 960, if a client's [MEDICAL CONDITION] (low blood oxygen) is severe and prolonged, [MEDICAL CONDITION] will result. A [MEDICAL CONDITION] is a sudden cessation of cardiac output and circulation. When this occurs, oxygen is not delivered to tissues, carbon [MEDICATION NAME] is not transported from tissues....Permanent heart, brain, and other tissue damage occur within ,[DATE] minutes. During [MEDICAL CONDITION] there is an absence of pulse and respiration. ...The "ABCs" of cardiopulmonary resuscitation are to establish an airway, initiate breathing, and maintain circulation...The purpose of CPR is to circulate [MEDICATION NAME] blood to the brain to prevent permanent tissue damage. During an interview on [DATE] at 12:08 p.m., CNA C said she was responsible for Resident #1's care on [DATE]. At about 6:15 a.m., she went into the room to get Resident #1's roommate up for breakfast. Resident #1 was in bed on her back with her feet near the foot board. At about 6:50 a.m. she was told LVN A found Resident #1 unresponsive and without a pulse. CNA C said LVN A was providing CPR when she entered the resident's room (exact time unknown). She said LVN A did only chest compressions and did not open the resident's airway or administer rescue breathing. CNA C said LVN A performed CPR by herself and stopped once the paramedics arrived at the facility. LVN A "just stopped performing CPR" before the paramedics were in the resident's room. The CNA said she offered to continue compressions when LVN A was tired, and LVN A told her no. During an interview on [DATE] at 1:18 p.m., LVN B said a CNA told her LVN A found Resident #1 unresponsive without a pulse on [DATE]. LVN B said when she went to Resident #1's room, LVN A said she had already called 911. LVN A asked LVN B to get the paperwork ready because she was going to initiate CPR. LVN B said she prepared the paperwork and when she was finished, she saw the paramedics in the facility on the way to Resident #1's room (time unknown). LVN B said that if she found a resident unresponsive, she would also leave the resident alone to call a code over the intercom. LVN B said her CPR certification was current. The LVN was not able to explain the steps to follow regarding CPR and said, "I guess I need to update my reading on CPR." LVN B said she had received no additional in-service training since this incident regarding facility required protocol for resident emergency situations. During an interview on [DATE] at 1:54 p.m., the DON said she had been working at the facility since [DATE]. The DON said after speaking with LVN A on [DATE], she realized not all staff were knowledgeable regarding CPR. She said a CPR class was completed [DATE] and another class was scheduled for [DATE]. She said she gave the staff until [DATE] to have current CPR certification. The DON said LVN A incorrectly performed CPR because she stopped when she got tired. The DON said no one else performed CPR for the resident until the paramedics entered the resident's room. The DON said she was not aware LVN A did not follow the ABCs (airway, breathing, and circulation) of CPR or that the LVN left the resident alone to call 911. The DON said the nurse was supposed to stay with the resident and pull the call light or yell for help. The DON said they had not completed any training and there was no documentation staff were educated on how to handle an emergency situation involving an unresponsive resident. During an observation at the time of the interview on [DATE] at 1:54 p.m., the DON could not locate the facility policy regarding CPR. The ADON came into the office and the DON asked her where the policy was. Neither could locate the policy. They called corporate office for a copy. During an interview on [DATE] at 3:01 p.m., the administrator said no training had been completed and there was no documentation staff were educated on how to handle an emergency situation involving an unresponsive resident. He said an in-service was scheduled for [DATE] (16 days after the incident occurred) to educate the staff on how to handle emergency situations. On [DATE] at 3:01 p.m., the survey team determined the failure to ensure nursing staff were knowledgeable about how to properly handle emergency situations and how to perform CPR contributed to an Immediate Jeopardy situation that had existed since [DATE]. On [DATE] at 3:01 p.m., the surveyor notified the administrator and DON of the Immediate Jeopardy situation. On [DATE] at 5:53 p.m., the facility's Plan of Removal was accepted and included the following: "Issue: [DATE] Charge nurses not able to properly perform Emergency Medical Interventions during Code Situations. The DON/Designee is responsible for education of staff members. Correction: Target date [DATE] a. Licensed Nurses are currently actively receiving CPR training. b. Licensed Nurses trained in activation of the 911 system during a Medical Emergency. c. Licensed Nurses are being trained by the DON regarding sequence of duties required while responding to a Medical Emergency. Use of Ambu-bag for rescue breathing and proper use of back board to ensure compressions are beneficial for resuscitation. d. Licensed Nurses have received training regarding Presumptive signs of death and the LVN responsibility when residents are discovered with presumptive signs of death in accordance with Texas Board of Nursing 15.2 Role of the Licensed Vocational Nurse in Pronouncement of death. 1. Patient is unresponsive 2. Patient has no respirations 3. Patient has no pulse 4. Patient pupils are fixed and dilated, 5. The patient's body temperature indicates hypothermia 6. The patient has generalized cyanosis. 7. Conclusive Sign of death: There is a presence of livor mortis (venous pooling in dependent body parts causing purple discoloration of the skin which does not blanch with pressure). e. Licensed Nurses have received training in SLP Code Status System. (Code status of each resident is located on Emergency Cart). f. Licensed Nurses have been trained in working together as a team during a Code Situation whereas the resident is not left alone. The person running the Code assigns another staff member to notify 911 and prepare the transfer information for the Emergency Medical Team. The team leader also assigns another staff member to assist with CPR. g. Licensed Nurses are trained to continue CPR unless the resident is revived, until help arrives (911 EMT) or if physically unable to continue. h. New Licensed Nurses are provided Orientation which includes the location and use of the Emergency Cart. i. The facility will train Licensed Nurses on Change of Conditions and responsibility of physician notification. j. All nursing staff will be competent and knowledgeable in following policy and procedure in Cardio-Pulmonary Resuscitation. " Plan of Removal verification: As of [DATE], all nurses had received the in-service training. Four nurses were interviewed and provided correct responses about how to handle emergencies. The survey team determined the facility had implemented its plan of removal sufficiently to remove the Immediate Jeopardy, effective [DATE]. On [DATE] at 12:15 p.m., the administrator, DON, vice president of clinical operations and corporate nurse consultant were informed the Immediate Jeopardy was lifted. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete all proficiency audits, and monitor and evaluate the effectiveness of the corrective systems. A list dated [DATE] identified 35 residents with full code status. On [DATE], three days after the survey exit, the facility provided documentation that an inservice was conducted on [DATE], but was not attended by all staff.

Based on interview and record review, the facility failed to ensure care provided for 1 of 4 residents sampled for full code status met professional standards of quality. (Resident #1) LVN A failed to open Resident #1's airway and perform rescue breaths when she was found unresponsive and not breathing. LVN A left Resident #1 in her room alone. Resident #1 died in the facility on [DATE]. Two of two LVNs on duty at the time of the incident said they would leave a resident alone to call emergency services. This failure potentially contributed to Resident #1's death. An Immediate Jeopardy identified [DATE] had existed since [DATE]. While the Immediate Jeopardy was removed [DATE], the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training for one staff member, monitor and evaluate the effectiveness of the corrective systems. This failure could place 35 residents with full code status at risk of neglect due to a lack of nursing staff knowledge about emergency intervention. Findings included: Texas Administrative Code: Standards Of Nursing Practice; Title 22 part 11, Chapter 217 states: "Standards applicable to all nurses... (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications." Resident #1's [DATE] physician orders [REDACTED]. The resident had a full code status. Resident #1's quarterly MDS dated [DATE] documented she was independent with all ADLs and was continent of bowel and bladder. Resident #1's plan of care with a revision date of [DATE] documented she had a full code status. Nursing notes dated [DATE] indicated at 6:50 a.m., LVN A found Resident #1 in bed unresponsive, with no pulse or respirations. Her fingers were blue. LVN A said she started CPR and called for help. The LVN performed CPR until she "was physically unable to continue." A Record of Death form dated [DATE] noted Resident #1 died on [DATE]. During an interview on [DATE] at 12:42 p.m., LVN A said she entered Resident #1's room to check her blood sugar level on [DATE] at about 7:00 a.m. Resident #1 looked like she had been sitting on the side of the bed and fell backwards. LVN A said the resident was unresponsive and had no pulse. She said she left Resident #1's side to call 911. LVN A returned to Resident #1's room with CNA C and she (LVN A) initiated CPR. She said CNA C was in the room observing. LVN A said she did not obtain the crash cart and did not reposition before she started chest compressions. LVN A said she performed only chest compressions. She said she did not open or maintain Resident #1's airway or provide rescue breathing. She said she did chest compressions until she was exhausted. She stopped because she heard the paramedics arrive at the facility. She said she did not know to open the airway, or to perform rescue breathing during CPR. She said when she was hired, she informed the facility her CPR certification had expired and they assured her they would set up a class. Following the incident, LVN A attended a CPR class on [DATE]. LVN A said she had received no additional in-service training since this incident regarding facility required protocol for resident emergency situations. A Payroll Action form in LVN A's employee file documented she was hired [DATE]. A Job Description for LVNs signed by LVN A on [DATE] documented the following: *The LVN works under the supervision of the DON to provide nursing care to residents as prescribed by the physician and in accordance with standards of nursing practices and regulations, and supervises the CNA staff in the delivery of direct resident care. * The essential function of the LVN was to "participate in in-service training; assist in implementing orientation programs and job skills training; and maintain professional competence." * The LVN was to be capable of performing the essential functions and responsibilities of the job with or without reasonable accommodations. According to Mosby's 2009 Fundamentals of Nursing p. 960, if a client's [MEDICAL CONDITION] (low blood oxygen) is severe and prolonged, [MEDICAL CONDITION] will result. A [MEDICAL CONDITION] is a sudden cessation of cardiac output and circulation. When this occurs, oxygen is not delivered to tissues, carbon [MEDICATION NAME] is not transported from tissues....Permanent heart, brain, and other tissue damage occur within ,[DATE] minutes. During [MEDICAL CONDITION] there is an absence of pulse and respiration. ...The "ABCs" of cardiopulmonary resuscitation are to establish an airway, initiate breathing, and maintain circulation...The purpose of CPR is to circulate [MEDICATION NAME] blood to the brain to prevent permanent tissue damage. During an interview on [DATE] at 12:08 p.m., CNA C said she was responsible for Resident #1's care on [DATE]. At about 6:15 a.m., she went into the room to get Resident #1's roommate up for breakfast. Resident #1 was in bed on her back with her feet near the foot board. At about 6:50 a.m. she was told LVN A found Resident #1 unresponsive and without a pulse. CNA C said LVN A was providing CPR when she entered the resident's room (exact time unknown). She said LVN A did only chest compressions and did not open the resident's airway or administer rescue breathing. CNA C said LVN A performed CPR by herself and stopped once the paramedics arrived at the facility. LVN A "just stopped performing CPR" before the paramedics were in the resident's room. The CNA said she offered to continue compressions when LVN A was tired, and LVN A told her no. During an interview on [DATE] at 1:18 p.m., LVN B said a CNA told her LVN A found Resident #1 unresponsive without a pulse on [DATE]. LVN B said when she went to Resident #1's room, LVN A said she had already called 911. LVN A asked LVN B to get the paperwork ready because she was going to initiate CPR. LVN B said she prepared the paperwork and when she was finished, she saw the paramedics in the facility on the way to Resident #1's room (time unknown). LVN B said that if she found a resident unresponsive, she would also leave the resident alone to call a code over the intercom. LVN B said her CPR certification was current. The LVN was not able to explain the steps to follow regarding CPR and said, "I guess I need to update my reading on CPR." LVN B said she had received no additional in-service training since this incident regarding facility required protocol for resident emergency situations. During an interview on [DATE] at 1:54 p.m., the DON said she had been working at the facility since [DATE]. The DON said after speaking with LVN A on [DATE], she realized not all staff were knowledgeable regarding CPR. She said a CPR class was completed [DATE] and another class was scheduled for [DATE]. She said she gave the staff until [DATE] to have current CPR certification. The DON said LVN A incorrectly performed CPR because she stopped when she got tired. The DON said no one else performed CPR for the resident until the paramedics entered the resident's room. The DON said she was not aware LVN A did not follow the ABCs (airway, breathing, and circulation) of CPR or that the LVN left the resident alone to call 911. The DON said the nurse was supposed to stay with the resident and pull the call light or yell for help. The DON said they had not completed any training and there was no documentation staff were educated on how to handle an emergency situation involving an unresponsive resident. During an observation at the time of the interview on [DATE] at 1:54 p.m., the DON could not locate the facility policy regarding CPR. The ADON came into the office and the DON asked her where the policy was. Neither could locate the policy. They called corporate office for a copy. During an interview on [DATE] at 3:01 p.m., the administrator said no training had been completed and there was no documentation staff were educated on how to handle an emergency situation involving an unresponsive resident. He said an in-service was scheduled for [DATE] (16 days after the incident occurred) to educate the staff on how to handle emergency situations. On [DATE] at 3:01 p.m., the survey team determined the failure to ensure nursing staff were knowledgeable about how to properly handle emergency situations and how to perform CPR contributed to an Immediate Jeopardy situation that had existed since [DATE]. On [DATE] at 3:01 p.m., the surveyor notified the administrator and DON of the Immediate Jeopardy situation. On [DATE] at 5:53 p.m., the facility's Plan of Removal was accepted and included the following: "Issue: [DATE] Charge nurses not able to properly perform Emergency Medical Interventions during Code Situations. The DON/Designee is responsible for education of staff members. Correction: Target date [DATE] a. Licensed Nurses are currently actively receiving CPR training. b. Licensed Nurses trained in activation of the 911 system during a Medical Emergency. c. Licensed Nurses are being trained by the DON regarding sequence of duties required while responding to a Medical Emergency. Use of Ambu-bag for rescue breathing and proper use of back board to ensure compressions are beneficial for resuscitation. d. Licensed Nurses have received training regarding Presumptive signs of death and the LVN responsibility when residents are discovered with presumptive signs of death in accordance with Texas Board of Nursing 15.2 Role of the Licensed Vocational Nurse in Pronouncement of death. 1. Patient is unresponsive 2. Patient has no respirations 3. Patient has no pulse 4. Patient pupils are fixed and dilated, 5. The patient's body temperature indicates hypothermia 6. The patient has generalized cyanosis. 7. Conclusive Sign of death: There is a presence of livor mortis (venous pooling in dependent body parts causing purple discoloration of the skin which does not blanch with pressure). e. Licensed Nurses have received training in SLP Code Status System. (Code status of each resident is located on Emergency Cart). f. Licensed Nurses have been trained in working together as a team during a Code Situation whereas the resident is not left alone. The person running the Code assigns another staff member to notify 911 and prepare the transfer information for the Emergency Medical Team. The team leader also assigns another staff member to assist with CPR. g. Licensed Nurses are trained to continue CPR unless the resident is revived, until help arrives (911 EMT) or if physically unable to continue. h. New Licensed Nurses are provided Orientation which includes the location and use of the Emergency Cart. i. The facility will train Licensed Nurses on Change of Conditions and responsibility of physician notification. j. All nursing staff will be competent and knowledgeable in following policy and procedure in Cardio-Pulmonary Resuscitation. " Plan of Removal verification: As of [DATE], all nurses had received the in-service training. Four nurses were interviewed and provided correct responses about how to handle emergencies. The survey team determined the facility had implemented its plan of removal sufficiently to remove the Immediate Jeopardy, effective [DATE]. On [DATE] at 12:15 p.m., the administrator, DON, vice president of clinical operations and corporate nurse consultant were informed the Immediate Jeopardy was lifted. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete all proficiency audits, and monitor and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the administrator and DON failed to effectively and efficiently manage the facility's resources for 1 of 4 resident sampled for full code states. (Resident #1) Two of two LVNs on duty at the time of the incident said they would leave a resident alone to call emergency services. 1.) The administrator and DON did not supervise the implementation of their abuse/neglect policy and CPR policy and procedure. 2.) The administrator did not ensure the DON trained nursing staff regarding CPR and critical thinking skills in emergency situations. This failure potentially contributed to Resident #1's death. An Immediate Jeopardy identified [DATE] had existed since [DATE]. While the Immediate Jeopardy was removed [DATE], the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training for one staff member, monitor and evaluate the effectiveness of the corrective systems. This failure could place 35 residents with full code status at risk of neglect due to a lack of nursing staff knowledge about emergency intervention. Findings included: Texas Administrative Code: Standards Of Nursing Practice; Title 22 part 11, Chapter 217 states: "Standards applicable to all nurses... (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications." Resident #1's [DATE] physician orders [REDACTED]. The resident had a full code status. Resident #1's quarterly MDS dated [DATE] documented she was independent with all ADLs and was continent of bowel and bladder. Resident #1's plan of care with a revision date of [DATE] documented she had a full code status. Nursing notes dated [DATE] indicated at 6:50 a.m., LVN A found Resident #1 in bed unresponsive, with no pulse or respirations. Her fingers were blue. LVN A said she started CPR and called for help. The LVN performed CPR until she "was physically unable to continue." A Record of Death form dated [DATE] noted Resident #1 died on [DATE]. During an interview on [DATE] at 12:42 p.m., LVN A said she entered Resident #1's room to check her blood sugar level on [DATE] at about 7:00 a.m. Resident #1 looked like she had been sitting on the side of the bed and fell backwards. LVN A said the resident was unresponsive and had no pulse. She said she left Resident #1's side to call 911. LVN A returned to Resident #1's room with CNA C and she (LVN A) initiated CPR. She said CNA C was in the room observing. LVN A said she did not obtain the crash cart and did not reposition before she started chest compressions. LVN A said she performed only chest compressions. She said she did not open or maintain Resident #1's airway or provide rescue breathing. She said she did chest compressions until she was exhausted. She stopped because she heard the paramedics arrive at the facility. She said she did not know to open the airway, or to perform rescue breathing during CPR. She said when she was hired, she informed the facility her CPR certification had expired and they assured her they would set up a class. Following the incident, LVN A attended a CPR class on [DATE]. LVN A said she had received no additional in-service training since this incident regarding facility required protocol for resident emergency situations. A Payroll Action form in LVN A's employee file documented she was hired [DATE]. A Job Description for LVNs signed by LVN A on [DATE] documented the following: *The LVN works under the supervision of the DON to provide nursing care to residents as prescribed by the physician and in accordance with standards of nursing practices and regulations, and supervises the CNA staff in the delivery of direct resident care. * The essential function of the LVN was to "participate in in-service training; assist in implementing orientation programs and job skills training; and maintain professional competence." * The LVN was to be capable of performing the essential functions and responsibilities of the job with or without reasonable accommodations. According to Mosby's 2009 Fundamentals of Nursing p. 960, if a client's [MEDICAL CONDITION] (low blood oxygen) is severe and prolonged, [MEDICAL CONDITION] will result. A [MEDICAL CONDITION] is a sudden cessation of cardiac output and circulation. When this occurs, oxygen is not delivered to tissues, carbon [MEDICATION NAME] is not transported from tissues....Permanent heart, brain, and other tissue damage occur within ,[DATE] minutes. During [MEDICAL CONDITION] there is an absence of pulse and respiration. ...The "ABCs" of cardiopulmonary resuscitation are to establish an airway, initiate breathing, and maintain circulation...The purpose of CPR is to circulate [MEDICATION NAME] blood to the brain to prevent permanent tissue damage. During an interview on [DATE] at 12:08 p.m., CNA C said she was responsible for Resident #1's care on [DATE]. At about 6:15 a.m., she went into the room to get Resident #1's roommate up for breakfast. Resident #1 was in bed on her back with her feet near the foot board. At about 6:50 a.m. she was told LVN A found Resident #1 unresponsive and without a pulse. CNA C said LVN A was providing CPR when she entered the resident's room (exact time unknown). She said LVN A did only chest compressions and did not open the resident's airway or administer rescue breathing. CNA C said LVN A performed CPR by herself and stopped once the paramedics arrived at the facility. LVN A "just stopped performing CPR" before the paramedics were in the resident's room. The CNA said she offered to continue compressions when LVN A was tired, and LVN A told her no. During an interview on [DATE] at 1:18 p.m., LVN B said a CNA told her LVN A found Resident #1 unresponsive without a pulse on [DATE]. LVN B said when she went to Resident #1's room, LVN A said she had already called 911. LVN A asked LVN B to get the paperwork ready because she was going to initiate CPR. LVN B said she prepared the paperwork and when she was finished, she saw the paramedics in the facility on the way to Resident #1's room (time unknown). LVN B said that if she found a resident unresponsive, she would also leave the resident alone to call a code over the intercom. LVN B said her CPR certification was current. The LVN was not able to explain the steps to follow regarding CPR and said, "I guess I need to update my reading on CPR." LVN B said she had received no additional in-service training since this incident regarding facility required protocol for resident emergency situations. During an interview on [DATE] at 1:54 p.m., the DON said she had been working at the facility since [DATE]. The DON said after speaking with LVN A on [DATE], she realized not all staff were knowledgeable regarding CPR. She said a CPR class was completed [DATE] and another class was scheduled for [DATE]. She said she gave the staff until [DATE] to have current CPR certification. The DON said LVN A incorrectly performed CPR because she stopped when she got tired. The DON said no one else performed CPR for the resident until the paramedics entered the resident's room. The DON said she was not aware LVN A did not follow the ABCs (airway, breathing, and circulation) of CPR or that the LVN left the resident alone to call 911. The DON said the nurse was supposed to stay with the resident and pull the call light or yell for help. The DON said they had not completed any training and there was no documentation staff were educated on how to handle an emergency situation involving an unresponsive resident. During an observation at the time of the interview on [DATE] at 1:54 p.m., the DON could not locate the facility policy regarding CPR. The ADON came into the office and the DON asked her where the policy was. Neither could locate the policy. They called corporate office for a copy. During an interview on [DATE] at 3:01 p.m., the administrator said no training had been completed and there was no documentation staff were educated on how to handle an emergency situation involving an unresponsive resident. He said an in-service was scheduled for [DATE] (16 days after the incident occurred) to educate the staff on how to handle emergency situations. On [DATE] at 3:01 p.m., the survey team determined the failure to ensure nursing staff were knowledgeable about how to properly handle emergency situations and how to perform CPR contributed to an Immediate Jeopardy situation that had existed since [DATE]. On [DATE] at 3:01 p.m., the surveyor notified the administrator and DON of the Immediate Jeopardy situation. On [DATE] at 5:53 p.m., the facility's Plan of Removal was accepted and included the following: "Issue: [DATE] Charge nurses not able to properly perform Emergency Medical Interventions during Code Situations. The DON/Designee is responsible for education of staff members. Correction: Target date [DATE] a. Licensed Nurses are currently actively receiving CPR training. b. Licensed Nurses trained in activation of the 911 system during a Medical Emergency. c. Licensed Nurses are being trained by the DON regarding sequence of duties required while responding to a Medical Emergency. Use of Ambu-bag for rescue breathing and proper use of back board to ensure compressions are beneficial for resuscitation. d. Licensed Nurses have received training regarding Presumptive signs of death and the LVN responsibility when residents are discovered with presumptive signs of death in accordance with Texas Board of Nursing 15.2 Role of the Licensed Vocational Nurse in Pronouncement of death. 1. Patient is unresponsive 2. Patient has no respirations 3. Patient has no pulse 4. Patient pupils are fixed and dilated, 5. The patient's body temperature indicates hypothermia 6. The patient has generalized cyanosis. 7. Conclusive Sign of death: There is a presence of livor mortis (venous pooling in dependent body parts causing purple discoloration of the skin which does not blanch with pressure). e. Licensed Nurses have received training in SLP Code Status System. (Code status of each resident is located on Emergency Cart). f. Licensed Nurses have been trained in working together as a team during a Code Situation whereas the resident is not left alone. The person running the Code assigns another staff member to notify 911 and prepare the transfer information for the Emergency Medical Team. The team leader also assigns another staff member to assist with CPR. g. Licensed Nurses are trained to continue CPR unless the resident is revived, until help arrives (911 EMT) or if physically unable to continue. h. New Licensed Nurses are provided Orientation which includes the location and use of the Emergency Cart. i. The facility will train Licensed Nurses on Change of Conditions and responsibility of physician notification. j. All nursing staff will be competent and knowledgeable in following policy and procedure in Cardio-Pulmonary Resuscitation. " Plan of Removal verification: As of [DATE], all nurses had received the in-service training. Four nurses were interviewed and provided correct responses about how to handle emergencies. The survey team determined the facility had implemented its plan of removal sufficiently to remove the Immediate Jeopardy, effective [DATE]. On [DATE] at 12:15 p.m., the administrator, DON, vice president of clinical operations and corporate nurse consultant were informed the Immediate Jeopardy was lifted. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete all proficiency audits, and monitor and evaluate the effectiveness of the corrective systems. On [DATE], three days after the survey exit, the facility provided documentation that an inservice was conducted on [DATE].