Every finding on record at Avir at Rose Trail

Based on observation, 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(s) when there is a significant change in the resident's physical, mental, or psychosocial status for 1 of 7 residents (Resident's #1) reviewed for a change of condition. 1. The facility failed to notify the physician and document an assessment and communication with the physician on 8/5/2026, 8/7/2026 and 8/8/2026 when Resident #1 was exhibiting symptoms of a stroke. 2. The facility failed to follow their Change of Condition Policy by utilizing the SBAR communication form to document the communication with the MD on 8/5/2026, 8/7/2026 and 8/8/2026. An Immediate Jeopardy (IJ) was identified on 8/13/2026 at 3:09 p.m. The IJ template was provided to the facility on 8/13/2026 at 3:09 p.m. While the IJ was removed on 8/14/2026 at 12:26 p.m., the facility remained out of compliance at a scope of pattern and a severity level of immediate jeopardy to resident health or safety due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. These failures could place residents at risk for delayed treatment after a change of condition leading to a decreased quality of life, and death. Findings Include: Record review of the face sheet dated 8/11/2026 indicated Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure) and hyperlipidemia (higher than normal levels of fats in your blood). Record review of the MDS assessment for Resident #1 dated 8/10/2026 indicated that Resident #1 has a BIMS of 15 (cognitively intact and able to communicate without limitation). Record review of the hospital discharge and referral documents dated 7/14/2026 indicated that Resident #1 has a history of CVA (stroke). Stroke history in January 2026. Record review of the hospital records dated 8/10/2026 indicated Resident #1 had a diagnoses of urinary tract infection, left sides weakness and hyperglycemia. Results from MRI brain scan on 8/11/2026, revealed scattered small acute strokes and Resident #1 was outside the window for thrombolytics (clot-busting drugs that break up and dissolve blood clots that get in the way of your blood flow) on presentation. Record review of the progress note for Resident #1 dated 8/7/2026 at 3:57 p.m., by LVN B indicated Resident #1 reported can't move her left arm, states she told her nurse on Wednesday and said, it was bothersome. States arm is numb feeling. Notified MD of this issue. Record review of the progress note for Resident #1 dated 8/8/2026 at 3:10 a.m., by RN C indicated Resident complains about having difficulty to move her left arm and not able to grab things with left hand. Denies headache or any other distress. Vital sign BP=118/67,Temp= 97.7, pulse 76, RR=18 breath/min and bs=356mg/dl. Md notified. instructed to assess peripheral pulses. Left radial pulses 2+ and regular and right radial pulse 2+ and regular. Resident is continuously observe for any changes in condition. Record review of the progress note for Resident #1 dated 8/8/2026 at 11:42 a.m., by LVN B indicated Resident #1 sat up in bed playing games on her cellphone. Denies no pain at this time. Left hand is at her side. Blood sugars are monitored per orders no distress is noted. Will monitor any changes. Record review of the progress note for Resident #1 dated 8/10/2026 at 2:51 a.m., by RN C indicated Resident #1 reports improvement in left hand movement compared with previous assessment. no acute distress noted. Vs within normal range. Bed in lowest position and call light within reached. ongoing plan of care. Record review of the progress note for Resident #1 dated 8/10/2026 at 7:40 a.m., by RN D indicated Upon rounding this morning and obtaining blood sugar. Resident is having a change in condition. Unable to move or lift her left arm and when asked to smile resident has left sided droop with some slurred speech. MD notified and instructed to send to the ER for further evaluation. Also called husband but unable to reach. Will continue to call husband. Record review of the physical therapy progress note dated 8/5/2026 by PT indicated that Resident #1 complained that her left arm felt weak. Resident #1 was noted to be leaning to her left. Resident #1 indicated that she had first noticed her weak left arm on that morning and had not told anyone. Nursing was notified of symptoms. During an interview on 8/11/2026 at 4:15 p.m., the DON stated what was reported to him regarding Resident #1 that nursing was notified about her left arm being numb on Friday (8/7/2026) and MD was notified and ordered that Resident #1 have her peripheral pulses assessed. He stated that there was no change beyond that until Monday (8/10/2026) morning when the nurse noticed drooping in her face, contacted the doctor and he sent her to the ER. He stated that typically when a resident is presenting with stroke symptoms it is not isolated to the arm, it is the total side of the body and with Resident #1 it was only her left arm until Monday morning when she was sent out to the ER. He stated that he first became aware of the issue with Resident #1's arm on Monday when she was sent out to the hospital. He stated that the expectation for nurses is that they would notify the physician if there is a change in condition in a resident and that they would document exactly what the doctor ordered and enter an order for anything that the nursing staff are to do to assess or monitor the resident per the direction of the doctor. He stated that he would consider the loss of the use of the left hand a change of condition that would require contacting the physician. He stated that documenting this change of condition is vital for the care of the resident as the next nurse that comes on should be aware of any changes to continue monitoring the resident and updating the physician as needed for further direction. During an observation and interview on 8/11/2026 at 5:40 p.m., Resident #1 was observed in their hospital room. She was awake and appeared well groomed and in no apparent distress. She was observed moving her left arm across her body with her right hand and appeared unable to move her left arm independently. Her face appeared normal (not droopy) but her speech was slurred. She stated the facility did not do anything for her even though she was telling them that something was wrong with her arm. She stated that she told them her arm was numb and that she couldn't move it 5 days ago but she could not remember the day of the week. She stated that they told her that they would call the doctor but they never told her what he said. She stated that the hospital told her she has had several mini strokes that have caused her left side paralysis and slurred speech. She stated that she will not be going back to the nursing facility and will be going to another facility when she is released. She stated that she does not know the name of the nurse she initially told about her arm but it was a large black female staff. During an interview on 8/12/2026 at 10:01 a.m., RN D stated on Monday she was completing her rounds and when she got to Resident #1 she went to check her blood sugar. She stated that she normally checks the blood sugar on her left hand and noticed that she could not lift her left hand. She stated that she asked Resident #1 to smile and when she smiled only her right side of her mouth lifted. She stated that she immediately thought stroke and stopped her assessment and called the doctor who directed her to send her to the emergency room. She stated that she normally works on the East wing of the facility and every few weeks she will work on the South wing and has seen Resident #1 before. She stated that she knew that she had a history of stroke due to the resident telling her and that she had wondered why it was not documented in her medical record. She stated that Resident #1 told her that the last time the stroke was on the right side of her body. She stated that for all skilled residents they do a skilled nursing assessment each day and in the neurological section, if the resident was complaining of issues she would go through the stroke assessment which has the resident to raise their eyebrows, smile, and raise each arm and leg and hold it above the bed for about 5 seconds. She stated that when she saw that her smile was drooping and she could not raise her left hand she did not complete the assessment but immediately stopped and called the doctor who sent her out to the emergency room. She stated that if a resident was having weakness in their arm and not their leg, she still would have gone through the stroke assessment and documented what she observed. She stated that if she had notified the doctor and he did not direct to send out a resident that she felt was in an emergency situation she would still send them to the emergency room as it is her license on the line. She stated that in any circumstance if the doctor tells her something, she documents that in the progress note and indicates his stated rationale for not sending the resident out. She stated that in a non-emergency situation the DON is the one who approves when a resident is sent out to the emergency room and he is good about sending them out if the resident insists on going. During an interview on 8/12/2026 at 10:36 a.m., LVN B stated that she works 6am to 6pm on the South wing at the nursing facility. She stated that on 8/7/2026 during her shift at around 3:30 p.m. one of the CNAs came to her and told her that Resident #1 was not able to move her left arm. She stated that she was not aware of any issues going on with Resident #1 prior to this notification by the CNA. She stated that nothing was communicated to her in that morning's report. She stated that she was not aware of Resident #1's stroke history at the time. She stated that she went into Resident #1's room and she was holding her phone with her left hand and playing with the phone with her right hand. She stated that she was not in any distress and indicated that she had told the nurse on Wednesday that her hand was numb and not feeling right. She stated that she called the MD and he told her to check the radial pulses in her wrists so she did and they were both even. She stated that she had Resident #1 grab her hands with both of her hands and the left side was weaker. She stated that she did not report this to the MD. She stated that she should have documented this but did not. She stated that she then went and spoke to LVN A, the nurse who was working on Wednesday and she told her that she had called the doctor and he told her to check the radial pulses as well. She stated that she should not have documented that she could not move her left hand because she was moving it, but was saying it was numb. She stated that she only talked to the doctor once and did not follow up with him after the left hand was weaker in her assessment. She stated that the next day she saw the resident and she was laying in bed in no distress and was playing on her phone with her left hand at her side. She stated that she did not complete a stroke assessment on the resident at that time and did not feel she had a reason to given what she was looking at with the resident. She stated that she observed her pull herself up in bed with both arms. She stated that a neurological assessment involves looking at the eyes of the resident for pupil dilation as well as movement control, she stated that it also includes checking the radial pulses and having them squeeze each hand to see grip strength. She stated that if she felt a resident was in an emergency situation she would send them out to the emergency room even if the doctor did not indicate to do so. During an interview on 8/12/2026 at 11:55 a.m., MD stated that he received a call sometime last week from a nurse at the facility regarding Resident #1 having some complications with her left side being numb. He stated that he instructed the nurse to check her radial pulses to gauge the strength as someone can sleep on their left side and pinch that radial nerve and it can cause numbness and if they lay flat for a while the sensation will return to normal. He stated that if it does not return then there could be more going on and he instructed them to send her to the emergency room if they had any concerns of a stroke. He stated that he did not receive any follow up calls regarding Resident #1 until Monday (8/10/2026) when the nurse called with concerns of facial drooping and left handed paralysis. He stated that he instructed that nurse to send the resident to the emergency room to be assessed and treated. He stated that a resident having full function of their left hand one day and then the next day being unable to move it is a big change of condition that needs to be addressed. He stated that delaying that treatment poses a risk to the resident but he cannot gauge the severity of the risk due to the variety of things that could be going on. He stated that he does not document the phone calls he receives from the facility and only documents when he sees the residents in person, but he remembers receiving one phone call from a nurse regarding the left arm of Resident #1 and no follow up until Monday when he directed them to send her to the emergency room. He does not remember the names of the nurses that he spoke to in those two phone calls. During an interview on 8/12/2026 at 1:50 p.m., LVN A stated that she does not normally work on the South wing of the facility and was not very familiar with Resident #1. She stated that last Wednesday she was working on the South wing and got notified by a CNA that the physical therapist sent her to tell her that something was going on with Resident #1. She stated that she went to assess her and that she did a thorough nursing assessment when it was reported that the resident was having weakness on her left side, she stated that everything was within normal limits but when the resident told her that she had a history of stroke she decided to call the doctor and the doctor stated that if everything was within normal limits to just monitor her and if she wanted to go out to the hospital, send her. She stated that the resident said she was fine and was not slurring her speech so she did not send her out. She stated that if she had shown any indicators she would have sent her out. She stated that she documented it but doesn't know why it is not in the medical record. She stated that she has not been trained to recognize the signs and symptoms of a stroke by the facility but she leaned in nursing school how to assess for a stroke. She stated that when she speaks to the doctor she is to document that she contacted them and what their response and directions were and enter any orders that they give. She stated that the physical therapist did not give her any details about what he had observed. During an interview on 8/12/2026 at 3:25 p.m., CNA E stated that she worked as the CNA on South wing with LVN B on 8/7/26 and was the CNA that notified LVN B that Resident #1 was complaining about her hand being numb. She stated that she has known Resident #1 for a long time as she worked with her at another facility and is very familiar with her demeanor and behavior. She stated that she worked on Thursday (8/6/26) and Friday (8/7/26) of last week and she did not notice any changes from what is normal for her. She stated that Resident #1 is always playing solitaire on her phone and holding it in her left hand and playing with her right hand. She stated that Resident #1's husband came on Friday and that morning she had given her a shower and helped her pull up in bed. She stated that during that time Resident #1 did not complain about her hand at all and was still using her left hand as she always did pulling herself up in bed and holding her phone with her left hand. She stated that afternoon that Resident #1's husband came to visit and she went in the room and Resident #1 told her that her hand was numb and that she had reported this to the nurse on Wednesday and that it was still bothering her. She stated that she asked her why she had not mentioned this before as she felt like she had a good rapport with her. She stated that Resident #1 told her that it comes and goes and sometimes she can use it and then sometimes it's like she loses all her strength in her hand. She stated that the husband asked her to tell the nurse so she went and told LVN B who went to look for documentation from Wednesday indicating the issue and she could not find anything so she decided to call the doctor. She stated that Resident #1 was still using her left hand on Friday and that she did not see any change of condition in the Thursday and Friday leading up to this past weekend. During an interview on 8/12/2026 at 3:45 p.m., the PT stated that he worked with Resident #1 last Wednesday (8/5/26) right before lunch and when he went to get her from her room she was clearly a little weaker than normal and complaining of her left arm being weak. He stated that Resident #1 is known to have good days and the week before last she was about to walk about 10 feet with assistance. He stated that on Wednesday she was struggling to sit up straight and leaning a bit to the left. He stated he got her to the gym and she was struggling to stand. He stated that he had her hold her arms out in front of her to check her resistance and she was clearly weaker on the left side and was not able to walk. He stated that some of this was normal for the resident but it was more noticeable on that day. He stated that he immediately sent a CNA to notify LVN A and she came to the gym and assessed Resident #1 and stated that she was not her normal nurse but she would call the doctor to see what he says. He stated that that was all he knows and did on that date. He stated that he did voice his concerns to LVN A and does not remember the exact words he used but indicated to her that he would not be saying anything if he was not noticing something outside of Resident #1's normal ability. During an interview on 8/13/2026 at 10:50 a.m., LVN A stated that on 8/5/2026 she was in the dining room when a CNA (she cannot remember the name) came to tell her that Resident #1 was complaining of her arm hurting. She stated that she went to the PT gym and checked all of Resident #1's vitals and everything was within normal limits. She stated that Resident #1 told her that she has a history of stroke so that prompted her to complete a neuro assessment and she had Resident #1 say a sentence and there was no slurred speech, she had her smile and she did not have a noticeable droop in her smile. She stated that she checked her grip strength and she had even strength at that time in both hands. She stated that she checked her resistance by having her hold her arms out and she was able to resist up and down when pressed. She stated that no one told her that the PT had observed her walking the week before and that she was favoring her left side. She stated that if she had known that she had been walking the week before and that she was leaning to the left side she would have sent her to the emergency room. She stated that after she had completed those assessments, she called the MD and informed him of what was going on and he told her to check the radial pulses and that if everything is in normal limits to observe the resident and if she wants to go to the emergency room, send her. She stated that she told the resident what the doctor said and the resident stated that she did not want to go to the hospital. She stated that she did not consider this a change of condition as all of her assessments where within normal limits. She stated that she should have documented her assessment and the reported issues and does not know why she did not. Record review of facility policy dated April 2025 and entitled Change in Resident's Condition or Status and indicated that 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; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications three (3) or more consecutive times); g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self -limiting); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 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. This was determined to be an Immediate Jeopardy (IJ) on 8/13/2026 at 3:09 p.m. The facility's Administrator, DON, ADON, and Regional Director of Clinical Operations were notified. The Administrator was provided with the IJ template on 8/13/2026 at 3:09 p.m. The following Plan of Removal (POR) submitted by the facility was accepted on 8/13/2026 at 10:00 p.m. Plan of Removal: 580: Notify of ChangesThe facility failed to immediately consult and follow up with the resident's physician when Resident #1 had a significant decline in condition as evidenced by the loss of the use of her left arm. IJ Called: 8/13/2026POR Submitted: 8/13/2026 How corrective action will be accomplished for those residents affected by the violation(s): Action: Resident #1 was sent to the hospital for stroke-like symptoms on 8/10/2026 and has not returned. Person(s) Responsible: Charge NurseDate: 8/10/2026 How the facility will identify other residents with the potential to be affected by the same violation(s): Action: Progress notes reviewed for 72 hours to search for change in condition that went unreported or delayed in reporting to the physician or physician extender. Any changes noted without physician or physician extender notification will be communicated and the facility will follow any new orders. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 8/13/2026 Action: Director of Nursing, Assistant Directors of Nursing, and/or Designee rounded on all residents in the facility assessing for changes in condition. Any change in condition noted will result in physician notification and the facility will then follow MD orders. Person(s) Responsible: Director of Nursing, Assistant Directors of Nursing, and/or DesigneeDate: 8/14/2026 What measures will be put into place or systemic changes made to ensure the violation(s) will not recur: Action: Director of Nursing and Assistant Directors of Nursing educated on Nurses educated on the facility's change in condition policy with emphasis on completing SBAR/e-interact, resident assessment, documentation, and notifying of change in condition such as stroke symptoms (arm tingling, facial drooping, slurred speech, etc.) to the physician or physician extender and follow orders by the [NAME] President of Clinical Operations . Train the TrainerPerson(s) Responsible: [NAME] President of Clinical OperationsDate: 8/13/2026Nurses educated on the facility's change in condition policy with emphasis on completing SBAR/e-interact, resident assessment, documentation, and notifying of change in condition such as stroke symptoms (arm tingling, facial drooping, slurred speech, etc.) to the physician or physician extender and follow orders. If the physician or physician extender is not responding promptly to make a nursing judgment and send resident to the hospital for further evaluation. Nurses will be educated prior to working their next shift. Competency test will be completed to ensure education retention. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate: 8/13/2026Action: LVN A, LVN B, & RN C educated 1:1 regarding resident assessment and the need and rationale to document your assessment and physician notification with a resident's change in condition. Competency test will be completed to ensure education retention. Person(s) Responsible: Director of Nursing and/or Designee Date: 8/13/2026 How the facility will monitor its corrective actions to ensure that the violation(s) is being corrected and will not recur: Action: During clinical meetings, daily, the 24 hour report will be reviewed for any changes in condition by clinical leadership. If change in condition is noted clinical leadership will ensure the physician was notified and any orders were followed. If change in condition was noted and documentation does not indicate the physician or physician extender was notified, clinical leadership will notify the physician and reeducate the responsible nurse. The charge nurse is responsible for documenting change in condition in the electronic medical record which is pulled into the electronic medical record's 24-hour report which the nurses review shift-to-shift. Director of Nursing & Assistant Directors of Nursing educated on the clinical meeting and reviewing for change in condition and notifying the physician with any noted changes that went unreported by the [NAME] President of Clinical Operations on 8/13/2026. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Weekend Nurse Supervisor, [NAME] President of Clinical Operations, and/or DesigneeDate: 8/13/2026 QAPI: Action: The facility notified the Medical Director of the Immediate Jeopardy of 580: Notify of Changes and the facility's plan to remove the immediacy. No additional recommendations. Person(s) Responsible: AdministratorDate: 8/13/2026Action: The administrator will oversee the action items and will ensure they are completed.Person(s) Responsible: Administrator Date: 8/13/2026 The State Surveyors monitored the Plan of Removal as follows: During interviews on 8/14/2026 from 8:50 a.m. to 9:25 a.m. the following nurse leadership staff indicated their understanding and role in the ongoing assessment and ensuring of following up with physicians or physician extenders of any changes of condition in residents at the nursing facility. They indicated their understanding in reviewing the 72 hour reports for any changes of condition and verifying that adequate information is portrayed in the medical record as well as appropriate follow-up with the medical director. They indicated understanding and affirmed that rounding on all residents was in process and ongoing and that no other changes of condition have been identified. They also stated that in-services regarding the Stop and Watch forms and Change of Condition are ongoing and that numerous staff had been in-serviced and all staff had been directed to be in-serviced before their next shift. They stated that in morning meetings they have begun reviewing the 24 hour reports for changes in condition and will follow up with the nurses to ensure that appropriate interventions are taken and that proper documentation is entered into the record including physician notification and follow-up. Interviews included: DON, ADON F, ADON G. During an interview on 8/14/2026 at 9:35 a.m., the [NAME] President of Clinical Operations indicated that she had completed one on one in-services regarding Nurses educated on the facility's change in condition policy with emphasis on completing SBAR/e-interact, resident assessment, documentation, and notifying of change in condition such as stroke symptoms (arm tingling, facial drooping, slurred speech, etc.) to the physician or physician extender and follow orders by the [NAME] President of Clinical Operations with DON, ADON F and ADON G. During an interview on 8/14/2026 at 10:00 a.m., the ADM stated that she spoke to the MD and made him aware of the immediate jeopardy and the facility's plan to remove it and he had no additional suggestions. Record review of in-service document dated 8/13/2026 entitled Stop and Watch indicated that 20 staff have been in-serviced on the Stop and Watch forms that was located at each nursing station for any staff who became aware of a change of condition to document that change and each nurse is responsible for reviewing those forms and following up and any necessary assessments or documentation pertaining to that report. Record review of in-service document dated 8/13/2026 entitled Change in a resident's condition Status and was signed by 14 employees at the time of the review. The signatures among those include the names of LVN A, LVN B, RN C and RN D. During interviews on 8/14/2026 from 10:05 a.m. to 12:20 p.m. the following staff indicated that they had been in-serviced on the Stop and Watch form implemented as part of this plan of removal. They were able to articulate their understanding and role in documenting any observed change of condition for the residents and ensuring that the nurse on duty was aware of what was observed. Nurses interviewed were able to articulate their role in following up with the resident to assess, treat and make any notifications related to the change of condition. Interviews Included: LVN A, LVN B, RN C, RN D, PT, CNA E, LVN H, LVN J, CNA K, CNA L, RN M, CNA N, CNA O, RN P, LVN Q, LVN R, LVN S, CNA T The Administrator was informed that the Immediate Jeopardy was removed on 8/14/2026 at 12:26 p.m. however, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 7 residents reviewed for quality of care.1. The facility failed to address Resident #1's history of a stroke and disorder of brain circulation as a medical diagnoses in the facility's EMR. Resident #1's medical records did not include signs or symptoms of a stroke or brain circulation complication to monitor for.2. The facility failed to document assessments/findings on Resident #1 related to displayed stroke symptoms on 8/5 per the facility's change of condition policy.3. The facility failed to identify Resident #1's reported, assessed and documented symptoms of inability to use left arm, left arm weakness, numbness and tingling as stroke symptoms.4. The facility failed to perform necessary assessments (Balance, Eyes, Face, Arms, Speech, & Time) to rule out a stroke on Resident #1.An Immediate Jeopardy (IJ) was identified on 8/13/2026 at 3:09 p.m. The IJ template was provided to the facility on 8/13/2026 at 3:09 p.m. While the IJ was removed on 8/14/2026 at 12:26 p.m., the facility remained out of compliance at a scope of pattern and a severity level of immediate jeopardy to resident health or safety due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. These failures could place residents at risk of delayed medical intervention, severe medical complications, or death. Findings Include: Record review of the face sheet dated 8/11/2026 indicated Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure) and hyperlipidemia (higher than normal levels of fats in your blood). Record Review of the MDS assessment for Resident #1 dated 8/10/2026 indicated that Resident #1 has a BIMS of 15 (cognitively intact and able to communicate without limitation). Record Review of the University of Texas Health discharge and referral documents dated 7/14/2026 indicated that Resident #1 has a history of CVA (stroke). Stroke history in January 2026. Record Review of the records dated 8/10/2026 indicated diagnoses of urinary tract infection, left sides weakness and hyperglycemia. Results from MRI brain scan revealed scattered small acute strokes and Resident #1 was outside the window for thrombolytics (clot-busting drugs that break up and dissolve blood clots that get in the way of your blood flow) on presentation. Record Review of the progress note for Resident #1 dated 8/7/2026 at 3:57 p.m. by LVN B indicated Resident #1 reported can't move her left arm, states she told her nurse on Wednesday and said, it was bothersome. States arm is numb feeling. Notified MD of this issue. Record Review of the progress note for Resident #1 dated 8/8/2026 at 3:10 a.m. by RN C indicated Resident complains about having difficulty to move her left arm and not able to grab things with left hand. Denies headache or any other distress. Vital sign BP=118/67,Temp= 97.7, pulse 76, RR=18 breath/min and bs=356mg/dl. Md notified. instructed to assess peripheral pulses. Left radial pulses 2+ and regular and right radial pulse 2+ and regular. Resident is continuously observe for any changes in condition. Record Review of the progress note for Resident #1 dated 8/8/2026 at 11:42 a.m. by LVN B indicated Resident #1 sat up in bed playing games on her cellphone. Denies no pain at this time. Left hand is at her side. Blood sugars are monitored per orders no distress is noted. Will monitor any changes. Record Review of the progress note for Resident #1 dated 8/10/2026 at 2:51 a.m. by RN C indicated Resident #1 reports improvement in left hand movement compared with previous assessment. no acute distress noted. Vs within normal range. Bed in lowest position and call light within reached. ongoing plan of care. Record Review of the progress note for Resident #1 dated 8/10/2026 at 7:40 a.m. by RN D indicated Upon rounding this morning and obtaining blood sugar. Resident is having a change in condition. Unable to move or lift her left arm and when asked to smile resident has left sided droop with some slurred speech. MD notified and instructed to send to the ER for further evaluation. Also called husband but unable to reach. Will continue to call husband. Record review of the physical therapy progress note dated 8/5/2026 by PT indicated that Resident #1 complained that her left arm felt weak. Resident #1 was noted to be leaning to her left. Resident #1 indicated that she had first noticed her weak left arm on that morning and had not told anyone. Nursing was notified of symptoms. During an interview on 8/11/2026 at 4:15 p.m., the DON stated what was reported to him regarding Resident #1 that nursing was notified about her left arm being numb on Friday (8/7/2026) and MD was notified and ordered that Resident #1 have her peripheral pulses assessed. He stated that the facility has not conducted any training on stroke assessment as this is taught in nursing school and nurses know this in order to get their license to be a nurse. He stated that since learning of this incident he was planning to conduct in-services to refresh the training for the nurses to ensure that they understand the BEFAST method of stroke assessment. He stated that the appearance of any signs or symptoms of a stroke the nurse should conduct and document a thorough stroke assessment and make any necessary notifications to the MD. During an observation and interview on 8/11/2026 at 5:40 p.m., Resident #1 was observed in their hospital room. She was awake and appeared well groomed and in no apparent distress. She was observed moving her left arm across her body with her right hand and appeared unable to move her left arm independently. Her face appeared normal (not droopy) but her speech was slurred. She stated the facility did not do anything for her even though she was telling them that something was wrong with her arm. She stated that she told them her arm was numb and that she couldn't move it 5 days ago but she could not remember the day of the week. She stated that they told her that they would call the doctor but they never told her what he said. She stated that the hospital told her she had several mini strokes that have caused her left side paralysis and slurred speech. She stated that she will not be going back to the nursing facility and will be going to another facility when she is released. She stated that she does not know the name of the nurse she initially told about her arm but it was a large black female staff. During an interview on 8/12/2026 at 10:01 a.m., RN D stated on Monday she was completing her rounds and when she got to Resident #1 she went to check her blood sugar. She stated that she normally checks the blood sugar on her left hand and noticed that she could not lift her left hand. She stated that she asked Resident #1 to smile and when she smiled only her right side of her mouth lifted. She stated that she immediately thought stroke and stopped her assessment and called the doctor who directed her to send her to the emergency room. She stated that she normally works on the East wing of the facility and every few weeks she will work on the South wing and had seen Resident #1 before. She stated that she knew that she had a history of stroke due to the resident telling her and that she had wondered why it was not documented in her medical record. She stated that Resident #1 told her that the last time the stroke was on the right side of her body. She stated that for all skilled residents they do a skilled nursing assessment each day and in the neurological section, if the resident was complaining of issues she would go through the stroke assessment which has the resident to raise their eyebrows, smile, and raise each arm and leg and hold it above the bed for about 5 seconds. She stated that when she saw that her smile was drooping and she could not raise her left hand she did not complete the assessment but immediately stopped and called the doctor who sent her out to the emergency room. She stated that if a resident was having weakness in their arm and not their leg, she still would have gone through the stroke assessment and documented what she observed. She stated that if she had notified the doctor and he did not direct to send out a resident that she felt was in an emergency situation she would still send them to the emergency room as it is her license on the line. She stated that in any circumstance if the doctor tells her something, she documents that in the progress note and indicates his stated rationale for not sending the resident out. She stated that in a non-emergency situation the DON is the one who approves when a resident is sent out to the emergency room and he is good about sending them out if the resident insists on going. During an interview on 8/12/2026 at 10:36 a.m., LVN B stated that she works 6am to 6pm on the South wing at the nursing facility. She stated that on 8/7/2026 during her shift at around 3:30 p.m. one of the CNAs came to her and told her that Resident #1 was not able to move her left arm. She stated that she was not aware of any issues going on with Resident #1 prior to this notification by the CNA. She stated that nothing was communicated to her in that morning's report. She stated that she was not aware of Resident #1's stroke history at the time and only became aware when the resident informed her. She stated that she went into Resident #1's room and she was holding her phone with her left hand and playing with the phone with her right hand. She stated that she was not in any distress and indicated that she had told the nurse on Wednesday that her hand was numb and not feeling right. She stated that she called the MD and he told her to check the radial pulses in her wrists so she did and they were both even. She stated that she had Resident #1 grab her hands with both of her hands and the left side was weaker. She stated that she knows how to complete a stroke assessment and does so by looking at the resident's face and eyes, checking her strength in her hands and legs and asking them to speak to see if they have slurred speech. She stated that she did not complete a total assessment at that time and did not notify the physician of the weak left hand. She stated that she based her decision on what she was seeing the resident do with her left hand at that time. During an interview on 8/12/2026 at 11:55 a.m., MD states that he received a call sometime last week from a nurse at the facility regarding Resident #1 having some complications with her left side being numb. He stated that he instructed the nurse to check her radial pulses to gauge the strength as someone can sleep on their left side and pinch that radial nerve and it can cause numbness and if they lay flat for a while the sensation will return to normal. He stated that if it does not return then there could be more going on and he instructed them to send her to the emergency room if they had any concerns of a stroke. He stated that he did not receive any follow up calls regarding Resident #1 until Monday (8/10/2026) when the nurse called with concerns of facial drooping and left handed paralysis. He stated that he instructed that nurse to send the resident to the emergency room to be assessed and treated. He stated that delaying that treatment poses a risk to the resident but he cannot gauge the severity of the risk due to the variety of things that could be going on. During an interview on 8/12/2026 at 1:50 p.m., LVN A stated that she does not normally work on the South wing of the facility and was not very familiar with Resident #1. She stated that last Wednesday she was working on the South wing and got notified by a CNA that the physical therapist sent her to tell her that something was going on with Resident #1. She stated that she went to assess her and that she did a thorough nursing assessment when it was reported that the resident was having weakness on her left side, she stated that everything was within normal limits but when the resident told her that she had a history of stroke she decided to call the doctor and the doctor stated that if everything was within normal limits to just monitor her and if she wanted to go out to the hospital, send her. She stated that the resident said she was fine and was not slurring her speech so she did not send her out. She stated that if she had shown any indicators she would have sent her out. She stated that she has not been trained to recognize the signs and symptoms of a stroke by the facility but she leaned in nursing school how to assess for a stroke. During an interview on 8/12/2026 at 3:25 p.m., CNA E stated that she worked as the CNA on South wing with LVN B on 8/7/26 and was the CNA that notified LVN B that Resident #1 was complaining about her hand being numb. She stated that she has known Resident #1 for a long time as she worked with her at another facility and is very familiar with her demeanor and behavior. She stated that she worked on Thursday (8/6/26) and Friday (8/7/26) of last week and she did not notice any changes from what is normal for her. She stated that Resident #1 is always playing solitaire on her phone and holding it in her left hand and playing with her right hand. She stated that Resident #1's husband came on Friday and that morning she had given her a shower and helped her pull up in bed. She stated that during that time Resident #1 did not complain about her hand at all and was still using her left hand as she always did pulling herself up in bed and holding her phone with her left hand. She stated that afternoon that Resident #1's husband came to visit and she went in the room and Resident #1 told her that her hand was numb and that she had reported this to the nurse on Wednesday and that it was still bothering her. She stated that she asked her why she had not mentioned this before as she felt like she had a good rapport with her. She stated that Resident #1 told her that it comes and goes and sometimes she can use it and then sometimes it's like she loses all her strength in her hand. She stated that the husband asked her to tell the nurse so she went and told LVN B who went to look for documentation from Wednesday indicating the issue and she could not find anything so she decided to call the doctor. She stated that Resident #1 was still using her left hand on Friday and that she did not see any change of condition in the Thursday and Friday leading up to this past weekend. During an interview on 8/12/2026 at 3:45 p.m., the PT stated that he worked with Resident #1 last Wednesday (8/5/26) right before lunch and when he went to get her from her room she was clearly a little weaker than normal and complaining of her left arm being weak. He stated that Resident #1 is known to have good days and the week before last she was about to walk about 10 feet with assistance. He stated that on Wednesday she was struggling to sit up straight and leaning a bit to the left. He stated he got her to the gym and she was struggling to stand. He stated that he had her hold her arms out in front of her to check her resistance and she was clearly weaker on the left side and was not able to walk. He stated that some of this was normal for the resident but it was more noticeable on that day. He stated that he immediately sent a CNA to notify LVN A and she came to the gym and assessed Resident #1 and stated that she was not her normal nurse but she would call the doctor to see what he says. He stated that that was all he knows and did on that date. He stated that he did voice his concerns to LVN A and does not remember the exact words he used but indicated to her that he would not be saying anything if he was not noticing something outside of Resident #1's normal ability. During an interview on 8/13/2026 at 10:50 a.m., LVN A stated that on 8/5/2026 she was in the dining room when a CNA (she cannot remember the name) came to tell her that Resident #1 was complaining of her arm hurting. She stated that she went to the PT gym and checked all of Resident #1's vitals and everything was within normal limits. She stated that Resident #1 told her that she has a history of stroke so that prompted her to complete a neuro assessment and she had Resident #1 say a sentence and there was no slurred speech, she had her smile and she did not have a noticeable droop in her smile. She stated that she checked her grip strength and she had even strength at that time in both hands. She stated that she checked her resistance by having her hold her arms out and she was able to resist up and down when pressed. She stated that no one told her that the PT had observed her walking the week before and that she was favoring her left side. She stated that if she had known that she had been walking the week before and that she was leaning to the left side she would have sent her to the emergency room. She stated that after she had completed those assessments, she called the MD and informed him of what was going on and he told her to check the radial pulses and that if everything is in normal limits to observe the resident and if she wants to go to the emergency room, send her. She stated that she told the resident what the doctor said and the resident stated that she did not want to go to the hospital. She stated that she did not consider this a change of condition as all of her assessments where within normal limits. This was determined to be an Immediate Jeopardy (IJ) on 8/13/2026 at 3:09 p.m. The facility's Administrator, DON, ADON, and Regional Director of Clinical Operations were notified. The Administrator was provided with the IJ template on 8/13/2026 at 3:09 p.m. The following Plan of Removal (POR) submitted by the facility was accepted on 8/13/2026 at 10:00 p.m. Plan of Removal: Plan of Removal: 684: Quality of CareThe facility failed to address Resident #1's history of a stroke and disorder of brain circulation as a medical diagnoses in the facility's EMR. Resident #1's medical records did not include signs or symptoms of a stroke or brain circulation complication to monitor for.LVN A failed document assessments/findings on Resident #1 related to displayed stroke symptoms on 8/5 per the facility's change of condition policy.LVN A, LVN B, and RN C failed to identify Resident #1's reported, assessed and documented symptoms of inability to use left arm, left arm weakness, numbness and tingling as stroke symptoms.The facility failed to perform necessary assessments (Balance, Eyes, Face, Arms, Speech, & Time) to rule out a stroke on Resident #1.IJ Called: 8/13/2026POR Submitted: 8/13/2026 How corrective action will be accomplished for those residents affected by the violation(s): Action: Resident #1 was sent to the hospital for stroke like symptoms on 8/10/2026 and has not returned. Resident #1's medical record updated to reflect past and current diagnosis.Person(s) Responsible: Charge NurseDate: 8/10/2026 How the facility will identify other residents with the potential to be affected by the same violation(s): Action: Residents', admitted in the last 30-days, that remain in house, admission paperwork reviewed and compared against the electronic medical record to ensure residents' diagnosis are present, so staff are aware of their pertinent history/diagnosis and what to monitor for. Care plans reviewed and updated as needed for diagnoses and interventions. The added diagnosis have been added to the diagnosis list and care plan for staff monitoring. *Staff will be aware of the new diagnosis because they are being added to the nurses notes, which will pull to the 24-hour report, staff will subsequently know to monitor for side effects of the newly added diagnosis upon reviewing the 24-hour report at shift to shift change. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, MDS Coordinator, Regional Reimbursement Nurse, and/or Designee Date: 8/13/2026 Action: Director of Nursing, Assistant Directors of Nursing, and/or Designee rounded on all residents in the facility assessing for changes in condition. Any change in condition noted will result in physician notification and the facility will then follow MD orders. Person(s) Responsible: Director of Nursing, Assistant Directors of Nursing, and/or DesigneeDate: 8/14/2026 What measures will be put into place or systemic changes made to ensure the violation(s) will not recur: Action: Director of Nursing and Assistant Directors of Nursing, educated on the facility's change in condition policy with emphasis on resident assessment, documentation of the assessment/findings/physician notification, and notifying of change in condition to the physician or physician extender and follow orders. Nurses educated on signs of a stroke: BEFAST- Balance, Eye, Face, Arm weakness/A-symmetry, Slurred speech, and Time for stroke-like symptoms, and will know to test for these things when resident is exhibiting stroke like symptoms and to notify the physician of the changes with the resident. Train the Trainer by the VP of Clinical on 8/13/2026. Nurses educated on the facility's change in condition policy with emphasis on resident assessment, documentation of the assessment/findings/physician notification, and notifying of change in condition to the physician or physician extender and follow orders. Nurses educated on signs of a stroke: BEFAST- Balance, Eye, Face, Arm weakness/A-symmetry, Slurred speech, and Time for stroke-like symptoms, and will know to test for these things when resident is exhibiting stroke like symptoms and to notify the physician of the changes with the resident. If the physician or physician extender is not responding promptly to make a nursing judgment and send resident to the hospital for further evaluation. Nurses will be educated prior to working their next shift. Competency test will be completed to ensure education retention. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate: 8/13/2026 Action: LVN A, LVN B, & RN C educated 1:1 regarding resident assessment and the need and rationale to document your assessment and physician notification with a resident's change in condition. Competency test will be completed to ensure education retention. Person(s) Responsible: Director of Nursing and/or Designee Date: 8/13/2026 Action: Stop and Watch Program initiated. All staff will be educated on the Stop and Watch form. Stop and Watch forms will be located at each nurses station. All staff will have access to them. Staff will know to write the change in condition on the Stop and Watch form. Staff will give a copy to the Charge Nurse and will give a copy to an administrative nurse to ensure follow up and oversight through education. All staff will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing and/or Designee Date: 8/13/2026 How the facility will monitor its corrective actions to ensure that the violation(s) is being corrected and will not recur: Action: During clinical meetings, daily, the 24 hour report will be reviewed for any changes in condition by clinical leadership. If change in condition is noted clinical leadership will ensure the physician was notified and any orders were followed. If change in condition was noted and documentation does not indicate the physician or physician extender was notified, clinical leadership will notify the physician and reeducate the responsible nurse. The charge nurse is responsible for documenting change in condition in the electronic medical record which is pulled into the electronic medical record's 24-hour report which the nurses review shift-to-shift. Director of Nursing & Assistant Directors of Nursing educated on the clinical meeting and reviewing for change in condition and notifying the physician with any noted changes that went unreported by the [NAME] President of Clinical Operations on 8/13/2026. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Weekend Nurse Supervisor, [NAME] President of Clinical Operations, and/or DesigneeDate: 8/13/2026 QAPI: Action: The facility notified the Medical Director of the Immediate Jeopardy of 684: Quality of Care and the facility's plan to remove the immediacy. No additional recommendations. Person(s) Responsible: AdministratorDate: 8/13/2026Action: The administrator will oversee the action items and will ensure they are completed.Person(s) Responsible: Administrator Date: 8/13/2026 The State Surveyors monitored the Plan of Removal as follows: During interviews on 8/14/2026 from 8:50 a.m. to 9:25 a.m., the following nurse leadership staff indicated that they had been in-serviced by the VP of Clinical Operations and that they understood their role in the review of residents admitted in the last 30 days for accurate diagnoses. They indicated that the admission records would be compared to the medical record and diagnoses updated for all nurses to be able to know what active diagnoses each resident has. They indicated understanding that they will play a role in updating all care plans to accurately reflect the resident's diagnoses in coordination with ongoing treatment. They indicated understanding their role in in-servicing nurses on the implemented changes and informing them that diagnoses will be added to the 24-hour report. They indicated that they had begun rounding on all residents to ensure that they are assessed for any change of conditions and that all changes are adequately documented in the medical record including notifications and directions form the physician and notification to all patient representatives when a change of condition is found. Interviews included: DON, ADON F, ADON G. During an interview on 8/14/2026 at 9:35 a.m. [NAME] President of Clinical Operations indicated that she has completed one on one in-services regarding Nurses educated on the facility's change in condition policy with emphasis on completing SBAR/e-interact, resident assessment, documentation, and notifying of change in condition such as stroke symptoms (arm tingling, facial drooping, slurred speech, etc.) to the physician or physician extender and follow orders by the [NAME] President of Clinical Operations with DON, ADON F and ADON G During interviews on 8/14/2026 from 10:05 a.m. to 12:20 p.m. the following staff indicated that they had been in-serviced on the Stop and Watch form implemented as part of this plan of removal. They were able to articulate their understanding and role in documenting any observed change of condition for the residents and ensuring that the nurse on duty was aware of what was observed. Nurses interviewed were able to articulate their role in following up with the resident to assess, treat and make any notifications related to the change of condition. Interviews Included: LVN A, LVN B, RN C, RN D, PT, CNA E, LVN H, LVN J, CNA K, CNA L, RN M, CNA N, CNA O, RN P, LVN Q, LVN R, LVN S, CNA T During interviews on 8/14/2026 from 10:05 a.m. to 12:20 p.m. the following staff indicated that they had been in-serviced on the BEFAST method of stroke assessment and that they understood how to assess a resident for stroke and take appropriate follow-up actions to ensure resident safety. They were able to articulate the meaning of BEFAST and appropriate steps if there were concerns of a stroke. Interviews included: LVN A, LVN B, RN C, RN D, LVN H, LVN J, RN M, RN P, LVN Q, LVN R, and LVN S. During an interview on 8/14/2026 at 10:00 a.m. ADM stated that she spoke to the MD and made him aware of the immediate jeopardy and the facility's plan to remove it and he had no additional suggestions. Record review of the Stop and Watch Policy dated 2021 indicated that if staff have identified a change while caring for or observing a resident/patient, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. The form uses an acronym with the words STOP AND WATCH which are defined as Seems different than usual, Talks or communicates less, Overall needs more help, Pain, new or worsening, Ate less, No bowel movement, Drank less, Weight change (swollen legs and feet), Agitated, Tired, weak confused or drowsy, Change in skin color or condition, Help with walking, transferring, toileting more than usual. Record review of in-service document dated 8/13/2026 entitled Stop and Watch indicated that 20 staff have been in-serviced on the Stop and Watch forms that was located at each nursing station for any staff who became aware of a change of condition to document that change and each nurse is responsible for reviewing those forms and following up and any necessary assessments or documentation pertaining to that report. Record review of in-service document dated 8/13/2026 entitled [NAME] in a resident's condition Status and was signed by 14 employees at the time of the review. The signatures among those include the names of LVN A, LVN B, RN C and RN D. The Administrator was informed that the Immediate Jeopardy was removed on 8/14/2026 at 12:26 p.m. however, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm that is not immediate jeopardy 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 the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation for 2 of 10 residents (Resident #1 and Resident #2) reviewed for misappropriation of funds. The facility failed to ensure CNA/Staffing Coordinator B did not take money from Resident #1 and Resident #2 for her personal use. This failure could place residents at risk for decreased quality of life and misappropriation of funds. The findings include: 1. A record review of Resident #1's face sheet dated 06/25/2026 indicated a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included chronic obstructive pulmonary disease with (acute) lower respiratory infection (a condition characterized by obstructed airflow due to inflammation and damage in the airways), cognitive communication deficit, unspecified lack of coordination, muscle weakness, and atherosclerotic heart disease of native coronary artery with unstable angina pectoris (a condition in which plaque buildup in the heart's arteries cause narrowing or blockage, leading to chest pain). A record review of Resident #1's most recent Quarterly MDS, dated [DATE], indicated a BIMS of 12, which indicated moderate cognitive impairment. Section GG of Resident #1's MDS indicated he was dependent on staff for toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. 2. A record review of Resident #2's face sheet dated 06/25/2026 indicated a [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #2 had diagnoses which included paraplegia, incomplete (partial paralysis of the lower body where some sensation or movement remains below the spinal cord injury), unspecified lack of coordination, muscle weakness, disorder of the autonomic nervous system (dysfunction in the nervous system that controls involuntary bodily functions such as heart rate, blood pressure, and sweating), and sickle-cell disease without crisis (an inherited blood disorder that causes red blood cells to become rigid and sticky which can block blood flow, cause pain, and damage organs). A record review of Resident #2's most recent Annual MDS, dated [DATE], indicated a BIMS of 15, which indicated intact cognitive function with minimal or no impairment. Resident #2's was dependent on staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. Resident #2 required substantial/maximum assistance for showering/bathing herself and upper body dressing. Resident #2 required partial/moderate assistance with personal hygiene. A record review of a witness statement dated 06/23/2026, signed by the ADM, indicated on 06/23/2026 a staff member notified her a resident alleged CNA/Staffing Coordinator B had borrowed money from him and failed to repay it. The ADM indicated the resident alleged CNA/Staffing Coordinator B withdrew $270.00 from his account; $150.00 which was permitted by the resident for CNA/Staffing Coordinator B to repay another staff member from whom CNA/Staffing Coordinator B had previously borrowed from and another unauthorized $120.00. A record review of a witness statement dated 06/23/2026, signed by the DON, indicated Resident #1 alleged CNA/Staffing Coordinator B informed him she needed $150.00, he provided her with his bank card, and she withdrew $270.00. Resident #1 alleged CNA/Staffing Coordinator B advised him she would pay him on her next payday, though she did not repay the money and four pay periods had passed. A record review of a witness statement dated 06/23/2026, signed by CNA/Staffing Coordinator B, indicated she denied she took money from Resident #1's account but did have his bank card to shop for Resident #1. CNA/Staffing Coordinator B indicated she notified the BOM and was told if it was over a certain amount to obtain a receipt. A record review of a witness statement dated 06/24/2026, signed by the ADM, indicated RN A notified the ADM during the investigation process CNA/Staffing Coordinator B borrowed money from herself and two residents. The ADM indicated she asked who the residents were and why RN A did not report this. RN A indicated the residents included Resident #1 and Resident #2. The ADM indicated she interviewed Resident #2 and she stated she loaned CNA/Staffing Coordinator B $200.00 and was paid back. A record review of a witness statement dated 06/24/2026 signed by RN A indicated she was told by Resident #2 CNA/Staffing Coordinator B borrowed money from her and paid her back later that day. RN A indicated she was told by Resident #1 CNA/Staffing Coordinator B borrowed money from him and had not paid him back. During an interview on 06/25/2026 at 9:46 AM, Resident #1 stated CNA/Staffing Coordinator B asked him for $150.00 an estimated 3 months prior. Resident #1 stated he gave CNA/Staffing Coordinator B his bank card and permitted her to withdraw the $150.00 and CNA/Staffing Coordinator B took another unauthorized $120.00. Resident #1 stated he did not know how to obtain these records and was aware because he got a notification from the bank on his phone. Resident #1 indicated he had not been repaid these funds. Resident #1 stated this event made him feel disappointed in CNA/Staffing Coordinator B and disappointed in himself for lending her the money. Resident #1 stated CNA B told him she took the extra $120.00 to play a gambling game on her phone. Resident #1 stated he did not want CNA/Staffing Coordinator B to lose her job and he did not want to press charges. During an interview on 06/25/2026 at 10:06 AM, Resident #2 declined to answer when asked if staff had ever asked for money. Resident #2 declined to identify how much money she had given staff but stated she was repaid. Resident #2 stated you already know her name when asked who the staff member was that borrowed money from her. Resident #2 nodded up and down when she was asked if the staff member that borrowed money from her was CNA/Staffing Coordinator B. Resident #2 declined to answer any further questions regarding this matter. During an interview on 06/25/2026 at 1:37 PM, CNA/Staffing Coordinator B denied she took money from Resident #1 and Resident #2. CNA/Staffing Coordinator B stated she would often obtain Resident #1's bank card to get him food, tobacco products, or items from the store. CNA/Staffing Coordinator B stated she also took Resident #2's bank card to run errands for her. CNA/Staffing Coordinator B stated she did not keep any receipts and gave them to the residents when she obtained them from the stores. CNA/Staffing Coordinator B stated she notified the BOM Resident #1 gave her his card and stated the BOM told her it was fine as long as it was not over a certain amount because she would need a receipt. CNA/Staffing Coordinator B stated an estimated month ago Resident #1 began making her feel uncomfortable with his requests and she stopped going to the store for him. CNA/Staffing Coordinator B stated she was assigned as his aide on 06/23/2026, he requested she not provide care, she notified RN C, RN C went to speak with Resident #1, and then she learned of the allegation that she took his money. During an interview on 06/25/2026 at 2:10 PM, Resident #1 stated he provided CNA/Staffing Coordinator B with his bank card for her to go to the store and buy him items. Resident #1 stated CNA/Staffing Coordinator B came to him one day and asked for $150.00 because she had lent money to RN A and RN A was requesting it from her and that was when he permitted her to use his bank card to withdraw $150.00. During an interview on 06/25/2026 at 2:15 PM, RN A stated she had recently learned CNA/Staffing Coordinator B borrowed money from Resident #1 and Resident #2. RN A stated she reported this to the ADM on 06/24/2026. RN A stated the ADM was the Abuse Coordinator. RN A stated CNA/Staffing Coordinator B owed her $400.00. RN A stated staff were educated that they were not to obtain money from residents for any reason. During an interview on 06/25/2026 at 3:21 PM, the BOM stated she was unaware of any staff members using any resident's cards aside from the activity director as part of the activities program. The BOM stated Resident #1 and Resident #2 were their own payee's and managed their own funds. The BOM stated she was unaware of any staff members asking residents for money. During an interview on 06/25/2026 at 3:35 PM, the SW stated Resident #1 confirmed to her that CNA/Staffing Coordinator B had taken his money. The SW stated Resident #1 did not want his money returned and he felt sorry for her. The SW stated it was plausible CNA/Staffing Coordinator B was taking money from residents as she had borrowed from multiple staff members. The SW stated Resident #1 stated CNA/Staffing Coordinator B took the money approximately in May. The SW stated Resident #2 denied to her CNA/Staffing Coordinator B ever asked her for money, but when asked by the ADM Resident #2 stated she took $200.00. During an interview on 06/26/2026 at 8:17 AM, RN C stated Resident #1 told her on Tuesday, 06/23/2026, he had given his bank card to CNA/Staffing Coordinator B to get money out of the ATM and was notified by his phone that CNA/Staffing Coordinator B took more out than he told her to. RN C stated she notified the ADM immediately. RN C stated there were no other residents she knew of that alleged misappropriation and no other staff members who knew of the allegations at that time. During an interview on 06/26/2026 at 10:19 AM, the DON stated the ADM notified him Tuesday, 06/23/2026, of the allegation of misappropriation. The DON stated CNA/Staffing Coordinator B was suspended immediately. The DON stated it was determined CNA/Staffing Coordinator B took the money from Resident #1 due to resident statement and multiple employee's reporting she borrowed money from them and had not repaid them. The DON stated CNA/Staffing Coordinator B had a trend of not repaying borrowed money. The DON stated he was unsure if CNA/Staffing Coordinator B received money from Resident #2 as she did not speak much about it. During a telephone interview on 06/26/2026 at 11:03 AM, the ADM stated RN C notified her of the allegation of misappropriation and it was immediately investigated. The ADM stated she did believe CNA/Staffing Coordinator B took Resident #1 and Resident #2's money. The ADM stated the SW completed safe surveys and no other residents were identified to have concerns regarding misappropriation. During an interview on 06/26/2026 at 12:10 PM, the DON stated he believed CNA/Staffing Coordinator B was a further risk to residents regarding misappropriation. The DON stated he would not allow CNA/Staffing Coordinator B to return to providing care to the residents as he felt she could do it again. A record review of an in-service training report, dated 01/12/2026, signed by CNA/Staffing Coordinator B, indicated CNA/Staffing Coordinator B was provided in-service training on the subject of abuse, neglect, exploitation, and misappropriation prevention program/reporting. A record review of a police report, dated 06/23/2026, indicated the police department was made aware a nurse had taken more than an agreed amount out of a residents banking account. The police report indicated the resident did not wish to make a report, but the ADM requested a report. A record review of a Record of Employee Counseling, dated 06/23/2026, signed by CNA/Staffing Coordinator B and the ADM, indicated CNA/Staffing Coordinator B was suspended pending the outcome of the investigation. A record review of a facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, indicated the following: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegations were made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for 2 of 10 residents (Resident #1 and Resident #2) reviewed for reporting misappropriation of property. The facility failed to ensure RN A immediately reported an allegation of misappropriation towards Resident #1 and Resident #2 by CNA/Staffing Coordinator B to the abuse coordinator. This failure could place residents at risk for financial exploitation, psychosocial harm, and unaddressed allegations of abuse. The findings included: 1. A record review of Resident #1's face sheet dated 06/25/2026 indicated a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included chronic obstructive pulmonary disease with (acute) lower respiratory infection (a condition characterized by obstructed airflow due to inflammation and damage in the airways), cognitive communication deficit, unspecified lack of coordination, muscle weakness, and atherosclerotic heart disease of native coronary artery with unstable angina pectoris (a condition in which plaque buildup in the heart's arteries cause narrowing or blockage, leading to chest pain). A record review of Resident #1's most recent Quarterly MDS, dated [DATE], indicated a BIMS of 12, which indicated moderate cognitive impairment. Section GG of Resident #1's MDS indicated he was dependent on staff for toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. 2. A record review of Resident #2's face sheet dated 06/25/2026 indicated a [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #2 had diagnoses which included paraplegia, incomplete (partial paralysis of the lower body where some sensation or movement remains below the spinal cord injury), unspecified lack of coordination, muscle weakness, disorder of the autonomic nervous system (dysfunction in the nervous system that controls involuntary bodily functions such as heart rate, blood pressure, and sweating), and sickle-cell disease without crisis (an inherited blood disorder that causes red blood cells to become rigid and sticky which can block blood flow, cause pain, and damage organs). A record review of Resident #2's most recent Annual MDS, dated [DATE], indicated a BIMS of 15, which indicated intact cognitive function with minimal or no impairment. Resident #2's was dependent on staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. Resident #2 required substantial/maximum assistance for showering/bathing herself and upper body dressing. Resident #2 required partial/moderate assistance with personal hygiene. A record review of a witness statement, dated 06/23/2026, signed by the ADM, indicated on 06/23/2026 a staff member notified her a resident alleged CNA/Staffing Coordinator B had borrowed money from him and failed to repay it. The ADM indicated the resident alleged CNA/Staffing Coordinator B withdrew $270.00 from his account; $150.00 which was permitted by the resident for CNA/Staffing Coordinator B to repay another staff member from whom CNA/Staffing Coordinator B had previously borrowed from and another unauthorized $120.00. A record review of a witness statement, dated 06/23/2026, signed by the DON, indicated Resident #1 alleged CNA/Staffing Coordinator B informed him she needed $150.00, he provided her with his bank card, and she withdrew $270.00. Resident #1 alleged CNA/Staffing Coordinator B advised him she would pay him on her next payday, though she did not repay the money and four pay periods had passed. A record review of a witness statement, dated 06/23/2026, signed by CNA/Staffing Coordinator B, indicated she denied she took money from Resident #1's account but did have his bank card to shop for Resident #1. CNA/Staffing Coordinator B indicated she notified the BOM and was told if it was over a certain amount to obtain a receipt. A record review of a witness statement, dated 06/24/2026, signed by the ADM, indicated RN A notified the ADM during the investigation process CNA/Staffing Coordinator B borrowed money from herself and two residents. The ADM indicated she asked who the residents were and why RN A did not report this. RN A indicated the residents included Resident #1 and Resident #2. The ADM indicated she interviewed Resident #2 and she stated she loaned CNA/Staffing Coordinator B $200.00 and was paid back. A record review of a witness statement, dated 06/24/2026, signed by RN A, indicated she was told by Resident #2 that CNA/Staffing Coordinator B borrowed money from her and paid her back later that day. RN A indicated she was told by Resident #1 CNA/Staffing Coordinator B borrowed money from him and had not paid him back. During an interview on 06/25/2026 at 9:46 AM, Resident #1 stated CNA/Staffing Coordinator B asked him for $150.00 an estimated 3 months prior. Resident #1 stated he gave CNA/Staffing Coordinator B his bank card and permitted her to withdraw the $150.00 and CNA/Staffing Coordinator B took another unauthorized $120.00. Resident #1 stated he did not know how to obtain these records and was aware because he got a notification from the bank on his phone. Resident #1 indicated he had not been repaid these funds. Resident #1 stated this event made him feel disappointed in CNA/Staffing Coordinator B and disappointed in himself for lending her the money. Resident #1 stated CNA B told him she took the extra $120.00 to play a gambling game on her phone. Resident #1 stated he did not want CNA/Staffing Coordinator B to lose her job and he did not want to press charges. During an interview on 06/25/2026 at 10:06 AM, Resident #2 declined to answer when asked if staff had ever asked for money. Resident #2 declined to identify how much money she had given staff but stated she was repaid. Resident #2 stated you already know her name when asked who the staff member was that borrowed money from her. Resident #2 nodded up and down when she was asked if the staff member who borrowed money from her was CNA/Staffing Coordinator B. Resident #2 declined to answer any further questions regarding this matter. During an interview on 06/25/2026 at 4:14 PM, RN A stated Resident #1 and Resident #2 notified her of the alleged misappropriation on Monday, 06/22/2026. RN A stated she did not report the allegation at that time, then was off for 2 days, when she returned there was a meeting regarding the issue and that was when she told the ADM. RN A stated she did not notify the ADM because she did not know it was such a big deal. RN A stated she was in-serviced on timely reporting of misappropriation. RN A stated she probably should have reported the allegations immediately. During an interview on 06/26/2026 at 10:19 AM, the DON stated he RN A did not work Monday. During an interview on 06/26/2026 at 10:40 AM, RN A stated she learned of the allegations of misappropriation on Sunday, 06/21/2026. RN A stated she did not inform the ADM until Wednesday, 06/24/2026. RN A stated she did not initially think it was a big deal because Resident #2 was repaid, then stated it was a big deal because staff should not take money from residents. RN A stated she was the weekend supervisor at the time she learned of the allegations. RN A stated that was probably poor judgement, but at the time she did not think it necessary to call the ADM. During an interview on 06/26/2026 at 10:43 AM, the DON stated RN A should have reported the allegations of misappropriation immediately. The DON stated RN A was in-serviced on timely reporting of allegations of misappropriation. The DON stated RN A should have reported this to the Abuse Coordinator, the ADM. The DON stated if misappropriation was not reported timely it left residents at risk for further harm. During a telephone interview on 06/26/2026 at 11:03 AM, the ADM stated she called the facility to speak with the weekend supervisor each Saturday and Sunday regarding general facility information. The ADM stated RN A did not inform her of the allegations of misappropriation during the phone call. The ADM stated RN A notified her while she and the DON were meeting with Resident #1 and RN A stated she knew and did not think it was a big deal. The ADM stated she expected staff to notify her immediately when they suspected any abuse, neglect, or exploitation. The ADM stated all staff were in-serviced on identifying and reporting abuse, neglect, and exploitation. The ADM stated the risk to residents for not reporting timely included further misappropriation and abuse to residents. A record review of RN A's personnel file indicated an Abuse, Neglect, and Exploitation Statement, dated 07/16/2025, signed by RN A, which indicated the following: Residents of the facility shall not be subject to abuse, neglect, or exploitation by company employees, and if a resident accuses an employee of abuse certain procedures will be followed (see Abuse Policy in the facility Policies and Procedures).Exploitation:The illegal or improper act or process of a caretaker, family member, or other individual who has an ongoing relationship with the elderly or disabled person using the resources of an elderly or disabled person for monetary or personal benefit profit, or gain without the informed consent of the elderly of disabled person. A record review of RN A's personnel file indicated a Record of Employee Counseling, dated 12/30/2025, which indicated RN A had failed to inform the ADM of an allegation of abuse. The Record of Employee Counseling indicated RN A was in-serviced individually on abuse, neglect, and reporting. A record review of an in-service training report, dated 12/30/2025, signed by RN A indicated RN A was provided in-service training individually on the subject of abuse, neglect, exploitation and misappropriation prevention program - reporting. A record review of an in-service training report, dated 01/28/2026, signed by RN A indicated RN A was provided in-service training on the subject of abuse, neglect, exploitation, and misappropriation prevention program. A record review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, indicated the following: If resident abuse, neglect, exploitation, 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 observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegations were made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for four of eight (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for abuse and neglect. The facility failed to report an allegation of abuse which involved Resident #1 which occurred 04/19/2026 at 10:06 PM until 04/20/2026 at 3:43 PM. The facility failed to report an allegation of neglect which involved Resident #2 which occurred 05/16/2026 at approximately 1:00 PM until 05/17/2026 at 7:39 PM. The facility failed to report an allegation of abuse which involved Resident #3 and Resident #4 which occurred 05/23/2026 at 10:57 AM until 05/23/2026 at 4:06 PM. These failures could place residents at risk of not receiving timely investigation into allegations of abuse and neglect. The findings included: 1. A record review of Resident #1's face sheet dated 06/02/2026 indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included chronic obstructive pulmonary disease with (acute) lower respiratory infection (a condition characterized by obstructed airflow due to inflammation and damage in the airways), cognitive communication deficit, unspecified lack of coordination, muscle weakness, and atherosclerotic heart disease of native coronary artery with unstable angina pectoris (a condition in which plaque buildup in the heart's arteries cause narrowing or blockage, leading to chest pain). A record review of Resident #1's most recent Quarterly MDS dated [DATE] indicated BIMS of 12, which indicated moderate cognitive impairment. Section GG of Resident #1's MDS indicated he was dependent on staff for toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During an interview on 06/02/2026 at 9:23 AM, Resident #1 stated that LVN E verbally and physically abused him. Resident #1 stated while CNA A and LVN E were providing care he was picking on CNA A and LVN E told him, Don't talk to my [f word] aide like that. Resident #1 stated he told LVN E that she could not talk to him like that and LVN E continued cussing and stated you need these black women to take care of your white [a word] don't you. Resident #1 stated LVN E was rough while providing care and pushed him forward so hard he thought he would fall out of the bed. Resident #1 stated that LVN E closed his door after providing care despite him having asked her not to. Resident #1 stated the following morning he notified the DON that the event occurred. A record review on 06/02/2026 at 11:04 AM indicated that LVN E was suspended on 04/19/2026 due to alleged verbal and physical abuse. LVN E's personnel file indicated she was terminated on 04/21/2026. A telephone interview was attempted on 06/02/2026 @ 2:27 PM with CNA A, but she did not answer or return a voicemail. A record review on 06/02/2026 at 3:45 PM of the provider investigation report indicated a witness statement dated 04/19/2026 from CNA A which stated LVN E verbally and physically abused Resident #1. CNA A indicated in the witness statement that LVN E told Resident #1 to shut the [f word] up and [f word] you. CNA A indicated LVN E closed Resident #1's door and told CNA A you can open it, I'm not. CNA A indicated LVN E pulled Resident #1 hard during care. CNA A indicated the DON spoke with Resident #1 and afterwards she informed the DON of the incident. A record review of TULIP case details on 06/02/2026 at 3:49 PM indicated the report of abuse which involved Resident #1 was received by HHSC on 04/20/2026 at 3:43 PM. During an interview on 06/03/2026 at 9:04 AM, the DON stated he believed it to be the next day that he was notified of the alleged abuse by Resident #1. The DON stated he notified the ADM, suspended LVN E, and began investigating the allegation. The DON stated if a staff member witnessed abuse he expected them to follow policy and contact the ADM, the abuse coordinator, but typically staff notified him and he notified the ADM. A record review of Resident #2's face sheet dated 06/02/2026 indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included parkinsonism (a brain condition that causes slowed movements, stiffness, and tremors), muscle weakness, active secondary progressive multiple sclerosis (progressive worsening of multiple sclerosis symptoms, including mobility and balance issues, weakness, fatigue, and sensory changes), and vascular dementia, severe, with agitation (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). A record review of Resident #2's most recent Annual MDS dated [DATE] indicated BIMS of 0, which indicated severe cognitive impairment. Section GG of Resident #2's MDS indicated Resident #2 was dependent on staff for toileting hygiene, required substantial/maximum assistance for eating, and required partial/moderate assistance for personal hygiene. Section GG of Resident #2's MDS indicated he utilized a manual wheelchair. An observation on 06/02/2026 at 9:48 AM revealed Resident #2 utilizing his wheelchair throughout the hall of the facility. Resident #2 did not stop when spoken to. A record review of a nursing note dated 05/16/2026 at 1:01 PM indicated Resident #2 was utilizing his wheelchair and fell backwards, hitting his head. The nursing note indicated Resident #2 was fighting staff who assisted him back into his wheelchair and was sent to the hospital. During an interview on 06/02/2026 at 1:28 PM, CNA B indicated she did not see Resident #2 fall but did hear a commotion and saw him lying down on the floor of the hallway. CNA B indicated she did not assist Resident #2 back into his wheelchair. CNA B indicated she returned to what she was doing at that time. A record review of the facility's provider investigation report on 06/02/2026 at 3:52 PM indicated an emergency department triage note dated 05/16/2026 at 1:55 PM which indicated Resident #2 complained of headache and back pain after the fall and had bleeding noted to his right great toe. Hospital notes dated 05/16/2026 at 4:16 PM indicated imaging which revealed a nondisplaced fracture of proximal phalanx of right great toe (a broken toe with the bones still in alignment). The provider investigation report indicated a witness statement dated 05/22/2026 by LVN F which indicated Resident #2 went down the hallway to his room, she heard a loud noise, and Resident #2 was found on the floor. The witness statement indicated that LVN F reported the incident to the physician who gave the order to send Resident #2 to the hospital, Resident #2's responsible party, and the DON. A record review of TULIP case details on 06/02/2026 at 3:55 PM indicated the report of neglect which involved Resident #2 was not reported to HHSC until 05/17/2026 at 4:43 PM. During an interview on 06/03/2026 at 8:32 AM, LVN F stated Resident #2 was had been going towards his room down the hall when she heard a loud bang and then found Resident #2 fallen backwards in his wheelchair. LVN F stated she assessed him, contacted the physician who instructed her to send Resident #2 to the hospital, and sent a group message to the ADM and the DON to notify them of Resident #2's unwitnessed fall and injury. LVN F stated unwitnessed falls with injuries were to be reported immediately to the ADM. During an interview on 06/03/2026 at 9:06 AM, the DON stated he was notified of Resident #2's fall and subsequent hospital visit. The DON stated once Resident #2 returned from the hospital and it was known that he had a fracture in his foot he notified the ADM. A record review of Resident #3's face sheet dated 06/02/2026 indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included transient cerebral ischemic attack (a temporary blockage of blood flow to the brain), muscle weakness, chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), and unspecified dementia. A record review of Resident #3's most recent Quarterly MDS dated [DATE] indicated BIMS of 11, which indicated moderate cognitive impairment. Section GG of Resident #3's MDS indicated Resident #3 was dependent on staff for toileting, shower/bathing, upper body dressing, lower body dressing, and putting on/taking off footwear. Section GG of the MDS indicated Resident #3 utilized a wheelchair. A record review of Resident #4's face sheet dated 06/02/2026 indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included type 2 diabetes mellitus without complications (a chronic condition characterized by insulin resistance and high blood sugar levels), depression, heart failure, and muscle wasting and atrophy. A record review of Resident #4's admission MDS dated [DATE] indicated BIMS of 12, which indicated moderate cognitive impairment. Section GG of Resident #4's MDS indicated Resident #4 required supervision or touching assistance with toileting hygiene, shower/bathing self, upper body dressing, and lower body dressing. Section GG indicated Resident #4 utilized a manual wheelchair. During an interview and observation on 06/02/2026 at 9:18 AM, Resident #3 had some redness under and around his right eye. Resident #3 stated Resident #4 hit him with a closed fist a few weeks prior. Resident #3 stated he felt Resident #4 was trying to hurt him intentionally and he did not know why. Resident #3 stated he had no further interactions with Resident #4 and felt safe at the facility. During an interview on 06/02/2026 at 10:43 AM, Resident #4 stated he got into an argument with Resident #3 and hit him in the face with an open hand. Resident #4 stated he and Resident #3 were arguing prior to hitting him. Resident #4 stated Resident #3 was swinging his arms at him but did not land any hits. During an interview on 06/02/2026 at 1:41 PM, CNA C stated she identified the bruising on Resident #3's eye and asked him what happened. CNA C stated Resident #3 put his finger to his lips, made a punching motion, and pointed to his roommate Resident #4. CNA C stated she again asked Resident #3 what happened and he stated Resident #4 punched him. CNA C stated she immediately reported it to RN D and the DON. During an interview on 06/02/2026 at 1:43 PM, RN D stated CNA C had notified him of the bruising on Resident #3's eye and he assessed Resident #3 and Resident #4 and separated them. RN D stated he notified the DON and believed her notified the ADM but could not recall at what time. RN D stated he believed the reporting timeframe for abuse to be within 12 hours. A record review on 06/02/2026 at 3:20 PM indicated an alert note dated 05/23/2026 at 10:57 AM which indicated the aide alerted the charge nurse of new onset bruising around Resident #3's right eye. A nursing note dated 05/23/2026 at 11:55 AM indicated during routine rounds, CNA staff entered Resident #3's room and observed bruising to the right eye. The note indicated when Resident #3 was asked what happened he appeared fearful and pointed in the direction of his roommate. The note indicated Resident #3 stated his roommate had punched him several times in the face. A record review on 06/02/2026 at 3:30 PM indicated an alert note dated 05/23/2026 at 11:03 AM which indicated Resident #4 was the aggressor towards his roommate resulting in an injury. The note indicated Resident #4 was moved to a new room. The note indicated the physician, DON, and ADM were notified of the event. A record review of TULIP case details on 06/02/2026 at 3:58 PM indicated the allegation of abuse regarding Resident #3 and Resident #4 was not reported to HHSC until 05/23/2026 at 4:06 PM. During an interview on 06/03/2026 at 9:10 AM the DON stated he was notified of the alleged abuse regarding Resident #3 and Resident #4 on 05/23/2026 at 10:33 AM by text message from CNA C. The DON stated he reported this immediately to the ADM. The DON stated he believed the timeframe for reporting abuse and neglect to HHSC to be within 24 hours and when he learned of any allegations he notified the ADM immediately. During an interview on 06/03/2026 at 9:53 AM, the ADM stated she was not aware the allegations of abuse and neglect were not reported within the 2-hour timeframe. The ADM stated in-services on abuse, neglect, and exploitation are held regularly and staff are educated to notify her, the abuse coordinator, if there are suspicions of abuse or neglect. The ADM stated that staff, particularly staff identified in the allegations regarding Resident #1, Resident #2, Resident #3, and Resident #4 have been educated to report abuse and neglect to her. The ADM stated the form for self-reported incidents can require lengthy information and that may have contributed to untimely reporting along with gaps in communication with staff. Record review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 indicated the following: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 9. Investigate and report any allegations within timeframes required by federal requirements. Record review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022 indicated the following: Policy StatementAll reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property 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. Policy Interpretation and ImplementationReporting Allegations to the Administrator and Authorities If resident abuse, neglect, exploitation, 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. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:The state licensing/certification agency responsible for surveying/licensing the facility. Immediately is defined as:Within two hours of an allegation involving abuse or result in serious bodily injury; or Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury

Based on interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 was administered his evening dose of apixaban (also known under the brand name Eliquis, an anticoagulant medication used to treat and prevent blood clots) on 1/1/26 and his morning dose (of apixaban) on 1/2/26. This failure could place residents at risk of not receiving the therapeutic effect of medications used to treat significant medical diagnosis and could result in significant health complications. Findings included: Record review of Resident #1's face sheet dated 03/05/26, reflected he was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included, unspecified multiple injuries, driver injured in collision with other motor vehicles, nondisplaced fracture of base of neck right femur (a crack in the upper thighbone near the hip joint where the bone remains in proper alignment), displaced segmental fracture of shaft of ulna, right arm (fracture to the forearm bone where it breaks in at least two distinct places, creating a completely separated intermediate bone segment), fracture of the lower end of the right radius (break in the larger forearm bone near the wrist), nondisplaced bicondylar fracture of the right tibia (the top of the right shinbone is cracked on both the inner and outer sides, but the bone pieces remain in proper alignment), nondisplaced bicondylar fracture of the left tibia (the top of the left shinbone is cracked on both the inner and outer sides, but the bone pieces remain in proper alignment), displaced [NAME] fracture of the right tibia (bottom of the right shinbone is broken into multiple, misaligned pieces, extending into the ankle joint), displaced intraarticular fracture of unspecified calcaneus (fracture of heel bone), history of pulmonary embolism (blood clot in the lungs). The face sheet indicated he was discharged home with home health services on 01/30/26. Record review of the MDS dated [DATE] for Resident #1 reflected he was admitted to the facility on [DATE] after an acute hospital stay. The MDS indicated Resident #1 made himself understood and understood others. The MDS indicated Resident #1 did not have cognitive impairment (BIMS of 15). The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated Resident #1 was dependent for all ADL care, and transfers. The MDS indicated Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS indicated Resident #1 had a history of pulmonary embolism. The MDS indicated Resident #1 had received anticoagulant therapy during the 7-day look back period. Record Review of Resident #1's care plan dated 1/5/26, did not address the administration of anticoagulant therapy. Record review of the hospital Discharge summary dated [DATE], reflected Resident #1 was to be administered, apixaban (also known as Eliquis) 5 mg by mouth twice a day. The hospital discharge summary reported Resident #1 had last been administered this medication at 8:59 a.m., on 1/1/26. Record review of physician order with a start date of 1/2/26, reflected Resident #1 was to be administered apixaban 5 mg twice a day. Record review of Resident #1's MAR for January 2026, reflected Resident #1 was not administered apixaban on the evening of 1/1/26 and his morning dose (of apixaban) on 1/2/26. Record review of the nursing progress notes for Resident #1 dated 1/1/26 did not document any administration of apixaban for the evening of 1/1/26. Record review of the nursing progress notes for Resident #1 dated 1/2/26 did not document any administration of apixaban for morning dose of 1/1/26. During an interview on 2/25/26 at 2:55 p.m., Resident #1's family member said he (Resident #1) had not been administered his anticoagulant medication on 1/1/26 or 1/2/26 while at the nursing facility. Resident #1's family member said Resident #1 did not develop a blood clot while in the nursing facility. Resident #1's family member said Resident #1 was now at home. During an interview on 3/5/26 at 11:25 a.m., LVN A said she recalled caring for Resident #1 on 1/1/26 upon his admission. LVN A said she worked the 6:00 a.m.- 6:00 p.m. shift on that date. LVN A said she had not administered apixaban to Resident #1 on 1/1/26 as he came late in the shift but did not know if the nurse taking care him on 6:00 p.m. on 1/1/26 to 6:00 a.m. (1/2/26) had administered the medication. LVN A said she cared for Resident #1 on 1/2/26 from 6:00 a.m. to 6:00 p.m. LVN A said she could not recall if she had administered apixaban during that shift (6:00 a.m. to 6:00 p.m. on 1/2/26). LVN A said if she had administered apixaban to Resident #1 it should be documented on the MAR. LVN A said she always handed her patients off to LVN B and would have been the nurse who cared for Resident #1 on the 6:00 p.m. to 6:00 a.m. shift on 1/1/26. A phone interview was attempted with LVN B on 3/5/26 at 11:44 a.m. and was unsuccessful.A phone interview was attempted with LVN C on 3/5/26 at 12:36 p.m. and was unsuccessful. During an interview on 3/5/26 at 11:10a.m., ADON D said with a new admission nurses can pull significant medications such as Eliquis once orders have been entered. The ADON said Eliquis was a medication in the E-kit medication dispensing system stocked by the contracted pharmacy (secured, pharmacy-supplied kit containing essential, pre-approved significant medications and supplies for immediate use. It enables nurses to administer significant medications, without waiting for pharmacy delivery, often during nights or weekends). Record review of the E-Kit medication inventory on 3/5/26, found the facility had ten doses of Eliquis 2.5 mg in stock. During an interview on 3/5/26 at 1:59 p.m., the DON said he expected nursing staff to administer medications as ordered by the physician and to follow the facility's policy and procedure with regard to medication administration. The DON said with a new admission from a hospital, after orders were entered by the nursing staff, significant medications such as apixaban, would be available in the E-Kit medication dispensing system. He explained the nurse must enter a code provided by the contracted pharmacy service in order to pull the medication for the resident. The DON explained the contracted pharmacy would not supply that code until the orders entered. The DON said the facility tried to put orders into the contracted pharmacy in advance in order to secure the code needed to pull any significant medications promptly upon the new admissions arrival but the pharmacy would not allow them to do so. The DON said the contracted pharmacy would not allow the orders to be put in until the new admission arrived to the facility. The DON said Eliquis was a medication in the E-kit medication dispensing system stocked by the contracted pharmacy. The DON said the facility requested a report from the contracted pharmacy for Eliquis dispensed on 1/1/26 and 1/2/26 and was told by the contracted pharmacy they could not run a report that would provide that information. The DON said it was important for residents to receive their ordered anticoagulant medications to prevent significant complications that could result from blood clots. During an interview on 3/5/26 at 2:20 p.m., the Administrator said she expected nursing staff to administer medications as ordered by the physician and to follow the facility's policy and procedure with regard to medication administration. During an interview on 3/6/26 at 10:27 a.m., the pharmacy consultant stated she reviewed the E-kit system information at the facility for the date 1/1/26 and the date of 1/2/26 and said no Eliquis was pulled form the facility's E-Kit on those dates. Record review of the E-Kit medication inventory on 3/5/26, found the facility had ten doses of Eliquis 2.5 mg in stock. Record review of the facility's staffing sheet for 1/1/26 indicated Resident #1 was cared for by LVN C on the 6:00 p.m. to 6:00 a.m. shift of 1/1/26. Record review of the facility's policy and procedure tiled, Administering Medications, revised April of 2019, stated Medications are administered in a safe and timely manner and as prescribed. Record review of the facility policy and procedure tiled. Medication Orders and Reorder, dated May of 2025, stated .4. Emergency Medication Ordering-Emergency or STAT medications may be obtained through emergency drug kits, Pyxis/Medbank, STAT pharmacy delivery, or provider STAT orders entered in EHR. Emergency medications must still be entered into EHR and documented on the eMAR.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for 10 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) of 13 residents reviewed for privacy and confidentiality. 1. The facility failed to ensure the care plan for Residents #1, #2, #5 and #6 was not left in the public survey binder in the lobby of the facility. 2. The facility failed to ensure the PIR that contained the SSN and PHI of Residents #3 and #4 was not left in the public survey binder in the lobby of the facility. 3. The facility failed to ensure that the Resident Identifier sheet and corresponding survey containing PHI of Residents #7, #8, #9, and #10 were not left in the public survey binder in the lobby of the facility. These failures could place the residents at risk of their medical information being exposed to unauthorized individuals.Findings included: Record review of Resident #1's Face Sheet, dated 12/31/2025, reflected a [AGE] year old female, admitted on [DATE]. The resident was diagnosed with dementia (a decline in mental ability affecting memory, thinking, language and judgement) and schizoaffective disorder, unspecified (delusions and disorganized thinking). Record review of Resident #2's Face Sheet, dated 12/31/2025, reflected a [AGE] year old female admitted on [DATE]. The resident was diagnosed with acute respiratory failure with hypoxia (when the lungs cannot get enough oxygen), acute kidney failure (sudden loss of kidney function), and atrial fibrillation (rapid, irregular heartbeat), Record review of Resident #3's Face Sheet, dated 12/31/2025, reflected a [AGE] year old female admitted on [DATE]. The resident was diagnosed with cerebral palsy (permanent brain damage causing movement, muscle control, posture and balance). Record review of Resident #4's Face Sheet, dated 12/31/2025, reflected a [AGE] year old female admitted on [DATE]. The resident was diagnosed with systemic Lupus Erythematosus (an autoimmune disease where the immune system attacks itself). Record review of Resident #5's Face Sheet, dated 12/31/2025, reflected a [AGE] year old male admitted on [DATE]. The resident was diagnosed with diffuse traumatic brain injury with loss of consciousness greater than 24 hours without returning to pre-existing conscious level with patient surviving sequela (extensive brain disruption with lasting deficits), and heart failure. Record review of Resident #6's Face Sheet, dated 12/31/2025, reflected a [AGE] year old male admitted on [DATE]. The resident was diagnosed with unspecified injury at unspecified level of cervical spinal cord subsequent encounter (spinal cord injury of unknown origin and location). Record review of Resident #7's Face Sheet, dated 12/31/2025, reflected a [AGE] year old male admitted on [DATE]. The resident was diagnosed with autistic disorder (developmental condition affecting communication, social interactions, and behaviors). Record review of Resident #8's Face Sheet, dated 12/31/2025, reflected a [AGE] year old male admitted on [DATE]. The resident was diagnosed with anoxic brain injury (brain injury caused by a lack of oxygen). Record review of Resident #9's Face Sheet, dated 12/31/2025, reflected a [AGE] year old male admitted on [DATE]. The resident was diagnosed with quadriplegia (paralysis of all four limbs). Record review of Resident #10's Face Sheet, dated 12/31/2025, reflected a [AGE] year old female admitted on [DATE]. The resident was diagnosed with Type 2 diabetes mellitus with diabetic neuropathy (high blood sugar that has caused nerve damage). Observation on 12/31/2025 at 10:00 a.m. of the public survey binder in the foyer of the facility revealed care plans for Residents #1, #2, #5 and #6 including PHI such as SSN, health diagnoses and treatments they were receiving. This observation further revealed the PIR dated 7/2025 submitted by the facility which showed PHI of Residents #3 and #4 including their names, SSN, Medicaid and Medicare numbers as well as health diagnoses. This binder also included a resident identifier sheet with a list of resident names and numbered identifiers as well as the survey for that identifier sheet with PHI in the survey. During an interview with the administrator on 12/31/2025 at 10:25 a.m., she stated the survey binders were kept in the lobby for anyone who was interested to see what tags were written at the facility and the facility's accepted plan of correction. She stated the only thing that should have been in the binder was the tag and plan of correction. She stated a resident's care plan should not have been in the binder as that was protected health information with diagnoses, treatment and other personal information that should not have been readily available to the public. She stated that the PIR should also not have been in the binder as it contained PHI. She stated that it was her and all staff's responsibility to ensure that PHI was protected from any unauthorized people. She stated she did not know who placed the care plans, PIR, and resident identifier sheets in the binder but those documents did not belong in the public binder. During an interview with the DON on 1/2/2026 at 2:00 p.m., he stated PHI was information was not available to the public as residents at the facility had a right to privacy. He stated all staff were trained to protect this information in their new hire training as well as frequent refresher in-services throughout the year. He stated he was in this position for a couple of weeks and would ensure staff were trained to safeguard this information. He stated this was important so residents felt safe and that their information was kept confidential from those without a valid reason to access this information. During an interview with the ADON on 12/31/2025 at 2:15 p.m., she stated PHI was to be safe-guarded by all staff and that they were trained initially on the importance of this in their onboarding process and were reminded frequently in in-service training. She stated it was important to keep PHI protected as there was information included that others might use to exploit the resident, such as their name, DOB, SSN, and health diagnoses as residents had a right to privacy. The ADON stated disclosure of this information would be a violation if HIPAA. Record review of the facility's HIPAA Policy, dated April 2025, indicated, All patient, personnel, and financial information are considered privileged and confidential. Access should not be granted to these confidential documents without proper authorization or in accordance with the Resident/Patient [NAME] of Rights.in accordance with HIPAA regulations, access to personal medical information is limited to qualified, designated personnel.your personal medical information will be maintained as confidential unless you allow the release of the information.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #5, Resident #62, and Resident #72) reviewed for infection control. The facility failed to ensure CNAs E and F wore PPE when providing ADL care to Resident #72.The facility failed to ensure RN D wore PPE when providing tracheostomy care to Resident #5. The facility failed to ensure RN D wore PPE when providing enteral feeding to Resident #62.These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirements.Findings included:In an observation on 12/3/2025 at approximately 9:35 AM, Resident #72 had EBP signage in place and PPE (Personal protective equipment) was noted at the entrance to the resident room.In an observation on 12/3/2025 at approximately 9:35 AM CNA E and F entered Resident #72's room to perform ADL care and failed to sanitize their hands before entering. Both failed to don (put on) a gown to perform the ADLs.During an interview on 12/3/2025 at approximately 10:00 AM with CNA's E and F both stated they both failed to put on a gown to do ADLs with Resident #72 only resident in room and room had sign indicating EBP, they said, the residents doesn't like it when they wear grown. Both CNAs had been trained with evidence of signature on, Staff - Enhanced Barrier Questionnaire dated10/3/2025During an interview on 12/3/2025 at 10:30 AM Resident #72 said, 'she never told any CNA not to wear a gown when taking care of her, she said she rarely sees them wear gowns and she was not ok with them not wearing a gown.In an observation on 12/3/2025 at 1:00 PM RN D was noted in Resident #5's room who was on isolation/EBP. She was cleaning around the tracheostomy site; RN (D) was not wearing a mask or gown. There was signage indicating EBP was to be used and PPE was present at the room entrance area.In an observation on 12/3/2025 at 4:15 PM RN (D) was observed in Resident #62's room doing an enteral feeding and not wearing a mask or gown. There was signage indicating EBP was to be used and PPE was present at the room entrance area.In an interview on 12/4/2025 at 8:45 am with RN(D) she said she didn't notice that she had not put on a gown for both Resident #5 and Resident #62, but was aware of the EBP and what she should have done when doing care for both of the residents; The EBP signage states: When providing care for Dressing, bathing/Showering, transferring, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care any skin opening requiring a dressing.In an interview on 12/4/2025 at 9:00 AM, with RN D and IP (Infection Preventionist Nurse) both were able to state a potential negative outcome for failure to observe EBP on at-risk residents. These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirements.In an interview on 12/4/2025 at 10 AM with the Administrator, VP of Operations and the Director of Regulatory Services who all stated the staff in the building have all been trained and retrained on EBP (Enhanced Barrier Precautions), all three were able to state a potential negative outcome for failure to observe EBP on at-risk residents, These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirements.Record Review on 12/04/2025 of EBP Enhanced Barrier Precautions Policy dated 03/2024 indicated, EBP employs targeted gown, and gloves use in addition to standard precaution during high contact residents care activities when contact precaution do not otherwise apply .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen.The facility failed to ensure a stainless steel sheet pan was clean and free of heavy carbon build-up.The facility failed to ensure food packaging in the dry pantry was sealed after opening.The facility failed to ensure the microwave was clean.The facility failed to ensure food items were labeled or dated.The facility failed to ensure scoops were not present in the bulk sugar container.These failures could place residents who ate food from the kitchen at risk of foodborne illness.Findings included:During observations and an interview on 12/01/25 of the kitchen the following was noted:*at 11:50 AM on the pan rack next to the prep sink a half-size stainless steel sheet pan was heavily caked with black carbon and the surface was burned black. The DM said at that time it was the emergency pan and it should be thrown away. He aid it could be used for baking potatoes,*at 11:55 AM in the dry pantry a 16 oz. bag of potato chips was open and placed inside an opened zippered bag,*at 11:57 AM the microwave was soiled inside with food splatters and food debris,*at 12:12 PM the bulk sugar bin contained a 4 oz. plastic dessert cup in the sugar,*at 12:16 PM in the walk in cooler one 46-oz. container of nectar thick sweetened tea was opened and the container was not marked with an open date. The packaging indicated After opening may be kept up to 7 days under refrigeration.During a return visit to the kitchen on 12/02/2025 observations and an interview the following was noted:*at 11:37 AM in the dry pantry a 16 oz. bag of potato chips was open and placed inside an opened zippered bag,*at 11:38 AM the bulk sugar bin contained a 4 oz. plastic dessert cup in the sugar,*at 11:39 AM in the walk in cooler one 46-oz. container of nectar thick sweetened tea was opened and the container was not marked with an open date. The packaging indicated After opening may be kept up to 7 days under refrigeration.During an interview on 12/02/2024 at 12:45 AM, the DM said staff were to make sure the food packages placed in zippered bags were re-closed and sealed. He said staff were not leave scoops inside the products in the bulk bins. He said staff had been told to always date items when they are opened because that would keep insects, bugs, and other contaimnants from getting into the foods. He said all staff should be aware but he was responsible to make sure it was done.Review of a facility policy, revised November 2022, on Sanitization indicated .2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning.Review of a facility policy, revised November 2022, on Food Receiving and Storage indicated .Foods shall be received and stored in a manner that complies with safe food handling practices.3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date) .7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.The Texas Food Establishment Rules, dated October 2015, revealed:S228.68. Preventing Contamination From Equipment, Utensils, and Linens. (a) Food shall only contact surfaces of: (1) equipment and utensils that are cleaned as specified under SS228.113, 228.114 and 228.115 of this title and sanitized as specified under SS228.116, 228.117 and 228.118 of this title; . S228.114. Frequency of Cleaning.(c) Nonfood-contact surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues Food and Drug Administration Code, Dated, 2013, indicated the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B)The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations 3-305.11 Food StorageFood shall be protected from contamination by storing the food:(1) In a clean, dry location;(2) Where it is not exposed to slash, dust or other contamination .4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris .

Based on interview and record review, the facility failed to ensure individuals with a diagnosis of mental illness were provided an accurate Preadmission Screening and Resident Review Level 1 (PASARR) Screening for 1 of 5 residents reviewed for PASARR (Resident #71). The facility failed to ensure that Resident #71 had an accurate PASARR Level 1 Screening indicating a diagnosis of mental illness on 06/24/2025. This failure could place residents at risk of not receiving needed assessments (PASARR Evaluation), individualized care, and specialized services to meet their needs. The findings included: Record review of an undated face sheet indicated Resident #71 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including schizophrenia (a psychiatric diagnosis usually characterized by psychotic behavior including delusions, hallucinations, withdrawal from reality, and disorganized patterns of thinking and speech) and depression (a mood disorder characterized by extreme sadness, poor concentration, sleep problems, and loss of appetite). Record review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #71 had a BIMS score of 0 (zero) indicating severely impaired cognition. The MDS section for PASARR indicated Resident #71 did not have a serious mental illness. The MDS section for active diagnoses indicated that Resident #71 had the psychiatric/mood disorders of depression and schizophrenia. Section B0100 indicated that Resident #71 was rarely/never understood, usually understands others, and has unclear speech. Record review of psychoactive medication consents for Resident #71 include consents for Depakote (an anticonvulsant used to treat mood disorders including mania, a state of abnormally elevated mood and energy) and Sertraline (an antidepressant used to regulate mood and emotions) dated 06/23/2025 and a nursing facility consent for antipsychotic or neuroleptic medication treatment for Olanzapine (an antipsychotic used to treat schizophrenia) dated 06/26/2025. Record review of physician's orders current as of 12/03/2025 indicated an order dated 10/28/2025 for 3 oral tablets of Sertraline 25 mg given daily for depression and an order dated 10/28/2025 for 1 oral tablet of Olanzapine 15 mg for schizophrenia. Record Review of Resident #71's PASARR Level 1 Screening completed by the referring entity on 06/24/2025 indicated in section C0100 this resident did not have evidence of having a mental illness. During an interview on 12/03/2024 at 3:19 PM, the MDS nurse stated she was responsible for tasks related to PASARR and MDS processes. The MDS nurse stated that Resident #71's PASARR Level 1 Screening should have indicated the diagnoses of depression and schizophrenia. She stated the potential negative outcome for not having accurate PASSAR screenings included the residents not getting the services they were entitled to. During an interview on 12/03/2025 at 2:00 PM, the ADM stated that residents who have a psychiatric diagnosis should have a completed PASSAR Level 1 Screening indicating these diagnoses. During an interview on 12/03/2025 at 3:45 PM, the [NAME] President of Clinical Operations acting as the interim DON stated that the facility did not have a policy on the PASSAR screening process and that they follow federal and state guidelines.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 4 residents (Resident #34 and Resident #71) reviewed for care plans. 1. The facility failed to ensure that Resident #34's care plan included interventions for sexually inappropriate behavior. 2. The facility failed to ensure that Resident #71's care plan reflected the physician's order and intervention of enteral feedings. These failures could place residents at an increased risk of decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed/implemented to address their needs.The findings included: 1. A record review of an undated face sheet indicated Resident #34 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses of senile degeneration of brain (a decline in cognitive function associated with aging, characterized by memory loss, impaired judgement, and changes in behavior), weakness, and unspecified lack of coordination. A record review of the quarterly Minimum Data Set (MDS) dated [DATE] reflected Resident #34 had a BIMS score of 10 which indicated mild cognitive impairment. The MDS indicated Resident #34 utilized a cane or wheelchair for ambulation, was continent of bowel and bladder, and was able to voice concerns and needs. The MDS did not indicate any physical, verbal, or other behavioral symptoms. A record review of Resident #34's comprehensive care plan dated 8/14/2024 and revised 10/17/2025 did not include any indication of Resident #34's sexually inappropriate behavior nor did it identify any interventions. A record review of a progress note dated 11/26/2024 at 7:53 AM written by LVN J stated Resident #34 was noted with multiple complaints of sexual inappropriateness. A record review of progress note dated 11/03/2025 at 9:13 AM written by SW stated she spoke with Resident #34 about inappropriate touching of staff and provided education to Resident #34. During an interview on 12/02/2025 at 1:21 PM, LVN C stated that she was aware of Resident #34 having a history of inappropriate behavior. She stated it happens and it should not happen. During an interview on 12/03/2025 at 9:05 AM, RN D stated that Resident #34 has behaved inappropriately towards her and that he goes behind me and rubs up against my butt. RN D stated that the interventions she was aware of for Resident #34's behavior was to just keep a really close eye on him. During an interview on 12/03/2025 at 9:11 AM, the ADON stated that Resident #34 was the first resident she has had that exhibited sexually inappropriate behavior. She stated interventions included notifying the physician, notifying family, and providing Resident #34 with education on appropriate behavior. The ADON stated Resident #34's inappropriate behaviors should have been care planned. She stated any behaviors should be care planned. During an interview on 12/03/2025 at 9:15 AM, SW stated she was aware of Resident #34's inappropriate behavior. SW stated interventions included speaking with the family and educating Resident #34 on appropriate behavior. SW stated that Resident #34 had a history of inappropriate behaviors because he had two incidents. SW stated everyone was responsible for developing a care plan for Resident #34's inappropriate behavior. During an interview on 12/03/2025 at 9:21 AM, the ADM stated that she was aware of Resident #34's inappropriate behavior and that they intervened through redirection, contacting family, and providing education. The ADM stated that Resident #34's inappropriate behavior should have been care planned. During an interview on 12/03/2025 at 3:19 PM, the MDS nurse stated that she was responsible for updating care plans. The MDS nurse stated that Resident #34's inappropriate behavior was not and should have been included in the care plan. 2. A record review of an undated face sheet indicated Resident #71 was a [AGE] year-old male who was admitted on [DATE] and readmitted to the facility on [DATE] after a hospital stay. Resident #71 has diagnoses of gastro-esophageal reflux disease without esophagitis (a medical illness where stomach acid flows back into the esophagus without causing inflammation or damage to its lining) and dysphagia oropharyngeal phase (a medical illness causing difficulty swallowing that occurs in the mouth and throat). A record review of the quarterly MDS dated [DATE] reflected Resident #71 had a BIMS score of 0, indicating severely impaired cognition. The MDS reflected Resident #71 was dependent of all functional abilities and used a feeding tube for nutritional approaches. A record review of Resident #71's physician's orders indicated an order for enteral feed every shift related to encounter for attention to gastrostomy. A record review of the Medication Administration Record dated 12/01/2025 through 12/03/2025 indicated Resident #71 received enteral feedings of Jevity 1.5 at 70 milliliters per hour via gastrostomy tube stationary pump with a down time of 2 hours at 50 cubic centimeter flushes per hour and receiving enteral site care each shift. A record review of Resident #71's comprehensive care plan dated 06/24/2025 and revised 10/16/2025 did not indicate Resident #71's enteral feeding status.During observation on 12/01/2025 at 11:31 AM, Resident #71 was observed lying in bed with the head rest propped up and enteral feeding on a continuous hang. During an interview on 12/03/2025 at 1:40 PM, the treatment nurse recognized that Resident #71 was on enteral feeding status. The treatment nurse was aware of Resident #71's enteral feeding status and physician order. The treatment nurse stated Resident #71's enteral feeding status should have been care planned. During an interview on 12/03/2025 at 1:50 PM, [NAME] President of Clinical Operations, acting as the DON, stated the MDS coordinator was responsible for care plans. She stated Resident #71's enteral feeding status should have been included in the care plans. During an interview on 12/03/2025 at 3:19 PM, the MDS nurse stated she was responsible for updating care plans. The MDS nurse stated Resident #71's enteral feeding status was not and should have been included in the care plan. A record review of the facility's policy dated March 2022 titled Care Plans, Comprehensive Person-Centered indicated the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan:a. Includes measurable objectives and timeframes;b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including:1. services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.;2. which professional services are responsible for each element of care.

Based on interviews and record review, the facility failed to treat each resident with respect and dignity and cared for in a manner and environment that promoted the maintenance and /or enhancement of quality of life for 1 of 5 residents (Resident #6) reviewed for dignity and respect. LVN-H handled the Resident # 6's oxygen nasal cannula in a rough and abrupt manner, slapped it against the bed, and displayed frustration, demonstrating unprofessional conduct that did not promote the resident's quality of life. This failure has the potential to impact on the dignity of residents in the facility by causing residents to feel intimidated, threatened, or degraded.Findings included: Resident #6's face sheet dated 12/1/2025 revealed she was a [AGE] year-old female admitted [DATE], diagnosis of atrial fibrillation, vasomotor rhinitis, muscle weakness, monoplegia (paralysis affecting a single limb or body part) of lower left limb, acute respiratory failure with hypoxia (insufficient supply of oxygen), schizophrenia, mood disorders, acute kidney failure, and hypertension. A review of Resident #6's, quarterly MDS dated [DATE], revealed a BIMS score of 11 which indicated she was moderately impaired. Reviewed Resident #6 Care Plans dated 10/15/2025 indicated Resident will be cared for with dignity, intervention provide the resident with supportive care and services to promote a sense of safety well-being and positive self-image. On 12/1/2025 at 11:24AM Resident #6 and Resident #2 were interviewed regarding an incident that occurred on the weekend early Sunday morning 11/31/2025. Resident #6 stated she said the charge nurse came into my room to change my nasal cannula, abruptly she hit the bed with the nasal cannula tubing, she coincidentally hit me on the nose above her lip with the end of the nasal cannula tubing. Resident #6 said LVN-H looked frustrated when she did it and said, it hurt and made her feel like the nurse did not want to take care of her. Resident #6 said CNA-G, and her roommate (Resident #2), both witnessed the incident and both residents said they reported the incident to the RN weekend supervisor. Resident #6 said, later that morning LVN-H returned to the room to apologize and said she had been stressed, and very busy. Resident #6 denied having any injury beyond momentary discomfort but stated the incident made her feel disrespected. Residents #6, and Resident #2 said they felt safe in the facility. Reviewed Resident #2's Face sheet dated 12/4/2025 revealed she was a [AGE] year-old female admitted [DATE], diagnosis of sepsis, insomnia, cognitive communication deficit, alcoholic cirrhosis of liver, hypertension, major depressive disorder, anxiety disorder, and heart disease. A review of Resident #2, quarterly MDS reviewed a BIMS score of 12 dated 11/17/2025, which indicated she was moderately impaired. On 12/1/2025 at 11:30AM Resident #2 was interviewed on initial survey rounds said she was unsure if the nasal cannula hit Resident #6 but confirmed the interaction between LVN-H described by Resident #6, stated the incident was reported to the RN weekend supervisor. A review of the facility's statements dated 12/01/25 were as follows:A review of CNA-G statement dated 12/1/2025 indicated on 11/30/2025 CNA-G had notified LVN-H, Resident #6 had requested a nasal cannula. CNA-G stated he went to central supply and found a small nasal cannula. LVN-H said the nasal cannula was not the right size. Resident #6 said she had wanted a nasal cannula to hook behind her ears. CNA-G said he notified LVN-H, Resident #6 requested a new nasal cannula and stated LVN-H responded by she can get it tonight. CNA-G said he went to the RN weekend supervisor, requested a new nasal cannula for Resident #6. The RN weekend supervisor said she would notify LVN-H to get another nasal cannula for Resident # 6. CNA-G said once he returned to the nursing station, LVN-H asked, why did I go and tell on her. CNA-G said once they got the new nasal cannula from central supply, LVN-H entered the resident's room, she snatched the old cannula off the o2 concentrator and flung it onto the bed, then placed the new nasal cannula on Resident # 6 and walked out of the room. A review of the RN weekend supervisor statement dated 12/1/2025 indicated on 11/30/2025, LVN-H refused to give the resident the nasal canula, voicing the night shift nurse is going to give the resident that. She indicated she immediately went to talk with Resident #6. The RN weekend supervisor stated Resident #6 complained of LVN-H and had refused to care for her and give her another replacement cannula. She further said LVN-H was mean, rude, and she was tired of her attitude. The RN weekend supervisor stated, Resident #6 did not mention the nasal cannula hitting her.A review of the LVN-H statement dated 12/1/2025 indicated on 11/30/2025, Resident #6 requested a nasal cannula. She followed CNA-G into the room, and the resident stated she no longer wanted the nasal cannula. LVN-H stated later that day, Resident #6 requested a new nasal cannula. She instructed CNA-G to explain that it was scheduled to be replaced on Sunday night. Afterward LVN-H said she received a text message from the RN weekend supervisor stating that we needed to ensure Resident #6 had what she needed. LVN-H said she went to the Central supply, retrieved a new nasal cannula and went into the resident's room. She removed the old nasal cannula and placed it on the bed, placed the new one on the resident's face, and left the room and threw the old one away. On 12/1/2025 at 11:35A.M., interviewed CNA-G said Resident #6 requested a replacement nasal cannula. CNA-G stated he notified LVN-H, who responded, The resident can get the nasal cannula tonight. CNA-G reported he informed Resident #6 of the nurse's response. The resident told him I want it now. CNA-G stated, he attempted to locate the correct size nasal cannula but could not find one, so he notified the night weekend supervisor. The RN weekend supervisor told him she would ask LVN-H to obtain the nasal cannula. CNA-G said when LVN-H was informed to find a nasal cannula, she became upset and asked him Why did you go and tell on me? CNA-G stated, when LVN-H entered the resident's room, she snatched the old cannula off the o2 concentrator and flung it onto the bed, then placed the new nasal cannula on the resident and walked out of the room. CNA-G further states he was unsure if the nasal cannula hit the resident. On 12/1/2025 at 11: 36A.M., an attempt was made to contact RN supervisor, however there was no answer. A message was left requesting a return call to the State Surveyor phone number, but no return call was received during investigation. It was reported by the Administrator the RN supervisor only worked on the weekends.On 1212025 at 11:37A.M., two attempts were made to contact LVN-H, however the attempts made was unsuccessful. The Administrator reported LVN-H denies allegations. On 12/1/2025 at 11:38A.M., interviewed the day shift RN-D said, she had morning report with the RN weekend supervisor, but the incident between Resident #6 and the weekend LVN-H was not reported. RN-D further stated that staff should never appear frustrated or irritated during residents' care. And the interaction between Resident # 6 and LVN-H should have been reported during morning report and to the abuse coordinator who was the Administrator. On 12/1/2025 at 11:40A.M., interviewed the ADON said this was the first time she had heard of the incident reported by Resident #6. ADON further said the LVN-H should never appear rushed during care and should have reported the incident to the Administrator, the abuse coordinator. On 12/1/2025 at 11:43A.M., interviewed the Administrator. said this was the first time she had learned of the incident between Resident #6 and LVN-H. She further stated she expects the facility staff to report any complaint or incident to her; she was the Abuse coordinator. The Administrator stated that the abuse policy was reviewed with the staff at least once a month. The Administrator said that a facility investigation immediately will be initiated. On 12/1/2025 at 12:15P.M., Administrator said on12/1/2025 staff that were named in the allegations were suspended pending investigation. The Administrator further said during a phone interview with LVN-H she denied the allegations of the nasal cannula hitting Resident #6. On 12/04/2025 at 1:30 p.m., interviewed the DON said the facility administration team had conducted and completed abuse, neglect, exploitation, and dignity in-services training with staff's members. Re-educated staff on reporting and investigating in-services training with staff members, all had verbalized understanding of policies and in-services, and who to report to, which is the Abuse Coordinators. Review of the facility 's Resident rights Policy states, Staff must not display anger, irritation, or disrespectful behavior during the provision of care. All staff must provide care in a manner that upholds dignity, respect, and resident preference.

Based on observations, interviews, and record reviews, the facility failed to ensure that a 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 and the residents goals and preferences for 1 of 2 residents (Resident #60) reviewed for oxygen therapy, in that: Resident #60's oxygen was set to 3.5 LPM on 3 consecutive days instead of 2 LPM as ordered by the physician. Resident #60's medical record did not include documentation of oxygen saturation checks and oxygen administration. These failures could place residents who receive oxygen therapy at risk for respiratory distress and incomplete medical records.Findings included: A review of a face sheet dated 12/03/2025 indicated Resident #60 was admitted to the facility on [DATE] with a diagnosis of respiratory failure. A review of a quarterly MDS assessment dated [DATE] noted Resident #60 had a BIMS score of 15 which indicated her cognition was intact. A review of Resident #60's physician orders dated 12/03/2025 reflected an order dated 07/08/2019 for Resident #60 to receive oxygen at 2 LPM as needed for shortness of breath to keep oxygen saturation above 92%. A review of Resident #60's undated care plan indicated Resident #60 had difficulty breathing and included directions to administer oxygen at 2LPM as needed to keep oxygen saturation above 92%. Resident #60 was observed receiving oxygen via a nasal cannula at 3.5 LPM on the following dates and times:- 12/01/2025 at 09:50 AM, - 12/01/2025 at 04:00 PM,- 12/02/2025 at 09:40 AM, and- 12/02/2025 at 04:30 PM, - 12/03/2025 at 09:30 AM. During an interview and observation on 12/03/2025 at 09:30 AM, Resident #60 said she wore oxygen all the time. She said she had been receiving oxygen therapy for years. She said she did not adjust the settings. She said she could not reach the oxygen concentrator from the bed to adjust the setting controls. Resident #60 reached her arm out toward the oxygen concentrator to demonstrate she could not reach it. Resident #60 said she depended on the nurses to regulate the oxygen settings. A review of Resident #60's December 2025 NMAR reflected a section designated for documentation of Resident #60's oxygen saturation and administration of oxygen. The section was blank and had no documentation to reflect oxygen saturation checks nor oxygen usage. Review of October 2025 and November 2025 NMARs indicated there was no documentation of oxygen saturation levels being checked nor any administration of oxygen therapy for those months. During an interview on 12/03/2025 at 09:36 AM, MA-A said she had been administering medications for a year at the facility and was a nurse aide at the facility prior to that. She said she knew Resident #60 had been receiving oxygen therapy for as long as she had been a medication aide and believed Resident #60 was receiving oxygen when MA-A was a nurse aide. During an interview and observation on 12/04/2025 at 09:41 AM, the Treatment Nurse said she was the nurse responsible for residents in the area where Resident #60 resided. She said the nurses were responsible for monitoring oxygen therapy to ensure flow rates were set as ordered by the physician. She said the nurses make rounds at the beginning of their shifts and throughout the day and check oxygen settings during those rounds. The Treatment Nurse said Resident #60's physician orders included an order for Resident #60 to receive oxygen at 2 LPM as needed. She said the nurses would have to check Resident #60's oxygen saturation to determine if oxygen therapy was needed. She said there were no instructions or orders regarding when or how often Resident #60's oxygen saturation was to be checked. She said she had not made it to Resident #60's room yet and did not know if Resident's was receiving oxygen at the physician ordered flow rate. The Treatment Nurse went to Resident #60's room, inspected the oxygen setting, and said it was set at 3.5 LPM. The nurse lowered the setting to 2 LPM. The Treatment Nurse said Resident #60 had been receiving oxygen therapy as long as she could remember. She said she did not know why Resident #60's oxygen therapy had not been documented in the medical record and could not identify any risks for a resident receiving oxygen at a rate higher than what is ordered by the physician. During an interview with the [NAME] President of Clinical Operations (who was also an RN) on 12/03/2025 at 10:05 AM, she said the charge nurses were responsible for monitoring oxygen administration and documentation of oxygen therapy. She said the nurses were supposed to document oxygen saturation checks and oxygen administration on the NMAR. A review of the facility's Oxygen Administration Policy dated 03/14/2019 indicated the following: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation1.Verify that there is a physician's order for this procedure. Review the physician's orders, facility protocol, for oxygen administration.AssessmentBefore administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 3.Signs of oxygen toxicity4.Vital signs5.Lung sounds6.Arterial blood gases or oxygen saturation, if applicable .Steps I procedure10.Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. DocumentationAfter completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record:1.The date and time that the procedure was performed.2.The name and title of the individual who performed the procedure.3The rate of oxygen flow, route, and rationale.4.The frequency and duration of the treatment.5.The reason for the p.r.n. treatment.

Based on observations, interviews, and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 5 residents (Resident #61 and Resident #74) reviewed for pharmacy services. MA-A failed to take action to acquire Resident #61s scheduled dose of Pantoprazole when she did not have it available for administration. MA-A failed to take action to acquire Resident #74's scheduled dose of Tegretol when she did not have it available for administration. MA-A incorrectly documented she administered a dose of Pantoprazole to Resident #61 and a dose of Tegretol to Resident #74 when she did not have the 2 (two) medications available for administration. These failures could place residents at risk of not receiving their medications as ordered, having adverse consequences due to inconsistent levels of medication in the body, and having incorrect medication administration records.Findings included: 1.A review of a face sheet and physician orders dated 12/02/2025 indicated Resident #61 admitted to the facility on [DATE] with diagnoses which included end stage kidney disease and GERD (gastroesophageal reflux disease, a condition where stomach acid flows back up into the esophagus). A review of the annual MDS assessment dated [DATE] noted Resident #61 had a BIMS score of 11 indicating her cognition was moderately impaired. The same MDS indicated Resident #61 was ambulatory with a rolling walker and was continent of bowel and bladder. A review of Resident #61's physician orders dated 12/02/2025 indicated Resident #61 had an order dated 05/06/2025 for 1 (one) tablet of Pantoprazole 40 MG to be administered two times a day. During observation and interview of medication administration on 12/02/2025 at 08:40 AM, MA-A said Resident #61 did not have any Pantoprazole 40 MG tablets available in the medication cart. MA-A was then observed to check the medication overflow cart for the Pantoprazole tablets. She said she did not find any Pantoprazole tablets in the overflow cart. When MA-A did not locate any Pantoprazole tablets in the overflow cart, she went back to her medication cart and began preparation of medications for Resident #74. 2. A review of a face sheet and physician orders dated 12/02/2025 indicated Resident #74 admitted to the facility on [DATE] with diagnoses which included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures). A review of a quarterly MDS assessment dated [DATE] noted Resident #74 had a BIMS score of 5 indicating his cognition was severely impaired. The same MDS indicated Resident #74 was non-ambulatory and dependent on staff for most activities of daily living. A review of Resident #74's physician orders dated 12/02/2025 indicated Resident #74 had an order dated 01/11/2023 for 1 (one) tablet of Tegretol 300 MG to be administered two times a day related to the diagnosis of epilepsy. During observation and interview of medication administration on 12/02/2025 at 08:49 AM, MA-A said Resident #74 did not have any Tegretol 300 MG tablets available in the medication cart. MA-A was then observed to check the medication overflow cart for the Tegretol tablets. She said she did not find any Tegretol tablets in the overflow cart. When MA-A did not locate any Tegretol tablets in the overflow cart, she went back to her medication cart and began preparation of medications for other residents. She said when she did not have a needed medication on the medication cart, she would check the medication overflow cart for the medication first. If the medication was not in the overflow cart, she said she would notify the nurse, and the nurse could check the secure medication dispenser cart for the needed medication. MA-A said she was finished with medication administration tasks for Residents # 61 and Resident #74 and had nothing else to do for them. A review of the Medication Administration Records for Resident #61 and Resident #74 on 12/02/2025 at 10:15 AM indicated MA-A had administered 1 (one) Pantoprazole 40 MG tablet to Resident #61 at 09:58 AM on 12/02/2025. Further review indicated MA-A had administered 1 (one) Tegretol 300 MG tablet to Resident #74 at 10:01 AM on 12/02/2025. During an interview with LVN-C on 12/02/2025 at 10:31 AM, she said she had not been informed of any resident not receiving their scheduled medications. LVN-C said it was important for Resident #64 to receive the physician ordered Pantoprazole medication because the medication helped to neutralize stomach acid and prevent damage to the lining of the esophagus. LVN-C said it was important for Resident #74 to receive his physician ordered Tegretol medication because it helped to prevent seizures. LVN-C said the medication aide was supposed to let the charge know when a medication was not available for administration. She said the medication aide was supposed to check the overflow cart for the needed medication first and if it was not there, the medication aide was supposed to check the medication room to see if the medication was there. She said the charge nurse would then check the emergency supply in the secure medication cabinet in the medication room to see if the needed medication was available. She said if the needed medication was not available, the charge nurse would notify the pharmacy who would either deliver the medication or obtain it from a local pharmacy for immediate delivery to the facility. During an interview with MA-A on 12/02/2025 at 10:35 AM, she said she did not tell the nurse that she did not have the Pantoprazole 40 MG tablets to give Resident #61 and could not explain why she documented that she had administered the medication. MA-A said she did not tell the nurse that she did not have the Tegretol 300 mg tablet to give to Resident #74 and did not know why she documented that she had administered it to Resident #74. MA-A said it was her responsibility to inform the charge nurse when a needed medication was not available. She said she forgot to inform the nurse. During an interview with LVN-C on 12/02/2025 at 11:30 AM, she said she had just found Resident #74's Tegretol medication in the medication room. She said the pharmacy delivered it last night. She said the nurse who received the pharmacy delivery was supposed to put the medication on the medication cart but did not. LVN-C said she obtained Resident #61's Pantoprazole medication from the emergency supply. LVN-C was noted to have both residents' medications in her hands. She said she informed the physician and she was instructed to administer them. During an interview with the [NAME] President of Clinical Operations (RN) on 12/03/2025 at 10:45 AM, she said she expected the medication aides to notify the charge nurse when a medication was not available for administration. She said she expected the nursing staff to document medication administration correctly. A review of the facility's policy dated as revised April 2019 and titled Administering Medications included the following: 4.Medications are administered in accordance with prescriber orders, including any required time frame.22.The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5 percent. There were 2 errors out of 27 opportunities, resulting in a 7 percent medication error rate involving 2 of 5 residents (Resident #61 and Resident #74). MA-A failed to administer a scheduled medication, pantoprazole 40 MG tablet, to Resident #61 as ordered by the physician. MA-A failed to administer a scheduled medication, Tegretol 300 MG tablet, to Resident #74 as ordered by the physician. These failures could place residents at risk of not receiving the therapeutic effects of the mediations and could result in a decline in health status.Findings included: 1.A review of a face sheet and physician orders dated 12/02/2025 indicated Resident #61 admitted to the facility on [DATE] with diagnoses which included end stage kidney disease and GERD (gastroesophageal reflux disease, a condition where stomach acid flows back up into the esophagus). A review of the annual MDS assessment dated [DATE] noted Resident #61 had a BIMS score of 11 indicating her cognition was moderately impaired. The same MDS indicated Resident #61 was ambulatory with a rolling walker and was continent of bowel and bladder. A review of Resident #61's physician orders dated 12/02/2025 indicated Resident #61 had an order dated 05/06/2025 for 1 (one) tablet of Pantoprazole 40 MG to be administered two times a day. During observation of medication administration on 12/02/2025 at 08:40 AM, MA-A said Resident #61 did not have any Pantoprazole 40 MG tablets available in the medication cart. MA-A was observed to obtain the remainder of Resident #61's scheduled medications and administer them to Resident #61 as ordered. MA-A was then observed to check the medication overflow cart for the Pantoprazole tablets. She said she did not find any Pantoprazole tablets in the overflow cart. When MA-A did not locate any Pantoprazole tablets in the overflow cart, she went back to her medication cart, and began preparation of medications for Resident #74. 2. A review of a face sheet and physician orders dated 12/02/2025 indicated Resident #74 admitted to the facility on [DATE] with diagnoses which included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures). A review of a quarterly MDS assessment dated [DATE] noted Resident #74 had a BIMS score of 5 indicating his cognition was severely impaired. The same MDS indicated Resident #74 was non-ambulatory and dependent on staff for most activities of daily living. A review of Resident #74's physician orders dated 12/02/2025 indicated Resident #74 had an order dated 01/11/2023 for 1 (one) tablet of Tegretol 300 MG to be administered two times a day related to the diagnosis of epilepsy. During observation of medication administration on 12/02/2025 at 08:49 AM, MA-A said Resident #74 did not have any Tegretol 300 MG tablets available in the medication cart. MA-A was observed to obtain the remainder of Resident #74's scheduled medications and administer them to Resident #74 as ordered. MA-A was then observed to check the medication overflow cart for the Tegretol tablets. She said she did not find any Tegretol tablets in the overflow cart. When MA-A did not locate any Tegretol tablets in the overflow cart, she went back to her medication cart and began preparation of medications for other residents. During an interview with LVN-C on 12/02/2025 at 10:31 AM, she said she had not been informed of any resident not receiving their scheduled medications. LVN-C said it was important for Resident #64 to receive the physician ordered Pantoprazole medication because the medication helped to neutralize stomach acid and prevent damage to the lining of the esophagus. LVN-C said it was important for Resident #74 to receive his physician ordered Tegretol medication because it helped to prevent seizures. After surveyor intervention, LVN-C obtained the 2 medications and administered them accordingly. During an interview with MA-A on 12/02/2025 at 10:35 AM, she said she forgot to tell the nurse that she did not have the Pantoprazole 40 MG tablets to give Resident #61. MA-A said she forgot to tell the nurse that she did not have the Tegretol 300 mg tablet to give to Resident #74. During an interview with the [NAME] President of Clinical Operations (who was also a RN) on 12/03/2025 at 10:45 AM, she said she expected the medication aides to notify the charge nurse when a medication was not available for administration. A review of the facility's policy dated as revised April 2019 and titled Administering Medications included the following: 4.Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #74) reviewed for significant medication errors. MA-A failed to take action to acquire and administer a scheduled medication, Tegretol (to prevent seizures related to diagnosis of epilepsy). This failure could place resident at risk of not receiving the therapeutic effect of mediations and could result in a decline in health status.Findings included: A review of a face sheet and physician orders dated 12/02/2025 indicated Resident #74 admitted to the facility on [DATE] with diagnoses which included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures).A review of a quarterly MDS assessment dated [DATE] noted Resident #74 had a BIMS score of 5 indicating his cognition was severely impaired. The same MDS indicated Resident #74 was non-ambulatory and dependent on staff for most activities of daily living. A review of Resident #74's physician orders dated 12/02/2025 indicated Resident #74 had an order dated 01/11/2023 for 1 (one) tablet of Tegretol 300 MG to be administered two times a day at 09:00 AM and 05:00 PM related to the diagnosis of epilepsy. A review of The Epilepsy Foundation's instructions on 12/3/25 indicated taking medications to treat epilepsy or seizures indicated these medications were to be consistently taken at the same time daily to maintain a therapeutic level in the bloodstream. During observation of medication administration on 12/02/2025 at 08:49 AM, MA-A said Resident #74 did not have any Tegretol 300 MG tablets available in the medication cart. MA-A was then observed to check the medication overflow cart for the Tegretol tablets. She said she did not find any Tegretol tablets in the overflow cart. When MA-A did not locate any Tegretol tablets in the overflow cart, she went back to her medication cart, said she didn't have any Tegretol, and began preparation of medications for other residents. During an interview with LVN-C on 12/02/2025 at 10:31 AM, she said she had not been informed of any resident not receiving their scheduled medications. LVN-C said it was important for Resident #74 to receive his physician ordered Tegretol medication because it helped to prevent seizures. LVN-C said the medication aide was supposed to let the charge know when a medication was not available for administration. She said the medication aide was supposed to check the overflow cart for the needed medication first and if it was not there, the medication aide was supposed to check the medication room to see if the medication was there. She said the charge nurse would then check the emergency supply in the secure medication cabinet in the medication room to see if the needed medication was available. She said if the needed medication was not available, the charge nurse would notify the pharmacy who would either deliver the medication or obtain it from a local pharmacy for immediate delivery to the facility. After surveyor intervention, LVN-C obtained the Tegretol medication and administered it on 12/02/2025 at 11:50 AM which was 2 hours and 50 minutes after the scheduled time of 09:00 AM. LVN-C said if the surveyor had not intervened, Resident #74 would most likely not have received the morning dose of Tegretol. During an interview with the [NAME] President of Clinical Operations (RN) on 12/03/2025 at 10:45 AM, she said she expected the medication aides to follow the rules of medication administration and notify the charge nurse when a medication was not available for administration. A review of the facility's policy dated as revised April 2019 and titled Administering Medications included the following: 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission and provide the resident and or the resident representative with a summary of the baseline care plan for 1 of 5 residents reviewed for the base line care plans. (Resident #90) The facility did not complete a baseline care plan within 48 hours of admission and provide a written summary of the baseline care plan to Resident #90 or their responsible party. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.Findings included:A review of Resident #90's face sheet and physician's orders for December 2025 indicated the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), mild neurocognitive (neurological disorders that affect cognitive functions) disorder, and cognitive communication disorder. A review of the electronic record on 12/01/2025 for Resident #90 indicated no documentation of a baseline care plan.During an interview on 12/03/2025 at 11:10 AM, the VP of Clinical Operations said the baseline care plan was not present in the clinical record for Resident #90. She said it was not done. She said the baseline care plan should have been initiated when Resident #90 admitted to the facility on [DATE] and completed on 11/28/2025. She said the RN in charge, usually the DON, should initiate the baseline care plan and the interdisciplinary team add to it and then it was presented to the resident and/or their responsible party and reviewed together. She said then the resident or the responsible party would sign they had received and reviewed the baseline care plan, and it would be indicated in the clinical record.A facility policy Care Plans - Baseline revised March 2022 indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission.4. The resident and/or representative are provided a written summary of the baseline care plan.5. Provision of the summary.is documented in the medical record.

Based on observation, interview and record review 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 care of the residents that meet professional standards of quality care within 48 hours of the residents' admission for 2 of 2 residents (Resident #1, Resident #2). The facility failed to ensure Resident #1, and Resident #2 had a baseline care plan.This failure could place residents at risk for not communicating appropriate treatment and services to meet their needs.Findings included: A Review of the physician's orders and face sheet dated [DATE] indicated Resident #1was a 58 -year-old female who admitted on [DATE] with diagnoses including acute respiratory failure, unspecified lack of coordination, scabies, urinary tract infection bacteremia muscle weakness, schizophrenia, borderline intellectual functioning, anemia, atrial fibrillation, mood disorder, pressure ulcer, rhabdomyolysis, acute kidney failure, Systemic inflammatory response syndrome, hyperkalemia, hyperlipidemia and hypertension. A review of Resident #1 quarterly MDS section C dated [DATE], revealed a BIM score of 05 (Brief Interview for Mental Status) score of 5 indicates severe cognitive impairment. Record review of Resident #1's care plans, there were none initiated since admission on [DATE] did not document, develop or implement any current diagnosis, care level, any measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a phone interview on 10/14/2025 at 10:20 AM with a daughter of resident #1, she said she has not had a care plan meeting with the facility. During an observation and interview on 10/14/2025 at 11:00 AM, Resident #1 was resting in her bed. Sher was awake with some noticeable confusion, she was totally dependent on staff for ADL's, room was clean without any odors noted she said she was going to be going back to her hometown to another facility which was closer to her family. She said she knew that the social worker was contacting the other facility to help get her transferred. During an interview on 10/14/2025 at 12:18PM, the administrator and the Social Worker both said they were not aware of issues of residents #1 & #2's care plans, and the MDS nurses were responsible for these, and the DON should have overseen that the care plans were completed appropriately and timely. Both admitted the care plans were an issue due to transition of interim DON and new MDS Nurse who was out sick and only been with the facility for a couple of weeks. The administrator said they were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened. During an interview on 10/14/2025 at 2:00 PM, the ADON said the care plans were the responsibility of the MDS Nurse (RN) she was an LVN, and it is the responsibility of the RN. A Review of the physician's orders and face sheet dated [DATE] indicated Resident #2 was a 63 -year-old male who admitted on [DATE] and re-admitted on [DATE] with hypertension, Dementia, severity with other Behavioral Disturbance, lack of Coordination, abnormal posture difficulty in walking, not elsewhere classified, unsteadiness on feet, muscle weakness, cerebral infarction, type 2 diabetes with diabetic neuropathy, anxiety disorder, altered mental status, shortness of breath, constipation, hemiplegia and hemiparesis, skin changes, pressure ulcer of sacral region, stage 3, disorders of ear, bilateral, candidiasis, dry eye syndrome. A review of Resident #2 quarterly MDS section C revealed a BIM score of 10 (Brief Interview for Mental Status) score of indicates moderately cognitive impairment. Record review of Resident #2's care plans, there were none initiated since admission on [DATE] did not document, develop or implement any current diagnosis, care level any measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During an interview on 10/13/2025 at 12:30 PM resident #2 was observed up in his specialized wheelchair, with hydraulics up high in air, he did not response to verbal stimuli with first attempt, after much encouragement he responded and stated he had no current issues with the facility. During an interview on 10/14/2025 at 12:18PM, the administrator and the Social Worker both said they were not aware of issues of residents #1 & #2's care plans, and the MDS nurses were responsible for these, and the DON should have overseen that the care plans were completed appropriately and timely. Both admitted the care plans were an issue due to transition of interim DON and new MDS Nurse who was out sick and only been with the facility for a couple of weeks. The administrator said they were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened. During an interview on 10/14/2025 at 2:00 PM, the ADON said the care plans were the responsibility of the MDS Nurse (RN) she was an LVN, and it is the responsibility of the RN. Record review of an undated care planning policy dated March 2022 indicated the care planning/interdisciplinary team shall develop a comprehensive care plan for each resident. The policy indicated a comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs which shall be developed for each resident. The policy indicated implementation included the resident's comprehensive care plan was to be developed within 7 days of the completion of the resident's comprehensive MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 4 of 4 residents reviewed for care plans (Resident #1, Resident #2 Resident #3, and Resident #4).The facility failed to ensure Residents 1, 2, 3, and 4 had documented a completed Comprehensive Care Plan. This failure could place residents at risk for not communicating appropriate treatment and services to meet their needs.Finding included: A Review of the physician's orders and face sheet dated [DATE] indicated Resident #1was a 58 -year-old female who admitted on [DATE] with diagnoses including acute respiratory failure, unspecified lack of coordination, scabies, urinary tract infection bacteremia muscle weakness, schizophrenia, borderline intellectual functioning, anemia, atrial fibrillation, mood disorder, pressure ulcer, rhabdomyolysis, acute kidney failure, Systemic inflammatory response syndrome, hyperkalemia, hyperlipidemia and hypertension. A review of Resident #1 quarterly MDS section C dated [DATE], revealed a BIM score of 05 (Brief Interview for Mental Status) score of 5 indicates severe cognitive impairment.Record review of Resident #1's care plans initiated since admission on [DATE] did not document, develop or implement any current diagnosis, care level any measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a phone interview on 10/14/2025 at 10:20 AM with a daughter of resident #1, she said she has not had a care plan meeting with the facility. During an observation and interview on 10/14/2025 at 11:00 AM, Resident #1 was resting in her bed. She was awake with some noticeable confusion, she was totally dependent on staff for ADL's, room was clean without any odor noted she said she was going to be going back to her hometown to another facility which was closer to her family. She said she knew that the social worker was contacting the other facility to help get her transferred. During an interview on 10/14/2025 at 12:18PM, the administrator and the Social Worker both said they were not aware of issues of resident's care plans, and the MDS nurses were responsible for these, and the DON should have overseen that the care plans were completed appropriately and timely. Both admitted the care plans were an issue due to transition of interim DON and new MDS Nurse who was out sick and only been with the facility for a couple of weeks. The administrator said they were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened. During an interview on 10/14/2025 at 2:00 PM, ADON said the care plans were the responsibility of the MDS Nurse (RN) she was a LVN, and it is the responsibility of the RN. A Review of the physician's orders and face sheet dated [DATE] indicated Resident #2 was a 63 -year-old male who admitted on [DATE] and re-admitted on [DATE] with hypertension, Dementia, severity with other Behavioral Disturbance, lack of Coordination, abnormal posture difficulty in walking, not elsewhere classified, unsteadiness on feet, muscle weakness, cerebral infarction, type 2 diabetes with diabetic neuropathy, anxiety disorder, altered mental status, shortness of breath, constipation, hemiplegia and hemiparesis, skin changes, pressure ulcer of sacral region, stage 3, disorders of ear, bilateral, candidiasis, dry eye syndrome. A review of Resident #2 quarterly MDS section C revealed a BIM score of 10 (Brief Interview for Mental Status) score of indicates moderately cognitive impairment. Record review of Resident #2's care plans initiated since admission on [DATE] did not document, develop or implement any current diagnosis, care level any measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During an interview on 10/13/2025 at 12:30 PM with resident #2 was observed up in his specialized wheelchair, with hydraulics up high in air, he did not response to verbal stimuli with first attempt, after much encouragement he responded and stated he had no current issues with the facility During an interview on 10/14/2025 at 12:18PM, the administrator and the Social Worker both said they were not aware of issues of resident's care plans, and the MDS nurses were responsible for these, and the DON should have overseen that the care plans were completed appropriately and timely. Both admitted the care plans were an issue due to transition of interim DON and new MDS Nurse who was out sick and only been with the facility for a couple of weeks. The administrator said they were addressing this issue in the daily morning meetings to be informed of changes to be care planned but did not know what happened. During an interview on 10/14/2025 at 2:00 PM, ADON said the care plans were the responsibility of the MDS Nurse (RN) she was an LVN, and it is the responsibility of the RN. A review of Resident #3's, face sheet and physician's orders both dated for [DATE], indicated Resident #3 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis including unspecified dementia, late onset Alzheimer, hypertension, dysphagia (difficulty swallowing foods or liquids), ataxia ( a disorders that affect co-ordination, balance and speech), schizophrenia, major depression, hyperlipidemia, bipolar disorder, and encephalopathy (a disease or damage that affects brain function or structure). A review of Resident #3's quarterly MDS assessments dated 08/25/2025 revealed a BIM score 0f (00) which indicated she was severely impaired. Observation of Resident #3 on 10/13/2025 at 09:30AM, revealed she was not Interview able. She was in her room lying in bed with her eyes closed, C/D & well groomed, bed in low position, fall mat at bedside, water at bedside, call light was in reach, no signs of abuse/neglect. The resident's room was clean and homelike and there was no physical environment hazards identified. The resident was cognitively impaired and unable to answer questions regarding her care at the facility. A review of Resident #3 's physician's orders dated 07 25/2025 indicated an order for Hospice for evaluation and treatment. Plus, an MD order for an Assignments of a skilled nurse 1xwk. social worker 1x months and, a hospice aide 3x week.A review of Resident #3's Hospice Group in-facility contract dated 07/2025 was signed and agreed to the terms and conditions by all parties.A review of Resident #3's Progress notes dated 10/10/2025, 10/13/2025, and 10/15/2025 revealed Resident #3 received hospice aide care three times a week.A review of Resident #3's comprehensive care plans dated 06/25/2025, was missing care plans for Hospice's care plans, goals, or intervention, and identified no documentation of Hospice care plans initiated or updated. A review of Resident #4, face sheet and physician's orders both dated for [DATE], indicated Resident #4 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis including hepatic encephalopathy (a disease or damage that affects brain function or structure), dysphagia (difficulty swallowing foods or liquids), tachycardia, sepsis, methicillin resistant staphylococcus infection, cognitive communication deficit, pressure ulcer of sacral region , other cirrhosis of liver, hypertension, and lack of co-ordination, balance and speech. A review of Resident #4's quarterly MDS assessments dated 10/10/2025 revealed a BIM score of (03) indicated she was severely impaired. Observation of Resident #4 on 10/13/2025 at 10:00AM, revealed she was not interview able. She was in her room lying in bed, with eyes closed, C/D & well groomed, bed in low position, water at bedside, call light was in reach, no signs of abuse/neglect. The resident's room was clean and homelike and there was no physical environment hazards identified. The resident was cognitively impaired and unable to answer questions regarding her care at the facility. A review of Resident #4's 's physician's orders dated 10/1/2025 indicated that the resident returned to facility from hospital on [DATE]. The wound care MD stated, resume previous wound orders treatments, and he will be here on Thursday to do round and see the resident. The wound care nurse notified the resident and the mother about the wound treatment orders. Also stated All the needs were to be met by nurses' staff on this shift. A review of Resident #4 wound care pressure dressing notes dated 10/11/2025 per wound care Md indicated, Wound Care: Stage 4 Pressure Wound of the right buttock full thickness: Clean with NS/WC, pat dry, and pack with gauze damped in Daikin ( half strength) to fill the wound bed completely and cover with super absorbent dressing with adhesive change daily and as needed PRN. A review of Resident #4's Care Plan dated 7/30/2025 indicated an IDT meeting scheduled today at 4:45PM with the residents' mother. Revealed No documentation of Social Worker reference to the interdisciplinary team (IDT) consultation with mother. No care plans were documented or updated by the MDS nurse or the DON RN, regarding IDT meeting with mother consultation or interventions on care for Resident #4. During an interview on 10/15/2025 at 10:18AM, the Wound Care nurse said, after the mother's arrival to facility late in the afternoons after 6:00PM, it had been discovered that the resident's mother had changed the Pressure Ulcer dressing on several occasions. She said it was discussed verbally with the mother to not change the dressing, and to notify the nursing staff if the Pressure Ulcer dressing had been soiled and needed changed. She said she informed the mother that the nursing staff will change the dressing daily and as needed PRN. The wound care nurse stated that she understood that after speaking with the MD and Social Worker that an IDT meeting would be scheduled, and care plans would be updated. During an interview on 10/15/2025 at 10:30AM, the Social Worker said, she only documented that the IDT meeting was scheduled for 07/30/2025 at 4:45PM, but no additional notes were added to progress notes or care plans. During an interview on 10/15/2025 at 1:30PM, the ADON LVN said, that Resident #3 was receiving Hospice care with a skilled nurse once a week and a hospice aide care three times a week. ADON LVN said, Resident #3 hospice care plans should had been added, and Resident #4 IDT care plans should had been added to the comprehensive care plans. The ADON LVN said, she had been with this facility for only 3 to 4 weeks but was informed by the corporate nurse, it is the responsibility of the DON RN to complete, update, and sign the admission base line care plans, and comprehensive care plans. During an interview on 10/15/2025 at 2:00pm the DON RN said, she was just hired as the interim DON RN due to the recent transition of the previous DON, and the new MDS nurse had been out sick. DON RN said, the team were addressing care plans issue in the daily morning meetings. During an interview on 10/15/2025 at 2:30PM the Administrator said that the RN, DON, and the MDS nurse were responsible for reviewing the admission care plans and updating the current care plans. The Admin. said, the DON and the MDS Coordinator were responsible for ensuring the MDS assessments were accurate and said the RAI manual was used as the guideline for the MDS's assessment. She said the policy would be to follow the Resident Assessment Instrument (RAI). The Administrator confirmed that the care plans did not address or document Hospice Care for Resident #3, nor did the care plans address IDT meeting with Resident # 4 mother's on requesting the nursing staff to change the PU dressing when soiled. Record review of an undated care planning policy dated March 2022 indicated the care planning/interdisciplinary team shall develop a comprehensive care plan for each resident. The policy indicated a comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs which shall be developed for each resident. The policy indicated implementation included the resident's comprehensive care plan was to be developed within 7 days of the completion of the resident's comprehensive MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (Resident's #1, # 2, #3) reviewed for infection control practices. The facility failed to ensure LVN A, LVN C, LVN D, and the Interim DON used sterile technique while performing tracheotomy suctioning on Resident #1. The facility failed to ensure RN B used sterile technique while performing tracheotomy care on Resident #2 on 09/29/25. The facility failed to follow the tracheotomy care and suctioning policy and procedure. The facility failed to ensure LVN A, LVN C, LVN D, the interim ADON, LVN G and CNA H wore enhanced barrier precautions while performing care on Resident #1, who had a feeding tube, tracheostomy tube, wound, and Foley catheter. The facility failed to ensure CNA E and CNA F wore enhanced barrier precautions while providing care to Resident #3 who had a Foley Catheter. The facility failed to ensure the nursing staff knew how to access PPE and sterile supplies for enhanced barrier precautions. Immediate jeopardy (IJ) was identified on 09/30/25 at 04:00 PM. The IJ template was provided to the facility on [DATE] at 04:38 PM. While the IJ was removed on 10/02/25 at 05:13 PM, the facility remained out of compliance at a scope of a patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on providing sterile tracheotomy care and suctioning and enhanced barrier precautions. These failures could place residents and staff at risk for cross contamination and serious injury, harm, impairment, and death from the spread of an infectious disease.Findings included: 1. Record review of a face sheet dated 09/29/25 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included autistic disorder (difficulties in social communication and interaction, strong preference for routine, sensory processing differences, focused interest and repetitive behaviors), schizoaffective disorders (symptoms of delusional, hallucinations, depressed episodes followed by manic periods of high energy), anemias, and neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination), tracheostomy status, encounter for attention to gastrostomy (feeding tube). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #1 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #1 did not have BIMS score, which indicated Resident #1 was unable to complete the assessment. The MDS assessment indicated Resident #1 was dependent on staff for all ADLs. The MDS assessment indicated Resident #1 had a tracheotomy. Record review of Resident #1's care plan with a target date of 10/21/25 indicated he had a tracheotomy with a goal of he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #1's Order Summary Report dated 09/29/25 indicated: Change tracheotomy dressing with tracheotomy care every day and PM with a start date of 06/27/25. Record review of Complaint/Grievance dated 08/12/25 indicated Resident #1's family member complained the staff was not providing tracheotomy care and suctioning using sterile technique. The grievance indicated the resolution was all nurses on North Hall were in serviced on tracheotomy care and suctioning using sterile technique. Record review of the admission hospital records dated 09/25/25 indicated Resident #1 was admitted with chronic respiratory failure with tracheostomy in place. Laboratory results indicated Resident #1 had bacteremia (bacteria is present in the bloodstream), staph hominis (gram positive bacteria in the bloodstream), and pseudomonas (gram positive bacteria found in lungs, skin, ears) 2. Record review of a face sheet dated 09/30/25 indicated Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included anoxic (lack of oxygen) brain damage, flaccid neuropathic bladder (central nervous system or nerves involved in the control of urination) , anemia, epilepsy (seizures), mild protein-calorie malnutrition, cerebral infarction due to embolism (stroke), acute respiratory failure, tracheostomy (surgical procedure that creates an opening in the front of the neck (trachea) and inserts a tube to help a person breath). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #2 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #4 did not have BIMS score, which indicated Resident #4 was unable to complete the assessment. The MDS assessment indicated Resident #4 was dependent on staff for all ADLs. The MDS assessment indicated Resident #4 had a tracheotomy. Record review of Resident #2's care plan with a target date of 10/14/25 indicated he had a tracheotomy with a goal of he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #2's Order Summary Report dated 09/30/25 indicated: Change tracheotomy dressing with tracheotomy care every shift with a start date of 06/25/25. Record review of Resident #2's Infection Screening Evaluation dated 07/29/25 indicated current active infection related to chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/02/25 indicated a current active infection related to chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/10/25 indicated current active infection related to chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's chest x-ray dated 09/10/2025 indicated pneumonia (infection of the lungs). Increased opacity is present at the left lung base representing either infiltrate or plural effusion. There has been no improvement with a prior chest x-ray performed on 09/02/25. Record review of SBAR communication Form dated 09/29/25, indicated Resident #2 was experiencing a fever with low oxygen sat of 77%. O2 increased to 10 liters and O2 now 93%. Record review of Resident #2 progress note dated 09/29/25 at 14:29 PM, indicated the physician ordered an x-ray related to a fever. Record review of progress note dated 09/30/35 at 12:48 PM indicated, Resident #2 had worsening pneumonia on the left side. Also reported that he has developed a temp of 101.8 along with O2 having to be increased to 10 Liters to keep oxygen saturations over 90%. Resident is on day 8 of 14 of his Bactrim. Secretions have become very thick, green in color and has a very foul odor. New order received to send resident out to ER for assessment. Wife informed and agrees with plan. Record review of in service dated 08/12/25 with a subject of tracheotomy care and suctioning using sterile technique indicated twelve nursing staff signatures including LVN C, the Interim DON, RN B. Record review of the following staff competency nurse check offs for sterile tracheotomy care and suctioning included:Interim DON dated 02/25/2025RN B dated 07/16/2025 During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/15/25 at 09:20 PM, CNA H and LVN G entered Resident #1's room wearing a mask, CNA H and LVN G donned gloves and repositioned Resident #1, provided incontinent care and adjusted the bed covers. CNA H and LVN G did not wear a gown for enhanced barrier precautions. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/16/25 at 05:09 AM, LVN A entered Resident #1's room wearing gloves and carrying a pitcher of water. LVN A flushed Resident #1's PEG tube (a feeding tube inserted into the abdomen into the stomach) and then provided incontinent care. LVN A did not change gloves or perform hand hygiene. LVN A proceeded to grab the suction catheter from the bedside table and suctioned Resident #1. LVN A did not change her gloves or use sterile technique during the suctioning procedure. LVN A repositioned Resident #1 in the bed, took off her gloves and exited the room. LVN A did not wear a gown for enhanced barrier precautions. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/23/25 at 11:09 AM, LVN C entered into Resident #1's room and put on non-sterile gloves. LVN C repositioned Resident #1's bedcovers. LVN C did not change her gloves or perform hand hygiene. Then LVN C grabbed the suction catheter from the bedside table drawer and unraveled Resident #1's TV control cord from the suction tubing. LVN C proceeded to suction Resident #1. LVN C took off her gloves and exited Resident #1's room. LVN C did not apply sterile gloves or use sterile technique for the suctioning procedure. LVN C did not wear a gown for enhanced barrier precautions. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/23/25 at 09:30 PM, LVN D was in Resident #1's room and had a sterile field set up on the bedside table. LVN D appeared to be wearing sterile gloves. LVN D touched the suctioning machine with her dominant hand and proceed to suction Resident #1. After LVN D touched the suction machine contaminating her dominant hand. LVN D failed to follow sterile technique for the suctioning procedure. LVN D removed her gloves, discarded the used supplies and exited the room. LVN D did not wear a gown for enhanced barrier protection. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/24/25 at 09:54 AM, the Interim DON and Resident #1's family member entered Resident #1's room. The Interim DON performed an assessment by taking Resident #1's temperature, checked his oxygen levels with the pulse oximetry (device use the measure the amount of oxygen in the blood), and listened to his lungs. The Interim DON removed the suction catheter from the bedside table drawer and suctioned Resident #1. Resident #1's family member asked the Interim DON why she was not using sterile gloves. The Interim DON said, the facility did not have the correct size to fit her hands in stock. The Interim DON did not apply sterile gloves or use sterile technique for the suctioning procedure. The Interim DON did no wear a gown for enhanced barrier protection. During an observation on 09/29/25 at 4:17 PM, the Treatment Nurse prepared Resident #2's bedside table for tracheostomy care. The Treatment Nurse placed a piece of wax paper on the table, then placed the following on the wax paper: two unopened bottles of sterile water, a tracheostomy care kit, which was slightly opened, unopened suction tubing, and 4 x 4 unsterile gauze pads from a multiuse package. RN B rearranged the items and positioned the bedside table for use. RN B washed her hands, then applied her sterile gloves, using sterile technique. RN B immediately picked up the unopened suction tubing package and opened it, which contaminated her sterile gloves. RN B then grabbed the unopened bottles of sterile water, opened it, and poured it into the sterile field. RN B then picked up the unsterile 4 x 4 gauze pads and placed them into sterile water. RN B did not reapply sterile gloves, after she contaminated her sterile gloves, and used the same gloves during the following care activities. RN B took the cotton-tipped applicators from the tracheostomy kit and then cleaned around the stoma (opening in the neck). RN B used the 4 x 4 gauze pads that were soaked in sterile water to clean around Resident #2's neck. RN B then cleaned inside the tracheostomy tubing with the 4 x 4 gauze pads. RN B removed her gloves and applied hand sanitizer. RN B replaced her gloves and replaced the tracheostomy neck ties. During an interview on 09/29/25 at 5:06 PM, RN B stated tracheostomy care was a sterile procedure. RN B stated the packaging should have been opened prior to applying her sterile gloves. RN B stated the outside packaging was not sterile. RN B stated everything completed after the sterile gloves were contaminated would not have been considered sterile. RN B stated she had not realized she broke sterile field during the procedure. RN B stated using sterile techniques during tracheostomy care was important to prevent the introduction of bacteria into the airway to prevent infections. RN B stated Resident #2 was currently being treated for pneumonia (lung infection).During an interview on 09/30/25 at 11:44 AM, the Medical Director stated nothing to do with tracheostomy care and suction was a sterile procedure. The Medical Director stated the throat was not sterile and tracheostomy care and suctioning was actually a dirty procedure. The Medical Director stated nurses were required to be certified and competent to perform tracheostomy care and suctioning. The Medical Director stated staff should have received frequent in-service training from a certified respiratory therapist. The Medical Director stated there was minimal risk for improperly performing tracheostomy care and suctioning. The Medical Director stated there was no risk of infection. The Medical Director stated having a tracheostomy placed residents at risk for bacterial infections from their own flora (bacteria) from their skin. During an interview on 09/30/25 at 12:46 PM, ADON K stated she was unable to locate the competency nurse check offs for infection control. ADON K stated the DON was responsible for completing competency checks for the nurses. ADON K stated the DON left a few weeks ago. During an interview on 09/30/25 at 1:13 PM, LVN A stated enhanced barrier precautions should have been used on any resident with a gastrostomy tube, Foley catheter, wounds, or a tracheostomy tube. LVN A stated enhanced barrier precautions was PPE, that included: an isolation gown, gloves, and shoe covers. LVN A stated hand hygiene should have been performed between patient care, or when visibly soiled. LVN A stated gloves should have been changed and hand hygiene performed between different procedures. LVN A stated tracheostomy care and suctions was considered a sterile procedure. LVN A stated the tracheostomy was direct airway into the lungs. LVN A stated the night of 09/15/25 into the morning of 09/16/25 was her last days as full time at the facility. LVN A stated she was unable to remember the care she provided to Resident #1. LVN A stated the PPE required for enhanced barrier precautions were not always available for use by the staff. LVN A stated she was unable to recall if it was available for use on the morning of 09/16/25. LVN A stated if the PPE was not available, she was probably in a hurry to get everything completed. LVN A stated it was important to ensure enhanced barrier precautions were used and sterile technique was maintained during tracheostomy care and suctioning to protect the staff and residents from infection. During an interview on 09/30/25 at 1:53 PM, the Administrator stated she expected direct care staff to ensure enhanced barrier precautions were worn into residents' room as required. The Administrator stated tracheostomy care and suctioning was considered a sterile procedure and sterile technique was required. The Administrator stated she expected the nurses to ensure sterile technique was used during tracheostomy care and suctioning. The Administrator stated sterile supplies and PPE supplies were always available. The Administrator stated it was important to ensure enhanced barrier precautions were used and sterile technique was maintained during tracheostomy care and suctioning to protect the residents from infection. During an interview on 09/20/25 at 2:08 PM, the Interim DON stated enhanced barrier precautions were utilized for residents with a tracheostomy, Foley catheter, or infection. The Interim DON stated the PPE required for enhanced barrier precautions included: face shield, mask, gown, gloves, and sometimes goggles. The Interim DON stated she expected PPE to be utilized, when it is available. The Interim DON stated she had issues with PPE supplies being unavailable. The Interim DON stated when PPE supplies was unavailable, she attempted to find it or borrow it from the nursing facility next door. The Interim DON stated it was reported to the person who reorders supplies. The Interim DON stated tracheostomy care and suctioning was considered a sterile procedure. The Interim DON stated sterile technique was required. The Interim DON stated it was important to maintain sterile technique during tracheostomy care and suctioning to decrease the risk of infection. The Interim DON stated not having the appropriate equipment and PPE supplies could have contributed to Resident #1, Resident #2, and Resident #4's infections. The Interim DON stated on 09/24/25 she performed unsterile tracheostomy suctioning because the facility did not have any sterile gloves that fit her. The Interim DON stated Resident #1 needed to be assessed and had obvious signs of respiratory distress. The Interim DON stated Resident #1's family had reported that LVN C refused to assess Resident #1, which was why she was in the room. The Interim DON stated she expected the nursing staff to perform a focused assessment for any change of condition. The Interim DON stated she expected the nurses to utilize the nursing judgment and prioritize care. The Interim DON stated airway and breathing were the two top priorities. The Interim DON stated an assessment was performed to ensure patient safety and maintain well-being. During an interview on 09/30/25 at 2:26 PM, LVN C stated she normally worked 6 AM - 2 PM shift on Monday through Friday. LVN C stated enhanced barrier precautions were utilized for resident's who had wounds or infections, a tracheostomy tube, a Foley catheter, or a feeding tube. LVN C stated a gown, gloves, mask, and goggles as needed should have been worn when providing care. LVN C stated tracheostomy care and suctioning was a sterile procedure and sterile technique was required. LVN C stated she did not always have access to the PPE supplies or sterile tracheostomy care kits. LVN C stated sometimes she had to perform tracheostomy care without PPE or sterile supplies. LVN C stated supplies were unavailable on a regular basis. LVN C stated it was important to ensure sterile technique was used to prevent infection. 3. Record review of a face sheet dated 10/01/25 indicated Resident #3 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included paraplegia (medical condition characterized by the partial or complete loss of motor and sensory function in the lower half of the body including both legs), chronic cystitis without hematuria (bladder infections), infection and inflammatory reaction due to indwelling urethral catheter, anemias, and neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system, or nerves involved in the control of urination), traumatic amputation at level between left hip and knee, colostomy status (surgical procedure creates opening in the abdominal wall through which the large intestine is brought to the surface of the body). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #3 was able to make himself understood and was able to understand others. The MDS assessment indicated Resident #3 had a BIMS score of 14, which indicated Resident #3 was cognitively intact. The MDS assessment indicated Resident #3 was dependent on staff for transfers, showers, toileting and dressing and required assistance for eating and personal hygiene. The MDS assessment indicated Resident #3 had a Foley catheter colostomy and wounds Record review of Resident #3's care plan with a target date of 09/28/2025 indicated he had indwelling Foley catheter with a goal of resident #3 would remain free from any catheter related trauma. Record review of Resident #3's Order Summary Report dated 10/01/2025 indicated: EBP: Staff must use gowns and gloves during high contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). every shift for EBP Precautions with a start date of 04/16/2025. Record review of Resident #3's Infection Screening Evaluation dated 09/13/25 indicated a current active diagnosis of infection related to new or increasing purulent drainage. Record review of Resident #3's nursing progress note dated 09/13/2025 indicated during wound care, noted resident wound to the sacrum increasing slough and drainage. Physician notified and new orders received. During an observation on 09/27/25 at 03:33 PM, CNA E and CNA F entered Resident #3's room. CNA E and CNA F donned gloves. CNA E and CNA F transfer Resident #3 from wheelchair to bed. CNA E and CNA F reposition Resident #3 once he was placed into the bed. CNA E and CNA F adjust bed covers. CNA E and CNA F exit Resident #3's room. During an interview on 09/27/25 at 04:15 PM, CNA E stated she should have put on a gown due to enhanced barrier precautions because Resident #3 has a wound and has a Foley catheter. CNA E said it was important to use enhanced barrier precautions to protect the residents from risk of infections. During an interview on 09/27/25 at 04:35 PM, CNA F stated she had forgotten to grab a gown when she transferred Resident #3. CNA F stated the importance of wearing the gown for enhanced barrier precautions was to prevent the spread of bacteria between residents during close contact. Record review of the facility's Infection Surveillance Monthly Report as of September 30. 2025 indicated 13 total infections and 5 confirmed infections. 4. Record review of a face sheet dated 09/29/25 indicated Resident #4 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included acute kidney failure, chronic respiratory failure, diffuse traumatic brain injury with loss of consciousness, disturbances of salivary secretions, neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination), tracheostomy status, encounter for attention to gastrostomy (feeding tube). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #4 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #4 did not have BIMS score, which indicated Resident #4 was unable to complete the assessment. The MDS assessment indicated Resident #4 was dependent on staff for all ADLs. The MDS assessment indicated Resident #4 had an indwelling catheter. Record review of Resident #4's care plan did not indicate he had an indwelling catheter Resident #1's care plan did not address securing his Foley catheter. Record review of Resident #4's Order Summary Report dated 09/29/25 indicated: Foley catheters care every shift and as needed and may use leg strap to secure Foley tubing with a start date of 07/26/25. EBP: Staff must use gowns and gloves during high contact resident care activities that could possibly result in the transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). every shift for EBP Precautions with a start date of 07/25/25. Record review of Resident #4's hospital admission record dated 07/08/25 indicated a diagnoses of septic shock bronchopneumonia due to Escherichia coli. Record review of Resident #4's hospital admission record dated 08/12/25 indicated a diagnosis of catheter associated urinary tract infection. Record review of Resident #4's nursing progress note dated 09/26/25 indicated Resident #4 has developed a fever with increased respiratory effort. A new order was received for a chest x-ray. 5. Record review of a face sheet dated 10/0/25 indicated Resident #5 was a [AGE] year-old female initially admitted to the facility on 05/2020 and a readmission date of 09/27/25 with diagnoses which included type 2 diabetes , neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination), dehydration, abnormal weight loss, anxiety disorder (excessive worry), insomnia, encounter for attention to gastrostomy (feeding tube), colostomy status Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #5 was able to make herself understood and was able to understand others. The MDS assessment indicated Resident #5 had a BIMS score of 9, which indicated Resident #5 was moderately cognitively impaired. The MDS assessment indicated Resident #5 was dependent on staff for transfers, toileting, showering, with set up assistance needed for eating and personal hygiene. The MDS assessment indicated Resident #5 had a colostomy and indwelling catheter Record review of Resident #5's care plan did not indicate he had an indwelling catheter Resident #1's care plan did not address securing his Foley catheter. Record review of Resident #4's Order Summary Report dated 09/29/25 indicated: Foley catheter care every shift and as needed and may use leg strap to secure Foley tubing with a start date of 06/03/25. Colostomy care every shift and as needed with a start date of 02/03/25. EBP: Staff must use gowns and gloves during high contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). every shift for EBP Precautions with a start date of 02/03/2025 Record review of Resident #5's hospital Discharge summary dated 09/2725 indicated a diagnosis of E Coli bacteremia, urinary tract infection secondary to ESBL producing E Coli upon admission.[TT3] Record Review of the facility's undated policy titled Suctioning the Tracheostomy Tube, indicated, The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.b. Suctioning the lower airway is a sterile procedure. Record Review of the facility's undated policy titled Tracheostomy Care, indicated, The purpose of this procedure is to guide tracheostomy care.2. Gloves must be used on both hands during any or all manipulation . sterile gloves must be used during performing these procedures. Record review of the NCBI Bookshelf (A service of the National Library of Medicine and National Institutes of Health) in Chapter 22 Tracheostomy Care & Suctioning reflected .Tracheostomy suctioning uses a sterile catheter that is inserted through the surgical opening into the neck to the trachea to create an artificial airway. always review and follow agency policy regarding this specific skill.put on sterile gloves.the dominant hand will manipulate the catheter and must remain sterile.tracheostomy care provided with sterile technique. Record Review of the facility's undated policy titled. Enhanced Barrier Precautions, indicated, Enhanced Barrier Precautions refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organism that employs targeted gown and glove used during high contact resident care activities.Enhanced Barrier Precautions are indicated for residents with wounds and/or indwelling medical devices. The Administrator was notified on 09/30/25 at 04:38 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator provided the Immediate Jeopardy template on 09/30/25 at 04:38 PM and a POR was requested. The following plan of removal was submitted by the facility and accepted on 10/01/25 a 04:30 PM and included the following: Problem: Infection ControlAlleged Issues: The facility failed to Implement the infection control policy and procedure for tracheostomy care/suctioning and enhanced barrier precautions.The facility failed to ensure LVN A, LVN C, LVN D, and the interim [NAME] used sterile technique while performing tracheostomy suctioning on resident number one.The facility failed to ensure RN B used sterile technique while performing tracheostomy care on resident #2 on 9/29/25.The facility failed to ensure LVN A, LVN C, LVN D, the interim Don, LVN G and C NA H wore enhanced barrier precautions while performing care on resident #1, who had a feeding tube, tracheostomy tube, wound, and Foley catheter.The facility failed to ensure LVN E LVN F wore enhanced barrier precautions while providing care to resident #3 who had a Foley catheter and wound.The facility failed to ensure the nursing staff knew how to access PPE and sterile supplies for enhanced barrier precautions and tracheostomy care/suctioning. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. Its employees or service providers are to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Approaches: RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. RN/DON A was serviced by Facility Respiratory Therapist with documented competencies on file at the facility and kept in binders in the DON's office and Administrator's office. The Administrator is not clinical but is aware of all in-services per the VP of Clinical Operations.Nursing staff will be in-serviced on the proper procedure for enhanced barrier precautions and the policy and procedure for enhanced barrier precautions. This in-service was initiated on 09/30/2025 by the RN/DON A. All nursing staff will be in-serviced prior to them arriving to the facility for their next shift. The Director of Nursing, Regional nurse consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. All facility staff will receive training on enhanced barrier precautions on 09/30/2025. Any staff who did not receive training on enhanced barrier precautions on 09/30/2025 will receive this education prior to their next scheduled shift on the floor caring for residents. The facility medical Director was informed of the IJ on 09/30/25 by the VP of Clinical Operations.1. Resident #1 is in the hospital 09/30/25. 2. Residents #2 was assessed on 9/29/2025; resident #3 was assessed on 8/21/25 & 9/13/25, resident #4 was assessed on 9/26/25; resident #5was assessed on 9/18/25. All are currently being treated with antibiotics for active infections. The Interim DON performed new assessments on 10/01/25 for residents 3, 4, and 5 on 10/01/2025. No further complications identified. Resident #1 is currently in the hospital. 3. All nurses will be trained in suctioning and care of tracheostomy per sterile technique and suctioning of tracheostomy by RN/DON A who has been trained by the facility respiratory therapist and by the facility respiratory therapist, on 09/30/2025. All nurses will be trained before they accept residents for their next scheduled shift. 4. RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. All nursing staff will be in-serviced prior to them arriving at the facility for their next shift. This will begin immediately, 09/30/2025. All facility staff will receive training on enhanced barrier precautions on 09/30/2025. Any staff who did not receive training on enhanced barrier precautions on 09/30/2025 will receive this education prior to their next scheduled shift on the floor cari

Based on observations, interviews, and record reviews, the facility failed to provide respiratory care, including tracheostomy care and tracheal suctioning consistent with professional standards of practice, the resident's care plan, and the resident's preferences, for 2 of 3 residents (Resident #1 and Resident #2) reviewed for respiratory care. The facility failed to ensure LVN C assessed Resident #1 when he exhibited abdominal retractions (a sign of respiratory distress) while breathing on 09/24/25. The facility failed to ensure LVN A, LVN C, LVN D, and the Interim DON used sterile technique while performing tracheotomy suctioning on Resident #1. The facility failed to ensure RN B used sterile technique while performing tracheotomy care on Resident #2 on 09/29/25. The facility failed to follow the tracheotomy care and suctioning policy and procedure. The facility failed to provide competency check offs for LVN A, LVN C and LVN D on tracheotomy care and suctioning. Immediate jeopardy (IJ) was identified on 09/30/25 at 04:00 PM. The IJ template was provided to the facility on [DATE] at 04:38 PM. While the IJ was removed on 10/02/25 at 05:13 PM, the facility remained out of compliance at a scope of a patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on the policy and procedure for sterile tracheotomy care and suctioning. These failures could place residents at risk of respiratory complications, infections and death.Findings included: 1. Record review of a face sheet dated 09/29/25 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of tracheostomy status. Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #1 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #1 did not have BIMS score, which indicated Resident #1 was unable to complete the assessment. The MDS assessment indicated Resident #1 was dependent on staff for all ADLs. The MDS assessment indicated Resident #1 had a tracheotomy. Record review of Resident #1's care plan dated 04/16/25 with a target date of 10/21/25 indicated he had a tracheotomy with a goal indicating he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #1's Order Summary Report dated 09/29/25 indicated: Change tracheotomy dressing with tracheotomy care every day and PM with a start date of 06/27/25. Record review of Complaint/Grievance dated 08/12/25 indicated Resident #1's family member complained the staff was not providing tracheotomy care and suctioning using sterile technique. Resident #1's family member provided videos of staff providing tracheotomy care without using sterile technique. The grievance indicated the resolution was all nurses on North Hall were in serviced on tracheotomy care and suctioning using sterile technique. Record review of Resident #1's electronic medical record did not indicate a re-assessment was performed by LVN C after 09/24/25 at 09:29 AM when Resident's #1 was showing signs and symptoms of respiratory distress . Record review of a nursing progress note dated 09/25/25 at 01:42 PM written by LVN C indicated [family member] called stated the hospital called and informed her that patient needed to go back to the hospital. I attempted to call the hospital and get more information but no luck. Doctor making rounds per his advice to send resident out to the hospital for further treatments since he was positive gram. Called [family member] informed of the situation of him going back to the hospital. Called EMS no estimated time of arrival on pick up time. ADON, DON aware of situation. Record review of a nursing progress note dated 09/25/25 at 05:20 PM indicated family at facility inquiring why resident was not yet transferred to hospital, this nurse explained that transportation had been set up but facility was waiting on non emergent EMS. Call placed to EMS for updated ETA. EMS stated that they had not received a call for transport. This nurse relayed that resident was needing to be transported to [name] Hospital. EMS stated that they would be on they way to transport. Record review of the admission hospital records dated 09/25/25 indicated Resident #1 was admitted with chronic respiratory failure with tracheostomy in place. Laboratory results indicated Resident #1 had bacteremia (bacteria is present in the bloodstream), staph hominis (gram positive bacteria in the bloodstream), and pseudomonas (gram positive bacteria found in lungs, skin, ears) During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/16/25 at 05:09 AM, LVN A entered Resident #1's room wearing gloves and carrying a pitcher of water. LVN A flushed Resident #1's PEG tube (a feeding tube inserted into the abdomen into the stomach) and then provided incontinent care. LVN A did not change gloves or perform hand hygiene. LVN A proceeded to grab the suction catheter from the bedside table and suctioned Resident #1. LVN A did not change her gloves or use sterile technique during the suctioning procedure. LVN A repositioned Resident #1 in the bed, took off her gloves and exited the room. During an interview on 09/30/25 at 1:13 PM, LVN A stated LVN A stated tracheostomy care and suctions was considered a sterile procedure. LVN A stated the tracheostomy was direct airway into the lungs. LVN A stated the night of 09/15/25 into the morning of 09/16/25 was her last days as full time at the facility. LVN A stated she was unable to remember the care she provided to Resident #1. LVN A stated it was important to ensure sterile technique was maintained during tracheostomy care and suctioning to protect the staff and residents from infection. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/23/25 at 11:09 AM, LVN C entered into Resident #1's room and put on non-sterile gloves. LVN C repositioned Resident #1's bedcovers. LVN C did not change her gloves or perform hand hygiene. Then LVN C grabbed the suction catheter from the bedside table drawer and unraveled Resident #1's TV control cord from the suction tubing. LVN C proceeded to suction Resident #1. LVN C took off her gloves and exited Resident #1's room. LVN C did not apply sterile gloves or use sterile technique for the suctioning procedure. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/23/25 at 09:30 PM, LVN D was in Resident #1's room and had a sterile field set up on the bedside table. LVN D appeared to be wearing sterile gloves. LVN D touched the suctioning machine with her dominant hand and proceed to suction Resident #1. After LVN D touched the suction machine contaminating her dominant hand. LVN D failed to follow sterile technique for the suctioning procedure. LVN D removed her gloves, discarded the used supplies and exited the room. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/24/25 at 09:29 AM, LVN C and Resident #1's family member entered the Resident #1's room. Resident #1's family member was heard stating he needs an assessment done. LVN C stated she already completed an assessment earlier and was not going to do it again. Resident #1''s family member told LVN C, it's obvious Resident #1 is having difficulty breathing - can you assess him. LVN C stated, and then what do you want me to do after I assess him - you are not a nurse - where do you work? Resident #1 was observed in his bed exhibiting abdominal retractions (a sign of respiratory distress) and gurgling was audible during the video. LVN C argued with Resident's #1's family member and refused to assess Resident #1's respiratory status. LVN C continued to argue and refused to provide tracheal suction. LVN C exited Resident #1's room without the necessary care provided. During an interview on 09/30/25 at 2:26 PM, LVN C stated she normally worked 6 AM - 2 PM shift on Monday through Friday. LVN C stated tracheostomy care and suctioning was a sterile procedure and sterile technique was required. LVN C stated she did not always have sterile tracheostomy care kits. LVN C stated sometimes she had to perform tracheostomy care without PPE or sterile supplies. LVN C stated supplies were unavailable on a regular basis. LVN C stated it was important to ensure sterile technique was used to prevent infection. LNV C stated everyone had issues with Resident #1's family member. LVN C stated on 09/24/25 she went into Resident #1's room during her morning rounds. LVN C stated she had performed a respiratory assessment, tracheostomy care, and suctioning. LVN C stated Resident #1 had some wet sounds that cleared after he was suctioned. LVN C stated later on the family called her in the room and stated Resident #1 had a temperature. LVN C stated she checked his temperature which was approximately 97.1. LVN C stated she attempted to remove the sheet, but did not perform another respiratory assessment as she was busy with another resident. LVN C stated she did not notice if Resident #1 was having trouble breathing. LVN C stated she did not obtain vital signs or an oxygen level. LVN C stated she notified the Interim DON because the family did not want her in the room. LVN C stated she notified the doctor, and a chest x-ray was ordered STAT (immediately). LVN C stated the family believed Resident #1 needed to be sent to the emergency room, so she called the doctor back and he gave the order to send to the emergency room. LVN C stated she was unable to recall if she called emergency transport. LVN C stated there was a lot going on that day. LVN C stated the Interim DON provided care to Resident #1 after she was asked to leave the room. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/24/25 at 09:54 AM, the Interim DON and Resident #1's family member entered Resident #1's room. The Interim DON performed an assessment by taking Resident #1's temperature, checked his oxygen levels with the pulse oximetry (device use the measure the amount of oxygen in the blood), and listened to his lungs. The Interim DON removed the suction catheter from the bedside table drawer and suctioned Resident #1. Resident #1's family member asked the Interim DON why she was not using sterile gloves. The Interim DON said, the facility did not have the correct size to fit her hands in stock. The Interim DON did not apply sterile gloves or use sterile technique for the suctioning procedure. During an interview on 09/30/25 at 2:08 PM, the Interim DON stated tracheostomy care and suctioning was considered a sterile procedure. The Interim DON stated sterile technique was required. The Interim DON stated it was important to maintain sterile technique during tracheostomy care and suctioning to decrease the risk of infection. The Interim DON stated on 09/24/25 she performed unsterile tracheostomy suctioning because the facility did not have any sterile gloves that fit her. The Interim DON stated Resident #1 needed to be assessed and had obvious signs of respiratory distress. The Interim DON stated Resident #1's family had reported that LVN C refused to assess Resident #1, which was why she was in the room. The Interim DON stated she expected the nursing staff to perform a focused assessment for any change of condition. The Interim DON stated she expected the nurses to utilize the nursing judgment and prioritize care. The Interim DON stated airway and breathing were the two top priorities. The Interim DON stated an assessment was performed to ensure patient safety and maintain well-being. 2. Record review of a face sheet dated 09/30/25 indicated Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included anoxic (lack of oxygen) brain damage acute respiratory failure, and tracheostomy (surgical procedure that creates an opening in the front of the neck (trachea) and inserts a tube to help a person breath). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #2 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #2 did not have BIMS score, which indicated Resident #2 was unable to complete the assessment. The MDS assessment indicated Resident #2 was dependent on staff for all ADLs. The MDS assessment indicated Resident #2 had a tracheotomy. Record review of Resident #2's care plan [dated 06/29/25 with a target date of 10/14/25 indicated he had a tracheotomy with a goal of he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #2's Order Summary Report dated 09/30/25 indicated: Change tracheotomy dressing with tracheotomy care every shift with a start date of 06/25/25. Record review of Resident #2's Infection Screening Evaluation dated 07/29/25 indicated recent chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/02/25 indicated recent chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/10/25 indicated recent chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's chest x-ray dated 09/10/2025 indicated pneumonia (infection of the lungs). Increased opacity is present at the left lung base representing either infiltrate or plural effusion. There has been no improvement with a prior chest x-ray performed on 09/02/25. Record review of SBAR communication Form written by RN B dated 09/29/25, indicated Resident #2 was experiencing a fever with low oxygen sat of 77%. O2 increased to 10 liters and O2 now 93%. Record review of progress note dated 09/29/25 at 2:29 PM written by RN B indicated the physician ordered an x-ray related to fever. Record review of progress note dated 09/30/35 at 12:48 PM written by RN B indicated, Resident #2 had worsening pneumonia on the left side. Also reported that he has developed a temp of 101.8 along with O2 having to be increased to 10 Liters to keep oxygen saturations over 90%. Resident is on day 8 of 14 of his Bactrim. Secretions have become very thick, green in color and has a very foul odor. New order received to send resident out to ER for assessment. [family member] informed and agrees with plan.During an observation on 09/29/25 at 4:17 PM, the Treatment Nurse prepared Resident #2's bedside table for tracheostomy care. The Treatment Nurse placed a piece of wax paper on the table, on the wax paper she placed the following: *two unopened bottles of sterile water, *a tracheostomy care kit, which was slightly opened, *unopened suction tubing, and *4 x 4 unsterile gauze pads from a multiuse package. RN B rearranged the items and positioned the bedside table for use. RN B washed her hands, then applied her sterile gloves, using sterile technique. RN B immediately picked up the unopened suction tubing package and opened it, which contaminated her sterile gloves. RN B then grabbed the unopened bottles of sterile water, opened it, and poured it into the sterile field. RN B then picked up the unsterile 4 x 4 gauze pads and placed them into sterile water. RN B did not reapply sterile gloves, after she contaminated her sterile gloves, and used the same gloves during the following care activities. RN B took the cotton-tipped applicators from the tracheostomy kit and then cleaned around the stoma (opening in the neck). RN B used the 4 x 4 gauze pads that were soaked in sterile water to clean around Resident #2's neck. RN B then cleaned inside the tracheostomy tubing with the 4 x 4 gauze pads. RN B removed her gloves and applied hand sanitizer. RN B replaced her gloves and replaced the tracheostomy neck ties. During an interview on 09/29/25 at 5:06 PM, RN B stated tracheostomy care was a sterile procedure. RN B stated the packaging should have been opened prior to applying her sterile gloves. RN B stated the outside packaging was not sterile. RN B stated everything completed after the sterile gloves were contaminated would not have been considered sterile. RN B stated she had not realized she broke sterile field during the procedure. RN B stated using sterile techniques during tracheostomy care was important to prevent the introduction of bacteria into the airway to prevent infections. RN B stated Resident #2 was currently being treated for pneumonia [TT15] (lung infection). During an interview on 09/30/25 at 11:44 AM, the Medical Director stated, nothing to do with tracheostomy care and suction was a sterile procedure The Medical Director stated the throat was not sterile and tracheostomy care and suctioning was a dirty procedure. The Medical Director stated nurses were required to be certified and competent to perform tracheostomy care and suctioning. The Medical Director stated staff should have received frequent in-service training from a certified respiratory therapist. The Medical Director stated there was a minimal risk for improperly performing tracheostomy care and suctioning. The Medical Director stated there was no risk of infection. The Medical Director stated having a tracheostomy placed residents at risk for bacterial infections from their own flora (bacteria) from their skin. During an interview on 09/30/25 at 12:46 PM, ADON K stated she was unable to locate the competency nurse check offs for sterile tracheotomy care and suctioning. ADON K stated the DON was responsible for completing competency checks for the nurses. ADON K stated the DON left a few weeks ago. During an interview on 09/30/25 at 1:53 PM, the Administrator stated tracheostomy care and suctioning was considered a sterile procedure and sterile technique was required. The Administrator stated she expected the nurses to ensure sterile technique was used during tracheostomy care and suctioning. The Administrator stated sterile supplies were always available. The Administrator stated it was important to ensure sterile technique was maintained during tracheostomy care and suctioning to protect the residents from infection. Record review of in service dated 08/12/25 with a subject of tracheotomy care and suctioning using sterile technique indicated twelve nursing staff signatures including LVN C, the Interim DON, RN B. Record review of the following staff competency nurse check offs for sterile tracheotomy care and suctioning included:Interim DON dated 02/25/2025RN B dated 07/16/2025. Record Review of the facility's undated policy titled Suctioning the Tracheostomy Tube, indicated, The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.b. Suctioning the lower airway is a sterile procedure. Record Review of the facility's undated policy titled Tracheostomy Care, indicated, The purpose of this procedure is to guide tracheostomy care.2. Gloves must be used on both hands during any or all manipulation . sterile gloves must be used during performing these procedures. Record review of the NCBI Bookshelf (A service of the National Library of Medicine and National Institutes of Health) in Chapter 22 Tracheostomy Care & Suctioning reflected .Tracheostomy suctioning uses a sterile catheter that is inserted through the surgical opening into the neck to the trachea to create an artificial airway. always review and follow agency policy regarding this specific skill.put on sterile gloves.the dominant hand will manipulate the catheter and must remain sterile.tracheostomy care provided with sterile technique. The Administrator was notified on 09/30/25 at 04:38 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator provided the Immediate Jeopardy template on 09/30/25 at 04:38 PM and a Plan of removal; (POR) was requested. The following plan of removal was submitted by the facility and accepted on 10/01/25 at 04:30 PM and included the following: Problem: Respiratory/Tracheostomy Care and SuctioningAlleged Issues: The facility failed to ensure LVN C assessed resident #1 when he exhibited abdominal retractions while breathing (a sign of respiratory distress), on 9/24/25The facility failed to ensure LVN A, LVN C, LVN D, and the Interim Don, use sterile technique while performing tracheotomy sectioning on resident number one.The facility failed to ensure RN B used sterile technique while performing tracheotomy care on resident #2 on 9/29/25.The facility failed to follow the tracheotomy care suctioning policy and procedureThe facility failed to provide competency check offs for LVN A, LVN C, LVN D on tracheotomy care and suctioning. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. Its employees or service providers are to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Approaches: RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. RN/DON A was in serviced by Facility Respiratory Therapist with documented competencies on file at the facility. The Administrator is not clinical but is aware of all in-services per the VP of Clinical Operations 1. Nursing staff will be in-serviced on the proper procedure tracheostomy care and suctioning. This in-service was initiated on 09/30/2025 by the RN/DON A. All nursing staff will be in-serviced prior to them arriving to the facility for their next shift. RN A, trained by the facility respiratory therapist RN A was trained July 16, 2025, and will deliver all following in service education to nurses one on one. Return demonstration by all nurses will be documented, and competency checklists will be kept in diners in the DON / Administrator's offices at the facility. All nurses will be trained before they accept residents for their next scheduled shift in Tracheostomy care and suctioning. 2. The regional nurse consultant will provide education regarding assessment of residents if changes in condition. This education will be provided to each nurse prior to the start of their next shift on the floor. This education will begin on 09/30/25 and continue until all staff are educated. An in-service on Respiratory assessments will be taught and any changes in condition will be documented and the physician will be notified of those changes. Changes in condition will include but not limited to shortness of breath; changes in respiratory status; using accessory muscles to breathe; drainage from trach; or decrease in 02 saturation. If provider orders transfer resident will be sent to the hospital via EMS transport as soon as possible. The facility respiratory therapist will be in the facility to provide further education with return demonstration, and competency checklists completed for facility nurses and interim DON on 10/1/2025. The Respiratory Therapist will visit monthly to ensure competency. 3. The facility medical Director was informed of the IJ on 09/30/25 in person, by the Facility Administrator. 4. Resident #1 is in the hospital 09/30/25. 5. Resident #2 is currently being treated with antibiotics for active infection. Resident #2 assessment was completed and resident sent to the hospital per physician orders. Resident #2 assessed on 9/29 /25 E interact change in condition form was completed and entered into the EMR. Resident was sent to the hospital on 9/30/25.Resident #3 assessment was completed on 10/1/2025; Resident #4 assessment was completed on 10/01/2025. 6. RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. All nursing staff will be in service prior to them arriving to the facility for their next shift. This will begin immediately, 09/30/2025. 7. Both the Administrator and DON will review new hire orientation packets to ensure these above in services are completed, and competency checklists are on file at the facility, prior to the first shift on the floor, including tracheostomy competencies including tracheostomy care per sterile technique and suctioning of the tracheostomy per sterile technique. RN/DON A who has been trained by the facility respiratory therapist and by the facility respiratory therapist provided this in-service to all facility nurses on staff at the time of the immediate jeopardy, nurses coming on shift at 10pm on 09/30/25 and all nurses coming on shift at 6am on 10/01/2025. The facility respiratory therapist will continue training on 10/01/2025 for any nurses who did not attend training, prior to their next scheduled shift on the floor. VP of Clinical will in-service the Administrator on this process ensuring all nurses will be trained on tracheostomy care and suctioning prior to their first shift on the floor caring for residents. DON and or RN trained by RT will complete the required tracheostomy training for nurses prior to their first shift on the floor, the administrator will ensure this training is completed. 8. All residents with enhanced barrier precautions were reviewed by the Don, ADON, and administrator, to ensure proper PPE was available outside the resident room. Monitoring:The DON, or designee will perform random in person audits with nursing staff to ensure they understand the tracheostomy suctioning/care via sterile technique procedure, at least 3 nursing staff weekly X1 month. This process will begin 10/03/2025. DON/ADON's will make rounds daily M-F, the weekend RN supervisor will round on all residents on the weekend, on all residents in facility to ensure nurses are properly performing trach care/suctioning per sterile technique. This process will be ongoing effective 09/30/2025. Assessment: All nurses on staff at the time of the immediate jeopardy were educated on tracheostomy suctioning and care of tracheostomy, with return demonstration by RN DON A is a DON from a sister facility assisting with training who has been trained by the facility respiratory therapist, with competency checklist on file at the facility on 09/30/25. QAPI Committee review: An interim QAPI committee meeting was completed on 09/30/25. IDT will review for compliance monthly in QAPI X3 months. On 10/02/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the immediate jeopardy (IJ) by: 1. Record review of DON GG 's competency, dated 07/16/25, reflected DON GG was competent with tracheostomy care and suctioning. DON GG was the DON from a sister facility who provided education to the facility nurses' on tracheostomy care and suctioning, including a competency check off and return skilled demonstration. 2. Record review of the in-service training report, dated 10/01/25, reflected the nurses were provided education on the proper procedure for tracheostomy care and suctioning. There were 11 nurse signatures. 3. Record review of the competency checkoffs dated between 09/30/25 and 10/01/25 reflected LVN A, LVN C, LVN D, LVN Y, LVN Z, LVN BB, RN B, RN X, RN AA, ADON K, ADON V, the Treatment Nurse, the MDS Coordinator, and the Interim DON were provided competency checks off with a return demonstration. The competencies reflected the nurses were competent with tracheostomy care and suctioning. 4. Record review of the in-service training report, dated 09/30/25, reflected nurses were provided education on how to perform a respiratory assessment, when it should be performed, notifying the physician, and implementing interventions. There were 5 nurse signatures. 5. During an interview on 10/02/25 at 4:01 PM, the Medical Director stated he was informed of the IJ from the Administrator at the facility. 6. Record review of Resident #1's hospital records, printed 09/29/25, reflected he was admitted on [DATE] with a diagnosis of bacteremia (blood infection). 8. Record review Resident #2's progress notes, dated 09/30/25, reflected Spoke with [Medical Director] after sending him the x-ray that resulted today showing worsening pneumonia on the left side. Also reported that he has developed a [temperature] of 101.8 along with [oxygen] having to be increased to 10 liters to keep oxygen saturations over 90%. Resident [2] is on day 8 of 14 of his [antibiotic]. Secretions have become very thick, green in color and has a very foul odor. New order received to send resident [#2] out to the [emergency room] for assessment. [Family member] informed and agrees with plan. 9. Record review of Resident #3's progress notes, dated 10/01/25 reflected [Resident #3] up to wheelchair with Foley catheter draining with amber color urine. No [complaints of] pain or discomfort at this time. No nausea or vomiting noted or reported. Resident continues on [antibiotics]. 10. Record review of Resident #4's progress notes, dated 10/01/25, reflected Skilled nurse assessed [Resident #4]. [Resident #4] bed at 45 degrees. [Respirations] 20, [Temperature] 98.0, [Blood Pressure] 132/87, saturation 95. Trach patent in place and air open. Secretions thin and clear. No odor at this time. No nasal flaring, no wheezing or grunting. No chest retractions. No coughing at this time. [Resident #4] rests at this time. 11.During an observation on 10/02/25 at 10:15 AM of PPE supplies outside the doors of all enhanced barrier precautions of the appropriate residents. Signage outside their door indicated the required PPE to be worn inside the room. There were isolation carts outside the rooms, which had face shields, isolation gowns, and gloves with hand sanitizer on top. The hand sanitizer dispensers were noted down the hallway. A staff member was dressed in an isolation gown and gloves and was preparing to enter Resident #4's resident room. 12.During an observation on 10/02/25 at 02:45 PM of proper sterile tracheostomy care and suction performed by RN B for Resident # 4. 13. During interviews on 10/02/25 conducted between 2:01 PM and 4:52 PM, LVN A, LVN C, LVN Y, LVN Z, LVN BB, RN B, RN X, RN AA, the Treatment Nurse, the MDS Coordinator, ADON K, ADON V, the Interim DON, and Administrator were able to verbalize sterile technique was required during tracheostomy care and suctioning. The nurses said tracheostomy care and suctioning should not have been performed without the proper supplies or equipment, which included sterile gloves and care kits. The nurses verified they were provided education and competency checkoffs on tracheostomy care and suctioning. The nursing managers were able to verbalize that monitoring will continue during rounds daily and checkoff competencies will be completed for new hires and nursing staff prior to working their next scheduled shift. 16. Record review of the Quality Assessment and Performance Improvement Plan, dated 09/30/25, reflected an impromptu meeting was conducted and 9 staff members were in attendance. The Administrator was informed the IJ was removed on 10/02/25 at 05:13 PM. The facility remained out of compliance at a scope of patterned and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy 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 the resident environment remained free of accidents hazards and each resident was provided adequate supervision to prevent elopement for 1 of 3 residents (Resident #1) reviewed for accident hazards. The facility failed to provide appropriate supervision to Resident #1 on 8/10/25 when she was exhibiting exit seeking behavior resulting in her elopement between 5:45 p.m. and 6:00 p.m. with Resident #1 being returned to the facility by local police on 8/10/25 at approximately 7:15 p.m. The noncompliance was identified as PNC IJ. The noncompliance began on 8/10/2025 and ended on 8/11/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of suffering heat related illness or injury or death.Findings Include: Record review of the face sheet dated 8/7/25 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including unspecified focal traumatic brain injury with loss of consciousness (brain injury to a specific spot in the brain by an unknown trauma that caused unconsciousness), unspecified dementia with unspecified severity without behavioral disturbances, without psychotic disturbance, without mood disturbance, and without anxiety (memory loss and cognitive decline with an unknown cause), epilepsy (seizures), major depressive disorder (depression), hypertension (high blood pressure), and chronic pain syndrome (persistent pain felt for long periods of time). Record review of the BIMS evaluation dated 8/8/25 indicated Resident # 1 has a BIMS score of 6 which means that she is severely cognitively impaired. Record review of the baseline care plan dated 8/8/25 indicated Resident #1 was at high risk for wandering and elopement. Records review of the self-reporting incident report dated 8/11/2025 indicated that the elopement of Resident #1 was reported to the family, physician, DON, and Administrator. The report recorded the incident as follows: Per video footage on 8/10/2025 at 5:30 PM resident was seen sitting in a chair in front of the nurse's station. She got up from the chair at 5:35 pm and walked over to the door and pushed the door but it didn't open, and she sat down. At 5:40 PM the resident walked back to the door and started pushing numbers on the keypad by the door. She pushed the door, but it didn't open so she sat back down. A CNA walked to the door and reset the wander guard alarm system. Around 5:46 PM the resident went down East Hall toward the front of the building and turned right towards North Hall nurse station. Once she got there, she made a left and walked down the hall. An aide was seen walking behind her and went into another resident's room. At 5:48 pm Resident #1 approached the side door and pushed it open and walked out of the building. The resident was assessed after her return to the facility on 8/10/2025 at 7:18 p.m.Record review of the progress notes dated 8/8/2025 indicate notification and agreement by the physician regarded Wanderguard placement. Record review of the progress note dated 8/10/2025 indicated the documentation of the elopement indicated by RN D that Resident observed outside of the nurses station and started helping pass dinner trays. At around 1820 as we were passing trays, I realized she was no longer sitting by the nurses station. An Aide and I made a walk=through the entire facility and realized she was not in the building. The aide and I left the building at 1840and drive around to the front where we saw another resident coming back from a pass. We stopped and asked him if he has seen the missing resident and he had not. As we were turning around to leave, 2 patrol cars turned in to parking lot, I flagged the officer down in the 2nd car. I asked if they had found a lady walking down the street? He stated his buddy had her in the first patrol car. The officers escorted her back inside the facility and as she crossed the wanderguard barrier she set the alarm off. I gave the officer the information he required and called the resident's daughter while he was at the desk. As soon as the officer left I called the DON at 1918 and the administration. During an interview on 8/13/25 at 2:56 p.m. the ADM said on the evening of 8/10/2025 she was notified that Resident #1 had eloped from the facility and was brought back by police who reported that she was a few blocks from the facility. The ADM went to the facility on the evening of 8/10/2025 after being notified by staff that the elopement of Resident # 1 had taken place and she and the facility DON reviewed facility video of the hallways to see which door Resident #1 had eloped through. The ADM saw Resident #1 attempt to go through a door near her room on at least two occasions and the Wanderguard device (a small device worn on a bracelet that is fitted to the wrist or ankle of a resident. The device will sound an alarm when the wearer goes near an exit armed with the system to warn nearby staff that the wearer is in close proximity to the door) she was wearing triggered the alarm on the door which prompted the staff (name unknown) to redirect Resident#1 to a seat near the nurse's station. Resident #1 then walked down the hall and exited the facility through a door on the North side of the building. The ADM then went to the door where Resident #1 had eloped from the facility and discovered that the door was propped open by an unknown staff who knew the code to the door which is against their policy and procedure. The ADM said that she and the DON immediately implemented one to one supervision for Resident #1 and reminded present staff that all doors are to remain secured. The ADM said that Resident #1 was found outside in the smoking area on a different day and had to be redirected back inside the facility (she said that she did not remember the exact day but that it had to be between her admission on [DATE] and 8/10/2025) and she indicated that the physician and family were notified and Wanderguard was ordered and administered for Resident #1. On 8/11/2025 the ADM and DON began in-servicing all shifts and all staff regarding wandering and elopement, safety and supervision of residents, missing persons policy and procedure, and alarmed entrance and exit doors. The ADM said she implemented a new policy regarding door monitoring logs where maintenance or nursing staff are required to check that all doors are secure every 30 minutes and record this in a logbook kept at the East wing nurse's station. The ADM said that the Wanderguard system was working when Resident #1 eloped, however, due to the door being propped open the alarm did not sound. ADM said the video is not available for the investigator to review as it recycles every 24 hours. During an interview on 8/13/25 at 2:15 p.m. Resident #1's family member said they received a call on the evening of 8/10/2025 around 7:15 p.m. from the facility letting her know that Resident #1 had eloped from the facility and was found a few blocks away by police and returned to the facility with no injuries. The family member said that an unknown staff member had informed her that Resident #1 had eloped from the facility a few days before this incident but had only made it outside the facility before she was redirected back inside. The family member said that she was advised of this when the facility informed her that they would be implementing the use of the Wanderguard device on Resident #1 to prevent elopement. The family member said that she did not feel that the facility was the right place for Resident #1 as she needed to be in a memory care facility but that she feels the facility took good care of Resident #1 other than this incident. Record review of the facility's wandering and elopement policy dated March 2019 indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment.if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.if the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials.when the resident returns to the facility the director of nursing services or charge nurse shall: examine the resident for injuries; contact the attending physician and report findings and conditions of the resident; notify the resident's legal representative.complete and file an incident report; and document relevant information in the resident's electronic health record. The Administrator was notified on 8/14/25 at 12:15 p.m. that a Past Non-Compliance Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 8/14/25 at 12:18 p.m. The facility had corrected the noncompliance prior to surveyor entrance by the following: Implementing one to one supervision for Resident #1 until she could be transferred to a memory care unit. In-servicing all staff regarding wandering and elopement, safety and supervision of residents, missing persons policy and procedure, and alarmed entrance and exit doors. This was verified by the in-service sheets showing all staff signed off their attendance to the aforementioned in-services. Implemented a new policy requiring the checking of doors every 30 minutes and recording this task in a logbook. This is verified by the in-service sheets signed by all staff and the policy entitled Inservice Door Alarms/Checks. Transferred Resident #1 to a higher level of care at a neighboring memory care unit on 8/11/2025. The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Record review of the Resident #1's monitoring log dated 8/10/25 indicated Resident #1 was on one-to-one monitoring beginning 8/10/25 at 7:00 p.m. and continued until 8/11/25 at 11:00 a.m when she was transferred to a memory care unit at another facility. Record review of in-services dated 8/11/25 indicated all active staff were in-serviced regarding wandering and elopement, safety and supervision of residents, missing persons policy and procedure, and alarmed entrance and exit doors and the new door monitoring log policy. Staff interviewed (LVN A, LVN B, LVN C, RN D, RN E, CNA F, CNA G, CNA H, and CNA J) on 8/13/25 between 11:00 a.m. and 4:07 p.m. were able to articulate the content of the new door log book policy, and what to do in the event of an elopement. Staff interviewed said that they would notify the charge nurse and attempt to redirect the resident if they saw someone attempting to elope from the facility. Investigator ensured all exits armed with Wanderguard system were in working order by approaching each exit with a Wanderguard device and hearing the alarm sound. The noncompliance was identified as PNC IJ. The noncompliance began on 8/10/2025 and ended on 8/11/2025. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect. The facility failed to prevent CNA B from physically abuse abusing Resident #1 when she slapped her arm and left a bruise. This failure could place residents at risk of abuse and neglect. Findings included: Record review of the Resident #1's face sheet, dated 5/17/24, indicated she was readmitted to the facility on [DATE] with diagnoses including, hypothyroidism (abnormally low activity of the thyroid gland), dysphagia (difficulty swallowing), diabetes, mild protein-calorie malnutrition, high blood pressure, muscle weakness, lack of coordination, heart failure and anxiety. Record review of the Resident #1's MDS, dated [DATE], reflected Resident #1 usually made herself understood and usually understood others. Resident #1 had severe cognitive impairment with a (BIMS of 7). Resident #1 had no physical or verbal behaviors symptoms directed towards herself or others. Resident #1 had no behavior of rejecting care. Resident #1 used a manual wheelchair for locomotion and required supervision or touch assistance with eating and oral hygiene. Resident #1 required patrial/moderate assistance with dressing her upper/lower body, personal hygiene, rolling side to side in the bed, moving from a sitting position to lying flat in the bed, and lying to sitting on the side of the bed. The MDS indicated Resident #1 required substantial/maximal assistance with showers/bathing, putting on/taking off footwear, the ability to stand from a sitting position, chair to bed/ bed to chair transfers, toilet transfers, and tub/shower transfers. The MDS indicated Resident #1 was dependent on staff for toileting. Record review of Resident #1's care plan dated 3/12/24, reflected Resident #1 had a risk for bruising and bleeding due to anticoagulant therapy. The care plan interventions included encourage resident to be aware of extremities in relation to environment. The care plan also indicated Resident #1 reported alleged mistreatment by staff and was at risk for increased anxiety. Record review of the facility's provider investigation report dated 5/17/24, reflected Resident #1 reported CNA B struck her arm. The police were notified. CNA B was terminated, detained and placed under arrest by the police. Record review of CNA B's signed statement, dated 5/13/24, reflected I'm not the only one that hits them . (Resident #1) was just mad because we didn't have a diaper that would fit her. She got mad and pulled the yellow diaper off. She hit me. I never hit anybody . During an observation and interview on 5/17/24 at 12:50 p.m., Resident #1 said she called for help in the early morning hours of 5/13/24 because her brief was coming off. Resident #1 demonstrated and described she pulled at the brief showing the CNA the brief did not fit and was coming off. Resident #1 then demonstrated and described that as she was doing this (pulling at the brief) CNA B slapped her arm and indicated she slapped her left arm hard while she (CNA B) stood on the left side of her bed. Resident #1 had a large bruise (approximately 7 inches in length and 3 inches in width) to the posterior aspect of her left forearm. Resident #1 said the bruise was where CNA B hit her. During an interview on 5/17/24 at 1:00 p.m., CNA C said it was not acceptable to hit a resident under any circumstances. CNA C said even if they (the residents) hit us (the staff), we the staff do not hit them back. CNA C said this was abuse. During an interview on 5/17/24 at 2:15 p.m., LVN D said Resident #1 was very descriptive and named CNA B as the aide who slapped her arm. LVN D said CNA B slapping Resident #1 no matter the reason was abuse. During an interview on 5/17/24 at 2:30 p.m., The Corporate RN said she was the acting DON. The Corporate RN said Resident #1 was consistent with her details of the event and had bruising to her left arm where she said a nurse had hit her. The Corporate RN said because of Resident #1's description of the staff member and her (Resident #1's) report that the staff member worked double almost every night- CNA B was identified. The Corporate RN said the Resident #1 had reported the incident happened sometime in the early morning hours. The Corporate RN said when the facility was made aware of the allegation they promptly reported the incident to the state agency and began their investigation. The Corporate RN said safety surveys were completed with no additional findings. The Corporate RN said the CNA B was not at work when they were notified of the allegation (she had worked 10:00 p.m. to 6:00 a.m.) so she was called to facility for interview and they kept here there until the police arrived and detained her. The Corporate RN said the police were notified and walked CNA B out in handcuffs. The Corporate RN said what CNA B did (slapping Resident #1's arm) was abuse and would not be tolerated. The Corporate RN said all staff were in-serviced over ANE. During an interview on 5/17/24 at 2:50 p.m., the Administrator said CNA B was immediately terminated and all other staff were in-serviced over abuse, neglect and exploitation. The Administrator said abuse of residents would not be tolerated at the facility. Record review of CNA B's personnel action form, dated 5/13/24, indicated she was terminated for misconduct regarding allegations of Abuse and was not eligible for rehire. The personnel action form also indicated criminal charges had were filed. Record review of the facility's policy and procedure, dated July 2022, titled Abuse, Neglect and Exploitation, stated It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish, It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 7 (Resident #1) residents reviewed for quality of care. 1.The facility failed to provide wound care to Resident #1's right lower extremity stump (the remaining part of the right leg after amputation) as ordered resulting in infection and surgical debridement (the removal of damaged tissues from a wound) to rule out osteomyelitis (inflammation of the bone caused by infection). 2.The facility failed to report redness to Resident #1's abdomen to the Nurse Practitioner or Wound Care Physician resulting in hospitalization related to cellulitis (bacterial skin infection) and panniculitis (inflammation of the subcutaneous fat) requiring intravenous (IV) antibiotics. 3.The facility failed to document wound care assessments per facility policy. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 2:35 p.m. on 4/2/24. While the IJ was removed on 4/3/24, the facility remained out of compliance with a scope identified as patterned and a severity of no actual harm with a 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. These failures could result in residents with venous stasis ulcer of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing. Findings Included: 1. Record review of the face sheet dated 4/3/24 indicated Resident #1 was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including panniculitis, morbid obesity, diabetes, acquired absence of right leg below the knee, localized edema (swelling), and congestive heart failure (chronic condition in which the heart does not pump blood as well as it should). Record review of the physician orders dated 4/3/24 indicated Resident #1 had an order to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate (highly absorptive, non-occlusive dressing made of soft, non-woven calcium alginate fibers), collagen (wound dressing derived from collagen used to absorb exudate (fluids excreted by a wound), and cover with a dry dressing daily and as needed starting on 2/5/24. The physician orders indicated Resident #1 had an order for lymphedema (swelling caused by a lymphatic system blockage) wound of left abdomen skin prep daily starting 4/2/24. Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #1 had a surgical wound and moisture associated skin damage. Record review of the care plan revised 4/3/24 indicated Resident #1 had actual impairment to skin integrity: unstageable [wound] to the right leg with interventions including cleanse wound, apply medications and dressings as ordered. The care plan indicated Resident #1 had an infection of the wound. The care plan indicated Resident #1 had panniculitis . The care plan indicated had potential impairment to skin integrity of the lower abdomen and skin folds related to morbid obesity/incontinence. Resident had wound to right leg with treatment continued. Record review of the TAR dated 2/1/24 through 2/29/24 indicated Resident #1's treatment to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate, collagen and cover with a dry dressing daily and as needed was only performed on 2/7/24, 2/8/24, 2/10/24, 2/12/24, 2/13/24, 2/15/24, 2/16/24, 2/17/24, 2/22/24, 2/26/24, 2/27/24, 2/28/24, and 2/29/24. Record review of the TAR dated 3/1/24 through 3/31/24 indicated Resident #1's treatment to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate, collagen and cover with a dry dressing daily and as needed was only performed on 3/1/24, 3/3/24, 3/10/24, 3/11/24, 3/30/24, and 3/31/24. Record review of the skin assessment dated [DATE] indicated Resident #1 had a right lower leg wound infection measuring 1.5cm x 0.3cm x 0.2cm. The skin assessment indicated Resident #1 had a wound to the right leg with treatment in place. Record review of the skin assessment dated [DATE] indicated Resident #1 had a right lower leg wound infection measuring 1.5cm x 0.3cm x 0.2cm. The skin assessment indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream (a product applied to the skin to help maintain the skins physical barrier, providing protection from irritants and preventing the skin from drying out) applied and Resident #1 was instructed to change positions every 2 hours. Record review of the skin assessment dated [DATE] indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream applied and Resident #1 was instructed to change positions every 2 hours. Record review of the skin assessment dated [DATE] indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream applied and Resident #1 was instructed to change positions every 2 hours. Record review of wound assessments indicated Resident #1 did not have a wound assessment performed by the facility from 2/1/24 through 3/13/24 when Resident #1 was transferred to the hospital. Record review of the Wound Care Physician's note dated 2/12/24 indicated Resident #1 had a right leg wound measuring 1cm x 0.3cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was healing as evidenced by 0% decrease in surface area within the wound bed. Record review of the Wound Care Physician's note dated 2/19/24 indicated Resident #1 had a right leg wound measuring 1cm x 0.3cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal. Record review of the Wound Care Physician's note dated 2/26/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound had exacerbated due to more edema in the leg. Record review of the Wound Care Physician's note dated 3/4/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal. Record review of the Wound Care Physician's note dated 3/11/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal. Record review of the nursing progress note dated 3/11/24 indicated Resident #1 received an order for Doxycycline (antibiotic) 100mg twice a day for 7 days related to right stump wound. Record review of the nursing progress note dated 3/13/24 indicated Resident #1 noted with change in condition including not feeling well, body aches, chills, fever, and right leg pain and swelling. The nursing progress note indicated a new order was received to send Resident #1 to the emergency department for evaluation and treatment. Record review of the nursing progress note dated 3/27/24 indicated Resident #1 returned to the facility. Record review of the hospital paperwork for hospital admitted d 3/13/24 through 3/27/24 indicated Resident #1 was admitted to the hospital with a primary diagnosis of acute panniculitis. The hospital paperwork indicated Resident #1 had discharge diagnoses including acute panniculitis, bacteremia (viable bacteria in the blood), and osteomyelitis of right tibia. The hospital paperwork indicated Resident #1 was admitted to the hospital with fever, chills and brought to emergency room for he was found to have an elevated white cell count of 17,200 (normal range 4,500 to 11,000) and large left-sided cellulitis involving his entire left abdominal wall pannus (excess skin and fat that hangs down from the abdomen). The hospital paperwork indicated Resident #1 was started on broad-spectrum IV antibiotics and based cellulitis spread from left flank to across his left midline. The hospital paperwork indicated Resident #1 had some evidence of wounds in his left abdominal wall. The hospital paperwork indicated Resident #1 had a right below-knee amputation stump ulcer with x-ray revealing osteomyelitis. The hospital paperwork indicated after right below the knee stump debridement on 03/21/2024 there was not any evidence of bone involvement. During an interview on 3/28/24 at 1:26 p.m. Resident #1 said there had been staffing issues with treatment nurses. Resident #1 said his wound care had not been done as scheduled. Resident #1 said he had just returned from the hospital due to infection to wound and cellulitis to abdomen. Resident #1 said he had surgery on his below the knee amputation while in the hospital to determine in the infection was in the bone. Resident #1 said the infection had not made it to the bone and was only in the soft tissue. Resident #1 said he had not been receiving proper wound care prior to being hospitalized . During an interview on 4/2/24 at 9:59 a.m. LVN A said she was familiar with Resident #1. LVN A said Resident #1's wound care was performed daily. LVN A said LVN F or LVN E were responsible for performing Resident #1's wound care. LVN A said the nurses were responsible for completing skin assessments. LVN A said she did not know if the increased redness to Resident #1's abdomen had been reported. LVN A said all wound treatments from the wound care physician were recommendations. LVN A said she would have to find out if the wound care physician recommendations were implemented or needed to be approved by the resident's primary care physician. LVN A said Resident #1 had a skin assessment dated [DATE] which indicated redness to left lateral abdomen. During an interview on 4/2/24 at 10:14 a.m. the Wound Care Physician said he was familiar with Resident #1. The Wound Care Physician said Resident #1 had lots of lymphedema (swelling, most often in an arm or leg, caused by lymphatic system blockage) in his right stump. The Wound Care Physician said the facility had not had a treatment nurse in months. The Wound Care Physician said it was not ideal for dressing changes that were ordered daily not to be performed. The Wound Care Physician said it was not out of the realm for a dressing change ordered daily and not being performed daily to lead to infection. The Wound Care Physician said he was not informed of redness or increased redness to Resident #1's abdomen but the facility may have informed his primary care physician. The Wound Care Physician said wound treatments in his notes were recommendations. The Wound Care Physician said he saw residents at the facility weekly. The Wound Care Physician said he could not say if lymphedema treatment recommendation not being performed would lead to worsening lymphedema or infection. During an interview on 4/2/24 at 10:21 a.m. the Nurse Practitioner said she was familiar with Resident #1. The Nurse Practitioner said she had not had any reports from the facility regarding Resident #1 having redness or increased redness to his abdomen. The Nurse Practitioner said most facilities notify them of changes in skin conditions or treatment orders, but this facility did not. The Nurse Practitioner said communication from this facility was lacking. The Nurse Practitioner said wound care treatments not performed as ordered could possibly lead to infection, but the surveyor would need to refer to the Wound Care Doctor. During an interview on 4/2/24 at 12:23 p.m. LVN B said charge nurses were responsible for wound care and skin assessments at this time. LVN B said the last training she had received at the facility regarding skin assessments, wound documentation, or wound care policies was a couple of months ago. LVN B said the TAR indicated whether wound care had been performed. LVN B said if it was not charted in the TAR wound care was performed you could look at the date on the dressing. LVN B said if it was further back than one day and was not charted in the TAR wound care was performed it could not be proved it was performed. LVN B said skin assessment should be completed weekly. Record review of the facility's Documentation of Wound Treatments policy dated 7/2022 indicated, The facility completes accurate documentation of the wound assessments and treatments, including response to treatments, change in condition, and changes in treatment. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates .Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift. Additional documentation shall include but is not limited to .e. Notification to physician and/or responsible party regarding wound or treatment changes. The Administrator was notified on 4/2/24 at 2:48 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 4/2/24 at 2:56 p.m. The facility's Plan of Removal was accepted on 4/3/24 at 9:40 a.m. and included: Plan of Removal 1. Immediate actions The Medical Director and Resident #1's Primary Care Physician were notified by the Assistant Director of Nursing on 04/02/2024. A full skin sweep was completed on all residents on 03/27-28/2024 by the Assistant Director of Nursing and the Director of Nursing. All residents admitted or readmitted from 03/27/2024 forward were reviewed to ensure for head-to-toe skin and wound assessments were completed appropriately. Any admitted or readmitted residents from 03/27/2024 forward that were identified to not have skin assessments were assessed immediately on 04/02/2024. An omissions report was pulled from 03/27/2024 forward and all omissions were addressed by the Director of Nursing. This was completed on 04/02/2024 and all staff were trained on how to pull the omissions report and directed to check it daily prior to the end of their shift to ensure no treatments are missed going forward. The omissions report identified staff who had not completed their treatments as ordered. Resident #1 was immediately provided a head-to-toe skin assessment by the Director of Nursing and treatment was provided according to the Physician's orders for all areas on 04/02/2024. 2. Education (provided by DON, ADON or Designee) The Regional Director of Clinical Services in-serviced the Director of Nursing and Assistant Director of Nursing on all of the below in-services on 04/02/2024. All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on appropriately completing skin assessments and notifying the Physician of all newly identified skin issues in a timely manner on 04/02/2024. Each nurse will be in-serviced prior to returning to shift. This will be completed by 04/03/2024 and nurses will not return to shift without the in-service. The Director of Nursing and Assistant Director of Nursing are responsible for ensuring each nurse completes their skin assessments. All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on Policy and Procedure for Pressure Injury Prevention and Skin and Wound Care Management on 04/02/2024. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. This in-service includes appropriately completing skin assessments, information on pressure and injury prevention, treatment for non-pressure injuries, the importance of wound care management and following the treatment orders. All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on pulling an omission's report prior to the end of each shift and correcting any absence of documentation on 04/02/2024. The Omission report would show any order on the TAR that was not completed during the scheduled shift. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on pulling and signing all MARs and TARs prior to the end of their shift on 04/02/2024. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. If a nurse is unable to complete an assessment or wound care during their shift, they will notify the Director of Nurses and Assistant Director of nurses prior to leaving their shift. The oncoming shift will be notified during report that an assessment or treatment was not completed. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy. 4. QAPI Committee Review - An interim QAPI committee meeting was completed on 04/02/2024. 5. Plan of removal date: 04/02/2024 On 4/3/24 it was onfirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review on 4/3/24 of 3 of 3 new admissions or re-admission from 3/27/24 through 4/3/24 indicated all admissions had skin assessments performed and wound assessments performed if applicable. Record review of a random sample of 16 of 66 residents on 4/3/24 indicated all sampled residents had skin assessments performed between 3/27/24 and 4/2/24. Record review of the QAPI sign-in sheet indicated the facility had an ad-hoc QAPI meeting on 4/2/24 regarding wound treatments, skin and wound assessments, physician notification, and omission report. The QAPI sign-in sheet indicated all appropriate members of the IDT team were present for the QAPI meeting. During interviews with staff (LVN C, LVN D, LVN E, LVN B, and the ADON) on 4/3/24 between 11:00 a.m. and 12:19 p.m. staff were able to explain importance of ensuring TARs and MARs were signed off, how to pull an omission audit to check to make sure all TARs and MARs had been signed off and treatments had been completed, how often skin and wound assessments should be performed, the importance of reporting changes in skin conditions to the PCP or wound care doctor, and interventions to prevent pressure ulcers including offloading, turning and repositioning every 2 hours, pressure relieving cushions in a resident's wheelchair, and bathing to aide in circulation. On 4/3/24 at 12:21 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as patterned and a severity of no actual harm with a 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.

Based on interview and record review, the residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation and the facility failed to ensure residents were free from Abuse, Neglect, and Exploitation for 2 of 8 residents reviewed for abuse. (Residents #1 and #2) The facility failed to ensure Resident #1 and Resident #2 were free from abuse and failed to implement their written policies and procedures that prohibited and prevented abuse, which resulted in Resident #1 stabbing his roommate Resident #2 with a pocket knife during a physical altercation and Resident #2 sustained multiple stab marks (non-invasive, and barely breaking skin) to right side of the chest and laceration to Resident #2's right hand that required stiches. This failure could place the residents at risk for increased risk for abuse and neglect. Findings included: 1)Record review of Resident #1's face sheet, printed on 12/15/23, indicated he was a [AGE] year-old male who admitted to facility on 02/16/23 and discharged on [DATE] to inpatient behavior hospital with diagnoses including acute respiratory failure (occurs when the lungs can't release enough oxygen into your blood), right lower leg contracture of muscle (is the result of stiffness or constriction in the connective tissues of the body), and abnormalities of gait and mobility (walking disorder. Record review of Resident #1's care plan indicated the following: Focus: The resident has potential to be physically aggressive due to poor impulse control. Date Initiated 12/13/23; Goal: The resident will verbalize understanding of need to control physically aggressive behavior. Interventions: Administer medications as ordered. Monitored/document for side effects and effectiveness. Communication- provide physical and verbal; cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encouraging seeking out of staff member when agitated. Monito/document/report PRN any sign or symptoms of resident posing danger to self and other. Record review of Resident #1's quarterly MDS dated [DATE] indicated he had clear speech but had difficulty communicating some word or finishing thought but was able if prompted per given time. Also, misunderstood some part/intent of message but comprehends most conversations. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated she had moderately impaired cognition. Section E - Behaviors was marked none of the above indicating no hallucinations nor delusions and no physical, no verbal and no other behavioral symptoms directed towards other. Record review of Resident #1's skin assessment dated and completed on 12/13/23 by LVN B indicated Resident #1 had multiple scratches to right upper chest and neck and scratch to chin from physical altercation. Record review of Resident #1's incident report dated 12/13/23 completed by the DON indicated the incident happened in Residents #1 and #2 room. Incident Description: Nursing Description - CNA C notified LVN B that Residents #1 and #2 were fighting in their room. Resident Description: Resident #1 stated he and his roommate were arguing back and forth and Resident #2 rolled over in his wheelchair and got up and began hitting him, so Resident #1 pulled out a knife to defend himself. Immediate Action Taken: Residents were separated, EMS/PD notified, knife removed by PD from resident. PD also removed a second multitool from resident's room. Notes: Resident #1 was placed under one-on-one observation during this time in facility after altercation. Notified Resident #1 that his information was being sent to local behavioral hospital for inpatient treatment. Resident #1 transported to behavioral hospital via facility transport van, accompted by transporter. Family made aware. Record review of Resident #1's Progress notes indicated the following: -On 12/13/23 at 8:07am; completed by LVN B: CNA C went into patients room after hearing yelling and cussing coming from room, upon entering room CNA C stating Nurse they are fighting come help me upon LVN B entering room it was noted that Resident #2 had his wheelchair next to his roommate Resident #1's bed and Resident #2 was standing over Resident #1 half way on the bed hitting Resident #1, and Resident #1 was stabbing Resident #2 with a knife. LVN B pulled Resident #2 off Resident #1 and into his wheelchair. Blood noted to be on Resident #1's bed, pillow covers, floor, wheelchair and on Resident #2. Upon assessment of Resident #2 it was noted that Resident #2 had multiple stab marks (non-invasive, barely breaking skin) to right side of chest, one measuring 1.5 with raised 4x3 hematoma multicolor, to right upper chest, another right below measuring 1x.5 and 2 small unmeasurable marks, minimal bleeding noted. 2.5x1x0.3 laceration to right inner hand below thumb, reopened scar to right middle shin, scratch marks to right elbow, redness to face. Resident #1 was noted to have scratch marks and red marks to right chest, right side of neck and chin. No bleeding noted. Resident #2 stated that Resident #1 was yelling and cussing at him so Resident #2 went over in his wheelchair to shut him up. Resident #1 stated that they were both verbally arguing back and forth, and Resident #2 rolled over in his wheelchair and got up and began hitting Resident #1, so Resident #1 pulled out a knife in defense, EMS was called. The DON and the Administrator were both notified. The Maintenance supervisor was in the facility and notified and retrieved knife from Resident #1. EMS and the local police department went to the facility. Resident #2 was sent out via EMS transport to the local hospital for evaluation and treatment. A full skin assessment was completed on Resident #2 and Resident #1. Resident #2's wounds were cleaned and wound to right hand was wrapped in gauze while waiting for EMS arrival. The MD was notified, police retrieved a second pocketknife from Resident #1, secured at the nurse station. Both residents were stable, alert, and oriented, in no acute distress at time of EMS arrival. -On 12/13/23 at 8:16am; completed by LVN B: Resident #1's sister was called and VM left. Local police case provided case number. -On 12/13/23 at 8:45am; completed by DON: Resident #1 placed on one-on-one supervision awaiting referral to the behavioral hospital. Resident resting in bed, no distress noted, no weapons noted in room. 2) Record review of Resident #2's face sheet, printed on 12/15/23, indicated he was a [AGE] year old male who originally admitted to facility on 10/20/23 and readmitted on [DATE] and discharged on [DATE] to an acute inpatient behavioral hospital with diagnoses including schizoaffective disorder-Bipolar type (s a mental illness that can affect your thoughts, mood and behavior), severe bipolar disorder with depression without the psychotic features (a mental health condition characterized by extreme mood swings that can affect a person's daily life. People with bipolar disorder experience periods of depression, referred to as depressive episodes), anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and cognitive communication deficit (a person has difficulty communicating because of injury to the brain that controls the ability to think). Record review of Resident #2's care plan indicated the following: Focus: The resident had a behavior problem, became very anxious with change. Resident had a new room-mate and felt crowded, stating too much stuff in here to get around, after he got his nebulizer machine cord tangled on his wheelchair causing it to break roommates new tv. Date Initiated: 6/27/22; -Goal: The resident will have no evidence of behavior problems. Interventions: Anticipate and meet the resident's needs. Anticipate the resident to develop more appropriate methods of coping and interacting before placing a new room-mate with this resident. Be aware of personal items that will be placed in room and try and keep room uncluttered. Focus: Resident had episodes of adverse behavior(s): keeps personal food items at bedside. Date initiated 12/01/23; Goal: Resident will remain injury free due to adverse behaviors. Interventions: Anticipate behavior(s) and redirect when in close proximity to others that might invoke aggression. Encourage to attend social activities of preference. Ensure staff is aware of my behaviors and successful interventions. Explain all procedures using terms/gestures that resident can understand. Maintain a calm environment. Record review of Resident #2's quarterly MDS dated [DATE] indicated he had clear comprehension and made himself understood. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated she had moderately impaired cognition. Section E - Behaviors was marked none of the above indicating no hallucinations nor delusions and no physical, no verbal and no other behavioral symptoms directed towards other. Record review of Resident #2's skin assessment dated [DATE] and completed on 12/15/23 by LVN B indicated Resident #2 had multiple stab marks (non-invasive, barely breaking skin) to right side of chest, one measuring 1.5 with raised 4x3 hematoma multicolor, to right upper chest, another right below measuring 1x.5 and 2 small unmeasurable marks, minimal bleeding noted. 2.5x1x0.3 laceration to right inner hand below thumb, reopened scar to right middle shin, scratch marks to right elbow, redness to face. Resident #1 was noted to have scratch marks and red marks to right chest, right side of neck and chin. No bleeding noted. Record review of Resident #2's ER After Visit Summary dated 12/13/23 indicated reason for visit: Assault Victim; Diagnoses: Assault, Knife Wound, and Laceration of right hand without foreign body and ER did a laceration repair. Follow up in 7 - 10 days for Suture removal. Record review of Resident #2's incident report dated 12/13/23 completed by the DON indicated the incident -happened in Residents #1 and #2 room. Incident Description: Nursing Description - CNA C notified LVN B that Residents #1 and #2 -were in a physical altercation. Upon entering the room, it was noted that Resident #2 had a wheelchair next to his roommate's bed and was standing over roommate, halfway on the bed hitting roommate. Roommate was stabbing Resident #2 with a knife. Resident Description - Resident #2 was stating that his roommate was yelling and cussing at him, so he went over in his wheelchair to shut him up. Immediate Action Taken: LVN B removed Resident #2 off Resident #1, assessed injuries, notified EMS/PD of incident. Placed resident on one-on-one supervision until able to be removed form facility via ambulance to ER. DON/MD/Administrator/Nephew notified. Notes: Resident #2 was placed under one-on-one supervision during time in facility after physical altercation with another resident until transported to ER via EMS. Upon Resident #2 return from ER, Resident #2 was again placed on one-on-one. Notified Resident #2 that his information was being sent to a Behavioral Hospital for inpatient treatment. Resident #2 was transported to the Behavioral Hospital facility via transport van, accompanied by transporter. Family aware of transport. Record review of Resident #2's Progress notes indicated the following: -On 12/13/23 at 7:46am; completed by LVN B: CNA C went into patients room after hearing yelling and cussing coming from room, upon entering room CNA C stating Nurse they are fighting come help me upon LVN B entering room it was noted that Resident #2 had his wheelchair next to his room mate Resident #1's bed and Resident #2 was standing over Resident #1 half way on the bed hitting Resident #1, and Resident #1 was stabbing Resident #1 with aa knife. LVN B pulled Resident #2 off Resident #1 and into his wheelchair. Blood noted to be on Resident #1's bed, pillow covers, floor, wheelchair and on Resident #2. Upon assessment of Resident #2 it was noted that Resident #2 had multiple stab marks (non-invasive, barely breaking skin) to right side of chest, one measuring 1.5 with raised 4x3 hematoma multicolor, to right upper chest, another right below measuring 1x.5 and 2 small unmeasurable marks, minimal bleeding noted. 2.5x1x0.3 laceration to right inner hand below thumb, reopened scar to right middle shin, scratch marks to right elbow, redness to face. Resident #1 was noted to have scratch marks and red marks to right chest, right side of neck and chin. No bleeding noted. Resident #2 stated that Resident #1 was yelling and cussing at him so Resident #2 went over in his wheelchair to shut him up. Resident #1 stated that they were both verbally arguing back and forth, and Resident #2 rolled over in his wheelchair and got up and began hitting Resident #1, so Resident #1 pulled out a knife in defense, EMS was called. The DON and the Administrator were both notified. The Maintenance supervisor was in the facility and notified and retrieved knife from Resident #1. EMS and the local police department went to the facility. Resident #2 was sent out via EMS transport to the local hospital for evaluation and treatment. A full skin assessment was completed on Resident #2 and Resident #1. Resident #2 wounds were cleaned and wound to right hand was wrapped in gauze while waiting for EMS arrival. The MD was notified, police retrieved a second pocketknife from Resident #1, secured at the nurse station. Both residents were stable, alert, and oriented, in no acute distress at time of EMS arrival. -On 12/13/23 at 11:10am; completed by DON: Resident #2 returned to facility via facility transport van, was placed on one-on-one supervision with CNA. The behavioral hospital was contacted, referral sent, awaiting response. -On 12/13/23 at 3:42pm; completed by DON: The Behavioral hospital health liaison was in facility to evaluate Resident #1; continued one-on-one supervision. -On 12/13/23 at 4:18pm; completed by LVN G: Resident #2 with no outburst since beginning of shift. Quiet with no facial, and with no behaviors noted. -On 12/13/23 at 4:40pm; completed by DON: Resident #2 was sent out via facility van to the behavioral hospital for voluntary admission; his belonging was sent with Resident #2 and report was called to the acute behavioral hospital. During an interview on 12/15/23 at 1:48 p.m., LVN B said she was working as the charge nurse the day of the incident and CNA C heard yelling and went to Resident #1 and Resident #2's room, CNA C came and got her and that's when she saw Resident #2 on top of Resident #1 and Resident #1 was stabbing Resident #2. LVN B said they separated the residents, assessed the residents, the Maintenance Director retrieved Resident #1's knife, she called 911 and EMS took Resident #2 to the ER for evaluation and stiches. LVN B said Resident #2 has had increased confusion for about a -year. Resident #2 was on psych services; he did have occasional aggression and would be verbally aggressive with staff when they assisted with bathing. LVN B said Resident #2 was schizophrenic, had anxiety disorder and had been involved in possibly two prior incidents. LVN B said Resident #1 rarely left his room or got out of bed, she said Resident #1 did not bother anyone. She said she was not aware Resident #1 had weapons prior to incident, she said the residents were not allowed to have weapons or knives. LVN B said Resident #1 told staff he had another knife and facility found two additional pocketknives that belonged to Resident #1. During an interview on 12/18/23 at 1:13 p.m., CNA C said the day of the day of the incident around 4:30am Resident #1 was upset she entered his room to do patient care on Resident #2. CNA C said Resident #2 pressed the call lights around 6:30amish, CNA C said she answered the call light, she said Resident #1 was upset and made the comment to her that she had already came to the fucking room at 4:30am ; Resident #2 requested for her to turn off the lights so he could get some sleep, she said told him it was time for breakfast and to leave the lights on, she said Resident #2 insisted she turned the lights off so she asked Resident #1 if it was okay to turn the lights off and Resident #1 said no he wanted the lights to stay on. CNA C said about 15 or 20 minutes later she heard a resident screaming help, she said she walked the halls to see who was yelling for help. CNA C she opened the door to Resident #1 and Resident #2's room and seen Resident #2 standing over Resident #1 who was in bed with the head elevated and was stabbing Resident #2 with a knife. CNA C said she yelled for the residents to stop as she stood in the doorway and then she yelled for help. CNA C said LVN B and CMA F immediately came to assist and separated the residents. CNA C said she normally worked the night shifts, and the residents were normally sleep and no issues. CNA C said after they separated the residents, she noticed Resident #2's hand was bleeding so she went and grabbed a sheet to wrap his hand and then LVN B took over and explained to Resident #2 that he needed to go to the hospital so they can look at his wound. CNA C said she observed Resident #1 had a bruise on left side of his neck or chest area but no wounds to her knowledge. She said Resident #1 told her he called the police because he was attacked by Resident #2. During an interview on 12/15/23 at 1:14 p.m., CNA E said she did not witness the incident between Resident #1 and Resident #2, but she was familiar with both residents. She said Resident #1 stayed to himself, only used the call light for patient care or whenever he needed a muscle relaxer for pain. She said Resident #1 stayed in bed and she did not have any issues with him. CNA E said recently Resident #2 behaviors had changed and he was verbally aggressive with other residents and staff. She said she would tell the nurses, not sure if they did anything about it. CNA E said for example if another resident asked Resident #2 a question or would speak to him, Resident #2 would become verbally aggressive, she noticed a change in behavior about two or three months ago. CNA E said she was not aware Resident #1 had any weapons, if she did, she would have told someone or got it from him. During an interview on 12/15/23 at 1:25 p.m., CMA F said she was familiar with Resident #1 and Resident #2. She Said Resident #1 occasionally was verbally aggressive with staff, but not with other residents. CMA F said Resident #2 was always rude and appeared bothered like or annoyed if anyone asked him a question or would speak to him. CMA F said she worked the morning of the incident but did not witness anything or did not assist with breaking up the residents. During an interview on 12/18/23 at 1:56 p.m., CNA D said she did not witness the incident between Resident #1 and Resident #2, but she was familiar with both of the residents. CNA D said Resident #1 stayed to himself, he was not mean and did not easily get mad, she Resident #1 did not give her any issues. Resident #2 was a sweet resident, she said she had seen Resident #2 ger upset and curse at other residents before. CNA D said she had seen Resident #2 slap another resident about a year ago in he outside smoking area. She said the incident also started off verbally because both residents were cursing, then she witnessed Resident #2 slap the other resident who he was arguing with, She said she immediately removed Resident #2 and brought him back to his room and told LVN G; CNA D said at that time the facility did not have a designated staff for residents smoking, she said she was cutting through the smoke area to go to the dining room whenever she witnessed the incident. She said she had a great relationship with Resident #2, and she did not have issues with Resident #2 and was to redirect. CNA D said Resident #2 did get upset easily; Example: If something was wrong with Resident #2 meals, or if he disliked the meal, he would start yelling and cursing. Example #2: If Resident #2 felt staff took to long to respond to his call lights (5 minutes), Resident #2 would yell, curse and get upset. Overall, Resident #2 was sweet resident, but when Resident #2 accidentally urine on himself he would say No if she wanted to assist with patient care. CNA D said she was not surprised Resident #2 had a physical altercation with another resident. She said surprised Resident #1 was in an altercation with another resident, and that Resident #2 had to do something bad for Resident #1 to have responded like that. CNA D said she did not recall previous incidents with Resident #1. During an interview on 12/18/23 at 3:34 p.m., LVN G said she did not witness the incident between Resident #1 and Resident #2. LVN G said she did not have any issues with the residents and both residents were impatient and did not like to wait. She said the residents were not aggressive. LVN G said she did not recall any prior physical altercations incidents involving Resident #2. LVN G said was not aware of any residents having a knife or weapon. She said she considered a pocket-knife to be a weapon. During an interview on 12/18/23 at 12:07 p.m., The Maintenance Supervisor said he did not see anything regarding the actual incident. He said the morning of the incident LVN B came to him around 6:45 am for assisting with a resident who had a knife. The maintenance Supervisor said both Resident #1 and Resident #2 were calm, and he saw blood from nurse station to the room. He said Resident #1 was still in the room and whenever he entered the room, he said he asked Resident #1 for the knife, and he willingly handed over a grey/silver like colored pocket-knife that was on the overbed table put the knife in a rubber glove and The Maintenance Supervisor said he handed the pocket-knife over to the Administrator. He said Resident #2 was standing at the nurse station. The maintenance Supervisor said he had no prior knowledge or issues with the residents and was not aware Resident #1 had a knife prior to the incident. During an interview on 12/18/19 at 1:44 p.m. and at 3:43 p.m., the DON said Resident #1 told her he knew he was not supposed to have the knife but he used the pocket knife to cut his meats, due to right side weakness and his right hand used to be his dominate hand but now had to used his left hand as the dominate hand and when cutting meat with his left hand it was hard to do with the facility utensils so he used a pocket knife to cut meat and it was easier. The DON said she was not aware he had a knife and said the residents were not allowed to have knives. She said she asked Resident #1 where she got the knife, and he told her a friend gave it to her but would not give a name and she did not know how long he had it the knives. The DON described Resident #1 as a resident who stayed to himself, and he rarely left his bed. The DON described Resident #2 as impulsive and did not like to wait and would want things one right then and there. The DON said Resident #2 would revolve around his smoke breaks and he was easily agitated. She said he was being treated for UTI during the incident between Resident #1 and Resident #2 and she was surprised the residents had a physical altercation because it was out of character for both residents. The DON said the police did not blame Resident #1 and considered Resident #1 as being the victim who was attacked and used the knife for self-defense against Resident #2 who physically attacked Resident #1. The DON called and left messages for the nurses at both behavioral hospitals for Resident #1 and Resident #2 for to speak with state surveyor, no return calls. During an interview on 12/18/23 at 4:03 p.m., the Administrator described Resident #1 as being calm, no issues; he described Resident #2 as having short term memory, and only programed to know smoke times only. The Administrator said was agitated or verbally aggressive with staff if it interfered with his smoke breaks. He said he recalled an incident when Resident #2 was wet and the Administrator asked Resident #2 to let staff assist with getting him cleaned up before going to smoke and Resident #2 would become loud and yell Go to hell, leave me alone mother fucker. The Administrator said he was the abuse coordinator and said he had not spoken with the other residents or staff regarding the weapon prohibition policy, nor did a room sweep for weapons. The administrator said on 12/19/23 he planned on meeting with the residents to go over weapon policy and if explained if they were caught with any type of weapons they would be discharged . The Administrator said he was going to in-service staff on 12/19/23 on what to do if they see a weapon. The Administrator said he was not aware Resident #1 had a pocket-knife and the residents were not allowed to have pocket-knives or any knives or weapons. He said he did consider a pocket-knife to be a weapon. He said Resident #1 told him he had always had the pocket-knives. Record review of abuse, neglect and exploitation policy dated 2023 revealed Policy: It was the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definition: Abuse - means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation. Record review firearm and weapon prohibition policy dated 07/2022 revealed Policy: A safe and secure environment is fundamental for fulfilling our company's mission of providing medical care and related health care services. Our company is committed to maintaining a safe workplace that is free of violence. Intent of Policy: To prevent the unauthorized possession of weapon(s) while on facility premises. Policy Explanation and Compliance Guidelines: 1. While on any part of our company's premises, individuals are prohibited from introducing, possessing, using, buying, or selling unauthorized weapons, firearms, ammunition, explosives, or any other item(s) deemed by management to be dangerous. 2.) The following definitions apply in the enforcement of this policy: a.) An employee is defined as any company employee regardless of employment status (e.g., full/part-time, consultant, temporaries, etc.). b.) Visitors include, but are not limited to, family members, visitors for staff, vendors, etc. c.) Residents are also included in this policy. 3.) Any employee who becomes aware of a violation of this policy is required to immediately notify his/her supervisor of such violation. 4.) Violation of this policy is considered a serious offense that endangers the safety of our patients, staff, and visitors. Therefore, this offense may result in termination of employment and criminal prosecution.

Based on interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 8 residents reviewed for accidents. (Residents #1 and #2). The facility failed to provide adequate supervision which resulted in Resident #1 stabbing his roommate Resident #2 with a pocketknife during a physical altercation and Resident #2 sustained multiple stab marks (non-invasive, and barely breaking skin) to right side of the chest and laceration to Resident #2's right hand that required stiches. This failure could place residents at risk for abuse and a diminished quality of life. Findings included: 1)Record review of Resident #1's face sheet, printed on 12/15/23, indicated he was a [AGE] year-old male who admitted to facility on 02/16/23 and discharged on [DATE] to inpatient behavior hospital with diagnoses including acute respiratory failure (occurs when the lungs can't release enough oxygen into your blood), right lower leg contracture of muscle (is the result of stiffness or constriction in the connective tissues of the body), and abnormalities of gait and mobility (walking disorder). Record review of Resident #1's care plan indicated the following: Focus: The resident has potential to be physically aggressive due to poor impulse control. Date Initiated 12/13/23; Goal: The resident will verbalize understanding of need to control physically aggressive behavior. Interventions: Administer medications as ordered. Monitored/document for side effects and effectiveness. Communication- provide physical and verbal; cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encouraging seeking out of staff member when agitated. Monito/document/report PRN any sign or symptoms of resident posing danger to self and other. Record review of Resident #1's quarterly MDS dated [DATE] indicated he had clear speech but had difficulty communicating some word or finishing thought but was able if prompted pr given time. Also, misunderstood some part/intent of message but comprehends most conversations. resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated she had moderately impaired cognition. Section E - Behaviors was marked none of the above indicating no hallucinations nor delusions and no physical, no verbal and no other behavioral symptoms directed towards other. Record review of Resident #1 skin assessment dated and completed on 12/13/23 by LVN B indicated Resident #1 multiple scratches to right upper chest and neck and scratch to chin from physical altercation. Record review of Resident #1's incident report dated 12/13/23 completed by the DON indicated the incident happened in Residents #1 and #2 room. Incident Description: Nursing Description - CNA C notified LVN B that Residents #1 and #2 were2 were fighting in their room. Resident Description: Resident #1 stated he and his roommate were arguing back and forth and Resident #2 rolled over in his wheelchair and got up and began hitting him, so Resident #1 pulled out a knife to defend himself. Immediate Action Taken: Residents were separated, EMS/PD notified, knife removed by PD from resident. PD also removed a second multitool from resident's room. Notes: Resident #1 was placed under one-on-one observation during this time in facility after altercation. Notified resident #1 that his information was being sent to local behavioral hospital for inpatient treatment. Resident #1 transported to behavioral hospital via facility transport van, accompted by transporter. Family made aware. Record review of Resident #1's Progress notes indicated the following: -On 12/13/23 at 8:07am; completed by LVN B: CNA C went into patients room after hearing yelling and cussing coming from room, upon entering room CNA C stating Nurse they are fighting come help me upon LVN B entering room it was noted that Resident #2 had his wheelchair next to his roommate Resident #1's bed and Resident #2 was standing over Resident #1 half way on the bed hitting Resident #1, and Resident #1 was stabbing Resident #1 with aa knife. LVN B pulled Resident #2 off Resident #1 and into his wheelchair. Blood noted to be on Resident #1's bed, pillow covers, floor, wheelchair and on Resident #2. Upon assessment of Resident #2 it was noted that Resident #2 had multiple stab marks (non-invasive, barely breaking skin) to right side of chest, one measuring 1.5 with raised 4x3 hematoma multicolor, to right upper chest, another right below measuring 1x.5 and 2 small unmeasurable marks, minimal bleeding noted. 2.5x1x0.3 laceration to right inner hand below thumb, reopened scar to right middle shin, scratch marks to right elbow, redness to face. Resident #1 was noted to have scratch marks and red marks to right chest, right side of neck and chin. No bleeding noted. Resident #2 stated that Resident #1 was yelling and cussing at him so Resident #2 went over in his wheelchair to shut him up. Resident #1 stated that they were both verbally arguing back and forth, and Resident #2 rolled over in his wheelchair and got up and began hitting Resident #1, so Resident #1 pulled out a knife in defense, EMS was called. The DON and the Administrator were both notified. The Maintenance supervisor was in the facility and notified and retrieved knife from Resident #1. EMS and the local police department went to the facility. Resident #2 was sent out via EMS transport to the local hospital for evaluation and treatment. A full skin assessment was completed on Resident #2 and Resident #1. Resident #2 wounds were cleaned and wound to right hand was wrapped in gauze while waiting for EMS arrival. The MD was notified, police retrieved a second pocketknife from Resident #1, secured at the nurse station. Both residents were stable, alert, and oriented, in no acute distress at time of EMS arrival. -On 12/13/23 at 8:16am; completed by LVN B: Resident #1's sister was called and VM left. Local police case provided case number. -On 12/13/23 at 8:45am; completed by DON: Resident #1 placed on one-on-one supervision awaiting referral to the behavioral hospital. Resident resting in bed, no distress noted, no weapons noted in room. 2) Record review of Resident #2's face sheet, printed on 12/15/23, indicated he was a [AGE] year old male who originally admitted to facility on 10/20/23 and readmitted on [DATE] and discharged on [DATE] to an acute inpatient behavioral hospital with diagnoses including schizoaffective disorder-Bipolar type (s a mental illness that can affect your thoughts, mood and behavior), severe bipolar disorder with depression without the psychotic features (a mental health condition characterized by extreme mood swings that can affect a person's daily life. People with bipolar disorder experience periods of depression, referred to as depressive episodes), anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and cognitive communication deficit (a person has difficulty communicating because of injury to the brain that controls the ability to think). Record review of Resident #2's care plan indicated the following: Focus: The resident had a behavior problem, became very anxious with change. Resident had a new roommate and felt crowded, stating too much stuff in here to get around, after he got his nebulizer machine cord tangled on his wheelchair causing it to break roommates new tv. Date Initiated: 6/27/22; Goal: The resident will have no evidence of behavior problems. Interventions: Anticipate and meet the resident's needs. Anticipate the resident to develop more appropriate methods of coping and interacting before placing a new roommate with this resident. Be aware of personal items that will be placed in room and try and keep room uncluttered. Focus: Resident had episodes of adverse behavior(s): keeps personal food items at bedside. Date initiated 12/01/23; Goal: Resident will remain injury free due to adverse behaviors. Interventions: Anticipate behavior(s) and redirect when in close proximity to others that might invoke aggression. Encourage to attend social activities of preference. Ensure staff is aware of my behaviors and successful interventions. Explain all procedures using terms/gestures that resident can understand. Maintain a calm environment. Record review of Resident #2's quarterly MDS dated [DATE] indicated he had clear comprehension and made himself understood. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated she had moderately impaired cognition. Section E - Behaviors was marked none of the above indicating no hallucinations nor delusions and no physical, no verbal and no other behavioral symptoms directed towards other. Record review of Resident #2 skin assessment dated [DATE] and completed on 12/15/23 by LVN B indicated Resident #2 had multiple stab marks (non-invasive, barely breaking skin) to right side of chest, one measuring 1.5 with raised 4x3 hematoma multicolor, to right upper chest, another right below measuring 1x.5 and 2 small unmeasurable marks, minimal bleeding noted. 2.5x1x0.3 laceration to right inner hand below thumb, reopened scar to right middle shin, scratch marks to right elbow, redness to face. Resident #1 was noted to have scratch marks and red marks to right chest, right side of neck and chin. No bleeding noted. Record review of Resident #2's ER After Visit Summary dated 12/13/23 indicated reason for visit: Assault Victim; Diagnoses: Assault, Knife Wound, and Laceration of right hand without foreign body and ER did a laceration repair. Follow up in 7 - 10 days for Suture removal. Record review of Resident #2's incident report dated 12/13/23 completed by the DON indicated the incident happened in Residents #1 and #2 room. Incident Description: Nursing Description - CNA C notified LVN B that Residents #1 and #2 were in a physical altercation. Upon entering the room, it was noted that Resident #2 had a wheelchair next to his roommate's bed and was standing over roommate, halfway on the bed hitting roommate. Roommate was stabbing Resident #2 with a knife. Resident Description - Resident #2 was stating that his roommate was yelling and cussing at him, so he went over in his wheelchair to shut him up. Immediate Action Taken: LVN B removed Resident #2 off Resident #1, assessed injuries, notified EMS/PD of incident. Placed resident on one-on-one supervision until able to be removed form facility via ambulance to ER. DON/MD/Administrator/Nephew notified. Notes: Resident #2 was placed under one-on-one supervision during time in facility after physical altercation with another resident until transported to ER via EMS. Upon Resident #2 return from ER, Resident #2 was again placed on one-on-one. Notified Resident #2 that his information was being sent to a Behavioral Hospital for inpatient treatment. Resident #2 was transported to the Behavioral Hospital facility via transport van, accompanied by transporter. Family aware of transport. Record review of Resident #2's Progress notes indicated the following: -On 12/13/23 at 7:46am; completed by LVN B: CNA C went into patients room after hearing yelling and cussing coming from room, upon entering room CNA C stating Nurse they are fighting come help me upon LVN B entering room it was noted that Resident #2 had his wheelchair next to his roommate Resident #1's bed and Resident #2 was standing over Resident #1 half way on the bed hitting Resident #1, and Resident #1 was stabbing Resident #1 with aa knife. LVN B pulled Resident #2 off Resident #1 and into his wheelchair. Blood noted to be on Resident #1's bed, pillow covers, floor, wheelchair and on Resident #2. Upon assessment of Resident #2 it was noted that Resident #2 had multiple stab marks (non-invasive, barely breaking skin) to right side of chest, one measuring 1.5 with raised 4x3 hematoma multicolor, to right upper chest, another right below measuring 1x.5 and 2 small unmeasurable marks, minimal bleeding noted. 2.5x1x0.3 laceration to right inner hand below thumb, reopened scar to right middle shin, scratch marks to right elbow, redness to face. Resident #1 was noted to have scratch marks and red marks to right chest, right side of neck and chin. No bleeding noted. Resident #2 stated that Resident #1 was yelling and cussing at him so Resident #2 went over in his wheelchair to shut him up. Resident #1 stated that they were both verbally arguing back and forth, and Resident #2 rolled over in his wheelchair and got up and began hitting Resident #1, so Resident #1 pulled out a knife in defense, EMS was called. The DON and the Administrator were both notified. The Maintenance supervisor was in the facility and notified and retrieved knife from Resident #1. EMS and the local police department went to the facility. Resident #2 was sent out via EMS transport to the local hospital for evaluation and treatment. A full skin assessment was completed on Resident #2 and Resident #1. Resident #2 wounds were cleaned and wound to right hand was wrapped in gauze while waiting for EMS arrival. The MD was notified, police retrieved a second pocketknife from Resident #1, secured at the nurse station. Both residents were stable, alert, and oriented, in no acute distress at time of EMS arrival. -On 12/13/23 at 11:10am; completed by DON: Resident #2 returned to facility via facility transport van, was placed on one-on-one supervision with CNA. The behavioral hospital was contacted, referral sent, awaiting response. -On 12/13/23 at 3:42pm; completed by DON: The Behavioral hospital health liaison was in facility to evaluate Resident #1; continued one-on-one supervision. -On 12/13/23 at 4:18pm; completed by LVN G: Resident #2 with no outburst since beginning of shift. Quiet with no facial, and with no behaviors noted. -On 12/13/23 at 4:40pm; completed by DON: Resident #2 was sent out via facility van to the behavioral hospital for voluntary admission; his belonging was sent with Resident #2 and report was called to the acute behavioral hospital. During an interview on 12/15/23 at 1:48 p.m., LVN B said she was working as the charge nurse the day of the incident and CNA C heard yelling and went to Resident #1 and Resident #2's room, CNA C came and got her and that's when she saw Resident #2 on top of Resident #1 and Resident #1 was stabbing Resident #2. LVN B said they separated the residents, assessed the residents, the Maintenance Director retrieved Resident #1's knife, she called 911 and EMS took Resident #2 to the ER for evaluation and stiches. LVN B said Resident #2 has had increased confusion for about a year. Resident #2 was on psych services; he did have occasional aggression and would be verbally aggressive with staff when they assisted with bathing. LVN B said Resident #2 was schizophrenic, had anxiety disorder and had been involved in possibly two prior incidents. LVN B said Resident #1 rarely left his room or got out of bed, she said Resident #1 did not bother anyone. She said she was not aware Resident #1 had weapons prior to incident, she said the residents were not allowed to have weapons or knives. LVN B said Resident #1 told staff he had another knife and facility found two additional pocketknives that belonged to Resident #1. During an interview on 12/18/23 at 1:13 p.m., CNA C said the day of the day of the incident around 4:30am Resident #1 was upset she entered his room to do patient care on Resident #2. CNA C said Resident #2 pressed the call lights around 6:30amish, CNA C said she answered the call light, she said Resident #1 was upset and made the comment to her that she had already came to the fucking room at 4:30am ; Resident #2 requested for her to turn off the lights so he could get some sleep, she said told him it was time for breakfast and to leave the lights on, she said Resident #2 insisted she turned the lights off so she asked Resident #1 if it was okay to turn the lights off and Resident #1 said no he wanted the lights to stay on. CNA C said about 15 or 20 minutes later she heard a resident screaming help, she said she walked the halls to see who was yelling for help. CNA C she opened the door to Resident #1 and Resident #2's room and seen Resident #2 standing over Resident #1 who was in bed with the head elevated and was stabbing Resident #2 with a knife. CNA C said she yelled for the residents to stop as she stood in the doorway and then she yelled for help. CNA C said LVN B and CMA F immediately came to assist and separated the residents. CNA C said she normally worked the night shifts, and the residents were normally sleep and no issues. CNA C said after they separated the residents, she noticed Resident #2's hand was bleeding so she went and grabbed a sheet to wrap his hand and then LVN B took over and explained to Resident #2 that he needed to go to the hospital so they can look at his wound. CNA C said she observed Resident #1 had a bruise on left side of his neck or chest area but no wounds to her knowledge. She said Resident #1 told her he called the police because he was attacked by Resident #2. During an interview on 12/15/23 at 1:14 p.m., CNA E said she did not witness the incident between Resident #1 and Resident #2, but she was familiar with both residents. She said Resident #1 stayed to himself, only used the call light for patient care or whenever he needed a muscle relaxer for pain. She said Resident #1 stayed in bed and she did not have any issues with him. CNA E said recently Resident #2 behaviors had changed and he was verbally aggressive with other residents and staff. She said she would tell the nurses, not sure if they did anything about it. CNA E said for example if another resident asked Resident #2 a question or would speak to him, Resident #2 would become verbally aggressive, she noticed a change in behavior about two or three months ago. CNA E said she was not aware Resident #1 had any weapons, if she did, she would have told someone or got it from him. During an interview on 12/15/23 at 1:25 p.m., CMA F said she was familiar with Resident #1 and Resident #2. She Said Resident #1 occasionally was verbally aggressive with staff, but not with other residents. CMA F said Resident #2 was always rude and appeared bothered like or annoyed if anyone asked him a question or would speak to him. CMA F said she worked the morning of the incident but did not witness anything or did not assist with breaking up the residents. During an interview on 12/18/23 at 1:56 p.m., CNA D said she did not witness the incident between Resident #1 and Resident #2, but she was familiar with both of the residents. CNA D said Resident #1 stayed to himself, he was not mean and did not easily get mad, she Resident #1 did not give her any issues. Resident #2 was a sweet resident, she said she had seen Resident #2 ger upset and curse at other residents before. CNA D said she had seen Resident #2 slap another resident about a year ago in he outside smoking area. She said the incident also started off verbally because both residents were cursing, then she witnessed Resident #2 slap the other resident who he was arguing with, She said she immediately removed Resident #2 and brought him back to his room and told LVN G; CNA D said at that time the facility did not have a designated staff for residents smoking, she said she was cutting through the smoke area to go to the dining room whenever she witnessed the incident. She said she had a great relationship with Resident #2, and she did not have issues with Resident #2 and was to redirect. CNA D said Resident #2 did get upset easily; Example: If something was wrong with Resident #2 meals, or if he disliked the meal, he would start yelling and cursing. Example #2: If Resident #2 felt staff took to long to respond to his call lights (5 minutes), Resident #2 would yell, curse and get upset. Overall, Resident #2 was sweet resident, but when Resident #2 accidentally urine on himself he would say No if she wanted to assist with patient care. CNA D said she was not surprised Resident #2 had a physical altercation with another resident. She said surprised Resident #1 was in an altercation with another resident, and that Resident #2 had to do something bad for Resident #1 to have responded like that. CNA D said she did not recall previous incidents with Resident #1. During an interview on 12/18/23 at 3:34 p.m., LVN G said she did not witness the incident between Resident #1 and Resident #2. LVN G said she did not have any issues with the residents and both residents were impatient and did not like to wait. She said the residents were not aggressive. LVN G said she did not recall any prior physical altercations incidents involving Resident #2. LVN G said was not aware of any residents having a knife or weapon. She said she considered a pocketknife to be a weapon. During an interview on 12/18/23 at 12:07 p.m., The Maintenance Supervisor said he did not see anything regarding the actual incident. He said the morning of the incident LVN B came to him around 6:45 am for assisting with a resident who had a knife. The maintenance Supervisor said both Resident #1 and Resident #2 were calm, and he saw blood from nurse station to the room. He said Resident #1 was still in the room and whenever he entered the room, he said he asked Resident #1 for the knife, and he willingly handed over a grey/silver like colored pocketknife that was on the overbed table put the knife in a rubber glove and The Maintenance Supervisor said he handed the pocketknife over to the Administrator. He said Resident #2 was standing at the nurse station. The maintenance Supervisor said he had no prior knowledge or issues with the residents and was not aware Resident #1 had a knife prior to the incident. During an interview on 12/18/19 at 1:44 p.m. and at 3:43 p.m., The DON said Resident #1 told her he knew he was not supposed to have the knife but he used the pocket knife to cut his meats, due to right side weakness and his right hand used to be his dominate hand but now had to used his left hand as the dominate hand and when cutting meat with his left hand it was hard to do with the facility utensils so he used a pocket knife to cut meat and it was easier. DON said she was not aware he had a knife and said the residents were not allowed to have knives. She said she asked Resident #1 where she got the knife, and he told her a friend gave it to her but would not give a name and she did not know how long he had it the knives. The DON described Resident #1 as a resident who stayed to himself, and he rarely left his bed. The DON described Resident #2 as impulsive and did not like to wait and would want things one right then and there. The DON said Resident #2 would revolve around his smoke breaks and he was easily agitated. She said he was being treated for UTI during the incident between Resident #1 and Resident #2 and she was surprised the residents had a physical altercation because it was out of character for both residents. The DON said the police did not blame Resident #1 and considered Resident #1 as being the victim who was attacked and used the knife for self-defense against Resident #2 who physically attacked Resident #1. The DON called and left messages for the nurses at both behavioral hospitals for Resident #1 and Resident #2 for to speak with state surveyor, no return calls. During an interview on 12/18/23 at 4:03 p.m., The Administrator described Resident #1 as being calm, no issues; he described Resident #2 as having short term memory, and only programed to know smoke times only. The Administrator said was agitated or verbally aggressive with staff if it interfered with his smoke breaks. He said he recalled an incident when Resident #2 was wet and the Administrator asked Resident #2 to let staff assist with getting him cleaned up before going to smoke and Resident #2 would become loud and yell Go to hell, leave me alone mother fucker. The Administrator said he was the abuse coordinator and said he had not spoke with the other residents or staff regarding the weapon prohibition policy, nor did a room sweep for weapons. The administrator said on 12/19/23 he planned on meeting with the residents to go over weapon policy and if explained if they were caught with any type of weapons they would be discharged . The Administrator said he was going to in-service staff on 12/19/23 on what to do if they see a weapon. The Administrator said he was not aware Resident #1 had a pocketknife and the residents were not allowed to have pocketknives or any knives or weapons. He said he did consider a pocketknife to be a weapon. He said Resident #1 told him he had always had the pocketknives. Record review firearm and weapon prohibition policy dated 07/2022 revealed Policy: A safe and secure environment is fundamental for fulfilling our company's mission of providing medical care and related health care services. Our company is committed to maintaining a safe workplace that is free of violence. Intent of Policy: To prevent the unauthorized possession of weapon(s) while on facility premises. Policy Explanation and Compliance Guidelines: 1. While on any part of our company's premises, individuals are prohibited from introducing, possessing, using, buying, or selling unauthorized weapons, firearms, ammunition, explosives, or any other item(s) deemed by management to be dangerous. 2.) The following definitions apply in the enforcement of this policy: a.) An employee is defined as any company employee regardless of employment status (e.g., full/part-time, consultant, temporaries, etc.). b.) Visitors include, but are not limited to, family members, visitors for staff, vendors, etc. c.) Residents are also included in this policy. 3.) Any employee who becomes aware of a violation of this policy is required to immediately notify his/her supervisor of such violation. 4.) Violation of this policy is considered a serious offense that endangers the safety of our patients, staff, and visitors. Therefore, this offense may result in termination of employment and criminal prosecution. Record review of accident and supervision policy dated 2023 revealed Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1) Identifying hazard(s) and risk(s). 2) Evaluating and analyzing hazard(s) and risk(s). 3) Implementing interventions to reduce hazard(s) and risk(s). 4) Monitoring for effectiveness and modifying interventions when necessary. Definitions: Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident. Environment refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas . Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. A) All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. B) The facility should make a reasonable effort to identify the hazards and risk factors for each resident. C) Various sources provide infom1ation about hazards and risks in the resident environment, d) These sources may include, but are not limited to: i. Quality assessment and assurance (QAA) activities ii. Environmental rounds iii. MDS/CAA data iv. Medical history v. Physical exam vi. Facility assessment vii. Individual observation e. This information is to be documented and communicated across all disciplines.

Based on interview, and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse. The facility did not follow facility policy by suspending or removing the CNA B from the premises after allegations of abuse were made. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 8/11/23 at 4:15 p.m. While the IJ was removed on 8/13/23, the facility remained out of compliance at no actual harm that is not immediate 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. This failure could place the resident at risk for unreported allegations of abuse, neglect, and injuries of unknown origin, and further abuse by the alleged perpetrator. Findings included: 1. Record review of the facility's Abuse Investigation and Reporting policy dated 7/2022 indicated, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation .D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. E. Protection from retaliation .Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specific time frames: a. Immediately, but no later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in seriously bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in seriously bodily injury. Record review of the face sheet orders dated 8/08/23 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, amputation of right and left leg below the knee, muscle weakness, lack of coordination, and anxiety. Record review of the MDS assessment dated [DATE] indicated Resident # 1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility. The MDS did not indicate Resident #1 used limb prosthesis (artificial device that replaces a missing body part) for mobility. Record review of the care plan last updated 7/14/23 indicated Resident #1 had an ADL self-care deficit with interventions including resident requires 1 staff member to assist with transfers and resident requires 1-2 staff members to assist with bed mobility. Record review of CNA B's time sheets from 8/05/23 through 8/08/23 indicated she worked the following shifts/hours: 8/05/23-5:56 a.m. to 2:12 p.m. 8/06/23-6:01 a.m. to 2:05 p.m. 8/07/23-6:02 a.m. to 1:16 p.m. 8/08/23-5:50 a.m. to 12:36 p.m. Record review in TULIP on 8/08/23 indicated there was not a facility report regarding abuse for Resident #1. During an interview on 8/08/23 at 11:17 a.m. RN A said she started at the facility in 2023. RN A said the weekend of August 4-6th she had witnessed abuse to Resident #1. RN A said CNA B had asked her to help get Resident #1 up about 7:00 a.m. RN A said Resident #1 was a double amputee and needed assistance with his prosthetics. RN A said Resident #1 could not hold his legs up at the same time as he was a large man. RN A said she got one prosthetic on and CNA B was trying to put on the other prosthetic and Resident #1 could not lift his leg. RN A said CNA B slapped the Resident #1's leg, cursed at him, and referred to him as an idiot. RN A said she asked CNA B to leave the room and she finished putting the other prosthetic on for Resident #1. RN A said she reported the incident to the DON and was informed to call the Administrator. RN A said she called the Administrator and left a message regarding the alleged abuse and had to leave him a message. RN A said she called the Administrator back on Monday and left another message. During an interview on 8/08/23 at 11:24 a.m. Resident #1 said there might have been an issue over assisting him with putting his prosthetic legs on over the weekend. Resident #1 said if someone had cussed him he would not have heard it because he chooses not to hear those words and said he does not know those type of words. Resident #1 said the surveyor would have to ask the staff about what happened and he was not saying anything. During an interview on 8/08/23 at 12:53 p.m. the DON said CNA B had been suspended on 8/08/23 pending investigation of abuse allegation. The DON said the abuse allegation was involving Resident #1 and happened over the weekend of August 4-6, 2023. The DON said she had been notified by RN A on 8/05/23 of the alleged abuse by CNA B to Resident #1. The DON said she advised RN A to contact the Administrator who was the Abuse Coordinator. The DON said she never told the Administrator of the alleged abuse because she was under the impression RN A had reported to him. During an interview on 8/08/23 at 12:54 p.m. the Administrator said CNA B had been suspended on 8/08/23 pending investigation of alleged abuse of Resident #1. The Administrator said he had spoken to RN A on 8/08/23 regarding the allegation of abuse. The Administrator said RN A had called and left him messages stating she need to speak with him. The Administrator said he was not aware she needed to speak with him regarding an abuse allegation. During an interview on 8/11/23 at 1:18 p.m. RN A said when the incident occurred on 8/05/23 with Resident #1 and CNA B she asked CNA B to leave the room but did not ask CNA B to leave the premises. RN A said she contacted the DON, reported what had happened, and asked if she needed to document anything or do anything else. RN A said the DON told her not to do anything else or document anything but to call the Administrator who was the Abuse Coordinator to report the incident. RN A said CNA B worked the rest of her shift on 8/05/23. Record review on 8/11/23 in TULIP indicated the allegation of abuse of Resident #1 by CNA B had not been reported to the state agency by the facility. 2. Record review of the face sheet dated 8/11/23 indicated Resident #2 was a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), muscle weakness, lack of coordination, and glaucoma (an eye condition where the nerve connecting the eye to the brain is damaged, usually due to high eye pressure, and can cause blindness) Record review of the MDS dated [DATE] indicated Resident #2 usually understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Record review of the care plan dated 6/12/23 indicated Resident #2 had a potential for an activities of daily living self-care performance deficit. Record review of a grievance dated 7/13/23 indicated the Social Worker from Resident #2's dialysis center reported to the facility that Resident #2 informed the dialysis center that CNA B had cursed her and pulled her leg causing pain. The grievance indicated the facility's resolutions were to have Resident #2 be a two-person transfer, not have CNA B provide care to Resident #2, and refer to psych services to ensure she is psychosocially and emotionally stable. During an interview on 8/11/23 at 3:06 p.m. the DON said CNA B did not get immediately suspended following the allegation of abuse against Resident #1. The DON said she instructed RN A to get CNA B out of Resident #1's room and CNA B was not to provide care for Resident #1. The DON said CNA B worked the rest of her shift on 8/05/23 and her scheduled shifts 8/06/23, 8/07/23, and 8/08/23 until suspension on 8/08/23. The DON said she worked the floor on 8/06/23 and CNA B did not interact with Resident #1. The DON said she did not follow up with the Administrator regarding the allegation of abuse because RN A said she had left a message for the Administrator and since she never heard back from RN A she assumed RN A had spoken with the Administrator. The DON said she was aware of the allegation of abuse made by the dialysis center's Social Work against CNA B. The DON said CNA B was working the date of 7/13/23 and completed her entire shift. The DON said since Resident #2 was at dialysis CNA B was not a threat to her pending investigation. The DON said CNA B's shift had ended and she was not at the facility when Resident #2 returned from dialysis. The DON said CNA B was permitted to return to work the next day (7/14/23) as it was determined no abuse occurred during the investigation. During an interview on 8/11/23 at 3:17 p.m. Resident #2 said the incident on 7/13/23 had been taken care of by the facility. Resident #2 said CNA B no longer provided care for her. Resident #2 said she needed assistance with sitting up and transferring. Resident #2 said CNA B would drop her legs and let them fall to the floor via gravity and not provide her support for sitting upright when transferring her. Resident #2 said CNA B called her a heifer. During an interview on 8/11/23 at 3:26 p.m. the Administrator said he did not return RN A's phone call on 8/05/23 because he was out of town. The Administrator said he did not see the message from RN A until Monday, 8/07/23. The Administrator said he returned RN A's phone call on Tuesday, 8/08/23. The Administrator said he would have expected the DON to suspend CNA B pending investigation after the allegation of abuse on 8/05/23. The Administrator said the grievance filed on 7/13/23 regarding CNA B and Resident #2 would be considered an allegation of abuse. The Administrator said Resident #2 was interviewed upon her return to the facility from dialysis and Resident #2 relayed a different story than what the Dialysis Social Worker reported. The Administrator said CNA B was not suspended following the allegation of abuse on 7/13/23 and the allegation was not reported to the state agency. The Administrator was notified on 8/11/23 at 5:10 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 8/11/23 at 5:13 p.m. The facility's Plan of Removal was accepted on 8/13/23 at 1:35 p.m. and included: 1. Immediate action(s) taken for the resident(s) found to have been affected include: A thorough investigation was conducted by the facility Administrator regarding the allegations made by resident #1 and Resident #2. CNA B was terminated upon investigation on 08/08/23. Staffing patterns were adjusted to assure the protection of the resident. The director of nursing assessed resident #1 and resident #2 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the RDCO, for Director of Nursing Services and the Administrator with all direct care and ancillary staff addressing the facility policies and procedures regarding alleged violations (8/12/23). The RDCO in-serviced the Administrator, DON, ADON, and social worker (8/11/23). This included the facility abuse policy, the timeframe for reporting abuse is within 2 hours of the time the abuse coordinator was made aware of the abuse allegation. The abuse coordinator, or RDCO in the absence of the abuse coordinator will begin the investigation immediately. This includes, Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation The results of the investigation must be reported within 5 days of alleged abuse allegation to DHHS. This was completed 08/12/23. The abuse policy was not revised, a separate in-service for the Administrator and Social Worker included the importance of reporting timely, and notification of RDCO if abuse coordinator was going to be unavailable, (8/11/23). No staff will be allowed to work until their training is completed. The abuse policy states that the alleged perpetrator should be immediately removed from the facility pending investigation, by a staff member. This was emphasized during the in-service (8/11/23). 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any alleged violations are identified, properly investigated and reported according to facility policy and procedures. Findings of this audit will be discussed weekly with the abuse coordinator. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. Corrective action completion date: 08/11/2023. On 8/13/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews with staff on 8/13/23 between 5:21 p.m. and 7:22 p.m. (CNA C, RN D, CNA E, Dietary Aide F, Cook G, Hospitality Aide H, Housekeeper J, RN A, LVN K, CNA L, Housekeeping Supervisor M, DON ,CNA O, Social Worker, and the Administrator) were performed. During the interviews staff were able to identify policies and procedures of the facility's Abuse and Neglect policy including reporting to the Abuse Coordinator, protecting the residents, and having alleged perpetrators leave the facility pending investigation. The Administrator, DON, and Social Worker were able to identify proper time frames in reporting allegations of abuse to the state agency and investigation protocols for allegations of abuse. On 8/13/23 at 7:35 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm that is not immediate 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 investigate allegations of abuse and prevent further potential abuse for 2 of 7 (Resident #1 and Resident #2) reviewed for abuse investigations. The facility failed to investigate allegation of physical and verbal abuse to Resident #1 and Resident #2 from CNA B. The facility failed to remove the alleged perpetrator (CNA B) from the facility to protect the residents from abuse. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 8/11/23 at 4:15 p.m. While the IJ was removed on 8/13/23, 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 result in residents experience serious harm, impairment, or death due to facility failure of thoroughly investigating abuse allegations and protecting residents from alleged perpetrators. Findings Included: 1. Record review of the face sheet orders dated 8/08/23 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, amputation of right and left leg below the knee, muscle weakness, lack of coordination, and anxiety. Record review of the MDS dated [DATE] indicated Resident # 1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility. The MDS did not indicate Resident #1 used limb prosthesis (artificial device that replaces a missing body part) for mobility. Record review of the care plan last updated 7/14/23 indicated Resident #1 had an ADL self-care deficit with interventions including resident requires 1 staff member to assist with transfers and resident requires 1-2 staff members to assist with bed mobility. Record review of CNA B's time sheets from 8/05/23 through 8/08/23 indicated she worked the following shifts/hours: 8/05/23-5:56 a.m. to 2:12 p.m. 8/06/23-6:01 a.m. to 2:05 p.m. 8/07/23-6:02 a.m. to 1:16 p.m. 8/08/23-5:50 a.m. to 12:36 p.m. During an interview on 8/08/23 at 11:17 a.m. RN A said she started at the facility in 2023. RN A said the weekend of August 4-6th she had witnessed abuse to Resident #1. RN A said CNA B had asked her to help get Resident #1 up about 7:00 a.m. RN A said Resident #1 was a double amputee and needed assistance with his prosthetics. RN A said Resident #1 could not hold his legs up at the same time as he was a large man. RN A said she got one prosthetic on and CNA B was trying to put on the other prosthetic and Resident #1 could not lift his leg. RN A said CNA B slapped the Resident #1's leg, cursed at him, and referred to him as an idiot. RN A said she asked CNA B to leave the room and she finished putting the other prosthetic on for Resident #1. RN A said she reported the incident to the DON and was informed to call the Administrator. RN A said she called the Administrator and left a message regarding the alleged abuse and had to leave him a message. RN A said she called the Administrator back on Monday and left another message. During an interview on 8/08/23 at 11:24 a.m. Resident #1 said there might have been an issue over assisting him with putting his prosthetic legs on over the weekend. Resident #1 said if someone had cussed him he would not have heard it because he chooses not to hear those words and said he does not know those type of words. Resident #1 said the surveyor would have to ask the staff about what happened and he was not saying anything. During an interview on 8/08/23 at 12:53 p.m. the DON said CNA B had been suspended on 8/08/23 pending investigation of abuse allegation. The DON said the abuse allegation was involving Resident #1 and happened over the weekend of August 4-6, 2023. The DON said she had been notified by RN A on 8/05/23 of the alleged abuse by CNA B to Resident #1. DON said she advised RN A to contact the Administrator who was the Abuse Coordinator. The DON said she never told the Administrator of the alleged abuse because she was under the impression RN A had reported to him. During an interview on 8/08/23 at 12:54 p.m. the Administrator said CNA B had been suspended on 8/08/23 pending investigation of alleged abuse of Resident #1. The Administrator said he had spoken to RN A on 8/08/23 regarding the allegation of abuse. The Administrator said RN A had called and left him messages stating she need to speak with him. The Administrator said he was not aware she needed to speak with him regarding an abuse allegation. During an interview on 8/11/23 at 1:18 p.m. RN A said when the incident occurred on 8/05/23 with Resident #1 and CNA B she asked CNA B to leave the room but did not ask CNA B to leave the premises. RN A said she contacted the DON, reported what had happened, and asked if she needed to document anything or do anything else. RN A said the DON told her not to do anything else or document anything but to call the Administrator who was the Abuse Coordinator to report the incident. RN A said CNA B worked the rest of her shift on 8/05/23. 2. Record review of the face sheet dated 8/11/23 indicated Resident #2 was a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), muscle weakness, lack of coordination, and glaucoma (an eye condition where the nerve connecting the eye to the brain is damaged, usually due to high eye pressure, and can cause blindness) Record review of the MDS dated [DATE] indicated Resident #2 usually understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Record review of the care plan dated 6/12/23 indicated Resident #2 had a potential for an activities of daily living self-care performance deficit. Record review of a grievance dated 7/13/23 indicated the Social Worker from Resident #2's dialysis center reported to the facility that Resident #2 informed the dialysis center that CNA B had cursed her and pulled her leg causing pain. The grievance indicated the facility's resolutions were to have Resident #2 be a two-person transfer, not have CNA B provide care to Resident #2, and refer to psychiatric services to ensure she is psychosocially and emotionally stable. During an interview on 8/11/23 at 3:06 p.m. the DON said CNA B did not get immediately suspended following the allegation of abuse against Resident #1. The DON said she instructed RN A to get CNA B out of Resident #1's room and CNA B was not to provide care for Resident #1. The DON said CNA B worked the rest of her shift on 8/05/23 and her scheduled shifts 8/06/23, 8/07/23, and 8/08/23 until suspension on 8/08/23. The DON said she worked the floor on 8/06/23 and CNA B did not interact with Resident #1. The DON said she did not follow up with the Administrator regarding the allegation of abuse because RN A said she had left a message for the Administrator and since she never heard back from RN A she assumed RN A had spoken with the Administrator. The DON said she was aware of the allegation of abuse made by the dialysis center's Social Work against CNA B. The DON said CNA B was working the date of 7/13/23 and completed her entire shift. The DON said since Resident #2 was at dialysis CNA B was not a threat to her pending investigation. The DON said CNA B's shift had ended and she was not at the facility when Resident #2 returned from dialysis. The DON said CNA B was permitted to return to work the next day (7/14/23) as it was determined no abuse occurred during the investigation. The DON said the investigation of Resident #2's allegation of abuse consisted of an interview with Resident #2 upon her return from dialysis. During an interview on 8/11/23 at 3:17 p.m. Resident #2 said the incident on 7/13/23 had been taken care of by the facility. Resident #2 said CNA B no longer provided care for her. Resident #2 said she needed assistance with sitting up and transferring. Resident #2 said CNA B would drop her legs and let them fall to the floor via gravity and not provide her support for sitting upright when transferring her. Resident #2 said CNA B called her a heifer. During an interview on 8/11/23 at 3:26 p.m. the Administrator said he did not return RN A's phone call on 8/05/23 because he was out of town. The Administrator said he did not see the message from RN A until Monday, 8/07/23. The Administrator said he returned RN A's phone call on Tuesday, 8/08/23. The Administrator said he would have expected the DON to suspend CNA B pending investigation after the allegation of abuse on 8/05/23. The Administrator said the grievance filed on 7/13/23 regarding CNA B and Resident #2 would be considered an allegation of abuse. The Administrator said Resident #2 was interviewed upon her return to the facility from dialysis and Resident #2 relayed a different story than what the Dialysis Social Worker reported. The Administrator said CNA B was not suspended following the allegation of abuse on 7/13/23. Record review of the facility's Abuse Investigation and Reporting policy dated 7/2022 indicated, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation .D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. E. Protection from retaliation .Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specific time frames: a. Immediately, but no later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in seriously bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in seriously bodily injury. The Administrator was notified on 8/11/23 at 5:10 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 8/11/23 at 5:13 p.m. The facility's Plan of Removal was accepted on 8/13/23 at 1:35 p.m. and included: 5. Immediate action(s) taken for the resident(s) found to have been affected include: Resident #1 and resident #2 physician and the resident's responsible party were notified promptly upon completion of the assessment by the Director of Nursing/Facility Administrator 08/08/23. A thorough investigation was initiated by the facility Administrator on 08/08/23. Safe surveys for residents were completed to ensure that no other allegations of abuse were voiced by residents on 8/11/23. The facility administrator and director of nursing interviewed resident #1 and resident #2. Interview statements were documented (08/08/23). The director of nursing completed the safe survey assessments on resident #1 and resident #2. (08/11/23) Identification of other residents having the potential to be affected was accomplished by the facility administrator/abuse coordinator (8/12/23). The facility has determined that all residents have the potential to be affected. 6. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the Regional Director of Clinical Operations with the Administrator addressing circumstances that require reporting for timely investigations, and his responsibilities related to investigations. (08/11/23). The administrator was in-serviced regarding reporting any allegation of abuse within 2 hours of learning of the allegation. The entire abuse policy, emphasizing that the alleged perpetrator should be removed from the facility immediately pending investigation. The facility administrator was educated by the RDCO regarding procedures for investigating potential abuse including, identifying the alleged perpetrator based on resident and staff interviews. Obtaining written statements from all staff witnesses and within immediate vicinity of alleged victim, the alleged perpetrator, as well as the victim statement. Facility administrator was also educated on investigating differed types of alleged violations, focusing on the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause and providing thorough documentation of the investigation, per facility abuse policy on (8/11/23). When an allegation of abuse has been identified, a staff member will stay with the resident until the alleged perpetrator is escorted from the facility by another staff member, pending investigation. Staff were in-serviced on the facility abuse policy, emphasizing this procedure, by the RDCO, Administrator, DON, and ADON on 8/11/23. The facility social worker will be in-serviced by the Administrator/RDCO prior to returning to work, regarding his responsibility regarding reporting any allegations of abuse to the abuse coordinator immediately. The social worker receives grievances from outside the facility. The social worker was in-serviced by the RDCO on immediately reporting any allegation of abuse to the abuse coordinator immediately so it can be investigated by the Abuse Coordinator/Facility Administrator. Education completed by RDCO/Facility Administrator 08/12/23 7. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any injuries are identified, properly investigated, and reported to the appropriate people. Findings of this audit will be discussed with the IDT team. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. Corrective action completion date: 08/11/23. On 8/13/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews with staff on 8/13/23 between 5:21 p.m. and 7:22 p.m. (CNA C, RN D, CNA E, Dietary Aide F, Cook G, Hospitality Aide H, Housekeeper J, RN A, LVN K, CNA L, Housekeeping Supervisor M, DON ,CNA O, Social Worker, and the Administrator) were performed. During the interviews staff were able to identify policies and procedures of the facility's Abuse and Neglect policy including reporting to the Abuse Coordinator, protecting the residents, and having alleged perpetrators leave the facility pending investigation. The Administrator, DON, and Social Worker were able to identify proper times frame in reporting allegations of abuse to the state agency and investigation protocols for allegations of abuse. Interview with Resident #1 and Resident #2 on 8/13/23 between 7:08 p.m. and 7:12 p.m. were performed. Resident #1 and Resident #2 both said they had no complaints or issues at this time. On 8/13/23 at 7:35 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse. The facility failed to protect Resident #1 and Resident #2 from verbal and physical abuse by CNA B. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 8/11/23 at 4:15 p.m. While the IJ was removed on 8/13/23, the facility remained out of compliance at no actual harm that is not immediate 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. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings Included: 1. Record review of the face sheet orders dated 8/08/23 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, amputation of right and left leg below the knee, muscle weakness, lack of coordination, and anxiety. Record review of the MDS dated [DATE] indicated Resident # 1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility. The MDS did not indicate Resident #1 used limb prosthesis (artificial device that replaces a missing body part) for mobility. Record review of the care plan last updated 7/14/23 indicated Resident #1 had an ADL self-care deficit with interventions including resident requires 1 staff member to assist with transfers and resident requires 1-2 staff members to assist with bed mobility. Record review of CNA B's time sheets from 8/05/23 through 8/08/23 indicated she worked the following shifts/hours: 8/05/23-5:56 a.m. to 2:12 p.m. 8/06/23-6:01 a.m. to 2:05 p.m. 8/07/23-6:02 a.m. to 1:16 p.m. 8/08/23-5:50 a.m. to 12:36 p.m. During an interview on 8/08/23 at 11:17 a.m. RN A said she started at the facility in 2023. RN A said the weekend of August 4-6th she had witnessed abuse to Resident #1. RN A said CNA B had asked her to help get Resident #1 up about 7:00 a.m. RN A said Resident #1 was a double amputee and needed assistance with his prosthetics. RN A said Resident #1 could not hold his legs up at the same time as he was a large man. RN A said she got one prosthetic on and CNA B was trying to put on the other prosthetic and Resident #1 could not lift his leg. RN A said CNA B slapped the Resident #1's leg, cursed at him, and referred to him as an idiot. RN A said she asked CNA B to leave the room and she finished putting the other prosthetic on for Resident #1. RN A said she reported the incident to the DON and was informed to call the Administrator. RN A said she called the Administrator and left a message regarding the alleged abuse and had to leave him a message. RN A said she called the Administrator back on Monday and left another message. During an interview on 8/08/23 at 11:24 a.m. Resident #1 said there might have been an issue over assisting him with putting his prosthetic legs on over the weekend. Resident #1 said if someone had cussed him he would not have heard it because he chooses not to hear those words and said he does not know those type of words. Resident #1 said the surveyor would have to ask the staff about what happened and he was not saying anything. During an interview on 8/08/23 at 12:53 p.m. the DON said CNA B had been suspended on 8/08/23 pending investigation of abuse allegation. The DON said the abuse allegation was involving Resident #1 and happened over the weekend of August 4-6, 2023. The DON said she had been notified by RN A on 8/05/23 of the alleged abuse by CNA B to Resident #1. The DON said she advised RN A to contact the Administrator who was the Abuse Coordinator. During an interview on 8/08/23 at 12:54 p.m. the Administrator said CNA B had been suspended on 8/08/23 pending investigation of alleged abuse of Resident #1. The Administrator said he had spoken to RN A on 8/08/23 regarding the allegation of abuse. 2. Record review of the face sheet dated 8/11/23 indicated Resident #2 was a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), muscle weakness, lack of coordination, and glaucoma (an eye condition where the nerve connecting the eye to the brain is damaged, usually due to high eye pressure, and can cause blindness). Record review of the MDS dated [DATE] indicated Resident #2 usually understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Record review of the care plan dated 6/12/23 indicated Resident #2 had a potential for an activities of daily living self-care performance deficit. Record review of a grievance dated 7/13/23 indicated the Social Worker from Resident #2's dialysis center reported to the facility that Resident #2 informed the dialysis center that CNA B had cursed her and pulled her leg causing pain. The grievance indicated the facility's resolutions were to have Resident #2 be a two-person transfer, not have CNA B provide care to Resident #2, and refer to psych67 services to ensure she is psychosocially and emotionally stable. During an interview on 8/11/23 at 3:06 p.m. the DON said CNA B did not get immediately suspended following the allegation of abuse against Resident #1. The DON said she instructed RN A to get CNA B out of Resident #1's room and CNA B was not to provide care for Resident #1. The DON said CNA B worked the rest of her shift on 8/05/23 and her scheduled shifts 8/06/23, 8/07/23, and 8/08/23 until suspension on 8/08/23. The DON said she worked the floor on 8/06/23 and CNA B did not interact with Resident #1. The DON said she did not follow up with the Administrator regarding the allegation of abuse because RN A said she had left a message for the Administrator and since she never heard back from RN A she assumed RN A had spoken with the Administrator. The DON said she was aware of the allegation of abuse made by the dialysis center's Social Work against CNA B. The DON said CNA B was working the date of 7/13/23 and completed her entire shift. The DON said since Resident #2 was at dialysis CNA B was not a threat to her pending investigation. The DON said CNA B's shift had ended and she was not at the facility when Resident #2 returned from dialysis. The DON said CNA B was permitted to return to work the next day (7/14/23) as it was determined no abuse occurred during the investigation. During an interview on 8/11/23 at 3:17 p.m. Resident #2 said the incident on 7/13/23 had been taken care of by the facility. Resident #2 said CNA B no longer provided care for her. Resident #2 said she needed assistance with sitting up and transferring. Resident #2 said CNA B would drop her legs and let them fall to the floor via gravity and not provide her support for sitting upright when transferring her. Resident #2 said CNA B called her a heifer. During an interview on 8/11/23 at 3:26 p.m. the Administrator said he did not return RN A's phone call on 8/05/23 because he was out of town. The Administrator said he did not see the message from RN A until Monday, 8/07/23. The Administrator said he returned RN A's phone call on Tuesday, 8/08/23. The Administrator said he would have expected the DON to suspend CNA B pending investigation after the allegation of abuse on 8/05/23. The Administrator said the grievance filed on 7/13/23 regarding CNA B and Resident #2 would be considered an allegation of abuse. The Administrator said Resident #2 was interviewed upon her return to the facility from dialysis and Resident #2 relayed a different story than what the Dialysis Social Worker reported. The Administrator said CNA B was not suspended following the allegation of abuse on 7/13/23 and the allegation was not reported to the state agency. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 2023 indicated, It is the policy of this facility to provide protection for the health, welfare, and right of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish, which can include staff to resident and certain resident to resident altercations .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations .The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written . The Administrator was notified on 8/11/23 at 5:10 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 8/11/23 at 5:13 p.m. The facility's Plan of Removal was accepted on 8/13/23 at 1:35 p.m. and included: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. RDCO in-serviced Administrator, Director of Nurses, and ADON on Abuse Policy and Implementation of Abuse Policy, as well as addendum related to reporting in the absence of the abuse coordinator. Emphasized the fact, when an allegation of abuse has been made, the alleged perpetrator is to be immediately suspended and must leave the facility until the investigation has been completed by the abuse coordinator. (Completion Date: 08/11/23) 2. Safe Surveys were completed on residents to identify any evidence of abuse or neglect. Concerns were not identified. Resident #1 and Resident #2 were interviewed by the DON, safe survey completed to ensure no psychological harm was done. No psychological harm was done, per resident #1 and resident #2 (completed 8/12/23). RN A assessed resident #1 on 08/12/23. Wound Care Nurse assessed resident #2 head to toe to ensure no physical harm was done. 08/11/23. 3. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 08/11/23) Disciplinary action was taken with staff member accused of abuse (staff member was terminated following investigation 08/08/23). (Statement received from witness RN who was in the room with C NA B Same alleged perpetrator for incident on 08/08/23 and abuse allegation from resident #2 on 07/13/23.C NA B was terminated by the administrator on 8/8/23). Alleged abuse was reported to DHHS on 08/08/2023. Administrator reported alleged abuse of resident #2 to HHSC on 08/12/23. Residents were interviewed/assessed by Administrator, DON, ADON to identify if they felt safe and if they had experienced abuse while living at the facility. Concerns were not identified. (08/11/23). Abuse policies were reviewed and additional in service was added for Administrator, Social Worker, ADON, to include: if abuse coordinator is not available, the DON will notify the RDCO for reporting allegations of abuse to HHSC. RDCO completed this in-service (08/11/23). Admin, DON, and designees educated all staff on facility abuse policies. Education included the facility abuse policy with emphasis on staff to stay with resident until alleged perpetrator is removed from facility pending investigation. Staff are not to wait for abuse coordinator to direct them to remove the alleged perpetrator, the staff member is to ask the alleged perpetrator to leave facility immediately. Completed 08/12/23. DON and designees educated all staff on abuse prevention and reporting. Education included the facility abuse policy with emphasis on staff to stay with resident until alleged perpetrator is removed from facility pending investigation. Staff are not to wait for abuse coordinator to direct them to remove the alleged perpetrator, the staff member is to ask the alleged perpetrator to leave facility immediately. Completed 08/12/23. Staff members were not permitted to work a shift until education had been completed. The regional/corporate consultant team members will visit the facility (at least weekly) to provide oversight, audits, and additional training as needed (08/11/2023). The DON will review 5 random residents monthly X3 months to ensure no further allegations of abuse. The Administrator or designee will continue to interview residents on a monthly basis to ensure they have not experienced abuse. The findings of these interviews will be presented to the QAA Committee. In-service given to DON, social worker and Administrator, to all review all grievances in am meeting to ensure no alleged abuse was reported. In-service conducted by RDCO on 08/12/23. On 8/13/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews with staff on 8/13/23 between 5:21 p.m. and 7:22 p.m. (CNA C, RN D, CNA E, Dietary Aide F, Cook G, Hospitality Aide H, Housekeeper J, RN A, LVN K, CNA L, Housekeeping Supervisor M, DON ,CNA O, Social Worker, and the Administrator) were performed. During the interviews staff were able to identify policies and procedures of the facility's Abuse and Neglect policy including reporting to the Abuse Coordinator, protecting the residents, and having alleged perpetrators leave the facility pending investigation. The Administrator, DON, and Social Worker were able to identify proper time frames in reporting allegations of abuse to the state agency and investigation protocols for allegations of abuse. Record review of skin assessment for Resident #1 and Resident #2 completed with no skin issue documented. Interview with Resident #1 and Resident #2 on 8/13/23 between 7:08 p.m. and 7:12 p.m. were performed. Resident #1 and Resident #2 both said they had no complaints or issues at this time. On 8/13/23 at 7:35 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm that is not immediate 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 observations, interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 6 (Resident #1) residents reviewed for quality of care. 1. The facility failed to intervene when Resident #1, who was on anticoagulants, fell on [DATE] and hit her head resulting in a raised area to her head. Resident #1 experienced a change in condition which included vomiting and loss of consciousness. Resident #1 was not sent to the hospital until 34 hours after the fall when the change of condition occurred. Resident #1 was pronounced deceased on [DATE] at 10:43 p.m. 2. The facility failed to document Resident #1's neuro checks per facility policy timely and accurately. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:44 p.m While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy 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 harm or death related to not receiving proper care or death following a fall with head injury while taking anticoagulation medication (blood thinners) or medications with similar traits. Findings Include: 1. Record review of Resident #1's face sheet, dated [DATE], indicated she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses including encephalopathy (temporary or permanent condition that affects the brain's structure or function causing an altered mental state and confusion), cerebral infarction (lack oxygen to the brain causing damage to brain tissue), and heart failure (heart muscle is unable to pump enough blood through the heart to meet the body's needs for blood and oxygen). Record review on [DATE] revealed there was no documentation of a MDS for Resident #1 in her file at this time. Record review on [DATE] revealed there was no documentation of a baseline or comprehensive care plan for Resident #1 in her file at this time. Record review of Resident #1's physician's orders dated [DATE] indicated Resident #1 had an order for Aspirin 81mg daily starting [DATE] for heart health and an order for Clopidogrel Bisulfate 75mg once a day starting [DATE] for stroke (lack oxygen to the brain causing damage to brain tissue) prevention. Record review of Resident #1's medication administration record for [DATE], indicated she was administered Aspirin 81mg and Clopidogrel Bisulfate 75mg on [DATE]. Record review of Resident #1's Admission assessment dated [DATE], indicated she was admitted for a stroke and had short and long-term memory problems. She was alert and talkative. She was totally dependent and required two-person assistance with transfers and bed mobility. She had a fall in the past 30 days and was admitted to the hospital after being found on the floor. She had normal respirations with clear right and left lung sounds to both upper and lower lobes. Her skin was cool, dry, warm and had no skin lesions. There were no documented skin concerns. Record review of Resident #1's nursing progress notes dated [DATE] at 11:00 a.m. by the ADON, indicated she was admitted to the facility, alert, oriented to herself, and unable to walk. Record review of Resident #1's nursing progress notes dated [DATE] at 11:45 p.m. by LVN B, indicated she screamed and hollered out most of the 2:00 p.m.-10:00 p.m She took her clothes off and tried to get out of bed continuously. Fall mats were placed and her bed was put in the lowest position. She fell and climbed out of bed multiple times during the shift on to the floor/floor mats and rolled around on the floor. She fell out of bed at approximately 9:00 p.m. and hit her head. She had a large hematoma approximately 6cm x 5cm x 1.5cm to the left side of her head that was purple and red in color. Neuro checks were started. The physician was notified and ordered Ativan and to monitor her hematoma and neuro status. Record review of an Incident Report dated [DATE] at 11:55 p.m. by LVN B, indicated Resident #1 fell out of bed at approximately 9:00 p.m. and hit her head. She had a large hematoma approximately 6cm x 5cm x 1.5cm to the left side of her head that was purple and red in color. Neuro checks were started. The physician was notified and ordered Ativan and to monitor her hematoma and neuro status. The incident report indicated Resident #1 was oriented to person and her predisposing physiological factors included a gait imbalance, impaired memory and confused. There were no witnesses. Record review of Resident #1's Neurological Assessment Flow sheet dated [DATE] indicated neuro checks were initiated at 9:00 p.m. and she was scheduled to have neuro checks conducted every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 1 hour for 4 hours, every 4 hours for 24 hours, then every 8 hours for 32 hours until [DATE] at 4:00 p.m Documented neuro checks on ,d+[DATE] at 9:00 p.m., 9:15 p.m., 9:30 p.m., 9:45 p.m., 10:00 p.m., 10:30 p.m.,11:00 p.m., 11:30 p.m. and on ,d+[DATE] at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m. indicated she was very drowsy, responded to touch stimuli and rambled when speaking. Documented neuro checks on ,d+[DATE] at 7:00 a.m. and 8:00 a.m. indicated she was awake, aware, oriented and her speech was clear. Resident #1's neuro check on ,d+[DATE] at 12:00 p.m. indicated there was no documented neuro check on her Neurological Assessment Flow sheet. Resident #1's neuro checks on ,d+[DATE] at 4:00 p.m. and 8:00 p.m. were documented on a sheet of paper, labeled Licensed Nurses Progress Notes, not on her Neurological Assessment Flow sheet and indicated she was lethargic, responded slowly to verbal stimuli and rambled when speaking. Documented neuro checks on ,d+[DATE] at 12:00 a.m. and 4:00 a.m. indicated she was awake, aware, oriented and rambled when speaking. Documented neuro checks on ,d+[DATE] at 8:00 a.m. and 4:00 p.m. indicated she was at the hospital. Record Review of an Admission History and Physical dated [DATE] by Resident #1's Physician, indicated she was screaming without complaints and had denied having shortness of breath or pain. She was a poor historian and unable to give a history of personal information. She had a history of a stroke, methamphetamine abuse, chronic screaming and agitation. The physical exam indicated she had a left anterior temporal bruise with no protuberance. The assessment/plan indicated she had a history of a stroke and was taking Aspirin and Clopidogrel Bisulfate. Continue neurochecks and if worse then send to the emergency department. Record review of Resident #1's nursing progress notes dated [DATE] at 10:21 p.m. by LVN B, indicated she screamed, cried out and tried to get out of bed during the 2:00 p.m.-10:00 p.m. shift. Resident #1's physician was in the facility and assessed her. Her physician indicated the resident acted the same way in the hospital screaming and crying all day. Record review of Resident #1's nursing progress notes dated [DATE] at 7:00 a.m. by LVN C, indicated she was notified by a CNA the resident had brown secretion coming from her nose and mouth. During her assessment, the resident had inspiratory (breathing air in) and expiratory (breathing air out) crackles (popping sounds in the lungs produced by fluid, mucus, or pus) and was using her accessory muscles (muscles not typically used for breathing) to breath. She notified EMS and put oxygen on the resident. The resident had a blood pressure of ,d+[DATE] (Normal range is less than ,d+[DATE]), heart rate of 145 (Normal range is 60 to 100 beats per minute), respirations of 26 (Normal range is ,d+[DATE] breaths per minute), and an oxygen level of 73% (Normal level is 95%-100%). EMS transferred the resident by stretcher. Record review of Resident #1's Hospital Records dated [DATE], indicated she was found unresponsive at the nursing on [DATE] and was transferred to the hospital. A CT scan revealed evidence she had a large left-sided subdural hemorrhage (blood accumulating under the skull) with intraventricular hemorrhage (bleeding inside or around the spaces in the brain that contain the cerebral spinal fluid). She was intubated (tube inserted into a patient's windpipe to help them breathe) emergency department and had fixed dilated pupils and no neurological (nervous system function) response. She was emergently taken by neurosurgery to the operating room for a left craniotomy (brain surgery that involves cutting a piece of the skull to access the brain) and evacuation of the subdural hematoma (blood accumulating under the skull). She was admitted to the intensive care unit (unit with specialized staff, equipment, and standards that handles severe, potentially life-threatening cases) after surgery. Resident #1's family was informed of her poor prognosis on [DATE], they expressed comfort care (care focused on the quality of the last days of life). Resident #1 was extubated (breathing tube taken out a patient's windpipe) on [DATE], after her family was informed of her poor prognosis and they expressed comfort care measures (care focused on the quality of the last days of life). Resident #1 was pronounced deceased on [DATE] at 10:43 p.m. During an observation on [DATE] at 6:05 p.m., Resident #1 was in a room on the ICU at the hospital. Resident #1 was lying in bed with her eyes closed unresponsive and had a white bandage wrapped around the top of her head. Resident #1 was connected to a ventilator (machine that helps you breathe). During an interview on [DATE] at 6:09 p.m., RN A said she was Resident #1's nurse in the ICU. RN A said Resident #1 was admitted to the hospital because she had bleeding in her brain. RN A said Resident #1 had brain surgery to stop the bleeding and to reduce the swelling to her brain caused by the blood collected around it. RN A said the doctor told Resident #1's family that she would not show any improvement because she had too much trauma to her brain. RN A said Resident #1's family had decided to take her off the ventilator tomorrow. During an interview on [DATE] at 2:14 p.m., LVN B said she worked the 2:00 p.m.-10:00 p.m. shift and was the charge nurse for Resident #1 when she fell on [DATE]. LVN B said a CNA notified her Resident #1 was on the floor. LVN B said she went to Resident #1's room immediately and found her lying on the floor next to her bed. LVN B said Resident #1's head was at the end of the bed with her feet facing toward the head of the bed. LVN B said Resident #1 had a dark purple and blue hematoma to the left side of her forehead near her temple and she initiated neuro checks on her. LVN B said neuro checks are scheduled checks over 72 hours consisting of checking a residents level of consciousness, blood pressure, arm and leg movements, and pupil size and reaction. LVN B said all scheduled neuro checks should be completed and documented on neuro check flow sheet in order to monitor the checks for any changes with the resident and notify the physician when there is a change. LVN B said Resident #1's initial neuro check was normal. LVN B said she notified Resident #1's physician immediately when she left her room and informed him of her fall, hematoma and neuro check findings. LVN B said Resident #1's physician ordered anxiety medication and told her to continue neuro checks and monitor her for any changes. LVN B said the fall protocol was to assess the resident, initiate neuro checks, notify the physician, initiate physician orders, and use good nursing judgement sending a resident to the hospital. LVN B said on [DATE] she worked the 2:00 p.m.-10:00 p.m., Resident #1's physician assessed her. LVN B said Resident #1's Physician said he was not concerned because she had no change in her level of consciousness and her hematoma was smaller. LVN B said she worked the 6:00 a.m.-2:00 p.m. shift on [DATE] when Resident #1 had a change in her level of consciousness and was sent to the hospital. LVN B said the facility implemented a new Head Injury policy a day or two after Resident #1 was sent to the hospital. LVN B said she was in-serviced on witnessed or unwitnessed resident falls with head injuries and sending them to the hospital for a CT scan including residents who were on anticoagulants/antiplatelets. LVN B said they did not have a policy on falls with head injuries before Resident #1 fell . During an interview with on [DATE] at 8:49 a.m., Resident #1's Physician said LVN B notified him on [DATE] that Resident #1 fell and that she had a hematoma about the size of a goose egg. The Physician said he ordered Resident #1 anxiety medication and told LVN B to continue neuro checks and monitor her for any changes. The Physician said he did not give an order to send Resident #1 to the hospital for a CT scan because he knew her medical and behavioral history prior to being admitted to the facility and there were no level of consciousness changes reported by LVN B or when he assessed her the day after the fall. The Physician said Resident #1 was on Aspirin and Clopidogrel Bisulfate which are antiplatelet medications with a lower risk for bleeding. The Physician said if Resident #1 was on an anticoagulant medication with a higher risk for bleeding, such as coumadin (blood thinner medication) or Eliquis (blood thinner medication), he would have sent her to the hospital immediately. The Physician said a resident who has a fall with a head injury and is on an anticoagulant medication is at risk of injury or death from a brain bleed. During an interview on [DATE] at 9:23 a.m., the DON said LVN B worked the 2:00 p.m.-10:00 p.m. shift on [DATE] when Resident #1 had an unwitnessed fall. The DON said LVN B assessed Resident #1, initiated neuro checks and notified the physician. The DON said if a resident has an unwitnessed fall the charge nurse was responsible to assess the resident, initiate neuro checks, and notify the physician of the fall and any injuries as a result of the fall. The DON said on [DATE] Resident #1 had a change in her conditions and she was sent to the hospital. The DON said neuro checks are scheduled checks over 72 hours consisting of checking a residents level of consciousness, blood pressure, arm and leg movements, and pupil size and reaction. The DON said on [DATE] Resident #1 had a change in her conditions and she was sent to the hospital. The DON said the facility implemented a new fall policy on [DATE]. The DON said the Head Injury policy addressed witnessed or unwitnessed falls with head injuries that included residents taking anticoagulant/antiplatelet medications. The DON said if a resident has a fall and was taking an anticoagulant/antiplatelet medication the resident was sent to the hospital for a CT scan. The DON said the fall policy did not address falls with head injuries until after Resident #1 was sent to the hospital. The DON said a resident who has a fall with a head injury and is on an anticoagulant/antiplatelet medication is at risk of injury or death from a brain bleed. The DON said on [DATE] at 12:00 p.m. there was no documented neuro check for Resident #1. The DON said all scheduled neuro checks should be completed and documented on the resident's neuro check flow sheet in order to monitor the checks for any changes in the resident and any changes in the resident should be reported to the physician. Record review of the facility's Falls-Evaluation and Prevention policy dated ,d+[DATE] indicated, Following a fall, the following steps should be taken .If there was a loss of conscious or the fall was unwitnessed, neuro signs should be initiated and checked for at least 72 hours .Notify the physician and responsible party. Document the physician orders and/or response from the physician and responsible party. The policy did not address falls with head injuries when a resident is on anticoagulant (blood thinner) or antiplatelet (prevents blood cells from sticking together and form a blood clot) medications. Record review of the facility's Head Injury policy implemented [DATE] indicated, It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury .2. Call 911/EMS and attempt to stabilize the resident's condition if respiratory distress or a hemorrhaging wound occurs .4. Notify physician and follow orders for care .c. Report any recent medication changes or use of antiplatelet/anticoagulant medications. Record review on [DATE] of https://premierneurologycenter.com/blog/blood-thinners-head-injuries-what-you-need-to-know/ indicated, .If you are taking an older blood thinner such as warfarin, clopidogrel, or you are taking aspirin in addition to a blood thinners, it is especially important to seek medical attention right away if you experience a head injury since the risk of delayed hemorrhage is higher in patients taking these medications. A CT scan will be performed to assess the extent of the injury . If you are taking a blood thinner, it is important to be aware of the risk associated with head injuries. If you experience a bump, blow, or jolt to the head, it is important to seek medical attention right away. Even if you do not feel any symptoms after the injury, it is still important to be evaluated by a doctor. If you are taking an older blood thinner such as .aspirin in addition to a blood thinner, it is especially important to seek medical attention right away if you experience a head injury since the risk of delayed hemorrhage is higher in patients taking these medications. The Administrator was notified on [DATE] at 1:38 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on [DATE] at 1:44 p.m. The facility's Plan of Removal was accepted on [DATE] at 5:20 p.m. and included: Approaches: The RDCO and DON will deliver in service education to nurses one on one. 1. All nurses will be educated on fall policy. All nurses on staff at this time besides one that is out of state on vacation, see #7. This policy includes head injuries, but not specific to head injuries with anticoagulants/antiplatelets, this was the point when we included the head injury policy. See #2. Completed [DATE] 2. Nurses will be in serviced on head injury policy. This policy is to be an addition to the fall policy. This policy includes instructions on sending residents who are on anticoagulant medications, and have a fall with head injury or unwitnessed fall, to the ER for CT. All nurses have completed this in service, with the exception of the one that is on vacation, when she returns, before she goes on the floor, she will be in serviced. We did speak with her and let her know. Completed [DATE] 3. Facility medical director will be informed of IJ being called. The RDCO notified the medical director. Completed [DATE]. 4. Nurses will be in serviced on properly completing neuro checks on approved form when a fall with head injury, or unwitnessed fall occurs. Documented on correct form, in completion, prior to the end of the nurse shift. The neuro check sheet is to be completed as the neuros are due. There should not be any blank areas. To be verified by the end of their shift. The RDCO/DON in serviced the nurses. Completed [DATE]. 5. Blank neuro check form to be distributed to nurse's stations with instructions on how to complete. The RDCO printed neuro sheets and provided to nurse's stations. Completed [DATE] 6. Any fall with head injury or unwitnessed fall that occurs with a resident who receives anticoagulant medications will be sent to the ER for CT scan. Education completed [DATE]. Nurses were in serviced that if neuros are abnormal for any reason, they are to call the provider for orders to send to ER. The RDCO/DON provided the in service. All nurses have completed this in service, with the exception of the one that is on vacation, when she returns, before she goes on the floor, she will be in serviced. We did speak with her and let her know. All residents who have had a fall with head injury or unwitnessed falls will be sent to ER immediately for CT if the resident is on an anticoagulant/antiplatelet medication. This will be added to the DON/ADON in service. Completed by RDCO [DATE]. 7. The nurse that is out of town on vacation will receive the in service one on one prior to beginning her shift. She has been called on the phone and informed of this. She verbalized understanding. We did all of these in services one on one. Monitoring: Upon hire, annually and as needed. Will review for compliance monthly in QAPI X3 months. The DON/designee will monitor falls daily in the am clinical meeting. Nurses call the DON with every fall. The DON has been in serviced to ask the question, is the resident on anticoagulant/antiplatelet medications, and if so, the DON will instruct the nurse to send the resident out to ER for CT if anticoagulant/antiplatelet medications are in use. The DON or designee will review falls in a.m. clinical meeting. Neuros following a fall will be reviewed daily as well for the entire 72 hours post fall, also daily in the clinical meeting, by the DON/Designee to validate completion. All falls from the last 30 days were reviewed by the RDCO to ensure neuro checks were completed and no delay of treatment occurred. The policy for head injuries states any change in neuro checks will warrant a call to the provider for further orders, including but not limited to, transfer to ER for CT. Placed note on EMR Dashboard on nurse's home screen, Nurses: You MUST notify the DON of all falls. If a fall is unwitnessed, or a resident has a head injury related to a fall, YOU MUST START NEUROS!! If the resident is on an anticoagulant/antiplatelet medication, you MUST SEND THEM TO THE ER FOR A CT SCAN. Notify provider that this is our policy. Any abnormality in neuros, SEND THEM TO THE ER On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director had been informed of the Immediate Jeopardy from a printed copy of a text message communication between the RDCO and the Medical Director. Interviews with 10 Licensed Nurses (on all shifts 6 a.m.- 2 p.m., 2 p.m.-10 p.m., 10 p.m.- 6 a.m. and Weekend Double) were performed on [DATE]. All licensed nurses were able to correctly identify falls, witnessed or unwitnessed falls with head injuries including residents who were on anticoagulants/antiplatelets and sending them to the hospital for a CT scan, properly completing neuro checks during and end of their shift to verify all checks were documented, calling the physician of abnormal neuro checks and for orders to send to the hospital. During an interview on [DATE] at 5:31 p.m., the DON said she in-serviced the nursing staff on the Head Injury policy. The DON said she the charges nurse are to call her with every fall and ask them if the resident is on anticoagulant/antiplatelet medications, and if they are, I will instruct nurse to send the resident out to ER for CT. The DON said she will review any falls in a.m. clinical meeting and review the neuro checks daily for the entire 72 hours post fall checks to ensure all neuro checks are documented and completed. Record review on [DATE] of resident falls within the last 30 days requiring neuro checks indicated with documented neuro checks were completed. Record review of the facility's Falls and Head Injury policies on [DATE] confirmed the updated language to call EMS if a resident with a head injury was on antiplatelet/anticoagulant medications. On [DATE] at 7:19 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for smoking. The facility failed to ensure Resident #1 was provided supervision when he smoked. Resident #1 had a history of attempting to smoke while wearing his oxygen tank (secured to the back of his motorized wheelchair). On 03/26/2023, a lit cigarette was discarded on the ground and ignited his oxygen tubing and catheter bag that was laying at the bottom of his motorized wheelchair. An Immediate Jeopardy (IJ) was identified on 04/01/2023 at 3:20 PM. While the IJ was removed on 04/03/2023 at 7:12 PM, the facility remained out of compliance at no actual harm because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm, severe injury, and possible death to residents who wear oxygen and were inadequately assessed for smoking safely unsupervised. The findings included: Record review of Resident #1's face sheet, dated 04/02/2023, revealed Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen levels), cognitive communication deficit (difficulty with thinking and how someone uses language), and paraplegia (impairment in motor (movement) or sensory (feeling) function of the lower extremities). Record review of the order summary report, dated 04/01/2023, revealed Resident #1 had an order, which started on 03/18/2023, for Oxygen continuously via nasal cannula . Record review of Resident #1's comprehensive MDS assessment, dated 03/24/2023, revealed it had not been completed. Record review of the comprehensive care plan, initiated on 03/20/2023, revealed Resident #1 had altered respiratory status and difficulty breathing. The interventions included oxygen at 2 LPM via NC every shift. The comprehensive care plan further revealed a smoking care plan was initiated on 03/26/2023 after Resident #1 ignited his oxygen tubing on the smoking patio. The intervention included Resident is deemed unsafe smoker, he smoked with oxygen tank in place after being educated to leave oxygen concentrator at nurses' station when going out to smoke. Record review of the occupational therapy treatment encounter note, dated 03/22/2023, revealed Resident #1 was educated on the safety concerns including the oxygen tank attached to his motorized wheelchair and not being allowed in the smoking courtyard. Record review of the nursing progress note, dated 03/22/2023 at 2:35 PM, revealed Resident #1 was repeatedly going outside in the common smoking area to smoke while oxygen was connected. The progress notes further revealed the charge nurse, ADON, and DON provided education and Resident #1 agreed not to smoke while using oxygen. Record review of the smoking assessment, effective date 03/22/2023, revealed Resident #1 had a history of smoking-related problems that would be hazardous to self or others. The smoking assessment revealed Resident went to smoking area in power chair with his oxygen tank. The tank was removed, and resident educated. The smoking assessment revealed Resident #1 was able to keep his lighter and cigarettes and was safe to smoke unsupervised. The assessment was signed by the DON on 03/27/2023. Record review of the nursing progress note, dated 03/25/2023 at 11:47 PM, revealed Resident #1 was provided additional education regarding removing his oxygen tank prior to going outside to smoke. Record review of the nursing progress note, dated 03/26/2023 at 3:45 PM, revealed Resident #1 had been off the hall for about an hour visiting another resident. Resident #1 went out to smoking area, and per resident witnesses' Resident #1 removed his nasal cannula and laid it on his foley catheter bag and proceeded to take out a cigarette and light it. While smoking, Resident #1 dropped his cigarette on top of oxygen tubing that was on ground. The oxygen tubing and foley catheter caught fire. A resident in the area grabbed the fire extinguisher and quickly put out the fire. There were no visible injuries, 911 was called, the doctor was notified, and a message with call back number was left for family. Record review of the incident report, dated 03/26/2023 at 3:30 PM, revealed Resident #1 was outside smoking with oxygen tank on, per witnesses' he took the nasal cannula off and placed it on the ground on his foley tubing prior to lighting the cigarette. He dropped his cigarette and the oxygen tubing ignited burning the oxygen tubing and foley tubing. Another resident immediately got the fire extinguisher and put out fire, and someone else hollered for nurse. Charge nurse went into smoking area and noted white substance all over resident. Nurse observed resident sitting in his power chair, holding the power cord to chair, and burnt oxygen tubing. The incident report further revealed immediate action taken was 911 was called, fire extinguisher was used, resident transported to ER to rule out any injury. Oxygen tank was turned off and removed from chair. Resident returned to nurses' station for eval. Record review of the Smoking Policy In-service, initiated on 03/26/2023, revealed staff were in-serviced on the smoking policy that was implemented in 06/2022 which indicated oxygen was prohibited in the smoking area. The in-service further revealed 7. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether supervision is required for smoking, or if resident is safe to smoke at all. 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. The in-service further revealed 13. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. Record review of the Supervised Smoking Schedule, undated, revealed instructions that included: Do not throw cigarettes on the ground, use the ashtrays. No cigarettes, cigars, lighters or matches (any lighting instrument) in a resident's room or on your person at any time. The schedule further revealed the smoking times as follows: 6:00 AM - 6:15 AM supervised by the staff on duty 9:00 AM - 9:15 AM supervised by the staff on duty 12:45 PM - 1:00 PM supervised by the staff on duty 4:00 PM - 4:15 PM supervised by the staff on duty 7:00 PM - 7:15 PM supervised by the staff on duty 10:00 PM - 10:15 PM supervised by the staff on duty During an interview on 04/01/2023 at 9:07 AM, LVN D stated the residents were able to take themselves out to the smoking area and smoke if they were able to smoke unsupervised. LVN D stated there were currently no designated smoking times in place and residents could go out whenever. LVN D stated the residents were able to keep their cigarettes and lighters. During an observation on 04/01/2023 at 9:05 AM, four residents (Resident's #2, #5, #6, and #7) were outside in the smoking courtyard. Residents #2, #5, #6, and #7 had their own cigarettes and lighters. During an interview 04/01/2023 at 9:10 AM, Resident #2 stated she was the person who used the fire extinguisher to put the fire out on 03/26/2023. Resident #2 stated it was windy the day of the incident and Resident #1 was sitting in his motorized wheelchair against the wall. Resident #2 stated Resident #1 had taken his nasal cannula out of his nose and placed it on top of his catheter bag. Resident #2 stated Resident #1 was not right in the head and had come out several times with his oxygen tank on the back of his motorized wheelchair. Resident #2 stated the nurses would have normally turned the oxygen tank off, but it was on the day of the incident. Resident #2 stated another resident had dropped his cigarette on the ground and the wind blew it toward the nasal cannula and the tubing ignited causing a fire. Resident #2 stated she immediately grabbed the fire extinguisher and put out the fire. Resident #2 stated she did not believe there were any injuries to Resident #1. During an interview on 04/01/2023 at 9:16 AM, Resident #5 stated the facility staff told them during the past week that the residents were not allowed to smoke without supervision anymore. Resident #5 stated the staff members had not supervised them this morning, but she was under the impression it was to have started. Resident #5 stated the facility told the residents who smoked they would also have to give up their cigarettes and lighters and could only smoke during the designated smoking times for only 15 minutes. Resident #5 stated the staff had not taken her cigarettes or lighter and had not provided supervision at this time. During an interview on 04/01/2023 at 9:47 AM, LVN C stated on the morning of the incident on 03/26/2023 and the day prior on 03/25/2023 she had talked to Resident #1 several times about going outside with his oxygen on. LVN C stated Resident #1 had gone to another hall to visit another resident. LVN C stated Resident #1 entered the smoking area after leaving the other resident's room. LVN C stated a CNA had come to tell her he was outside with oxygen on. LVN C stated RN F had beat her to the smoking area and the fire was already extinguished. LVN C stated paramedics had been called so Resident #1 could have been checked out. LVN C stated he had some redness to his bilateral lower extremities, but they looked like that prior to the incident. LVN C stated to her knowledge, he took his nasal cannula off and placed it at the bottom of his motorized wheelchair where it caught fire. LVN C stated he had no injuries. LVN C stated some residents required supervision and some did not dependent on their smoking assessment. LVN C stated the facility had no set times for residents who were able to smoke unsupervised. LVN C stated the facility did an in-service stating residents had to be supervised while smoking and should have designated times but was usure when it started. LVN C stated it should have been implemented by today. During an observation on 04/01/2023 at 9:54 AM, four residents were outside smoking with no staff supervision. During an interview on 04/01/2023 at 9:58 AM, Resident #3 stated she did not smoke but liked to sit outside. Resident #3 stated she witnessed the incident that happened on 03/26/2023 with Resident #1. Resident #3 stated Resident #1 was confused and would often become naked by taking his gown off. Resident #3 stated Resident #1 had taken his oxygen off and placed it on his catheter bag. Resident #3 stated Resident #1 threw his lit cigarette on the ground, and he started yelling he was on fire. Resident #3 stated the flames were going and another resident grabbed the fire extinguisher and put out the fire. Resident #3 stated a different resident hollered for a nurse. Resident #3 stated the fire department arrived at the facility and told her Everyone could have been blown to pieces. During an interview on 04/01/2023 at 10:18 PM, the DON stated on 03/26/2023 Resident #1 had taken his oxygen tank attached to his motorized wheelchair out into the smoking area. The DON stated it was discovered during the investigation that Resident #1 was not actually smoking but another resident was smoking beside him and dropped his cigarette on the ground. The DON said the cigarette rolled toward Resident #1's motorized wheelchair where his oxygen tubing was laying on his catheter bag and ignited. The DON stated another resident put out the fire using the fire extinguisher and Resident #1 was sent to the emergency room as a precaution. The DON stated when Resident #1 returned to the facility he was re-assessed as an unsafe smoker and his smoking materials were taken. The DON stated Resident #1 had one prior incident on 03/22/2023 where he was found outside with his oxygen tank on. The DON stated herself, the ADON, the nurse, and therapy provided Resident #1 with education regarding taking his oxygen tank into the smoking area. The DON stated he was deemed a safe smoker at that time because he was able to verbalize understanding of the smoking policy. The DON stated the corporate office had changed the smoking policy and she had in-serviced the residents and the staff. The DON stated the supervised smoking at designated times was supposed to have been implemented on Monday, 04/03/2023. During an observation and interview on 04/01/2023 at 12:35 PM, Resident #1 was sitting up in his hospital bed. Resident #1 looked frail and unkempt as evidenced by the hospital gown falling off his bony shoulders and his hair was disheveled and falling into his face. Resident #1 was wearing a nasal cannula and was struggling to breath during the interview. Resident #1 stated he remembered the incident that occurred on 03/26/2023. Resident #1 stated he was not smoking but another resident was sitting beside him and was smoking. Resident #1 stated the other resident dropped his cigarette and about 5 minutes later his nasal cannula and foley catheter tubing caught on fire. Resident #1 stated it was a small flame and he was not injured. Resident #1 stated the facility made him go to the hospital and he believed they made a mountain out of a molehill. Resident #1 stated he knew all about safety and for significant damage to have been done, it would have needed to happen in an enclosed space. Resident #1 stated he normally went into the smoking area with his oxygen tank, but the staff would turn off the oxygen or he would himself. During an interview on 04/01/2023 at 1:22 PM, CNA B stated she worked the hall were Resident #1 resided and had taken care of him. CNA B stated Resident #1 wanted to do what he wanted to when he wanted to do it. CNA B stated Resident #1 had behaviors, but it seemed like they were getting better. CNA B stated she observed Resident #1 outside in the smoking area on multiple occasions with his oxygen tank on the back of his motorized wheelchair. CNA B stated Resident #1 was an unsupervised smoker, and she believed the nurses were turning the oxygen off. CNA B stated all the nurses were aware Resident #1 was going outside with his oxygen tank on. CNA B stated she was provided an in-service on the new smoking policy and stated all residents were going to be supervised while smoking and only allowed to smoke at designated times. During an interview on 04/01/2023 at 1:41 PM, MA E stated she worked on the hall were Resident #1 resided. MA E stated Resident #1 was told things and he would forget them. During an interview on 04/01/2023 at 2:29 PM, COTA R stated 03/22/2023 was the first day Resident #1 was out of the bed. COTA R stated she was performing a safe motorized wheelchair assessment on Resident #1 when he mentioned he wanted to go outside for a cigarette. COTA R stated she provided education on safety to Resident #1 and instructed him it was not appropriate to go outside with his oxygen tank hooked on the back of his motorized wheelchair. COTA R stated she informed the nurse he was asking for a cigarette. COTA R stated Resident #1 was later found outside with his oxygen tank on his motorized wheelchair. Record review of the Resident Smoking policy, updated in 03/2023, revealed 7. Residents who smoke will be assessed, using the Resident Safe Smoking Assessment, to determine the level of supervision the resident requires. 8. All residents who smoke will be allowed to smoke in designated smoking areas (weather permitting), at designated times with supervision, and in accordance with his/her care plan. The policy further revealed 13. Smoking materials of residents who smoke will be maintained by nursing staff. The Administrator was notified on 04/01/2023 at 3:52 PM that an immediate jeopardy situation was identified due to the above failures. The Administrator and the DON was provided the immediate jeopardy template on 04/01/2023 at 3:59 PM. During an interview on 04/02/2023 at 10:55 AM, the DON stated before the incident on 03/26/2023, the facility assessed residents for safe smoking, the need for supervision, and whether residents were able to keep their smoking materials by performing a smoking assessment. The DON stated it had been the policy from the time she started at the facility. The DON stated there was no set person to complete the smoking assessment. The DON stated often the MDS nurse, the charge nurse, or herself would have completed the smoking assessments. The DON stated this was monitored during daily clinical meetings and if the assessment was not completed, she would do it. The DON stated Resident #1 had a BIMS score of 14, which indicated no cognitive impairment and was able to verbalize understanding of the smoking policy. The facility's plan of removal was accepted on 04/03/2023 at 2:56 PM and included the following: The facility failed to provide supervision to Resident #1 who required oxygen and smoked. All Smoking assessments and Care plans were reviewed for residents who smoke, and changes were made as necessary on 3/26/2023 by the director of nurses. Residents who smoke were reviewed for care plan and if a care plan was not noted, a care plan was completed. On 3/31/2023 residents who smoked and used oxygen were asked to attend a care plan meeting so that the care plan could be updated to reflect that they used oxygen and understood that they could not go outside to smoke with oxygen. Every resident who smokes verified they understood that they were not allowed go outside to smoke with oxygen. Resident #1 was assessed and transferred to ER 3/26/2023 at approximately 3:45 PM to evaluate and treat as necessary. The Resident returned 3/26/2023 at approximately 9:00 PM with no new orders and with no injuries reported by the ER. The facility smoking policy was updated on 3/31/2023 and at that time DON/ADON began in-servicing facility staff on the policy changes. Facility policy was updated by corporate office to provide scheduled supervised smoking times for all residents who smoke on 3/31/2023. Assigned smoking times are supervised as follows: 6:00am to 6:15am - Charge Nurse on North Wing will assign staff member to take residents smoking paraphernalia out to smoke area and allow residents to smoke while being supervised. 9:00am - 915am - Activity Director or her designee will supervise M-F, Housekeeping staff member on duty will supervise during this time on Sat - Sun. 12:45pm - 1:00pm - Social Services will supervise during this time frame and housekeeping staff member will supervise on Sat - Sun. 4:00pm - 4:15pm - North Wing Charge Nurse will assign Aide/C.N.A. 7:00pm- 715: pm - South Wing Charge Nurse will assign Aide/C.N.A. 10:00 pm - 10:15pm - East Wing Charge nurse will assign Aide/C.N.A. DON, ADON, and the wound care nurse in-serviced all staff regarding the new smoking policy and the supervised smoking requirements. This will be monitored by the Administrator, DON and ADON. Smoking policy will be covered during orientation for new hires. All staff currently on duty were in-serviced at 11:00 AM on 4/3/2023. Any staff members not available for in-service will be in-serviced prior to returning to shift. All resident smokers were invited to a meeting on 3/31/2023 conducted by Social Worker and Administrator. Each resident in attendance was provided a copy of the changes. The Smoking policy is part of the admission agreement, and the revised policy will be placed in admission packet immediately. Not all residents who smoke showed up for the meeting. For those who did not attend, the ADON went to each resident on 4/2/2023 at 2:00PM to educate them on the new smoking policy to ensure they understood. Also, the residents were reminded that they must turn in all cigarettes and lighters to the nurse. The new smoking policy was updated on 3/31/2023 to reflect that oxygen tanks are not allowed in the smoking area. The person assigned to supervise smoking will ensure there are no oxygen tanks in the smoking area. Policy related to supervision during smoking times has been implemented and is in place. The new smoking policy implementation explanation started 3/31/23 with all residents who smoke. The new smoking policy implementation was completed on 4/2/2023 for all residents who smoke. All residents who smoke were asked again on 4/3/2023 at 11:00 AM to turn in cigarettes and lighters to the charge nurse for storage. Staff in-serviced again regarding the new smoking policy to ensure everyone understood on 4/03/2023 at 12:00PM. On 04/03/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 04/03/2023 at 4:25 PM, 13 residents were outside smoking supervised by CNA B. During resident interviews on 04/03/2023 between 4:33 PM - 5:09 PM, Resident's #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 were able to verbalize understanding of the new smoking policy, which included supervised smoking and designated smoking times, verbalize understanding of not going into the smoking area with oxygen, and verified all cigarettes and lighters were turned into the facility staff. Record review of the comprehensive care plan for Resident's #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27 revealed they had been reviewed and revised as necessary. Record review of the smoking assessments for Resident's #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #22, #23, #24, #25, #26, and #27 revealed they had been reviewed and revised as necessary. Record review of the new smoking policy in-service provided to staff, dated 03/31/2023, 04/01/2023, and 04/02/2023, revealed 42 staff members had signed and dated the read and understood the new smoking policy, which included oxygen was not allowed in the smoking area, residents were required to keep their cigarettes and lighters at the nurse's station, and designated smoking times and supervision. During interview on 04/03/2023 between 4:25 PM and 6:28 PM, the following staff members, LVN K, MA L, LVN M, CNA N, CNA O, CNA P, CNA B, LVN D, CNA Q, and the ADON were interviewed and verbalized understanding that no oxygen was allowed in the smoking area, residents were required to keep their cigarettes and lighters at the nurse's station, and the new digitated smoking times and supervision. On 04/03/2023 at 7:12 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility neglected to provide goods and services necessary to avoid mental anguish and physical harm for 1 of 7 residents sampled for neglect. (Resident #1) The facility failed to provide an appropriately sized wheelchair to a bariatric resident who was forced to stay in bed continually. The resident was unable to attend therapy or activities because she did not have a wheelchair. The facility failed to provide her with an appropriate chair for several months. This failure caused the resident emotional distress and possible deterioration of mobility functions. Findings included: Record review of a face sheet dated indicated Resident #1 was a [AGE] year-old female admitted to the facility initially on 07/16/22 and readmitted on [DATE]. Her diagnoses were morbid obesity, congestive heart failure, and lymphedema (swelling in the arm or leg caused by lymphatic system blockage.) Record review of a Resident #1's quarterly MDS dated [DATE] indicated no cognitive impairment. Her bed mobility and transfer status were extensive assist with two people. The resident required limited assistance of one person on and of the unit for locomotion. Record review of Resident #1's care plan dated 09/07/22 indicated she had a diagnosis of depression/bipolar and was at risk for fluctuation in mood, little interest or pleasure in doing things and decreased socialization. An intervention was to encourage the resident to be an active participant in decision making. Resident #1 had a Focus area of she liked to look at magazines, listen to gospel, play bingo, enjoyed doing her makeup and nails. She also enjoyed being outside in nice weather and doing flower beds. Some of the interventions were all staff to converse with the resident while providing care, invite the resident to scheduled activities, provide the resident with an activities calendar, and notify the residents of changes. Resident #1 had Focus area of ADL self-care performance deficit. The goal was for the resident to maintain current level of function through the next review. Interventions indicated the resident was totally dependent on 1-2 staff to provide a bath. The bed mobility the resident required assistance of 1-2 staff to turn and reposition in the bed. During transfers the resident required a mechanical lift with 1-2 staff assist for transfers. Record review of Resident #1's computerized physician's orders indicated an order for Venlafaxine (anti- depression medication) 75 mg with a start date of 09/08/22. Record review of Resident #1's Transfer-Mobility assessment dated [DATE] indicted Resident #1 was non ambulatory, non-weight bearing, and had difficulty standing. She was alert and oriented and able to follow directions. Moving from sitting to stating position did not occur, walking with an assistive device did not occur. Moving on and off toilet did not occur, and surface to surface transfer between bed and wheelchair did not occur. The Physical status indicated the resident was morbidly obese and unable to walk. Record review of a Physical therapy evaluation and plan of treatment dated 09/08/22 listed some of Resident #1's treatment approaches as wheelchair management training. Manual therapy techniques, and group therapeutic procedure. Record review of Resident #1's Weight Summary indicated on 9/11/22 the resident weighed 421 pounds and was weighed using a digital wheelchair scale. There are no other weights. Record review of the Medical Equipment company 's measurement form dated 09/22/22 indicated Resident #1 needed a size 36 inches wide. Record Review of Resident #1's Physical Therapy Discharge summary dated 11/11/22 indicated Resident #1 was currently waiting on the facility to acquire a wheelchair that was big enough for her to fit in so she can get out of bed. Therapy would reassess the resident when chair was in the facility in hopes of progressing resident with functional mobility skills. During an interview on 11/30/22 at 10:00 a.m. Resident #1 said the facility did not have a wheelchair big enough to fit her. She said they promised her a chair on several occasions. She said just recently therapy said something about a possible electric wheelchair, but she said she had not seen that either. During an interview on 11/30/22 at 10:17 a.m. CNA B said Resident #1 did not get up because she did not have a bariatric wheelchair. During an interview on 11/30/22 at 2:59 p.m. the DON said she worked at the facility for one year. She said they were unable to take Resident #1 down for showers because they did not have a chair big enough. She said Resident #1 did not have a wheelchair. They had been trying to find one that will fit her. The DON said they had therapy measure her for a specialty chair but Resident #1 did not qualify. During an interview on 12/5/22 at 9:17 a.m. the director of Rehab - PTA said Resident #1 did not have a wheelchair. They measured her and tried to get Medicaid to cover the cost of a specialty chair, but they would not. The last he knew the DON was working on getting her a chair a couple of months ago. He said it was not the resident's weight that was the problem it was her girth. She could not bear weight. He said recently they were looking into getting her a customized power chair and her insurance might cover it. He said they had to discontinue therapy because she did not have a wheelchair. A Manuel wheelchair would cost the facility about $4000. During an interview on 12/5/22 at 1:17 p.m. Resident #1 said she was confined to the bed, and it made her depressed. She started to cry and said it was difficult just lying in the bed all day and night. They were unable to get her up even for showers, she just laid in the bed and looked at the walls. Resident #1 said she thought therapy would help her get some of her strength back, but she could not go to therapy because she did not have a chair. She said all she does was lay in the bed and pray. She said she cannot get up to socialize, attend activities, or go to church programs provided by the facility. She was dependent on staff to come and talk to her and they are always in a hurry. The facility promised her a wheelchair and she had not received a chair. She had a loaner chair for a few days when she was first admitted but they took it away. During an interview on 12/5/22 at 1:32 a.m. the social worker said Resident #1 told her she wanted to get out of bed and did not have a chair. The resident told her she believed therapy was working on getting her a chair. She did not know anything else about the wheelchair. During an interview on 12/5/22 at 3:22 p.m. COTA A said Resident #1 was not on her case load, but she knew she needed a wheelchair. When Resident #1 first arrived, she had a loaner chair. That chair was too small, and the resident started to get some skin breakdown because of the difficulty she had getting in and out of the chair. When the resident came back from the hospital the chair was gone. The therapy department contacted a Medical Equipment company to have Resident #1 a special chair made but due to her insurance restrictions she did not qualify. A person from that company came to the facility and measured the resident to ensure she had a size appropriate chair. She gave those measurements to the DON about the first of October 2022. She said they had to discontinue therapy because they were not able to get the resident to the therapy room, because she did not have a wheelchair. The COTA said usually when a resident did not qualify for a personal specialty chair the facility provided a chair. During an interview on 12/05/22 at 3:58 p.m. CNA C said Resident #1 received a bed bath. Resident #1 could not fit in the shower. She said Resident #1 said she wanted to get up on occasion but did not have a wheelchair. During an interview on 12/05/22 at 4:00 p.m. CNA D said Resident #1 said she wanted to get up but did not have a wheelchair. She said the resident cannot fit the shower chair she was too wide. She said the resident told her they were supposed to be ordering her a wheelchair months ago, but she did not have one. During an interview on 12/05/22 at 4:15 p.m. therapy director said it was the facility's responsibility to get the resident a wheelchair if they are denied by their insurance company. He was told the administration was under financial pressure. During an interview on 12/05/22 at 4:23 p.m. the administrator said he was aware Resident #1 did not have a wheelchair and he had been working on getting a wheelchair for the resident. The administrator said, he did not say it was not responsibility of the facility to provide a wheelchair for Resident #1. He said they had tried to obtain a wheelchair. The do not have an exact date or method of obtaining the wheelchair. The administrator said he did not have any documentation to provide regarding his attempts to get Resident #1 a wheelchair. He said a Medical Equipment company was sending an email to verify their attempts. Record review of an email from the Equipment Company indicated: {December 5, 2022 To whom it may concern: We have been working with the facility to try and accommodate a customized manual wheelchair that would work for the resident. Due to the resident's width of 36 inches, a customized manual chair would not fit through the doorways at the facility. The resident did not have an Applied income at the time, because she had just moved into the facility, so we had to figure out another route to go. We then proceeded towards looking into a Custom Power Wheelchair that would accommodate the width. Per the guidelines the resident did not meet the clinical criteria to be able to proceed. A different Equipment Company has since been contacted and we are working with them to see if they would cover the equipment for the resident to get a Custom Power Wheelchair under special circumstances. We have also found a basic power chair since the resident now has an Applied Income, but the width is only 32 inches if we cannot proceed after the insurance change to other Equipment Company to get her a Custom Power Wheelchair. } Not dates Record review of the facility Abuse, Neglect policy dated 07/2022 indicated neglect means failure of the facility, its employees , or service providers to provide goods and services to a resident that is necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interview, and record review, the facility failed ensure the residents received adequate supervision to prevent accidents for 5 of 5 residents and 1 of 9 doors (South Wing exit) reviewed for accidents, hazards and supervision. (Residents #1, #2, #3, #4, and #5) The facility failed to ensure the wander guard system (system designed to sound an audible alarm when approached by a resident wearing a WanderGuard bracelet) was working on the south wing exit door. Residents (#1, #2, #3) who had a WanderGuard bracelet were not being checked for function of the device. The facility did not ensure all magnetic doors were secured to prevent residents from eloping through an exit door on the South wing. The facility installed a button on this door, accessible to any individual, which allowed the door to open without sounding the alarm. Resident #5 was identified as an elopement risk on his most recent elopement risk assessment; however, the facility did not supervise the resident to prevent him from having access to exit the facility through the South wing door. The resident could push the button to override the alarm system to exit the South wing door. Staff did not supervise the resident when he would go outside. Resident #4 was not identified to be at risk for elopement. Resident #4 was found outside the South wing exit door with Resident #5. Staff did not report Resident #4 exiting the facility or implement interventions to prevent the resident from exiting through the door until after surveyor intervention. An Immediate Jeopardy (IJ) situation was identified on 8/20/2021. While the IJ was removed on 8/23/2021, the facility remained out of compliance at a severity of 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. This failure could place residents at risk for elopement and serious injury from accidents due to lack of supervision. Findings included: During an interview and observation on 8/18/21 at 10:55 a.m., the maintenance director said all exits were secured with a magnetic locking system that required a code to release the door. He said the doors were also equipped with a WanderGuard system that would sound an alarm if a resident who was wearing a WanderGuard device got close to it. The maintenance director said he arrived every day at 5:00 am and checked all the doors to make sure they were functioning correctly. The surveyor observed the maintenance director check all the exits in the building. As the surveyor and maintenance director approached the covered exit on the South wing, the maintenance director said the WanderGuard had been disabled on that door. The maintenance director said the fire alarm company had disabled it previously when they had done other work. The maintenance director said it had not worked in about 2 months. The WanderGuard system did not sound an alarm when tested with the WanderGuard transmitter. The maintenance director also identified a red button mounted on the wall that was used to release the magnetic locks on the door without sounding an alarm. 1. Record review of physician orders dated 8/20/21 indicated Resident #1, an [AGE] year-old male, was admitted on [DATE] and had diagnoses including unspecified dementia with behavioral disturbance, auditory hallucinations, and cognitive communication deficit. An order dated 7/13/21 indicated Resident #1 was to have a WanderGuard device (radio transmitter that causes an alarm to sound when approaching an exit, usually worn as a bracelet on the wrist or ankle) at all times related to elopement risk. The order specified that function and placement of the device were to be checked every shift. Record review of the most recent MDS assessment, dated 7/20/21 indicated Resident #1 had severely impaired cognition, and had wandered in the last one to three days of the assessment period. The assessment indicated Resident #1 required supervision and set up help only for transfers, walking in the hallway, locomotion on and off the unit, dressing, and eating. The assessment indicated Resident #1 had no impairment in range of motion and used a cane as a mobility device. The assessment indicated Resident #1 was independent with ambulation. Record Review of a care plan dated 7/13/21 indicated Resident #1 had a safety risk related to wandering, and a diagnosis of dementia. The care plan indicated Resident #1 needed cueing and redirection at times, and that he had a WanderGuard device for elopement risk. Record review of an elopement risk assessment, dated 7/14/21, indicated Resident #1 ambulated independently with a device, displayed restless behaviors, did not recognize stop lights or signs, and was considered to be at high risk for elopement. Record review of skilled administration records dated August 2021 indicated Resident #1 was checked for placement and function of the WanderGuard device every shift. During an observation and interview on 8/17/21 at 3:50 p.m., Resident #1 was standing in the hallway outside his room on the East wing. Resident #1 said that he did not live here, and could not name the purpose of the WanderGuard bracelet on his left wrist. During an observation on 8/17/21 at 4:10 p.m. Resident #1 walked toward the front door exit. Staff (unidentified) redirected Resident #1 away from the exit. During an interview on 8/23/21 at 3:50 p.m., LVN C said she normally worked on the East wing and Resident #1 was part of her assignment. LVN C said she was supposed to check the placement, date, and function of the WanderGuard bracelet every shift. LVN C said function of the bracelet was checked by having the resident walk to each exit to ensure the alarm would sound when the resident approached the door. LVN C then said function of the bracelet was checked only the first time the WanderGuard bracelet was placed on the resident, and subsequent checks of the bracelet included checking the date and placement only. 2. Record Review of physician orders dated 8/20/21 indicated Resident #2, admitted [DATE], was a [AGE] year-old male with diagnoses including unspecified dementia without behavioral disturbance, cognitive communication deficit, and chronic respiratory failure. An order dated 6/14/21 indicated Resident #2 was to have a WanderGuard device at all times related to elopement risk. The order specified that function and placement of the device were to be checked every shift. Record review of the most recent MDS assessment, dated 6/23/21, indicated Resident #2 had severe cognitive impairment and had wandered in the past 3 days of the assessment period. The assessment indicated Resident #2 needed supervision only for all ADLs, had no impairment in range of motion, and was able to stabilize without staff assistance for transfers and walking. Record review of a care plan intervention dated 6/22/21 indicated Resident #2 had a focus area of elopement risk related to dementia. Interventions included a WanderGuard device. Record review of an elopement risk assessment dated [DATE] indicated Resident #2 had a history of elopement from a previous facility and was considered at high risk for elopement. Record review of Resident #2's Skilled Administration Records for August 2021 revealed there was no documentation of routine checks for placement and function of his WanderGuard device. During an observation and interview on 8/18/21 at 10:45 a.m., Resident #2 was self-propelling his wheelchair to a set of double glass doors at the end of the hall. Resident #2 opened the door and maneuvered his wheelchair through the door without assistance. Resident #2 had a WanderGuard bracelet on his wrist. An interview was attempted but no meaningful information gained due to garbled speech. During a telephone interview on 8/30/21 at 3:20 p.m., the DON said Resident #2's Skilled Administration Record did not include an entry for staff to document checking the function and placement of his WanderGuard device every shift because of a data entry error. The DON said there was no other documentation that placement and function of Resident #2's WanderGuard device was being checked for function every shift. 3. Record review of physician orders dated 8/20/21 indicated Resident #3, admitted [DATE], was a [AGE] year-old female with diagnoses including [CONDITION(S)] disorder, major depressive disorder, and essential hypertension. An order dated 8/6/21 indicated to update the expiration date of the WanderGuard device when new device is placed every shift for elopement risk. An order dated 8/18/21 indicated Resident #3 was to have a WanderGuard at all times. The order specified the device was to be checked for function and placement every shift. Record review of the most recent MDS assessment (admission), dated 8/2/21 indicated Resident #3 was admitted from a psychiatric hospital Record review of Resident #3's care plan, initiated 8/4/21, indicated the plan was revised on 8/19/21 to include potential for elopement related to impaired safety awareness. Interventions included placement of the WanderGuard device. Record review of an elopement risk assessment, dated 8/3/21, indicated Resident #3 ambulated independently, had moderately impaired cognition, had attempted to leave the facility one or more times in the last week, had restless behavior, and was considered to be high risk for elopement. Record review Resident #3's Skilled Administration Record for August 2021, conducted on 8/18/21, indicated staff were checking the date of the WanderGuard device each shift. There was no documentation that staff was checking the functionality of the device on 8/3/21, 8/4/21, 8/5/21, 8/6/21, 8/7/21, 8/821, 8/9/21, 8/10/21, 8/11/21, 8/12/21, 8/13/21, 8/14/21, 8/15/21, 8/16/21, and 8/17/21. During a telephone interview on 8/30/21 at 3:20 p.m., the DON said there was no physician order to check the placement and function of Resident #3's WanderGuard device until 8/18/21. The DON said the omission of an order was an oversight. The DON said Resident #3 had been wearing a WanderGuard since 8/3/21, but there was no documentation that staff had been checking for placement and function each shift. 4. Record review of physician's orders dated 8/20/21 indicated Resident #5, admitted [DATE], was a [AGE] year-old male with diagnoses including unspecified [CONDITION(S)], unspecified dementia without behavioral disturbance, and cognitive communication deficit. Record review of the most recent MDS assessment, dated 6/22/21, indicated Resident #5 had severely impaired cognition and had not displayed wandering behavior during the assessment period. The assessment indicated Resident #5 needed supervision and set up help only for all ADLs. Record review of Resident #5's care plan included a focus area initiated 12/03/20 which indicated Resident #5 was an elopement risk/wanderer. A revision on 7/19/21 indicated Resident #5 refused WanderGuard placement. Record review of an elopement risk assessment, dated 8/19/21, indicated Resident #5 was a high risk for elopement. The assessment indicated Resident #5 understood and verbalized acceptance of need for nursing home care, had no attempts to leave the facility, recognized stop lights and signs, knew precautions when crossing streets, and recognized physical needs. The assessment indicated the IDT had determined WanderGuard was not indicated at this time, resident is not actively exit seeking. 5. Record review of a physician orders dated 8/20/21indicated Resident #4, admitted [DATE], was a [AGE] year-old female with diagnoses including unspecified dementia with behavioral disturbances, senile degeneration of the brain, and cognitive communication deficit. Record review Resident #4's most recent MDS, dated [DATE],i indicated she had severely impaired cognition and had not wandered during the assessment period. Resident #4 extensive assistance of two staff for bed mobility and toileting. Locomotion on and off the unit required physical assistance of one staff but only occurred once or twice during the assessment period. The assessment indicated Resident #4 used a wheelchair for a mobility device. Record review of a progress note dated 11/9/20 written by LVN G indicated Resident #4's WanderGuard was discontinued. The note indicated Resident #4 was wheelchair bound and no longer wanders. Record review of an elopement risk assessment, dated 12/15/20, indicated Resident #4 was not considered a wandering risk. Record Review of Resident #4's care plan indicated a revision on 8/19/21 to include elopement risk related to dementia (after surveyor intervention). Interventions included placement of the WanderGuard device. 5. During an interview on 8/18/21 at 3:25 p.m., Dietary Aid M said the timeclock was near the South wing exit. She said that on 8/13/21 the alarm was sounding when she clocked out. She said Resident #4 was in her wheelchair on the sidewalk near the street. She said Resident #5 was standing with her. Dietary Aid M said Dietary Aid L was coming to work as she was leaving, and that he alerted Nursing staff on the South wing that Resident #4 was outside. During an interview on 8/18/21 at 3:43 p.m., Dietary Aide L said that he did not know about a resident being found outside, and that he had nothing to say. During an interview on 8/19/21 at 2:05 p.m., LVN O said on 8/13/21 she was alerted by Dietary Aide L that Resident #4 was out of the building. LVN O said Resident #4 had gone out of the covered exit on the South wing and was on the sidewalk in her wheelchair near the curb. LVN O said she did not recall hearing an alarm go off, and that she had been passing medications on that hall at the time. LVN O said the red button on the wall could be pushed and the doors could be opened without an alarm. LVN O said the release button had been there for a long time, at least a year or two. During an interview on 8/18/21 at 5:23 p.m., LVN N said Resident #4 was found outside the building on 8/13/21. LVN N said Resident #4 never got off the sidewalk. LVN N said Resident #4 had a WanderGuard device and that the alarm at the door was sounding. LVN N said she did not document anything in Resident #4's record nor did she notify the family, physician, or DON because it didn't seem like a big deal to her, and that Resident #4 never got off the property. LVN N said Resident #4 always wants to go out that door. During an interview on 8/19/21 at 5:44 p.m., CNA P said she was working the 2p-10p shift on the South wing on 8/13/21. CNA P said Resident #4 was being assisted by LVN O to return to the building when she first saw her that day. CNA P said she heard the door alarm. CNA P said she had seen Resident #4 gesture toward the keypad with her hand and had redirected her. CNA P said Resident #4 liked to sit near the South wing exit and that a lot of people redirect her all the time. CNA P said Resident #4 needed a WanderGuard at all times, but she was not sure if she was wearing one that day. CNA P said Resident #4 and #5 were intelligent, and that they know where the doors are at. During an interview on 8/19/21 at 1:20 p.m., the DON said the facility had learned that Resident #4 had gotten out of the building, and that Resident #5 was with her. The DON said LVN O was the first staff to respond from the South wing. The DON said LVN O had reported that the alarm was not sounding. The DON said there was no evidence the Resident #4's family or physician was notified, and there was no incident report for the event. The DON said neither Resident #4 nor Resident #5 was considered an elopement risk at the time, and neither of them had been wearing a WanderGuard bracelet. The DON said Resident #4 had been considered an elopement risk in the past, but the risk had been downgraded after she became wheelchair bound and could not ambulate. During an interview on 8/19/21 at 10:50 a.m., the ADM said on 8/18/21 the fire alarm vendor replaced the release button with a keypad on the South wing exit (after surveyor intervention). The ADM said he was not aware that the WanderGuard sensor was not working on that door. The ADM said after interviewing staff it was now known that the residents outside the building were Resident #4 and Resident #5. The ADM said it was unknown if Resident #4 got out of the building on her own or if Resident #5 let her out. During an interview on 8/18/21 at 11:31 a.m., the DON said all doors should be secure, and that if the WanderGuard system was not working, or if an exit had a release mechanism that would allow the doors to open without sounding an alarm, that would create a hazard for residents at risk for elopement. During an interview on 8/18/21 at 11:52 a.m., the ADM said the facility had a WanderGuard system and it's purpose was to alarm when residents at risk of elopement were attempting to exit. He said the WanderGuard system will sound an alarm to alert staff that a resident is near the door. The ADM said in addition to the WanderGuard system all the doors were equipped with magnetic locks that required a code to release the doors. The ADM said he was not aware that the covered South wing exit did not have a functioning keypad nor that the WanderGuard alarm was not working on that door. The ADM said he was not aware of any elopements. The ADM said the facility did not have a policy specific to the WanderGuard system. During an interview on 8/18/21 at 12:20 p.m., the maintenance director said the WanderGuard had been disabled probably for a couple of months. He said the fire alarm vendor had installed the release button for the magnetic locks and disabled the WanderGuard at the same time. He said the electronic tracking system for maintenance was not used to document completed work orders. The maintenance director said there was a notebook at each nursing station for maintenance requests and that he checked them every day. He said when maintenance requests were completed, he left them in the notebook and did not know what happened to them after that. Record review of maintenance requests on all resident units (North, South, and East wings) indicated there were no pending maintenance requests, nor none completed. During an interview and observation on 8/18/21 at 12:45 p.m., the maintenance director said that he had checked the WanderGuard system on the South wing door and found that it was unplugged in the ceiling. He said when he plugged it in it started working. The WanderGuard system sounded an alarm when approached with a bracelet. During an interview on 8/19/21 at 11:28 a.m., the maintenance director said when he tested the doors, he was testing the magnetic locking system, and not the WanderGuard system. He said the fire alarm vendor had not disabled the WanderGuard, and that he thought it had been accidentally disabled when his helper was working in the ceiling. The maintenance director said that the release button for the magnetic locks had been there for 5 or 6 years to give EMS quick access to the facility in the event of an emergency. The maintenance director said the facility did not have an operators manual for the WanderGuard system. During a telephone interview on 8/19/21 at 5:12 p.m., the fire alarm vendor he said the audible alarm for the magnetic door lock had been disconnected. He said they repaired the door so that the alarm would work with a keypad rather than the release button. The fire alarm vendor said it was a good idea to check the WanderGuard system once a week to make sure it is functioning correctly. Record review of a facility policy titled Wandering and Elopement, revised March 2019, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. When the resident returns to the facility, the Director of Nurses or Charge Nurse shall: *examine the resident for injuries *contact the physician and report findings and condition of the resident *notify the resident's legal representative *complete and file an incident report *document relevant information in the resident's medical record. Record review of a WanderGuard user manual, dated 2012 and provided by the ADM indicated: *test the Wander Guard system weekly *test the bracelets daily *staff must know how to test door monitors and bracelets and to record testing results. The administrator, DON, and the regional corporate nurse was notified on 8/20/2021 at 6:42 p.m., that an IJ situation was identified related to hazards and supervision due to the above failure. The administrator was provided the IJ template at this time. The facility's Plan of Removal was accepted on 8/21/2021 at 9:30 a.m., and included the following interventions: On 8/19/21, administration was made aware of two residents that had exited the facility. Neither resident was considered an elopement risk according to their current assessment. The Wander Guard system and Mag Locks for all doors were evaluated for proper functionality. The side door's Wander Guard sensor was not working properly although the Mag Lock was. Maintenance supervisor immediately accessed the attic and found a loose wire and once it was re-connected the system was in working order and verified. The alarm system vendor was contacted and on the same day evaluated the system on all doors, locks, and alarms to ensure in working order. The release button on the wall that would open the door when pushed was removed and a secure keypad was installed in it's place. New elopement risk assessments were completed for the two residents that were noted to be outside the facility. On 8/19/21, Audit was completed of all residents to ensure current elopement risk assessment. On 8/19/21, education was initiated with staff on staff response and notification of residents being outside the facility. Administrator in-serviced the maintenance director on monitoring process for Wander Guard system and documentation requirements. Maintenance Director/Designee to test the Wander Guard system on all doors daily x 2 weeks and weekly thereafter. Administrator will randomly check 2 doors daily x 2 weeks and weekly for 4 weeks. Any system failures will be reviewed during monthly QAPI for 3 months. On 8/23/2021 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by interviews with nursing staff, dietary staff, and therapy staff confirming knowledge of in-services regarding elopement, the WanderGuard system, and reporting of incidents. On 8/23/2021 at 4:50 p.m., the administrator, DON, and regional corporate nurse were informed the IJ was removed; however, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems

Based on interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 3 of 6 residents (Resident #6, #7 and #10) reviewed for medication and 1 of 1 facility reviewed for pharmacy services. The facility failed to ensure the new liberalized medication administration procedures were not in contraindication to medication orders or would cause negative side effects. The facility failed to thoroughly train staff and inform residents of the new liberalized medication administration procedures prior to implementing the process. An Immediate Jeopardy was identified on 08/25/21. While the Immediate Jeopardy was removed on 08/26/21 at 1:04 p.m., the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. This failure could place residents requiring assistance with medication administration at risk for adverse effects, death, overdose and decline in health. The findings included: Record Review of Liberalized Medication Pass Times policy and procedure dated 11/2020 revealed Residents will be administered their medications using liberalized medication pass times to promote a home like environment and meet the residents needs effectively. Each resident's medication time preference will be modified in accordance with his or her daily schedule. The Liberalized Medication Time Pass policy did not address the process the facility was going to use to educate and train the residents and staff on the liberalized medication pass, and it did not address how the facility was going to determine how each individual medication time preference would be obtained to see what the residents daily schedule was at home prior to admission into the facility. The policy also did not address which medications would or would not be acceptable to be safely administered using liberalized medication pass times. Record Review of an email titled Liberalized Medication Times from Director of Clinical Services to the Regional Nurse Consultant dated May 13, 2021 and timed 10:55 a.m. revealed the facility was informed to have all of their MAR's changed to liberalized medications times by the end of May 2021. The email revealed that diabetic medications should not be on liberated medication times; however, blood pressure medications was not listed. There was additional documentation in the email that Some medication times cannot be diverted due to the efficacy (the maximum response that can be achieved) of the medication, but those specific medications were not listed in the email. Record Review of a facility in-service for nursing staff and certified medication aides dated 7/27/2021 revealed Attached is a copy of the new Liberalized Medication Pass Times. Please review so that you are aware of what we are doing. The plan is to have all times changed by August 1, 2021. We will start on East wing 7/27/2021. The in-service did not include specific training to the staff regarding liberalized medication process or medications that were not able to be administered on the liberalized times due to safety, half-life (the length of time that the effect of the medication lasts in an individual's blood stream), and efficacy. There was no documentation on the in-service regarding staff training on how the staff were to obtain information regarding what the residents daily schedule was at home prior to admission into the facility regarding the liberalized process of administration. There was no staff training on how to look up specific medication times to see when the exact time a medication was administered and by whom using the electronic record for liberalized medication times. During an interview on 8/25/2021 at 10:18 a.m., LVN A said a new company bought the facility in May 2021 and they initiated the liberalized medication system either at the end of July 2021 or the first of August 2021. LVN A said the only training she received by the facility on the liberalized medication system was that the medication times were changing on the MAR. During an interview on 8/24/2021 at 11:00 a.m., the DON stated that on the evening of 8/24/2021 her and the regional nurse started looking into the liberalized medication pass times with TID blood pressure medications and insulin after the surveyors questioned if it was or was not acceptable. She stated there was a potential for TID blood pressure medications to be administered to close together and could cause the blood pressure to drop to low. She stated the facility did not consult with pharmacist or physicians or medical director prior to implementing the liberalized medication system. During an interview on 8/24/2021 at 3:11 p.m., LVN B said the facility started a liberalized medication pass system about 4-5 weeks ago. She denied being trained on the liberalized medication system. She said she was told that the times would allow them to have a 4-hour time window to administer medications and it was to make it more homelike for the residents. During an interview on 8/24/2021 at 3:50 p.m., the DON said the facility had a liberalized medication pass system which was resident centered toward a home like atmosphere. She said it allowed the residents to take their medications anytime they wanted to like they would at home. She stated the nurses and medications aides received very minimal training about the liberalized medication process which included that the facility was changing the medication times and that was it. She denied educating the nurses and medication aides on medications that were not allowed on liberalized medication pass times, they were not educated on efficacy and half-life of certain medications such as blood pressure medications. The DON also denied that the residents or their families were educated on liberalized medication times to obtain the specific times the residents took their medications at home since the liberalized medication pass was resident centered. During an interview on 8/25/2021 at 12:13 p.m., the pharmacy consultant denied consulting with the facility on the liberalized medication process. She said that on July 9, 2021 the facility told her they wanted to start a liberalized medication pass system but that was the only thing they discussed about it. She stated she was not aware that the administration times for the TID [MEDICATION(S)] (blood pressure medication) were 6 am - 10 am, 2 p.m.- 6 p.m. and 6 pm - 10 p.m. She said if she would have seen those times on the MAR it would have been a red flag to her, and it would have needed to be clarified. She said it was a potential risk of the medication being administered to close together. She said [MEDICATION(S)] must be administered 4 hours apart because of its half-life and the times on the MAR does not give that time frame availability. During an interview on 8/25/2021 at 3:28 p.m., the medical director said he was not consulted, nor did he participate in establishing liberalized medications times or process. He said that was up to the facility and he pharmacy consultant. He said he did not think times frames were important on TID blood pressure medication. He stated that if the blood pressure medication is administered TID as ordered then the time it is administered does not matter. He stated people must be very careful with insulin administration because you could potentially kill someone. 1.Review of Resident #6's Admission Record revealed he was [AGE] years old and was initially admitted into the facility on [DATE]. It also revealed he was discharged to an acute care hospital on 8/16/2021 at 5:15 a.m. Review of Resident #6's Order Review Report dated 8/23/2021 and timed 4:34 p.m. revealed he had a diagnosis of [CONDITION(S)] (low potassium), dementia without behavioral disturbances, [CONDITION(S)], type 2 diabetes mellitus with diabetic [CONDITION(S)], congestive heart failure, hypertension, [CONDITION(S)], and cognitive communication deficit. He had an order for [MEDICATION(S)] (diabetic medication/insulin) 10 units onetime a day for diabetes and inject 30 units onetime a day for diabetes. The start date on the order was 7/27/2021 and the end date on the order was 8/22/2021. There was an order for trajenta (diabetic pill) 5 mgs daily for diabetes and the start date was 7/28/2021 and [MEDICATION(S)] (diabetic insulin) pre sliding scale before meals for diabetes that revealed a start date of 10/16/2020. Review of Resident #6's MDS dated [DATE] revealed he had the ability to express ideas and wants to make himself understood, and he had a clear comprehension to understand verbal content by others and his speech was clear. It revealed he was independent with making consistent and reasonable decisions regarding his tasks of daily life. Resident #6's care plan for diabetes with a revision date of 7/26/2021 documented the resident was to be administer 10 units of [MEDICATION(S)] in the evenings and 30 units in the mornings as ordered and to monitor for signs and symptoms of [CONDITION(S)]. Resident #6's had a care plan for unplanned weight loss with a revision date of 5/04/2021. An intervention on the care plan was to monitor and record food intake at each meal, and the revision date on the intervention was 3/2/2021. Review of Resident #6's Skilled Administration Record dated 8/1/2021 - 8/31/2021revealed he was to be administered 10 units of [MEDICATION(S)] daily between 6:00 p.m. - 10:00 p.m., and 30 units of [MEDICATION(S)] daily between 6:00 a.m. - 10:00 a.m. It was documented that the insulin was administered between those time ranges on 8/15/2021. The Skilled Administration Record revealed LVN C checked Resident #6's blood sugar on 8/15/2021 was at 4:30 p.m. and it was 125. There was no further documentation of a blood sugar check after that time. Review of Resident #6's Documentation Survey Report for August 2021 revealed no documented meal intake for 2:00 pm. - 10:00 p.m. on 8/15/2021. In an interview on 8/24/2021 at 3:56 p.m., LVN C stated that she membered Resident #6 ate some summer sausage at the nursing station on 8/15/2021, but she could not remember what time he ate it. She stated she administered 10 units of [MEDICATION(S)] to Resident #6 on 8/15/2021 between 6 p.m. - 10:00 p.m. Review of Resident #6's Progress Notes with a late entry dated 8/15/2021 and timed 1:40 a.m. revealed he was found on the floor in his room at 1:40 a.m. and again at 1:55 a.m. At 1:55 a.m. Resident #6 was agitated grabbing side rails, and refusing to return to bed, resident attempting to speak and refusing assistance . at 2:05 a.m. EMS called. at 2:25 a.m. EMS in the facility to transport the resident to the ER. There was no documentation of residents' blood sugar or vital signs and RN L electronically signed the note. On 8/26/2021 at 2:29 p.m., RN L was called to be interviewed, but she was unable to be reached. Review of Resident #6's hospital physician notes revealed he arrived at the hospital on 8/16/2021 at 6:12 a.m. It revealed This was a [AGE] year-old male presenting from the nursing home for which EMS was called. The patient rolled out of a 3 feet bed off the ground. Upon EMS arrival they found the patients glucose (blood sugar) to be 48 mg/dL, improving to 157 after 250 ml of D10 (medication used to increase a severely low blood sugar), for his fall and [CONDITION(S)] (low blood sugar) he was brought to the hospital. Resident #6's admitting diagnosis was [CONDITION(S)], metabolic acidosis (a condition in which too much acid accumulates in the body), and hypothermia (a significant and potentially dangerous drop in body temperature). Review of Resident #6's hospital Admission and History and Physical dated 8/16/2021 and timed 11:07 a.m. revealed his [CONDITION(S)] could be related to him skipping meals, and his hypothermia was suspected to be induced by his underlying [CONDITION(S)]. It also revealed the patient recalls nothing about the events of this morning, but states he was in his usual health up until that point. His only complaint is that the food is often cold at the facility and at the facility a lot of times he will skip meals, but he still receives his insulin in that setting. During an interview on 8/24/2021 at 11:50 a.m., Resident #6 stated he does not like the food at the facility, he does not eat every meal the facility serves him because he is not hungry. He said the nurses still administered his insulin to him even though he does not eat his food. He denied the facility educating him or talking to him about the liberalized medication pass. During an interview on 8/29/2021 at 12:41 p.m., LVN A stated that Resident #6 was very particular about his food. She stated Resident #6 would leave his food untouched in his room and he would eat it later if he became hungry. She stated they administer him his insulin prior to him eating so it was very important for them to monitor his food intake. During an interview on 8/24/2021 at 3:50 p.m., the DON said that insulin should not be on liberalized medication pass because you should know the amount of food that they have or have not eaten prior to administration and that was difficult to do on a liberated medication. During an interview on 8/26/2021 at 12:25 p.m., the Regional Nurse said in May 2021 the Director of Clinical Services had a conference call with her, other regional nurses and the DON's at the facilities and they were informed that the company had implemented liberalized medication pass for all facilities. She stated the Director of Clinical Services sent an email of medications that were not supposed to be on liberalized medication pass and think insulin was on the list. 2. Review of Resident#10 's Admission Record revealed he was [AGE] years old and his admitted was 7/07/2021. Review of Resident # 10 's August 2021 order summary report revealed he had diagnosis of dehydration, adult failure to thrive, history of falling, and essential (primary) hypertension. The order also revealed he was to be administered 25 mg of [MEDICATION(S)] HCl (blood pressure medication) three times a day for [CONDITION(S)]. Review of Resident #10 's MDS dated [DATE] revealed he had the ability to express ideas and wants to make himself understood, and he had a clear comprehension to understand verbal content by others. It revealed he was independent with making consistent and reasonable decisions regarding his tasks of daily life. Review of Resident #10's care plan for hypertension with an initiated date of 7/26/2021 and a revision date of 8/25/2021 (which was after surveyor intervention) documented the facility was to educate the resident/family/caregiver about the importance of medication and diet compliance. Review of Resident #10 's MAR dated 8/1/2021 - 8/31/2021 revealed an order for 25 mgs of [MEDICATION(S)] HCl by mouth three times a day for [CONDITION(S)]. The administration times on the MAR were 6:00 a.m. - 10:00 a.m., 2:00 p.m. - 6:00 p.m. and 6:00 p.m. - 10:00 p.m. The start date on the MAR for the [MEDICATION(S)] was 7/27/2021 at 6:00 p.m. Documentation revealed the [MEDICATION(S)] was administered between the scheduled times on the MAR. During an interview on 8/24/2021 at 3:56 p.m., LVN C stated she does not like the new liberalized medication process that the facility implemented. She said Resident #10 has an order to be administered [MEDICATION(S)] three times a day and the evening and the liberalized times on the MAR for the medication to be administered between 2:00 p.m. - 6:00 p.m. an 6:00 p.m. - 10:00 p.m. has the potential to lead to him being over medicated if someone administered the medication to close together. During an interview on 8/25/2021 at 11:00 a.m., DON said they have not educated Resident #10 or his family on new liberalized medication pass process that the facility implemented. During an interview with Resident #10 on 8/26/2021 at 11:15a.m. he denied being educated on liberalized medications by the facility. 3. Review of Resident #7's Admission Record revealed she was [AGE] years old and she was initially admitted into the facility on [DATE]. Review of Resident #7 's August 2021 order summary report revealed she had diagnosis of essential (primary) hypertension, abnormalities if gait and mobility, dementia without behavioral disturbance, [CONDITION(S)], history of falling, chest pains, and cognitive communication deficit. The order also revealed an order to start her on 100 mg of [MEDICATION(S)] HCl (blood pressure medication) three times a day for [CONDITION(S)] on 8/24/2021. Review of Resident #7 's MDS dated [DATE] revealed she had the ability to express ideas and wants to make herself understood, she had a clear comprehension to understand verbal content by others and her speech was clear. Review of Resident #7's care plan for hypertension with an initiated date of 2/06/2020 documented the facility was to educate the resident/family/caregiver about the importance of medication and diet compliance. During an interview on 8/25/2021 at 11:00 a.m., DON said they have not educated Resident #7 or her family on the new liberalized medication pass process that the facility implemented. During an interview with Resident #7 on 8/25/2021 at 12:02 p.m. she denied being educated on liberalized medications by the facility. Review of Resident #7 's MAR dated 8/1/2021 - 8/31/2021 revealed an order for 100 mgs of [MEDICATION(S)] HCl by mouth three times a day for [CONDITION(S)]. The administration times on the MAR were 6:00 a.m. - 10:00 a.m., 2:00 p.m. - 6:00 p.m. and 6:00 p.m. - 10:00 p.m. The start date on the MAR for the [MEDICATION(S)] was 8/24/2021 at 2:00 p.m. The Administrator, DON and Regional Nurse was notified of the Immediate Jeopardy on 08/25/21 at 3:42 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/26/21 at 8:00 a.m. and reflected the following: What immediate interventions were initiated for resident identified? STEP 1: On 8/24/21 it was noted that the insulin orders for a resident were scheduled as liberalized times instead of scheduled times. It was noted that some of the orders for blood pressure medications were scheduled as liberalized time codes. The orders were discontinued, and a new order was entered with scheduled time codes. This was done by the DON on 8/24/2021 What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? STEP 2: On 8/24/21, Audit was completed of all residents with orders for insulin and what the time schedules were, and 2 residents were noted to have liberalized time codes ordered. The orders were discontinued, and new orders written for scheduled times. Audit was completed for all resident s with ordered blood pressure medications, and multiple residents were noted to have liberalized time code orders. The orders were discontinued, and new orders written for scheduled times. This was done on 8/24/21 by the DON and nursing management What system changes were made or modified? What systemic education was completed to enhance knowledge development of team members? STEP 3: On 8/24/21, Regional Nurse in serviced the director of nursing and 2 assistant directors of nursing on liberalized medication policy including initiation of policy and the inclusion of Physician and Pharmacy Consultant. On 8/24/21 education was initiated with nursing staff regarding the policy and specific medications that cannot be scheduled for liberalized medication pass times. This education will be included in new hire orientation. 8/24/2021 QAPI was developed and reviewed with Medical Director. This was done on 8/24/21 by the administrator and the DON Continued Quality Assurance audits implemented to ensure enhanced system compliance? Monitoring plan STEP 4: DON/designee will complete reviews of orders daily in the Clinical meeting, any inappropriate time codes will be immediately corrected, and education provided to the nurse making the order entry. DON to report findings monthly for 3 months to QAPI. This was done on 8/24/21 by the DON and nursing management. Monitoring of the facilities Plan or removal included the following: Interviews, and record reviews were conducted on 08/26/21 starting at 10:35 a.m. and continued through 08/26/21 at 1:04 p.m. with all nursing and MA that were on duty and that were administering medications in the facility during this time. The in-services included liberalized med times and not all meds were to be on liberalized med times such as hypertension medications, insulins, [CONDITION(S)] medications, intravenous antibiotics, and Parkinson medications and the removal of 4-hour time frames for those medications, medication administration was changed to standard times and the staff were provided with list of medications that were unacceptable for liberalized medication pass times. Record reviews revealed residents no longer had 4-hour time frame ranges on the MARS for insulin and TID blood pressure medications. The medication times for residents were changed to standard medication times. During an interview on 8/26/2021 at 10:35 a.m., LVN E stated the facility has recently in-serviced her on liberalized medications and she was educated on which medications were not to be on liberalized scheduled such as insulin and blood pressure medications. She stated she received a packet from the facility on the acceptable medications and times that can be administered. During an interview on 8/26/2021 at 11:00 a.m., MA K said she passed medications on all units in the facility. She stated she was not trained on liberalized medications pass when the facility first initiated it. MA K said she was not aware of the change to the liberalized medication process until she came to work one day and the time changes on the MAR were different and they had a four-hour window to administer medications. MA K said she did not like the 4-hour medication range on blood pressure medication that were ordered TID. She said the liberalized medication pass times on the MAR on TID blood pressure medication was 6 a.m.- 10:00 a.m., 2:00 p.m. - 6:00 p.m. and 6:00 p.m. - 10:00 p.m. MA K said she did not like those time ranges because a person could be following the MAR and give a blood pressure medication at 5:00 p.m. and according to the MAR the next dose could be administered as early as 6:00 p.m. and if so that would possibly cause a residents blood pressure to drop really low. She stated that on 8/26/2021 the facility trained her on what medications could be safely administered on liberalized medication pass schedule and what medications could not be administered. She said the facility has currently changed the times on the TID blood pressure medications and the new times are more specific and safer for administration. During an interview on 8/26/2021 at 11:40 a.m., LVN J said the facility told her they were changing to the liberalized medication pass times, but she said the facility did not train her on the it. She stated she would give the insulin on regular scheduled time; however, she felt as if there would be a problem administering TID blood pressure on a liberalized time schedule because she stated they had no way of knowing the exact time the last medication was administered. She said she could not look back at the electronic record to see what time and who administered a specific medication. She stated all she could see was when medication was due on her shift. LVN J stated that some people sign the MAR later and not actually when they administered the medication, so the documented administration times could also be off and not accurate. She stated the facility recently provided her with a thorough training on liberalized medications. During an interview on 8/26/2021 at 11:20 a.m., LVN I said this was the first facility she worked at that used liberalized medication times and she was not familiar with it. She said prior to 8/26/2021 the facility had not provided her with specific training on the process other than give the medication according to the time ranges on the MAR. She said the TID medication time ranges on the MAR were to close and if administered to close together in the time ranges it could cause the residents blood pressure to bottom out. She stated that on 8/25/2021 and 8/26/2021 the facility in-serviced her on liberalized medication pass times and they provided her with a list of specific medications that were not acceptable to be administered on liberalized times. She said the facility changed the times to more standardized times. During an interview on 8/26/2021 at 11:32 a.m., MA H stated that she started working as a MA in the facility in January 2021. She said the only training the facility gave her on liberalized medications times was that they were changing the medication times to allow for a larger window time for administration. She stated that the facility has recently in-serviced her on specific medications, the time frame and when what medications could and could not be administered using the liberalized times. During an interview on 8/26/2021 at 11:40 a.m., LVN G said a new company took over ownership of the facility in May 2021 and they started the liberalized medication pass as of August 1, 2021. LVN G said they were told that medication times were going to be between 4-hour time ranges and that was all the training they had received at that time on liberalized medications times. She said as of 8/26/2021 the facility trained her more thoroughly on liberalized medication times and on what medications can and cannot be placed on liberalized time. During an interview on 8/26/2021 at 11:53 a.m., RN F stated she started working at the facility about a week and a half ago and she was not educated or trained on liberalized medication at that time. She stated the facility in-serviced her on liberalized medications and times this week. She stated that since the recent in-service she was aware of which medications could be administered using liberalized times. During an interview on 8/26/2021 at 12:50 p.m., the administrator stated he was not really involved with the implementation of the liberalized medication pass times because he left it up to the clinical team. He said the liberalized medication pass was resident centered to make it a more home like atmosphere. He stated that although the liberalized medication process was centered around the residents, the facility had not educated, trained, or reached out to the residents or their families regarding the process. He stated that he believes that the new process they have implemented due to the IJ would be better going forward to make sure adequate time is given in between medication doses. On 8/26/2021 at 1:49 p.m., the administrator, DON and Regional Nurse were informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems

Based on interview and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries to 1 of 4 residents (Resident #1) reviewed for pressure ulcers. The facility failed to identify, assess and provide care for Resident #1's facility acquired pressure injuries. Resident was transferred to the hospital due to a change in condition and 3 unstageable (the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) pressure ulcers were identified. This deficient practice could place residents at risk for pressure injuries, pain, and a decline in health. Findings included: physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders did not indicate a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS assessment dated [DATE] indicated Resident #1 was readmitted to the facility from an acute hospital on 3/4/21. The assessment indicated Resident #1 had no speech but could sometimes be understood and sometimes understood others. The Brief Interview for Mental Status (BIMS) was not conducted; a staff assessment for mental status indicated Resident #1 had short- and long-term memory problems and had severely impaired cognitive skills for daily decision making. The assessment indicated Resident #1 did not reject care. The assessment indicated Resident #1 needed extensive assistance of two people for moving to and from lying position, turning side to side, and body positioning. The assessment indicated Resident #1 needed extensive assistance of two people for dressing, extensive assistance of one person for personal hygiene and eating and was totally dependent on two people for toileting and bathing. The assessment indicated Resident #1 was always incontinent of urine and bowel. The assessment indicated Resident #1 was assessed for risk of pressure injury using a formal assessment tool (unspecified). The assessment indicated Resident #1 had no unhealed pressure injuries and was not at risk of developing pressure injuries. A Braden Scale for Predicting Pressure Sore Risk, dated 3/29/21, indicated Resident #1 was at risk for developing a pressure injury. An Admission/Readmission Nursing Evaluation, dated 3/4/21, indicated Resident #1 was totally dependent on assistance of two people for bed mobility, transfers, dressing, eating, toilet use, and bathing. The assessment noted the following skin conditions: bilateral gluteal folds - previous wound scars; lips dry and skin splitting; scab left inner ankle; scab left knee; scab on the neck (used to be trach); scab right knee; scab to left lower leg; scar left heel; scar left side/ribcage, scar left lower leg; has generalized scattered scars, long nails, dry skin and bilateral heel dry. A nursing/skin note dated 3/5/21, by LVN B, indicated Resident #1 had a healing abrasion to her left inner ankle and right knee. The note indicated no other skin issues or areas of concern noted on readmission. The note indicated staff would turn and reposition frequently and continue to monitor (unspecified). During an interview on 4/7/21 at 11:50 a.m., LVN B said she was the treatment nurse for the facility. LVN B recalled looking at Resident #1's skin and writing the note on 3/5/21. LVN B said Resident #1's wound was a superficial, dry, abrasion. LVN B said she wrote that the abrasion was healing, and that it was a follow up from a previous admission in February when it was noted on that admission from the hospital. LVN B said Resident #1 did not have any new skin areas, and that all the areas noted were present when she was transferred to the hospital on 3/2/21. A care plan revised 3/1/21 indicated Resident #1 had focus areas including self-care deficit for ADLs. Interventions included assistance of two staff for showering or bathing, bed mobility and dressing, assistance of two staff for transferring, dependence on two staff for incontinent care, and assistance of one staff for eating. The care plan indicated a focus area related to potential/actual impairment to skin integrity related to itching, [MEDICATION(S)] rash incontinence and limited mobility. Interventions included apply barrier cream after every incontinent episode; cleanse area (unspecified) with wound cleanser apply triple antibiotic ointment and cover with dry dressing every day until healed once a day for shear, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan indicated a focus area related to bowel and bladder incontinence, and associated risk of urinary tract infection (UTI) and skin breakdown. Interventions included apply barrier cream to coccyx after every incontinent episode, incontinent checks and care every two hours and as needed and monitor and report all red areas and/or abnormalities noted. The care plan indicated a focus area related to potential for pressure ulcer development related to diabetes mellitus, immobility, and incontinence. Interventions included low air loss mattress, monitor nutritional status including intake and record, and monitor/document/report as needed any changes in skin status including appearance, color, wound healing, signs of infection, wound size, and stage. The care plan did not indicate Resident #1 had actual pressure injuries. During an interview on 4/7/21 at 1:25 p.m., LVN A said she was the MDS nurse. LVN A said Resident #1 had a care plan review on 3/1/21 before being transferred to the hospital on 3/2/21, and the care plan was still in effect when Resident #1 returned to the facility on [DATE]. LVN A said the care plan provided to the surveyor was the resident's most recent care plan. Skin assessments dated 3/11/21, 3/18/21, 3/25/21, and 3/31/21 indicated Resident #1 had no abnormal skin areas, i.e., bruises, skin tears, pressure ulcers, or non-pressure wounds. During an interview on 4/6/21 at 4:31 p.m., LVN B said she had been the Treatment Nurse since April 2020. LVN B said the charge nurses were responsible for completing the weekly skin assessments unless a resident had a wound. LVN B said she was responsible for wound care and completing assessments for residents with wounds. LVN B said Resident #1 was being assessed by the charge nurses because she did not have a wound and had not had any skin problems during this admission. LVN B said when staff identified a resident with a potential skin problem, they would either tell her directly, or complete a written communication form and place it in her office. LVN B said she had not been notified that Resident #1 had any skin problems. ADL documentation for March 2021 defined bed mobility as how the resident moves to and from lying position, turns side to side, and positions body while in bed. The ADL documentation for bed mobility indicated the following: *3/5/21 2-10 and 10-6 shifts no care was documented *3/6/21 10-6 shift no care was documented *3/7/21 2-10 shift no care was documented *3/11/21 2-10 shift no care was documented *3/12/21 2-10 shift no care was documented *3/13/21 2-10 shift no care was documented *3/14/21 2-10 shift no care was documented *3/16/21 2-10 shift no care was documented *3/17/21 10-6 shift no care was documented *3/18/21 10-6 shift no care was documented *3/19/21 2-10 shift no care was documented *3/20/21 2-10 and 10-6 shift no care was documented *3/21/21 10-6 shift no care was documented *3/24/21 6-2 shift care was documented as not applicable *3/25/21 2-10 and 10-6 shift no care was documented *3/26/21 10 -6 shift no care was documented *3/28/21 6-2 shift no care was documented *3/29/21 6-2 shift no care was documented *3/29/21 6-2 and 10-6 shift no care was documented *3/31/21 6-2 shift no care was documented ADL documentation for April 2021 indicated the following for bed mobility: *4/1/21 10-6 shift no care was documented *4/2/21 10-6 shift no care was documented *4/3/21 10-6 shift no care was documented ADL documentation of skin observation for March 2021 indicated the following: *3/5/21 6-2 shift skin observation was documented as not applicable; 2-10 and 10-6 shifts no skin observation was documented *3/6/21 6-2 and 2-10 shifts skin observation was documented as not applicable; 2-10 shift no skin observation was documented *3/7/21 6-2 and 10-6 shifts, skin observation was documented as not applicable; 2-10 shift no skin observation was documented *3/8/21 6-2 and 10-6 shifts, skin observation was documented as not applicable *3/9/21 6-2 and 10-6 shifts, skin observation was documented as not applicable *3/10/21 6-2 and 10-6 shifts, skin observation was documented as not applicable *3/11/21 6-2 shift, skin observation was documented as not applicable; 2-10 shift no skin observation was documented *3/12/21 6-2 and 10-6 shifts, skin observation was documented as not applicable; 2-10 shift no skin observation was documented *3/13/21 6-2 and 10-6 shifts, skin observation was documented as not applicable; 2-10 shift no skin observation was documented *3/14/21 6-2 and 10-6 shifts, skin observation was documented as not applicable; 2-10 shift no skin observation was documented *3/15/21 6-2 shift, skin observation was documented as not applicable *3/16/21 6-2 and 10-6 shifts, skin observation was documented as not applicable; 2-10 shift no skin observation was documented *3/17/21 6-2 shift, skin observation was documented as not applicable; 10-6 shift no skin observation was documented *3/18/21 6-2 shift, skin observation was documented as not applicable; 10-6 shift no skin observation was documented *3/19/212-10 shift, no skin observation was documented; 0-6 shift, skin observation was documented as not applicable *3/20/21 2-10 and 10-6 shifts, no skin observation was documented *3/21/21 6-2 and 2-10 shifts, skin observation was documented as not applicable; 10-6 shift, no skin observation was documented. *3/2216/21 2-10 shift, skin observation was documented as not applicable *3/23/21 6-2 and 2-10 shifts, skin observation was documented as not applicable *3/25/21 2-10 and 10-6 shifts, skin observation was documented as not applicable *3/16/21 6-2 and 10-6 shifts, skin observation was documented as not applicable; 2-10 shift no skin observation was documented *3/26/21 2-10 shift, skin observation was documented as not applicable; 10-6 shift no skin observation was documented *3/27/21 6-2 and 2-10 shifts, skin observation was documented as not applicable *3/28/21 6-2 shift, no skin observation was documented; 2-10 shift, skin observation was documented as not applicable *3/29/21 6-2 shift, no skin observation was documented; 2-10 shift, skin observation was documented as not applicable *3/30/21 6-2 and 10-6 shifts, no skin observation was documented; 2-10 shift, skin observation was documented as not applicable *3/31/21 2-10 shift, no skin observation was documented ADL documentation of skin observation for April 2021 indicated the following: *4/1/21 10-6 shift no skin observation was documented *4/2/21 2-10 shift, skin observation was documented as not applicable; 10-6 shift no skin observation was documented *4/3/21 2-10 shift, skin observation was documented as not applicable; 10-6 shift no skin observation was documented *4/4/21 6-2 shift, documentation indicated Resident #1 had no scratches, red areas, discoloration, skin tears or open areas. A progress note dated 4/4/21 at 9:41 a.m., written by LVN F, indicated Resident #1 was lethargic and had respirations at a rate of 24 per minute. A new order was received to transfer Resident #1 to the hospital for evaluation and treatment. The note did not include any information regarding skin conditions. Review of hospital records included a skin note dated 4/5/21 at 7:00 p.m., by a hospital nurse. The note indicated Resident #1 had an unstageable pressure wound with slough on her lower right leg measuring 2 centimeters (cm) in long (L) x 2 cm wide (W) x 0.5 cm deep(D). The note indicated Resident #1 had an unstageable pressure wound on her lower left leg with slough measuring 2 cm L x 2 cm W x 0.5 D. The note indicated Resident #1 had an unstageable pressure injury to her left ear that was not measured. A wound care consultation note, dated 4/6/21, written by a hospital physician indicated she was consulted because Resident #1 had an unstageable pressure injury on her left ear, an unstageable pressure injury on her medial left lower leg, and an unstageable pressure injury on her lateral right lower leg, all present on admission. The note indicated the pressure injury on the left lower leg was 1 cm L x 1 cm W with no depth specified; the pressure injury on the right lower leg was 1 cm x 1 cm W with no depth specified. The pressure injury on the left ear was not measured. During an interview on 4/7/21 at 1:20 p.m., the DON said assessments should be based on information gained from direct observation or other credible sources. The DON said in addition to the weekly skin assessments, staff should be observing skin while providing care. The DON said blanks in documentation mean that the care was not documented. Staff are supposed to initial what they do on the MAR, TAR, and on the ADLs. The DON said she had reviewed the note written by LVN F regarding the transfer of Resident #1 to the hospital on 4/4/21. She said LVN F did not document anything about Resident #1's skin, and that he had been instructed to do a skin assessment when he sends someone out, going forward. During an interview on 4/7/21 at 1:06 p.m., LVN K said she had taken care of Resident #1. LVN K said Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN K said Resident #1 needed help to turn, eat, and for incontinent care. LVN K said staff make rounds every two hours and that Resident #1 was changed as needed. LVN K said she did weekly skin assessments, and never saw any issue with Resident #1's skin. During an interview on 4/7/21 at 1:49 p.m., CNA G said she had taken care of Resident #1 before she was transferred to the hospital. CNA G said Resident #1 needed help with all ADLs and was total care. CNA G said Resident #1 could not eat or drink by herself. CNA G said she provided incontinent care and turned Resident #1 every two hours. CNA G said she would usually have to change the whole bed because Resident #1 went a lot. CNA G said positioning wedges were used to offload Resident #1's legs and feet, and she had never noticed anything abnormal about her skin. CNA G said if she had seen a problem with Resident #1's skin, she would have reported it to the charge nurse and the treatment nurse. During an interview on 4/7/21 at 1:23 p.m., MA J said she took care of Resident #1 and gave her medications. MA J said she last saw Resident #1 was on 4/2/21, and that she had given her water every chance she had, even when she was not giving her medication. MA J said Resident #1 had to have help to turn in bed and to eat. MA J said she did not remember any wound on her skin, including on her ear. During an interview on 4/7/21 at 1:58 p.m., HA I said she worked as a hospitality aid, and had completed the CNA course but had not taken the test to be certified. She said she had assisted with Resident #1's care, but that was not her usually assigned area She said she had helped Resident #1 eat and had assisted with incontinent care. She said she never saw anything abnormal about Resident #1's skin, and she had not seen any open or scabbed areas. HA I said if staff saw any thing wrong with a resident's skin, they were supposed to report it immediately. During an interview on 4/7/21 at 2:10 p.m., CNA H said she took care of Resident #1 on the 6-2 shift the day she was transferred to the hospital on 4/4/21. CNA H said Resident #1 was still at the facility when her shift ended. CNA H said she had provided incontinent care 3 times during the shift. CNA H said during incontinent care she had observed Resident #1's lower extremities but that she had socks on her feet. CNA H said she did not recall seeing any open areas on Resident #1's skin, nor anything on her ear. CNA H said if she saw a problem with anyone's skin, she would notify the nurse. CNA H said Resident #1 was not eating, and she had notified LVN F. CNA H said LVN F went to check on Resident #1 and then told her he was going to send Resident #1 to the hospital. During an interview on 4/7/21 at 2:55 p.m., the Administrator said the DON, ADON, wound care nurse, and MDS nurse had completed skin assessments on 100% of the facility residents on 4/6/21, with no new skin problems identified. During a telephone interview on 4/7/21 at 3:23 p.m., LVN F said he was the nurse assigned to Resident #1 when she was transferred to the hospital on 4/4/21 related to altered mental status and lethargy. LVN F said the charge nurses do skin assessments on every resident every week. LVN F said there were no skin problems documented in Resident #1's record. LVN F said Resident #1's lower extremities were uncovered when he helped transfer Resident #1 to the stretcher, and he did not notice any problems with her skin. During an interview on 4/7/21 at 11:30 a.m., a hospital wound care nurse said she was a wound care nurse at the hospital where Resident #1 was admitted on [DATE]. The wound care nurse said the wound department was consulted related to Resident #1's wounds, and that she had seen the wounds on 4/5/21, the day after Resident #1 was admitted . The wound care nurse said Resident #1 had a pressure wound on the medial (inner) aspect of her left leg which contained slough, a pressure wound on the lateral (outer) side of her right ankle with necrotic tissue, and a pressure injury on her left ear with eschar. The wound care nurse said the wounds had developed over time and had progressed too far to have occurred since leaving the nursing facility. During a telephone interview on 4/8/21 at 5:05 p.m., a hospital physician said she was asked to see Resident #1 related to her wounds, and that she saw Resident #1 for the first time in the hospital on 4/6/21. The hospital said Resident #1 had an unstageable pressure injury on her left ear that was scabbed over with some exudate and redness, an unstageable pressure injury near her right malleolus (bony projection of the ankle) which had a scabbed area with some epithelialization (wound healing), and an unstageable pressure injury on her medial left lower extremity by her ankle which had slough (yellow necrotic tissue). The hospital physician said she had reviewed the notes from the wound care nurse at the hospital and agreed with them. The hospital physician said it was not possible that the wounds occurred between the time Resident #1 left the nursing facility and the time she was seen by the physician in the hospital. The hospital physician said the wounds were open craters and had the appearance of chronic wounds. The hospital physician said the left leg wound contained slough, which developed over time. The hospital physician said the right leg wound had a scabbed appearance and appeared to have been deeper at one point. The hospital physician said the wound on the right leg had epibole (rounding of the wound) which indicated it was a chronic wound. The hospital physician said, these wounds did not just happen. An email dated 4/12/21 from the DON, in response to a surveyor request for copies of Resident #1's TARs for March 2021 and April 2021, indicated there were no treatment records for Resident #1 due to no wounds being treated during that time. A facility policy titled Prevention of Pressure Ulcers/Injuries, dated July 2017 indicated: *assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. *conduct a comprehensive skin assessment upon admission, including any evidence of existing or developing pressure ulcers or injuries *inspect the skin on a daily basis when performing or assisting with personal care or ADLs *identify any signs of developing pressure injuries. For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency. *reposition resident as indicated on the care plan. *monitor resident for weight loss and intake of food and fluids *choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance *at least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. *at least every two hours reposition residents who are reclining and dependent on staff for repositioning. *reposition more frequently as needed, based on the condition of the skin and the resident's comfort *evaluate, report, and document potential changes in the skin *review the interventions and strategies for effectiveness on an ongoing basis A facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated April 2018, indicated: *the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers *the nurse shall describe and document/report a full assessment of pressure sore, including location, stage, length, width and depth, and presence of exudates or necrotic tissue A facility policy titled Charting and Documentation, dated July 2017, policy statement indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy further indicated: *information to be documented in the resident medical record included objective observations, treatments or services performed, changed in the resident's condition, and progress toward or changes in the care plan goals and objectives. *documentation in the medical record will be objective, complete, and accurate. Guidelines from the National Pressure Injury Advisory Panel, accessed on 4/19/21 at https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf indicated: The updated staging system includes the following definitions: Pressure Injury: 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 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. 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 [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. 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 [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided based on the comprehensive assessment to promote healing and prevent new injuries from developing for 1 of 2 residents reviewed for pressure injuries. (Resident #2) The facility did not provide treatments for Resident #2's stage 4 pressure injuries on his left ischium (gluteal fold) and sacrum area for 2 days and did not provide weekly assessments. The pressure injuries worsened in size and had a foul odor. The resident developed a new stage 2 pressure injury on his right ischium (gluteal fold). This failure could place 7 residents who had pressure injuries at risk for worsening of existing pressure injuries and developing new pressure injuries. Findings included: Physician orders [REDACTED].#2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2 had orders for daily wound care to his sacrum (area above tailbone) and left ischium wounds (gluteal fold). An MDS dated [DATE] indicated Resident #2 understood others and made his needs known. He was dependent on staff with bed mobility, dressing, and toilet use. He required extensive assistance with transfers and personal hygiene. He had a [MEDICAL CONDITION] bag and urinary catheter. The MDS indicated Resident #2 was at risk for developing pressure injuries and Resident #2 was admitted with pressure injuries. A care plan dated 02/13/17 indicated Resident #2 had skin breakdown to his abdomen, left ischium, and sacrum. Interventions included evaluating the wound area daily including the surrounding tissue and providing daily wound care. The most recent pressure injury assessment dated [DATE] indicated Resident #2's left ischium wound was a stage 4 and measured 4.0 cm x 4.0 cm x 4.6 cm. The most recent pressure injury assessment dated [DATE] indicated Resident #2's sacral wound was a stage 4 and measured 3.8 cm x 3.8 cm x 10.2 cm. During an interview on 03/12/17 at 11:29 a.m., LVN B said she was the charge nurse for Resident #2. She said she had not performed wound care on Resident #2 today (03/12/17) because she did not have time yet. She said the treatment nurse provided treatments Monday through Friday and the charge nurses provided the treatments on the weekends. She said the treatment nurse was responsible for weekly skin assessments. During an interview on 03/12/17 at 1:48 p.m., Resident #2 said staff had not performed wound care on his 2 pressure injuries since Friday (03/10/17). During an observation on 03/12/17 at 3:31 p.m., Resident #2's dressings on his sacrum and left ischium pressure injuries were dated 03/10/17. LVN B removed the soiled, yellow stained dressings that smelled of infection. LVN B removed the soiled packing from Resident #2's sacrum and left ischium wound beds. The packing was stained brownish red and smelled of rotten flesh. Resident #2 said his wounds smelled bad because his dressings were not changed for 2 days. Resident #2's stage 4 left ischium pressure injury wound bed was bright red and measured 5 cm x 3.1 cm x 5 cm. Resident #2's stage 4 sacral wound bed was bright red and measured 3.5 cm x 5.8 cm x 9.2 cm. Resident #2 had an undocumented new pressure injury on his right ischium (gluteal fold) that was covered by the old bandage. The right ischium stage 2 pressure injury was red in color and measured 0.7 cm by 0.3 cm. During an interview on 03/12/17 at 5:11 p.m., LVN C said she worked 03/11/17 and documented that she performed wound care on Resident #2, but did not actually do the treatment. During an interview on 03/12/17 at 5:22 p.m., LVN B said she documented that she performed wound care on Resident #2 prior to performing his wound care. She said she did not have enough time to do the treatment for [REDACTED]. During an interview on 03/12/17 at 5:30 p.m., the DON said Resident #2's wound care should have been provided daily. The skin integrity management policy with a revised date of 11/28/16 indicated: .Perform skin inspection upon admission/readmission and weekly . .Perform daily monitoring of wounds or dressings for presence of complications or declines and document . .For wounds requiring daily dressing changes or wounds without a dressing, monitor for signs of decline in wound status . The National Pressure Ulcer Advisory Panel (NPUAP) website, http://www.npuap.org/resources/educational-and-clinical-resources, indicated the following: Pressure Injury: 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 . .Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury . The CMS 672 dated 03/12/17 indicated 7 residents had pressure injuries.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures to prohibit neglect for 1 of 6 residents reviewed for neglect. (Resident #1) Resident #1 was bitten by a rat while in his bed. Staff and residents reported seeing rats in the building. The facility did not ensure an effective pest control plan was in place to protect residents from harm. This failure caused Resident #1 to be bitten by a rat and this failure could place the census of 88 residents at risk for illness, harm, and poor quality of life. Findings included: A facility policy revised 07/01/06 indicated neglect is defined as .failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Housekeeping Policy and Procedures effective 04/15/2011 indicated All housekeepers should report to the housekeeping supervisor any sign of rodents .The housekeeping supervisor takes immediate action to remove the pests . Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE]. An MDS dated [DATE] indicated Resident #1 was moderately impaired cognitively, was understood by others, and understood others. The resident did not have any signs of [MEDICAL CONDITION] or disorganized thinking and did not have behaviors such as hallucinations or delusions. Resident #1 was totally dependent on staff for all activities of daily living including transfers and bed mobility. A history and physical dated 04/06/15 indicated Resident #1 had [DIAGNOSES REDACTED]. A daily morning meeting information sheet dated 06/22/15 indicated rat droppings were in a resident's room, in the shower and bathroom floor. Rats were thought to be coming from the hole in the wall. Rooms were to be checked for old food and thrown away. An incident report dated 06/23/15 indicated Resident #1 was Bitten by a rat. Telephone physician orders [REDACTED].#1 received wound care to his left thumb, to give the resident tetanus shot stat, and to contact the state health department to see if the [DIAGNOSES REDACTED] shots were needed. During an observation and interview on 06/24/15 at 9:55 a.m., Resident #1 was lying in his bed and had a bandage on his left thumb. Resident #1 stated I was bitten by a rat. The resident said he was bed bound and not able to get out of bed. He said he had been telling staff for a couple weeks there were rats in his room and were getting into his bed at night. He said staff did not do anything about the rats in his room until after he was bitten on 06/23/15. He said he called the ombudsman after he was bitten because the facility was not doing anything about the rats. He said, I am afraid I might get [DIAGNOSES REDACTED]. There were rat droppings in the resident's bathroom. There were two spring loaded rat traps in the corner of his room. There were rat droppings in a dresser drawer beside resident's bed. A box in the resident's closet was chewed on the corners and there were two holes in the closet wall. There was a smell of rat urine in the room. During an interview on 06/24/15 at 12:20 p.m., HKA-E said the rats were not new to the facility. HKA-E said the maintenance director asked the staff when they see rats, not to write down in the maintenance book and to just to tell him. HKA-E said she reported seeing rats, rat droppings, and holes in the walls for weeks, but nothing was done until a resident was bitten. During an interview on 06/24/15 at 1:30 p.m., HKA-D said told the maintenance director about a rat was spotted on 06/18/15. HKA-D also reported cleaning up rat droppings on the north wing on 06/23/15. During an interview on 06/24/15 at 11:10 a.m. CNA-A said she reported seeing a big rat on 06/21/15 on the evening shift. During an interview on 06/24/15 at 11:00 a.m., LVN-B said she worked the night shift on 06/21/15 and saw a rat in hall 300. She said she reported to the maintenance director. During an interview on 06/24/15 at 10:30 a.m. the DON said a rat was killed in her office on 06/22/15 the day before Resident #1 reported being bitten. She said she bought some rat poison and put it in her office. She said she first knew of the rats in the building on 06/21/15. During an observation and interview on 06/24/15 at 10:40 a.m., the maintenance director said on 06/22/15 a rat was caught in a resident's room on the 300 hall. He said he did not keep a pest control log. He said he was only required to inspect the facility for pest once a month. The pest control company contract dated 04/01/14 indicated the contract had not been undated since 04/01/14. A maintenance work history report dated 06/24/15 indicated the facility was last inspected by the maintenance director for pest on 05/07/15. A billing statement for service dated 05/28/15 indicated monthly service-general for ants, roaches and mice was done on 05/14/15. Pest control services were last provided on 05/14/15. During an observation and interview on 06/24/15 at 12:50 p.m., there were rat droppings between the sink and shower in Resident #2's room. There was a spring loaded rat trap and rat droppings behind the trash can in the resident's bathroom. Resident #2 said about three days ago she trapped a rat with her walking cane and pinned it against the base board in her room. She said she yelled for someone to come and get it. There were rat droppings in the draw of the night stand and a chewed ketchup package. During an interview 06/23/15 at 4:00 p.m., the ombudsman said Resident #1 called them after he was bitten by a rat. The ombudsman said she went to the facility to investigate on 06/23/15 and found rat droppings everywhere and there was a significant problem with rat infestation. During an interview on 06/24/15 at 9:15 a.m., the administrator said the maintenance director should have a log of reported rodent sightings. During an interview on 06/24/15 at 9:25 a.m., the maintenance director said there had been five or six rats recently caught inside the building. The CMS 672 dated 06/24/15 indicated a census of 88.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure the facility was free of rodents. Staff and residents reported seeing rats in the building. The facility had did not ensure the pest control contract was up to date and ensure rodents were not in the building to protect residents from harm. This failure could place the census of 88 residents at risk for illness and poor quality of life. Findings included: The pest control company contract dated 04/01/14 indicated the contract had not been undated since 04/01/14. A maintenance work history report dated 06/24/15 indicated the facility was last inspected by the maintenance director for pest on 05/07/15. A billing statement for service dated 05/28/15 indicated monthly service-general for ants, roaches and mice was done on 05/14/15. Pest control services were last provided on 05/14/15. A daily morning meeting information sheet dated 06/22/15 indicated rat droppings were in a resident's room, in the shower and bathroom floor. Rats were thought to be coming from the hole in the wall. Rooms were to be checked for old food and thrown away. An incident report dated 06/23/15 indicated Resident #1 was Bitten by a rat. During an observation and interview on 06/24/15 at 9:55 a.m., Resident #1 was lying in his bed and had a bandage on his left thumb. Resident #1 stated I was bitten by a rat. The resident said he was bed bound and not able to get out of bed. He said he had been telling staff for a couple weeks there were rats in his room and were getting into his bed at night. He said staff did not do anything about the rats in his room until after he was bitten on 06/23/15. He said he called the ombudsman after he was bitten because the facility was not doing anything about the rats. He said, I am afraid I might get [DIAGNOSES REDACTED]. There were rat droppings in the resident's bathroom. There were two spring loaded rat traps in the corner of his room. There were rat droppings in a dresser drawer beside resident's bed. A box in the resident's closet was chewed on the corners and there were two holes in the closet wall. There was a smell of rat urine in the room. During an interview on 06/24/15 at 12:20 p.m., HKA-E said the rats were not new to the facility. HKA-E said the maintenance director asked the staff when they see rats, not to write down in the maintenance book and to just to tell him. HKA-E said she reported seeing rats, rat droppings, and holes in the walls for weeks, but nothing was done until a resident was bitten. During an interview on 06/24/15 at 1:30 p.m., HKA-D said told the maintenance director about a rat was spotted on 06/18/15. HKA-D also reported cleaning up rat droppings on the north wing on 06/23/15. During an interview on 06/24/15 at 11:10 a.m. CNA-A said she reported seeing a big rat on 06/21/15 on the evening shift. During an interview on 06/24/15 at 11:00 a.m., LVN-B said she worked the night shift on 06/21/15 and saw a rat in hall 300. She said she reported to the maintenance director. During an observation and interview on 06/24/15 at 10:40 a.m., a yellow dried urine-like substance was in the window seal in room 306 and rat droppings in the bathroom. The maintenance director said a rat was caught in the room on 06/22/15. He said LVN-B reported seeing a rat on 06/21/15 in the hallway that ran into room 310. During an interview on 06/24/15 at 10:30 a.m., the DON said a rat was killed in her office on 06/22/15 the day before Resident #1 reported being bitten. She said she bought some rat poison and put it in her office. She said she first knew of the rats in the building on 06/21/15. During an observation on 06/24/15 at 10:25 a.m., rat droppings were in the North Wing air conditioning closet. During an observation on 06/24/15 at 10:35 a.m., two spring loaded rat traps were under a therapy table in the satellite therapy room. There was a chewed on ketchup package with rat droppings under the desk and more rat droppings in a box under the desk. During an observation and interview on 06/24/15 at 10:45 a.m., rat droppings were in room 310 behind the bed. There was a hole in the closet wall on the right side of a drainage pipe. The maintenance director said the pipe lead outside. During an observation and interview on 06/24/15 at 12:50 p.m., Resident #2 said about three days ago she trapped a rat in her room with her walking cane and pinned it against the base board. She said she yelled for someone to come and get it. There were rat droppings between the resident's bathroom sink and shower. A spring loaded rat trap with rat droppings around it were behind the trash can in the bathroom. There was a three inch hole in the bathroom next to the drain pipe of the sink. There were rat droppings in Resident #2's night stand and a chewed ketchup package. During an observation and interview on 06/24/15 at 1:05 p.m., a stack of white towels was under the sink in the employee's break room. There was a large amount of rat droppings and yellow stains on the towels. A four inch hole was next to the drain pipe under the sink. The maintenance director said it appeared the rat droppings had been there for a long time because they were dried. During an interview 06/23/15 at 4:00 p.m., the ombudsman said Resident #1 called them after he was bitten by a rat. The ombudsman said she went to the facility to investigate on 06/23/15 and found rat droppings everywhere and there was a significant problem with rat infestation. During an interview on 06/24/15 at 9:15 a.m., the administrator said the maintenance director should have a log of reported rodent sightings. A contract with a pest control service was signed by the administrator on 06/23/15 for commercial outside pest control. Housekeeping Policy and Procedures effective 04/15/2011 indicated All housekeepers should report to the housekeeping supervisor any sign of rodents .The housekeeping supervisor takes immediate action to remove the pests . The CMS 672 dated 06/24/15 indicated a census of 88.

Based on observation, interview, and record review, the facility failed to implement their policies and procedures to prohibit neglect for 1 of 6 residents reviewed for neglect. (Resident #1) Resident #1 was bitten by a rat while in his bed. Staff and residents reported seeing rats in the building. The facility did not ensure the pest control contract was up to date to protect residents from harm. This failure could place the census of 88 residents at risk for illness, harm, and poor quality of life. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE]. An MDS dated [DATE] indicated Resident #1 was moderately impaired cognitively, was understood by others, and understood others. The resident did not have any signs of [MEDICAL CONDITION] or disorganized thinking and did not have behaviors such as hallucinations or delusions. Resident #1 was totally dependent on staff for all activities of daily living including transfers and bed mobility. A history and physical dated 04/06/15 indicated Resident #1 had [DIAGNOSES REDACTED]. A daily morning meeting information sheet dated 06/22/15 indicated rat droppings were in a resident ' s room, in the shower and bathroom floor. Rats were thought to be coming from the hole in the wall. Rooms were to be checked for old food and thrown away. An incident report dated 06/23/15 indicated Resident #1 was Bitten by a rat. Telephone physician orders [REDACTED].#1 received wound care to his left thumb, to give the resident tetanus shot stat, and to contact the state health department to see if the [DIAGNOSES REDACTED] shots were needed. During an observation and interview on 06/24/15 at 9:55 a.m., Resident #1 was lying in his bed and had a bandage on his left thumb. Resident #1 stated I was bitten by a rat. The resident said he was bed bound and not able to get out of bed. He said he had been telling staff for a couple weeks there were rats in his room and were getting into his bed at night. He said staff did not do anything about the rats in his room until after he was bitten on 06/23/15. He said he called the ombudsman after he was bitten because the facility was not doing anything about the rats. He said, I am afraid I might get [DIAGNOSES REDACTED]. There were rat droppings in the resident's bathroom. There were two spring loaded rat traps in the corner of his room. There were rat droppings in a dresser drawer beside resident's bed. A box in the resident's closet was chewed on the corners and there were two holes in the closet wall. There was a smell of rat urine in the room. During an interview on 06/24/15 at 12:20 p.m., HKA-E said the rats were not new to the facility. HKA-E said the maintenance director asked the staff when they see rats, not to write down in the maintenance book and to just to tell him. HKA-E said she reported seeing rats, rat droppings, and holes in the walls for weeks, but nothing was done until a resident was bitten. During an interview on 06/24/15 at 1:30 p.m., HKA-D said told the maintenance director about a rat was spotted on 06/18/15. HKA-D also reported cleaning up rat droppings on the north wing on 06/23/15. During an interview on 06/24/15 at 11:10 a.m. CNA-A said she reported seeing a big rat on 06/21/15 on the evening shift. During an interview on 06/24/15 at 11:00 a.m., LVN-B said she worked the night shift on 06/21/15 and saw a rat in hall 300. She said she reported to the maintenance director. During an interview on 06/24/15 at 10:30 a.m. the DON said a rat was killed in her office on 06/22/15 the day before Resident #1 reported being bitten. She said she bought some rat poison and put it in her office. She said she first knew of the rats in the building on 06/21/15. During an observation and interview on 06/24/15 at 10:40 a.m., the maintenance director said on 06/22/15 a rat was caught in a resident ' s room on the 300 hall. He said he did not keep a pest control log. He said he was only required to inspect the facility for pest once a month. The pest control company contract dated 04/01/14 indicated the contract had not been undated since 04/01/14. A maintenance work history report dated 06/24/15 indicated the facility was last inspected by the maintenance director for pest on 05/07/15. A billing statement for service dated 05/28/15 indicated monthly service-general for ants, roaches and mice was done on 05/14/15. Pest control services were last provided on 05/14/15. During an observation and interview on 06/24/15 at 12:50 p.m., there were rat droppings between the sink and shower in Resident #2's room. There was a spring loaded rat trap and rat droppings behind the trash can in the resident's bathroom. Resident #2 said about three days ago she trapped a rat with her walking cane and pinned it against the base board in her room. She said she yelled for someone to come and get it. There were rat droppings in the draw of the night stand and a chewed ketchup package. During an interview 06/23/15 at 4:00 p.m., the ombudsman said Resident #1 called them after he was bitten by a rat. The ombudsman said she went to the facility to investigate on 06/23/15 and found rat droppings everywhere and there was a significant problem with rat infestation. During an interview on 06/24/15 at 9:15 a.m., the administrator said the maintenance director should have a log of reported rodent sightings. During an interview on 06/24/15 at 9:25 a.m., the maintenance director said there had been five or six rats recently caught inside the building. A facility policy revised 07/01/06 indicated neglect is defined as .failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Housekeeping Policy and Procedures effective 04/15/2011 indicated All housekeepers should report to the housekeeping supervisor any sign of rodents .The housekeeping supervisor takes immediate action to remove the pests . The CMS 672 dated 06/24/15 indicated a census of 88.

Based on interview and record review, the facility failed to provide the necessary care and services in accordance with the comprehensive assessment and plan of care for 1 of 6 residents reviewed for a change in condition. (Resident #4) Resident #4 experienced changes in his level of consciousness, had diarrhea, and refused to eat; however, the facility did not assess or provide treatment for [REDACTED]. Resident #4 was sent to the local emergency room and admitted with altered mental status, profound dehydration, urinary tract infection, metabolic acidosis, and [MEDICAL CONDITION] (elevated potassium). Resident #4 died in the hospital on [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual 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 census of 86 residents at risk for experiencing an unrecognized change of condition at risk for delay in medical evaluation and treatment. Findings included: Physician orders [REDACTED].#4 was [AGE] years old and admitted on [DATE] with the [DIAGNOSES REDACTED]. An admission assessment dated [DATE] indicated Resident #4 was alert and independent with decision making and could answer questions appropriately. He was assessed with [REDACTED]. He had normal bowel sounds and no diarrhea. The most recent MDS dated [DATE] indicated Resident #4 usually was understood by others and he understood others. Resident #4 required extensive assistance with transfers, dressing, bathing, and personal hygiene. He required limited assistance of one person for eating. Resident #4 was frequently incontinent of bowel and bladder. A comprehensive care plan dated [DATE] indicated Resident #4 was at risk for dehydration related to use of [MEDICATION NAME] (diuretic), history of pneumonia, and possible insufficient fluid intake. The goal for Resident #4 was not to show signs and symptoms of dehydration. The approaches included; maintain intake and output when indicated and report signs of dehydration (lethargy, increased confusion, change of LOC, concentrated urine, dry skin, with poor skin turgor and dry oral mucosa). The facility Medication Administration Record [REDACTED]. During an interview on [DATE] at 3:00 p.m., the OT said on Friday [DATE], Resident #4 performed his therapy without a problem. The OT said the resident was smiling and talkative. During an interview on [DATE] at 3:15 p.m., CNA E said she cared for Resident #4 on the 6 a.m.- 2 p.m. shift Saturday [DATE] and Sunday [DATE]. She said on both days Resident #4 was "not his usual self " and he was weaker than normal. She said Resident #4 was not able to sit up as he normally did and she had to put him to bed early. CNA E said she notified LVN B of Resident #4's decline. During an interview on [DATE] at 5:25 p.m., CNA F said she provided care for Resident #4 on Saturday [DATE] and Sunday [DATE]. CNA F said Resident #4 was in bed on her 2 p.m.-10 p.m. shift both days which was not his norm. She said Resident #4 ate 25 percent of his evening meal and only drank a few sips of fluids which was not normal for him. CNA F said Resident #4's urine had a strong smell and she reported this to her charge nurse. The 24 hour report sheet dated Saturday [DATE] night shift indicated Resident #4 had diarrhea. There was no indication a physician was notified. A nursing note by RN C dated [DATE] at 12:00 a.m. indicated Resident #4 had loose stools three times and poor skin turgor. The note did not indicate a physician was notified. During an interview on [DATE] at 4:10 p.m., LVN B said she provided care for Resident #4 on Sunday [DATE] and Resident #4's sister voiced concern about Resident #4 not eating or drinking well. LVN B said on Sunday Resident #4 stayed in bed, had extremely dry skin, and did not eat well. She said she thought the resident looked the same. LVN B said she did not call the physician. A nursing note by RN A dated Sunday [DATE] at 12:00 a.m. indicated Resident #4 was drooling. There was no other documentation in the nursing notes from [DATE] - [DATE] of the resident drooling. The note did not indicate a physician was notified of the change. During an interview on [DATE] at 3:45 p.m., Resident #4's sister said she came to the facility on [DATE] a little after 8:00 a.m. because her sibling called her very upset about Resident #4's condition change on Sunday [DATE]. She said she found Resident #4 unable to talk and he was "so very weak." Resident #4's sister said his morning meal was on his bedside table untouched. She said she went to the nurse's station and demanded someone send him to the hospital. During an interview on [DATE] at 2:10 p.m., ADON D said Resident #4's sister was at the nursing station saying "something is wrong with him" and requested his transfer to the emergency room . ADON D said she assisted RN A with transferring Resident #4. ADON D said the resident looked like he had a stroke. During an interview on [DATE] at 2:50 p.m., RN A said Resident #4's sister was convinced he had a decline in condition on [DATE] and requested he be sent to the ER. RN A said Resident #4 was "his usual total care, nothing unusual." RN A said she pushed fluids on Resident #4 because of decreased food and fluid consumption. RN A said when she assessed Resident #4 prior to sending him to the emergency room she saw no change in him, she saw no signs of dehydration and did not see any reason to notify the physician prior to the sister's request. She said she called the physician because the sister said "she could see a whole lot of difference in him." A nursing note by RN A dated Monday [DATE] at 9:00 a.m. indicated Resident #4 was lying in bed alert but slow to respond. The resident did not follow directions, had decreased tactile sensation, increased right sided facial drooling, was very weak, and had a very poor appetite. The note indicated the family was present and requested Resident #4 be transferred to the hospital. At 9:30 a.m. the nursing note indicated after the family's insistence, the nurse practitioner was notified and an order was given to send to ER for evaluation. The note indicated at 10:10 a.m. EMS was at the facility to transfer Resident #4 to the ER. The undated nursing home transfer to hospital form completed by RN A indicated Resident #4's vital signs were: blood pressure ,[DATE], heart rate 63, respirations 16, temperature 97.1, and oxygen saturation 90%. The reason for transfer was listed as "possible TIA" ([MEDICAL CONDITION]- mini stroke). During an interview on [DATE] at 3:10 p.m., the DON said she was not familiar with Resident #4's condition when he left the facility. The DON said there was not an intake and output record for Resident #4. The DON said his disease processes did not warrant use of monitoring using intake and output recordings. She said she was not notified of Resident #4 having diarrhea, decreased appetite, and weakness. The DON said she expected the nurse to assess the resident and to call the physician when residents experienced changes in condition. The hospital admission lab results dated [DATE] at 10:50 a.m. indicated Resident #4 had the following abnormal results: *white blood cell count of 22.7 (Normal range 3XXX,[DATE].6), *sodium 145 (normal range ,[DATE]), *potassium 6.1 (normal range 3XXX,[DATE].1), *chloride 118 (normal range ,[DATE]), *BUN 170 (normal range ,[DATE]) and, *creatinine 6.94 (normal range 0XXX,[DATE].30). *The urine WBCs were loaded (too many to count) and had heavy bacteria. *A chest x-ray indicated atelectasis in the lung basis. A hospital history and physical dated [DATE] at 2:40 p.m. indicated when Resident #4 arrived in the emergency room his mental status was very altered, he was barely awake and could not respond at all. The laboratory reports indicated the resident had increased potassium and increased BUN and creatinine. Resident #4's general assessment was blood pressure ,[DATE], heart rate 111, temperature 97.7, and respirations 13. The resident's tongue was very dry and he was unable to respond to verbal commands. The assessment indicated Resident #4 [MEDICAL CONDITION] secondary to a urinary tract infection with severe dehydration resulting in acute kidney injury. A renal consult report from the urologist on [DATE] at 2:40 p.m. indicated Resident #4 was lethargic and severely dehydrated. Resident #4's oral mucosa were very dry and his skin turgor was very poor. The note indicated the etiology of Resident #4's acute [MEDICAL CONDITION] was secondary to profound dehydration. Resident #4 also presented with [MEDICAL CONDITION] (increased potassium) and metabolic acidosis. (Life threatening condition that occurs when the kidneys can't eliminate acid buildup) A cardiopulmonary resuscitation note dated [DATE] at 6:25 a.m. indicated Resident #4 expired in the intensive care unit. The policy and procedure dated ,[DATE] indicated " ..to notify the physician and inform the resident and resident's responsible party of a significant change in the resident's physical, mental psychological status including accidents and when there is a need to alter treatments significantly. "Change of Condition" related to physician notification is defined as the physician should be notified of any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denoting a new problem, complication or permanent change in status and requiring a medical assessment, coordination and consultation with the physician or physician extender and a change in the treatment plan. 1. It is the responsibility of the person observing the change to report that change to the licensed nurse. 3. The licensed nurse is responsible for making all notifications of changes to the physicians, the resident and the resident's representative. 4. Examples of changes may include but not limited to: abnormal findings, gastrointestinal problems, neurological changes.. " The administrator and DON were notified on [DATE] at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 5:55 p.m. and included: *All nursing staff will be re-educated on the use of the Interact tools which include changes of condition, stop and watch early warning tool, evaluation, SBAR forms and progress notes, acute change in condition file cards, MD Notification, Acute care transfer and quality improvement program. In-services will begin immediately until all nursing staff were re-educated. *The change in condition tool reflects on vital signs, laboratory test/diagnostic procedures, symptoms and signs, acute mental status changes, behavior changes, dehydration, fever, gastrointestinal symptoms, shortness of breath, [MEDICAL CONDITION] and urinary tract infections. *Stop and watch reflects on the early signs of changes in condition. *SBAR is the communication form and progress note that is started prior to calling the physician to gather all the information necessary for the physician to make a decision as to what actions needs to be taken. *Change in condition file cars are used to identify specific conditions and the signs and symptoms to report to the physician. *All the tools are located at each nursing station for the staff to use. *The administrative staff will review the 24 hour reports daily to identify any potential changes of condition in the morning clinical meeting. On [DATE], the survey team confirmed the POR had been implemented sufficiently to remove the IJ as evidenced by: *12 LVNs were interviewed and were able state how to use the facility tools to help recognize a change of condition and how to respond to that change appropriately. *5 RNs were interviewed and were able to state how to use the facility tools to help recognize a change of condition and how to respond to that change appropriately. On [DATE] at 2:00 p.m., the administrator and DON were informed the IJ was removed: however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 86.

Based on interview and record review, the facility failed to consult with the physician about a significant change of condition for 1 of 6 residents reviewed for a change of condition. (Resident #4) Resident #4 experienced changes in his level of consciousness, had diarrhea, and refused to eat; however, the physician was not consulted until two days later ([DATE]). Resident #4 was sent to the local emergency room and admitted with altered mental status, profound dehydration, urinary tract infection, metabolic acidosis, and [MEDICAL CONDITION] (elevated potassium). Resident #4 died in the hospital [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to a delay in Resident #4 receiving needed medical treatment and could place 86 residents at risk for delay in medical evaluation and treatment or death. Findings included: Physician orders [REDACTED].#4 was [AGE] years old and admitted on [DATE] with the [DIAGNOSES REDACTED]. An admission assessment dated [DATE] indicated Resident #4 was alert and independent with decision making and could answer questions appropriately. He was assessed with [REDACTED]. He had normal bowel sounds and no diarrhea. The most recent MDS dated [DATE] indicated Resident #4 usually was understood by others and he understood others. Resident #4 required extensive assistance with transfers, dressing, bathing, and personal hygiene. He required limited assistance of one person for eating. Resident #4 was frequently incontinent of bowel and bladder. A comprehensive care plan dated [DATE] indicated Resident #4 was at risk for dehydration related to use of [MEDICATION NAME] (diuretic), history of pneumonia, and possible insufficient fluid intake. The goal for Resident #4 was not to show signs and symptoms of dehydration. The approaches included; maintain intake and output when indicated and report signs of dehydration (lethargy, increased confusion, change of LOC, concentrated urine, dry skin, with poor skin turgor and dry oral mucosa). The facility Medication Administration Record [REDACTED]. During an interview on [DATE] at 3:00 p.m., the OT said on Friday [DATE], Resident #4 performed his therapy without a problem. The OT said the resident was smiling and talkative. During an interview on [DATE] at 3:15 p.m., CNA E said she cared for Resident #4 on the 6 a.m.- 2 p.m. shift Saturday [DATE] and Sunday [DATE]. She said on both days Resident #4 was "not his usual self " and he was weaker than normal. She said Resident #4 was not able to sit up as he normally did and she had to put him to bed early. CNA E said she notified LVN B of Resident #4 ' s decline. During an interview on [DATE] at 5:25 p.m., CNA F said she provided care for Resident #4 on Saturday [DATE] and Sunday [DATE]. CNA F said Resident #4 was in bed on her 2 p.m.-10 p.m. shift both days which was not normal for him. She said Resident #4 ate 25 percent of his evening meal and only drank a few sips of fluids which was not his norm. CNA F said Resident #4 ' s urine had a strong smell and she reported this to her charge nurse. The 24 hour report sheet dated Saturday [DATE] night shift indicated Resident #4 had diarrhea. There was no indication a physician was notified or any medications to help with the diarrhea were administered. A nursing note by RN C dated [DATE] at 12:00 a.m. indicated Resident #4 had loose stools three times and poor skin turgor. The note did not indicate a physician was notified or medication administered. During an interview on [DATE] at 4:10 p.m., LVN B said she provided care for Resident #4 on Sunday [DATE] and Resident #4's sister voiced concern about Resident #4 not eating or drinking well. LVN B said on Sunday Resident #4 stayed in bed, had extremely dry skin, and did not eat well. She said she thought the resident looked the same. LVN B said she did not call the physician. A nursing note by RN A dated Sunday [DATE] at 12:00 a.m. indicated Resident #4 was drooling. The note did not indicate a physician was notified. During an interview on [DATE] at 3:45 p.m., Resident #4's sister said she came to the facility on [DATE] a little after 8:00 a.m. because her sibling called her very upset about Resident #4's condition change on Sunday [DATE]. She said she found Resident #4 unable to talk and he was "so very weak." Resident #4's sister said his morning meal was on his bedside table untouched. She said she went to the nurse's station and demanded someone send him to the hospital. During an interview on [DATE] at 2:10 p.m., ADON D said Resident #4's sister was at the nursing station saying "something is wrong with him" and requested his transfer to the emergency room . ADON D said she assisted RN A with transferring Resident #4. ADON D said the resident looked like he had a stroke. During an interview on [DATE] at 2:50 p.m., RN A said Resident #4's sister was convinced he had a decline in condition on [DATE] and requested he be sent to the ER. RN A said Resident #4 was "his usual total care, nothing unusual." RN A said she pushed fluids on Resident #4 because of decreased food and fluid consumption. RN A said when she assessed Resident #4 prior to sending him to the emergency room she saw no change in him, she saw no signs of dehydration and did not see any reason to notify the physician prior to the sister's request. She said she called the physician because the sister said "she could see a whole lot of difference in him. A nursing note by RN A dated Monday [DATE] at 9:00 a.m. indicated Resident #4 was lying in bed alert but slow to respond. The resident did not follow directions, had decreased tactile sensation, increased right sided facial drooling, was very weak, and had a very poor appetite. The note indicated the family was present and requested Resident #4 be transferred to the hospital. At 9:30 a.m. the nursing note indicated after the family's insistence, the nurse practitioner was notified and an order was given to send to ER for evaluation. The note indicated at 10:10 a.m. EMS was at the facility to transfer Resident #4 to the ER. The undated nursing home transfer to hospital form completed by RN A indicated Resident #4's vital signs were: blood pressure ,[DATE], heart rate 63, respirations 16, temperature 97.1, and oxygen saturation 90%. The reason for transfer was listed as "possible TIA" ([MEDICAL CONDITION]- mini stroke). During an interview on [DATE] at 3:10 p.m., the DON said she was not familiar with Resident #4's condition when he left the facility. The DON said there was not an intake and output record for Resident #4. The DON said his disease processes did not warrant use of monitoring using intake and output recordings. She said she was not notified of Resident #4 having diarrhea, decreased appetite, and weakness. The DON said she expected the nurse to assess the resident and to call the physician when resident ' s experienced changes in condition. The hospital admission lab results dated [DATE] at 10:50 a.m. indicated Resident #4 had the following abnormal results: *white blood cell count of 22.7 (Normal range 3XXX,[DATE].6), *sodium 145 (normal range ,[DATE]), *potassium 6.1 (normal range 3XXX,[DATE].1), *chloride 118 (normal range ,[DATE]), *BUN 170 (normal range ,[DATE]) and, *creatinine 6.94 (normal range 0XXX,[DATE].30). *The urine WBCs were loaded (too many to count) and had heavy bacteria. *A chest x-ray indicated atelectasis in the lung basis. A hospital history and physical dated [DATE] at 2:40 p.m. indicated when Resident #4 arrived in the emergency room his mental status was very altered, he was barely awake, and could not respond at all. The laboratory reports indicated the resident had increased potassium and increased BUN and creatinine. Resident #4's general assessment was blood pressure ,[DATE], heart rate 111, temperature 97.7, and respirations 13. The resident ' s tongue was very dry and he was unable to respond to verbal commands. The assessment indicated Resident #4 [MEDICAL CONDITION] secondary to a urinary tract infection with severe dehydration resulting in acute kidney injury. A renal consult report from the urologist on [DATE] at 2:40 p.m. indicated Resident #4 was lethargic and severely dehydrated. Resident #4's oral mucosa were very dry and his skin turgor was very poor. The note indicated the etiology of Resident #4's acute [MEDICAL CONDITION] was secondary to profound dehydration. Resident #4 also presented with [MEDICAL CONDITION] (increased potassium) and metabolic acidosis. (Life threatening condition that occurs when the kidneys can't eliminate acid buildup) A cardiopulmonary resuscitation note dated [DATE] at 6:25 a.m. indicated Resident #4 expired in the intensive care unit. The policy and procedure dated ,[DATE] indicated " ..to notify the physician and inform the resident and resident's responsible party of a significant change in the resident's physical, mental psychological status including accidents and when there is a need to alter treatments significantly. "Change of Condition" related to physician notification is defined as the physician should be notified of any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denoting a new problem, complication or permanent change in status and requiring a medical assessment, coordination and consultation with the physician or physician extender and a change in the treatment plan. 1. It is the responsibility of the person observing the change to report that change to the licensed nurse. 3. The licensed nurse is responsible for making all notifications of changes to the physicians, the resident and the resident's representative. 4. Examples of changes may include but not limited to: abnormal findings, gastrointestinal problems, neurological changes.. " The administrator and DON were notified on [DATE] at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 5:55 p.m. and included: *All nursing staff will be re-educated on the use of the Interact tools which include changes of condition, stop and watch early warning tool, evaluation, SBAR forms and progress notes, acute change in condition file cards, MD Notification, Acute care transfer and quality improvement program. In-services will begin immediately until all nursing staff were re-educated. *The change in condition tool reflects on vital signs, laboratory test/diagnostic procedures, symptoms and signs, acute mental status changes, behavior changes, dehydration, fever, gastrointestinal symptoms, shortness of breath, [MEDICAL CONDITION] and urinary tract infections. *Stop and watch reflects on the early signs of changes in condition. *SBAR is the communication form and progress note that is started prior to calling the physician to gather all the information necessary for the physician to make a decision as to what actions needs to be taken. *Change in condition file cars are used to identify specific conditions and the signs and symptoms to report to the physician. *All the tools are located at each nursing station for the staff to use. *The administrative staff will review the 24 hour reports daily to identify any potential changes of condition in the morning clinical meeting. On [DATE], the survey team confirmed the POR had been implemented sufficiently to remove the IJ as evidenced by: *12 LVNs were interviewed and were able state how to use the facility tools to help recognize a change of condition and how to respond to that change appropriately. *5 RNs were interviewed and were able to state how to use the facility tools to help recognize a change of condition and how to respond to that change appropriately. On [DATE] at 2:00 p.m., the administrator and DON were informed the IJ was removed: however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 86.

Based on interview and record review, the facility failed to ensure an oral [MEDICAL CONDITION] medication was not used for excessive duration for 1 of 1 resident sampled for [MEDICAL CONDITION]. (Resident #17) Resident #17 was administered an oral [MEDICAL CONDITION] medication daily since 04/15/11. She experienced severe decrease in blood volume, bruising, decline in blood count, oral pain and rash, and decrease in oral intake. The medication was ordered to be administered for only 5 days out of every 28 days. This failure contributed to Resident #17 being hospitalized . This failure could place 6 residents with a [DIAGNOSES REDACTED]. Findings included: Physician orders [REDACTED]. The most current MDS dated [DATE] indicated the Resident #17 required the extensive assistance of two people for bed mobility. Resident #17 was independent in eating and had no problems with dehydration, internal bleeding or swallowing. Admission physician orders [REDACTED]. Resident #17 was to have daily [MEDICAL CONDITION] treatments Monday - Friday. There was no specific timeframe for how long the [MEDICAL CONDITION] treatments would last. A March 2011 MAR indicated [REDACTED]. An oncologist progress note dated 04/06/11 indicated Resident #17 had completed [MEDICAL CONDITION] treatments and [MEDICATION NAME]. The plan was to change [MEDICATION NAME] to 200mgs/m2/D (meters squared per day) x 5 days every 28 days. A physician order [REDACTED]. Then resume current dose. An April 2011 MAR indicated [REDACTED]. Lab reports dated 04/20/11 indicated the following results for Resident #17: WBC 4.6 (RR 4.1-9.3) RBC 3.64 (RR 4.2-5.4) HGB 13.1 (RR 12-15.6) HCT 37.6 (RR 35-46) Platelet Count 106 (RR 173-402) Nursing notes dated 04/24/11 at 10:20 a.m. indicated Resident #17 complained of a sore throat and had yellow patches on her tongue. Nursing notes dated 04/27/11 at 9:40 p.m. indicated Resident #17 was started on intravenous fluids. An April 2011 MAR indicated [REDACTED]. A May 2011 MAR indicated [REDACTED]. An oncologist progress note dated 05/04/11 indicated Resident #17 had completed her [MEDICAL CONDITION] and [MEDICATION NAME]. The plan was to change [MEDICATION NAME] to 200mgs/m2/Day x 5 days every 28 days. The note stated, "Unsure if this is schedule followed at the nursing home." The plan was to ascertain that the dose of [MEDICATION NAME] had been administered for 5 days at a dose of 200mg/m2/Day X 5 days every 28 days and not any longer. Nursing notes indicated the following for Resident #17: *05/04/11 at 12:00 noon, the resident had a decreased potassium level of 3.0 and received orders for potassium chloride 10 meq by mouth every day. *05/07/11 at 11:03 a.m., resident very weak and unable to bear weight/assist. The resident continued on [MEDICATION NAME] for stomatitis. She continued to have a sore throat and raspy voice. Soft foods and fluids were encouraged. *05/09/11 at 4:00 p.m., the resident continued to complain of not feeling well and her throat was still hurting. The resident voiced she was spitting up blood and there was a cup sitting on the table with bright red blood in it. At 9:00 p.m., the resident continued to refuse to eat, drink and complained of her mouth and throat being sore. *05/09/11 at 1:30 p.m., an order was received for an endoscopy of the mouth and throat. *05/12/11 at 10:30 a.m., the endoscopy was scheduled for 05/13/11. Lab reports dated 05/12/11 indicated the following results for Resident #17: WBC 2.0 (RR 4.1-9.3) RBC 2.88 (RR 4.2-5.4) HGB 10.4 (RR 12-15.6 HCT 30.4 (RR 35-46) Platelet Count 35 (RR 173-402) Nursing notes dated 05/13/11 at 5:00 p.m. indicated a facility nurse had spoken to the oncology nurse several times. New orders were received to discontinue the [MEDICATION NAME] indefinitely. Staff were to monitor Resident #17's platelet count closely and if it dropped below 35, they were to call the oncology nurse. Staff were to closely monitor the resident for bruising, black spots in the mouth, black lips and other signs of internal bleeding. A hospital history and physical dated 05/14/11 indicated Resident #17 was admitted for volume depletion, throat pain, trouble swallowing, and pancytopenia such that her white count was 3.1, hemoglobin 9.8 and platelet count 43. Resident #17 had easy bruising secondary to her low platelet count. According to the report, Resident #17 had been on [MEDICATION NAME] daily with [MEDICAL CONDITION]. The dose was subsequently changed upon completion of [MEDICAL CONDITION] to be given five days consecutively, and repeated every 28 days. Resident #17 received blood [MEDICAL CONDITION] during her hospital. The plan was to admit the resident; administer intravenous antibiotics, intravenous antifungals, intravenous fluids; and order a speech consult for a swallow study. During an interview on 06/08/11 at 12:45 p.m., LVN O said she entered the nursing note dated 05/13/11 at 5:00 p.m. She said on 05/13/11 she was on the phone a "long time" with the oncology nurse about Resident #17's medication. The nurse wanted to know if the resident was getting the medication every day. The oncology nurse said the drug was usually given 5 out of 28 days. During an interview on 06/08/11 at 2:52 p.m., the consultant pharmacist said the [MEDICATION NAME] was given 1-5 days every 28 days for malignant tumors. It was to be given a maximum of 49 days with [MEDICAL CONDITION]. During an interview on 06/08/11 at 3:05 p.m., the DON said she was unaware Resident #17 was taking an oral [MEDICAL CONDITION] drug. If she had known, the drug would have been researched to see how staff needed to monitor. The resident was given intravenous fluids in the facility because her electrolytes were "off." A website <http://www.drugs.com/[MEDICATION NAME].html>, accessed 06/02/11, provided the following information: "[MEDICATION NAME] interferes with the development [MEDICAL CONDITION] cells, slowing their growth and spread in the body. [MEDICATION NAME] is used together with [MEDICAL CONDITION] therapy to treat certain types of [DIAGNOSES REDACTED] in adults. It is sometimes given after [MEDICAL CONDITION] medications have been tried without successful treatment of [REDACTED]. [MEDICATION NAME] is often given together with [MEDICAL CONDITION] treatment and then continued for several weeks or months after [MEDICAL CONDITION] treatment ends. There may be periods of time when you will take [MEDICATION NAME] for only a few days in a row and then wait another 2 to 4 weeks before you start a new treatment cycle and take it again. Follow your doctor's instructions carefully. [MEDICATION NAME] can lower blood cells that help your body fight infections." Some of the side effects mentioned were: "*Signs of infection such as fever, chills, sore throat, flu symptoms, easy bruising or bleeding, loss of appetite, nausea, vomiting, and unusual weakness. *White patches or sores inside your mouth or on your lips *[MEDICATION NAME] for more than 5 days in a row can cause life-threatening overdose. Overdose symptoms may include fever, pale skin, increased thirst, dry skin, easy bruising or bleeding, confusion, weakness, and urinating less than usual or not at all." A facility list dated 06/13/11 indicated there were 6 residents with a [DIAGNOSES REDACTED].