Every finding on record at Avir at San Antonio

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 5 of 5 residents (Residents #1, #2, #3, #4, and #5) reviewed for care plans: The facility failed to develop a comprehensive care plan for Resident #1 and Resident #5.The facility failed to ensure Residents #2, #3, and #4 had a completed comprehensive care plan. This failure could place residents at risk of not receiving care and services needed to meet individualized needs.The findings included: Record review of Resident #1's Face Sheet dated 05/08/26 documented an [AGE] year-old male admitted to the facility 04/20/26. Diagnoses included sepsis, unspecified organism (a life-threatening emergency condition where the body has a severe systemic response to an infection, but the specific bacteria, fungus, or virus causing it has not been identified), chronic pain syndrome (a condition where pain persists for 3 to 6 months or longer), Type 2 Diabetes Mellitus without complications (elevated blook sugar levels without developing associated damage to organs or nerves), encephalopathy (a disease in which the functioning of the brain is affected by some agency or condition), chronic kidney disease, Stage 3, unspecified (moderate kidney damage with an estimated reduction in function of about 40%-70%) and chronic pancreatitis (a long-lasting, progressive, and irreversible inflammatory condition of the pancreas that causes persistent structural damage and loss of function, leading to chronic abdominal pain, malabsorption and diabetes). Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 1 indicating he was severely cognitively impaired. In Section GG - Functional Assistance, the MDS indicated Resident #1 required minimal to maximal assistance with various ADLs. Record review of Resident #1's medical record did not reveal the presence of a Comprehensive Care Plan which was due no later than 05/03/26.Record review of Resident #2's Face Sheet dated 05/08/26 documented a [AGE] year-old male initially admitted to the facility 03/21/26 with the most recent admission date of 04/12/26. Diagnoses included gangrene, not elsewhere classified (tissue death not caused by diabetes, infection, or specific vascular diseases), bipolar disorder, current episode depressed, severe, with psychotic features (a psychiatric emergency where a severe depressive episode includes hallucinations, delusions, or disorganized thinking), type 2 diabetes mellitus with diabetic neuropathy, unspecified (a condition where chronic high blood sugar damages peripheral nerves, causing numbness or pain), other schizophrenia (mental health condition with symptoms similar to schizophrenia, such as hallucinations or delusions, but which do not meet the full diagnostic criteria for schizophrenia, schizoaffective disorder, or bipolar disorder), and acquired absence of right leg below knee and acquired absence of left leg below knee. Record review of Resident #2's Quarterly MDS dated [DATE] documented a BIMS score of 14 indicating no cognitive impairment. Record review of Resident #2's Care Plan with the last revision date of 03/21/26 only had 1 focus of Wound Management with a goal of Wound will show signs of improvement and interventions that included Measure ulcer on at regular intervals; Monitor ulcer for signs of progression or declination, Notify provider if no signs of improvement on current wound regimen, and Provide wound care per treatment order. The Care Plan did not include instructions for mental health medications and treatment, ADL care, dietary needs or activities. During an observation and interview with Resident #2 on 05/06/26 at 10:55 am, resident stated his wounds were almost healed where his legs were amputated. Resident #2 stated he was now getting double portions but still had some problems getting snacks in the evening. Resident #2 stated he had to ask for them and sometimes was told either they had not been brought to the nourishment room yet or they did not have what he wanted. Resident #2 stated he could get himself to the bathroom and did not have to use his call light much. Record review of Resident #3's Face Sheet dated 05/08/26 documented a [AGE] year-old male admitted to the facility 04/17/26. Diagnoses included leukemia, unspecified, in relapse (a cancer of the blood-forming tissues that returned after a period of remission), autoimmune hemolytic anemia, unspecified (a rare disorder where the immune system mistakenly destroys red blood cells faster than they can be replaced), Alzheimer's Disease with late onset (dementia, developing in individuals aged 65 or older, characterized by progressive memory loss, cognitive decline, and personality changes). Record review of Resident #3's admission MDS dated [DATE] with a completed date of 04/30/26, documented a BIMS score of 4 indicating severe cognitive impairment.Record review of Resident #3's undated Baseline Care Plan contained information on ADLs, communication, dietary orders, and therapy goals. A Comprehensive Care Plan with a date initiated on 05/06/26 just included a focus of Resident #3 gas exchange related to end state disease as evidenced by shortness of breath, a goal of Resident #3 will remain comfortable with reduced signs of respiratory distress while receiving oxygen therapy, and an intervention that included Administer oxygen as ordered and as tolerated. The other care plan components included a focus Resident is high risk for falls related to confusion with initiated date of 04/20/26 with a goal The resident will be free of falls through the review date with the target date of 07/06/26. The last focus area with a date initiated on 04/18/26 documented The resident has had an actual fall with no injury - poor balance, a goal of The resident will resume usual activities without further incident through the review date with a target date of 06/18/26 and interventions that included Keep bed in lowest position and Remind resident to lock rollator prior to sitting. Surveyor was informed that Resident #3 discharged to another nursing facility on 05/07/26. Record review of Resident #4's Face Sheet dated 05/06/26 documented a [AGE] year-old male initially admitted to the facility 01/28/26 with the most recent admission date of 04/16/26. The diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (a serious condition that causes paralysis or weakness on the right side of the body, often accompanied by language difficulties), aphasia following cerebral infarction (a language impairment that causes trouble speaking, understanding, reading, or writing, but does not affect intelligence), dysphagia following cerebral infection (difficulty or discomfort in swallowing), obstructive and reflux uropathy, unspecified (refers to a blockage or backward flow of urine anywhere in the urinary tract), altered mental status (a broad, non-specific symptom indicating a change in a person's baseline consciousness, cognition, or awareness, ranging from mild confusion to coma), and acquired absence of left leg above knee. Record review of Resident #4's Significant Change MDS dated [DATE] documented a Staff Assessment for Mental Status due to resident's inability to participate in the BIMS questions. The assessment indicated Resident #4 had short-term and long-term memory impairment and was severely impaired for daily decision making. Record review of an undated Comprehensive Care Plan found for Resident #4 had a focus of Wound management dated 02/22/26, a goal of Wound will be free of signs or symptoms of infection with a date initiated 02/22/26 and a target date of 02/16/26. There were no interventions or tasks listed for this focus. No other focus items or goals were listed to indicate how staff would communicate with or care for Resident #4 to ensure his needs were met. Record review of Resident #5's admission sheet dated 05/052026 documented a [AGE] year-old female with a primary diagnosis of dislocation of internal left hip prosthesis, subsequent encounter. Record review of Resident #5's MDS assessment dated [DATE] documented a BIMS score of 13 of 15 indicated intact cognition. Record review of Resident #5's care plan report, no date, revealed no data found. During an interview on 05/07/2026 at 10:02 a.m., the MDS Coordinator stated they were responsible for care plans, and comprehensive care plans for new admissions should be completed 7 days after the initial MDS assessment is completed. The MDS Coordinator stated comprehensive care plans are uploaded to the resident's electronic health record. The MDS Coordinator stated Resident #5's comprehensive care plan should have been completed by now. The MDS Coord stated comprehensive care plans were used by staff to know how to care for the residents. During an interview on 05/07/2026 at 11:17 a.m., the DON stated comprehensive care plans are completed upon admission and quarterly. The DON stated comprehensive care plans are used by staff to know how to care for the residents as well as how to address interventions. Record review of the facilities policy titled, Care Planning - Interdisciplinary Team, updated 12/2024, revealed:Policy Interpretation and ImplementationResident care plans are developed according to the timeframes and criteria established by S483.21. Record review of the code of federal regulations S483.21 Comprehensive person-centered care planning, dated October 4, 2016, revealed: b) Comprehensive care plans. (2) A comprehensive care plan must be-(i) Developed within 7 days after completion of the comprehensive assessment.

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, are reported immediately, but not later than 2 hours for 1 of 1 provider investigation reports reviewed for freedom of abuse, neglect, and exploitation. The facility failed to report an alleged abuse incident within 2 hours of the incident occurring on 2/20/26. This failure could place residents at risk for abuse.The findings include: Record review of the provider investigation report dated 02/27/2026 revealed a resident-to-resident altercation that stated the incident occurred on 02/20/2026 at 9:30am and was reported to HHS on 02/20/2026 at 12:30pm. During an interview on 05/07/2026 at 6:07 p.m., the ADM stated they were in charge of reports made to HHS and that alleged abuse needs to be reported within 2 hours. The ADM confirmed they submitted the provider investigation report, regarding the resident-to-resident altercation, to the state after the 2-hour mark from when the incident occurred. The ADM stated there was no risk due to the facility had already taken care of the situation and that there was no immediate harm. Record review of the facilities policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed: 9. Investigate and report any allegations within timeframes required by federal requirements. Record review of long-term care regulation provider letter titled, Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC), issued on August 29, 2024, revealed: Do Report: abuse (with or without serious bodily injury.) When to report:Immediately, but not later than two hours after the incident occurs or is suspected.

Based on interview and record review the facility failed to have the comprehensive care plan reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 5 residents (Resident #7) reviewed for comprehensive care plans. The facility failed to revise Resident #7's care plan after a change in behavior. This failure could place residents at risk of not receiving needed care and treatment.The findings include: Record review of Resident #7's admission sheet dated 05/05/2026 documented a [AGE] year-old male with a primary diagnosis of Alzheimer's disease with early onset (progressive memory loss, cognitive decline, and behavioral changes). Record review of Resident #7's MDS assessment dated [DATE] documented a BIMS score of 9 of 15 indicating moderate cognitive impairment. Record review of a provider investigation report dated 02/27/2026 revealed a resident-to-resident altercation involving Resident #7 that stated the incident occurred on 02/20/2026 at 9:30 a.m. Record review of Resident #7's care plan revised on 05/05/2026 revealed no mention of the resident-to-resident altercation on 02/20/2026. Record review of Resident #7's psychiatry progress note on 03/03/2026 revealed an order to discharge the medication Trazodone. Record review of Resident #7's behavior monitoring document following the altercation revealed monitoring for 72 hours to include 15-minute checks with no record of any behaviors during the period. During an interview on 05/07/2026 at 10:02 a.m., the MDS Coordinator stated they were in charge of care plans. The MDS Coordinator stated care plans should be revised when a resident has a change of condition or change in behavior. The MDS Coordinator stated Resident #7's care plans should have been updated after the resident-to-resident altercation they were involved in. The MDS Coordinator stated the risk of not revising the care plan could be staff not knowing how to care for the residents. During an interview on 05/07/2026 at 11:17 a.m., the DON stated care plans should be updated when there is a change with the resident. The DON stated Resident #7's care plans should have been updated after the resident-to-resident altercation they were involved in. The DON stated it was important to have the care plan updated to know how to care for the residents. At the time of exit no facility policy was given regarding revision of comprehensive care plans.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 (Resident #6) reviewed for medications and pharmacy services, in that: The facility failed to ensure Resident #6 did not have medication in their room. These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.The findings include: Record review of Resident #6's admission sheet dated 05/05/2026 documented a [AGE] year-old female with diagnoses including major depressive disorder, recurrent unspecified (mood disorder characterized by repeated episodes of depression without specifying severity or particular features). Record review of Resident #6's MDS assessment dated [DATE] documented a BIMS score of 15 indicating intact cognition. Record review of Resident #6's care plan documented Risk for Harm: Self Directed or other-directed anxiety and depression with revision date 03/11/2026 with a goal Administer medications as prescribed with revision date 03/11/2026. During an observation and interview on 05/06/2026 at 2:06 p.m., a cup with 2 pills were on Resident #6's bedside table. Resident #6 stated the pills in the cup were her medications that she was still needing to take. Resident #6 stated the mediation aide did not usually leave them in the room, but when they came in the resident was busy and asked for the medication aid to set them down. During an interview on 05/06/2026 at 4:35 p.m., LVN B stated when medication was given to residents' staff should have watched the resident take all of their medication before leaving the room. LVN B stated staff should not be leaving medication in a resident's room due to the resident could have possibly overdosed, not taken it, or the roommate could have possibly taken it. During an interview on 05/06/2026 at 5:07 p.m., CMA C stated they gave medication to Resident #6. CMA C stated they did leave the medication in Resident #6's room because the resident was being transferred and they asked for another staff member to ensure Resident #6 took her medication. CMA C stated they were supposed to watch Resident #6 take the medication. CMA C stated the risk of not having watched a resident take their medication could be someone or the roommate grabbing the medication and taking it themselves. During an interview on 05/06/2026 at 5:55 p.m., the DON stated the nurse or medication aide who gave the resident their medication should have watched the resident take their medication. The DON stated there was a risk to leaving medication in a resident's room and the risk depended on the medication. Record review of the facilities policy titled, 1.0 Medication Preparation for Administering, undated, revealed:J. Medication Administration:8. Ensure that the customer swallows all the medication(s).

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents reviewed (Resident #6) for infection control. The facility failed to ensure Resident #6's indwelling urinary catheter bag and tubing were not touching the floor These failures could place residents at risk for cross contamination and infection.The findings include: Record review of Resident #6's admission sheet dated 05/05/2026 documented a [AGE] year-old female with diagnoses including major depressive disorder, recurrent unspecified (mood disorder characterized by repeated episodes of depression without specifying severity or particular features). Record review of Resident #6's MDS assessment dated [DATE] documented a BIMS score of 15 indicating intact cognition and revealed Resident #6 had an indwelling catheter. Record review of Resident #6's care plan documented The resident has indwelling FC Catheter. with revision date 03/11/2026 with a goal Catheter: The resident has indwelling FC. Position catheter bag and tubing below the level of the bladder and away from entrance room door with revision date 03/11/2026. Record review of Resident #6's order summary dated 05/05/2026 revealed an order check foley catheter tubing secure device placement every shift, every shift for placement may use leg strap to secure foley in place with a start date of 03/11/2026. During an observation and interview on 05/06/2026 at 2:06 p.m., Resident #6's catheter bag and tubing were on the floor under the bed. Resident #6 stated that the catheter bag and tubing were not normally on the floor, but that staff were in the room earlier and transferred her to her bed and it could have occurred then. During an interview on 05/06/2026 at 3:12 p.m., CNA A stated the catheter bag should be attached to the left or right side of the bed and the tubing and catheter bag should not be touching the floor. CNA A stated the catheter or tubing touching the floor could be a contamination issue. During an interview on 05/06/2026 at 4:35 p.m., LVN B stated the catheter bag should be below the bladder and the catheter bag and tubing should not be touching the floor. LVN B stated the catheter bag or tubing being on the floor could lead to a risk of contamination. During an interview on 05/06/2026 at 5:55 p.m., the DON stated the catheter bag should be hanging from the bed, below the bladder, and that the catheter bag and tubing should never be touching the floor. The DON stated the risk of the catheter bag or tubing touching the floor could be infection control. Record review of the facilities policy titled, Catheter Care, Urinary, updated July 2024, revealed:Infection controlMaintain clean technique when handling or manipulating the catheter, tubing, or drainage bag/b. Be sure the catheter tubing and drainage bag or kept off the floor.

Based on interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 7 residents (Residents #1) reviewed for care plans, in that: The facility failed to review and revise Resident #1's comprehensive care plan after the resident's quarterly assessment dated [DATE] and annual assessment dated [DATE].This deficient practice could place residents at risk of receiving inadequate care to meet their physical, psychosocial and functional needs. The findings included:Record review of Resident #1's electronic face sheet, accessed on 12/18/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and again 08/22/2025 with diagnoses including Alzheimer's disease with early onset (a progressive disease, where dementia symptoms gradually worsen over a number of years), vascular dementia (a common form of dementia caused by an impaired supply of blood to the brain, such as may be caused by a series of small strokes), Schizoaffective disorder - bipolar type (a condition mixing psychosis with manic symptoms such as high energy, less sleep, risky behavior and sometimes depressive symptoms), Parkinson's disease (a progressive brain disorder causing tremors, slow movement and sleep issues) and hallucinations (experiences involving the apparent perception of something not present).Record review of Resident #1's annual MDS with an ARD of 10/26/2025 revealed a BIMS of 08/15, indicating moderately impaired cognition.Record review of Resident #1's EHR revealed the resident received a quarterly MDS with an ARD of 08/08/2025.Record review of Resident #1's comprehensive care plan in his EHR revealed it was last reviewed and updated on 05/27/2025.During an interview on 12/18/2025 at 10:55 AM the DON stated a review of Resident #1's comprehensive care plan review should have been completed after the quarterly MDS review dated 08/08/2025 and again after the annual MDS review dated 10/26/2025. The DON stated the facility had transitioned from one EHR software platform to a different one within the last few months and in the interim, some resident records were updated manually on paper; however, she was unable to find an updated comprehensive care plan for Resident #1. During an interview on 12/18/2025 at 12:05 PM, the Administrator stated the MDS coordinator was responsible for updating resident care plans after MDS assessments and Resident #1's comprehensive care plan should have been updated since 05/27/2025 despite the facility's transition from one EHR software platform to another one. The facility terminated the employment of its prior MDS coordinator in the first week of November 2025, and in the interim, had one part-time MDS coordinator who worked at the facility 2-3 times per week and a regional MDS coordinator. MDS coordinators had full access to the residents' EHR. The facility's new MDS coordinator was scheduled to start work on 12/29/2025.Record review of the facility's policy Care Plans, Comprehensive Person-Centered dated March 2022 revealed, 12. The Interdisciplinary team reviews and updates the care plan: d. at least quarterly, in conjunction with the required quarterly MDS assessment.Record review of CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, October 2025, 2.7 The Care Area Assessment (CAA) Process and Care, revealed, . the resident's care plan must be reviewed after each assessment, as required by S483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1's room) of 12 resident rooms reviewed for physical environment.The facility failed to ensure there were no pests in Resident #1's room on 9/5/25.This failure could place residents at risk of psychosocial harm due to diminished quality of life and/or physical harm. Findings included:Record review of Resident #1's admission Record, dated 9/20/25, revealed the resident was admitted on [DATE] with diagnoses which included: Need for Assistance with Personal Care, Muscle Weakness, Polyneuropathies (disorder affecting multiple peripheral nerves, causing damage/dysfunction), and history of other diseases of the nervous system and sense organs] .Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15, indicating intact cognition.Record review of Resident #1's Progress Notes revealed: 9/5/25 at 10:00 am - Aide notified this nurse of finding ants on the bed, noticed ants under sheets, at which time, maintenance staff notified room and bed sprayed, bed and mattress decontaminated, cont. Patient encouraged to be out of bed daily and to eat in bed to a minimal [sic] in order for bed and surrounding to be checked for ants [LVN A] 9/5/25 at 4:00 pm - DON and this nurse spoke [with] resident regarding ants in room.[ADON] 9/8/25 at 11:00 am - CNA [A] called to room [and] resident c/o having ant bites to bilat inner thighs and [right] flank area. Both inner thigh areas have fluid filled pustules [with] redness from scratching or rubbing area. [Right] flank area also [with] redness [and] few pustules noted. NP notified and n/o for hydrocortisone cream 1% apply thin layer to affected area TID until healed. Monitor for s/s of infection q shift, resident noted with no c/o pain or discomfort [LVN B] 9/8/25 - Resident mention [sic] she had ants in her bed Fri am, has ant bites on inner groin leg, RT back reported to Tx nurse, she called NP got orders - [LVN C] (Rt flank area, inner groin [with] redness and pus [LVN C] Record review of Resident #1's Weekly Skin Assessment, dated 9/5/25, completed by the ADON, revealed: Red raised area to bilateral inner thighs [and] [right] flank area. Record review of an Event Report, dated 9/5/25, revealed: .ant bites to bilateral inner thighs [and] [right] flank area. area red and raised. This nurse was made aware that resident had ants in her bed earlier but no visible ant bites. When CNA put resident to bed CNA noted ant bites and notified this nurse. Resident assessed and ant bites noted. red and raised [with] no blisters. [PCP] called and made aware gave PRN order for hydrocortisone 1% apply TID PRN. Resident denies pain/discomfort to area. Resident did not want this nurse to apply hydrocortisone to noted bites as she wasn't having any pain/burning/itching to area. R/p called [and] made aware - [ADON].Record review of photographs (HHSC 6339 Documentation of Photographic Evidence 1-8), received by HHSC on 9/11/25, revealed areas of redness and pustules to the Resident #1's groin and thighs.Record review of video (HHSC 6339 Documentation of Video Evidence), received by HHSC on 9/11/25, revealed numerous ants on Resident #1's bed.During an interview and observation of skin assessment for Resident #1 on 9/18/25 at 3:11 pm, small circular scars were noted to the resident's bilateral thighs and right flank area. Resident #1 and Treatment Nurse said these scars were because of ant bites.During an interview on 9/18/25 at 3:14 pm, Resident #1 said on 9/5/25 about 6:00 am there were ants in her bed, fire ants. Resident #1 further said she could not feel and did not realize the ants were on her. Resident #1 said she felt something on her shoulder and told CNA A, who said it was an ant. Resident #1 further said when CNA A removed the covers, there were more ants on the bed. Resident #1 said there were a whole bunch, on that day (9/5/25) they (the ants) were big and bit me. Resident #1 further said the ants were coming from the window/AC area.During an interview on 9/19/25 at 10:47 am, the DON said she first learned about the ants in Resident #1's bed on the morning of 9/5/25 about 9:45 am. On 9/19/25 at 12:45 pm, the DON verified Resident #1 did not have any skin breakdown on 9/4/25 as documented on her shower sheet. During an interview on 9/19/25 at 10:51 am, LVN A] said he was notified about ants in Resident #1's bed on 9/5/25 about 9:40 am.During an interview on 9/19/25 at 2:11 pm, the MS said he saw the ants in Resident #1's room, which were coming from the AC unit.During an interview on 9/19/25 at 3:21 pm, CNA A said on 9/5/25, at about 8:30 am - 9:00 am, Resident #1 said she felt like something was crawling on her shoulder. CNA A further said when she removed the resident's covers to check the bed she noticed more ants on the bed. CNA A said she placed a sheet under the resident to provide a barrier until a second staff arrived to help transfer the resident out of bed using the lift. CNA A further stated she did not notice any food in or around the resident's bed.During an interview on 9/20/25 at 2:46 pm, CNA A said she had not noticed any redness to Resident #1's thighs or between her thighs before.During an interview on 9/20/25 at 4:16 pm, Resident #1 said she felt bad the ants being in her bed. Resident #1 further said that sometimes she felt like something was crawling on her arm.Record review of the facility's Maintenance Logs revealed ants were reported in Resident #1's bed on 9/5/25.During an interview on 9/20/25 at 3:31 pm, the Administrator said it was important to check for the facility for pests and treat any identified issues, as they did with the ants on 9/5/25, and ensure no other issues with pests. The Administrator further said the MS and herself were responsible for ensuring the facility was pest free. The Administrator said the nursing staff were responsible for reporting any pest activity. The Administrator further said that residents were at risk for bug bites if the facility had increased pest activity. Record review of the facility's policy, Abuse/ Reportable Events, undated, revealed: .The facility will provide and ensure the promotion and protection of resident rights.This facility establishes an environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity.

Based on interview and record review the facility failed to ensure all alleged violations involving abuse or neglect, exploitation or mistreatment were reported immediately, but not later than 2 hours after the allegation was made, if the events resulted in serious bodily injury for 1 of 4 residents (Resident #1) reviewed for reporting.The facility failed to report to the state survey agency that Resident #1 sustained an injury as a result of ants in her bed on 9/5/25.This failure could place residents at risk for neglect, diminished quality of life, physical, and/or psychosocial harm.Findings included:Record review of Resident #1's admission Record, dated 9/20/25, revealed the resident was admitted on [DATE] with diagnoses which included: Need for Assistance with Personal Care, Muscle Weakness, Polyneuropathies (disorder affecting multiple peripheral nerves, causing damage/dysfunction), and history of other diseases of the nervous system and sense organs.Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15, indicating intact cognition Record review of Resident #1's Progress Notes revealed: 9/5/25 at 10:00 am - Aide notified this nurse of finding ants on the bed, noticed ants under sheets, at which time, maintenance staff notified room and bed sprayed, bed and mattress decontaminated, cont. Patient encouraged to be out of bed daily and to eat in bed to a minimal [sic] in order for bed and surrounding to be checked for ants [LVN A] 9/5/25 at 4:00 pm - DON and this nurse spoke [with] resident regarding ants in room.[ADON] 9/8/25 at 11:00 am - CNA [A] called to room [and] resident c/o having ant bites to bilat inner thighs and [right] flank area. Both inner thigh areas have fluid filled pustules [with] redness from scratching or rubbing area. [Right] flank area also [with] redness [and] few pustules noted. NP notified and n/o for hydrocortisone cream 1% apply thin layer to affected area TID until healed. Monitor for s/s of infection q shift, resident noted with no c/o pain or discomfort [LVN B] 9/8/25 - Resident mention [sic] she had ants in her bed Fri am, has ant bites on inner groin leg, RT back reported to Tx nurse, she called NP got orders - [LVN C] (Rt flank area, inner groin [with] redness and pus [LVN C] Record review of Resident #1's Weekly Skin Assessment, dated 9/5/25, completed by the ADON, revealed: Red raised area to bilateral inner thighs [and] [right] flank area. Record review of an Event Report, dated 9/5/25, revealed: .ant bites to bilateral inner thighs [and] [right] flank area. area red and raised. This nurse was made aware that resident had ants in her bed earlier but no visible ant bites. When CNA put resident to bed CNA noted ant bites and notified this nurse. Resident assessed and ant bites noted. red and raised [with] no blisters. [PCP] called and made aware gave PRN order for hydrocortisone 1 apply TID PRN. Resident denies pain/discomfort to area. Resident did not want this nurse to apply hydrocortisone to noted bites as she wasn't having any pain/burning/itching to area. R/p called [and] made aware - [ADON].Review of facility intakes on TULIP on 9/17/25 revealed there were no self-reported incidents about the event involving ants in Resident #1's bed with subsequent ant bites to her body. During an interview and observation of skin assessment for Resident #1 on 9/18/25 at 3:11 pm, small circular scars were noted to the resident's bilateral thighs and right flank area. Resident #1 and Treatment Nurse said these scars were because of ant bites.During an interview on 9/18/25 at 3:14 pm, Resident #1 said on 9/5/25 about 6:00 am there were ants in her bed, fire ants. Resident #1 further said she could not feel and did not realize the ants were on her. Resident #1 said she felt something on her shoulder and told CNA A, who said it was an ant. Resident #1 further said when CNA A removed the covers, there were more ants on the bed. Resident #1 said there were a whole bunch, on that day (9/5/25) they (the ants) were big and bit me. Resident #1 further said the ants were coming from the window/AC area. During an interview on 9/20/25 at 3:31 pm, the Administrator said it was important to check for the facility for pests and treat any identified issues, as they did with the ants on 9/5/25, and ensure no other issues with pests. The Administrator further said the MS and herself were responsible for ensuring the facility was pest free. The Administrator said the nursing staff were responsible for reporting any pest activity. The Administrator further said that residents were at risk for bug bites if the facility had increased pest activity[KA1] .Record review of the facility's policy, Abuse/ Reportable Events, undated, revealed: .It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Adverse event: untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Reporting: Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation.

Based on observation, interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 16 residents (Residents #9 and #63) reviewed for accidents and hazards. 1. Resident #9 was observed with her own smoking paraphernalia which included a lighter (a self-contained ignition source used to lite cigarettes) and was observed smoking on the facility property without supervision and or at the assigned agreed upon times for supervised smoking. 2. Resident #106 was discovered with smoking paraphernalia which included a lighter and cigarettes, and was actively smoking, while receiving oxygen therapy, in his bathroom twice, once on 8/12/2025 and again on 8/21/2025. The noncompliance was identified as PNC. The IJ began on 6/13/2025 and ended on 8/25/2025. The facility had corrected the noncompliance before the survey began. These failures could have exposed residents to harm by neglecting to provide supervision. The findings included:The findings included: 1. A record review of Resident #9's admission record dated 8/29/2025 revealed an admission date of 6/2/2025 and a discharge date of 8/27/2025 with diagnoses which included chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause airflow obstruction and breathing difficulties), left lower leg amputation, intermittent explosive disorder (recurrent episodes of impulsive, aggressive, and violent behavior that is disproportionate to the triggering situation), and diabetes mellitus II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin and results in high concentrations of sugars in the bloodstream with potential negative outcomes). A record review of Resident #9's quarterly MDS dated [DATE] revealed resident #9 was a [AGE] year-old female admitted for long term care with supports for safe supervised smoking. Resident was assessed with a BIMS score of 15 out of 15 which indicated no cognitive impairment. A record review of Resident #9's care plan dated 8/27/2025 revealed, problem; resident is a smoker . instruct Resident about smoking risks and hazards and about smoking cessation aids that are available . instruct residents about the facility policy on smoking locations, times, safety concerns, . notify charge nurse immediately if it is suspected resident has violated facility smoking policy . observe clothing and skin for signs of cigarette burns . A record review of Resident #9's nursing progress notes revealed on 6/13/2025 at 4:16 AM LVN F documented, patient noted going into (another residents) room multiple times throughout the night and taking patient out to smoke. A record review of Resident #9's nursing progress notes revealed on 6/15/2025 at 11:47 AM LVN X documented, resident observed outside in courtyard smoking with another Resident, resident was redirected. When nurse asked for lighter and cigarette, resident refused and stated she could smoke outside. Resident nurse notified. During an interview on 8/30/2025 at 1:51 PM LVN F stated Resident #9 would often smoke unsupervised and at unassigned time. LVN F stated Resident often had her own cigarettes and lighter and would surrender the lighter when asked but would often obtain another lighter, most likely from when she would sign herself out on pass. smoked out in the courtyard unsupervised and reported to the ADON and previous DON. LVN F stated there was a risk for burns. LVN F stated he recalled his documentation on 6/12/2025 at 4 AM when he observed Resident #9 in the facility courtyard smoking cigarettes. LVN F stated he reported the incident at the change of shift to the previous DON and the ADON. 2. Record review of Resident #63's admission record dated 8/30/2025 revealed an admission date of 5/14/2025 with diagnoses which included malnutrition, anxiety, pain, hypertension (high blood pressure), muscle spasms / weakness, reflux, and chronic obstructive pulmonary disease. A record review of Resident #63 quarterly MDS dated [DATE] revealed Resident #63 was a [AGE] year-old male admitted for long term care with supports for safe supervised smoking. Resident #63 was assessed with a BIMS score of 11 out of a possible 15 which indicated moderate cognitive impairment. A record review of Resident #63's physicians order dated 5/14/2025 revealed the physician prescribed for Resident #63 to receive continuous oxygen therapy every shift every day and night. Record review of Resident #63's care plan dated 8/30/2024 revealed that he was an intermittent smoker (start date 5/14/2025) with a revision on 8/12/2025 indicating that he was noncompliant with the smoking policy and smoking in his bathroom and was educated/acknowledged smoking agreement. A record review of the facility's event report dated 8/12/2025 revealed at 4:00 PM the Social Worker and LVN A discovered Resident #63 in his bathroom smoking while receiving oxygen therapy via a nasal cannula and an oxygen concentrator. A record review of the facility's event report dated 8/21/2025 revealed at an unknown time prior to 4:00 PM LVN A and CNA B discovered Resident #63 was in his bathroom smoking while receiving oxygen therapy via a nasal cannula and an oxygen concentrator. During an observation and interview on 8/28/2025 at 1:40 PM revealed Resident #63 was in his room and was assisted to pack and gather his belongings to discharge to another facility. Resident #63 stated he was discharged related to his episodes of smoking in his rooms' bathroom. Resident #63 stated he did not participate in the supervised assigned smoke breaks due to his inability to participate in the smoke break without his oxygen therapy. Resident #63 stated he could not endure very long without his oxygen because of his COPD. During an interview on 8/28/2025 at 1:50 PM LVN A stated she and the SW discovered Resident #63 smoking in his bathroom twice in August 2025. LVN A stated the ADON, the DON, and the Administrator were aware of Resident #63's smoking incidents. LVN A stated Resident #63's smoking could have had serious injury potential to include fires and or burns. LVN A stated the incidents were reported to the facility's leadership who implemented safety measures which included assessing peer residents who smoke for smoking paraphernalia and monitoring Resident smokers for safe smoking practices. LVN A stated Resident #63 was monitored and reviewed for safety every 2 hours every day until he was discharged . During an interview on 8/28/2025 at 4:10 PM the ADON stated she was aware of Resident #63's smoking incidents while he was on oxygen therapy and had reviewed the incidents in the morning IDT meetings with the DON and the Administrator and could not recall anyone discussing a report to the state agency for the incidents. During an interview on 8/28/2025 at 5:00 PM the Administrator stated she had received a report from nursing staff that Resident #9 and Resident #63 had a history of smoking unsupervised and at unassigned times. The Administrator stated LVN A and the SW reported that Resident #63 had been caught smoking in his bathroom on 8/12/2025 and again on 8/21/2025. The Administrator stated the facility could no longer meet Resident #63's and Resident #9's needs for safe smoking and non-compliant behavior and discharged the Residents. The Administrator stated the IDT and herself had not considered the incidents as incidents which were reportable to the state agency and had not reported the incidents to the state agency. During an interview on 8/29/2025 at 4:40 PM NP C stated he was the NP for the MD and was responsible for Resident #63's medical care. NP C stated Resident #63 had a need for oxygen therapy related to his poor gas exchange and should never be able to smoke while receiving oxygen therapy. NP C stated the practice was dangerous not only to Resident #63 but to the public to include a potential for fires and explosions. A record review of the facility's smoking policy dated 2017 revealed It is the policy of this home that: All residents who smoke will be supervised. Smoking will be permitted in designated safe area(s) only. Oxygen equipment is not permitted in the smoking area(s). The minimum safe distance for oxygen equipment from the smoking area is 50 feet. Residents not complying with the home's smoking policy may be discharged from the home. PNC verification A record review of the facility's Ad Hoc QAPI meeting documentations titled AD Hoc QAPI Meeting / Four Point Plan of Correction Agenda and Summary revealed the Ad Hoc committee members met which included the Medical Director, the Administrator, the DON, the ADON, the Maintenance Director, the Housekeeping Supervisor, the Social Worker, and the Business Manager. Further review revealed an action plan which included:1. Corrective actiona. What specifi9c action would you take for the identified residents? i. Identify residents who smoke ii. Provide re-education regarding safe smoking practices completed (policies.) iii. Proper notification to administration regarding non-compliance with smoking policy. iv. Monitoring of system to ensure compliance.2. Identification of othersa. What other residents might be a risk in the same deficient practice and why? All smokers could be potentially at risk for committing deficient practice. Therefore, continued reeducation of smoking policy has been implemented. Smokers were invited to resident council meeting to discuss smoking practices and ensure compliance with smoking policy.3. Systemic changesa. what changes would you make based on the results of your root cause analysis? Administrator, director of nursing, and assistant director of nursing will closely monitor smoking system and ensure compliance. Admissions - to identify smoker status prior to administration and communicate status with nursing team. Nurses have been in service on ensuring safe smoking practices are followed based on smoking policy and transparent communication will be required of non-compliance with administration and nursing administration teams.b. How will changes be communicated to staff? In services and one-on-one education on updated policies will be provided by the administrator and nurse managers including the director of nurses.c. Identification of non-compliant residents who smoke must be communicated to the administration team for interventions and safety practices put in place.4. Monitoringa. How will you sustain compliance? By making compliance monitoring rounds, education of staff and residents as appropriate.b. How do you plan to monitor corrective action? When and how long will monitoring occur? Monitoring will be ongoing. It will be monitored by all department managers to ensure compliance and reviewed monthly during QAPI meetings until further notice.c. Resident council will be included to provide smoking policy and ongoing education regarding safe practices. A record review of the smoker's club Resident council meeting dated 8/18/2025 revealed 10 residents which included Resident #9 and #63 received a review of the facility's smoking policy, It is the policy of this home that: All residents who smoke will be supervised. Smoking will be permitted in designated safe area(s) only. Oxygen equipment is not permitted in the smoking area(s). The minimum safe distance for oxygen equipment from the smoking area is 50 feet. Residents not complying with the home's smoking policy may be discharged from the home. A record review of the facility's in-service dated 8/21/2025 titled Smoking Supplies revealed the entire staff had received the in-service which included, all smoking supplies must be kept in smoking box no resident should be smoking in Rome all residents found with supplies for smoking must be taken away and notify the administrator. A record review of the facility's AdHoc QAPI files dated 8/21/2025 revealed a statement authored by the DON which included, on 8/21/25 myself and a DON rounded and searched all residents who smoke for any smoking paraphernalia smoking paraphernalia was found on any residence all smoking residents were able to verbalize they can only smoke during scheduled smoke breaks. Further review revealed the DON and the ADON signed the statement. A record review of the facility's AdHoc QAPI files dated 8/21/2025 revealed a monitoring worksheet for Resident #63 dated from 8/21/2025 until 8/27/2025. Further review revealed Resident #63 was monitored every 2 hours for safety and behavior without incident. During an observation and interview on 8/28/2025 at 1:40 PM revealed Resident #63 was in his room and was assisted to pack and gather his belongings to discharge to another facility. Resident #63 stated he was discharged related to his episodes of smoking in his rooms' bathroom. Resident #63 stated he did not participate in the supervised assigned smoke breaks due to his inability to participate in the smoke break without his oxygen therapy. Resident #63 stated he could not endure very long without his oxygen because of his COPD. During an interview on 8/28/2025 at 1:50 PM LVN A stated she had received training for safe smoking practices which included monitoring residents for smoking paraphernalia and had monitored Resident #63 every 2 hours when she was on shift to do so. During an observation and interview on 8/27/2025 at 11:39 AM revealed the facility's designated smoking area, the courtyard, where 6 residents assembled for a smoke break. Further review revealed the Activities Director supplied the residents with cigarettes and lite the cigarettes for the residents. The Activities Director was observed to supply clothing protectors for residents who had a need for clothing protectors. The Activities Director stated the facility had developed and implemented a smoking program for residents which included 4 smoke breaks on Monday through Friday, four times a day, at 9:30 AM, 11:30 AM, 1:30 PM, and again at 4:00 PM. The Activities Director stated she organized and supervised the residents smoke breaks which included the storage of residents' cigarettes and lighters in a locked room at the nurse's station. During an observation and interview on 8/29/2025 at 4:33 PM revealed Resident #20, Resident #1, Resident #63, and Resident #36 assembled in the courtyard for a supervised smoke break. Residents #20, #1, #63, and #36 stated they smoked while supervised at the smoke breaks and the staff kept their cigarettes and lighters. During an interview on 8/28/2025 at 11:00 AM LVN X and LVN Z stated the activities Director would coordinate and supervise the smoke breaks for residents Monday through Friday and the nurses would take turns supervising the smoke breaks on the weekends. LVN X and LVN Z stated the cigarettes and lighters were stored locked in the medication room and the nurses would provide the cigarettes. LVN X stated no one should smoke in the facility and any violations would be reported to the leadership to include the Administrator and the DON. During an interview on 8/28/2025 at 4:10 PM the ADON stated she had reviewed the facility smokers several times during June 16/2025 through 8/21/2025 to include monitoring for smoking paraphernalia and safe smoking times with supervision. The ADON stated she and the entire staff had been in serviced several times for safe smoking policies and reporting unsafe smoking practices. During an interview on 8/28/2025 at 5:00 PM the Administrator stated she became aware of Resident #9's and Resident #63's unsafe smoking behaviors in June 15/2025 and in August 12th and august 21st 2025 and began an investigation on 8/13/2025 which concluded with an Ad Hoc QAPI meeting, a plan of correction which included systemic changes, increased monitoring for safe smoking practices and a safe discharge for residents #9 and Resident #63 to facilities which could meet their needs for safe smoking to include smoking cessation efforts.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 1 (Resident #60) of 6 residents reviewed for unnecessary medications.The facility failed to ensure Resident #60 received a gradual dose reduction for anti-psychotic medication, Zyprexa. This deficient practice could affect any resident receiving medications and could result in adverse effects and ultimately a decline in physical condition.The findings were:Review of Resident #60's face sheet dated 8/30/35 revealed she was admitted to the facility on [DATE] with diagnoses including Vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Major Depressive Disorder, recurrent, severe with psychotic symptoms, Mood disorder due to known physiological condition with mixed features and Generalized anxiety disorder. Review of Resident #60's History and Physical, dated 2/18/25, revealed her BIMS was 0 of 15 reflective of severe cognitive impairment. Review of a prescription order, dated 1/4/24, revealed Resident #60 was prescribed Olanzapine (Zyprexa) tablet; 5 mg, 1 tablet, oral, once a day. Review of Resident #60's consolidated orders from 7/29/25 to 8/29/25 revealed an order for Olanzapine (Zyprexa) tablet; 5 mg, 1 tablet, oral, once a day for diagnosis of physiological condition with mixed features. Review of Resident #60's pharmacy reviews from January 2025 to August 2025 revealed there had not been an attempt to do a gradual dose reduction for the order for Zyprexa. Interview on 8/30/25 at 5:45 PM with the ADON revealed she was responsible for tracking the pharmacy reviews and to monitor GDRs for psychotropic medications. The ADON stated Resident #60 had been taking Zyprexa, an antipsychotic medication since 1/4/24 per psychiatric group. Upon reviewing Resident #60's medical chart, the ADON stated a gradual dose reduction had not been attempted. The ADON stated Resident #60 was on Hospice services and they had decided to continue Resident #60 on the medication. The ADON stated the facility and Hospice services were to coordinate services and further stated she had not discussed a gradual dose reduction with the Hospice nurse. The ADON stated the purpose of a gradual dose reduction was to reduce or eliminate the medication altogether if possible. She stated some of the side effects for prolonged use could include Tardive Dyskinesia, (twitching body parts), tremors, weight loss and neurological side effects. Review of a facility policy, Behavior Management - Psychoactive Medication - Antipsychotic Drug Therapy, dated 12/2017, read in relevant part Policy It is the policy of this home to use antipsychotic medications per CMS guidelines and to perform dose reductions and monitoring as required by regulation, to promote the highest level of resident care and safety. Definitions 1. A gradual dose reduction is a tapering of the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether.

Based on observations, interviews, and record reviews in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported not later than 24 hours if the events that caused the allegation do not involve abuse and 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 8 residents (Residents #9 and #63) reviewed for allegations of neglect. 1. Resident #9 was observed with her own smoking paraphernalia which included a lighter (a self-contained ignition source used to light cigarettes) and was observed smoking on the facility property without supervision and or at the assigned agreed upon times for supervised smoking.2. Resident #63 was discovered with smoking paraphernalia which included a lighter and cigarettes, and was actively smoking, while receiving oxygen therapy, in his bathroom, twice once on 8/12/2025 and again on 8/21/2025. These failures could place residents at risk of harm.The findings included: 1. A record review of the Texas Unified Licensure Information Portal (TULIP) for the time May 1st, 2025, through August 30th, 2025, revealed no evidence of a report to the state agency for the smoking incidents for Resident #9 on 6/12/2025 and again on 6/15/2025. A record review of Resident #9's admission record, dated 8/29/2025, revealed an admission date of 6/2/2025 and a discharge date of 8/27/2025 with diagnoses which included chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause airflow obstruction and breathing difficulties), left lower leg amputation, intermittent explosive disorder (recurrent episodes of impulsive, aggressive, and violent behavior that is disproportionate to the triggering situation), and diabetes mellitus II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin and results in high concentrations of sugars in the bloodstream with potential negative outcomes). A record review of Resident #9's quarterly MDS dated [DATE] revealed resident #9 was a [AGE] year-old female admitted for long term care with supports for safe supervised smoking. Resident was assessed with a BIMS score of 15 out of 15 which indicated no cognitive impairment. A record review of Resident #9's care plan dated 8/27/2025 revealed, problem: resident is a smoker . instruct resident about smoking risks and hazards and about smoking cessation aids that are available . instruct resident about the facility policy on smoking locations, times, safety concerns, . notify charge nurse immediately if it is suspected resident has violated facility smoking policy . observe clothing and skin for signs of cigarette burns . A record review of Resident #9's nursing progress notes revealed on 6/13/2025 at 4:16 AM, LVN F documented, patient noted going into (another resident's) room multiple times throughout the night and taking patient out to smoke. A record review of Resident #9's nursing progress notes revealed on 6/15/2025 at 11:47 AM, LVN X documented, resident observed outside in courtyard smoking with another resident, resident was redirected. When nurse asked for lighter and cigarette, resident refused and stated she could smoke outside. Resident nurse notified. During an interview on 8/30/2025 at 1:51 PM, LVN F stated Resident #9 would often smoke unsupervised and at unassigned time. LVN F stated Resident #9 often had her own cigarettes and lighter and would surrender the lighter when asked but would often obtain another lighter, most likely from when she would sign herself out on pass. smoked out in the courtyard unsupervised and reported to the ADON and previous DON stated risk for burns LVN F stated he recalled his documentation on 6/12/2025 at 4:00 a.m. when he observed Resident #9 in the facility courtyard smoking cigarettes. LVN F stated he reported the incident at the change of shift to the previous DON and the ADON. During an interview on 8/30/2025 at 2:01 PM, the ADON stated she had not received a report from LVN F regarding Resident #9's possession of smoking paraphernalia and unsupervised smoking. The ADON stated the routine for facility IDT was to meet daily and review the previous days incidents which included a review of the nursing progress notes. The ADON stated she could not recall the IDT morning meeting on 6/13/2025 and 6/16/2025 which could have revealed the smoking incidents for Resident #9. The ADON stated the smoking incidents were not reported to the state agency and the decision to report would be made by the IDT team and by the Administrator. 2. A record review of the Texas Unified Licensure Information Portal (TULIP) for the time May 1st, 2025, through August 30th, 2025, revealed no evidence of a report to the state agency for the smoking incidents for Resident #63 on 8/12/2025 and again on 8/21/2025. Record review of Resident #63's admission record dated 8/30/2025 revealed an admission date of 5/14/2025 with diagnoses which included malnutrition, anxiety, pain, hypertension (high blood pressure), muscle spasms / weakness, reflux, and chronic obstructive pulmonary disease. A record review of Resident #63 quarterly MDS, dated [DATE], revealed Resident #63 was a [AGE] year-old male admitted for long term care with supports for safe supervised smoking. Resident #63 was assessed with a BIMS score of 11 out of a possible 15 which indicated moderate cognitive impairment. A record review of Resident #63's physicians order, dated 5/14/2025, revealed the physician prescribed for Resident #63 to receive continuous oxygen therapy every shift every day and night. Record review of Resident #63's care plan, dated 8/30/2025, revealed he was an intermittent smoker (start date 5/14/2025) with a revision on 8/12/2025 indicating he was noncompliant with the smoking policy and smoking in his bathroom and was educated/acknowledged smoking agreement. A record review of the facility's event report, dated 8/12/2025, revealed at 4:00 PM the Social Worker and LVN A discovered Resident #63 in his bathroom smoking while receiving oxygen therapy via a nasal cannula and an oxygen concentrator. A record review of the facility's event report, dated 8/21/2025, revealed at an unknown time prior to 4:00 PM LVN A and CNA B discovered Resident #63 was in his bathroom smoking while receiving oxygen therapy via a nasal cannula and an oxygen concentrator. During an observation and interview on 8/28/2025 at 1:40 PM, revealed Resident #63 was in his room and was assisted to pack and gather his belongings to discharge to another facility. Resident #63 stated he was discharged related to his episodes of smoking in his room's bathroom. Resident #63 stated he did not participate in the supervised assigned smoke breaks due to his inability to participate in the smoke break without his oxygen therapy. Resident #63 stated he could not endure very long without his oxygen because of his COPD. During an interview on 8/28/2025 at 1:50 PM, LVN A stated she and the SW discovered Resident #63 smoking in his bathroom twice in August 2025. LVN A stated the ADON, the DON, and the Administrator were aware of Resident #63's smoking incidents. LVN A stated Resident #63's smoking had serious injury potential to include fires and/or burns. During an interview on 8/28/2025 at 4:10 PM, the ADON stated she was aware of Resident #63's smoking incidents while he was on oxygen therapy and had reviewed the incidents in the morning IDT meetings with the DON and the Administrator and could not recall anyone discussing a report to the state agency for the incidents. During an interview on 8/28/2025 at 5:00 PM, the Administrator stated she had received a report from nursing staff that Resident #9 and Resident #63 had a history of smoking unsupervised and at unassigned times. The Administrator stated LVN A and the SW reported that Resident #63 had been caught smoking in his bathroom on 8/12/2025 and again on 8/21/2025. The Administrator stated the facility could no longer meet Resident #63's and Resident #9's needs for safe smoking and non-compliant behavior and discharged the residents. The Administrator stated the IDT and herself had not considered the incidents as incidents which were reportable to the state agency and had not reported the incidents to the state agency. During an interview on 8/29/2025 at 4:40 PM, NP C stated he was the NP for the MD and was responsible for Resident #63's medical care. NP C stated Resident #63 had a need for oxygen therapy related to his poor gas exchange and should never be able to smoke while receiving oxygen therapy. NP C stated the practice was dangerous not only to Resident #63 but to the public to include a potential for fires and explosions. A record review of the facility's smoking policy dated 2017 revealed, It is the policy of this home that: All residents who smoke will be supervised. Smoking will be permitted in designated safe area(s) only. Oxygen equipment is not permitted in. the smoking area(s). The minimum safe distance for oxygen equipment from the smoking area is 50 feet. Residents not complying with the home's smoking policy may be discharged from the home.

Based on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 16 residents (Resident #91 and Resident #106) whose records were reviewed for quality of care. 1. Facility staff failed to identify, respond, and act upon Resident #91's critical lab, glucose (blood sugar) level of 40 received on 8/14/25. 2. Facility staff failed to follow Resident #106's transferring physicians orders for eye patch/assistance, monitoring for potential adverse reactions to medications, and his physician's prescribed lab orders. These deficient practices could affect any resident and could contribute to the decline of the resident's health statuses. The findings were: 1. Record review of Resident #91's face sheet, dated 8/28/25, revealed he was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood) without complications and Major depressive disorder, recurrent, mild ( pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #91's admission MDS assessment, dated 7/28/25, revealed his BIMS score was 13 of 15 reflective of minimal cognitive impairment, diagnosis of diabetes mellitus and it reflected he received insulin injections on a regular basis. Record review of Resident #91's Care Plan, dated 7/29/28, revealed it did not reflect that he had diabetes mellitus or that he was receiving insulin injections. Record review of Resident #91's physician orders for July and August 2025 revealed an order which reflected to call MD if his blood sugar level was under 70. Record review of Resident #91's lab report, dated 8/13/25, revealed LVN W received a call from the lab company at about 2:30 AM on 8/13/25. The lab results revealed a critical lab, glucose (blood sugar), level of 40. Record review of Resident #91's nursing progress note, dated 8/13/25, revealed the last entry was made at 10:00 which reflected he was on antibiotic treatment, Levaquin, for UTI. Record review of Resident #91's meal intake document for 8/13/25 revealed he ate 75% of his breakfast and 50% of his lunch and dinner. Further review revealed the document did not reflect whether or not he had a PM snack. Record review of a progress notes dated 8/14/25 revealed the only AM entry was at 0900. There were no other entries. Record review of Resident #91's monitoring flowsheet for August 2025 revealed an order, vital signs monitoring, Other test. Every shift 07/23/25 - Open Ended. Further review of the flowsheet revealed Resident #91's vital signs for the night shift on 8/13/25 were: temperature 97, pulse 88, respirations 18, blood pressure 140/70 and 02 saturation was 98. The monitoring flowsheet did not reflect a time the vitals were taken. Record review of Resident #91's Diabetic flowsheet from 8/1/25 to 8/31/25 revealed an order for Humalog U-100 Insulin (insulin lispro) solution; 100 unit/mL; 6 units, subcutaneous, Other Test: Before Meals administer 6 units before meals in addition to sliding scale for Type 2 diabetes mellitus without complications. The document reflected he received 3 doses per physician orders on 8/13/25. Further review revealed a sliding scale order for insulin lispro, insulin pen; 100 unit/mL If blood sugar is less than 70, call MD. If blood sugar is 71 to 150, give 0 units. The document reflected his blood sugar at 2100 (9:00 PM) was 117 and he did not receive Insulin lispro. Record review of the nursing facility staffing schedule for 8/13/25 revealed LVN W was scheduled to work from 7:00 PM to 7:00 AM. Observation and interview on 8/27/25 at 12:32 PM revealed Resident #91 lying in bed. He stated his left shoulder and hip hurt related to a fall he had prior to coming to the facility. Interview on 8/29/25 at 5:10 PM with Resident #91's NP C, revealed he did not receive a phone call during the early morning on 8/13/25 related to Resident #91's critical blood sugar level of 40. He stated to date, nursing staff had not called him about it. He stated he was familiar with LVN W and stated he checked his phone log and did not receive a call from the facility on 8/13/25. He stated he would have expected LVN W to call him and inform him of Resident #91's critical lab results (change of condition). NP C stated he would have asked LVN W to assess Resident #91, to take vitals and an Accu-Chek (check his blood sugar level). He stated he would have asked about Resident #91's blood sugar levels throughout the day and night on 8/13/25 up until LVN W received the call from the lab company. He would have asked about Resident #91's insulin administration for the same time frame. NP C stated this would provide him with the information he needed to provide a new order as necessary. Interview on 8/29/25 at 5:53 PM with LVN W revealed he stated he worked on 8/13/25 from 7:00 PM to 7:00 AM. LVN W stated he remembered Resident #91 and understood his condition was very complex. He stated he could not recall receiving a call from the lab company about a critical blood sugar level of 40. He stated in this situation he would be expected to complete an SBAR for a change in condition to include vital signs. He stated for a critical lab blood sugar level of 40 he would expect NP C to ask him for Resident #91's vitals, possibly ask for Accu-Chek to determine current blood sugar level, provide information about his blood sugar values throughout the day, meal intake and insulin received. LVN W further stated he would be expected to call the ADON, DON and Resident #91's responsible party. LVN W again stated he did not recall any events which occurred on 8/13/25 related to Resident #91's critical lab report. Observation and interview on 8/30/25 at 5:45 PM with the ADON revealed she could not remember receiving a call from LVN W regarding Resident #91's critical blood sugar level of 40, dated 8/13/25. She stated she did not remember the topic coming up during the morning meeting on 8/14/25 based on 24-hour report. Observation of the ADON revealed she reviewed Resident #91's lab report, dated 8/13/25 and nurse's progress notes dated 8/13/25 to 8/14/25. The ADON stated she became aware of the critical lab upon Surveyor intervention. The ADON stated LVN W should have called the NP, her, the DON, the RP and followed any new orders; completed an SBAR and progress note reflecting the critical lab, blood sugar level of 40. She stated she did not see any documentation that reflected LVN W took any action related to the critical lab value. The ADON stated it was important to take immediate action anytime there was a change in a resident's condition to ensure the resident received the necessary treatment. Otherwise, the resident could experience a decline in condition and even death. Interview on 8/30/25 at 6:05 PM with the DON revealed she was not aware that a critical lab, blood sugar level of 40 was received regarding Resident #91 until Surveyor intervention. The DON stated she expected a nurse to take immediate action when a resident had a changed of condition to include assessing the resident, calling the PCP/NP, the RP, her and the ADON and follow any new orders. She stated it was critical that a resident received the necessary care as needed so the resident did not have a decline in their health. Review of facility policy titled, Nursing Policy and Procedure, Change of Condition-Observing Reporting and Recording, dated 12/2017 read in relevant part: It is the policy of this home to inform the resident, the resident's physician and if indicated the residents responsible party of the following. 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental or psychosocial status, in life-threatening conditions or clinical complications. Procedure Observing, Reporting and Documenting a Change in Condition: 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline. 2. Do not leave the resident alone when a change in condition is identified until the licensed nurse has determined that the resident is not in danger in any way related to their medical or mental changes in condition. 3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible if the resident is stable (change inn condition is resolved such as a fall without injury or head trauma). 4. Complete an incident/accident report if indicated (fall, injury etc.). 5. Notify resident's responsible party. 6. If necessary, due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation. 2. A record review of Resident #106's admission record dated 8/1/2025 revealed Resident #106 was a [AGE] year-old male admitted for LTC with an admission date of 8/15/2025 and diagnoses which included legal blindness, generalized anxiety disorder, and seizures. A record review of Resident #106's transfer discharge report dated 8/15/2025 revealed Resident #106 was transferred to the facility from a previous SNF on 8/15/2025. Resident #106 was prescribed by the physician to receive: - yearly labs to include a lipid panel and a valproic acid lab. - adverse effects monitoring for: - antidepression medications. - antianxiety medications. - anticonvulsant medications. -assistance with wearing an eye patch to his left eye to strengthen his right eye. A record review of Resident #106's physicians orders dated 8/17/2025 revealed no orders for Resident #106's eye patch, medication monitoring for adverse effects, and or labs needed. During an interview on 8/27/2025 at 11:10 AM LVN MG stated Resident #106 had no orders for adverse drug reaction monitoring, no order for an eye patch, and no orders for labs. LVN MG stated she was the admitting nurse for Resident #106 when he transferred from the previous SNF and had reviewed his transfer documents to include previous orders and had failed to recognize the orders for Resident #106's eye patch, labs, or monitoring for adverse effects from hiss medications. LVN MG stated she had no recollection on how she failed to transcribe the orders and stated she would immediately assess Resident #106 and report to the physician and recommend labs, monitoring, and an eye patch. LVN MG stated her supervisor was the ADON and the DON. During an interview on 8/27/2025 at 11:50 AM the ADON stated Resident #106 did not have any orders for labs, monitoring for adverse effects of medications, and no eye patch. The ADON stated the expectation for admission nurses was a thorough and complete review of the admission records and transcription of all orders for transition of care. During an interview on 8/28/2025 at 1:09 PM Resident #106 stated he was transferred to this facility from a previous SNF, and he was legally blind but had partial sight to see shapes and some colors. Resident #106 stated he could see better out of one eye and had used an eye patch over one of his eyes in the past. Resident #106 stated he had not used an eyepatch while at this facility. During an interview on 8/30/2025 at 1:00 PM NP C stated he was the NP for Resident #106 and was unaware Resident #106 had a need for an eye patch, lab work, and or monitoring for adverse effects for medications he was receiving. NP C stated he would expect for the admission nurse to completely review and report to the physician all orders from the previous SNF for continuation of care. NP C stated a potential negative outcome could be delay of care. A quality-of-care policy was requested from the Administrator on 8/30/2025 at 7:52 PM to which the Administrator replied, the facility followed HHSC guidelines.

Based on observation, interview and record review the facility failed to promptly notify the ordering physician of laboratory results that fell outside of clinical reference ranges for 1 (Resident #91) of 16 residents whose medical records were reviewed for lab work. Facility staff failed to identify, respond, and act upon Resident #91's critical lab, glucose (blood sugar) level of 40 received on 8/14/25. This deficient practice could affect any resident and could contribute to the decline of the resident's health statuses. The findings were:Record review of Resident #91's face sheet, dated 8/28/25, revealed he was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood) without complications and Major depressive disorder, recurrent, mild ( pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #91's admission MDS assessment, dated 7/28/25, revealed his BIMS score was 13 of 15 reflective of minimal cognitive impairment, diagnosis of diabetes mellitus and it reflected he received insulin injections on a regular basis. Record review of Resident #91's Care Plan, dated 7/29/28, revealed it did not reflect that he had diabetes mellitus or that he was receiving insulin injections. Record review of Resident #91's physician orders for July and August 2025 revealed an order which reflected to call MD if his blood sugar level was under 70. Record review of Resident #91's lab report, dated 8/13/25, revealed LVN W received a call from the lab company at about 2:30 AM on 8/13/25. The lab results revealed a critical lab, glucose (blood sugar), level of 40. Record review of Resident #91's nursing progress note, dated 8/13/25, revealed the last entry was made at 10:00 which reflected he was on antibiotic treatment, Levaquin, for UTI. Record review of Resident #91's meal intake document for 8/13/25 revealed he ate 75% of his breakfast and 50% of his lunch and dinner. Further review revealed the document did not reflect whether or not he had a PM snack. Record review of a progress notes dated 8/14/25 revealed the only AM entry was at 0900. There were no other entries. Record review of Resident #91's monitoring flowsheet for August 2025 revealed an order, vital signs monitoring, Other test. Every shift 07/23/25 - Open Ended. Further review of the flowsheet revealed Resident #91's vital signs for the night shift on 8/13/25 were: temperature 97, pulse 88, respirations 18, blood pressure 140/70 and 02 saturation was 98. The monitoring flowsheet did not reflect a time the vitals were taken. Record review of Resident #91's Diabetic flowsheet from 8/1/25 to 8/31/25 revealed an order for Humalog U-100 Insulin (insulin lispro) solution; 100 unit/mL; 6 units, subcutaneous, Other Test: Before Meals administer 6 units before meals in addition to sliding scale for Type 2 diabetes mellitus without complications. The document reflected he received 3 doses per physician orders on 8/13/25. Further review revealed a sliding scale order for insulin lispro, insulin pen; 100 unit/mL If blood sugar is less than 70, call MD. If blood sugar is 71 to 150, give 0 units. The document reflected his blood sugar at 2100 (9:00 PM) was 117 and he did not receive Insulin lispro. Record review of the nursing facility staffing schedule for 8/13/25 revealed LVN W was scheduled to work from 7:00 PM to 7:00 AM. Observation and interview on 8/27/25 at 12:32 PM revealed Resident #91 lying in bed. He stated his left shoulder and hip hurt related to a fall he had prior to coming to the facility. Interview on 8/29/25 at 5:10 PM with Resident #91's NP C, revealed he did not receive a phone call during the early morning on 8/13/25 related to Resident #91's critical blood sugar level of 40. He stated to date, nursing staff had not called him about it. He stated he was familiar with LVN W and stated he checked his phone log and did not receive a call from the facility on 8/13/25. He stated he would have expected LVN W to call him and inform him of Resident #91's critical lab results (change of condition). NP C stated he would have asked LVN W to assess Resident #91, to take vitals and an Accu-Chek (check his blood sugar level). He stated he would have asked about Resident #91's blood sugar levels throughout the day and night on 8/13/25 up until LVN W received the call from the lab company. He would have asked about Resident #91's insulin administration for the same time frame. NP C stated this would provide him with the information he needed to provide a new order as necessary. Interview on 8/29/25 at 5:53 PM with LVN W revealed he stated he worked on 8/13/25 from 7:00 PM to 7:00 AM. LVN W stated he remembered Resident #91 and understood his condition was very complex. He stated he could not recall receiving a call from the lab company about a critical blood sugar level of 40. He stated in this situation he would be expected to complete an SBAR for a change in condition to include vital signs. He stated for a critical lab blood sugar level of 40 he would expect NP C to ask him for Resident #91's vitals, possibly ask for Accu-Chek to determine current blood sugar level, provide information about his blood sugar values throughout the day, meal intake and insulin received. LVN W further stated he would be expected to call the ADON, DON and Resident #91's responsible party. LVN W again stated he did not recall any events which occurred on 8/13/25 related to Resident #91's critical lab report. Observation and interview on 8/30/25 at 5:45 PM with the ADON revealed she could not remember receiving a call from LVN W regarding Resident #91's critical blood sugar level of 40, dated 8/13/25. She stated she did not remember the topic coming up during the morning meeting on 8/14/25 based on 24-hour report. Observation of the ADON revealed she reviewed Resident #91's lab report, dated 8/13/25 and nurse's progress notes dated 8/13/25 to 8/14/25. The ADON stated she became aware of the critical lab upon Surveyor intervention. The ADON stated LVN W should have called the NP, her, the DON, the RP and followed any new orders; completed an SBAR and progress note reflecting the critical lab, blood sugar level of 40. She stated she did not see any documentation that reflected LVN W took any action related to the critical lab value. The ADON stated it was important to take immediate action anytime there was a change in a resident's condition to ensure the resident received the necessary treatment. Otherwise, the resident could experience a decline in condition and even death. Interview on 8/30/25 at 6:05 PM with the DON revealed she was not aware that a critical lab, blood sugar level of 40 was received regarding Resident #91 until Surveyor intervention. The DON stated she expected a nurse to take immediate action when a resident had a changed of condition to include assessing the resident, calling the PCP/NP, the RP, her and the ADON and follow any new orders. She stated it was critical that a resident received the necessary care as needed so the resident did not have a decline in their health. Review of facility policy titled, Nursing Policy and Procedure, Change of Condition-Observing Reporting and Recording, dated 12/2017 read in relevant part: It is the policy of this home to inform the resident, the resident's physician and if indicated the residents responsible party of the following. 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental or psychosocial status, in life-threatening conditions or clinical complications. Procedure Observing, Reporting and Documenting a Change in Condition: 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline. 2. Do not leave the resident alone when a change in condition is identified until the licensed nurse has determined that the resident is not in danger in any way related to their medical or mental changes in condition. 3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible if the resident is stable (change inn condition is resolved such as a fall without injury or head trauma). 4. Complete an incident/accident report if indicated (fall, injury etc.). 5. Notify resident's responsible party. 6. If necessary, due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation.

Based on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for disposal of garbage. The facility's dumpster presented with 1 30-gallon bag of trash besides the garbage dumpster and scattered garbage surrounding the dumpster area. This failure could place residents at risk for reduced health status and degraded morale. The findings included: During an observation on 8/28/2025 at 10:13 AM revealed the facility's dumpster concrete pad had a large steel dumpster with the sliding doors opened. Further observation revealed a 30-gallon plastic bag filled with garbage on the concrete besides the dumpster. Further review revealed scattered trash surrounding the dumpster. During an interview on 8/28/2025 at 10:22 AM the HK manager stated the dumpster was utilized by the dietary staff, nursing staff, and the housekeeping staff. The HK manager stated the expectation for the staff was for all trash to be placed in the dumpster and for the dumpster doors to be closed when not in use. The HK manager stated the surrounding area should be cleaned to have all the trash placed in the dumpster. The HK manager stated the potential risk for residents could be reduced morale. A trash dumpster policy was requested from the Administrator on 8/30/2025 at 7:52 PM to which the Administrator replied, the facility followed HHSC guidelines.

Based on interview and record review the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status (that is, a deterioration in health status, (status in either life-threatening conditions or clinical complications) for 1 of 6 Residents (Resident #91) whose records were reviewed. LVN W failed to notify Resident #91's physician on 8/14/25 when he received a critical lab reflecting Resident #91's blood sugar was 40. This deficient practice could place residents at risk for a delay in treatment and a decline in the resident's physical condition. The findings were:Review of Resident #91's face sheet, dated 8/28/25, revealed he was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood) without complications and Major depressive disorder, recurrent, mild (pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Review of Resident #91's admission MDS assessment, dated 7/28/25, revealed his BIMS score was 13 of 15 reflective of minimal cognitive impairment, diagnosis of diabetes mellitus and it reflected he received insulin injections on a regular basis. Review of Resident #91's Care Plan, dated 7/29/28, revealed it did not reflect that he had diabetes mellitus or that he received insulin injections. Review of the nursing facility staffing schedule for 8/13/25 revealed LVN W was scheduled to work from 7:00 PM to 7:00 AM. Review of Resident #91's lab report, dated 8/13/25, revealed LVN W received a call from the lab company at about 2:30 AM on 8/13/25. The lab results revealed a critical lab, glucose (blood sugar), level of 40. Review of Resident #91's nursing progress note, dated 8/13/25, revealed the last entry was made at 10:00 which reflected he was on antibiotic treatment, Levaquin, for UTI. Review of a progress note dated 8/14/25 revealed the first entry was at 0900 AM and it reflected Resident #91 continued on antibiotic treatment, Levaquin, for diagnosis of UTI. Further review revealed there were no progress notes entered between 8/13/25 at 2:30 AM and 8/14/25 at 10:00. Interview on 8/29/25 at 5:10 PM with Resident #91's NP C, stated he did not receive a phone call from the facility during the early morning of 8/13/25. He stated he was familiar with LVN W and stated he checked his phone log and did not receive a call from LVN W. NP C stated he would have expected LVN W to call him and inform him of Resident #91's critical lab results (change of condition). NP C stated he would have expected LVN W to have assessed Resident #91 and to do an Accu-Chek (check his blood sugar level) and provide him with a report. He stated he would have asked about Resident #91's blood sugar levels throughout the day and night on 8/13/25 up until LVN W received the call from the lab company. He stated he would have asked about Resident #91's insulin administration for the same time frame. NP C stated this would provide him with the information needed to provide a new order as necessary. Interview on 8/29/25 at 5:53 PM with LVN W stated he worked on 8/13/25 from 7:00 PM to 7:00 AM. LVN W stated he remembered Resident #91 but could not recall receiving a call from the lab company about a critical blood sugar level of 40. He stated he was expected to complete an SBAR anytime there was a change in a resident's condition. He stated for a critical lab, blood sugar level of 40 he would be expected to call the NP, to assess the resident, possibly check his blood sugar level, provide the NP with the resident's blood sugar values throughout the day, meal intake and insulin received. LVN W further stated he was also required to call the ADON or DON and Resident #91's responsible party. LVN W again stated he did not recall any events which occurred on 8/13/25 related to Resident #91. Interview on 8/30/25 at 5:45 PM with the ADON revealed she could not remember receiving a call from LVN W regarding Resident #91's critical lab related to his blood sugar level of 40, dated 8/13/25. She stated she did not remember the topic coming up during the morning meeting on 8/14/25. The ADON reviewed Resident #91's lab report, dated 8/13/25 and nurse's progress notes dated 8/13/25 to 8/14/25. The ADON stated LVN W should have called the NP, her, the DON, the RP and followed any new orders; completed an SBAR and progress note reflecting the critical lab, blood sugar level of 40. The ADON stated it was important to immediately take action anytime there was a change in a resident's condition to ensure the resident received the necessary treatment, otherwise, the resident could experience a decline in condition. The ADON stated she did not see any evidence to reflect LVN W took any action related to Resident #91. Interview on 8/30/25 at 6:05 PM with the DON revealed she was not aware that a critical lab, blood sugar level of 40 was received regarding Resident #91. The DON stated she expected a nurse to take immediate action when a resident had a change of condition to include assessing the resident, calling the PCP/NP, the RP, her and or the ADON and follow any new orders. She stated it was critical that a resident received the necessary care as needed so the resident did not have a decline in their health. Review of facility policy titled, Nursing Policy and Procedure, Change of Condition-Observing Reporting and Recording, dated 12/2017 read in relevant part: It is the policy of this home to inform the resident, the resident's physician and if indicated the residents responsible party of the following. 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental or psychosocial status, in life-threatening conditions or clinical complications. Procedure Observing, Reporting and Documenting a Change in Condition: 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline. 2. Do not leave the resident alone when a change in condition is identified until the licensed nurse has determined that the resident is not in danger in any way related to their medical or mental changes in condition. 3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible if the resident is stable (change inn condition is resolved such as a fall without injury or head trauma). 4. Complete an incident/accident report if indicated (fall, injury etc.). 5. Notify resident's responsible party. 6. If necessary, due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation.

Based on observation, interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 6 Residents (Resident #76) whose MDS records were reviewed.MDS Coordinator/LVN T failed to include in Resident #76's MDS assessment that she had lost weight in the last 6 months. This deficient practice could place residents at risk of not receiving the care and services as needed.The findings were:Record review of Resident #76's face sheet, dated 8/30/25, revealed she was admitted to the facility on [DATE] with diagnoses including muscle weakness (generalized), unsteadiness on feet and other lack of coordination. Record review of Resident #76's quarterly MDS, dated [DATE], revealed her BIMS score was 12 of 15 reflective of moderate cognitive impairment and she was dependent on staff for all ADL's. Further review revealed it did not reflect she had lost weight during July 2025. Record review of Resident #76's Care Plan, dated 7/16/25, revealed she had a significant unplanned/unexpected weight loss due to poor food intake. Observation and interview on 08/26/25 at 12:34 PM revealed Resident #76 eating her lunch meal. She stated she did not like the food and had a family member bring her take out. Interview on 08/30/2025 at 4:40 PM the MDS Coordinator/LVN T stated it was important that Resident #76's MDS assessment accurately reflect her status, so everyone was on the same page in regard to identified problems, goals and approaches to help Resident #76 manage her weight loss. LVN T stated otherwise staff would not know what interventions to implement. She stated as a result Resident #76 could lose more weight. Further interview with LVN T revealed she used the RAI as a policy for completing MDS assessments.

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 resident that meet professional standards of quality care within 48 hours of a resident's admission and failed to include the minimum healthcare information necessary to properly care for a resident including, but not limited to, initial goals based on admission and physician orders for 1 of 6 residents (Resident #104), reviewed for comprehensive resident centered care plans. Resident #104's baseline care plan dated 8/23/25 did not include her diagnoses, contact isolation for MRSA (Methicillin-resistant Staphylococcus Aureus bacteria) to her wound, and did not have interventions and goals for 5 of 5 days during the survey period. This failure could place residents at risk of not receiving their individualized needed care and services.The findings were: Record review of the facility documentation for Resident #104 revealed there was no face sheet for Resident #104. Record review of Resident #104's admission assessment dated [DATE] revealed the resident was a female admitted by ambulance on a stretcher on 8/22/25 at 11:53 p.m. and had only 1 diagnosis listed osteomyelitis (inflammation of the bone caused by an infection, which may spread to the bone marrow and tissues near the bone). The resident had a right above knee amputation with 29 staples, a sacral wound, and a left lower extremity wound, and the resident had an indwelling foley catheter. Record review of Resident #104's information in IQIES on 8/27/25 and 9/3/25 at 8:50 a.m., revealed no information found for the resident's MDS assessment due to being a new admission. Record review of Resident #104's admission care plan, dated 8/23/25, was a paper with check boxes next to different body systems and revealed the resident was [AGE] years old, and under bladder control the box was checked for incontinent and catheter was not checked. Under special problems affecting ADL decubitus(skin breakdown that occurs when prolonged pressure on the same area of the body cuts off blood flow and oxygen to the tissues)/stasis ulcers (open sore that develops on the lower legs due to poor blood circulation) was checked and handwritten next to it was sacral (anatomical region of the body located at the base of the spine, just above the buttocks)/LLE (Left Lower Extremity), and amputations was checked and handwritten next to it was July 2025. Under rehabilitation measures/programs the box intake/output was checked, and output was circled, wound dressing was checked, and decubitus/stasis ulcers was checked. All lines next to the boxes with check marks under this rehabilitation measures/programs section were blank. There was a second page to the admission care plan that had 3 columns and was blank. Record review of Resident #104's weekly skin assessment dated [DATE], and handwritten next to the date was on admission revealed under skin findings was 27 staples to R BKA (Right Below knee Amputation), left heel pressure and pressure had been marked through and written arterial- eschar (thick, black, dead tissue), left anterior foot arterial eschar, stage 4 to sacrum/coccyx pressure, and stage 3 to right buttock. The skin assessment continued with wound measurements and boxes checked for vitamin C, protein supplement, multivitamin, zinc, pillows to float heels, and an air mattress with the physician being notified on 8/23/25 at 8:00 a.m. The skin assessment is signed 8/26/25 at 10:00 a.m. and unable to make out the signature. Review of Resident #104's physician telephone orders revealed orders dated 8/23/25 at 8:00 a.m. for catheter care every shift and as needed, 16 FR 10cc foley change as needed, ensure foley was secured with anchor and draining below bladder, and contact precautions, and wound dressing orders for left heel, sacral wound, left anterior ankle, and right buttock and skin assessments weekly on Saturday night shift. Record review of Resident #104's hospital discharge paperwork dated 8/19/25 to 8/22/25 revealed the resident had bilateral heel osteomyelitis, constipation, MRSA to sacral wound, Right AKA on 7/21/25, and diabetes mellitus (a disease of inadequate control of blood levels of glucose), and was bed bound (confined to bed). Record review of Resident #104's history and physical, dated 8/25/25, revealed the resident's past medical history included stroke with residual right sided deficit (refers to damage to tissues in the brain due to a loss of oxygen to the area resulting in weakness and loss of strength on one side of the body), bed bound status (confined to her bed), bowel and bladder incontinence, history of pulmonary embolism (occurs when a blood clot travels to the lungs and blocks one or more pulmonary arteries), asthma (a chronic respiratory condition that causes inflammation and narrowing of the airways, leading to symptoms such as wheezing, shortness of breath, and chest tightness), Type 2 diabetes mellitus (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), hyperlipidemia (high levels of lipids (fats) in the blood, including cholesterol and triglycerides), sacral pressure ulcer, acute respiratory failure (life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide), pneumonia (infection of one or both of the lungs caused by bacteria, viruses, or fungi), and anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). Record review of Resident #104's history and physical, dated 8/25/25, revealed under assessment and plan was documented continue to monitor respiratory status, maintain adequate oxygenation, pulmonary rehabilitation as tolerated, continue physical therapy for strengthening and mobility, occupational therapy for ADL training, monitor surgical site for proper healing, pain management as needed, continue appropriate antibiotic therapy, monitor for signs of infection progression, wound care as directed, specialized wound care per protocol, regular repositioning to prevent further pressure injury, nutritional support to promote wound healing, monitor for signs of infection, monitor hemoglobin and hematocrit levels, nutritional support with iron rich diet, neurological monitoring, continue insulin sliding scale, diabetic diet, regular glucose monitoring, continue medication for hyperlipidemia, monitor lipid levels periodically, monitor for signs and symptoms of DVT/PE (Deep Vein Thrombosis/Pulmonary Embolism), monitor for constipation and implement bowel regimen as needed. Record review of Resident 104's hospital transfer form and telephone orders, dated 8/22/25, revealed the resident was a full code. Record review of Resident 104's baseline care plan, dated 8/23/25, did not include the resident's code status, diagnoses, MRSA of her wound, contact isolation, or urinary catheter. The baseline care plan did not include any goals or interventions. In an observation on 8/27/25 at 10:29 a.m., Resident #104 was sleeping in her bed, respirations were even and unlabored. There was a sign on the resident's door for contact isolation and to see the nurse for further instructions. A PPE cart was outside of the resident's room. In an observation on 8/28/25 at 10:00 a.m., wound care was completed as ordered for Resident #104 with no issues or concerns. The resident had a right AKA closed with staples that was free of redness, swelling, or drainage, and a urinary catheter with a privacy flap. In an observation and interviews on 8/27/25 at 4:45 p.m., LVN S stated she had made Resident #104's baseline care plan but was unable to locate it. LVN S logged in to their old computer program for medical records and the resident's information was not located. LVN S stated the MDS nurse had all other care plans on a jump drive and when she left for the day she left it with the nursing staff. LVN S escorted me to the MDS office and MDS T stated Resident #104 was a new admission so the resident's information would be with the ADON or DON. LVN S escorted me to that office and the ADON stated being the resident #104 was a new admission, medical records had the resident's information and care plan. The MR V was in her office and stated she had scanned over 128 resident medical records by resident but had not finished going through them all and renaming them for each resident as they were scanned in with generic file names and she would have to open each one to find it. MR V stated she was unable to supply the medical record papers that were scanned at this time. In an observation and interview on 8/28/25 at 10:30 a.m., Resident #104 was alert and oriented to person, and place initially but had some confusion. The resident stated she was doing okay and had pain but stated she was able to tolerate the wound care due to the staff pre-medicating her. The resident stated the staff at the facility provided wound and catheter care, pain management, and stated the staff fed her all her meals as she cannot do it for herself. The resident stated her goal was to go home. In an interview on 8/30/25 at 1:07 p.m., the DON stated she was responsible for baseline care plans, but that Resident #104 had been admitted to the facility late on a Friday night, so the nurse had made the baseline care plan. The DON stated it was important for the baseline care plan to be completed so that nursing staff would know how to care for the resident. The DON stated the baseline care plan had been completed for Resident #104. In an interview on 8/30/25 at 4:45 p.m., with the DON and the ADON, they both stated the facility did not have a baseline care plan policy and they followed the RAI manual.

Based on observation, interview and record review the facility failed to develop a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 6 Residents (Resident #76 and Resident #91) reviewed for care plans . The facility failed to include in Resident #76's comprehensive care plan that she had a self-performance deficit, and she was dependent on staff for all activities of daily living.The facility failed to include in Resident #91's comprehensive care plan that he had diabetes mellitus and received insulin on a regular basis. This deficient practice could place residents at risk of not receiving the care and services as needed. The findings were: 1. Record review of Resident #76's face sheet, dated 8/30/25, revealed she was admitted to the facility on [DATE] with diagnoses including muscle weakness (generalized), unsteadiness on feet and other lack of coordination. Record review of Resident #76's MDS, dated [DATE], revealed Resident #76's BIMS score was 12 of 15 reflective of moderate cognitive impairment and she was dependent on staff for all ADL's. Record review of Resident #76's Care Plan, dated 7/16/25, revealed it did not reflect that Resident #76 had a self-care performance deficit and was dependent on staff for all ADLs. Observation and interview on 08/26/25 at 12:34 PM revealed Resident #76 was sitting in a wheelchair eating her lunch meal. Resident #76 stated staff assisted her with ADLs. Interview on 08/30/2025 at 4:40 PM the MDS Coordinator/LVN T revealed Resident #76's Care Plan did not include Resident #76 was dependent on staff for all ADLs. She stated it was important that her ADL dependency was included so that all staff knew what they needed to do for the Resident and so everyone was on the same page in regard to the problem areas and approaches. LVN T stated the information was necessary so Resident #76 received the care and services as needed. 2. Review of Resident #91's face sheet, dated 8/28/25, revealed he was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood) without complications and Major depressive disorder, recurrent, mild ( pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Review of Resident #91's admission MDS assessment, dated 7/28/25, revealed his BIMS score was 13 of 15 reflective of minimal cognitive impairment, diagnosis of diabetes mellitus and it reflected he received insulin injections on a regular basis. Review of Resident #91's Diabetic flowsheet from 8/1/25 to 8/31/25 revealed an order for Humalog U-100 Insulin (insulin lispro) solution; 100 unit/mL;6 units, subcutaneous, Other Test: Before Meals administer 6 units before meals in addition to sliding scale for Type 2 diabetes mellitus without complications. Further review revealed a sliding scale order for insulin lispro, insulin pen; 100 unit/mL Review of Resident #91's Care Plan, dated 7/29/28, revealed it did not reflect that he had diabetes mellitus or that he was receiving insulin injections. Interview on 08/30/2025 at 4:40 PM with MDS Coordinator/LVN T revealed Resident #91's Care Plan did not include that Resident #91 had a diagnosis of diabetes mellitus and that he received insulin. She stated it was important that a resident's CP included all problem areas so all staff were on the same page and could identify the problem areas, goals and approaches when addressing the area of concern. LVN T stated the CP was a communication tool and the information was necessary so Resident #91 received the care and services as needed. Review of the facility's policy, titled, Care Plan - Resident, dated 12/2017, read in relevant part It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident. Procedure 1. Long-Term Goal a. Must be measurable and must related to the discharge objective (goal). Example: long-term goal - independent ambulation; discharge plan goal - return to home. b. Must be time limited. List a target date for the resident to achieve the long-term goal. [Review in ____ weeks/months] is not recommended since sometimes the date the goal was established is not clear. 4. Concerns and Problems a. Review CAA [Care Area Assessment] triggers on the MDS. If the interdisciplinary Team [IDCPT] decides to proceed with care planning, list the problem.

Based on observation, interview and record review the facility failed ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 6 Residents (Resident #54) whose records were reviewed. Nursing staff failed to apply a splint on Resident #54's right arm/wrist as tolerated for a right-hand contracture for 5 days, during the survey process. This deficient practice could affect residents with range of motion deficits and could contribute and result in a resident's decrease in their range of motion. The findings were: Review of Resident #54's face sheet, dated 8/30/25, revealed she was admitted to the facility on [DATE] with diagnoses including Vascular dementia (describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), moderate, withoutbehavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Muscle wasting and atrophy (is the loss of muscle mass and strength; thinning or wasting of muscle tissue) not elsewhere classified, multiple sites. Review of Resident #54's quarterly MDS, dated [DATE], revealed her BIMS score was 4 of 15 reflective of severe cognitive impairment and she had a range of motion impairment on one side: upper and lower extremity. Upper extremity including (shoulder, elbow, wrist, hand). Review of Resident #54's Care Plan, dated 7/8/25, revealed Resident #54 had polyneuropathy and is at risk for increased pain, contractures, and skin breakdown. One of the approaches included RESIDENT MAY UTILIZE RIGHT HAND SPLINT AS TOLERATED TO ASSIST WITH DECREASING RISK OF PROGRESSION OF CONTRACTURE. Review of Resident #54's Occupational Therapy Plan of Care, dated 12/23/24, read Resident #54 was referred for therapy due to due to risk of decline without intermittent therapy. Without therapeutic intervention, patient is at risk for decline in range of motion. Underlying impairments. Range of motion RUE. Long term Goal(s) ROM The patient tolerates application of R RHS for 60 minutes in order to facilitate maximum ROM and joint alignment thus preventing deformity and pain. Goal 2/23/25. Review of Resident #54's progress notes for August 2025 did not reflect she had refused to have a splint applied to her right wrist/hand. Observation on 8/26/2025 at 12:27 PM revealed Resident #54 was sitting in a wheelchair in the dining room. She was being assisted with eating her lunch meal. Further observation revealed Resident #54 had a right-hand contracture and did not have hand rolls or a splint on. Observation and interview on 8/27/2025 at 11:17 AM revealed Resident #54 was sitting in a wheelchair by the dayroom. Attempted interview revealed Resident #54 did not engage in conversation. Further observation revealed Resident #54 had a right-hand contracture. Noted she did not have hand rolls or a splint on her arm/wrist. Observation and interview on 08/28/2025 at 5:32 PM revealed Resident #54 was sitting in a wheelchair by the dayroom. She did not have a hand roll or split applied on right arm/wrist. Observation and interview on 08/29/2025 at 5:05 PM CNA Y revealed she had worked at the NF for 2 years primarily from 6AM to 6PM. She stated she worked with Resident #54 on a regular basis, and she had never known Resident #54 to wear a splint on her right arm/wrist. She stated restorative CNA AA would help with splint application but again stated she had never seen Resident #54 wear a splint. Observation revealed CNA Y looking for a splint in Resident #54's closet and drawers. She stated she did not find one. Observation and interview on 08/29/2025 at 5:32 PM revealed Resident #54 was sitting in a wheelchair by the dayroom. She did not have a hand roll or splint applied on right arm/wrist. Resident #54 stated she was doing ok. Interview on 08/29/2025 at 5:40 PM with LVN Z revealed he had seen Resident #54 with a splint on her right hand/arm a couple of weeks ago. He stated she did not tolerate it for long. Interview on 08/30/2025 at 11:20 AM with the DON revealed Resident #54 refused to wear a splint since she started working at the facility about 2 months ago. She stated staff had tried to apply the splint and the Resident refused every time. The DON stated she had talked with Resident #54 who she stated was able to answer simple questions. She stated Resident #54 told her she did not want to wear a splint. Observation and interview on 8/30/2025 at 11: 24 AM revealed Resident #54 was sitting in a wheelchair by the dayroom. She was drinking a milk shake. Resident #54 was not wearing a splint on her arm/wrist. Surveyor asked her if she was willing to wear a splint on her right hand/wrist to help straighten it? Resident #54 nodded her head, yes. Observation revealed the DON had joined Surveyor and Resident #54. Surveyor asked Resident #54 if anyone had tried to put one on and she shook her head, no. Further observation revealed the DON asked Resident if she wanted her to put the splint on? Resident #54 nodded her head, yes. The DON commented, you've said no before, but I will put it on if you want me to. Resident #54 again nodded her head, yes. The DON left and returned. She stated she was looking for the splint, but she could not find it.Interview on 8/30/2025 at 11:35 AM with the DON stated Resident #54 had never agreed to wear the splint. She stated the splint would help with her contracture/joint alignment. If she did not wear it her contracture would probably get worse. Review of facility policy titled, Activities of Daily Living, dated 12/2017, read in relevant part It is the policy of this home to assure residents have their activities of daily living needs met. Equipment1. Appropriate clothing.2. Appropriate footwear.3. Appropriate assistive devices.4. Grooming supplies. Surveyor did not obtain any other policy pertaining to this regulation.

Based on observations and interviews the facility failed to ensure food was stored, prepared, distributed and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for expired foods. The facility stored 13, 46 ounce, containers of thickened orange juice which were expired by 17 days. This deficient practice could place residents at risk for food borne illnesses. The findings included:During an observation on 8/26/2025 at 9:15 AM revealed the facility's kitchen pantry stored 13 46 oz. containers of thickened orange with manufactures labeling which included, best if used by [DATE]. During an interview on 8/26/2025 at 9:18 AM [NAME] G stated the thickened orange juice was stored in the pantry and was available for residents. The cook stated all staff were responsible for reviewing foods for expiration dates. The cook reviewed the thickened orange juice and stated the juice was expired and should not be stored and available for service. During an interview on 8/28/2025 9:33 AM the FSM stated the thickened orange juice was ordered before he began his tenure, and [NAME] G was responsible for ensuring foods in the pantry were within the expiration dates and failed to do so. The FSM stated the potential adverse reaction could be poor quality juice and or food borne illness. A dietary safe food policy was requested from the Administrator on 8/30/2025 at 7:52 PM to which the Administrator replied, the facility followed HHSC guidelines.

Based on observations, interviews and record reviews, the facility failed to ensure provided food was prepared in the proper form to meet residents needs for 1 of 6 residents reviewed, (Resident #1), reviewed for food form. On 7/21/24 the facility failed to ensure Resident #1 was given the correct physician-ordered diet texture of a meal which led to choking. An IJ was identified on 07/22/24. The IJ template was provided to the facility on [DATE] at 7:07 pm. While the IJ was removed on 07/26/24 the facility remained out of compliance at a scope of isolated 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. This failure could place residents at risk of choking, decline in health and death. Findings include: Record review of Resident #1's Admission Record documented a [AGE] year-old female first admitted to facility on 09/26/06 with latest admission on 08/17/14. Resident #1's diagnoses included Alzheimer's Disease, aphasia following cerebral infarction, dysphagia following cerebral infarction, contracture of muscle, right lower leg, and Type 2 diabetes mellitus without complications. Record review of Resident #1's Physician's Orders dated 06/25/24 - 07/25/24 revealed she had an order for a regular diet with puree texture and nectar thickened liquids with meals. The orders also included snacks BID (pudding, yogurt, applesauce, or other pureed snack). Record review of Progress Note dated 07/21/24 revealed that Resident #1 was served a regular mech soft diet instead of pureed/nectar liquids, spoon fed by CNA 100%. Resident started vomiting, face flushed. Nurse on unit performed Heimlich maneuver, called ADON, DON, on call PA, and family member. PA ordered stat chest x-ray, monitor O2 frequently during night. X-ray ordered. Vital signs indicated that oxygen was 93% during the event and 98% about an hour later. Record review of Progress Note dated 07/22/24 at 4:48 pm revealed Resident awake and alert. Spoon fed pureed diet as ordered. No s/s of SOB, cough or congestion. X-ray results were negative for aspiration, no Cardio Pulmonary abnormalities. MD made aware. During an interview on 07/22/4 at 1:02 pm with CNA A, it was revealed that CNA B, an agency aide, was assigned to work Hall 300 after having been originally oriented to Halls 100 and 200 earlier in the day. CNA A went to the dining room to assist with the supper meal. When it was discovered that Resident #1 was not in the dining room, CNA A brought Resident #1's tray to the resident's room to give to CNA B. CNA B told CNA A that she had already fed Resident #1. CNA A then realized that CNA B had given Resident #1's roommate's tray to her which was mechanical soft. CNA A then noticed that Resident #1 had bubbles coming out of her mouth. CNA A told charge nurse LVN C who was in the dining room that Resident #1 was having trouble and LVN C told CNA A to get LVN D who was also on the hall as a Med Nurse. LVN D then went to the room and found Resident #1 to be red and choking and did the Heimlich maneuver. CNA A stated she went to get the crash cart and brought it to the room but it was not needed. CNA A stated that Resident #1's tray should have been on the hall tray cart since she normally eats in the dining room for breakfast and lunch and then goes back to bed. Resident #1's roommate, Resident #48, ate either in the dining room or in her room depending on whether or not her family was visiting. On this date, the family was in the dining room with Resident #48. Since her tray had gone to the hall, the dietary department just made her another plate. CNA A stated they try to tell the kitchen whether the residents will eat in the dining room or in their rooms so the trays can be placed on the correct cart. During an interview with LVN D on 07/22/24 at 1:40 pm, it was revealed that she was serving as a Medication Aide on 300 and 400 Halls. LVN D stated that CNA A came and told her that she was needed in Resident #1's room since it appeared she may be choking. LVN D stated, I saw that she was red so I did the Heimlich maneuver and did a finger sweep in her mouth and got some broccoli out. LVN D stated she then relieved LVN C so LVN C could call the doctor, get an order for an x-ray and call the family. LVN D stated that her color came back to normal and her vital signs were good. LVN D stated she was coughing a little. LVN D stated that Resident #1 sometimes eats in the dining room but if she has been up all day she will be put back to bed and eat in her room. LVN D stated that Resident #48 usually sleeps until 1:00 pm and then she usually eats in the dining room or may eat in her room if her family comes and wants to feed her there. LVN D stated that Resident #1 needed total assistance to eat since she was contracted on her right side. LVN D stated she had never seen the agency CNA B in the facility before. LVN D stated that CNAs usually do a walk around to orient agency aides. She said that CNA B left right after this incident since it was at the end of the shift. During a telephone interview with CNA B on 07/22/24 at 2:00 pm, she stated that the nurse checked the trays and told her that they were all correct and to hand them out. She said she did not get any orientation on the residents on that hall since she had originally been placed on the other side of the facility. CNA B also stated she had never worked in the facility before so did not know any of the residents. CNA B stated she just looked at the room number and did not know which was the A bed or B bed. Since Resident #1 was in the room, she fed her the tray with that room number on it. CNA B also said she fed most of the tray which consisted of noodles and some other things but no vegetables. During the interview with LVN C on 07/24/24 at 3:20 pm, she explained the sequence of events for the incident with Resident #1. LVN C stated the hall trays came to the unit and I checked all the trays. The agency CNA B came out of a room and I told her I was going to the dining room. In the dining room, I saw that Resident #48's tray didn't come out on the dining room cart so I asked CNA A to go get her tray from the cart on the hall. Resident #48's family brought her to the dining room. LVN C then stated that she didn't know if Resident #48's family was going to feed her in the dining room or in her room prior to her going to the dining room. Resident #1's tray was on the dining room cart. LVN C stated that when CNA A returned to the dining room CNA A told her about the mixed-up trays so they ordered another tray for Resident #48. LVN C stated that is also when CNA A told her about Resident #1 getting the wrong tray and having issues. LVN C told CNA A to go get LVN D to either assist Resident #1 or come to the dining room so she could go and assist Resident #1. LVN C stated that LVN D took care of the situation with Resident #1 and when she was finished in the dining room she called the doctor and the family. LVN C stated she took Resident #1's vital signs and the oxygen came back up to 95% and by the time she left around 7:00 pm the oxygen level was at 98% and resident was back to normal. A review of the menu on 7/21/24 revealed turkey tetrazzini, broccoli florets, breadstick and mandarin oranges. Interview on 7/22/24 at 4:17 pm with the DON revealed an agency CNA passed the trays. CNA B got the A bed and B bed mixed up. Resident #1 did not get the correct diet and started choking. LVN D performed the Heimlich maneuver. The DON stated, When possible, the agency aides will not pass hall trays; they should be assigned to the dining room since facility nurses are always in the dining room. The DON stated, We are inservicing staff on this now. The DON further stated that after the incident with Resident #1, her oxygen level was 93% and that should have been fine. The DON also stated that Resident #1's x-ray was clear. Facility's policy titled Meal Service-Nursing Responsibilities, dated 12/2017, stated .Nursing Services associates will follow these guidelines regarding meal service: 1. Distribute food trays to residents in resident rooms, dining rooms, and ancillary dining rooms. 2. Trays will be passed in a timely manner. Food must remain covered while being distributed through the hallways and tray cards should remain with trays throughout meal service .14. A licensed member of the nursing staff must check meals trays for accuracy, and be present in the dining room during the entire meal service. The Administrator was notified of the IJ situation on 07/22/24 at 7:07 pm due to the above failures and a template was given. On 07/23/24 at 1:43 pm the POR was accepted. It was documented as follows: 7/22/2024 [Facility] Plan of Removal - F 805 Immediate Action Taken Resident Specific Resident # 1 will receive the appropriate physician ordered diet for all meals going forward. Resident # 1 has had a chest x ray. The results reveal no negative outcome to her lungs. Resident # 1's physician who is also the medical director has been notified both of the incident and the IJ status at the facility. System Changes Starting on 7/22/2024 at 11:20 am a facility audit took place to ensure that all residents requiring modified texture diets for meals will receive their meals in the appropriate texture. Starting on 7/22/2024 at 1:00 pm DON and the dietary consultant audited all residents who require their diet to be served in an altered texture for meals to ensure that their meal tickets reflect the residents individual needs regarding texture with food in accordance with physician's diet orders. * Starting on 7/22/2024 and ongoing there will be a 3 part system to ensure that all diets are served with the correct texture to include the following: * The dietary department designee will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate. * The nurse in the dining room will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate. * The nurse on the hall will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate. Starting on 7/22/2024 and ongoing the DON will monitor two meals daily x 5 days a week to ensure staff compliance with ensuring that all meals/trays have the appropriate texture that matches the meal ticket and the physician ordered diet. Starting on 7/22/2024 and ongoing residents meal texture statuses will be audited upon admission, change of condition, appropriate mds cycles and or anytime necessary. Starting on 7/22/2024 at 11:00 am the facility's mechanism for ensuring correct diet texture for the residents is that all trays will be compared to the actual plated meal for the resident by a licensed staff member prior to being served to the resident. The printed meal ticket will be compared to the tray/plate for accuracy. Education Starting on 7/22/2024 at 12:30 pm the Assistant Director of Nursing provided education to all staff regarding residents requiring specially textured meals to ensure those residents will receive the appropriately textured meal at all times. Staff on future shifts will be educated prior to taking the floor. This will be accomplished by having a designated staff member in the building for that purpose and with that specific assignment. Licensed staff will be assigned by the DON to ensure that all trays/plates are correct prior to being served to the residents. Diet orders will match correctly to what is being served to the residents. This assigned licensed staff member will ensure specifically that the texture of all resident meals matches the physician ordered diet. Starting on 7/22/2024 at 12:00 pm the Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding residents requiring specially textured diets for meals. Starting on 7/22/2024 at 12:00 pm the regional clinical consultant will be responsible for ensuring that staff receive the inservice/training regarding residents requiring specially textured food for meals. Starting on 7/22/2024 the residents dietary food texture status will be communicated to facility staff directly by the DON and ADON. This process will be accomplished through photo copy and or written communication. Starting on 7/22/2024 the DON or their designee will be responsible for ensuring that the residents who require specially textured diets receive their food with the appropriate texture according to the physician's ordered diet. Starting on 7/23/2024 at 9:00 am during the daily stand up process all recommendations and orders will be audited by the clinical team in consultation with the dietary supervisor to ensure compliance and follow up for all residents with orders and recommendations. The clinical consultant will review orders and recommendations daily x 4 weeks as a tool for oversight to ensure compliance. Starting on 7/22/24 at 11:00 am staff have bee re educated to identify the resident's diet by room number and bed designation of A or B. 100% Staff education compliance for those who may serve food to a resident will be completed by 3:00 pm 7/23/24. On 7/26/24 the surveyor confirmed the facility implemented their plan of removal (POR) sufficiently to remove the IJ by: During the interview on 07/24/24 at 3:20 pm, LVN C stated she was called for the inservice following the IJ. LVN C stated they are going to put A and B on the doors beside the residents' names and we are not going to let agency CNAs pass trays on the halls. Agency CNAs will only pass trays in the dining room. LVN C stated when she was in the dining room she would check each tray and give it to the aide to pass to the resident. LVN C also stated she helped feed residents in the dining room. Record review of the facility staff list indicated there were a total of 71 staff members and 5 contracted therapists who work full time in the facility. Record review in-service documentation dated 7/22/24 indicated 71 staff members and 5 contracted therapists had been inserviced either in person or by phone on the new procedures which included adding the letters A and B beside each resident name on the doors to indicate bed position in the room whereby the A bed was closest to the door and the B bed was closest to the window. The procedure also includes having only full time staff pass trays in the halls. Agency staff will pass trays in the dining room along with a full time nurse. No agency staff will pass trays without assistance from full time staff members. The charge nurse will check all trays to ensure the meal ticket matches the meal texture, specialized utensils, and liquid texture on the plate prior to its distribution to the resident. Record review of documentation dated 7/23/24 showing the DON had contacted the staffing agencies used by facility and had them place a copy of the inservice on their paperwork for agency staff who may come to work in the facility. Interviews beginning at 4:13 pm on 07/24/24 through 6:00 pm on 07/25/24 with 20 staff members and 1 contract therapist revealed their understanding of the new procedures which included adding the letters A and B beside each resident name on the doors to indicate bed position in the room whereby the A bed was closest to the door and the B bed was closest to the window. The procedure also included having only full time staff pass trays in the halls. Agency staff will only pass trays in the dining room along with a full time nurse. No agency staff will pass trays without assistance from full time staff members. The charge nurse will check all trays to ensure the meal ticket matches the meal texture, specialized utensils, and liquid texture on the plate prior to its distribution to the resident. Interviews with 3 dietary staff and 1 DM on 07/25/24 at 11:30 am, revealed their understanding of the above procedure. Additionally, the dietary staff had highlighted residents who had pureed diets on the meal ticket and had written the word Pureed in yellow highlighter. Observation of Resident #1 on 07/25/24 at 11:45 am revealed the resident was being fed a pureed diet with nectar thickened liquids according to meal ticket and physician orders. Record review of Resident #1's chest x-ray indicated no abnormalities. Record review review of documentation that medical director who was the attending physician for Resident #1 had been notified of the incident and IJ status. Record review and interview with DON and ADON on 07/25/24 at 2:00 pm, provided meal audit forms and identified room/bed changes. Interview with DON revealed she and the Dietary Consultant had audited residents who required altered texture for meals by comparing the facility EHR system with the dietary electronic system to ensure that all diet textures matched on 07/22/24 at 1:00 pm. Record review of dietary audits provided. Observation of meal tickets and interview with dietary staff on 07/25/24 at 11:30 am revealed that room numbers with A or B and pureed textures had been highlighted for all residents requiring specialized texture with the highlighted word Pureed on the ticket. Meal tickets also contained the resident's room number with bed designation of A or B. The Dietary Manager (DM) revealed they are doing this on all meal tickets going forward. Observed nurse in dining room on 07/25/24 at 12:10 pm checking meals coming from dietary to compare ticket with what is being served on plate. Observed nurse on hall checking trays and tickets on hall carts on 07/25/24 at 11:45 pm. Interview with DON on 07/25/24 at 10:00 am revealed she was monitoring the nurses for breakfast and lunch to ensure they are checking trays and ADON is monitoring nurses for supper meal. On weekends the charge nurse will monitor. Record review of audit sheets completed. Interview with DON on 07/25/24 at 10:00 am revealed the DON will monitor meals 2 meals per day 5 times per week. The DON reported that she will continue to monitor meals and once compliance was achieved over a 30 day period, they will do random checks twice a week. Observed the DON in dining room during lunch beginning at 12:15 pm on 07/22/24, 07/24/24, and 07/25/ 24. Interview with the DON on 07/25/24 at 10:00 am stated during their facility Clinical Meeting, dietary textures will be audited and monitored. Interview with the ADON on 07/25/24 at 10:00 am stated during the Care Plan meetings diet changes will be discussed and monitored. Interview with DON on 07/25/24 at 10:00 am, the DON stated mechanism to ensure correct diet texture was included in staff education. Observation of resident room doors on 07/25/24 at 9:00 am revealed A and B had been added to the end of each resident name to indicate their designated bed assignment. While the IJ was removed on 07/26/24 the facility remained out of compliance at a scope of isolated 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.

Based on observation, interview and record review the facility failed to implement written policies and procedures that would prohibit and prevent neglect of residents for 1 of 4 residents (#1) whose records were reviewed for abuse/neglect. The SW did not follow up with the status of having a guardian assigned to Resident #1 after 2 months of submitting the guardianship application. This resulted in a delay of treatment for [REDACTED]. The fracture caused the resident prolonged pain and it affected her ability to use her left arm. This deficient practice could affect 4 residents who the facility determined to be cognitively impaired and who did not have a guardian and it could lead to a delay in critical treatment. The findings were: Review of Resident #1's medical face sheet, dated 5/25/17 revealed she was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed there were no identified family members or friends for Resident #1. Review of an application for a need for Guardian dated 6/28/17 revealed the SW was requesting the court to investigate the resident's circumstances due to her inability to make decisions regarding her care due to Dementia. Review of Resident #1's quarterly MDS dated [DATE] revealed her BIMS was 2, indicative of severe cognitive impairment. Further review revealed she required extensive to total care assistance with all ADL's by 1 or 2 persons; she had an extensive history of falls including a fall with a major injury. Review of Resident #1's care plan revised on 7/12/17 confirmed she had impaired cognitive function/dementia or impaired thought processes reason to short term memory loss. Further review revealed she was incapable of making an informed decision. One of the approaches was to notify the physician to assess capacity of the resident and certify capacity or incapacity. Review of a PT-Therapist Progress & DC Summary dated end of care 8/11/17 revealed that on 8/10/17 Resident #1 was able to propel in her wheelchair 100 feet using B UE and LE requiring stand by assistance. Analysis of Functional Outcome: Caregiver reports improved performance of transfers, prior to fall. Summary of skilled services provided since start of care in part included transfer and gait training; graded therapeutic exercise activities which improved patient's abilities. Further review read: Patient unable to progress towards goals at this time, as recent fx may restrict WB status on said extremity. Review of an incident report dated 8/11/17 at 9:57 p.m. revealed res found prone on floor; pt pull up and clothes on floor, rt forearm caught in SR; urinated all over herself bed and floor. Assisted to sitting position on the floor. Review of nurses note dated 8/11/17 at 10:00 p.m. revealed Resident #1 was found on the floor in prone position. Pt right forearm was caught in between side rails. Pt c/o left shoulder pain. Pt unable to move left arm. Left shoulder swollen, no redness noted to left shoulder at this time. Review of a nurses note dated 8/12/17 at 2:00 a.m. revealed c/o pain to left shoulder. Medicated for pain with little effect Further review revealed x-rays confirmed Resident #1 had a fracture to the left humerus (shoulder). Notified on-call physician's office. Review of a nurse's note dated 8/12/17 at 2:30 a.m. revealed received new orders, send resident to the hospital for evaluation and treatment of [REDACTED]. Review of admission hospital documentation dated 8/12/17 revealed x-ray results confirmed a markedly displaced humeral neck fracture; displaced 100% or more, surgical neck fracture, Left humerus. Review of systems revealed pain to the left upper extremity. Assessment and Plan read: left humeral fracture, traumatic. She is to undergo open reduction and internal fixation by an orthopedic surgeon. Further review of post left arm fracture revealed Resident #1 did not receive surgery yesterday as did not receive medical clearance by a second position; Hospitalist physician was asked but felt it was not an emergency and did not sign consent for humeral head repair. Presently appears comfortable except with movement. Review of post acute service hospital orders for Resident #1 dated 8/12/17 revealed consent needed for surgery, needs family consent or surrogate decision-maker. Review of the hospital nurse's note narrative for Resident #1 dated 8/13/17 revealed 2 physician signatures need to be obtained in order for resident to have surgery. Pt. has Dementia and is unable to sign for self and pt has no family. Further review revealed the attending physician requested assistance with contacting family for surgical consent. Review of Physical Therapy Plan of Care dated from 8/11/17 to 8/14/17 revealed Resident #1 was referred for skilled PT services after recent hospitalization in relation to treatment for [REDACTED]. Patient presents with multisystem impairments including 1) decreased bilateral LE muscle power and recruitment, 2) impaired coordination, 3) impaired balance reaction speed and accuracy, 4) impaired postural alignment and control, and 5) impaired gait mechanics which are contributory to decline. It was noted that resident had therapy in the past prior to this severe decline and regained ambulatory status. Review of Resident #1's Consolidated Physician order [REDACTED]. Review of Resident #1's MAR for (MONTH) (YEAR) revealed Resident #1 received [MEDICATION NAME] 325 mg tab daily from 8/14/17 to 8/24/17 except on 8/21/17 and on 8/22/17. Further review revealed there was no documentation to determine whether the medication was effective. Review of a T.O. dated 8/15/17 revealed an order for [REDACTED]. Review of Resident #1's MAR for (MONTH) (YEAR) revealed she received Tylenol #3 [MEDICATION NAME] from 8/17/17 to 8/24/17 except on 8/22/17. A note on the back of the MAR indicated [REDACTED]. There was no other documentation to indicate whether or not the medication was effective for the other dates it was given. Review of nurse's notes dated 8/16/17 and 8/17/17 revealed Resident #1 complained of pain 10/10 to left arm still awaiting order for Tylenol #3 [MEDICATION NAME]. Further review revealed the resident had bruising around her left shoulder. Review of nurse's note dated 8/18/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 [MEDICATION NAME] given 0 a,r (apparent relief) noted. Further review revealed the resident returned from orthopedic appointment unable to to complete evaluation and treatment to left humerus fracture d/t mental status; no other responsible party available DON notified, resident is her own responsible party. Review of nurse's note dated 8/19/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 [MEDICATION NAME] given 0 a,r (apparent relief) noted. Review of nurse's note dated 8/20/17 revealed Resident #1 complained of pain 9/10 to left arm, Tylenol #3 [MEDICATION NAME] given. No indication whether the medication was effective. Review of nurse's note dated 8/23/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 [MEDICATION NAME] given. No indication whether the medication was effective. Review of nurse's note dated 8/24/17 revealed Resident #1 complained of pain 8/10 to left arm, Tylenol #3 [MEDICATION NAME] given 0 a,r (apparent relief) noted. Observation on 8/24/17 at 12:52 p.m. revealed Resident #1 was sitting up in bed eating lunch using her right arm and hand; she kept her left arm by her side. Resident #1 did not attempt to use her left arm. Her left arm was swollen and she had visible purple bruising to the upper left extremity around the shoulder. Resident #1 stated me duele mucho, it hurts a lot. Interview on 8/24/17 at 2:32 p.m. with the Admissions Coordinator revealed that as the previous risk manager she knew of Resident #1's history of falls including falls with major injury. The Admissions Coordinator stated she knew the resident had severe cognitive impairment; was not able to make decisions regarding her care and did not have a RP. She stated the SW had filed guardianship paperwork regarding Resident #1. Interview on 8/24/17 at 2:40 p.m. with the SW confirmed she filed a Guardianship request with the court on 6/28/17, but stated she had not called to inquire about the status. The SW stated she would call today. Interview on 8/24/17 at 2:45 p.m. with the DON revealed he was not familiar with all of the details regarding Resident #1's circumstances. The DON stated he knew the SW filed guardianship paperwork, but was not aware there had not been any follow up. He stated hospital staff was trying to get two doctor's to sign a form to approve surgery. The DON stated the resident returned from the hospital on [DATE] with a recommendation for surgery, orthopedic follow up, but was unable to attend her appointment because she did not have a RP. Interview on 8/24/17 at 4:47 p.m. with the DON, ADM, and ADON revealed the DON stated the hospital treating physician was unable to get another physician to sign for surgery for [REDACTED]. The physician referred the resident to an orthopedic who stated Resident #1 must have a MPOA to consent for treatment. The DON stated the Medical Director clarified there was no longer a 2 doctor rule for performing non-emergency medical procedures; a two doctor rule could only be implemented in critical situations. The ADM stated he learned on this date the Guardianship paperwork was submitted, but there had not been any follow up. The ADON stated she had not called other Orthopedic offices or had not talked with the PCP to discuss treatment options for Resident #1. Interview on 8/24/17 at 5:10 p.m. with the SW revealed she did not have a reason why she had not called to inquire about the guardianship status other than she understood establishing guardianship was a long process. The SW stated she was aware Resident #1 was not able to make decisions regarding her care, however, had not considered obtaining guardianship as an urgent matter until her most recent incident and when she learned today they would not be able to get 2 doctors to consent for surgery. The SW also confirmed she was aware there was no family or friends available to assign as Resident #1's RP. She stated again she would call to inquire about the guardianship status. Observed on 8/24/17 at 5:37 p.m. revealed the Resident #1 sitting up in her wheelchair eating dinner in the assisted dining room. She stated her arm hurt. Observed swelling to left arm. Resident #1 held it down on her side. Interview on 8/24/17 at 5:45 p.m. with CNA C revealed since the fall, Resident #1 could not assist with transfers because her left arm hurt; the resident complained of pain. CNA C stated the resident guarded her left arm. Interview on 8/25/17 at 10:30 a.m. with the DON revealed the SW was going to call a local organization to help with the financial aspect of trying to get Guardianship in place for Resident #1. In the meantime, he was not sure what the plan was for treatment. He stated he would be calling the MD. Interview on 8/25/17 at 11:04 a.m. with PTA D revealed he was familiar with Resident #1 and stated she was on caseload due to her most recent fall. He stated the resident's level of engagement changed due to her level of lucidity for the day. He stated the main goals were strengthening so she could assist with transfers. PTA D stated the resident was much more fearful since the fall; she was afraid of falling again; she complained of pain and would rate it at a level 10 (pain scale 1-10). PTA D stated she was able to associate the pain with the fall and was reluctant to engage in therapy or stand up and walk. PTA D stated another goal was wheelchair mobility training, but had not considered initiating due to her injury. PTA D confirmed that the resident's level of engagement had decreased since her recent injury. Interview on 8/25/17 at 12:17 p.m. with the ADM and SW revealed the SW had worked on several avenues in an attempt to obtain guardianship for Resident #1. The SW stated she called the court on this date and was told they could not find the application she submitted on 6/28/17. She had to re-submit the application and was then advised the process would take about 10 days to get an attorney ad-litem to assess the resident at the facility and make a determination regarding her mental capacity. The ADM stated they had done all they could do in the mean time. Interview on 8/25/17 at 12:30 p.m. with the ADM revealed it was not acceptable that the SW did not follow up on the matter or had not tried to seek other avenues to obtain a RP until this incident. Interview on 8/25/17 at 12:35 p.m. with Resident #1's PCP and MD confirmed that Resident #1 had a left shoulder fracture and her attending hospital physician recommended surgery to repair the fracture. She stated hospital staff were unable to get the 2 doctor's to consent to surgery because it was not a medical emergency for Resident #1. She confirmed the orthopedic required that the resident have a MPOA. The MD stated she had educated staff on the guardianship program that could costs upwards of $20,000. The concern discussed was the staff's lack of effort in exploring options to obtain a RP prior to this recent incident even though the resident had a long standing history of medical/mental illnesses; had several falls where she sustained major injuries which should have alerted staff to follow up with the guardianship process. The MD confirmed the SW should have been more proactive and was not sure why she had not followed up with this matter. Review of a facility policy titled, Abuse/Reportable Events (undated) revealed under Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of a document provided by the facility on 8/25/17 revealed there were 4 residents who were cognitively impaired who did not have a guardian.

Based on observation, interview and record review the facility failed to implement written policies and procedures that would prohibit and prevent neglect and failed to implement procedures for reporting incidents of neglect of residents for 1 of 4 residents (#1) whose records were reviewed for abuse/neglect. 1. The SW did not follow up with the status of having a guardian assigned to Resident #1 after 2 months of submitting the guardianship application. This resulted in a delay of treatment for [REDACTED]. The fracture caused the resident prolonged pain and it affected her ability to use her left arm. 2. The ADM did not report Resident #1's shoulder fracture, an allegation of neglect, to DADS until the day after the incident date. These deficient practice could affect: 4 residents who the facility determined to be cognitively impaired and who did not have a guardian; 2 residents involved in a self-reportable during (MONTH) (YEAR) and it could lead to a delay in critical treatment and in a delay in investigating injuries of unknown origin. The findings were: 1. Review of a facility policy titled, Abuse/Reportable Events (undated) revealed under Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident #1's medical face sheet, dated 5/25/17 revealed she was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed there were no identified family members or friends for Resident #1. Review of an application for a need for Guardian dated 6/28/17 revealed the SW was requesting the court to investigate the resident's circumstances due to her inability to make decisions regarding her care due to Dementia. Review of Resident #1's quarterly MDS dated [DATE] revealed her BIMS was 2, indicative of severe cognitive impairment. Further review revealed she required extensive to total care assistance with all ADL's by 1 or 2 persons; she had an extensive history of falls including a fall with a major injury. Review of Resident #1's care plan revised on 7/12/17 confirmed she had impaired cognitive function/dementia or impaired thought processes reason to short term memory loss. Further review revealed she was incapable of making an informed decision. One of the approaches was to notify the physician to assess capacity of the resident and certify capacity or incapacity. Review of a PT-Therapist Progress & DC Summary dated end of care 8/11/17 revealed that on 8/10/17 Resident #1 was able to propel in her wheelchair 100 feet using B UE and LE requiring stand by assistance. Analysis of Functional Outcome: Caregiver reports improved performance of transfers, prior to fall. Summary of skilled services provided since start of care in part included transfer and gait training; graded therapeutic exercise activities which improved patient's abilities. Further review read: Patient unable to progress towards goals at this time, as recent fx may restrict WB status on said extremity. Review of an incident report dated 8/11/17 at 9:57 p.m. revealed res found prone on floor; pt pull up and clothes on floor, rt forearm caught in SR; urinated all over herself bed and floor. Assisted to sitting position on the floor. Review of nurses note dated 8/11/17 at 10:00 p.m. revealed Resident #1 was found on the floor in prone position. Pt right forearm was caught in between side rails. Pt c/o left shoulder pain. Pt unable to move left arm. Left shoulder swollen, no redness noted to left shoulder at this time. Review of a nurses note dated 8/12/17 at 2:00 a.m. revealed c/o pain to left shoulder. Medicated for pain with little effect Further review revealed x-rays confirmed Resident #1 had a fracture to the left humerus (shoulder). Notified on-call physician's office. Review of a nurse's note dated 8/12/17 at 2:30 a.m. revealed received new orders, send resident to the hospital for evaluation and treatment of [REDACTED]. Review of admission hospital documentation dated 8/12/17 revealed x-ray results confirmed a markedly displaced humeral neck fracture; displaced 100% or more, surgical neck fracture, Left humerus. Review of systems revealed pain to the left upper extremity. Assessment and Plan read: left humeral fracture, traumatic. She is to undergo open reduction and internal fixation by an orthopedic surgeon. Further review of post left arm fracture revealed Resident #1 did not receive surgery yesterday as did not receive medical clearance by a second position; Hospitalist physician was asked but felt it was not an emergency and did not sign consent for humeral head repair. Presently appears comfortable except with movement. Review of post acute service hospital orders for Resident #1 dated 8/12/17 revealed consent needed for surgery, needs family consent or surrogate decision-maker. Review of the hospital nurse's note narrative for Resident #1 dated 8/13/17 revealed 2 physician signatures need to be obtained in order for resident to have surgery. Pt. has Dementia and is unable to sign for self and pt has no family. Further review revealed the attending physician requested assistance with contacting family for surgical consent. Review of Physical Therapy Plan of Care dated from 8/11/17 to 8/14/17 revealed Resident #1 was referred for skilled PT services after recent hospitalization in relation to treatment for [REDACTED]. Patient presents with multisystem impairments including 1) decreased bilateral LE muscle power and recruitment, 2) impaired coordination, 3) impaired balance reaction speed and accuracy, 4) impaired postural alignment and control, and 5) impaired gait mechanics which are contributory to decline. It was noted that resident had therapy in the past prior to this severe decline and regained ambulatory status. Review of Resident #1's Consolidated Physician order [REDACTED]. Review of Resident #1's MAR for (MONTH) (YEAR) revealed Resident #1 received [MEDICATION NAME] 325 mg tab daily from 8/14/17 to 8/24/17 except on 8/21/17 and on 8/22/17. Further review revealed there was no documentation to determine whether the medication was effective. Review of a T.O. dated 8/15/17 revealed an order for [REDACTED]. Review of Resident #1's MAR for (MONTH) (YEAR) revealed she received Tylenol #3 [MEDICATION NAME] from 8/17/17 to 8/24/17 except on 8/22/17. A note on the back of the MAR indicated [REDACTED]. There was no other documentation to indicate whether or not the medication was effective for the other dates it was given. Review of nurse's notes dated 8/16/17 and 8/17/17 revealed Resident #1 complained of pain 10/10 to left arm still awaiting order for Tylenol #3 [MEDICATION NAME]. Further review revealed the resident had bruising around her left shoulder. Review of nurse's note dated 8/18/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 [MEDICATION NAME] given 0 a,r (apparent relief) noted. Further review revealed the resident returned from orthopedic appointment unable to to complete evaluation and treatment to left humerus fracture d/t mental status; no other responsible party available DON notified, resident is her own responsible party. Review of nurse's note dated 8/19/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 [MEDICATION NAME] given 0 a,r (apparent relief) noted. Review of nurse's note dated 8/20/17 revealed Resident #1 complained of pain 9/10 to left arm, Tylenol #3 [MEDICATION NAME] given. No indication whether the medication was effective. Review of nurse's note dated 8/23/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 [MEDICATION NAME] given. No indication whether the medication was effective. Review of nurse's note dated 8/24/17 revealed Resident #1 complained of pain 8/10 to left arm, Tylenol #3 [MEDICATION NAME] given 0 a,r (apparent relief) noted. Observation on 8/24/17 at 12:52 p.m. revealed Resident #1 was sitting up in bed eating lunch using her right arm and hand; she kept her left arm by her side. Resident #1 did not attempt to use her left arm. Her left arm was swollen and she had visible purple bruising to the upper left extremity around the shoulder. Resident #1 stated me duele mucho, it hurts a lot. Interview on 8/24/17 at 2:32 p.m. with the Admissions Coordinator revealed that as the previous risk manager she knew of Resident #1's history of falls including falls with major injury. The Admissions Coordinator stated she knew the resident had severe cognitive impairment; was not able to make decisions regarding her care and did not have a RP. She stated the SW had filed guardianship paperwork regarding Resident #1. Interview on 8/24/17 at 2:40 p.m. with the SW confirmed she filed a Guardianship request with the court on 6/28/17, but stated she had not called to inquire about the status. The SW stated she would call today. Interview on 8/24/17 at 2:45 p.m. with the DON revealed he was not familiar with all of the details regarding Resident #1's circumstances. The DON stated he knew the SW filed guardianship paperwork, but was not aware there had not been any follow up. He stated hospital staff was trying to get two doctor's to sign a form to approve surgery. The DON stated the resident returned from the hospital on [DATE] with a recommendation for surgery, orthopedic follow up, but was unable to attend her appointment because she did not have a RP. Interview on 8/24/17 at 4:47 p.m. with the DON, ADM, and ADON revealed the DON stated the hospital treating physician was unable to get another physician to sign for surgery for [REDACTED]. The physician referred the resident to an orthopedic who stated Resident #1 must have a MPOA to consent for treatment. The DON stated the Medical Director clarified there was no longer a 2 doctor rule for performing non-emergency medical procedures; a two doctor rule could only be implemented in critical situations. The ADM stated he learned on this date the Guardianship paperwork was submitted, but there had not been any follow up. The ADON stated she had not called other Orthopedic offices or had not talked with the PCP to discuss treatment options for Resident #1. Interview on 8/24/17 at 5:10 p.m. with the SW revealed she did not have a reason why she had not called to inquire about the guardianship status other than she understood establishing guardianship was a long process. The SW stated she was aware Resident #1 was not able to make decisions regarding her care, however, had not considered obtaining guardianship as an urgent matter until her most recent incident and when she learned today they would not be able to get 2 doctors to consent for surgery. The SW also confirmed she was aware there was no family or friends available to assign as Resident #1's RP. She stated again she would call to inquire about the guardianship status. Observed on 8/24/17 at 5:37 p.m. revealed the Resident #1 sitting up in her wheelchair eating dinner in the assisted dining room. She stated her arm hurt. Observed swelling to left arm. Resident #1 held it down on her side. Interview on 8/24/17 at 5:45 p.m. with CNA C revealed since the fall, Resident #1 could not assist with transfers because her left arm hurt; the resident complained of pain. CNA C stated the resident guarded her left arm. Interview on 8/25/17 at 10:30 a.m. with the DON revealed the SW was going to call a local organization to help with the financial aspect of trying to get Guardianship in place for Resident #1. In the meantime, he was not sure what the plan was for treatment. He stated he would be calling the MD. Interview on 8/25/17 at 11:04 a.m. with PTA D revealed he was familiar with Resident #1 and stated she was on caseload due to her most recent fall. He stated the resident's level of engagement changed due to her level of lucidity for the day. He stated the main goals were strengthening so she could assist with transfers. PTA D stated the resident was much more fearful since the fall; she was afraid of falling again; she complained of pain and would rate it at a level 10 (pain scale 1-10). PTA D stated she was able to associate the pain with the fall and was reluctant to engage in therapy or stand up and walk. PTA D stated another goal was wheelchair mobility training, but had not considered initiating due to her injury. PTA D confirmed that the resident's level of engagement had decreased since her recent injury. Interview on 8/25/17 at 12:17 p.m. with the ADM and SW revealed the SW had worked on several avenues in an attempt to obtain guardianship for Resident #1. The SW stated she called the court on this date and was told they could not find the application she submitted on 6/28/17. She had to re-submit the application and was then advised the process would take about 10 days to get an attorney ad-litem to assess the resident at the facility and make a determination regarding her mental capacity. The ADM stated they had done all they could do in the mean time. Interview on 8/25/17 at 12:30 p.m. with the ADM revealed it was not acceptable that the SW did not follow up on the matter or had not tried to seek other avenues to obtain a RP until this incident. Interview on 8/25/17 at 12:35 p.m. with Resident #1's PCP and MD confirmed that Resident #1 had a left shoulder fracture and her attending hospital physician recommended surgery to repair the fracture. She stated hospital staff were unable to get the 2 doctor's to consent to surgery because it was not a medical emergency for Resident #1. She confirmed the orthopedic required that the resident have a MPOA. The MD stated she had educated staff on the guardianship program that could costs upwards of $20,000. The concern discussed was the staff's lack of effort in exploring options to obtain a RP prior to this recent incident even though the resident had a long standing history of medical/mental illnesses; had several falls where she sustained major injuries which should have alerted staff to follow up with the guardianship process. The MD confirmed the SW should have been more proactive and was not sure why she had not followed up with this matter. Review of a document provided by the facility on 8/25/17 revealed there were 4 residents who were cognitively impaired who did not have a guardian. 2. Review of a facility policy titled, Abuse/Reportable Events (undated) read: Reporting: Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of [REDACTED]. The facility administrator or designee will report the allegation to HHSC. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. Review of Resident #1's medical face sheet, dated 5/25/17 revealed she was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurses note dated 8/11/17 at 10:00 p.m. revealed Resident #1 was found on the floor in prone position. Pt right forearm was caught in between side rails. Pt c/o left shoulder pain. Pt unable to move left arm. Left shoulder swollen, no redness noted to left shoulder at this time. Review of a nurses note dated 8/12/17 at 2:00 a.m. revealed x-rays revealed Resident #1 had a fracture to the left humerus (shoulder). Review of the Provider Investigation Report signed by the ADM on 8/16/17 revealed that on 8/11/17 at 9:57 p.m. Resident #1 was found on the floor with redness to her right forearm, redness to the left inner upper arm, redness to the left forearm, and swelling to the left shoulder; resident did not want arm touched. She also had redness to the center lower back. Further review revealed the incident was reported to DADS on 8/12/17 at 3:08 p.m. Interview on 9/18/17 at 5:00 p.m. with the ADM revealed nursing staff did not let him know about Resident 1's injury until the following day. He stated he was at the facility until late the same evening investigating another incident and commented there was no reason for staff not to let him know about Resident #1's injuries right away. Review of a document provided by the facility on 9/18/17 revealed there were 2 residents involved in self-reportable incidents during (MONTH) (YEAR).

Based on observation, interview and record review the facility failed to provide medically-related social services to attain the highest practicable physical well-being of each resident for 1 of 4 residents (#1) whose records were reviewed for social services. The SW did not follow up with the status of having a guardian assigned to Resident #1 after 2 months of submitting the guardianship application. This resulted in a delay of treatment for [REDACTED]. The fracture caused the resident prolonged pain and it affected her ability to use her left arm. This deficient practice could affect 4 residents who the facility determined to be cognitively impaired and who did not have a guardian and it could lead to a delay in critical treatment. The findings were: Review of Resident #1's medical face sheet, dated 5/25/17 revealed she was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed there were no identified family members or friends for Resident #1. Review of an application for a need for Guardian dated 6/28/17 revealed the SW was requesting the court to investigate the resident's circumstances due to her inability to make decisions regarding her care due to Dementia. Review of Resident #1's quarterly MDS dated [DATE] revealed her BIMS was 2, indicative of severe cognitive impairment. Further review revealed she required extensive to total care assistance with all ADL's by 1 or 2 persons; she had an extensive history of falls including a fall with a major injury. Review of Resident #1's care plan revised on 7/12/17 confirmed she had impaired cognitive function/dementia or impaired thought processes reason to short term memory loss. Further review revealed she was incapable of making an informed decision. One of the approaches was to notify the physician to assess capacity of the resident and certify capacity or incapacity. Review of a PT-Therapist Progress & DC Summary dated end of care 8/11/17 revealed that on 8/10/17 Resident #1 was able to propel in her wheelchair 100 feet using B UE and LE requiring stand by assistance. Analysis of Functional Outcome: Caregiver reports improved performance of transfers, prior to fall. Summary of skilled services provided since start of care in part included transfer and gait training; graded therapeutic exercise activities which improved patient's abilities. Further review read: Patient unable to progress towards goals at this time, as recent fx may restrict WB status on said extremity. Review of an incident report dated 8/11/17 at 9:57 p.m. revealed res found prone on floor; pt pull up and clothes on floor, rt forearm caught in SR; urinated all over herself bed and floor. Assisted to sitting position on the floor. Review of nurses note dated 8/11/17 at 10:00 p.m. revealed Resident #1 was found on the floor in prone position. Pt right forearm was caught in between side rails. Pt c/o left shoulder pain. Pt unable to move left arm. Left shoulder swollen, no redness noted to left shoulder at this time. Review of a nurses note dated 8/12/17 at 2:00 a.m. revealed c/o pain to left shoulder. Medicated for pain with little effect Further review revealed x-rays confirmed Resident #1 had a fracture to the left humerus (shoulder). Notified on-call physician's office. Review of a nurse's note dated 8/12/17 at 2:30 a.m. revealed received new orders, send resident to the hospital for evaluation and treatment of [REDACTED]. Review of admission hospital documentation dated 8/12/17 revealed x-ray results confirmed a markedly displaced humeral neck fracture; displaced 100% or more, surgical neck fracture, Left humerus. Review of systems revealed pain to the left upper extremity. Assessment and Plan read: left humeral fracture, traumatic. She is to undergo open reduction and internal fixation by an orthopedic surgeon. Further review of post left arm fracture revealed Resident #1 did not receive surgery yesterday as did not receive medical clearance by a second position; Hospitalist physician was asked but felt it was not an emergency and did not sign consent for humeral head repair. Presently appears comfortable except with movement. Review of post acute service hospital orders for Resident #1 dated 8/12/17 revealed consent needed for surgery, needs family consent or surrogate decision-maker. Review of the hospital nurse's note narrative for Resident #1 dated 8/13/17 revealed 2 physician signatures need to be obtained in order for resident to have surgery. Pt. has Dementia and is unable to sign for self and pt has no family. Further review revealed the attending physician requested assistance with contacting family for surgical consent. Review of Physical Therapy Plan of Care dated from 8/11/17 to 8/14/17 revealed Resident #1 was referred for skilled PT services after recent hospitalization in relation to treatment for [REDACTED]. Patient presents with multisystem impairments including 1) decreased bilateral LE muscle power and recruitment, 2) impaired coordination, 3) impaired balance reaction speed and accuracy, 4) impaired postural alignment and control, and 5) impaired gait mechanics which are contributory to decline. It was noted that resident had therapy in the past prior to this severe decline and regained ambulatory status. Review of Resident #1's Consolidated Physician order [REDACTED]. Review of Resident #1's MAR for (MONTH) (YEAR) revealed Resident #1 received Acetaminophen 325 mg tab daily from 8/14/17 to 8/24/17 except on 8/21/17 and on 8/22/17. Further review revealed there was no documentation to determine whether the medication was effective. Review of a T.O. dated 8/15/17 revealed an order for [REDACTED]. Review of Resident #1's MAR for (MONTH) (YEAR) revealed she received Tylenol #3 codeine from 8/17/17 to 8/24/17 except on 8/22/17. A note on the back of the MAR dated 8/20/17 read the medication was effective. There was no other documentation to indicate whether or not the medication was effective for the other dates it was given. Review of nurse's notes dated 8/16/17 and 8/17/17 revealed Resident #1 complained of pain 10/10 to left arm still awaiting order for Tylenol #3 codeine. Further review revealed the resident had bruising around her left shoulder. Review of nurse's note dated 8/18/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 codeine given 0 a,r (apparent relief) noted. Further review revealed the resident returned from orthopedic appointment unable to to complete evaluation and treatment to left humerus fracture d/t mental status; no other responsible party available DON notified, resident is her own responsible party. Review of nurse's note dated 8/19/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 codeine given 0 a,r (apparent relief) noted. Review of nurse's note dated 8/20/17 revealed Resident #1 complained of pain 9/10 to left arm, Tylenol #3 codeine given. No indication whether the medication was effective. Review of nurse's note dated 8/23/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 codeine given. No indication whether the medication was effective. Review of nurse's note dated 8/24/17 revealed Resident #1 complained of pain 8/10 to left arm, Tylenol #3 codeine given 0 a,r (apparent relief) noted. Observation on 8/24/17 at 12:52 p.m. revealed Resident #1 was sitting up in bed eating lunch using her right arm and hand; she kept her left arm by her side. Resident #1 did not attempt to use her left arm. Her left arm was swollen and she had visible purple bruising to the upper left extremity around the shoulder. Resident #1 stated me duele mucho, it hurts a lot. Interview on 8/24/17 at 2:32 p.m. with the Admissions Coordinator revealed that as the previous risk manager she knew of Resident #1's history of falls including falls with major injury. The Admissions Coordinator stated she knew the resident had severe cognitive impairment; was not able to make decisions regarding her care and did not have a RP. She stated the SW had filed guardianship paperwork regarding Resident #1. Interview on 8/24/17 at 2:40 p.m. with the SW confirmed she filed a Guardianship request with the court on 6/28/17, but stated she had not called to inquire about the status. The SW stated she would call today. Interview on 8/24/17 at 2:45 p.m. with the DON revealed he was not familiar with all of the details regarding Resident #1's circumstances. The DON stated he knew the SW filed guardianship paperwork, but was not aware there had not been any follow up. He stated hospital staff was trying to get two doctor's to sign a form to approve surgery. The DON stated the resident returned from the hospital on [DATE] with a recommendation for surgery, orthopedic follow up, but was unable to attend her appointment because she did not have a RP. Interview on 8/24/17 at 4:47 p.m. with the DON, ADM, and ADON revealed the DON stated the hospital treating physician was unable to get another physician to sign for surgery for [REDACTED]. The physician referred the resident to an orthopedic who stated Resident #1 must have a MPOA to consent for treatment. The DON stated the Medical Director clarified there was no longer a 2 doctor rule for performing non-emergency medical procedures; a two doctor rule could only be implemented in critical situations. The ADM stated he learned on this date the Guardianship paperwork was submitted, but there had not been any follow up. The ADON stated she had not called other Orthopedic offices or had not talked with the PCP to discuss treatment options for Resident #1. Interview on 8/24/17 at 5:10 p.m. with the SW revealed she did not have a reason why she had not called to inquire about the guardianship status other than she understood establishing guardianship was a long process. The SW stated she was aware Resident #1 was not able to make decisions regarding her care, however, had not considered obtaining guardianship as an urgent matter until her most recent incident and when she learned today they would not be able to get 2 doctors to consent for surgery. The SW also confirmed she was aware there was no family or friends available to assign as Resident #1's RP. She stated again she would call to inquire about the guardianship status. Observed on 8/24/17 at 5:37 p.m. revealed the Resident #1 sitting up in her wheelchair eating dinner in the assisted dining room. She stated her arm hurt. Observed swelling to left arm. Resident #1 held it down on her side. Interview on 8/24/17 at 5:45 p.m. with CNA C revealed since the fall, Resident #1 could not assist with transfers because her left arm hurt; the resident complained of pain. CNA C stated the resident guarded her left arm. Interview on 8/25/17 at 10:30 a.m. with the DON revealed the SW was going to call a local organization to help with the financial aspect of trying to get Guardianship in place for Resident #1. In the meantime, he was not sure what the plan was for treatment. He stated he would be calling the MD. Interview on 8/25/17 at 11:04 a.m. with PTA D revealed he was familiar with Resident #1 and stated she was on caseload due to her most recent fall. He stated the resident's level of engagement changed due to her level of lucidity for the day. He stated the main goals were strengthening so she could assist with transfers. PTA D stated the resident was much more fearful since the fall; she was afraid of falling again; she complained of pain and would rate it at a level 10 (pain scale 1-10). PTA D stated she was able to associate the pain with the fall and was reluctant to engage in therapy or stand up and walk. PTA D stated another goal was wheelchair mobility training, but had not considered initiating due to her injury. PTA D confirmed that the resident's level of engagement had decreased since her recent injury. Interview on 8/25/17 at 12:17 p.m. with the ADM and SW revealed the SW had worked on several avenues in an attempt to obtain guardianship for Resident #1. The SW stated she called the court on this date and was told they could not find the application she submitted on 6/28/17. She had to re-submit the application and was then advised the process would take about 10 days to get an attorney ad-litem to assess the resident at the facility and make a determination regarding her mental capacity. The ADM stated they had done all they could do in the mean time. Interview on 8/25/17 at 12:30 p.m. with the ADM revealed it was not acceptable that the SW did not follow up on the matter or had not tried to seek other avenues to obtain a RP until this incident. Interview on 8/25/17 at 12:35 p.m. with Resident #1's PCP and MD confirmed that Resident #1 had a left shoulder fracture and her attending hospital physician recommended surgery to repair the fracture. She stated hospital staff were unable to get the 2 doctor's to consent to surgery because it was not a medical emergency for Resident #1. She confirmed the orthopedic required that the resident have a MPOA. The MD stated she had educated staff on the guardianship program that could costs upwards of $20,000. The concern discussed was the staff's lack of effort in exploring options to obtain a RP prior to this recent incident even though the resident had a long standing history of medical/mental illnesses; had several falls where she sustained major injuries which should have alerted staff to follow up with the guardianship process. The MD confirmed the SW should have been more proactive and was not sure why she had not followed up with this matter. Review of a document provided by the facility on 8/25/17 revealed there were 4 residents who were cognitively impaired who did not have a guardian.

Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (#1) whose records were reviewed for abuse/neglect. The SW did not follow up with the status of having a guardian assigned to Resident #1 after 2 months of submitting the guardianship application. This resulted in a delay of treatment for [REDACTED]. The fracture caused the resident prolonged pain and it affected her ability to use her left arm. This deficient practice could affect 4 residents who the facility determined to be cognitively impaired and did not have a responsible party and could lead to a delay in critical treatment. The findings were: Review of Resident #1's medical face sheet, dated 5/25/17 revealed she was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed there were no identified family members or friends for Resident #1. Review of an application for a need for Guardian dated 6/28/17 revealed the SW was requesting the court to investigate the resident's circumstances due to her inability to make decisions regarding her care due to Dementia. Review of Resident #1's quarterly MDS dated [DATE] revealed her BIMS was 2, indicative of severe cognitive impairment. Further review revealed she required extensive to total care assistance with all ADL's by 1 or 2 persons; she had an extensive history of falls including a fall with a major injury. Review of Resident #1's care plan revised on 7/12/17 confirmed she had impaired cognitive function/dementia or impaired thought processes reason to short term memory loss. Further review revealed she was incapable of making an informed decision. One of the approaches was to notify the physician to assess capacity of the resident and certify capacity or incapacity. Review of a PT-Therapist Progress & DC Summary dated end of care 8/11/17 revealed that on 8/10/17 Resident #1 was able to propel in her wheelchair 100 feet using B UE and LE requiring stand by assistance. Analysis of Functional Outcome: Caregiver reports improved performance of transfers, prior to fall. Summary of skilled services provided since start of care in part included transfer and gait training; graded therapeutic exercise activities which improved patient's abilities. Further review read: Patient unable to progress towards goals at this time, as recent fx may restrict WB status on said extremity. Review of an incident report dated 8/11/17 at 9:57 p.m. revealed res found prone on floor; pt pull up and clothes on floor, rt forearm caught in SR; urinated all over herself bed and floor. Assisted to sitting position on the floor. Review of nurses note dated 8/11/17 at 10:00 p.m. revealed Resident #1 was found on the floor in prone position. Pt right forearm was caught in between side rails. Pt c/o left shoulder pain. Pt unable to move left arm. Left shoulder swollen, no redness noted to left shoulder at this time. Review of a nurses note dated 8/12/17 at 2:00 a.m. revealed c/o pain to left shoulder. Medicated for pain with little effect Further review revealed x-rays confirmed Resident #1 had a fracture to the left humerus (shoulder). Notified on-call physician's office. Review of a nurse's note dated 8/12/17 at 2:30 a.m. revealed received new orders, send resident to the hospital for evaluation and treatment of [REDACTED]. Review of admission hospital documentation dated 8/12/17 revealed x-ray results confirmed a markedly displaced humeral neck fracture; displaced 100% or more, surgical neck fracture, Left humerus. Review of systems revealed pain to the left upper extremity. Assessment and Plan read: left humeral fracture, traumatic. She is to undergo open reduction and internal fixation by an orthopedic surgeon. Further review of post left arm fracture revealed Resident #1 did not receive surgery yesterday as did not receive medical clearance by a second position; Hospitalist physician was asked but felt it was not an emergency and did not sign consent for humeral head repair. Presently appears comfortable except with movement. Review of post acute service hospital orders for Resident #1 dated 8/12/17 revealed consent needed for surgery, needs family consent or surrogate decision-maker. Review of the hospital nurse's note narrative for Resident #1 dated 8/13/17 revealed 2 physician signatures need to be obtained in order for resident to have surgery. Pt. has Dementia and is unable to sign for self and pt has no family. Further review revealed the attending physician requested assistance with contacting family for surgical consent. Review of Physical Therapy Plan of Care dated from 8/11/17 to 8/14/17 revealed Resident #1 was referred for skilled PT services after recent hospitalization in relation to treatment for [REDACTED]. Patient presents with multisystem impairments including 1) decreased bilateral LE muscle power and recruitment, 2) impaired coordination, 3) impaired balance reaction speed and accuracy, 4) impaired postural alignment and control, and 5) impaired gait mechanics which are contributory to decline. It was noted that resident had therapy in the past prior to this severe decline and regained ambulatory status. Review of Resident #1's Consolidated Physician order [REDACTED]. Review of Resident #1's MAR for (MONTH) (YEAR) revealed Resident #1 received [MEDICATION NAME] 325 mg tab daily from 8/14/17 to 8/24/17 except on 8/21/17 and on 8/22/17. Further review revealed there was no documentation to determine whether the medication was effective. Review of a T.O. dated 8/15/17 revealed an order for [REDACTED]. Review of Resident #1's MAR for (MONTH) (YEAR) revealed she received Tylenol #3 [MEDICATION NAME] from 8/17/17 to 8/24/17 except on 8/22/17. A note on the back of the MAR indicated [REDACTED]. There was no other documentation to indicate whether or not the medication was effective for the other dates it was given. Review of nurse's notes dated 8/16/17 and 8/17/17 revealed Resident #1 complained of pain 10/10 to left arm still awaiting order for Tylenol #3 [MEDICATION NAME]. Further review revealed the resident had bruising around her left shoulder. Review of nurse's note dated 8/18/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 [MEDICATION NAME] given 0 a,r (apparent relief) noted. Further review revealed the resident returned from orthopedic appointment unable to to complete evaluation and treatment to left humerus fracture d/t mental status; no other responsible party available DON notified, resident is her own responsible party. Review of nurse's note dated 8/19/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 [MEDICATION NAME] given 0 a,r (apparent relief) noted. Review of nurse's note dated 8/20/17 revealed Resident #1 complained of pain 9/10 to left arm, Tylenol #3 [MEDICATION NAME] given. No indication whether the medication was effective. Review of nurse's note dated 8/23/17 revealed Resident #1 complained of pain 10/10 to left arm, Tylenol #3 [MEDICATION NAME] given. No indication whether the medication was effective. Review of nurse's note dated 8/24/17 revealed Resident #1 complained of pain 8/10 to left arm, Tylenol #3 [MEDICATION NAME] given 0 a,r (apparent relief) noted. Observation on 8/24/17 at 12:52 p.m. revealed Resident #1 was sitting up in bed eating lunch using her right arm and hand; she kept her left arm by her side. Resident #1 did not attempt to use her left arm. Her left arm was swollen and she had visible purple bruising to the upper left extremity around the shoulder. Resident #1 stated me duele mucho, it hurts a lot. Interview on 8/24/17 at 2:32 p.m. with the Admissions Coordinator revealed that as the previous risk manager she knew of Resident #1's history of falls including falls with major injury. The Admissions Coordinator stated she knew the resident had severe cognitive impairment; was not able to make decisions regarding her care and did not have a RP. Interview on 8/24/17 at 2:40 p.m. with the SW confirmed she filed a Guardianship request with the court on 6/28/17, but stated she had not called to inquire about the status. The SW stated she would call today. Interview on 8/24/17 at 2:45 p.m. with the DON revealed he was not familiar with all of the details regarding Resident #1's circumstances. The DON stated hospital staff was trying to get two doctor's to sign a form to approve surgery. The DON stated the resident returned from the hospital on [DATE] with a recommendation for surgery, orthopedic follow up, but was unable to attend her orthopedic appointment because she did not have a RP. Interview on 8/24/17 at 4:47 p.m. with the DON, ADM, and ADON revealed the DON stated the hospital treating physician was unable to get another physician to sign for surgery for [REDACTED]. The DON stated the Medical Director clarified there was no longer a 2 doctor rule for performing non-emergency medical procedures; a two doctor rule could only be implemented in critical situations. The ADON stated she had not called other Orthopedic offices or had not talked with the PCP to discuss treatment options for Resident #1. Interview on 8/24/17 at 5:10 p.m. with the SW revealed she did not have a reason why she had not called to inquire about the guardianship status other than she understood establishing guardianship was a long process. The SW stated she was aware Resident #1 was not able to make decisions regarding her care, however, had not considered obtaining guardianship as an urgent matter until her most recent incident and when she learned today they would not be able to get 2 doctors to consent for surgery. The SW also confirmed she was aware there was no family or friends available to assign as Resident #1's RP. Observed on 8/24/17 at 5:37 p.m. revealed the Resident #1 sitting up in her wheelchair eating dinner in the assisted dining room. She stated her arm hurt. Observed swelling to left arm. Resident #1 held it down on her side. Interview on 8/24/17 at 5:45 p.m. with CNA C revealed since the fall, Resident #1 could not assist with transfers because her left arm hurt; the resident complained of pain. CNA C stated the resident guarded her left arm. Interview on 8/25/17 at 10:30 a.m. with the DON revealed the SW was going to call a local organization to help with the financial aspect of trying to get Guardianship in place for Resident #1. In the meantime, he was not sure what the plan was for treatment. He stated he would be calling the MD. Interview on 8/25/17 at 11:04 a.m. with PTA D revealed he was familiar with Resident #1 and stated she was on caseload due to her most recent fall. He stated the resident's level of engagement changed due to her level of lucidity for the day. He stated the main goal was to work on strengthening so she could assist with transfers. PTA D stated the resident was much more fearful since the fall; she was afraid of falling again; she complained of pain and would rate it at a level 10 (pain scale 1-10). PTA D stated she was able to associate the pain with the fall and was reluctant to engage in therapy or stand up and walk. PTA D stated another goal was wheelchair mobility training, but had not considered initiating due to her injury. PTA D confirmed that the resident's level of engagement had decreased since her recent injury. Interview on 8/25/17 at 12:17 p.m. with the ADM and SW revealed the SW called the court on this date and was told they could not find the application she submitted on 6/28/17. She had to re-submit the application and was then advised the process would take about 10 days to get an attorney ad-litem to assess the resident at the facility and make a determination regarding her mental capacity. Interview on 8/25/17 at 12:30 p.m. with the ADM revealed it was not acceptable that the SW did not follow up on the matter or had not tried to seek other avenues to obtain a RP until this incident. Interview on 8/25/17 at 12:35 p.m. with Resident #1's PCP and MD confirmed that Resident #1 had a left shoulder fracture and her attending hospital physician recommended surgery to repair the fracture. She stated hospital staff were unable to get the 2 doctor's to consent to surgery because it was not a medical emergency for Resident #1. She confirmed the orthopedic required that the resident have a MPOA. The MD stated she had educated staff on the guardianship program that could costs upwards of $20,000. The concern discussed was the staff's lack of effort in exploring options to obtain a RP prior to this recent incident even though the resident had a long standing history of medical/mental illnesses; had several falls where she sustained major injuries which should have alerted staff to follow up with the guardianship process. The MD confirmed the SW should have been more proactive and was not sure why she had not followed up with this matter. Review of a document provided by the facility on 8/25/17 revealed there were 4 residents who were cognitively impaired who did not have a guardian.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibited neglect of residents for 4 of 11 residents (#3, #4, #9 & #12) whose records were reviewed for neglect in that: 1. Nursing staff did not ensure Resident #4, who was an elopement risk, had a wanderguard bracelet on. LVN B and LVN V did not conduct morning rounds. Resident #4 eloped from the facility; was gone for at least 2 and 1/2 hours and no one knew she was gone. A stranger gave her a ride to the police station. 2. Nursing staff did not ensure Resident #9, who was an elopement risk, had a wanderguard bracelet on the right ankle. Resident #9 eloped from the facility and was gone an undetermined amount of time. A stranger returned her to the facility. 3. LVN O did not ensure Resident #3, who was an elopement risk, had a wanderguard bracelet on. 4. Nursing staff did not ensure Resident #12, who was an elopement risk, did not have a wanderguard bracelet on. 5. The ADM and MS did not ensure the wanderguard system was working properly on the two doors equipped with a wanderguard system; the entrance doors and the South door by the rehabilitation room. In addition, the MS did not ensure the alarm on the exit door at the end of 100 hall was working properly. 6. The DON did not ensure that staff were trained and knew what doors were armed with a wanderguard system or how to check the wanderguard devices for functionality. These deficient practices resulted in an Immediate Jeopardy (IJ) on 7/6/16. The IJ was removed on 7/7/16. The facility remained out of compliance at a scope of pattern at no actual harm with potential for more than minimal harm due to the facility's need to complete in-service training and to evaluate the effectiveness of their corrective systems. These deficient practices could affect 11 residents who were identified as an elopement risk and placed the residents at risk for eloping. The findings were: 1. Review of a face sheet revealed Resident #4 was admitted into the facility on [DATE]. Review of physician orders [REDACTED].#4's [DIAGNOSES REDACTED]. Review of a Wander Data Collection Tool dated 12/14/15 revealed Resident #4 was an elopement risk and the interventions were to use personal safety alarm devices on exit and stairwell alarms. Review of an Elopement Risk Alert dated 3/21/16 revealed Resident #4 was an elopement risk and the areas and places to focus a search were the South rehab door and outside. Review of a quarterly MDS dated [DATE] revealed Resident #4's BIMS was a 3 indicating she was severely cognitively impaired and that she had Non-Alzheimer's Dementia. Review of Elopement Risk assessment dated [DATE] revealed Resident #4's score was a 2 indicating there was no potential for elopement. Review of a t.o. dated 4/1/16 revealed the use of the wanderguard was discontinued for Resident #4. Review of a care plan dated 4/27/16 revealed Resident #4 would remove the wanderguard. Further review revealed to monitor and replace. Review of the provider investigation report dated 5/27/16 revealed that on 5/23/16 Resident #4 eloped from the facility. Resident #4 was last seen about 5:00 a.m. Staff noticed she was not at breakfast at 7:30 a.m. and initiated a search of the facility and surrounding grounds. The ADM called 911 at 8:54 a.m. At 9:00 a.m. Officer R called the ADM and let her know the resident had walked into the substation at 6:00 a.m. The resident was confused but able to give Officer R her brother's name and phone number. Officer R contacted the brother and attempted to contact the daughters. She had EMS assess the resident and no injuries were noted. Officer R returned Resident #4 to the facility at 9:30 a.m. An assessment was completed and an X-Ray was ordered because she complained of pain to her wrist. The resident's vital signs were stable and there were no signs of dehydration. The X-Ray results were normal. The resident apologized for leaving the facility and stated she wanted to get some fresh air and to see her daughters. Further review revealed Resident #4 eloped during 12/15 but had not eloped since that time. The findings were confirmed, however, it was noted: it does not rise to the level of neglect. It was noted that 1 staff statement (CNA J) was attached to the investigation report. Review of a nurse's note dated 5/23/16 revealed that a CNA notified LVN D at 7:30 a.m. that Resident #4 was not in her room and staff started searching the premises and grounds. At 9:09 a.m. LVN D called the daughter who was upset and asking if she had that bracelet to lock doors and explained to her that she removes bracelets and hides them. Review of a nurse's note dated 5/23/16 at 1300 (1:00 p.m.) revealed Resident #4 returned to the facility from pass with the daughter. Resident #4 requested left wrist wrapped for comfort. Review of a telephone order dated 5/23/16 read: X-Ray to left wrist fall Review of a Final X-Ray Report dated 5/23/16 revealed Resident #4 had mild osteopenia but no acute fractures or subluxations were identified. Review of a nurse's note dated 5/24/16 at 9:55 p.m. read Resident #4 back from out on pass with daughter. States was taken to (Dr. _____) and was diagnosed with [REDACTED]. Splint was placed on wrist. Resident wearing splint @ this time. No orders were brought with daughter. Review of Resident #4's care plan revised on 5/23/16 identified that she wandered due to Dementia and the interventions and approaches listed were: 1. Nursing to assess resident. 2. Contact physician and RP. 3. Provide treatments and meds as ordered. 4. resident complained of pain to wrist X-rays. 5. Q 15 min checks. 6. Wanderguard in place. 7. Find resident secure unit. Review of in-Services from February to June 2016 revealed in-services were conducted on the prevention of elopement on 2/5/16, 5/13/16 and on 5/23/16. Further review of the in-service dated 5/23/16 revealed the content discussed was safety checks for Resident #4 and all residents at risk for exit seeking. The content read: Check placement of wanderguard at each occurrence of visit. At a minimum check placement every 2 hours-right wrist! Visually check resident every 15 minutes to verify whereabouts. If found exit seeking, talk to resident to find out her needs. Re-direct as necessary. Report any incidents to nurse. Further review of nurse's notes from 5/24/16 to 6/2/16 revealed that Resident #4 removed the wanderguard bracelet at least 10 times; she was on 15 minute checks and finally the wanderguard bracelet was placed on the back center belt loop for elopement safety. Review of a Discharge Summary dated 6/4/16 revealed Resident #4 was transferred to another facility. Interview on 7/5/16 at 3:18 p.m. with the ADM revealed while interviewing staff about Resident #4's elopement, CNA J stated she saw Resident #4 in the hallway about 5:00 a.m. She stated she also interviewed LVN D, CNA F and CNA M who started their shifts at 6:00 a.m. The ADM stated CNA M reported she did not conduct her rounds upon starting her shift which the ADM stated would be what staff was expected to do. The ADM stated LVN U was the night nurse and no contact was made with him. The ADM stated the resident would wander all over the facility and go into other residents' rooms to sleep. She stated she called the police when staff completed their search and determined the resident was not in the facility. The ADM stated LVN D contacted the residents' 2 daughters and they came to the facility. They were very upset. The ADM confirmed that there was a question of lack of supervision due to the 2 and 1/2 hour period that staff could not account for the resident's whereabouts. However, she stated she did not believe staff was neglectful because there was no willful intent. The ADM stated they completed in-services on elopement and conducted mock elopement drills every quarter or at least twice a year. Interview on 7/5/16 at 3:46 p.m. with the DON revealed Resident #4's reasoning skills were very much compromised. She stated an elopement risk assessment was completed in March 2016 and her score was low which indicated a wander guard bracelet did not have to be used. She stated Resident #4 had not tried to exit since December 2015. However, she stated the wanderguard bracelet served as a reminder for the resident not to leave the facility. The DON stated she did not provide staff who did not conduct their morning rounds verbal counseling. Interview on 7/5/16 at 4:25 p.m. with the DON revealed that Resident #4 was not wearing a wanderguard bracelet upon her return to the facility. However, confirmed again that nursing staff were using a wanderguard bracelet for monitoring purposes. Interview on 7/6/16 at 9:38 a.m. with LVN D revealed she was on duty when Resident #4 eloped from the facility. She stated she was working 100 hall and LVN B was working 200 hall; Resident #4 was on 200 hall. LVN D stated staff was aware that Resident #4 was a wanderer and that the resident would take the wanderguard bracelet off. She stated she did not see Resident #4 that morning, but then CNA's F & M let her know they did not see Resident #4 at breakfast between 7:10 and 7:15 a.m. LVN D stated she reported the resident's elopement to the DON and conducted a search of the facility and surrounding grounds. She learned later that morning that Resident #4 had been at the police station since about 4:00 a.m. LVN D stated Resident #4's daughter was upset when she notified her that her mother was missing. She stated she did not see a wanderguard bracelet on Resident #4 upon her return to the facility. She stated the wanderguard for Resident #4 had not been discontinued. She stated staff was to monitor for placement and to conduct 15 minute checks regularly to ensure her safety. LVN D stated Resident #4 would move around the facility, but was not sure when she last eloped from the facility. LVN D stated residents sometimes had the wanderguard bracelets on the wrong side (left). She stated the censors were on the right wall of the door and they would not always detect the wanderguard when on the left side (wrist/ankle). LVN D also stated that the alarm on the South door leading to the rehabilitation room did not always sound. She stated this had been going on for at least 2 months. LVN D stated she had never participated in a mock elopement drill. However, she was able to verbalize the elopement protocol. LVN D stated staff was to take the following steps when a resident was suspected to have eloped from the facility: search premises when in question about a resident's whereabouts. If cannot locate call code Abuelita (grandmother) and continue conducting search until resident was found. If the resident was not found report it to administrative staff who would then alert the ADM. Interview on 7/6/16 at 1:27 p.m. with CNA M revealed she had worked at the facility for [AGE] years. She confirmed she worked on 5/23/16 from 6:00 a.m. to 2:00 p.m. on 200 hall. She stated the CNA who worked the night shift left without giving her report so she started her routine duties including showering residents. CNA M confirmed she did not conduct her morning rounds and did not realize Resident #4 was missing until she started passing out the breakfast trays at 7:00 a.m. She stated the resident was usually up and awake and in the dining room by 6:00 a.m. She stated she saw her male friend (another resident) in the dining room, but did not see Resident #4 in the dining room. CNA M stated she did not look for the resident at this time. She stated the nurse then told her they needed to search for Resident #4 because they could not find the resident. CNA M stated she did not know if Resident #4 had a wanderguard bracelet on that day. She stated the resident was confused and had Alzheimer's and would often wander, but had not tried to leave before this incident. CNA M stated she had no reason to believe there was a reason to be concerned about the resident eloping from the facility. However, CNA M stated she was expected to conduct morning rounds upon starting her shift and was expected to check on the residents who wandered more frequently. CNA M stated she thought most residents wore a wanderguard bracelet when asked what residents wore a wanderguard. She stated she would look to see if residents had a bracelet on during ADL care. She was unsure how to check if the device was working. CNA M stated the side door leading to the rehabilitation room did not have a code. She stated it would sound if a resident was wearing a wanderguard bracelet but if not then a resident could walk out. CNA M stated if Resident #4 was not wearing a bracelet she probably left through the side door. Interview on 7/6/16 at 4:20 p.m. with LVN B revealed she was the charge nurse on the day Resident #4 eloped from the facility. She stated she worked 6:00 a.m. to 2:00 p.m. LVN B stated it was very busy at the facility and she was anxious to start her medication pass and to start her other duties. LVN B confirmed she did not conduct rounds with the nurse who left for the day. She stated LVN V was in a hurry to leave and did not provide her with a morning report. LVN B stated she had no idea that Resident #4 had eloped. She heard the resident left and ended up at a substation 8 miles away. LVN B stated she looked at the resident when she came back to the facility. The resident reported some man asked if she needed a ride. Resident #4 also reported she fell and complained of pain to her wrist. LVN B stated she was not sure if Resident #4 was wearing a wanderguard bracelet. She stated she did not always check for placement of the wanderguard and did not know how to check if it was working. She also stated the devices did not always work or there were none available to put on residents who used them; they would be on order. She stated administrative staff was aware the devices did not always work. LVN B confirmed she understood that she was supposed to conduct morning rounds upon starting her shift but stated they had been short staffed due to high turnover of nurses. LVN B stated she often felt overwhelmed. LVN B stated she noticed the day before that the TARs had written instructions to, check for wander guard placement for those residents who wore one. She confirmed the order had not been on the TAR prior to that time and again stated she did not always check for placement. An attempt was made to call the night nurse LVN V on 7/6/16 at 6:30 p.m. A message was left and she did not return the call. Interview on 7/7/16 at 9:40 a.m. with CNA F revealed she was on duty when Resident #4 eloped from the facility. She stated she was working 100 hall and Resident #4 was on 200 hall. She stated she was familiar with the residents on both halls and knew that Resident #4 was an early riser and would meet another resident, a male friend, in the dining room for breakfast. CNA F stated she noticed that Resident #4 was not in the dining room when she was passing out trays and then she noted that a tray was sent to the hall for the resident because she did not eat in the dining room. CNA F stated she knew at that time that something was wrong and she started asking about the resident. CNA F stated she learned the night CNA left without giving report. She alerted her nurse and staff on both halls and staff then started looking for the resident and then the ADM called 911. She stated Resident #4 was found at a police substation miles away. She believed the resident was gone for hours based on the distance of the substation. CNA F stated she believed the resident left overnight. She stated she was talking with Resident #4 when she came back to the facility and stated the resident looked confused and scared. CNA F stated the resident told her, she was scared because she was lost and stated she fell 2 or 3 times. Resident #4 stated a gentleman saw her and took her to the police station. CNA F stated she did not know if Resident #4 was wearing a wanderguard device. She thought the device might have a light that would come on if it was not working. CNA F stated she was not sure how to check the device. CNA F confirmed that Resident #4 wandered the facility and they were supposed to check on the residents who wandered more frequently. Interview on 7/13/16 at 4:51 p.m. with Resident #4's RP confirmed LVN D called her to notify her that her mother had left the facility. The RP stated she went to the facility as soon as she was notified her mother left. She stated they found her mother at a police substation. The RP stated her mother was crying, confused and afraid when she saw her. Her mother reported she had fallen by some rail road tracks and a male picked her up and took her to the police station. Her mother's right arm and knee were swollen and her mother reported she also hit the back of her head. The RP stated that per the officer, her mother stumbled into the police station. The RP stated she drove from the facility to the police substation and she clocked it at 4 miles away from the facility. She stated staff told her they were going to monitor her mother every 15 minutes. She stated she visited daily and every time she visited her mother, she was not wearing a wanderguard bracelet. The RP stated it was very upsetting because her mother was very confused. The RP stated she had not been happy with the facility's care because her mother was always injured. The RP stated the SW called to let her know they could not provide her mother with the care she needed so the facility made arrangements to transfer her mother out to another facility. Review of google maps via online revealed the walking distance from the facility to the South police substation was 1.2 miles and it would take 24 minutes to walk the distance. Further review revealed there were 3 major intersections along the way to the police station. It was noted there was also a major interstate close by the facility. 2. Review of a face sheet revealed Resident #9 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Elopement Risk Alert (undated) revealed Resident #9 was identified as an elopement risk; it was noted she was ambulatory and the areas and places to focus a search would be the (rehab door and SWG hospital). Review of Resident #9's MAR for June 2016 revealed to check wanderguard placement q shift. Review of Resident #9's admission MDS dated [DATE] revealed her BIMS was a 2 indicating she was extremely cognitively impaired and she was ambulatory without the use of mobility devices. Review of Resident #9's plan of care revised on 7/7/16 did not reflect that she was an elopement risk. Review of a nurse's note dated 5/16/16 at 7:45 p.m. read: As I was walking out building for break saw (Resident #9) getting of a car. Immediately approached car and got close to driver of vehicle. She stated she worked front desk at (__ hospital) and resident was walking on premises. I immediately escorted Res. into facility. Advised CNA's supervision every 15 min till end of shift & will cont. with incoming shift. Called DON & advised, also called granddaughter and l/m no answer. Will cont. to monitor resident. Review of a nurse's note dated 6/28/16 revealed Resident #9 was up ambulating and exit seeking voicing wanted to go home. Review of nurse's note dated 6/29/16 at 8:00 a.m. revealed Resident #9 was exit seeking and was verbally and physically aggressive. Further review of the note revealed at 12:15 p.m. Resident #9 was noted in parking, staff redirected and brought resident back inside. At 12:30 p.m. Resident #9 was exit seeking and was verbally and physically abusive to staff striking out at administrator. Review of incident reports from April 2016 to June 2016 did not reveal any elopement incidents for Resident #9. Review of a discharge summary dated 6/30/16 revealed Resident #9 was transferred to another facility after the investigation was initiated. Observation on 6/28/16 at 10:50 a.m. revealed Resident #9 sitting up in a wheelchair. In talking with her she appeared very confused and her answers to questions did not correspond to the questions. Further observation revealed a wanderguard bracelet on her left wrist. Interview on 7/6/16 at 9:38 a.m. with LVN D revealed that Resident #9 had eloped from the facility several times. She stated on 5/16/16 Resident #9 was found at the hospital across the street. She stated on 6/29/16 the resident left the facility. LVN D stated residents sometimes had the wanderguard bracelets on the wrong side (left). She stated the censors were on the right wall of the door and they would not always detect the wanderguard when on the left side (wrist/ankle). LVN D also stated that the alarm on the South door leading to the rehabilitation room did not always sound. She stated this had been going on for at least 2 months. Interview on 7/6/16 at 1:00 p.m. with LVN S/MDS Coordinator revealed she was aware that Resident #9 was exit seeking, but did not have any firsthand knowledge of Resident #9 eloping. Interview on 7/6/16 at 1:50 p.m. revealed ADON T/risk mgt. was not aware that Resident #9 had eloped during May 2016. Interview on 7/6/16 at 1:57 p.m. with LVN N confirmed she was the charge nurse the day Resident #9 eloped from the facility. She reiterated what she wrote on the nurse's note dated 5/16/16. She stated she assessed the resident and stated Resident #9 had a wanderguard bracelet on. However, stated the alarm would not sound if the bracelet was covered with the resident's clothing. LVN N stated she reported the incident to the DON and wrote the nurse's note, but did not remember completing an incident report. Interview on 7/6/16 at 2:15 p.m. with the DON confirmed LVN N told her about seeing Resident #9 getting out of a strangers car. She confirmed an incident report was not completed and stated the incident was not investigated or reported to DADS. Interview on 7/6/16 at 2:28 p.m. with the ADM revealed she had witnessed Resident #9 exiting the front door not long ago. She commented the resident never left their line of sight. She stated her and the Admissions Coordinator followed her out to the parking lot and finally got the resident back into the facility. The ADM stated she could not remember if the resident had a wanderguard bracelet on. Further interview revealed the ADM did not have any knowledge about the resident eloping from the facility on 5/16/16 and that a stranger returned her to the facility. She stated the incident would have been a reportable incident, however, because she did not know about it, she did not report it to DADS. The ADM stated that her, the DON and ADON T typically conducted incident investigations. Interview on 7/6/16 at 2:56 with LVN N revealed she did not know the resident was gone and she did not ask the woman driving the car for any identifying information. LVN N stated she was more concerned about getting the resident back into the facility. LVN N stated the resident usually ate in her room, but could not remember at what point she last saw the resident that day. She stated staff had to watch her closely because she constantly wandered and was always crying and looking for her family. LVN N stated residents who sat along the South door were quick to let staff know when another resident was getting close to the door. She stated she thought Resident #9 exited through the entrance doors. Interview on 7/7/16 at 9:40 a.m. with CNA F revealed she was familiar with Resident #9. CNA F stated Resident #9 was very confused, was at risk for falling and she often wandered up and down the halls. She stated the resident would try to exit from the South door by the rehabilitation room and staff had to often re-direct her. She commented the resident was fast; required close supervision and constant re-direction. CNA F stated Resident #9 had become more and more difficult to manage; she was more demanding and aggressive especially at night. An attempt was made to contact Resident #9's RP on 7/13/16 at 2:01 p.m. She returned the call on 7/19/16 at 1:59 p.m. and stated that to her knowledge her grandmother had eloped from the facility 3 times. She stated each time a staff member confirmed it. The RP stated on one occasion her grandmother eloped to the hospital across the street and her grandmother stated, a nice handsome man brought her back. She stated it was not until the 2nd incident that staff started to put a bracelet on her grandmother. The RP stated on two separate occasions her grandmother was found in the parking lot. On the last occasion her grandmother became combative with the ADM or a nurse and she was advised that her grandmother would have to move. The RP stated that her grandmother would cry a lot and was very anxious. She stated her grandmother never seemed to like the facility much; she did not interact with many people and would not get involved in activities. 3. Review of Resident #3's face sheet dated 2/21/16 revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly MDS dated [DATE] revealed her BIMS was 7 which indicated she was cognitively moderately impaired. Further review revealed she was ambulatory with a walker. Review of Resident #3's care plan updated on 4/27/16 revealed that she was an elopement risk due to her wandering aimlessly. One of the interventions noted was to check the wanderguard for function and placement at least daily. Review of Resident #3's MAR for June 2016 did not include instructions to check for placement or function of the wanderguard. Observation on 6/28/16 at 12:21 p.m. revealed Resident #3 was lying down in bed. Further observation revealed she did not have a wanderguard bracelet on her wrists or ankles. Observation on 7/6/16 at 3:33 p.m. revealed Resident #3 was sitting up in a chair in the family room. Further observation revealed she did not have a wanderguard bracelet on her wrists or ankles. Interview with the DON at this same time confirmed this finding. The DON asked the resident about the bracelet and the resident stated she did not have one. The DON proceeded to the resident's room and she conducted a search of the resident's room for the wanderguard bracelet and did not find it. Interview on 7/6/16 at 3:37 p.m. with LVN O revealed she was Resident #3's charge nurse. She stated she did not know Resident #3 did not have a wanderguard bracelet on. LVN O stated she had not checked for placement. Interview on 7/6/16 with the DON at 3:45 p.m. revealed nursing staff was supposed to check the placement of the wanderguard every shift and the nurses were to document it on the MAR's. The DON proceeded to check Resident #3's MAR for July 2016. There were no instructions to check for placement on the MAR and the DON stated she would not be able to confirm if the nurses were checking for placement based on the MAR. The DON stated she was responsible for auditing charts and tried to audit 3 a week. She stated she had not had the time to do this in months. Review of a telephone order dated 7/6/16 read: clarification: wanderguard placement every shift (check placement). Review of Resident #3's MAR page #3 (undated) read: wander guard check placement Q shift. Further review revealed staff initials started on date 7/6/16. 4. Review of Resident #12's temporary face sheet dated 4/26/16 revealed she was admitted into the facility with [DIAGNOSES REDACTED]. Further review revealed she ambulated short distances with a w/c or walker. Review of Resident #12's admission MDS dated [DATE] revealed she was admitted into the facility on [DATE]. Further review revealed her BIMS was 5 indicating she was cognitively moderately impaired and used a wheelchair for mobility. Review of Resident #12's care plan updated on 5/18/16 revealed that she would go to the front entrance and stay; she would refuse to go to her room. One of the interventions noted was to use wanderguard. Review of telephone order dated 6/2/16 read: Resident must have wanderguard. Review of Resident #12's MAR for June 2016 read: 6/2/16 May have wanderguard on (placed on rt wrist); Wandeguard placed on right ankle (no date), there was a note to discontinue (no date). Further review read: 6/3/16 wanderguard to right ankle; it was discontinued on 6/8/16. The last instructions (undated) read: wanderguard to right side of w/c; staff initials started on 6/9/16. Review of Resident #12's MAR for July 2016 revealed that on 7/5/16 the following instructions were added, check for wanderguard placement Q shift. Interview on 6/28/16 at 7:30 a.m. with LVN B revealed the criteria for elopement was a resident who was exit seeking. She stated Resident #12 was an elopement risk and she wore a wanderguard bracelet as a security measure. LVN B stated Resident #12 would go up to the exit door at the end of 300 hall and would try to push it open. She stated staff had to monitor closely and to re-direct her as needed. LVN B stated Resident #12 was easily re-directed. Observation on 7/6/16 at 3:26 p.m. revealed Resident #12 was lying down in bed. Further observation revealed she did not have a wanderguard bracelet on her wrists or ankles. Interview with the DON at this same time confirmed this finding and she stated the resident was supposed to have one on. The DON conducted a search in the resident's room for the wanderguard bracelet and did not find it. The resident stated she did not know what happened to it. 3. Observation on 6/28/16 at 1:30 p.m. revealed LVN H testing the wanderguard system on the exit door at the end of 100 hall. It was not working properly. Further observation revealed LVN H testing the wanderguard system by swiping a wanderguard device along the right side of the wall and over the keypad. Interview at this same time with LVN H revealed the device was supposed to trigger an indicator light on the keypad and the alarm was supposed to sound. The device never triggered an indicator light on the keypad and the alarm did not sound. In addition, the alarm never sounded when LVN H opened the door. LVN H was observed repeating this procedure multiple times. LVN H was asked to check the functionality of the wanderguard system and she tested each of the 6 exit doors and the entrance doors. Observation on 6/28/16 at 1:40 p.m. revealed the ADM testing the alarm on the same exit door on the end of 100 hall using the same procedure as LVN H used. The wanderguard device did not trigger the indicator light and the alarm did not sound. However, the alarm sounded when she opened the door. She repeated this procedure multiple times. The ADM stated she would have her Maintenance Supervisor look at it. Interview on 7/5/16 at 4:40 p.m. with the M.S. revealed he made sure all exit doors were working every morning. Observation at this same time revealed he checked the side door exiting 100 hall and it sounded when he pushed it open. The M.S. stated the only doors armed with a wanderguard device were the entrance doors and the South door leading to the rehabilitation room. Observation on 7/6/16 at 3:15 p.m. revealed the alarm on the entrance doors did not sound and the doors did not lock when the wanderguard system was tested by using a wanderguard device. The indicator light went off on the keypad, but there was no sound. Interview at this same time with the DON confirmed that the alarm did not sound and the doors did not lock. The DON s

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibited neglect of residents for 2 of 11 residents (#4 & #9) who were reviewed for neglect in that: 1. Nursing staff did not ensure Resident #4, who was an elopement risk, had a wanderguard bracelet on. LVN B and LVN V did not conduct morning rounds. Resident #4 eloped from the facility; was gone for at least 2 and 1/2 hours and no one knew she was gone. A stranger gave her a ride to the police station. 2. Nursing staff did not ensure Resident #9, who was an elopement risk, had a wanderguard bracelet on the right ankle. Resident #9 eloped from the facility and was gone an undetermined amount of time. A stranger returned her to the facility. 3. LVN O did not ensure Resident #3, who was an elopement risk, had a wanderguard bracelet on. 4. Nursing staff did not ensure Resident #12, who was an elopement risk, did not have a wanderguard bracelet on. 5. The ADM and MS did not ensure the wanderguard system was working properly on the two doors equipped with a wanderguard system; the entrance doors and the South door by the rehabilitation room. In addition, the MS did not ensure the alarm on the exit door at the end of 100 hall was working properly. 6. The DON did not ensure that staff were trained and knew what doors were armed with a wanderguard system or how to check the wanderguard devices for functionality. These deficient practices resulted in an Immediate Jeopardy (IJ) on 7/6/16. The IJ was removed on 7/7/16. The facility remained out of compliance at a scope of pattern at no actual harm with potential for more than minimal harm due to the facility's need to complete in-service training and to evaluate the effectiveness of their corrective systems. These deficient practices could affect 11 residents who were identified as an elopement risk and placed the residents at risk for eloping. The findings were: 1. Review of a facility policy, Abuse and Neglect Prevention dated 7/28/15 read: The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. It is the policy of the facility, to ensure that each resident is treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. (Neglect) is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a Resident does receive a lack of care in one or more areas (e.g., failure to provide assistance with feeding for a resident known to require assistance with meal service). Review of facility policy, Prevention of Elopement dated 8/1/15 read: To provide a safe environment by assessing residents' risk factors and implementing a plan of care to prevent accidents related to wandering behavior or elopement. Assessments will be conducted upon admission/readmission and upon significant change in condition for all residents and then quarterly for those residents identified at risk for wandering behavior or elopement. Elopement is defined as leaving the facility or supervised environment without accompaniment or knowledge of the staff prior to their scheduled discharge. Residents with Alzheimer ' s Disease/Dementia that are independently ambulatory will be automatically considered at risk for elopement and an individualized care plan will be implemented and quarterly assessments will be completed. Facilities with door alarms should place a (wander guard alarm bracelet) on the resident and have the alarms activated at all times when clinically indicated. Residents wearing wander guard alarm bracelets will have the presence and function checked routinely. 1. Review of a face sheet revealed Resident #4 was admitted into the facility on [DATE]. Review of physician orders [REDACTED].#4's [DIAGNOSES REDACTED]. Review of a Wander Data Collection Tool dated 12/14/15 revealed Resident #4 was an elopement risk and the interventions were to use personal safety alarm devices on exit and stairwell alarms. Review of an Elopement Risk Alert dated 3/21/16 revealed Resident #4 was an elopement risk and the areas and places to focus a search were the South rehab door and outside. Review of a quarterly MDS dated [DATE] revealed Resident #4's BIMS was a 3 indicating she was severely cognitively impaired and that she had Non-Alzheimer's Dementia. Review of Elopement Risk assessment dated [DATE] revealed Resident #4's score was a 2 indicating there was no potential for elopement. Review of a t.o. dated 4/1/16 revealed the use of the wanderguard was discontinued for Resident #4. Review of a care plan dated 4/27/16 revealed Resident #4 would remove the wanderguard. Further review revealed to monitor and replace. Review of the provider investigation report dated 5/27/16 revealed that on 5/23/16 Resident #4 eloped from the facility. Resident #4 was last seen about 5:00 a.m. Staff noticed she was not at breakfast at 7:30 a.m. and initiated a search of the facility and surrounding grounds. The ADM called 911 at 8:54 a.m. At 9:00 a.m. Officer R called the ADM and let her know the resident had walked into the substation at 6:00 a.m. The resident was confused but able to give Officer R her brother's name and phone number. Officer R contacted the brother and attempted to contact the daughters. She had EMS assess the resident and no injuries were noted. Officer R returned Resident #4 to the facility at 9:30 a.m. An assessment was completed and an X-Ray was ordered because she complained of pain to her wrist. The resident's vital signs were stable and there were no signs of dehydration. The X-Ray results were normal. The resident apologized for leaving the facility and stated she wanted to get some fresh air and to see her daughters. Further review revealed Resident #4 eloped during 12/15 but had not eloped since that time. The findings were confirmed, however, it was noted: it does not rise to the level of neglect. It was noted that 1 staff statement (CNA J) was attached to the investigation report. Review of a nurse's note dated 5/23/16 revealed that a CNA notified LVN D at 7:30 a.m. that Resident #4 was not in her room and staff started searching the premises and grounds. At 9:09 a.m. LVN D called the daughter who was upset and asking if she had that bracelet to lock doors and explained to her that she removes bracelets and hides them. Review of a nurse's note dated 5/23/16 at 1300 (1:00 p.m.) revealed Resident #4 returned to the facility from pass with the daughter. Resident #4 requested left wrist wrapped for comfort. Review of a telephone order dated 5/23/16 read: X-Ray to left wrist fall Review of a Final X-Ray Report dated 5/23/16 revealed Resident #4 had mild osteopenia but no acute fractures or subluxations were identified. Review of a nurse's note dated 5/24/16 at 9:55 p.m. read Resident #4 back from out on pass with daughter. States was taken to (Dr. _____) and was diagnosed with [REDACTED]. Splint was placed on wrist. Resident wearing splint @ this time. No orders were brought with daughter. Review of Resident #4's care plan revised on 5/23/16 identified that she wandered due to Dementia and the interventions and approaches listed were: 1. Nursing to assess resident. 2. Contact physician and RP. 3. Provide treatments and meds as ordered. 4. resident complained of pain to wrist X-rays. 5. Q 15 min checks. 6. Wanderguard in place. 7. Find resident secure unit. Review of in-Services from February to June 2016 revealed in-services were conducted on the prevention of elopement on 2/5/16, 5/13/16 and on 5/23/16. Further review of the in-service dated 5/23/16 revealed the content discussed was safety checks for Resident #4 and all residents at risk for exit seeking. The content read: Check placement of wanderguard at each occurrence of visit. At a minimum check placement every 2 hours-right wrist! Visually check resident every 15 minutes to verify whereabouts. If found exit seeking, talk to resident to find out her needs. Re-direct as necessary. Report any incidents to nurse. Further review of nurse's notes from 5/24/16 to 6/2/16 revealed that Resident #4 removed the wanderguard bracelet at least 10 times; she was on 15 minute checks and finally the wanderguard bracelet was placed on the back center belt loop for elopement safety. Review of a Discharge Summary dated 6/4/16 revealed Resident #4 was transferred to another facility. Interview on 7/5/16 at 3:18 p.m. with the ADM revealed while interviewing staff about Resident #4's elopement, CNA J stated she saw Resident #4 in the hallway about 5:00 a.m. She stated she also interviewed LVN D, CNA F and CNA M who started their shifts at 6:00 a.m. The ADM stated CNA M reported she did not conduct her rounds upon starting her shift which the ADM stated would be what staff was expected to do. The ADM stated LVN U was the night nurse and no contact was made with him. The ADM stated the resident would wander all over the facility and go into other residents' rooms to sleep. She stated she called the police when staff completed their search and determined the resident was not in the facility. The ADM stated LVN D contacted the residents' 2 daughters and they came to the facility. They were very upset. The ADM confirmed that there was a question of lack of supervision due to the 2 and 1/2 hour period that staff could not account for the resident's whereabouts. However, she stated she did not believe staff was neglectful because there was no willful intent. The ADM stated they completed in-services on elopement and conducted mock elopement drills every quarter or at least twice a year. Interview on 7/5/16 at 3:46 p.m. with the DON revealed Resident #4's reasoning skills were very much compromised. She stated an elopement risk assessment was completed in March 2016 and her score was low which indicated a wander guard bracelet did not have to be used. She stated Resident #4 had not tried to exit since December 2015. However, she stated the wanderguard bracelet served as a reminder for the resident not to leave the facility. The DON stated she did not provide staff who did not conduct their morning rounds verbal counseling. Interview on 7/5/16 at 4:25 p.m. with the DON revealed that Resident #4 was not wearing a wanderguard bracelet upon her return to the facility. However, confirmed again that nursing staff were using a wanderguard bracelet for monitoring purposes. Interview on 7/6/16 at 9:38 a.m. with LVN D revealed she was on duty when Resident #4 eloped from the facility. She stated she was working 100 hall and LVN B was working 200 hall; Resident #4 was on 200 hall. LVN D stated staff was aware that Resident #4 was a wanderer and that the resident would take the wanderguard bracelet off. She stated she did not see Resident #4 that morning, but then CNA's F & M let her know they did not see Resident #4 at breakfast between 7:10 and 7:15 a.m. LVN D stated she reported the resident's elopement to the DON and conducted a search of the facility and surrounding grounds. She learned later that morning that Resident #4 had been at the police station since about 4:00 a.m. LVN D stated Resident #4's daughter was upset when she notified her that her mother was missing. She stated she did not see a wanderguard bracelet on Resident #4 upon her return to the facility. She stated the wanderguard for Resident #4 had not been discontinued. She stated staff was to monitor for placement and to conduct 15 minute checks regularly to ensure her safety. LVN D stated Resident #4 would move around the facility, but was not sure when she last eloped from the facility. LVN D stated residents sometimes had the wanderguard bracelets on the wrong side (left). She stated the censors were on the right wall of the door and they would not always detect the wanderguard when on the left side (wrist/ankle). LVN D also stated that the alarm on the South door leading to the rehabilitation room did not always sound. She stated this had been going on for at least 2 months. LVN D stated she had never participated in a mock elopement drill. However, she was able to verbalize the elopement protocol. LVN D stated staff was to take the following steps when a resident was suspected to have eloped from the facility: search premises when in question about a resident's whereabouts. If cannot locate call code Abuelita (grandmother) and continue conducting search until resident was found. If the resident was not found report it to administrative staff who would then alert the ADM. Interview on 7/6/16 at 1:27 p.m. with CNA M revealed she had worked at the facility for [AGE] years. She confirmed she worked on 5/23/16 from 6:00 a.m. to 2:00 p.m. on 200 hall. She stated the CNA who worked the night shift left without giving her report so she started her routine duties including showering residents. CNA M confirmed she did not conduct her morning rounds and did not realize Resident #4 was missing until she started passing out the breakfast trays at 7:00 a.m. She stated the resident was usually up and awake and in the dining room by 6:00 a.m. She stated she saw her male friend (another resident) in the dining room, but did not see Resident #4 in the dining room. CNA M stated she did not look for the resident at this time. She stated the nurse then told her they needed to search for Resident #4 because they could not find the resident. CNA M stated she did not know if Resident #4 had a wanderguard bracelet on that day. She stated the resident was confused and had Alzheimer's and would often wander, but had not tried to leave before this incident. CNA M stated she had no reason to believe there was a reason to be concerned about the resident eloping from the facility. However, CNA M stated she was expected to conduct morning rounds upon starting her shift and was expected to check on the residents who wandered more frequently. CNA M stated she thought most residents wore a wanderguard bracelet when asked what residents wore a wanderguard. She stated she would look to see if residents had a bracelet on during ADL care. She was unsure how to check if the device was working. CNA M stated the side door leading to the rehabilitation room did not have a code. She stated it would sound if a resident was wearing a wanderguard bracelet but if not then a resident could walk out. CNA M stated if Resident #4 was not wearing a bracelet she probably left through the side door. Interview on 7/6/16 at 4:20 p.m. with LVN B revealed she was the charge nurse on the day Resident #4 eloped from the facility. She stated she worked 6:00 a.m. to 2:00 p.m. LVN B stated it was very busy at the facility and she was anxious to start her medication pass and to start her other duties. LVN B confirmed she did not conduct rounds with the nurse who left for the day. She stated LVN V was in a hurry to leave and did not provide her with a morning report. LVN B stated she had no idea that Resident #4 had eloped. She heard the resident left and ended up at a substation 8 miles away. LVN B stated she looked at the resident when she came back to the facility. The resident reported some man asked if she needed a ride. Resident #4 also reported she fell and complained of pain to her wrist. LVN B stated she was not sure if Resident #4 was wearing a wanderguard bracelet. She stated she did not always check for placement of the wanderguard and did not know how to check if it was working. She also stated the devices did not always work or there were none available to put on residents who used them; they would be on order. She stated administrative staff was aware the devices did not always work. LVN B confirmed she understood that she was supposed to conduct morning rounds upon starting her shift but stated they had been short staffed due to high turnover of nurses. LVN B stated she often felt overwhelmed. LVN B stated she noticed the day before that the TARs had written instructions to, check for wander guard placement for those residents who wore one. She confirmed the order had not been on the TAR prior to that time and again stated she did not always check for placement. An attempt was made to call the night nurse LVN V on 7/6/16 at 6:30 p.m. A message was left and she did not return the call. Interview on 7/7/16 at 9:40 a.m. with CNA F revealed she was on duty when Resident #4 eloped from the facility. She stated she was working 100 hall and Resident #4 was on 200 hall. She stated she was familiar with the residents on both halls and knew that Resident #4 was an early riser and would meet another resident, a male friend, in the dining room for breakfast. CNA F stated she noticed that Resident #4 was not in the dining room when she was passing out trays and then she noted that a tray was sent to the hall for the resident because she did not eat in the dining room. CNA F stated she knew at that time that something was wrong and she started asking about the resident. CNA F stated she learned the night CNA left without giving report. She alerted her nurse and staff on both halls and staff then started looking for the resident and then the ADM called 911. She stated Resident #4 was found at a police substation miles away. She believed the resident was gone for hours based on the distance of the substation. CNA F stated she believed the resident left overnight. She stated she was talking with Resident #4 when she came back to the facility and stated the resident looked confused and scared. CNA F stated the resident told her, she was scared because she was lost and stated she fell 2 or 3 times. Resident #4 stated a gentleman saw her and took her to the police station. CNA F stated she did not know if Resident #4 was wearing a wanderguard device. She thought the device might have a light that would come on if it was not working. CNA F stated she was not sure how to check the device. CNA F confirmed that Resident #4 wandered the facility and they were supposed to check on the residents who wandered more frequently. Interview on 7/13/16 at 4:51 p.m. with Resident #4's RP confirmed LVN D called her to notify her that her mother had left the facility. The RP stated she went to the facility as soon as she was notified her mother left. She stated they found her mother at a police substation. The RP stated her mother was crying, confused and afraid when she saw her. Her mother reported she had fallen by some rail road tracks and a male picked her up and took her to the police station. Her mother's right arm and knee were swollen and her mother reported she also hit the back of her head. The RP stated that per the officer, her mother stumbled into the police station. The RP stated she drove from the facility to the police substation and she clocked it at 4 miles away from the facility. She stated staff told her they were going to monitor her mother every 15 minutes. She stated she visited daily and every time she visited her mother, she was not wearing a wanderguard bracelet. The RP stated it was very upsetting because her mother was very confused. The RP stated she had not been happy with the facility's care because her mother was always injured. The RP stated the SW called to let her know they could not provide her mother with the care she needed so the facility made arrangements to transfer her mother out to another facility. Review of google maps via online revealed the walking distance from the facility to the South police substation was 1.2 miles and it would take 24 minutes to walk the distance. Further review revealed there were 3 major intersections along the way to the police station. It was noted there was also a major interstate close by the facility. 2. Review of a face sheet revealed Resident #9 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Elopement Risk Alert (undated) revealed Resident #9 was identified as an elopement risk; it was noted she was ambulatory and the areas and places to focus a search would be the (rehab door and SWG hospital). Review of Resident #9's MAR for June 2016 revealed to check wanderguard placement q shift. Review of Resident #9's admission MDS dated [DATE] revealed her BIMS was a 2 indicating she was extremely cognitively impaired and she was ambulatory without the use of mobility devices. Review of Resident #9's plan of care revised on 7/7/16 did not reflect that she was an elopement risk. Review of a nurse's note dated 5/16/16 at 7:45 p.m. read: As I was walking out building for break saw (Resident #9) getting of a car. Immediately approached car and got close to driver of vehicle. She stated she worked front desk at (__ hospital) and resident was walking on premises. I immediately escorted Res. into facility. Advised CNA's supervision every 15 min till end of shift & will cont. with incoming shift. Called DON & advised, also called granddaughter and l/m no answer. Will cont. to monitor resident. Review of a nurse's note dated 6/28/16 revealed Resident #9 was up ambulating and exit seeking voicing wanted to go home. Review of nurse's note dated 6/29/16 at 8:00 a.m. revealed Resident #9 was exit seeking and was verbally and physically aggressive. Further review of the note revealed at 12:15 p.m. Resident #9 was noted in parking, staff redirected and brought resident back inside. At 12:30 p.m. Resident #9 was exit seeking and was verbally and physically abusive to staff striking out at administrator. Review of incident reports from April 2016 to June 2016 did not reveal any elopement incidents for Resident #9. Review of a discharge summary dated 6/30/16 revealed Resident #9 was transferred to another facility after the investigation was initiated. Observation on 6/28/16 at 10:50 a.m. revealed Resident #9 sitting up in a wheelchair. In talking with her she appeared very confused and her answers to questions did not correspond to the questions. Further observation revealed a wanderguard bracelet on her left wrist. Interview on 7/6/16 at 9:38 a.m. with LVN D revealed that Resident #9 had eloped from the facility several times. She stated on 5/16/16 Resident #9 was found at the hospital across the street. She stated on 6/29/16 the resident left the facility. LVN D stated residents sometimes had the wanderguard bracelets on the wrong side (left). She stated the censors were on the right wall of the door and they would not always detect the wanderguard when on the left side (wrist/ankle). LVN D also stated that the alarm on the South door leading to the rehabilitation room did not always sound. She stated this had been going on for at least 2 months. Interview on 7/6/16 at 1:00 p.m. with LVN S/MDS Coordinator revealed she was aware that Resident #9 was exit seeking, but did not have any firsthand knowledge of Resident #9 eloping. Interview on 7/6/16 at 1:50 p.m. revealed ADON T/risk mgt. was not aware that Resident #9 had eloped during May 2016. Interview on 7/6/16 at 1:57 p.m. with LVN N confirmed she was the charge nurse the day Resident #9 eloped from the facility. She reiterated what she wrote on the nurse's note dated 5/16/16. She stated she assessed the resident and stated Resident #9 had a wanderguard bracelet on. However, stated the alarm would not sound if the bracelet was covered with the resident's clothing. LVN N stated she reported the incident to the DON and wrote the nurse's note, but did not remember completing an incident report. Interview on 7/6/16 at 2:15 p.m. with the DON confirmed LVN N told her about seeing Resident #9 getting out of a strangers car. She confirmed an incident report was not completed and stated the incident was not investigated or reported to DADS. Interview on 7/6/16 at 2:28 p.m. with the ADM revealed she had witnessed Resident #9 exiting the front door not long ago. She commented the resident never left their line of sight. She stated her and the Admissions Coordinator followed her out to the parking lot and finally got the resident back into the facility. The ADM stated she could not remember if the resident had a wanderguard bracelet on. Further interview revealed the ADM did not have any knowledge about the resident eloping from the facility on 5/16/16 and that a stranger returned her to the facility. She stated the incident would have been a reportable incident, however, because she did not know about it, she did not report it to DADS. The ADM stated that her, the DON and ADON T typically conducted incident investigations. Interview on 7/6/16 at 2:56 with LVN N revealed she did not know the resident was gone and she did not ask the woman driving the car for any identifying information. LVN N stated she was more concerned about getting the resident back into the facility. LVN N stated the resident usually ate in her room, but could not remember at what point she last saw the resident that day. She stated staff had to watch her closely because she constantly wandered and was always crying and looking for her family. LVN N stated residents who sat along the South door were quick to let staff know when another resident was getting close to the door. She stated she thought Resident #9 exited through the entrance doors. Interview on 7/7/16 at 9:40 a.m. with CNA F revealed she was familiar with Resident #9. CNA F stated Resident #9 was very confused, was at risk for falling and she often wandered up and down the halls. She stated the resident would try to exit from the South door by the rehabilitation room and staff had to often re-direct her. She commented the resident was fast; required close supervision and constant re-direction. CNA F stated Resident #9 had become more and more difficult to manage; she was more demanding and aggressive especially at night. An attempt was made to contact Resident #9's RP on 7/13/16 at 2:01 p.m. She returned the call on 7/19/16 at 1:59 p.m. and stated that to her knowledge her grandmother had eloped from the facility 3 times. She stated each time a staff member confirmed it. The RP stated on one occasion her grandmother eloped to the hospital across the street and her grandmother stated, a nice handsome man brought her back. She stated it was not until the 2nd incident that staff started to put a bracelet on her grandmother. The RP stated on two separate occasions her grandmother was found in the parking lot. On the last occasion her grandmother became combative with the ADM or a nurse and she was advised that her grandmother would have to move. The RP stated that her grandmother would cry a lot and was very anxious. She stated her grandmother never seemed to like the facility much; she did not interact with many people and would not get involved in activities. 3. Review of Resident #3's face sheet dated 2/21/16 revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly MDS dated [DATE] revealed her BIMS was 7 which indicated she was cognitively moderately impaired. Further review revealed she was ambulatory with a walker. Review of Resident #3's care plan updated on 4/27/16 revealed that she was an elopement risk due to her wandering aimlessly. One of the interventions noted was to check the wanderguard for function and placement at least daily. Review of Resident #3's MAR for June 2016 did not include instructions to check for placement or function of the wanderguard. Observation on 6/28/16 at 12:21 p.m. revealed Resident #3 was lying down in bed. Further observation revealed she did not have a wanderguard bracelet on her wrists or ankles. Observation on 7/6/16 at 3:33 p.m. revealed Resident #3 was sitting up in a chair in the family room. Further observation revealed she did not have a wanderguard bracelet on her wrists or ankles. Interview with the DON at this same time confirmed this finding. The DON asked the resident about the bracelet and the resident stated she did not have one. The DON proceeded to the resident's room and she conducted a search of the resident's room for the wanderguard bracelet and did not find it. Interview on 7/6/16 at 3:37 p.m. with LVN O revealed she was Resident #3's charge nurse. She stated she did not know Resident #3 did not have a wanderguard bracelet on. LVN O stated she had not checked for placement. Interview on 7/6/16 with the DON at 3:45 p.m. revealed nursing staff was supposed to check the placement of the wanderguard every shift and the nurses were to document it on the MAR's. The DON proceeded to check Resident #3's MAR for July 2016. There were no instructions to check for placement on the MAR and the DON stated she would not be able to confirm if the nurses were checking for placement based on the MAR. Review of a telephone order dated 7/6/16 read: clarification: wanderguard placement every shift (check placement). Review of Resident #3's MAR page #3 (undated) read: wander guard check placement Q shift. Further review revealed staff initials started on date 7/6/16. 4. Review of Resident #12's temporary face sheet dated 4/26/16 revealed she was admitted into the facility with [DIAGNOSES REDACTED]. Further review revealed she ambulated short distances with a w/c or walker. Review of Resident #12's admission MDS dated [DATE] revealed she was admitted into the facility on [DATE]. Further review revealed her BIMS was 5 indicating she was cognitively moderately impaired and used a wheelchair for mobility. Review of Resident #12's care plan updated on 5/18/16 revealed that she would go to the front entrance and stay; she would refuse to go to her room. One of the interventions noted was to use wanderguard. Review of telephone order dated 6/2/16 read: Resident must have wanderguard. Review of Resident #12's MAR for June 2016 read: 6/2/16 May have wanderguard on (placed on rt wrist); Wandeguard placed on right ankle (no date), there was a note to discontinue (no date). Further review read: 6/3/16 wanderguard to right ankle; it was discontinued on 6/8/16. The last instructions (undated) read: wanderguard to right side of w/c; staff initials started on 6/9/16. Review of Resident #12's MAR for July 2016 revealed that on 7/5/16 the following instructions were added, check for wanderguard placement Q shift. Interview on 6/28/16 at 7:30 a.m. with LVN B revealed the criteria for elopement was a resident who was exit seeking. She stated Resident #12 was an elopement risk and she wore a wanderguard bracelet as a security measure. LVN B stated Resident #12 would go up to the exit door at the end of 300 hall and would try to push it open. She stated staff had to monitor closely and to re-direct her as needed. LVN B stated Resident #12 was easily re-directed. Observation on 7/6/16 at 3:26 p.m. revealed Resident #12 was lying down in bed. Further observation revealed she did not have a wanderguard bracelet on her wrists or ankles. Interview with the DON at this same time confirmed this finding and she stated the resident was supposed to have one on. The DON conducted a search in the resident's room for the wanderguard bracelet and did not find it. The resident stated she did not know what happened to it. 3. Observation on 6/28/16 at 1:30 p.m. revealed LVN H testing the wanderguard system on the exit door at the end of 100 hall. It was not working properly. Further observation revealed LVN H testing the wanderguard system by swiping a wanderguard d

Based on observation, interview, and record review, the facility failed to ensure the resident environment was as free of accident hazards as was possible and that each resident received adequate supervision to prevent accidents for 6 of 6 residents (Resident #s 15, 14, 19, 11, 13, and 20) on 4 of 5 halls (100, 200, 300, and 500) whose care was reviewed for safe smoking in that: 1. Resident #13 had an incident of suspected smoking in her room. There was no evidence that this incident was investigated. Resident #13's evaluation for unsupervised smoking was incomplete, and her care plan did not address smoking. She was not supervised while smoking, smoked in an area not designated for smoking, and had a lighter in her purse. 2. Resident #s 15, 14, and 19 were not evaluated for unsupervised smoking, informed of the facility smoking policy and regulations, and care-planned for smoking for 26 days after admission. They were not supervised while smoking and had cigarettes and lighters in their rooms. 3. Resident #11 was not evaluated for unsupervised smoking and informed of the facility smoking policy and regulations for 26 days after admission. He was not supervised while smoking and had cigarettes in his room. 4. Resident #20 refused to sign the safe smoking agreement. Her evaluation for unsupervised smoking was incomplete. She was not supervised while smoking and had cigarettes and a lighter in her possession. 5. Cigarette butts were found in grassy areas, around the diesel generator, and outside of the designated smoking area. 6. The designated area for resident smoking included ash trays not approved by the National Fire Protection Association and trash cans being used for trash and cigarette butts. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) at 2:05 p.m. on 3/5/15. While the IJ was removed, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet completing in-service training for all staff on enforcement of the smoking policy and not having all residents who smoked sign a safe smoking agreement. These failures could result in fire hazard with injury and could affect 74 residents living in the 100, 200, 300, and 500 halls of the facility. The findings were: 1. Record review of Resident #13's care plan revealed admission date of [DATE] with [DIAGNOSES REDACTED]. Her care plan did not address smoking. Record review of Resident #13's significant change MDS assessment (ARD 12/22/14) revealed that she scored a 15 on the BIMS (indicating that she was cognitively intact). Record review of Resident #13's safe smoking agreement dated 2/18/15 revealed that she signed it. Record review of Resident #13's evaluation for unsupervised smoking dated 2/18/15 revealed that it was incomplete. There was no indication of whether or not Resident #13 was able to or not able to smoke unsupervised. Mild cognitive impairment was documented. Record review of Resident #13's nursing note dated 11/17/14 revealed Resident was given a 30-day discharge notice today due to the incident last night of her smoking in her room, which was reported to the SW (social worker) this morning. Resident denies she was smoking in her room. She states she was smoking outside on the wheelchair ramp and the fire alarm went off. Record review of Resident #13's nursing note dated 11/19/14 revealed On 11/17/14 4:30 a.m. 11/7 nurse called. The alarm system has been ringing and unable to reset. Fireman having trouble resetting. Called (the ADON). Nurse stated resident on 100 hall found smoking in her room. Record review of Resident #13's nursing note dated 2/21/15 revealed Resident was observed leaving the foyer area between the 100 hall and rehab in order to go outside and smoke. Immediately after being witnessed going towards the outside door, the fire station next to the door was activated, causing the fire alarm to sound. This is the third episode where the fire alarm has sounded and the only person near the alarm was this resident. The fire department was dispatched to the facility. A search of the building found no fire or smoke. During an interview with the ADON at 1:05 p.m. on 3/5/15, she reported that Resident #13 had smoked in the lobby area between the rehabilitation gym and the 100 hall. During an interview with the rehabilitation director at 8:07 a.m. on 3/6/15, she reported that she had never seen Resident #13 smoking in the lobby area but had seen her smoking outside of the rehabilitation/100 hall lobby area doors unsupervised and not in the designated smoking area. During an interview with MDS Coordinator R at 8:12 a.m. on 3/6/15, she reported that Resident #13 smoked in the outside area between the rehabilitation gym and the 100 hall often without supervision. She reported that there was no ash tray in this area - just a plastic trash can - and that this area was not the designated smoking area. During an interview with the ADON at 3:56 p.m. on 3/5/15, she reported that there was no incident/accident report for Resident #13's smoking incident because no staff actually saw her smoking and because she denied it. There was no evidence that Resident #13's smoking incident was investigated and/or that corrective measures were put in place to prevent it from reoccurring. During an interview with Resident #13 at 11:18 a.m. on 3/5/15, she reported that her lighter was in her purse. 2. Review of Resident #15's facesheet dated 3/3/15 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #15's admission MDS assessment (ARD 2/11/15) revealed that she scored a 12 on the BIMS (indicating that she was cognitively intact). Review of Resident #15's clinical record revealed no evaluation for unsupervised smoking, no safe smoking agreement, and no care plan to address smoking. During the group interview at 9:15 a.m. on 3/5/15, Resident #15 had cigarettes and a lighter in her possession. Observation of Resident #15's bedroom at 10:07 a.m. on 3/5/15 revealed 2 packs of cigarettes and a lighter on her bedside table. Observation of the smoking area on 3/5/15 at 11:00 a.m. revealed Resident #15 was smoking without staff supervision. In an interview with Resident #15 on 3/5/15 at 11:04 a.m., she confirmed that cigarettes and a lighter were kept in her possession. During an interview with Resident #15 at 11:15 a.m. on 3/5/15, the DON asked her where her lighter was. Resident #15 then handed her lighter to the DON. 3. Record review of Resident #14's facesheet dated 2/12/15 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #14's admission MDS assessment (ARD 2/20/15) revealed that he scored a 15 on the BIMS (indicating that he was cognitively intact). Record review of Resident #14's social services assessment dated [DATE] revealed that he preferred to use tobacco product daily. Record review of Resident #14's MDS assessment (ARD 2/20/15) and progress note dated 2/20/15 revealed that he was a smoker. Review of Resident #14's clinical record revealed no evaluation for unsupervised smoking and no safe smoking agreement. Record review of Resident #14's care plan (initiated 2/26/15) revealed that it did not address smoking. Observation of Resident #14's bedroom on 3/5/15 at 10:38 a.m. revealed a lighter located in his dresser drawer. During an interview with the maintenance assistant and LVN H at this time, they confirmed that the lighter was in Resident #14's drawer and reported that lighters were supposed to be kept in a bucket in the medication room. Observation of a bucket in the medication room (intended for lighters) at 10:52 a.m. on 3/5/15 revealed that no lighters were in it. Observation of the smoking area on 3/5/15 at 2:20 p.m. revealed that Resident #14 lit a cigarette with a lighter and placed the lighter in his pocket. There was no staff present while resident #14 was in the smoking area and smoking. Observation revealed that Resident #14 lit a second cigarette using the already-lit cigarette. Further observation revealed that Resident #14 extinguished his cigarette on the metal chair and tossed the butt on the ground. Further observation revealed that Resident #14 picked up the cigarette butt off of the ground and tossed both cigarette butts into the black metal trash can. 4. Record review of Resident #19's facesheet dated 2/12/15 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #19's admission MDS assessment (ARD 2/20/15) revealed that he scored greater than 5 and less than 8 on the BIMS (indicating that he had moderately-impaired cognition). Record review of Resident #19's social services assessment dated [DATE] revealed that he preferred to use tobacco product daily. Record review of Resident #19's MDS assessment (ARD 2/20/15) revealed that he was a smoker. Review of Resident #19's clinical record revealed no evaluation for unsupervised smoking and no safe smoking agreement. Record review of Resident #19's care plan (initiated 2/26/15) revealed that it did not address smoking. During group interview at 9:15 a.m. on 3/5/15, Resident #19 reported that there was no set schedule to smoking and no staff supervision. Resident #19 reported that cigarettes and lighters were kept in his possession. Observation of the smoking area on 3/5/15 at 11:00 a.m. revealed Resident #19 was smoking without staff supervision. Resident #19 was observed lighting Resident #15's cigarette for her. During an interview with Resident #19 at 11:12 a.m. on 3/5/15, he reported that his lighter was in his pocket. The DON observed and confirmed this. 5. Record review of Resident #11's care plan (initiated 2/26/15) revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's admission MDS assessment (ARD 2/20/15) revealed that he was cognitively intact. During an interview with Resident #11 in his room at 10:13 a.m. on 3/5/15, he reported that he had cigarettes in his pocket and pulled out 3 cigarettes to show the surveyor. Record review of Resident #11's MDS assessment (ARD 2/20/15), diet roster dated 2/7/15, and activities progress note dated 2/19/15 revealed that he was a smoker. Review of Resident #11's clinical record revealed no evaluation for unsupervised smoking and no safe smoking agreement. Record review of Resident #11's care plan revealed smoking interventions/tasks (initiated on 2/26/15 and revised on 3/2/15) that nursing staff was to store his cigarettes and lighters in a secured location, that he was to smoke in designated areas only, that smoking assessment was to be completed on admission and quarterly as long as he continued to smoke, and that his smoking activity was to be supervised as needed. 6. Review of Resident #20's facesheet (not dated) revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's quarterly MDS assessment (ARD 1/16/15) revealed that she was unable to complete the BIMS (indicating severe cognitive impairment). Record review of Resident #20's annual MDS assessment (ARD 10/23/14) revealed that she used tobacco product daily. Record review of Resident #20's safe smoking agreement dated 2/18/15 revealed that she refused to sign it. Handwritten on this agreement was (ADON) spoke with her . Sent (the administrator) an email 2/19/15. Record review of Resident #20's evaluation for unsupervised smoking dated 2/18/15 revealed that it was incomplete. Questions pertaining to physical ability numbered 6-8 and 10 were not answered. There was no indication of whether or not Resident #20 was able to or not able to smoke unsupervised. Record review of Resident #20's care plan (last revised 1/30/15) revealed that she had right-sided [DIAGNOSES REDACTED], impaired visual function, and impaired communication and wished to smoke. Interventions/tasks pertaining to smoking dated 7/14/13, 9/5/14, and 1/30/15 revealed that Resident #20 was to be encouraged to smoke in designated areas only, that Resident #20 was to be monitored for any decline in smoking ability, that nursing staff were to store her cigarettes and lighters in a secured location, that a smoking apron was to be provided as indicated, that smoking assessment was to be completed on admission and quarterly as long as she continued to smoke, and that her smoking activity was to be supervised as needed. Observation of the smoking area on 3/5/15 at 11:36 a.m. revealed Resident #20 smoking without staff supervision. During an interview with LVN H on 3/5/15 at 11:36 a.m., she reported that Resident #20 did not check out cigarettes or a lighter from her prior to going outside to smoke nor did she have a lighter or cigarettes belonging to Resident #20. 7. Observation of the outside environment on 3/4/15 at 10:22 a.m. revealed 8 cigarette butts scattered on the grassy area located on the left side of the entrance door. Observation of the rehabilitation entrance door revealed 48 cigarette butts on the ground, 16 cigarette butts by the end of the rehabilitation ramp, and 29 cigarette butts in the grassy area. Observation of the back area of the rehabilitation side of the building revealed a picnic table with 25 cigarette butts on the ground. Observation of the 300 hall revealed 19 cigarette butts scattered on the ground outside the exit door. Observation of the front generator area on 3/4/15 at 10:48 a.m. revealed 19 cigarette butts scattered on the ground and 10 cigarette butts behind the generator. Further observation revealed 13 cigarette butts scattered on the ground by the walkway near the generator. In an interview with the Director of Maintenance on 3/4/15 at 10:52 a.m., he confirmed there were cigarette butts within the diesel generator area and reported that he would address it with the Administrator. The Director of Maintenance reported that the designated smoking area was in the court yard. 8. Observation of the designated smoking area on 3/4/15 at 1:00 p.m. revealed 2 chimney tower ash trays with cigarette butts on the ground around them. Further observation of the smoking area revealed an appropriate ash tray over-filled with cigarette butts. Observation of a red metal trash can in the smoking area revealed cigarette butts with ashes in it and on top of styrofoam cups, paper, and plastic items. Observation of the smoking area on 3/5/15 at 2:00 p.m. revealed a red metal trash can with cigarette butts and ashes in it and on top of styrofoam cups, paper, and plastic items. Further observation of the smoking area revealed a black metal trash can with cigarette butts and ashes in it and on top of styrofoam cups, paper, and plastic items. In an interview with the Director of Maintenance on 3/5/15 at 2:04 p.m., he reported that the red metal trash can and black metal trash can were used for trash. The Director of Maintenance observed the red metal trash can with cigarette butts and ashes on top of styrofoam cups, paper, and plastic items in it. He also observed the black metal trash can with cigarette butts and ashes on top of styrofoam cups, paper, and plastic items in it. The Director of Maintenance confirmed that cigarette butts should not be placed in either the red metal trash can or the black metal trash can. The Director of Maintenance confirmed that the red metal trash can and the black metal trash can had cigarette butts and ashes on top of styrofoam cups, paper, and plastic items in them. In an interview with the DON on 3/5/15 at 10:11 a.m., she reported that 7 residents smoked cigarettes and had possession of their own cigarettes and lighters. Interview with the DON on 3/5/15 at 11:45 a.m. revealed no safe smoking evalutions had been completed for any of the smoking residents. She reported that all smoking residents were supposed to have signed copies of the smoking assessment policy in their charts and did not. During further interview with the DON at 1:15 p.m. on 3/5/15, she reported that she found smoking evaluations for Resident #s 13 and 20 but was unable to find any smoking evaluations or signed copies of the smoking policy for any of the other smoking residents. Interview with the ADON (the QA Coordinator) at 12:12 p.m. on 3/6/15 revealed that smoking was not an issue that had been addressed by the QA committee because the facility had been a nonsmoking facility prior to the admission of residents from a closed home nearby. She reported that 2 residents (Resident #20 and another resident who no longer smoked) were grandfathered in. She reported that Resident #20 complied with the facility's smoking rules and smoked outside with her daughter only. The ADON reported that, when the facility got the new smoking residents from the closed home nearby, We totally lost control of the situation. We weren't used to having smoking residents. Review of the facility's smoking policy (revised on 2/5/12) revealed It is the policy of this facility to establish and maintain a safe resident smoking environment . 1. Prior to, or upon admission, residents shall be informed in writing that smoking is permitted in designated areas only and that smoking materials of any kind are to be stored in the nurses' station and not permitted to be stored in resident living or sleeping quarters. 2. All residents will: 2.1 Be evaluated by licensed nursing staff regarding smoking preferences upon admission, quarterly, and with a significant change in resident mental or physical condition. 2.2 Be evaluated for risk factors and responsibility. 2.3 Be orientated to smoking areas and procedures. 2.4 Have a care plan developed related to this activity . 6. Smoking articles: 6.1 All residents who smoke, regardless of their classification, will not be permitted to keep any smoking articles/paraphernalia in their room. This included but is not limited to the following: 6.1.1 Cigarettes . 6.1.5 Lighters of any kind . 6.3 Through the ambassador program, staff will visit rooms daily and be alert for any smoking materials improperly stored 6.4 Any infractions related to storage of smoking materials may warrant more frequent and thorough inspections of living and sleeping areas 6.5 Residents classified as responsible shall not be permitted to give non-responsible residents smoking articles Note: All persons shall be alerted to this fact and report any and all such incidents to on-duty charge nurse and/or risk manager immediately . 7. Purchasing and/or storage of smoking articles: . 7.3 All smoking articles for all residents will be stored at the nurses' station in a safe area restricted to resident access . 7.4 Responsible residents: 7.4.1 Will request their specific smoking materials and will be given appropriate materials/paraphernalia, including lighter 7.4.2 Will return lighters to the nursing station/designated area 7.4.3 Nurses will check with the resident upon their return from the smoking area to ensure that all smoking materials/paraphernalia are returned to safe storage 7.5 Nonresponsible residents will not be given their smoking materials/paraphernalia unless accompanied by the person designated to provide direct supervision. The administrator was notified on 3/5/15 at 2:23 p.m. that an IJ situation had been identified due to the above failures. The facility's plan of removal was provided by the administrator on 3/6/15 and accepted by the facility's program manager on 3/6/15 at 1:45 p.m. The facility took the following actions to remove the IJ: -Nursing evaluated all 88 residents for smoking/nonsmoking. -All current residents and rooms were checked for smoking paraphernalia and, if found, it was removed and placed in a locked box at the nursing station. -All current smoking residents (6 identified) were given a smoking agreement and a schedule of the smoking times. Residents were oriented to the designated smoking area. -All smoking residents were to be reevaluated if there was a decline in their condition and/or behavior changes, as well as significant changes, quarterly, and annually. -The one designated smoking area (the court yard) was equipped with a large, table top ash tray that could accomodate the number of current smokers. Three more metal ash trays were purchased and installed. -All smokers were to be supervised by a staff member during the smoking times posted. -Facility staff were in-serviced on all residents (smokers and nonsmokers) completing a smoking evaluation upon admission and readmission and, if appropriate, ensuring that smoking residents sign a smoking agreement. -Smoking time schedules were to be given and/or posted in the smoking residents' rooms to remind them of times they may smoke. -The 6 identified smokers were educated on the smoking policy and were asked to sign a smoking agreement. -If a resident was suspected of having smoking paraphernalia, staff were to search their room in a respectful manner. -Smoking times were posted. -Residents who did not agree to comply with the smoking policy were to be given a 30-day notice of discharge. -Residents who smoked were to sign a copy of the safe smoking agreement and smoking policy to ensure acknowledgement and understanding. -Residents who smoked and non-smokers were evaluated for unsupervised smoking. -All staff were to receive in-services regarding the smoking policy. -Smoking Schedules signs were placed on the inside wall by the double door leading to the smoking area. -The maintenance director removed the 2 chimney tower ashtrays and replaced them with approved/appropriate ashtrays. Interviews with nurses and CNAs on 3/6/15 from 2:50 p.m. to 3:00 p.m. revealed nurses and CNAs had received training on the facility smoking policy and enforcement of the policy. They all listed the designated smoking times as 9:00 a.m., 2:00 p.m., 6:30 p.m., and 8:00 p.m. They all said that no smoking materials were to keep in residents' rooms and that all smoking items were to be stored in the nursing station cabinet. Interviews with residents who smoked on 3/6/15 from 3:23 p.m. to 3:33 p.m. revealed that they had received education/counseling on the smoking policy. Record review of resident safe smoking assessments revealed that all residents who smoked had been assessed/reassessed on 3/5/15 and signed copies of the smoking policy. Smoking schedules had been given to residents who smoked. Observation of the front entrance on 3/6/15 at 1:00 p.m. revealed a sign informing all visitors, family, and staff Please do not give or light cigarettes for any resident. Observation on 3/6/15 at 10:30 a.m. revealed a sign saying Smoker's club scheduled supervised smoke breaks are as followed: 9:00 a.m., 2:00 p.m., 6:30 p.m., and 8:00 p.m. Note: No in between breaks. Resident #s 15, 11, 14, and 19 were observed smoking in the designated area with staff (the Activity Director) and following smoking rules at 9:21 a.m. and 1:55 p.m. on 3/6/15. On 3/6/15 at 3:48 p.m., the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity level of potential harm that was not an immediate jeopardy with the scope of pattern until all measures listed in the plan of removal were completed. According to a census list dated 3/3/15 and information provided by the facility on 3/6/15, there were 74 residents living on 4 of 5 halls (100, 200, 300, and 500) and 6 residents who smoked.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for 6 of 6 residents (Resident #s 15, 14, 19, 11, 13, and 20) on 4 of 5 halls (100, 200, 300, and 500) whose care was reviewed for safe smoking in that: 1. Resident #13 had an incident of suspected smoking in her room. There was no evidence that this incident was investigated. Resident #13's evaluation for unsupervised smoking was incomplete, and her care plan did not address smoking. She was not supervised while smoking, smoked in an area not designated for smoking, and had a lighter in her purse. 2. Resident #s 15, 14, and 19 were not evaluated for unsupervised smoking, informed of the facility smoking policy and regulations, and care-planned for smoking for 26 days after admission. They were not supervised while smoking and had cigarettes and lighters in their rooms. 3. Resident #11 was not evaluated for unsupervised smoking and informed of the facility smoking policy and regulations for 26 days after admission. He was not supervised while smoking and had cigarettes in his room. 4. Resident #20 refused to sign the safe smoking agreement. Her evaluation for unsupervised smoking was incomplete. She was not supervised while smoking and had cigarettes and a lighter in her possession. 5. Cigarette butts were found in grassy areas, around the diesel generator, and outside of the designated smoking area. 6. The designated area for resident smoking included ash trays not approved by the National Fire Protection Association and trash cans being used for trash and cigarette butts. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) at 2:05 p.m. on 3/5/15. While the IJ was removed, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet completing in-service training for all staff on enforcement of the smoking policy and not having all residents who smoked sign a safe smoking agreement. These failures could result in fire hazard with injury and could affect 74 residents living in the 100, 200, 300, and 500 halls of the facility. The findings were: 1. Record review of Resident #13's care plan revealed admission date of [DATE] with [DIAGNOSES REDACTED]. Her care plan did not address smoking. Record review of Resident #13's significant change MDS assessment (ARD 12/22/14) revealed that she scored a 15 on the BIMS (indicating that she was cognitively intact). Record review of Resident #13's safe smoking agreement dated 2/18/15 revealed that she signed it. Record review of Resident #13's evaluation for unsupervised smoking dated 2/18/15 revealed that it was incomplete. There was no indication of whether or not Resident #13 was able to or not able to smoke unsupervised. Mild cognitive impairment was documented. Record review of Resident #13's nursing note dated 11/17/14 revealed Resident was given a 30-day discharge notice today due to the incident last night of her smoking in her room, which was reported to the SW (social worker) this morning. Resident denies she was smoking in her room. She states she was smoking outside on the wheelchair ramp and the fire alarm went off. Record review of Resident #13's nursing note dated 11/19/14 revealed On 11/17/14 4:30 a.m. 11/7 nurse called. The alarm system has been ringing and unable to reset. Fireman having trouble resetting. Called (the ADON). Nurse stated resident on 100 hall found smoking in her room. Record review of Resident #13's nursing note dated 2/21/15 revealed Resident was observed leaving the foyer area between the 100 hall and rehab in order to go outside and smoke. Immediately after being witnessed going towards the outside door, the fire station next to the door was activated, causing the fire alarm to sound. This is the third episode where the fire alarm has sounded and the only person near the alarm was this resident. The fire department was dispatched to the facility. A search of the building found no fire or smoke. During an interview with the ADON at 1:05 p.m. on 3/5/15, she reported that Resident #13 had smoked in the lobby area between the rehabilitation gym and the 100 hall. During an interview with the rehabilitation director at 8:07 a.m. on 3/6/15, she reported that she had never seen Resident #13 smoking in the lobby area but had seen her smoking outside of the rehabilitation/100 hall lobby area doors unsupervised and not in the designated smoking area. During an interview with MDS Coordinator R at 8:12 a.m. on 3/6/15, she reported that Resident #13 smoked in the outside area between the rehabilitation gym and the 100 hall often without supervision. She reported that there was no ash tray in this area - just a plastic trash can - and that this area was not the designated smoking area. During an interview with the ADON at 3:56 p.m. on 3/5/15, she reported that there was no incident/accident report for Resident #13's smoking incident because no staff actually saw her smoking and because she denied it. There was no evidence that Resident #13's smoking incident was investigated and/or that corrective measures were put in place to prevent it from reoccurring. During an interview with Resident #13 at 11:18 a.m. on 3/5/15, she reported that her lighter was in her purse. 2. Review of Resident #15's facesheet dated 3/3/15 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #15's admission MDS assessment (ARD 2/11/15) revealed that she scored a 12 on the BIMS (indicating that she was cognitively intact). Review of Resident #15's clinical record revealed no evaluation for unsupervised smoking, no safe smoking agreement, and no care plan to address smoking. During the group interview at 9:15 a.m. on 3/5/15, Resident #15 had cigarettes and a lighter in her possession. Observation of Resident #15's bedroom at 10:07 a.m. on 3/5/15 revealed 2 packs of cigarettes and a lighter on her bedside table. Observation of the smoking area on 3/5/15 at 11:00 a.m. revealed Resident #15 was smoking without staff supervision. In an interview with Resident #15 on 3/5/15 at 11:04 a.m., she confirmed that cigarettes and a lighter were kept in her possession. During an interview with Resident #15 at 11:15 a.m. on 3/5/15, the DON asked her where her lighter was. Resident #15 then handed her lighter to the DON. 3. Record review of Resident #14's facesheet dated 2/12/15 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #14's admission MDS assessment (ARD 2/20/15) revealed that he scored a 15 on the BIMS (indicating that he was cognitively intact). Record review of Resident #14's social services assessment dated [DATE] revealed that he preferred to use tobacco product daily. Record review of Resident #14's MDS assessment (ARD 2/20/15) and progress note dated 2/20/15 revealed that he was a smoker. Review of Resident #14's clinical record revealed no evaluation for unsupervised smoking and no safe smoking agreement. Record review of Resident #14's care plan (initiated 2/26/15) revealed that it did not address smoking. Observation of Resident #14's bedroom on 3/5/15 at 10:38 a.m. revealed a lighter located in his dresser drawer. During an interview with the maintenance assistant and LVN H at this time, they confirmed that the lighter was in Resident #14's drawer and reported that lighters were supposed to be kept in a bucket in the medication room. Observation of a bucket in the medication room (intended for lighters) at 10:52 a.m. on 3/5/15 revealed that no lighters were in it. Observation of the smoking area on 3/5/15 at 2:20 p.m. revealed that Resident #14 lit a cigarette with a lighter and placed the lighter in his pocket. There was no staff present while resident #14 was in the smoking area and smoking. Observation revealed that Resident #14 lit a second cigarette using the already-lit cigarette. Further observation revealed that Resident #14 extinguished his cigarette on the metal chair and tossed the butt on the ground. Further observation revealed that Resident #14 picked up the cigarette butt off of the ground and tossed both cigarette butts into the black metal trash can. 4. Record review of Resident #19's facesheet dated 2/12/15 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #19's admission MDS assessment (ARD 2/20/15) revealed that he scored greater than 5 and less than 8 on the BIMS (indicating that he had moderately-impaired cognition). Record review of Resident #19's social services assessment dated [DATE] revealed that he preferred to use tobacco product daily. Record review of Resident #19's MDS assessment (ARD 2/20/15) revealed that he was a smoker. Review of Resident #19's clinical record revealed no evaluation for unsupervised smoking and no safe smoking agreement. Record review of Resident #19's care plan (initiated 2/26/15) revealed that it did not address smoking. During group interview at 9:15 a.m. on 3/5/15, Resident #19 reported that there was no set schedule to smoking and no staff supervision. Resident #19 reported that cigarettes and lighters were kept in his possession. Observation of the smoking area on 3/5/15 at 11:00 a.m. revealed Resident #19 was smoking without staff supervision. Resident #19 was observed lighting Resident #15's cigarette for her. During an interview with Resident #19 at 11:12 a.m. on 3/5/15, he reported that his lighter was in his pocket. The DON observed and confirmed this. 5. Record review of Resident #11's care plan (initiated 2/26/15) revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's admission MDS assessment (ARD 2/20/15) revealed that he was cognitively intact. During an interview with Resident #11 in his room at 10:13 a.m. on 3/5/15, he reported that he had cigarettes in his pocket and pulled out 3 cigarettes to show the surveyor. Record review of Resident #11's MDS assessment (ARD 2/20/15), diet roster dated 2/7/15, and activities progress note dated 2/19/15 revealed that he was a smoker. Review of Resident #11's clinical record revealed no evaluation for unsupervised smoking and no safe smoking agreement. Record review of Resident #11's care plan revealed smoking interventions/tasks (initiated on 2/26/15 and revised on 3/2/15) that nursing staff was to store his cigarettes and lighters in a secured location, that he was to smoke in designated areas only, that smoking assessment was to be completed on admission and quarterly as long as he continued to smoke, and that his smoking activity was to be supervised as needed. 6. Review of Resident #20's facesheet (not dated) revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's quarterly MDS assessment (ARD 1/16/15) revealed that she was unable to complete the BIMS (indicating severe cognitive impairment). Record review of Resident #20's annual MDS assessment (ARD 10/23/14) revealed that she used tobacco product daily. Record review of Resident #20's safe smoking agreement dated 2/18/15 revealed that she refused to sign it. Handwritten on this agreement was (ADON) spoke with her . Sent (the administrator) an email 2/19/15. Record review of Resident #20's evaluation for unsupervised smoking dated 2/18/15 revealed that it was incomplete. Questions pertaining to physical ability numbered 6-8 and 10 were not answered. There was no indication of whether or not Resident #20 was able to or not able to smoke unsupervised. Record review of Resident #20's care plan (last revised 1/30/15) revealed that she had right-sided [MEDICAL CONDITION], impaired visual function, and impaired communication and wished to smoke. Interventions/tasks pertaining to smoking dated 7/14/13, 9/5/14, and 1/30/15 revealed that Resident #20 was to be encouraged to smoke in designated areas only, that Resident #20 was to be monitored for any decline in smoking ability, that nursing staff were to store her cigarettes and lighters in a secured location, that a smoking apron was to be provided as indicated, that smoking assessment was to be completed on admission and quarterly as long as she continued to smoke, and that her smoking activity was to be supervised as needed. Observation of the smoking area on 3/5/15 at 11:36 a.m. revealed Resident #20 smoking without staff supervision. During an interview with LVN H on 3/5/15 at 11:36 a.m., she reported that Resident #20 did not check out cigarettes or a lighter from her prior to going outside to smoke nor did she have a lighter or cigarettes belonging to Resident #20. 7. Observation of the outside environment on 3/4/15 at 10:22 a.m. revealed 8 cigarette butts scattered on the grassy area located on the left side of the entrance door. Observation of the rehabilitation entrance door revealed 48 cigarette butts on the ground, 16 cigarette butts by the end of the rehabilitation ramp, and 29 cigarette butts in the grassy area. Observation of the back area of the rehabilitation side of the building revealed a picnic table with 25 cigarette butts on the ground. Observation of the 300 hall revealed 19 cigarette butts scattered on the ground outside the exit door. Observation of the front generator area on 3/4/15 at 10:48 a.m. revealed 19 cigarette butts scattered on the ground and 10 cigarette butts behind the generator. Further observation revealed 13 cigarette butts scattered on the ground by the walkway near the generator. In an interview with the Director of Maintenance on 3/4/15 at 10:52 a.m., he confirmed there were cigarette butts within the diesel generator area and reported that he would address it with the Administrator. The Director of Maintenance reported that the designated smoking area was in the court yard. 8. Observation of the designated smoking area on 3/4/15 at 1:00 p.m. revealed 2 chimney tower ash trays with cigarette butts on the ground around them. Further observation of the smoking area revealed an appropriate ash tray over-filled with cigarette butts. Observation of a red metal trash can in the smoking area revealed cigarette butts with ashes in it and on top of styrofoam cups, paper, and plastic items. Observation of the smoking area on 3/5/15 at 2:00 p.m. revealed a red metal trash can with cigarette butts and ashes in it and on top of styrofoam cups, paper, and plastic items. Further observation of the smoking area revealed a black metal trash can with cigarette butts and ashes in it and on top of styrofoam cups, paper, and plastic items. In an interview with the Director of Maintenance on 3/5/15 at 2:04 p.m., he reported that the red metal trash can and black metal trash can were used for trash. The Director of Maintenance observed the red metal trash can with cigarette butts and ashes on top of styrofoam cups, paper, and plastic items in it. He also observed the black metal trash can with cigarette butts and ashes on top of styrofoam cups, paper, and plastic items in it. The Director of Maintenance confirmed that cigarette butts should not be placed in either the red metal trash can or the black metal trash can. The Director of Maintenance confirmed that the red metal trash can and the black metal trash can had cigarette butts and ashes on top of styrofoam cups, paper, and plastic items in them. In an interview with the DON on 3/5/15 at 10:11 a.m., she reported that 7 residents smoked cigarettes and had possession of their own cigarettes and lighters. Interview with the DON on 3/5/15 at 11:45 a.m. revealed no safe smoking evalutions had been completed for any of the smoking residents. She reported that all smoking residents were supposed to have signed copies of the smoking assessment policy in their charts and did not. During further interview with the DON at 1:15 p.m. on 3/5/15, she reported that she found smoking evaluations for Resident #s 13 and 20 but was unable to find any smoking evaluations or signed copies of the smoking policy for any of the other smoking residents. Interview with the ADON (the QA Coordinator) at 12:12 p.m. on 3/6/15 revealed that smoking was not an issue that had been addressed by the QA committee because the facility had been a nonsmoking facility prior to the admission of residents from a closed home nearby. She reported that 2 residents (Resident #20 and another resident who no longer smoked) were grandfathered in. She reported that Resident #20 complied with the facility's smoking rules and smoked outside with her daughter only. The ADON reported that, when the facility got the new smoking residents from the closed home nearby, We totally lost control of the situation. We weren't used to having smoking residents. Record review of the facility's Abuse Prevention Program policy and procedure (not dated) revealed that neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or deterioration of a resident's physical or mental condition. Some examples of neglect include but are not limited to . Failure to carry out the resident's plan of care . Failure to adequately supervise the whereabouts and/or activities of a resident . Failure to provide supervision as necessary . Record review of the facility's Staff Responsible for Coordinating and Implementing the Abuse Prevention Program policy and procedure (not dated) revealed that the administrator had the overall responsibility for the coordinating and implementing of the facility's Abuse Prevention Program policies and procedures. Further record review of the facility's Abuse Prevention Program policy and procedure (not dated - section 2(i)) revealed Residents are to be assessed, care-planned, and monitored for needs and behaviors that may lead to conflict or neglect. Further record review of the facility's Abuse Prevention Program policy and procedure (not dated - section 2(n)) revealed that the facility was to identify areas within the facility that may make abuse and/or neglect more likely to occur and to monitor these areas on a regularly scheduled basis. Review of the facility's smoking policy (revised on 2/5/12) revealed It is the policy of this facility to establish and maintain a safe resident smoking environment . 1. Prior to, or upon admission, residents shall be informed in writing that smoking is permitted in designated areas only and that smoking materials of any kind are to be stored in the nurses' station and not permitted to be stored in resident living or sleeping quarters. 2. All residents will: 2.1 Be evaluated by licensed nursing staff regarding smoking preferences upon admission, quarterly, and with a significant change in resident mental or physical condition. 2.2 Be evaluated for risk factors and responsibility. 2.3 Be orientated to smoking areas and procedures. 2.4 Have a care plan developed related to this activity . 6. Smoking articles: 6.1 All residents who smoke, regardless of their classification, will not be permitted to keep any smoking articles/paraphernalia in their room. This included but is not limited to the following: 6.1.1 Cigarettes . 6.1.5 Lighters of any kind . 6.3 Through the ambassador program, staff will visit rooms daily and be alert for any smoking materials improperly stored 6.4 Any infractions related to storage of smoking materials may warrant more frequent and thorough inspections of living and sleeping areas 6.5 Residents classified as responsible shall not be permitted to give non-responsible residents smoking articles Note: All persons shall be alerted to this fact and report any and all such incidents to on-duty charge nurse and/or risk manager immediately . 7. Purchasing and/or storage of smoking articles: . 7.3 All smoking articles for all residents will be stored at the nurses' station in a safe area restricted to resident access . 7.4 Responsible residents: 7.4.1 Will request their specific smoking materials and will be given appropriate materials/paraphernalia, including lighter 7.4.2 Will return lighters to the nursing station/designated area 7.4.3 Nurses will check with the resident upon their return from the smoking area to ensure that all smoking materials/paraphernalia are returned to safe storage 7.5 Nonresponsible residents will not be given their smoking materials/paraphernalia unless accompanied by the person designated to provide direct supervision. The administrator was notified on 3/5/15 at 2:23 p.m. that an IJ situation had been identified due to the above failures. The facility's plan of removal was provided by the administrator on 3/6/15 and accepted by the facility's program manager on 3/6/15 at 1:45 p.m. The facility took the following actions to remove the IJ: -Nursing evaluated all 88 residents for smoking/nonsmoking. -All current residents and rooms were checked for smoking paraphernalia and, if found, it was removed and placed in a locked box at the nursing station. -All current smoking residents (6 identified) were given a smoking agreement and a schedule of the smoking times. Residents were oriented to the designated smoking area. -All smoking residents were to be reevaluated if there was a decline in their condition and/or behavior changes, as well as significant changes, quarterly, and annually. -The one designated smoking area (the court yard) was equipped with a large, table top ash tray that could accomodate the number of current smokers. Three more metal ash trays were purchased and installed. -All smokers were to be supervised by a staff member during the smoking times posted. -Facility staff were in-serviced on all residents (smokers and nonsmokers) completing a smoking evaluation upon admission and readmission and, if appropriate, ensuring that smoking residents sign a smoking agreement. -Smoking time schedules were to be given and/or posted in the smoking residents' rooms to remind them of times they may smoke. -The 6 identified smokers were educated on the smoking policy and were asked to sign a smoking agreement. -If a resident was suspected of having smoking paraphernalia, staff were to search their room in a respectful manner. -Smoking times were posted. -Residents who did not agree to comply with the smoking policy were to be given a 30-day notice of discharge. -Residents who smoked were to sign a copy of the safe smoking agreement and smoking policy to ensure acknowledgement and understanding. -Residents who smoked and non-smokers were evaluated for unsupervised smoking. -All staff were to receive in-services regarding the smoking policy. -Smoking Schedules signs were placed on the inside wall by the double door leading to the smoking area. -The maintenance director removed the 2 chimney tower ashtrays and replaced them with approved/appropriate ashtrays. Interviews with nurses and CNAs on 3/6/15 from 2:50 p.m. to 3:00 p.m. revealed nurses and CNAs had received training on the facility smoking policy and enforcement of the policy. They all listed the designated smoking times as 9:00 a.m., 2:00 p.m., 6:30 p.m., and 8:00 p.m. They all said that no smoking materials were to keep in residents' rooms and that all smoking items were to be stored in the nursing station cabinet. Interviews with residents who smoked on 3/6/15 from 3:23 p.m. to 3:33 p.m. revealed that they had received education/counseling on the smoking policy. Record review of resident safe smoking assessments revealed that all residents who smoked had been assessed/reassessed on 3/5/15 and signed copies of the smoking policy. Smoking schedules had been given to residents who smoked. Observation of the front entrance on 3/6/15 at 1:00 p.m. revealed a sign informing all visitors, family, and staff Please do not give or light cigarettes for any resident. Observation on 3/6/15 at 10:30 a.m. revealed a sign saying Smoker's club scheduled supervised smoke breaks are as followed: 9:00 a.m., 2:00 p.m., 6:30 p.m., and 8:00 p.m. Note: No in between breaks. Resident #s 15, 11, 14, and 19 were observed smoking in the designated area with staff (the Activity Director) and following smoking rules at 9:21 a.m. and 1:55 p.m. on 3/6/15. On 3/6/15 at 3:48 p.m., the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity level of potential harm that was not an immediate jeopardy with the scope of pattern until all measures listed in the plan of removal were completed. According to a census list dated 3/3/15 and information provided by the facility on 3/6/15, there were 74 residents living on 4 of 5 halls (100, 200, 300, and 500) and 6 residents who smoked.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for 6 of 6 residents (Resident #s 15, 14, 19, 11, 13, and 20) on 4 of 5 halls (100, 200, 300, and 500) whose care was reviewed for safe smoking in that: 1. Resident #13 had an incident of suspected smoking in her room. There was no evidence that this incident was investigated. Resident #13's evaluation for unsupervised smoking was incomplete, and her care plan did not address smoking. She was not supervised while smoking, smoked in an area not designated for smoking, and had a lighter in her purse. 2. Resident #s 15, 14, and 19 were not evaluated for unsupervised smoking, informed of the facility smoking policy and regulations, and care-planned for smoking for 26 days after admission. They were not supervised while smoking and had cigarettes and lighters in their rooms. 3. Resident #11 was not evaluated for unsupervised smoking and informed of the facility smoking policy and regulations for 26 days after admission. He was not supervised while smoking and had cigarettes in his room. 4. Resident #20 refused to sign the safe smoking agreement. Her evaluation for unsupervised smoking was incomplete. She was not supervised while smoking and had cigarettes and a lighter in her possession. 5. Cigarette butts were found in grassy areas, around the diesel generator, and outside of the designated smoking area. 6. The designated area for resident smoking included ash trays not approved by the National Fire Protection Association and trash cans being used for trash and cigarette butts. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) at 2:05 p.m. on 3/5/15. While the IJ was removed, the facility remained out of compliance at a scope of pattern with a severity of potential for more than minimal harm that was not an immediate jeopardy due to the facility not yet completing in-service training for all staff on enforcement of the smoking policy and not having all residents who smoked sign a safe smoking agreement. These failures could result in fire hazard with injury and could affect 74 residents living in the 100, 200, 300, and 500 halls of the facility. The findings were: Record review of the facility's Abuse Prevention Program policy and procedure (not dated) revealed that neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or deterioration of a resident's physical or mental condition. Some examples of neglect include but are not limited to . Failure to carry out the resident's plan of care . Failure to adequately supervise the whereabouts and/or activities of a resident . Failure to provide supervision as necessary . Record review of the facility's Staff Responsible for Coordinating and Implementing the Abuse Prevention Program policy and procedure (not dated) revealed that the administrator had the overall responsibility for the coordinating and implementing of the facility's Abuse Prevention Program policies and procedures. Further record review of the facility's Abuse Prevention Program policy and procedure (not dated - section 2(i)) revealed Residents are to be assessed, care-planned, and monitored for needs and behaviors that may lead to conflict or neglect. Further record review of the facility's Abuse Prevention Program policy and procedure (not dated - section 2(n)) revealed that the facility was to identify areas within the facility that may make abuse and/or neglect more likely to occur and to monitor these areas on a regularly scheduled basis. Review of the facility's smoking policy (revised on 2/5/12) revealed It is the policy of this facility to establish and maintain a safe resident smoking environment . 1. Prior to, or upon admission, residents shall be informed in writing that smoking is permitted in designated areas only and that smoking materials of any kind are to be stored in the nurses' station and not permitted to be stored in resident living or sleeping quarters. 2. All residents will: 2.1 Be evaluated by licensed nursing staff regarding smoking preferences upon admission, quarterly, and with a significant change in resident mental or physical condition. 2.2 Be evaluated for risk factors and responsibility. 2.3 Be orientated to smoking areas and procedures. 2.4 Have a care plan developed related to this activity . 6. Smoking articles: 6.1 All residents who smoke, regardless of their classification, will not be permitted to keep any smoking articles/paraphernalia in their room. This included but is not limited to the following: 6.1.1 Cigarettes . 6.1.5 Lighters of any kind . 6.3 Through the ambassador program, staff will visit rooms daily and be alert for any smoking materials improperly stored 6.4 Any infractions related to storage of smoking materials may warrant more frequent and thorough inspections of living and sleeping areas 6.5 Residents classified as responsible shall not be permitted to give non-responsible residents smoking articles Note: All persons shall be alerted to this fact and report any and all such incidents to on-duty charge nurse and/or risk manager immediately . 7. Purchasing and/or storage of smoking articles: . 7.3 All smoking articles for all residents will be stored at the nurses' station in a safe area restricted to resident access . 7.4 Responsible residents: 7.4.1 Will request their specific smoking materials and will be given appropriate materials/paraphernalia, including lighter 7.4.2 Will return lighters to the nursing station/designated area 7.4.3 Nurses will check with the resident upon their return from the smoking area to ensure that all smoking materials/paraphernalia are returned to safe storage 7.5 Nonresponsible residents will not be given their smoking materials/paraphernalia unless accompanied by the person designated to provide direct supervision. 1. Record review of Resident #13's care plan revealed admission date of [DATE] with [DIAGNOSES REDACTED]. Her care plan did not address smoking. Record review of Resident #13's significant change MDS assessment (ARD 12/22/14) revealed that she scored a 15 on the BIMS (indicating that she was cognitively intact). Record review of Resident #13's safe smoking agreement dated 2/18/15 revealed that she signed it. Record review of Resident #13's evaluation for unsupervised smoking dated 2/18/15 revealed that it was incomplete. There was no indication of whether or not Resident #13 was able to or not able to smoke unsupervised. Mild cognitive impairment was documented. Record review of Resident #13's nursing note dated 11/17/14 revealed Resident was given a 30-day discharge notice today due to the incident last night of her smoking in her room, which was reported to the SW (social worker) this morning. Resident denies she was smoking in her room. She states she was smoking outside on the wheelchair ramp and the fire alarm went off. Record review of Resident #13's nursing note dated 11/19/14 revealed On 11/17/14 4:30 a.m. 11/7 nurse called. The alarm system has been ringing and unable to reset. Fireman having trouble resetting. Called (the ADON). Nurse stated resident on 100 hall found smoking in her room. Record review of Resident #13's nursing note dated 2/21/15 revealed Resident was observed leaving the foyer area between the 100 hall and rehab in order to go outside and smoke. Immediately after being witnessed going towards the outside door, the fire station next to the door was activated, causing the fire alarm to sound. This is the third episode where the fire alarm has sounded and the only person near the alarm was this resident. The fire department was dispatched to the facility. A search of the building found no fire or smoke. During an interview with the ADON at 1:05 p.m. on 3/5/15, she reported that Resident #13 had smoked in the lobby area between the rehabilitation gym and the 100 hall. During an interview with the rehabilitation director at 8:07 a.m. on 3/6/15, she reported that she had never seen Resident #13 smoking in the lobby area but had seen her smoking outside of the rehabilitation/100 hall lobby area doors unsupervised and not in the designated smoking area. During an interview with MDS Coordinator R at 8:12 a.m. on 3/6/15, she reported that Resident #13 smoked in the outside area between the rehabilitation gym and the 100 hall often without supervision. She reported that there was no ash tray in this area - just a plastic trash can - and that this area was not the designated smoking area. During an interview with the ADON at 3:56 p.m. on 3/5/15, she reported that there was no incident/accident report for Resident #13's smoking incident because no staff actually saw her smoking and because she denied it. There was no evidence that Resident #13's smoking incident was investigated and/or that corrective measures were put in place to prevent it from reoccurring. During an interview with Resident #13 at 11:18 a.m. on 3/5/15, she reported that her lighter was in her purse. 2. Review of Resident #15's facesheet dated 3/3/15 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #15's admission MDS assessment (ARD 2/11/15) revealed that she scored a 12 on the BIMS (indicating that she was cognitively intact). Review of Resident #15's clinical record revealed no evaluation for unsupervised smoking, no safe smoking agreement, and no care plan to address smoking. During the group interview at 9:15 a.m. on 3/5/15, Resident #15 had cigarettes and a lighter in her possession. Observation of Resident #15's bedroom at 10:07 a.m. on 3/5/15 revealed 2 packs of cigarettes and a lighter on her bedside table. Observation of the smoking area on 3/5/15 at 11:00 a.m. revealed Resident #15 was smoking without staff supervision. In an interview with Resident #15 on 3/5/15 at 11:04 a.m., she confirmed that cigarettes and a lighter were kept in her possession. During an interview with Resident #15 at 11:15 a.m. on 3/5/15, the DON asked her where her lighter was. Resident #15 then handed her lighter to the DON. 3. Record review of Resident #14's facesheet dated 2/12/15 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #14's admission MDS assessment (ARD 2/20/15) revealed that he scored a 15 on the BIMS (indicating that he was cognitively intact). Record review of Resident #14's social services assessment dated [DATE] revealed that he preferred to use tobacco product daily. Record review of Resident #14's MDS assessment (ARD 2/20/15) and progress note dated 2/20/15 revealed that he was a smoker. Review of Resident #14's clinical record revealed no evaluation for unsupervised smoking and no safe smoking agreement. Record review of Resident #14's care plan (initiated 2/26/15) revealed that it did not address smoking. Observation of Resident #14's bedroom on 3/5/15 at 10:38 a.m. revealed a lighter located in his dresser drawer. During an interview with the maintenance assistant and LVN H at this time, they confirmed that the lighter was in Resident #14's drawer and reported that lighters were supposed to be kept in a bucket in the medication room. Observation of a bucket in the medication room (intended for lighters) at 10:52 a.m. on 3/5/15 revealed that no lighters were in it. Observation of the smoking area on 3/5/15 at 2:20 p.m. revealed that Resident #14 lit a cigarette with a lighter and placed the lighter in his pocket. There was no staff present while resident #14 was in the smoking area and smoking. Observation revealed that Resident #14 lit a second cigarette using the already-lit cigarette. Further observation revealed that Resident #14 extinguished his cigarette on the metal chair and tossed the butt on the ground. Further observation revealed that Resident #14 picked up the cigarette butt off of the ground and tossed both cigarette butts into the black metal trash can. 4. Record review of Resident #19's facesheet dated 2/12/15 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #19's admission MDS assessment (ARD 2/20/15) revealed that he scored greater than 5 and less than 8 on the BIMS (indicating that he had moderately-impaired cognition). Record review of Resident #19's social services assessment dated [DATE] revealed that he preferred to use tobacco product daily. Record review of Resident #19's MDS assessment (ARD 2/20/15) revealed that he was a smoker. Review of Resident #19's clinical record revealed no evaluation for unsupervised smoking and no safe smoking agreement. Record review of Resident #19's care plan (initiated 2/26/15) revealed that it did not address smoking. During group interview at 9:15 a.m. on 3/5/15, Resident #19 reported that there was no set schedule to smoking and no staff supervision. Resident #19 reported that cigarettes and lighters were kept in his possession. Observation of the smoking area on 3/5/15 at 11:00 a.m. revealed Resident #19 was smoking without staff supervision. Resident #19 was observed lighting Resident #15's cigarette for her. During an interview with Resident #19 at 11:12 a.m. on 3/5/15, he reported that his lighter was in his pocket. The DON observed and confirmed this. 5. Record review of Resident #11's care plan (initiated 2/26/15) revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's admission MDS assessment (ARD 2/20/15) revealed that he was cognitively intact. During an interview with Resident #11 in his room at 10:13 a.m. on 3/5/15, he reported that he had cigarettes in his pocket and pulled out 3 cigarettes to show the surveyor. Record review of Resident #11's MDS assessment (ARD 2/20/15), diet roster dated 2/7/15, and activities progress note dated 2/19/15 revealed that he was a smoker. Review of Resident #11's clinical record revealed no evaluation for unsupervised smoking and no safe smoking agreement. Record review of Resident #11's care plan revealed smoking interventions/tasks (initiated on 2/26/15 and revised on 3/2/15) that nursing staff was to store his cigarettes and lighters in a secured location, that he was to smoke in designated areas only, that smoking assessment was to be completed on admission and quarterly as long as he continued to smoke, and that his smoking activity was to be supervised as needed. 6. Review of Resident #20's facesheet (not dated) revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's quarterly MDS assessment (ARD 1/16/15) revealed that she was unable to complete the BIMS (indicating severe cognitive impairment). Record review of Resident #20's annual MDS assessment (ARD 10/23/14) revealed that she used tobacco product daily. Record review of Resident #20's safe smoking agreement dated 2/18/15 revealed that she refused to sign it. Handwritten on this agreement was (ADON) spoke with her . Sent (the administrator) an email 2/19/15. Record review of Resident #20's evaluation for unsupervised smoking dated 2/18/15 revealed that it was incomplete. Questions pertaining to physical ability numbered 6-8 and 10 were not answered. There was no indication of whether or not Resident #20 was able to or not able to smoke unsupervised. Record review of Resident #20's care plan (last revised 1/30/15) revealed that she had right-sided [MEDICAL CONDITION], impaired visual function, and impaired communication and wished to smoke. Interventions/tasks pertaining to smoking dated 7/14/13, 9/5/14, and 1/30/15 revealed that Resident #20 was to be encouraged to smoke in designated areas only, that Resident #20 was to be monitored for any decline in smoking ability, that nursing staff were to store her cigarettes and lighters in a secured location, that a smoking apron was to be provided as indicated, that smoking assessment was to be completed on admission and quarterly as long as she continued to smoke, and that her smoking activity was to be supervised as needed. Observation of the smoking area on 3/5/15 at 11:36 a.m. revealed Resident #20 smoking without staff supervision. During an interview with LVN H on 3/5/15 at 11:36 a.m., she reported that Resident #20 did not check out cigarettes or a lighter from her prior to going outside to smoke nor did she have a lighter or cigarettes belonging to Resident #20. 7. Observation of the outside environment on 3/4/15 at 10:22 a.m. revealed 8 cigarette butts scattered on the grassy area located on the left side of the entrance door. Observation of the rehabilitation entrance door revealed 48 cigarette butts on the ground, 16 cigarette butts by the end of the rehabilitation ramp, and 29 cigarette butts in the grassy area. Observation of the back area of the rehabilitation side of the building revealed a picnic table with 25 cigarette butts on the ground. Observation of the 300 hall revealed 19 cigarette butts scattered on the ground outside the exit door. Observation of the front generator area on 3/4/15 at 10:48 a.m. revealed 19 cigarette butts scattered on the ground and 10 cigarette butts behind the generator. Further observation revealed 13 cigarette butts scattered on the ground by the walkway near the generator. In an interview with the Director of Maintenance on 3/4/15 at 10:52 a.m., he confirmed there were cigarette butts within the diesel generator area and reported that he would address it with the Administrator. The Director of Maintenance reported that the designated smoking area was in the court yard. 8. Observation of the designated smoking area on 3/4/15 at 1:00 p.m. revealed 2 chimney tower ash trays with cigarette butts on the ground around them. Further observation of the smoking area revealed an appropriate ash tray over-filled with cigarette butts. Observation of a red metal trash can in the smoking area revealed cigarette butts with ashes in it and on top of styrofoam cups, paper, and plastic items. Observation of the smoking area on 3/5/15 at 2:00 p.m. revealed a red metal trash can with cigarette butts and ashes in it and on top of styrofoam cups, paper, and plastic items. Further observation of the smoking area revealed a black metal trash can with cigarette butts and ashes in it and on top of styrofoam cups, paper, and plastic items. In an interview with the Director of Maintenance on 3/5/15 at 2:04 p.m., he reported that the red metal trash can and black metal trash can were used for trash. The Director of Maintenance observed the red metal trash can with cigarette butts and ashes on top of styrofoam cups, paper, and plastic items in it. He also observed the black metal trash can with cigarette butts and ashes on top of styrofoam cups, paper, and plastic items in it. The Director of Maintenance confirmed that cigarette butts should not be placed in either the red metal trash can or the black metal trash can. The Director of Maintenance confirmed that the red metal trash can and the black metal trash can had cigarette butts and ashes on top of styrofoam cups, paper, and plastic items in them. In an interview with the DON on 3/5/15 at 10:11 a.m., she reported that 7 residents smoked cigarettes and had possession of their own cigarettes and lighters. Interview with the DON on 3/5/15 at 11:45 a.m. revealed no safe smoking evalutions had been completed for any of the smoking residents. She reported that all smoking residents were supposed to have signed copies of the smoking assessment policy in their charts and did not. During further interview with the DON at 1:15 p.m. on 3/5/15, she reported that she found smoking evaluations for Resident #s 13 and 20 but was unable to find any smoking evaluations or signed copies of the smoking policy for any of the other smoking residents. Interview with the ADON (the QA Coordinator) at 12:12 p.m. on 3/6/15 revealed that smoking was not an issue that had been addressed by the QA committee because the facility had been a nonsmoking facility prior to the admission of residents from a closed home nearby. She reported that 2 residents (Resident #20 and another resident who no longer smoked) were grandfathered in. She reported that Resident #20 complied with the facility's smoking rules and smoked outside with her daughter only. The ADON reported that, when the facility got the new smoking residents from the closed home nearby, We totally lost control of the situation. We weren't used to having smoking residents. The administrator was notified on 3/5/15 at 2:23 p.m. that an IJ situation had been identified due to the above failures. The facility's plan of removal was provided by the administrator on 3/6/15 and accepted by the facility's program manager on 3/6/15 at 1:45 p.m. The facility took the following actions to remove the IJ: -Nursing evaluated all 88 residents for smoking/nonsmoking. -All current residents and rooms were checked for smoking paraphernalia and, if found, it was removed and placed in a locked box at the nursing station. -All current smoking residents (6 identified) were given a smoking agreement and a schedule of the smoking times. Residents were oriented to the designated smoking area. -All smoking residents were to be reevaluated if there was a decline in their condition and/or behavior changes, as well as significant changes, quarterly, and annually. -The one designated smoking area (the court yard) was equipped with a large, table top ash tray that could accomodate the number of current smokers. Three more metal ash trays were purchased and installed. -All smokers were to be supervised by a staff member during the smoking times posted. -Facility staff were in-serviced on all residents (smokers and nonsmokers) completing a smoking evaluation upon admission and readmission and, if appropriate, ensuring that smoking residents sign a smoking agreement. -Smoking time schedules were to be given and/or posted in the smoking residents' rooms to remind them of times they may smoke. -The 6 identified smokers were educated on the smoking policy and were asked to sign a smoking agreement. -If a resident was suspected of having smoking paraphernalia, staff were to search their room in a respectful manner. -Smoking times were posted. -Residents who did not agree to comply with the smoking policy were to be given a 30-day notice of discharge. -Residents who smoked were to sign a copy of the safe smoking agreement and smoking policy to ensure acknowledgement and understanding. -Residents who smoked and non-smokers were evaluated for unsupervised smoking. -All staff were to receive in-services regarding the smoking policy. -Smoking Schedules signs were placed on the inside wall by the double door leading to the smoking area. -The maintenance director removed the 2 chimney tower ashtrays and replaced them with approved/appropriate ashtrays. Interviews with nurses and CNAs on 3/6/15 from 2:50 p.m. to 3:00 p.m. revealed nurses and CNAs had received training on the facility smoking policy and enforcement of the policy. They all listed the designated smoking times as 9:00 a.m., 2:00 p.m., 6:30 p.m., and 8:00 p.m. They all said that no smoking materials were to keep in residents' rooms and that all smoking items were to be stored in the nursing station cabinet. Interviews with residents who smoked on 3/6/15 from 3:23 p.m. to 3:33 p.m. revealed that they had received education/counseling on the smoking policy. Record review of resident safe smoking assessments revealed that all residents who smoked had been assessed/reassessed on 3/5/15 and signed copies of the smoking policy. Smoking schedules had been given to residents who smoked. Observation of the front entrance on 3/6/15 at 1:00 p.m. revealed a sign informing all visitors, family, and staff Please do not give or light cigarettes for any resident. Observation on 3/6/15 at 10:30 a.m. revealed a sign saying Smoker's club scheduled supervised smoke breaks are as followed: 9:00 a.m., 2:00 p.m., 6:30 p.m., and 8:00 p.m. Note: No in between breaks. Resident #s 15, 11, 14, and 19 were observed smoking in the designated area with staff (the Activity Director) and following smoking rules at 9:21 a.m. and 1:55 p.m. on 3/6/15. On 3/6/15 at 3:48 p.m., the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity level of potential harm that was not an immediate jeopardy with the scope of pattern until all measures listed in the plan of removal were completed. According to a census list dated 3/3/15 and information provided by the facility on 3/6/15, there were 74 residents living on 4 of 5 halls (100, 200, 300, and 500) and 6 residents who smoked.

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status such as, body weight for one (#1) of 2 residents reviewed for weight loss in that: Resident #1 had a severe weight loss of 7.6 % in 3 months and 10.8% in 6 months with no interventions put in place to prevent further weight loss and decline. This deficient practice resulted in a significant weight loss for Resident #1 and could affect 33 residents in the facility who had a weight loss and could place residents at risk for continued weight loss. The Findings were: Observation on 12/17/2013 at 3:00 p.m. revealed Resident #1's surgical site to the right buttock was healed. Observation on 12/18/2013 at 8:05 a.m. revealed Resident #1 lying in bed with the head of bed up 30 degrees and [MEDICATION NAME] 1.5 Cal infusing at 50 cc an hour via pump thru the G/Tube. Review of Resident #1's face dated 12/18/2013 revealed Resident #1 was originally admitted on [DATE] and had a readmit on 12/5/2013. Resident #1's admitting [DIAGNOSES REDACTED]. Review of an MDS dated [DATE] revealed resident #1's weight was 129 lbs., with a loss of 5% or more in the last month or loss of 10% or more in last 6 months. Resident #1 was not on a physician prescribed weight loss regimen. Review of the facility's Weights and Vitals Summary for Resident #1 included the following weights: April 23, 2013 142.0 pounds [DATE] 137.0 pounds [DATE] 135.0 pounds Sept. 3, 2013 130.6 pounds [DATE] 127.6 pounds ( by Mechanical Lift) [DATE] 129.0 pounds [DATE] 128.4 pounds [DATE] 126.6 pounds 10.8% weight loss since April 2013) which was a severe weight loss. According to the facility's Weights and Vitals Summary from July 2013 to October 2013 resident #1 had a 7.59% weight loss in 3 months. Review of a monthly weight review record for the month of May 2013 by the Dietician revealed weight 142 lbs. fair appetite, continue plan of diet. Review of Dietary Consulting Reports for the month of April, 2013 thru September 2013 revealed no dietary intervention recommended for Resident #1. Review of a Quarterly Nutritional progress notes from Dietician dated on 9/17/2013 revealed weight was slowly trending down. Resident needed some assistance with feeding herself per nursing department. The Resident was on a Mechanical soft diet with NSP (No salt packets on tray). Dietician recommended fortified foods to increase the protein intake. Review of a Therapy referral and screening on 9/12/2013 revealed the resident was observed being fed by staff in the dining room and consumed less than 75% of meal without difficulty , no further speech therapy intervention was indicated at this time. Review of a Nutritional evaluation dated 10/1/2013 revealed weight was 130 lbs. BMI was 31.5. She had 2.5 cm stage II/III. Interview on 12/20/1013 at 8:50 a.m. with Unit Manager I revealed resident #1 was fed per staff, had weight loss and was not eating well. Weekly weights by Restorative aide was implemented per facility protocol when weight loss was noted in July. The Dietician was to follow weight loss and makes recommendations. Interview on 12/20/2013 at 10:55 a.m. with LVN Q Restorative Nurse, revealed resident #1 had weight gain in April 2013 and then resident #1 started to have decline in weight starting in the month of July. The computer system in place used by the facility should have flagged the decline in weight loss but did not. Interview on 12/20/2013 at 10:07 a.m. with the dietician revealed the April weight was up, July weight was stable, and September weight was down (9/17/2013). The Dietician said she was not aware of significant weight loss, but should have been notified. In a handwritten document by the Interim Acting DON 33 resident's had a weight loss in the months from May 2013 to September 2013.

Based on observation, interview and record review the facility failed to ensure services met professional standard of quality in that 6 licensed nurses (RN W, LVN L, Interim DON, LVN S, LVN R, LVN MM) administered only 20 mEq of Potassium Chloride (KCl) instead of the 120 mEq the physician had ordered to address 1 resident's (#7) Hypokalemia (low potassium) and did not consult with the resident's physician about the high dosage that was ordered before changing to the lower dosage. Following readmission from a hospital with a [DIAGNOSES REDACTED]. Resident #7 was readmitted to the hospital with [REDACTED]. (normal range was 3.5 to 5.1) Serious side effects of potassium include uneven heartbeat, muscle weakness or limp feeling, severe stomach pain, and numbness or tingling in your hands, feet, or mouth. http://www.drugs.com/potassium chloride,html downloaded on 11/27/12 An Immediate Jeopardy was identified 11/09/12. The I J was removed on 11/09/12 at 3:38 p.m.The facility remained out of compliance at the severity level of potential for more than minimal harm that is not an IJ at a scope of pattern because the facility had not had time to implement, monitor and evaluate the effectiveness of the Plan of Removal This deficient practice placed 12 residents receiving KCl at risk for abnormal potassium levels and could result in a decline in residents' health. The findings were: Texas Administrative Code. Rule 217.11 Standards of Nursing Practice state (1) all vocational nurses, registered nurses shall (D) accurately and completely report and document (iii) physician orders (iv) administration of medications (N) clarify any order regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioners and notifying the ordering practitioner when the nurse makes the decision not to administer the medication. (http://info.sos.state.tx.us/pls/pub/readtac.$ext.TacPage?sl=R&app=9&p_rloc=&p downloaded 11/27/12.) Resident #7 failed to receive 120 mEq of Potassium Chloride four times daily as ordered by the physician after recently being hospitalized for a critically low Potassium level of 1.8. from 11/1/12 through 11/7/12. (Normal range is 3.5 - 5.1) "Hypokalemia is associated with increased risk of arrhythmia in patients with cardiovascular disease, as well as increased all cause mortality, by up to 10-fold. The more at risk of fatal arrhythmia and sudden cardiac death a patient is, the more attention should be given to the potassium homeostasis." Article review "Hypokalemia and sudden cardiac death" by K. Kjeldsen. Exp Clinical Cardiology 2010;15 (4):e96-e99. Review of resident #7's face sheet, dated 10/31/12, revealed he was originally admitted into the facility on [DATE] and readmitted to the facility on [DATE] from a recent hospital stay for a [DIAGNOSES REDACTED]. Review of resident #7's Discharge Summary from the hospital dated 10/31/12 revealed Resident #7 was admitted [DATE] with a critical Potassium value of 1.8. Resident #7's discharge medication orders included orders for 120 mEq of KCl four times daily and to have a blood test on 11/8/12 or 11/9/12 to monitor the Potassium level in the blood. Resident #7's Potassium level, when discharged from the hospital on [DATE], was 3.1 and was receiving 100 mEq of KCl four times daily while in the hospital. Review of the physician's orders [REDACTED]. Review of November 2012 MAR for resident #7 revealed the MAs, RNs and LVNs were signing they were giving 120 mEq of KCl four times daily. Observation and interview on 11/05/12 at 7:55 p.m. on initial rounds with RN W revealed resident #7 was lying in bed. He told the nurse he was feeling tired and weak, he had abdominal pain and he was nauseated which could be symptoms of a low potassium level. Interview on 11/05/12 at 8:00 p.m. with RN W revealed resident #7 had recently returned from the hospital with a [DIAGNOSES REDACTED]. Interview on 11/7/12 at 3:00 p.m. with MA U revealed he had given one 20 mEq of KCl on his shift. He stated he was told by LVN L the order for 120 mEq of KCl must be one 20 mEq of KCl instead of 120 mEq because she had never heard of anyone receiving 120 mEq in a day much less four times a day. He administered one 20 mEq of KCl on 11/1/12, 11/3/12, 11/5/12 and 11/6/12 at the 6:00 p.m. med pass. Observation on 11/7/12 at 3:05 p.m. with MA U revealed resident's #7's previous Pharmacy blister pack of KCl had a label that he was to receive 20 mEq of KCl twice daily which contradicted the M.D. order on 10/31/12 for 120 mEq of KCl every 6 hours. In an interview with MA U at that time, he stated the staff did not go by what the Pharmacy blister pack said, just what the MAR indicated [REDACTED]. He stated the policy was when a resident returned from the hospital, all medication orders were to be faxed to the Pharmacy by the nurse. He stated he never questioned anyone regarding this discrepancy. Interview on 11/7/12 at 3:50 p.m. with the LVN MM for resident #7 revealed she checked over the orders the day after his hospital readmission and reconciled the order was for 120 mEq of KCl. She stated she did not fax the medication order to the Pharmacy because the task was supposed to be done by the nurse on duty when the resident was admitted back to the facility. Interview on 11/8/12 at 9:00 a.m. with MA T revealed she gave one 20 mEq of KCl on all the shifts she worked. She stated the blister pack for resident #7 stated to give one 20 mEq twice a day and she thought it had been changed to 20 mEq of KCl four times a day. She administered one 20 mEq of KCl on 11/2/12 at 6:00 a.m. and 12 noon, 11/5/12 at 6:00 a.m. and 12 noon, 11/6/12 at 6:00 a.m. and 11/7/12 at 6:00 a.m. and 12 noon for a total of 7 doses of 20 mEq of KCl. She stated resident #7 had refused the KCl on 11/1/12 at 6:00 a.m. and 11/6/12 at 12:00 noon. She did not remember why she had circled her initials on 11/1/12 at 12 noon but failed to give a reason on the back of the MAR indicated [REDACTED] Interview on 11/8/12 at 12 noon with the interim DON revealed when he worked as a floor nurse he only gave one 20 mEq of KCl instead of 120 mEq as ordered. He stated he did not verify the order with the physician. He gave one 20 mEq of KCl on 11/3/12 and 11/4/12 at 6:00 a.m. and 12 midnight. He stated he failed to give a dose on 11/5/12 because he forgot about giving resident #7 his KCl. Interview on 11/8/12 at 3:40 p.m. with RN W revealed he thought he had faxed the October 31, 2012 Admission Medication List to the Pharmacy with the 120 mEq of KCl listed on the sheet. Interview on 11/8/12 at 4:40 p.m. with LVN L revealed she made the statement that she had never seen 120 mEq of KCl given in 24 hours much less in one dose. She stated she did not call the doctor to verify the dose and told the Med Aides to just give one 20 mEq of KCl four times a day. She stated she did not read the discharge instructions from the physician. She stated she thought that 120 mEq of KCl was an error. She stated she gave one 20 mEq of KCl on 11/4/12 at 6:00 p.m. Interview on 11/9/12 at 6:50 a.m. with RN Q revealed she had given no KCl to resident #7. She stated she did not remember if it was not in the drawer or why but she did not give any KCl to resident #7 on 11/1/12 and 11/2/12 at midnight as scheduled. Interview on 11/9/12 at 9:50 a.m. with LVN S revealed she had only given one 20 mEq tablet to resident #7. She stated she did not verify the order with anyone. She gave one 20 mEq of KCl on 11/3/12 and 11/4/12 at 12 noon and on 11/6/12 and 11/7/12 at 12 midnight. Interview on 11/9/12 at 10:00 a.m. with LVN R revealed she had only given one 20 mEq tablet to resident #7. She stated she did not verify the order with anyone. She gave resident #7 one 20 mEq of KCl on 11/3/12 at 6:00 p.m. Record review of Lab report dated 11/7/12 at 7:20 p.m. revealed resident #7's Potassium level was at a critical low level of 2.6. It revealed the test had been repeated because of the critical level and verified as accurate. A handwritten note on the bottom of the lab report stated "11/7/12 left voice message with M.D. at 10:00 p.m." and signed by RN W. Interview on 11/9/12 at 3:25 p.m. with RN W revealed he left two messages for resident #7's physician to report the critical Potassium lab value of 2.6 but had no response. He stated he did not think about calling the facility's Medical Director. Review of resident #7's Nurses Notes dated 11/8/12 revealed the ADON called resident #7's physician at 6:00 a.m. and received orders to continue 120 mEq of KCl four times daily. At 6:40 a.m. the ADON received orders to transport resident #7 to the emergency room for treatment of [REDACTED]. Review of the Hospital's Physician admission orders [REDACTED]. Review of the Hospital's lab value for resident #7 on 11/9/12 revealed his critical level of Potassium remained at 2.7. Review of the facility's Policy and Procedure revealed a policy titled General Dose Preparation and Medication Administration, with a revision date of 1/15/09. The policy revealed "Facility staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident." Review of the facility's Long Term Care Procedures (procedure 365) dated 2006 revealed "If the attending physician is not available, call alternate physician. If not available, contact physician responsible for emergency care of residents or arrange transportation to an appropriate facility for emergency care. Record exact time physician was called and exact time physician responded to call. Identify underlying condition that required emergency care. Develop a plan to treat the condition. Observe and monitor resident's response to treatment." Immediate Jeopardy: The administrator was notified on 11/9/12 that an Immediate Jeopardy situation was identified due to the above failures.. The facility's Plan of Removal was accepted on 11/9/12 at 3:38 p.m. and included: 1. Resident identified as not receiving medications as ordered per physician order [REDACTED]. No other residents were identified as affected. 2. Residents in the facility receiving medications have the potential to be affected. Nursing staff will: a. Complete a center wide MAR indicated [REDACTED]. b. Nursing staff will receive in-service training on principles of medication administration to include: Medication Pass Administration competency of all staff administering medications. c. The Potassium medications will be administered by the nurses instead of the Medication Aides, until competency with medication administration is achieved. 3. The Director of Nursing and/or designee will review the Medication Administration Records q shift for 7 days and then weekly for 4 weeks and monthly for at least 1 quarter to validate competency in medication administration. 4. Results will be presented to the QA and A Committee for review and modification of plan as necessary. Plan of Removal Verification: The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ as follows: 1. Verified all 8 MAs had completed the requirements for a current MA permits. 2. Verified a MAR indicated [REDACTED]. 3. 14 nurses and 1 MA were interviewed on 11/9/12 between 3:30 p.m. to 6:20 p.m. to verify knowledge of inservice training received in relation to only nurses being able to give Potassium and to verify and clarify M.D. orders. 4. All Potassium blister packs were removed from the MAs' cart and placed in the nurses medication carts. While the IJ was removed on 11/09/12 at 3:38 p.m., the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of pattern because the facility had not had time to implement, monitor and evaluate the effectiveness of the Plan of Removal. Interview on 11/14/12 at 8:45 a.m. with the ADON revealed resident #7 was still in the hospital because of his Hypokalemia. A sheet given by the ADON on 11/9/12 revealed 12 residents on KCl. .

Based on observation, interview and record review the facility failed to ensure that 1 of 23 residents (Resident #7) reviewed for medications was free of significant medication errors. Resident #7 failed to receive 120 mEq of Potassium Chloride four times daily as ordered by the physician after recently being hospitalized for a critically low Potassium level of 1.8. from 11/1/12 through 11/7/12. (Normal range is 3.5 - 5.1) "Hypokalemia is associated with increased risk of arrhythmia in patients with cardiovascular disease, as well as increased all cause mortality, by up to 10-fold. The more at risk of fatal arrhythmia and sudden cardiac death a patient is, the more attention should be given to the potassium homeostasis." Article review "Hypokalemia and sudden cardiac death" by K. Kjeldsen. Exp Clinical Cardiology 2010;15 (4):e96-e99. Resident #7 was admitted back to the hospital just 8 days after discharge from a previous hospitalization for low potassium levels of 2.6. An Immediate Jeopardy was identified 11/09/12. The I J was removed on 11/09/12 at 3:38 p.m.The facility remained out of compliance at the severity level of potential for than minimal harm that is not an IJ at a scope of pattern because the facility had not had time to implement, monitor and evaluate the effectiveness of the Plan of Removal. This deficient practice placed 12 residents receiving Potassium supplements at risk for low Potassium levels and could result in a decline in residents' health. The findings were: Review of resident #7's face sheet, dated 10/31/12, revealed he was originally admitted into the facility on [DATE] and readmitted to the facility on [DATE] from a recent hospital stay for a [DIAGNOSES REDACTED]. Review of resident #7's Discharge Summary from the hospital dated 10/31/12 revealed Resident #7 was admitted [DATE] with a critical Potassium value of 1.8. Resident #7's discharge medication orders included orders for 120 mEq of KCl four times daily and to have a blood test on 11/8/12 or 11/9/12 to monitor the Potassium level in the blood. Resident #7's Potassium level when discharged from the hospital on [DATE] was 3.1 and was receiving 120 mEq of KCl four times daily while in the hospital. Review of the physician's orders [REDACTED]. Review of resident #7's November 2012 MAR indicated [REDACTED]. The November 2012 MAR for resident #7 had a circle around his KCl dose on 11/1/12 at 12 noon which indicates the medication was not given but there was no explanation why this medication was not given. Four times there were no initials recorded that the KCl had been administered. Review of November 2012 MAR for resident #7 revealed the MAs, RNs and LVNs were signing they were giving 120 mEq of KCl four times daily. Observation and interview on 11/05/12 at 7:55 p.m. on initial rounds with RN W revealed resident #7 was lying in bed. He told the nurse he was feeling tired and weak, he had abdominal pain and he was nauseated which could be symptoms of a low potassium level. Interview on 11/05/12 at 8:00 p.m. with RN W revealed resident #7 had recently returned from the hospital with a [DIAGNOSES REDACTED]. Interview on 11/7/12 at 3:00 p.m. with MA U revealed he had given one 20 mEq of KCl on his shift. He stated he was told by LVN L the order for 120 mEq of KCl must be one 20 mEq of KCl instead of 120 mEq because she had never heard of anyone receiving 120 mEq in a day much less four times a day. He administered one 20 mEq of KCl on 11/1/12, 11/3/12, 11/5/12 and 11/6/12 at the 6:00 p.m. med pass. Observation on 11/7/12 at 3:05 p.m. with MA U revealed resident's #7's previous Pharmacy blister pack of KCl had a label that he was to receive 20 mEq of KCl twice daily which contradicted the M.D. order on 10/31/12 for 120 mEq of KCl every 6 hours. In an interview with MA U at that time, he stated the staff never went by what the Pharmacy blister pack said, just what the MAR indicated [REDACTED]. He stated the policy was when a resident returned from the hospital, all medication orders were to be faxed to the Pharmacy by the nurse. He stated he never questioned anyone regarding this discrepancy. Interview on 11/7/12 at 3:50 p.m. with the LVN MM for resident #7 revealed she checked over the orders the day after his hospital readmission and reconciled the order was for 120 mEq of KCl. She stated she did not fax the medication order to the Pharmacy because the task was supposed to be done by the nurse on duty when the resident was admitted back to the facility. Interview on 11/8/12 at 9:00 a.m. with MA T revealed she gave one 20 mEq of KCl on all the shifts she worked. She stated the blister pack for resident #7 stated to give one 20 mEq twice a day and she thought it had been changed to 20 mEq of KCl four times a day. She administered one 20 mEq of KCl on 11/2/12 at 6:00 a.m. and 12 noon, 11/5/12 at 6:00 a.m. and 12 noon, 11/6/12 at 6:00 a.m. and 11/7/12 at 6:00 a.m. and 12 noon for a total of 7 doses of 20 mEq of KCl. She stated resident #7 had refused the KCl on 11/1/12 at 6:00 a.m. and 11/6/12 at 12:00 noon. She did not remember why she had circled her initials on 11/1/12 at 12 noon but failed to give a reason on the back of the MAR indicated [REDACTED] Interview on 11/8/12 at 12 noon with the interim DON revealed when he worked as a floor nurse he only gave one 20 mEq of KCl instead of 120 mEq as ordered. He stated he did not verify the order with the physician. He gave one 20 mEq of KCl on 11/3/12 and 11/4/12 at 6:00 a.m. and 12 midnight. He stated he failed to give a dose on 11/5/12 because he forgot about giving resident #7 his KCl. Interview on 11/8/12 at 3:40 p.m. with RN W revealed he thought he had faxed the October 31, 2012 Admission Medication List to the Pharmacy with the 120 mEq of KCl listed on the sheet. Interview on 11/8/12 at 4:40 p.m. with LVN L revealed she made the statement that she had never seen 120 mEq of KCl given in 24 hours much less in one dose. She stated she did not call the doctor to verify the dose and told the Med Aides to just give one 20 mEq of KCl four times a day. She stated she did not read the discharge instructions from the physician. She stated she thought that 120 mEq of KCl was an error but she did not change the order on the November 2012 MAR. She stated she gave one 20 mEq of KCl on 11/4/12 at 6:00 p.m. Interview on 11/9/12 at 6:50 a.m. with RN Q revealed she had given no KCl to resident #7. She stated she did not remember if it was not in the drawer or why but she did not give any KCl to resident #7 on 11/1/12 and 11/2/12 at midnight as scheduled. Interview on 11/9/12 at 9:50 a.m. with LVN S revealed she had only given one 20 mEq tablet to resident #7. She stated she did not verify the order with anyone. She gave one 20 mEq of KCl on 11/3/12 and 11/4/12 at 12 noon and on 11/6/12 and 11/7/12 at 12 midnight. Interview on 11/9/12 at 10:00 a.m. with LVN R revealed she had only given one 20 mEq tablet to resident #7. She stated she did not verify the order with anyone. She gave resident #7 one 20 mEq of KCl on 11/3/12 at 6:00 p.m. Record review of Lab report dated 11/7/12 at 7:20 p.m. revealed resident #7's Potassium level was at a critical level of 2.6. It revealed the test had been repeated because of the critical level and verified as accurate. A handwritten note on the bottom of the lab report stated "11/7/12 left voice message with M.D. at 10:00 p.m." and signed by R.N. W. Interview on 11/9/12 at 3:25 p.m. with RN W revealed he left two messages for resident #7's physician to report the critical Potassium lab value of 2.6 but had no response. He stated he did not think about calling the facility's Medical Director. Review of resident #7's Nurses Notes dated 11/8/12 revealed the ADON called resident #7's physician at 6:00 a.m. and received orders to continue 120 mEq of KCl four times daily. At 6:40 a.m. the ADON received orders to transport resident #7 to the emergency room for treatment of [REDACTED]. Review of the Hospital's Physician admission orders [REDACTED]. Review of the Hospital's lab value for resident #7 on 11/9/12 revealed his critical level of Potassium remained at 2.7. Review of the facility's Policy and Procedure revealed a policy titled General Dose Preparation and Medication Administration, with a revision date of 1/15/09. The policy revealed "Facility staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident." Review of the facility's Long Term Care Procedures (procedure 365) dated 2006 revealed "If the attending physician is not available, call alternate physician. If not available, contact physician responsible for emergency care of residents or arrange transportation to an appropriate facility for emergency care. Record exact time physician was called and exact time physician responded to call. Identify underlying condition that required emergency care. Develop a plan to treat the condition. Observe and monitor resident's response to treatment." Immediate Jeopardy: The administrator was notified on 11/9/12 that an Immediate Jeopardy situation was identified due to the above failures.. The facility's Plan of Removal was accepted on 11/9/12 at 3:38 p.m. and included: 1. Resident identified as not receiving medications as ordered per physician order [REDACTED]. No other residents were identified as affected. 2. Residents in the facility receiving medications have the potential to be affected. Nursing staff will: a. Complete a center wide MAR indicated [REDACTED]. b. Nursing staff will receive in-service training on principles of medication administration to include: Medication Pass Administration competency of all staff administering medications. c. The Potassium medications will be administered by the nurses instead of the Medication Aides, until competency with medication administration is achieved. 3. The Director of Nursing and/or designee will review the Medication Administration Records q shift for 7 days and then weekly for 4 weeks and monthly for at least 1 quarter to validate competency in medication administration. 4. Results will be presented to the QA and A Committee for review and modification of plan as necessary. Plan of Removal Verification: The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ as follows: 1. Verified all 8 MAs had completed the requirements for a current MA permits. 2. Verified a MAR indicated [REDACTED]. 3. 14 nurses and 1 MA were interviewed on 11/9/12 between 3:30 p.m. to 6:20 p.m. to verify knowledge of inservice training received in relation to only nurses being able to give Potassium and to verify and clarify M.D. orders. 4. All Potassium blister packs were removed from the MAs' cart and placed in the nurses medication carts. While the IJ was removed on 11/09/12 at 3:38 p.m., the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of pattern because the facility had not had time to implement, monitor and evaluate the effectiveness of the Plan of Removal. Interview on 11/14/12 at 8:45 a.m. with the ADON revealed resident #7 was still in the hospital because of his Hypokalemia. A sheet given by the ADON on 11/9/12 revealed 12 residents on KCl. .

Based on observation, interview and record review, the facility failed to provide emergency dental services to meet the needs of 2 of 23 sampled residents (#2 & 7). A. Resident #2 had loose teeth, bleeding, and dental pain that was identified 9/12/10 and ordered to see a dentist, which was not arranged until 10/5/10. Resident #2 was admitted to the hospital with [REDACTED]. B. Resident #7 experienced dental pain since admission in April 2010 and had requested to see a dentist, which was not arranged until 10/13/10. Failure to provide dental consultations could affect 5 residents in the facility with pending dental visits by causing a delay in care, continuing pain, and deterioration in dental problems The findings were: A. 1. Observation on 10/12/10 at 9:21 a.m. of resident #2 revealed the resident was in bed. Interview with LVN V at that time revealed that the resident recently had a dental appointment (10/5/10) where she had 7 teeth pulled due to an abscess. Review of resident #2's history and physicals, dated 3/07/09 and also 3/07/10, revealed the resident had poor dental hygiene. Review of resident #2's nursing notes dated 9/12/10 revealed the resident was noted to have blood to the corner of her mouth. The nurse noted that upon assessment, the resident's tooth was bleeding. Further notes on 9/12/10 revealed that the physician was notified of the resident's dental bleeding, and an order was received for a dental consult and mouth care TID. Review of resident #2's physician progress notes [REDACTED]. Review of facility 24 hour change in condition report dated 9/12/10 revealed resident #2 had been bleeding from tooth and a new order for a dental consult and mouth care was received. Review of resident #2's nursing notes dated 9/13/10 revealed the resident was not in any pain or distress. The nurse noted the resident was up and out of bed to go to activities and to visit with family. The nurse noted that she informed the social worker of the order for a dental consult, and the social worker said she would call the resident's insurance and family to make arrangements. The nurse noted the resident had no bleeding in the resident's mouth. Review of resident #2's social worker's notes dated 9/13/10 revealed the social worker was informed the resident's tooth was bleeding and there was a request for a dental consult. The social worker noted she called the resident's family, who would come in to the facility to sign paperwork. Review of resident #2's nursing notes dated 9/14/10 at 3:45 a.m. revealed the resident was noted with a small amount of dried blood during oral care. Review of resident #2's nursing notes dated 9/14/10 at 3:50 p.m. revealed that no bleeding from the resident's mouth was noted. The nurse noted that the resident did not wish to join in activities. The nurse noted the resident's family signed the paperwork to see the dentist but no appointment had been made. Review of resident #2's social worker notes dated 9/14/10 revealed the resident's family member came in to the facility and signed paperwork for the resident to see the dentist. The social worker noted she sent the necessary forms to the resident's attending physician and would wait for the physician to return the papers to schedule the resident's dentist appointment. Review of the 24 hour Change of Condition Report for 9/14/10 and 9/15/10 revealed resident #2 had a dental consult pending. Review of resident #2's nursing notes dated 9/15/10 at 3:25 p.m. revealed that no bleeding from the resident's mouth was noted. The nurse noted that the resident did not participate in activities. Review of the 24 hour Change of Condition Report for 9/16/10 revealed the evening shift nurse reported that resident #2 was noted with bleeding to her top right teeth. Review of the 24 hour Change of Condition Report for 9/19/10-9/21/10 noted resident #2 had a pending dental consultation; the nurse on 9/21/10 day shift noted the resident had soreness in her mouth. Review of resident #2's nurses notes dated 9/21/10 at 10 p.m. revealed the resident's family visited and was concerned about the resident's loose tooth. The family asked how long until the resident would get a dental appointment. The nurse noted she informed the family that she would ask the social worker. The social worker stated she was waiting for the dentist to get back with her. Review of the 24 hour Change of Condition Report for 9/22/10 revealed resident #2 had a pending dental consultation. The nurse on 9/22/10 day shift noted the resident's physician had ordered [MEDICATION NAME] (a pain reliever) that day to be given as needed. Treatment record for September 2010 revealed resident #2 received the [MEDICATION NAME] on September 23 (1x), twice on the 24th, twice on the 25th, twice on the 2, twice on the 29th, and once on the 30. Review of the 24 hour Change of Condition Report for 9/23/10-9/25/10 noted resident #2 still had a pending dental consultation and the nurse on 9/21/10 day shift noted the resident had soreness in her mouth. Review of resident #2's social worker notes dated 9/24/10 revealed she had received the paperwork from resident #2's physician and paperwork to be attached with the dental application was gathered together. Review of resident #2's nursing notes dated 9/26/10 at 8:30 p.m. revealed resident #2's family was in the facility and expressed concern to the nurse at 7:15 p.m. that the resident felt warm. Resident #2's temperature was taken, and the resident had a fever of 101.2. The nurse noted she called the resident's physician and gave the resident Tylenol. The nurse noted the resident was lethargic and hard to arouse. The nurse noted that the physician called back, and the nurse requested antibiotic treatment, because the resident was already on respiratory treatment for [REDACTED]. what is going on. We need to get her checked. Send to (the hospital)." The nurse noted the resident's temperature was taken again at 8:15 p.m. and read 101.5. The resident was transported to the hospital. Review of resident #2's Resident Transfer Form dated 9/26/10 revealed the resident was sent to the hospital due to increased temperature, lethargy, and with an upper respiratory infection. The resident's temperature was listed as 101.5, pulse was 88, respirations 22 and blood pressure was 142/86. Review of resident #2's September MARs revealed the resident's blood pressure would range from 112/60 to 132/84 prior to 9/12/10. After 9/12/10 until her hospitalization , her blood pressure ranged from 121/65 to 156/92. Review of resident #2's hospital History and Physical dated 9/26/10 revealed the resident was taken to the hospital for persistent fevers for the past 2 days. The physician noted that the resident's family stated she had tooth pain for the past 2 weeks and the family had been trying to seek out a dentist for her with help from the facility staff. The physician assessed the resident was having mouth and tooth pain. The resident was noted with significant tooth decay with a tooth almost completely blackened of the right upper molar. The physician also noted mild [DIAGNOSES REDACTED] (swelling and redness) around her teeth with pain upon "palpation" (touching). Also, the resident would moan and try to move her head back when the area was touched. The physician diagnosed the resident with an oral abscess with tooth decay. The resident was to start on [MEDICATION NAME] and [MEDICATION NAME] (antibiotics) intravenously, have [MEDICATION NAME] (a pain reliever) applied to her mouth, and [MEDICATION NAME] and [MEDICATION NAME] for pain. Review of resident #2's hospital physician's assessment dated [DATE] revealed the resident had a fever of 100.6. The physician noted resident #2's mouth was foul smelling, and that the resident had multiple dental cavities. Review of resident #2's hospital discharge summary dated 9/27/10 revealed the dental cavities were the reason for the low-grade fevers resident #2 had. The resident was started on [MEDICATION NAME] (an antibiotic) twice a day for two weeks. The physician noted that resident #2 should "follow-up with an orthodontist soon" for her dental cavities. Resident #2's hospital discharge orders, dated 9/27/10, revealed the resident was diagnosed with [REDACTED]. Review of resident #2's facility social worker notes dated 9/27/10 revealed the social worker faxed and mailed the required information to the dentist's office. Review of resident #2's nursing notes dated 9/28/10 revealed the resident was readmitted to the facility with an oral abscess. Review of resident #2's social worker notes dated 9/28/10 revealed the social worker called the dentist's office. The social worker noted the dentists requested updated MARs, and that the dentist would need to wait for the original dental application paperwork to be provided before a dental appointment could be made. The social worker noted she was informed by the dentist that since the resident was just started on [MEDICATION NAME], the dentist would like her to be on it for a few days before seeing the resident. Review of resident #2's nursing notes dated 9/29/10 revealed the resident had "unscalable pain in mouth by pointing, moaning and grimacing." Review of resident #2's nursing notes dated 9/30/10 revealed the resident had pain in her mouth that was "unratable. " Review of resident #2's September 2010 MAR indicated [REDACTED]. The resident was medicated with [MEDICATION NAME] for pain 9 times from 9/23/10-9/30/10, and [MEDICATION NAME] (a pain reliever) 22 times from 9/12/10-9/30/10. Review of resident #2's nursing notes dated 10/1/10 revealed the resident was medicated with [MEDICATION NAME] for pain to mouth. Review of resident #2's social worker notes dated 10/1/10 revealed the social worker contacted the dentist to verify receipt of the dental application. The dentist office stated the papers were received. The social worker noted that she would work with the family to make an appointment. Review of resident #2's social worker notes dated 10/4/10 revealed the resident had a dental appointment made for 10/5/10. Review of resident #2's dental progress notes dated 10/5/10 revealed the resident had severe halitosis (bad breath), gingival (gum) swelling, and severe gingivitis and periodontitis (gum and mouth inflammation). The dentist noted cavities on all front teeth. The dentist noted 7 teeth were not restorable. Interview on 10/13/10 at 11:32 a.m. with CNA FF revealed she took care of resident #2. CNA FF revealed resident #2 mouth pain about a month ago. She stated about a month ago, resident #2's mouth began to bleed, so she told LVN V. CNA FF stated resident #2 went to the hospital due to infection in her mouth. Interview on 10/13/10 at 11:53 a.m. with LVN V, charge nurse for resident #2, revealed the resident was noted with blood and inflamed gums. LVN V stated they performed oral care, and it seemed to get better prior to resident #2's admission to the hospital. She came back from the facility with the oral abscess and orders for antibiotics. LVN V stated resident #2 was in pain and needed to be medicated. Interview on 10/13/2010 at 11:59 a.m. with resident #2's family member revealed he noticed resident #2 had loose teeth on 9/10/2010. On 9/13/2010, he noticed resident #2's mouth was infected and swollen as big a golf ball. He revealed he discussed the situation with the DON and LVN V and requested a visit with the dentist. He stated he was told the dentist will not be coming to visit the facility for another three weeks. He revealed on 9/13/2010 resident #2 looked as if she was in pain. She was wiggling around in bed, her mouth was swollen and had been bleeding. Interview on 10/13/10 at 12:00 p.m. with the facility social worker revealed the social worker remembered hearing resident #2 had an infection, so she called the family. She stated she mailed resident #2's attending physician the insurance paperwork and waited for the physician to return it. She stated she asked the Medical Records technician daily until it was returned. She stated when the paperwork was returned from the attending physician, she mailed it to the dentist. She stated she had difficulties getting the dentist what they needed, and that residents who were supposed to be seen in September were never seen. She stated that for emergency dental care, the order needed to read "emergency" in order for the resident to be seen quickly. Interview on 10/13/2010 at 2:20 p.m. with DON revealed she assessed resident #2 mouth and found her have inflamed gums, plaque, some broken teeth and her gums were red. She stated that if a resident had loose teeth or was bleeding from her teeth, it could constitute a dental emergency, and the resident would be sent to the emergency room for care. She stated sending a resident to the emergency room would get them seen by a dentist sooner. Interview with resident #2's dentist on 10/14/10 at 2:40pm revealed that all 7 bottom teeth had been broken and decayed. The dentist did not know how long the teeth were like that, but teeth are only removed when symptomatic and all 7 teeth were symptomatic. Interview on 10/14/10 at 3:14 p.m. with the AD revealed resident #2 would come to activities, mainly Bingo and musical entertainment. The AD stated resident #2 loved Bingo. The AD stated that after the resident returned from the hospital, she wouldn't come to activities because she wasn't feeling well. B. Interview on 10/14/10 at 4:10pm with resident #7 revealed that she had been in the faciity for 6 months (since April 2010) and had experienced difficulty trying to get an appointment to see the dentist as she had a lot of pain. She also stated that the social worker tried to get her an appointment and had talked to one dentist who would not take her because a balance was supposed to paid by the faciity first. She (resident #7) indicated that the social worker had called her daughter asking for $400 so resident #7 could see the dentist for the pain in her mouth. The daughter did not have the money so she (resident #7) just suffered in pain. Resident #7 also reported that she had finally been to a dentist the day before (10/13/10) but because she was on a stretcher, she could not get into the dentist's office. She was then taken to another dentist who put her on antibiotics and scheduled a follow-up appointment for the following week, 10/21/10, to remove her teeth. Interview on 10/13/10 at 5:05pm with the social worker revealed that on resident #7's admission (April 2010) she had tried to get a dental appointment for her. The dentist at that time said that he would not take her until the facility's bills were paid. The dentist wanted $400 up front before he would see her. The social worker relayed that she then contacted resident #7's daughter and she did not have the money. She (the social worker) then dropped it because of the money issue. She did not get her an appointment untill 10/13/10 to see a dentist. Review of list of residents with dental needs (no date) provided by the facility revealed 5 residents were awaiting dental visits. .