Every finding on record at Avir at Schertz

Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. Resident #1's electronic medical record did not contain complete and accurate documentation that LVN B and LVN C recorded in the March 2026 TAR (Treatment Administration Record) that the resident received wound care on 3/9/26, 3/12/26, 3/15/26, and 3/16/26. This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to nursing and medical staff involved in wound care given to residents.Findings include: Record review of Resident #1's face sheet, dated 3/20/26, reflected an -[AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia (decline in memory cognition), surgical aftercare for digestive system, HTN (hypertension), muscle wasting, lymphedema (localized swelling) and DM (diabetes (too much sugar in the blood stream). The RP was listed as: self.Record review of Resident #1's admissions MDS, dated [DATE], reflected a BIMS score of 14, indicative of no impairment in cognition. The ADLs for: B/B was incontinent of both; Transfer and Mobility was total care. ROM was no impairment. Assistive devices: W/C. Record review of Resident# 1's Care Plan, dated 2/27/26, revealed the goals and interventions included:wound care for pressure ulcers, notify MD for changes, follow treatment orders, pressure release mattress, supplements, and proteins. Record review of Resident #1's physician orders, dated March 2026, reflected: the physician's wound orders were:Great toe left and right (q shift); Left and right heel Tuesday/Thursday/Saturday; and Sacrum q shift and PRN. Record review of Resident #1's March 2026 TAR reflected wound care was not documented as follows:Great toe left and right (q shift): not documented 3/7/26, 3/12/26, and 3/15/26, and 3/16/26 [last wound care was 3/17 and documented]Left and right heel T/T/S: not documented 3/7/26, 3/12/26 [last treatment was on 3/17/26 and documented]Sacrum q shift and PRN: not documented 3/7/26, 3/9/26, 3/12/26, 3/15/26, and 3/16/26 [last treatment was 3/17/26 and documented] Record review of Resident #1's Discharge summary dated [DATE] reflected the resident was sent to the ER per request of a family member. During an observation and interview on 3/20/26 at 5:30 PM, Resident #1 was in a hospital medical bed picking at his dinner meal. The resident was alert and oriented towards person, place, and time. The resident stated he was in the hospital for wound care treatment. The resident stated the nursing home provided him wound care and his wounds had improved. However, the resident stated that he might have missed wound care on some days; the resident could not provide specifics as to the days he had missed wound care. The resident denied ANE at the nursing home. During an interview on 3/20/26 at 9:30 AM, MD stated Resident #1 had poor blood circulation around his toes and had developed dead tissues. The MD stated the skin condition had declined and the resident received daily wound care. The MD stated the resident needed to be assessed by a surgeon to determine whether the resident was a suitable candidate for surgery. The MD stated the resident was not neglected around wound care. During an interview on 3/20/26 at 9:35 AM, the DON stated Resident #1 was discharged to hospital on 3/17/26 because his wounds around the toes were not improving and the family wanted him assessed at the hospital. The DON stated the family was informed that Resident #1 was a candidate for hospice, but the family refused. The DON stated the resident was provided with daily wound care and was not neglected. During an interview on 3/20/26 at 11:47 AM, the ADON stated that she had been observing, as an RN, wound care provided to Resident #1 since his admission [DATE] and sent to the hospital on 3/17/26). The ADON stated Resident #1 had orders for daily wound care of the sacrum. The ADON stated Resident #1 had a diagnosis of lymphedema which caused swelling and oozing to both legs. The ADON stated the wound care orders were for: great toe left and right (q shift-12-hour shifts), left and right heel Tuesday/Thursday/Saturday and PRN; both legs T/T/S and PRN; sacrum q shift and PRN. The ADON stated the two nurses responsible for wound care were: LVN B and LVN C. ADON stated she could not explain why physician orders were not documented for wound care to Resident #1 on 3/7/26, 3/9/26, 3/12/26, 3/15/26 and 3/16/26. ADON stated the family member requested that the resident be sent to the hospital for an assessment and/or treatment of wounds. ADON stated the family member felt the resident was declining in health. ADON stated she was not sure whether providing or not providing wound care as ordered by the physician would have led to a decline in the condition of the wounds. ADON stated the resident was at an end stage of skin failure for his wounds. ADON stated she monitored the wound care on 3/16/26 but it was not documented; and she had a photo available to prove care was done on 3/16/26. During an interview on 3/20/26 at 1:37 PM, Regional RN stated: the lack of documentation on 3/7/26 wound care in the TAR was due to resident being in the hospital for a fall without injury; and the resident returned on 3/8/26. The Regional RN stated on 3/9/26, LVN B had stated to him that wound care was done but not documented. Regional RN stated he had no explanation for the non-documentation on 3/12, and 3/15. Regional RN stated the wound care was done on the 3/16 at 12:09 PM and witnessed by the ADON but not documented. During an interview on 3/20/26 at 1:47 PM, LVN A stated she witnessed LVN C provide wound care on 3/12/26 but was not certain whether the March TAR was documented. During telephone interview on 3/20/26 at 2:10 PM, LVN B stated: she put a wound patch on one of Resident #1's wounds on 3/9/26 but did not document the TAR because she forgot. During phone interview on 3/20/26 at 3:11 PM, the Wound NP stated the resident was dying but the family did not want to place the resident under hospice care. The NP stated her expectation was for nursing staff to follow physicians' orders and document the clinical record. The NP stated she could not explain the dates wound care was not documented. The NP stated the resident refused facility meals and only took limited amounts of liquids which made him susceptible to more wounds or worsening wounds. NP stated the family on 3/17/26 insisted on Resident #1 going to the ER because the resident stated to a family member, he could not feel his legs. During interview on 3/20/26 at 3:30 PM, the DON stated based on the timeline of wound care by MD orders the following occurred:---3/7/26 resident was in the hospital for fall without injury for observation and tests (resident hit his head on floor unwitnessed, not reportable to HHSC) and wound care was not documented.---3/9/26 wound care done to the sacrum but not documented; DON stated she heard LVN B tell the night nurse to observe for the patch to the sacrum because the resident was having loose stools.---3/12/26, 3/15/26 the DON stated LVN C told her wound care was done but not documented.---3/16/26 wound care was done by LVN C and witnessed by the ADON but not documented. The DON stated she could not give an explanation why LVN C did not document wound care on 3/12, 3/15 and 3/16 on the TAR March 2026. DON stated the Wound Nurse NP visited the facility weekly. The DON stated based on her best knowledge wound care was provided to Resident #1 on 3/9/26, 3/12/26, 3/15/26, and 3/16/26 but not documented. The DON stated she expected nurses to document care and the two nurses (LVN B and LVN C) that provided wound care to Resident #1 were competent in documentation. During an interview on 3/20/26 at 5:35 PM, hospital RN D stated the resident was admitted to the hospital for debridement of wounds to the toes, heels, and sacrum. The RN stated that she saw no neglect of care at the nursing home based on hospital progress notes. RN stated that the resident sometimes refused medications in the hospital and did not eat all his food. During an interview on 3/20/26 at 5:37 PM, hospital RN E stated the resident was admitted for follow-up wound care. RN stated the resident had a lot of necrotic issues to his wounds. The RN stated the resident was at times non-compliant in accepting his medications. The RN read the hospital admissions notes and it stated there was no neglect mentioned in the notes involving any wound care at the nursing home. Record review of Resident #1's photo of sacrum area taken by the ADON on 3/16/26 reflected photo of the sacrum as proof wound care was done on 3/16/26. Record review of Text message dated 3/20/26 at 3:50 PM from LVN C stated that she did wound care for Resident #1 on 3/12/26, 3/15/26 and 3/16/26. Record review of facility's Nurse Orientation/Competency Checklist undated reflected the competency of Charting/POC/ Dashboards for LVN B (1/29/26) and LVN C (3/17/26). Record review of facility's Charting and Documentation policy undated, read All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.

Based on observation, interview and record review the facility failed to ensure staff disposed of garbage and refuse properly in 1 of 1 dumpster reviewed for disposal of trash. The facility failed to ensure the grounds around the dumpster were clean and free from food items. This deficient practice could place residents at risk for rodent and insect activity in the facility. The findings were:Observation and interview of the dumpster located outside about 100 yards from the facility. Interview with the DM stated all staff used the one dumpster to dispose of trash. Further observation revealed about 2 servings of sweet potatoes on the ground a few feet from the dumpster. The DM stated the food looked like sweet potatoes and stated it could attract insects and rodents. The DM stated the facility including resident rooms could become infested with insects and rodents. She stated the insects and rodents could carry diseases and infect the residents. Review of facility policy, Sanitation, dated November 2022 read 14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters, compacters with lids (or otherwise covered).15. Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests.

Based on observation, interview and record review the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety from 1 of 1 kitchen observed for safe food handling practices. The DM failed to ensure weekend kitchen staff deep cleaned the convection oven.Cook P failed to cover the four cooking sheets of chocolate chip cookies and to allow the plate covers (domes) to air dry before stacking them.The DM failed to ensure lunch items (pork chop with gravy, mixed vegetables and whipped sweet potatoes (regular diet) maintained safe range temperature on 2/26/26. The facility failed to ensure the handwashing sink in the kitchen was functional. These deficient practice could place residents at risk of food borne illnesses and result in a decline in the resident's health. The findings were:Review of the facility Safe Food Temperatures in the Dietary Log read as follows: Cold holding of food 41 degreesHot holding of food 135 degreesMeat, fish and raw shell eggs 145 degreesGround meat and fish injected meat 155 degreesPoultry and ground poultry 165 degrees Review of week at a glance menu for the Fall/Winter 2025-26 read: Thursday 2/26/26Lunch Sliced Pork with GravyWhipped Sweet PotatoSeasoned Spinach Honey Kissed RollMargarineFruit Cobbler Observation and Interview on 2/24/26 at 9:27 AM revealed built up black residue build up on the bottom of the convection oven. [NAME] Q stated they deep cleaned all appliances on the weekends. Interview on 2/24/26 at 9:30 AM with the DM revealed the weekend staff would deep clean all kitchen appliances. She stated the convection oven had not been cleaned for about 2 weeks and stated there was caked on burnt food on the bottom and steel trays in the convection oven. The DM stated the food being baked would be contaminated if crumbs fell on it. Observation and interview on 2/24/26 at 9:33 AM revealed 4 baking sheets of chocolate cookies sitting on the prep table along the front wall. They were not covered. Interview with [NAME] P revealed she baked the cookies in the convection oven and she brought them out not even 5 minutes ago. She stated she should have covered them right away, so they were not contaminated by debris but stated she got busy with washing the dishes. Observation on 02/24/2026 at 9:35 AM revealed the hand-washing sink in the kitchen was not working. There was no running water. Further observation revealed staff was washing their hands at sink by the stove. Observation and interview on 2/24/26 at 9:40 AM revealed about 5 stacks of plate covers (domes) stacked in front of the partition for the stove. QA P checked them/turned them over and said there was still water in between and should wait until they were dry before stacking them. She stated bacteria could grow in most areas. The DA stated there was not enough space to spread them out to allow them to air dry. Observation and interview on 02/26/2026 at12:21 PM revealed the DM taking the temperature of the lunch meal including all stated items per the week at a glance menu for 2/26/26. The DM stated she substituted seasoned spinach with mixed vegetables. The DM removed the last two trays from the 200-hall cart; 1 was a regular diet and 1 was a puree diet. The DM took temperatures with a digital thermometer. The regular diet temperatures she called out were as follows: whipped sweet potatoes 135 degrees, mixed vegetables 134 degrees, pork chop with brown gravy 133 degrees. The puree diet temperatures as the DM called out were as follows: pork chop with gravy 141 degrees, whipped sweet potatoes 130 degrees, mixed vegetables 125 degrees. Observation and interview on 02/26/2026 at 3:57 PM revealed the hand-washing sink in the kitchen was still not working. It did not have running water. Interview on 02/27/2026 at 2:44 PM with the DM revealed the temperatures she took of the food items served for lunch earlier (2/26/26) on the sampled trays did not reach the safe temperature range of 135 degrees except the sweet potatoes served on the regular diet. The DM stated the pork should have reached 145 degrees. She stated serving the food that was not in the safe range could result in the spread of foodborne illness and the residents could get sick or complain the food was too cold. Interview on 2/27/26 at 4:42 PM with the DM revealed the hand-washing sink in the kitchen had not been working for about 2 weeks. She stated it looked like there was not any pressure and there was no running water. The DM stated the previous MS looked at it but was not able to fix it. She stated the sink she and other dietary staff used to wash their hands was normally used for rinsing dishes. The DM further stated she was aware the plate covers/domes were dry before being stacked but stated they should be dry before stacking them. The DM bacteria could grow and get the resident's sick. Interview on 2/27/26 at 7:15 PM with the MS revealed he had started working for the facility about 1 week ago. He stated he learned the hand-washing sink was not working. He stated he ordered parts for it this week and he would repair it upon receipt of the parts. Review of facility policy, Sanitation, dated November 2022, read The food service area is maintained in a clean and sanitary manner. 1. All kitchen, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions', open seams, cracks and chipped areas that may affect their use or proper cleaning.3. All equipment, food contact surfaces and utensils are cleaning and sanitized using heat or chemical sanitizing solutions.7. Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Review of a facility policy, Food Receiving and Storage, dated November 2022, read Foods shall be received and stored in a manner that complies for safe food handling practices. 1. Critical Control Point means a specific point, procedure, or step in food preparation and serving process at which control can be exercised to reduce, eliminate, or prevent the possibility of a food safety hazard. Some operational steps that are critical to control in facilities to prevent or prevent food safety hazards are thawing, cooking, holding, reheating foods and employee hygienic practices.2. Danger Zone means temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow the rapid growth of pathogenic microorganisms that can cause food borne illness.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident and identify the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 of 24 Residents (Resident #3, #20, #23, #18, and #19) whose records were reviewed for resident needs. Nursing staff failed to identify in Resident #3's care plan her mental health status, care and services she required.Nursing staff failed to identify in Resident #20's care plan his behavior of removing his colostomy bag and throwing it on the floor.The facility failed to ensure Resident #23's care plan included his being a smoker. The facility failed to ensure Resident #18's care plan reflected the cares for the resident's wound and tube feeding. The facility failed to ensure Resident #19's care plan reflected the cares for the resident's smoking. These deficient practices could place residents at risk of not receiving proper care and services. Findings included:1. Review of Resident #3's face sheet, dated 2/27/26, revealed she was admitted to the facility on [DATE] with diagnoses including anxiety, depression and schizoaffective disorder bipolar type. Review of Resident #3's quarterly MDS, dated [DATE], revealed Resident #3 was diagnosed with depression and schizophrenia. Further review revealed her BIMS score was 3 of 15 reflecting severe cognitive impairment. Review of Resident #3's Care Plan dated 2/18/26 revealed it did not include Resident #3's history of mental illness including depression, anxiety and schizoaffective disorder, bipolar type. Further review revealed Resident #3 had impaired cognitive function related to dementia and a communication problem. Observation and attempted interview on 2/25/26 at 4:45 PM with Resident #3 revealed she was lying in bed. She answered yes or no questions but did not answer open-ended questions. Resident #3 presented as being alert to self with confusion. Interview on 2/27/26 at 1:58 PM with the MDS Coordinator revealed he had worked at the nursing facility for about one year and as the MDS Coordinator since September 2025. He stated he would write the comprehensive care plan for the residents and nursing staff would add any acute issues. He stated he was not involved in writing residents' care plan who had been in the facility longer than one year. However, the MDS Coordinator stated a resident's care plan should reflect a resident's care needs and services to be provided as identified in the MDS assessment. He stated otherwise nursing staff would not know the care and services to provide the resident. He stated ultimately, the resident, would not receive the care and services as needed. Interview on 2/7/26 at 6:56 PM with the DON revealed Resident #3's care plan did not include her history of mental illness including depression, anxiety and schizoaffective disorder, bipolar type. She stated a resident's care plan should reflect the resident's care areas and services required to meet the resident's needs. The DON stated otherwise nursing staff would not know what care and services to provide the resident. 2. Review of Resident #20's quarterly MDS, dated [DATE], revealed he was admitted to the facility on [DATE], with diagnoses including Cancer, Heart Failure and Renal insufficiency, Renal Failure (the gradual loss of kidney function — reaches an advanced state), or End Stage Renal disease (the kidneys no longer work as they should to meet your body's needs). Further review revealed the resident had an ostomy; to include colostomy and he did not exhibit behaviors towards himself or others. Observation and interview on 2/24/26 at 2:54 PM with Resident #42 revealed he was lying in bed. He engaged in conversation and shared some of his experiences while at the facility. He reported his roommate Resident #20 would remove his colostomy bag and throw it on the floor. He stated staff would not check on him regularly and Resident #20 would lie in bed while he was covered in feces. Resident #42 stated it smelled badly of feces in their room. He stated he reported it to staff. Observation and attempted interview on 2/24/26 at 3:00 PM revealed Resident #20 was lying in bed. Attempted interview revealed he shook his hand and would not engage in conversation. Review of Resident #20's Care Plan, dated 2/1/26, did not reveal Resident #20 would remove his colostomy bag and throw it on the floor. Review of Resident #20's progress notes from 1/1/26 to 2/27/26 did not reveal Resident #20 would remove his colostomy bag and throw it on the floor. Interview on 2/24/26 at 3:15 PM with LVN D revealed he had never seen Resident #20 remove his colostomy bag, but other nursing staff reported he had removed his colostomy bag several times and would throw it on the floor. Interview on 02/26/20264 at 5:20 PM with the DON revealed Resident #20 was able to make his basic needs known. The DON stated Resident #20's care plan did not identify that he would remove his colostomy bag and throw it on the floor. She stated she was not aware that he had the behavior and if true then it should be included so that staff would know how to approach the situation and how to address the concern with Resident #20. The DON stated not including this behavior would place him at risk of nursing staff not knowing how to address the behavior. Review of a facility policy, Care Plans, Comprehensive Person-Centered dated March 2022 read A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary team, (IDT) in conjunction with the resident, his/her family or legal representative, develops and implements a person-centered care plan for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered from the comprehensive assessment. 7. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well- being. 3. Record review of Resident #23's face sheet, dated 02/26/2026, revealed he was admitted to the facility on [DATE] with diagnoses which included: post-traumatic stress disorder, unspecified, and depression, unspecified. Record review of Resident #23's Quarterly MDS assessment, dated 02/20/2026, revealed the resident's BIMS score of 9 which indicated the resident had moderate cognitive impairment. Record review of Resident #23's Smoking assessment, dated 08/21/2025, revealed, Supervision during smoking at all times/Facility will store cigarettes and lighters/Resident is safe to hold and smoke cigarettes. Record review of Resident #23's care plan, with a revision date of 12/10/2025, revealed there was not a care plan reflecting Resident #23's smoking behavior. Observation on 02/27/2026 at 11:06 a.m. revealed Resident #23 smoking with supervision with other residents in the designated smoking area. During an interview and observation on 02/27/2026 at 11:55 a.m. the DON stated a resident smoking should be care planned because it was part of a resident's care plan. The DON further stated the care plan reflects everything that included their care and how to manage a resident's care. The DON stated there were 3 of them that were responsible for care plans which included herself, the MDS Coordinator and the ADON. The DON reviewed Resident #23's care plan and stated she did not see where smoking had been care planned. The DON stated smoking would i be care planned to make sure the residents were safe. The DON stated Resident #23 was considered a safe smoker. The DON stated by not care planning smoking the staff would not be aware of if the resident was a safe smoker or if the resident needed assistive items while smoking. During an interview on 02/27/2026 at 4:13 p.m. the MDS Coordinator stated he had not known they were doing care plans for smoking. The MDS Coordinator stated he did not know who did them before he started in November 2025. The MDS Coordinator stated he would be doing them now. The MDS Coordinator stated the care plan gave basic guidance on how they were going to care for a patient or an outline. The MDS Coordinator stated by not care planning smoking staff might not know if a resident needed a smoking apron. 4. Record review of Resident #18's face sheet, dated 02/27/2026, revealed the resident was an 85-years-old male and admitted to the facility on [DATE] with diagnosis of protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), pressure ulcer of buttock – stage 3 (wound that from as a direct result of pressure over a bony prominence to the buttock area), and gastrostomy status (surgical opening into the stomach for nutritional support or gastric decompression). Record review of Resident #18's quarterly MDS assessment, dated 01/28/2026, revealed the resident's BIMS score was 14 out of 15, which indicated the resident's cognitive was intact, and in Section M (Skin conditions), it was coded that Resident #18 did not have one or more unhealed pressure ulcers/injuries. Further record review of the MDS assessment revealed the resident had a mechanically altered diet which was required change in texture of food or liquids, for example, pureed food or thickened liquids in Section K (Swallowing/Nutritional Status). Record review of Resident #18's physician's order revealed the resident had the order of Wound Care: Left Ankle, right great toe, and left foot 4th interspace area - Cleanse with wound care cleanser, pat dry, apply Iodine, leave open to air. Every day shift related to UNSPECIFIED SKIN CHANGES. Started dated 02/14/2026 and Verify enteral tube placement by checking for residual gastric volume prior to medication admin and feedings every shift and Enteral Feed Order every shift Complete enteral site care every shift and as needed. Started 10/17/2025. Record review of Resident #18's comprehensive care plan, dated 02/24/2026, revealed there were no care plans regarding the resident's wound and tube feeding. Interview on 02/26/2026 at 4:51 p.m. MDS coordinator stated Resident #18 did not have any wounds when he was admitted to the facility on [DATE], but the resident had skin changes to his left ankle, right great toe, and left foot 4th interspace area on 02/14/2026 and received wound cares. The MDS coordinator said the facility ADON had the responsibility for developing care plans for wounds and did not know what reason the facility ADON did not develop the care plan for Resident #18's wound. Further interview with the MDS coordinator on 02/27/2026 at 8:21 a.m. said Resident #18 took all foods and medications by mouth, instead of gastrostomy tube and that was why tube feeding was not coded in MDS assessment per the guideline, but the facility nurses were providing care the resident's gastrostomy tube as ordered such as checking residual and clean the site, so the care plan should have reflected the care regarding the resident's gastrostomy tube, and not developing the care plan regarding tube feeding was the MDS coordinator's mistake. The MDS coordinator stated not developing care plan for tube feeding might affect inappropriate care to Resident #18. Interview on 02/26/2026 at 4:54 p.m. the ADON stated she was providing wound care to Resident #18 as ordered, and she thought the MDS Coordinator had the responsibility to develop Resident #18's care plans for wounds, instead of the facility ADON, and the facility ADON assumed the MDS Coordinator already developed the care plan. The facility ADON said there was some miscommunications between the ADON and MDS Coordinator regarding Resident #18's care plan for wounds, and no care plans might affect the resident could not receive correct wound care. Interview on 02/27/2026 at 3:53 p.m. the DON stated the facility ADON and MDS Coordinator should have developed the care plans regarding Resident #18's wound and tube feeding, and no care plan might affect the resident could have inappropriate cares. 5. Record review of Resident #19's face sheet, dated 02/27/2026, revealed the resident was a 65-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem), cystitis (inflammation of the bladder), and psychosis (losing some contact with reality). Record review of Resident #19's quarterly MDS assessment, dated 01/17/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive was intact, and the resident required Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to sit to stand and chair to bed. Record review of Resident #19's smoking assessment, dated 08/21/2025, revealed Resident #19 was smoking and Supervision during smoking at all times / Facility will store cigarettes and lighters / Resident is safe to hold and smoke cigarettes. Record review of Resident #19's comprehensive care plan, undated, revealed there was no care plan regarding Resident #19's smoking. Interview on 02/27/2026 at 8:33 a.m. the DON stated Resident #19 was smoking since she was admitted to the facility on [DATE], but there was no care plan regarding Resident #19's smoking, and developing a care plan for smoking was the DON and MDS nurse's responsibility. The DON said she did not know what reason she did not develop the care plan, and it was her mistake. The DON stated no care plan might affect the resident could receive inappropriate care regarding smoking. Record review of the facility policy, Care Plans, Comprehensive Person-Centered dated March 2022 read A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary team, (IDT) in conjunction with the resident, his/her family or legal representative, develops and implements a person-centered care plan for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered from the comprehensive assessment. 7. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well- being.

Based on interview and record review the facility failed to ensure the facility implemented and maintained an effective training program for all existing staff for 4 of 8 staff (MA G, MA I, CNA J and CNA K) whose records were reviewed for training. The facility failed to ensure MA G, MA I, CNA J and CNA K completed the required yearly competency skill set training. This deficient practice could place residents at risk of being cared by unqualified nursing staff. The findings were:Review of personnel files for MA G, MA I, CNA J and CNA K all of who were hired on 3/1/25 revealed they had not completed their yearly competency skill set training. Further review revealed their competency check off lists did not include the trainer's name and the completion date for training was left blank. Review of facility, CNA Orientation/Competency Checklist included the following training:System AccessFacility EmailTeamsShare Point-Policies and ProceduresLMS ReliasMeetingsRoundsIntake ProceduresOral Intake MeasurementsPercentage of Solid Food MeasurementPercentage of LiquidCalorie Counts/Tray MonitorDistribute-Set up and Collect TraysAssist/Feed Meals to ResidentsProvide Between Meals NourishmentsHandout SnacksPass Drinking WaterFeed the swallowing impairedCorrect Documentation/Charting ProceduresBedmaking ProceduresOccupiedUnoccupiedMaking Specialized BedInfection ControlHandwashing TechniqueHandling of LinenIsolation TechniquesBlood and Body Fluid PrecautionsAdmission/Discharge Packets Measuring WeightMeasuring HeightRecording/Caring for Belongings and Valuablesadmission ProcessDischarge ProcessADL AssistPersonal Hygiene, Bathing, Showering and Bed BathTransfer Techniques: Mechanical Lift, 1 & 2 Person AssistDressingOral Hygiene: Brushing Teeth & Cleaning DenturesToileting AssistMobility Assist: [NAME] & WheelchairObservation DocumentationProperly Reporting any Changes in Resident Status to NurseCorrectly Document All Flowsheets, Charts and KiosksGeneral DutiesProvide For Resident PrivacyWork as a Team MemberCorrect Change Procedures for SuppliesProper Telephone EtiquetteCommunicate with Other Departments EffectivelyInteract with Families and Staff Professionally Interview on 2/27/26 at 4:15 PM with the HR staff revealed that MA G and MA I were also CNA's and were required to complete the same competency training as the CNA's. The HR staff reviewed the competency for MA G, MA I, CNA J and CNS J and stated it did not look like they completed their yearly competency skill set training. She stated she believed the staff completed the training but stated the competency check off lists did not include the trainers name or the date the training was completed. The HR staff stated both the DON and ADON would train the staff . She stated the trainers had to sign and date the check off lists otherwise she could not prove staff MA G, MA I, CNA J and CNA K completed their yearly competency skill set training. The HR staff was asked for a facility policy for competency training, and it was not provided by the end of survey on 2/27/26 at 8:30 PM. Interview on 2/27/26 at 6:56 PM with the DON revealed they had competency training for multiple nursing staff one day during the month of February 2026 but could not remember who all she and the ADON trained. The DON stated she could not attest to whether or not MA G, MA I, CNA J and CNA K completed the competency skill set training.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 4 (Resident #71, #7, #5, and #56) of 24 residents reviewed for infection control practices. 1. When the facility ADON was providing wound care to Resident #71 on EBP (Enhanced Barrier Precaution), the ADON did not wear a gown, and the facility did not attach the sign of EBP on the door of the resident. 2. When CNA-L was providing urinary indwelling catheter care to Resident #7 on EBP (Enhanced Barrier Precaution), the CNA-L did not wear a gown. 3. When CNA-O was providing incontinent care to Resident #5 on 02/26/2026, the CNA-O touched new and clean brief with old and dirty gloves. 4. When CNA-J was providing incontinent care to Resident #56 on 02/26/2026, the CNA-J touched new and clean brief with old and dirty gloves. This deficient practice could place residents at risk for cross contamination and infections. The findings included: 1. Record review of Resident #71's face sheet, dated 02/27/2026, revealed the resident was an [AGE] year-old-male and admitted to the facility on [DATE] with diagnoses of encounter for surgical aftercare following surgery on the digestive system (postoperative care related to digestive system surgery), hypertension (high blood pressure), and lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that is usually drained through the body's lymphatic system). Record review of Resident #71's admission MDS assessment, dated 02/24/2026, revealed the resident's BIMS score was 14 out of 15 which indicated the resident's cognitive was intact and required Substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to sit to stand, chair to bed, and toilet transfer. Further record review of the MDS assessment revealed the resident had one or more unhealed pressure ulcers/injuries. Record review of Resident #71's comprehensive care plan, dated 02/17/2026, revealed the resident had the care plan of Provide wound care per treatment order and Risk for Infection - Administer antibiotic therapy as prescribed and Evaluate surgical incision and temperature. Record review of Resident #71's physician order, dated 02/26/2026, revealed the resident had the order of WOUND CARE: Cleanse RIGHT GREAT TOE with wound cleanser, pat dry, paint with betadine and leave open to air daily. Everyday shift, and WOUND CARE: Cleanse RIGHT LOWER LEG with wound cleanser, pat dry, apply xeroform, apply abdominal pad and wrap with kerlix and ace bandage. Every Tuesday, Thursday, and Saturday. Observation on 02/26/2026 at 10:32 a.m. revealed the facility ADON washed her hands with water, put on new gloves, and provided wound care to Resident #71 without putting on a gown. Further observation revealed there was no sign on the door regarding EBP (Enhanced Barrier Precaution). Interview on 02/26/2026 at 11:29 a.m. with the facility ADON said Resident #71 was supposed to have EBP because of his wounds per the facility policy, but the facility did not attach the EBP sign on the door of the resident's room, and she forgot to wear a gown while she was providing wound care to the resident. ADON stated she should have put on a gown when providing wound care to the resident to prevent possible infection even though there was no sign on the door, and it was her mistake. Interview on 02/26/2026 at 3:47 p.m. with the DON stated Resident #71 was supposed to have EBP because of his wounds per the facility policy, but the DON did not attach the EBP sign on the door of the resident's room. The DON said Resident #71 was new, so she missed it, and attaching EBP sign on the door was the DON's responsibility, and ADON should have put on a gown when providing wound care to the resident to prevent possible infection. 2. Record review of Resident #7's face sheet, dated on 02/27/2026, revealed the resident was a [AGE] year-old-male, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of cerebral infarction (brain tissue death due to the blood vessel blockage), neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), and urinary tract infection (an infection in any part of kidneys, bladder, and urethra). Record review of Resident #7's quarterly MDS assessment, dated 01/15/2026, revealed the resident's BIMS score was 10 out of 15 which indicated the resident had moderate cognitive impairment and Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) to chair to bed transfer, and had indwelling urinary catheter. Record review of Resident #7's comprehensive care plan, dated 10/31/2025, the resident had the care plan of [Resident #7] has a urinary tract infection related to use of indwelling urinary catheter. For intervention - EBP: Staff must use gown and gloves during high-contact resident care activities that could possibly to result in transfer of Multi Dru Resistant Organisms (MDRO) to hands and clothing of staff. Record review of Resident #7's physician order, dated 09/08/2025, revealed the resident had the order of EBP: Staff must use gown and gloves during high contact resident care activities that could possibly to result in transfer of Multi Dru Resistant Organisms (MDRO) to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). every shift for EBP Precautions. Observation on 02/26/2026 at 3:09 p.m. revealed CNA-L washed her hands with water and provided indwelling urinary catheter care to Resident #7 without putting on a gown, and on the door, there was EBP sign, use gown and gloves during high contact resident care activities such as catheter care. Interview on 02/26/2026 at 3:14 p.m. with CNA-L stated she did not put on a gown when providing urinary indwelling catheter care to Resident #7. CNA-L said she was nervous so forgot to wear a gown, and she should have put on a gown while providing catheter care to the resident because the resident had EBP to prevent possible infection. Interview on 02/26/2026 at 3:47 p.m. with the DON said per the facility policy, CNA-L should have put on a gown while providing catheter care to Resident #7 because the resident had EBP to prevent possible infection. Record review of the facility policy, titled Enhanced Barrier Precaution, revised 02/2025, revealed . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include - device care or use (central lines, urinary catheter, feeding tube, and tracheostomy) and wound care (any skin opening requiring a dressing). 3. Record review of Resident #5's face sheet, dated 02/27/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses of epilepsy (a brain disorder that causes people to have recurring seizures), restlessness and agitation (sudden, distressing state of intense restlessness), and schizoaffective (exhibiting symptoms of both schizophrenia and a mood disorder such as bipolar disorder). Record review of Resident #5's admission MDS assessment, dated 02/16/2026 reflected that she was assessed to have a BIMS score was 3 out of 15 indicating she had severe cognitive impairment. Resident #5 was assessed to always incontinence to bowel and bladder. Record review of Resident #5's comprehensive care plan, dated 02/24/2026, reflected the resident had the care plan of The resident has bowel and bladder incontinence. For intervention - Clean peri-area with each incontinence episode. Observation on 02/26/2026 at 2:04 p.m. revealed CNA-O opened Resident #5's old and dirty brief, cleaned the resident's right and left groin areas, and cleaned the resident's genital area (middle area) without opening the resident's labia area, then cleaning the resident's buttock areas. Further observation revealed CNA-O removed old and dirty brief and put the new and clean brief under the resident without changing the old and dirty gloves and then closed the new and clean brief. Interview on 02/26/2026 at 2:12 p.m. with CNA-O stated when she cleaned Resident #5's genital area, she should have changed her gloves to new and clean gloves when putting new and clean brief under the resident to prevent possible cross contamination. Interview on 02/26/2026 at 3:54 p.m. with the DON said CNA-O should have changed her gloves to new and clean gloves when putting new and clean brief under the resident to prevent possible infection. 4. Record review of Resident #56's face sheet, dated 02/27/2026, revealed the resident was a 38-years-old male and admitted to the facility on [DATE] with diagnosis of encounter for other orthopedic aftercare (intensive physical rehabilitation), fracture of part of neck of right femur (fracture to right thigh bone), and infection following a procedure deep incisional surgical site (infection to surgical site). Record review of Resident #56's admission MDS assessment, dated 02/13/2026, revealed the resident's BIMS score was 0 out of 15 which indicated the resident had severe cognitive impairment, required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to chair to bed and toilet transfer, and always incontinent to bowel and bladder. Record review of Resident #56's comprehensive care plan, dated 02/16/2026, revealed the resident had the care plan of self-care deficit for bathing, dressing, and feeding. For intervention - provide assistance with activities of daily livings. Observation on 02/26/2026 at 1:25 p.m. revealed when CNA-J opened Resident #56's old and dirty brief, the resident was uncircumcised. CNA-J cleaned the resident's right and left groin area, then cleaned the resident's penis area without pulling back the foreskin of the resident's penis with multiple pass of one wipe, then turned the resident to side and cleaned the resident's buttock area. Further observation revealed CNA-J put new and clean brief under the resident without changing her gloves to new and clean gloves, then closed the new and clean brief. Interview on 02/26/2026 at 1:32 p.m. with CNA-J stated when she was providing incontinent care to Resident #56, she put new and clean brief under the resident without changing her gloves to new and clean gloves because she was very nervous. Further interview with CNA-J said she should have should have changed her gloves to new and clean gloves when putting a new and clean brief to the resident, and should have used a new wipe with each stroke to prevent infection. Interview on 02/26/2026 at 3:52 p.m. with the DON said CNA-J should have changed her gloves to new and clean gloves when putting a new and clean brief to the resident, and should have used a new wipe with each stroke to prevent infection. Record review of the facility policy, titled Perineal Care, revised 02/2018, revealed Female - cleanse the peri area with wipes going front to back to dirty and separate the labia and use a new wipe with each stroke. Male - if the resident is uncircumcised gently pull back the foreskin and wipe the head of the penis beginning at the urethral opening working outward and away from the penis head.4. discard soiled gloves, sanitize hands. Re-glove prior to touching clean lines or adult brief.

Based on observations, interviews, 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 2 (B-hall nursing cart and A-hall nursing cart) out of 3 medication carts and 2 (Resident #61 and #30) out of 3 residents reviewed for pharmacy services. 1. There were three bottles of sterile water that expired 02/09/2026 and one spray bottle of safe simple-odor eliminate clear lubricant for ostomy pouch that expired 09/02/2025 found inside the B-hall nursing cart on 02/25/2026. 2. There was one bottle of Geri care Iron supplement liquid ferrous sulfate 220 mg/5ml that expired on 07/2025 and one bottle of calcium carbonate 500 mg that expired on 01/2026 found inside the A-hall nursing cart on 02/25/2026. 3. The facility nurses opened Resident #61's insulin pen (Glargine-Lantus) on 01/23/2026 and used the insulin on 02/25/2026. However, the label of the insulin indicated Discard 28 days after opening, and 28th day was 02/20/2026. 4. The facility nurses did not check Resident #30's blood sugars and did not give the resident's insulin Lispro per the sliding scale on 02/17/2026, 02/18/2026, 02/19/2026, and 02/20/2026. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: 1. Observation on 02/25/2026 at 3:12 p.m. revealed there were three 250 ml bottles of sterile water inside the B-hall nursing cart, and the bottles expired on 02/09/2026. Further observation revealed there was one spray bottle of safe simple-odor eliminate clear lubricant for ostomy pouch inside the B-hall nursing cart, and it expired 09/02/2025. Interview on 02/25/2026 at 3:36 p.m. LVN-M stated there were three bottles of sterile water that expired 02/09/2026 and one spray bottle of safe simple-odor eliminate clear lubricant for ostomy pouch that expired 09/02/2025 found inside the B-hall nursing cart, and nurses might use sterile water for cleaning wounds and spray for eliminating odor from colostomy care. Further interview, LVN-M said she did not know what reason they were stored in the nursing cart, and any expired medications should have been removed from the cart per the facility policy. Interview on 02/25/2026 at 3:30 p.m. the DON said any expired medications should have been removed from the cart per the facility policy because using expired medication might cause not reaching therapeutic effects. 2. Observation on 02/25/2026 at 3:43 p.m. revealed there was one bottle of Geri care Iron supplement liquid ferrous sulfate 220 mg/5ml inside the A-hall nursing cart, and the bottle expired on 07/2025. Further observation revealed there was one bottle of calcium carbonate 500 mg found inside the A-hall nursing cart, and it expired on 01/2026. Interview on 02/25/2026 at 3:55 p.m. LVN-N stated there was one bottle of Geri care Iron supplement liquid ferrous sulfate 220 mg/5ml that expired on 07/2025 and one bottle of calcium carbonate 500 mg that expired on 01/2026 found inside the A-hall nursing cart on 02/25/2026. Further interview, LVN-N said she did not use the medications and did not know what reason they were stored in the nursing cart, and any expired medications should have been removed from the cart per the facility policy. Interview on 02/25/2026 at 3:46 p.m. with the DON said any expired medications should have been removed from the cart per the facility policy because using expired medication might not reach therapeutic effects. 3. Record review of Resident #61's face sheet, dated 02/27/2026, revealed the resident was 69-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (problem in the brain due to chemical imbalance in the blood), diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), and dementia (loss of memory and thinking ability). Record review of Resident #61's quarterly MDS assessment, dated 01/16/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive was intact and received insulin injections every day. Record review of Resident #61's physician's order, dated 08/12/2025, revealed the resident had the order of Basaglar KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Glargine-Lantus) Inject 10 unit subcutaneously in the morning related to DIABETES MELLITUS. Observation on 02/25/2026 at 3:43 p.m. revealed Resident #61's insulin pen of Insulin Glargine-Lantus inside the A-hall nursing cart, and the pen had open date of 01/23/2026. Further observation revealed the pen had the label of Discard 28 days after opening. Interview on 02/25/2026 at 3:55 p.m. LVN-N stated Resident #61's insulin pen of Insulin Glargine-Lantus was inside the A-hall nursing cart, and the pen had an open date of 01/23/2026, and the pen had the label of Discard 28 days after opening. Further interview, LVN-N stated she used it on 02/25/2026, but she should have discarded it on 02/20/2026 because 2/20/2026 was the 28th day after opening the insulin pen, and it was her mistake. LVN-N stated expired insulin might not have therapeutic effects. Interview on 02/26/2025 at 3:56 p.m. the DON stated the facility nurses should have discarded Resident #61's insulin pen of Insulin Glargine-Lantus on 02/20/2026 because 2/20/2026 was the 28th day after opening the insulin pen as the label, and using expired insulin might not have therapeutic effects. 4. Record review of Resident #30's face sheet, dated 02/27/2026, revealed the resident was a 79-years-old female and admitted to the facility on [DATE] with diagnosis of fracture of left lower leg, type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), and dementia (loss of memory and thinking ability). Record review of Resident #30's admission MDS assessment, dated 01/29/2026, revealed the resident's BIMS was 11 out of 15 which indicated the resident had moderate cognitive impairment and was Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) to chair to bed and toilet transfer. Record review of Resident #30's physician order, dated 02/12/2026, revealed the resident had the order of Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 25 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS and Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen injectorInject as per sliding scale: if 150 - 199 = 2units Give 2 units; 200 - 249 = 4 units Give 4 units; 250 - 299 = 6 units Give 6 units; 300 - 349 = 8 units Give 8 units; 350 - 400 = 10 units If above 400 give 10 units and notified MD, subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS. Started 02/21/2026. Record review of Resident #30's medication administration record from 02/01/2026 to 02/28/2026 revealed the resident received her long acting insulin of Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine)-Inject 25 unit subcutaneously at 9:00 PM every night since 02/12/2026 as ordered. Further record review of the resident's medication administration record revealed the resident received her short acting insulin (Lispro) as per sliding scale from 02/12/2026 to 02/16/2026, but there was no documented evidence the resident received her short acting insulin on 02/17/2026, 02/18/2026, 02/19/2026, and 02/20/2026. The resident resumed receiving the short acting insulin since 02/21/2026. Interview on 02/25/2026 at 1:14 p.m. the DON stated Resident #30's primary care physician started the resident's long acting and short acting insulin on 02/12/2026, and the facility nurses administered the long and short acting insulin to the resident as ordered. However, on 02/17/2026, the facility pharmacy staff deleted Resident #30's short acting insulin order from the system by accident, and the DON realized Resident #30's short acting insulin order disappeared from the system by accident on 02/21/2026 so she put the order on the system immediately, so the facility nurses resumed giving the short acting insulin to Resident #30 on 02/21/2026 as ordered. The DON said as a result, Resident #30 did not receive short acting insulin for 4 days, which were 02/17/2026, 02/18/2026, 02/19/2026, and 02/20/2026, and the resident did not have any negative effect such as signs or symptoms related to high blood sugars or low blood sugars for those days. The DON said the facility nurses should have asked regarding Resident #30's short acting insulin when it was disappeared on the system, but if the order was disappeared on the system by accident, the facility nurses could not see the order on the electronic medication administration record, and this was why facility nurses did not ask regarding Resident #30's short acting insulin to the DON. The DON said not giving insulin might cause the resident to have high blood sugars, but Resident #30 did not have any negative effect because the resident received long-acting insulin every day as ordered, and the facility did not have policy regarding specifically insulin, but nurses should follow physician orders. Interview on 02/26/2026 at 1:50 p.m. Resident #30's Nurse Practitioner said he started long-acting and short-acting insulin for Resident #30 on 02/12/2026 because the resident's blood sugars were a little bit high (average 200 mg/dL), and the facility DON reported the resident did not receive short-acting insulin for 4 days (02/17/2026, 02/18/2026, 02/19/2026, and 02/20/2026) because the order disappeared by accident due to the pharmacy and it was resumed on 02/21/2026. The Nurse Practitioner stated based on his assessment the resident did not have any negative effect regarding missing the short-acting insulin for 4 days because the resident received long-acting insulin every day as ordered and did not have any signs or symptoms regarding low and high blood sugars; and the resident's blood sugars were controlled with the long-acting insulin for those days on the resident's baselines, so missing short-acting insulin for 4-days did not cause any harm to the resident. Record review of the facility policy, titled Medication Storage and Labeling, dated 06/2023, revealed Multi-dose vials which have not been opened or accessed should be discarded according to the manufacturer's expiration date.

Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 2 of 2 residents (Residents #43 and Resident #48) and in 1 of 4 rooms (room [ROOM NUMBER]) reviewed for respiratory care.1. Resident #43's CPAP (continuous positive airway pressure) mask was not covered in a plastic bag when it was not used on 02/24/2026.2. The facility failed to ensure Resident #48 did not have a physician's order for oxygen that was observed being used on 02/24/2026 and 02/27/2026.3. The facility failed to store 2 portable oxygen cylinders in the designated oxygen storage room. This failure could place residents at risk of illness, respiratory complications and accidents.Findings included:Observation on 02/24/2026 at 2:23 PM in room [ROOM NUMBER] revealed two (2) oxygen cylinders by bed A along the wall by the dresser. The oxygen cylinders were placed on the floor; they were not secured on a stand. Observation and Interview on 02/24/2026 at 2:41 PM with LVN D revealed he stated the oxygen cylinders should not be placed on the floor in the resident's room. He stated they should be secured in a stand, so the oxygen cylinders were not knocked over. He stated it was dangerous and could cause a fire or blow up if knocked over on the floor. LVN D stated the residents could get injured. He stated there was a room in the front of the facility where they stored all oxygen cylinders that were empty or not being used. Interview on 2/27/26 at 5:20 PM with the DON revealed oxygen cylinders should not be placed on the floor in a resident's room and should be stored in the oxygen storage room located in the front of the facility. The DON stated oxygen concentrators were highly flammable and stated she had seen an oxygen cylinder pop, create an explosion when it was knocked over on the floor. She stated not securing the oxygen cylinders on a caddie or stand was dangerous and the residents could get injured. Review of facility policy, Oxygen Storage, undated, read It is the policy of center to maintain appropriate and safe storage of oxygen. Interior 3. All cylinders will be secured to the wall or be stored in appropriate transport carts or stands. 2. Record review of Resident #48's face sheet dated 02/24/2026, revealed Resident #48 was admitted to the facility on [DATE], original admission date 10/17/2025 with diagnoses that included: Chronic Obstructive Pulmonary Disease, unspecified (a progressive, incurable, yet treatable lung disease that obstructs airflow and makes breathing difficult), acute respiratory failure with hypoxia (critical condition where the lungs cannot adequately transfer oxygen to the blood), and anoxic brain damage, not elsewhere classified (severe, non-traumatic injury caused by a complete lack of oxygen to the brain). Record review of Resident #48's Quarterly MDS assessment, dated 01/14/2026, revealed the resident's BIMS score was 03 indicating severe cognitive impairment. Section O Special Treatments, Procedures, and Programs revealed C1 Oxygen Therapy was coded for Resident #48's oxygen use while a resident. Record review of Resident #48's care plan, revised on 02/24/2026, revealed Resident #48 had a focus of Impaired Gas Exchange and interventions/task of Administer oxygen as prescribed or per standing order. Record review of Resident #48's physician's order summary report, dated 02/26/2026, revealed there was not an order for oxygen use. Observation on 02/24/2026 at 10:35 a.m. Resident #48 was observed sitting up in the wheelchair in her room with her oxygen cannula under her chin, with the tubing attached to the oxygen concentrator that was set at 4 liters per minute. Observation on 02/24/2026 at 12:13 p.m. Resident #48 was observed sitting in her wheelchair at a dining table with the oxygen concentrator plugged in behind her with the tubing attached. The resident was holding the oxygen tubing in her hand as a staff member assisted her with placing it on her face. Observation and interview on 02/27/2026 at 9:54 a.m. Resident #48 was observed sitting in the television/common area wearing her oxygen cannula and smiling as she watched television. The oxygen concentrator was attached to a nasal cannula and was set a below 2 liters per minute at approximately 1 liter per minute with the maintenance light red. LVN C stated Resident #48 should have the oxygen concentrator set between 2 and 3 liters per minute. LVN C stated that typically the red light would come on if the back of the concentrator was too close to the wall or was blocked from air circulation. LVN C was observed taking Resident #48's nasal cannula off feeling for oxygen and then checked the oxygen concentrator setting, adjusted it to between 2 and 3 liters per minute and the red maintenance light then changed to green. LVN C proceeded to check Resident #48's orders for oxygen to confirm the setting and could not find an order. LVN C stated she was sure Resident #48 had an order but could not see it. During an interview on 02/27/2026 12:05 p.m., the DON stated Resident #48's oxygen concentrator should be set at 2 to 6 liters per minute. The DON stated Resident #48 should have had orders for her oxygen and did not know why Resident #48 did not have orders for the oxygen, however, she had been to the hospital and returned. The DON stated physician orders were necessary for the staff to know what the oxygen concentrator should be set at as far as her oxygen liters per minute. The DON stated by not having orders and not knowing the proper settings for the oxygen concentrator Resident #48 could potentially be put at risk of being short of breath, not getting adequate oxygen, and she would not be able to rest properly. During an interview on 02/27/2026 at 5:22 p.m., the Administrator stated the nurse was responsible for ensuring orders were received. The Administrator stated the orders were important for the nurses to know what the residents were to receive. During an interview on 02/27/2026 at 5:24 p.m., the RNC stated it was important to have orders so the nurses would know what they were doing and for patient safety. Record review of the facility's policy titled, Oxygen Administration, revised October 2010, read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders, facility protocol for oxygen administration. 1. Record review of Resident #43's face sheet, dated 02/27/2026, revealed the resident was a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery (buildup of plaque inside the artery walls), sleep apnea (breathing stops and restarts many times while sleeping), and diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels). Record review of Resident #43's quarterly MDS assessment, dated 12/18/2025, revealed the resident's BIMS score was 12 out of 15 which indicated the resident had moderate cognitive impairment and had non-invasive mechanical ventilator, which was CPAP (continuous positive airway pressure). Record review of Resident #43s comprehensive care plan, dated 12/10/2025, revealed the resident had the care plan of CPAP (continuous positive airway pressure) therapy for sleep apnea. For intervention – educate resident on the importance of CPAP (continuous positive airway pressure) therapy. Observation on 02/24/2026 at 10:51 a.m. revealed Resident #43 was on the bed, watching television in her room. Resident #43's CPAP (continuous positive airway pressure) mask was uncovered and connected to a machine that was on the nightstand. Interview on 02/24/2026 at 10:52 a.m. Resident #43 stated she was using her CPAP (continuous positive airway pressure) every night when she was sleeping. Interview on 02/24/2026 at 11:28 a.m. LVN-C stated Resident #43's CPAP (continuous positive airway pressure) mask was on the nightstand without a plastic bag. Further interview, LVN-C said the resident's CPAP (continuous positive airway pressure) mask should have been covered with a plastic bag when it was not used to prevent possible infection. Interview on 02/26/2026 at 4:03 p.m. the DON stated there was no specific facility policy for how to store the mask, but Resident #43's CPAP (continuous positive airway pressure) mask should have been covered in a plastic bag when it was not used to prevent possible infections.

Based on observation, interviews and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 3 of 8 residents (Resident #3, Resident #4 and Resident #23) whose records were reviewed for PASARR services.The facility failed to include Resident #3, Resident #4, and Resident #23's mental health status was coded on the PASARR screening Level I.These deficient practices could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses.Review of Resident #3's face sheet, dated 2/27/26, revealed she was admitted to the facility on [DATE] with diagnoses including anxiety and schizoaffective disorder bipolar type (condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania. Bipolar type, which includes bouts of hypomania or mania and sometimes major depression.) . Review of Resident #3's quarterly MDS, dated [DATE], revealed Resident #3 had Schizophrenia. Further review revealed her BIMS score was 3 of 15 reflecting severe cognitive impairment. Review of Resident #3's Care Plan dated 2/18/26 revealed it did not include history of mental illness including depression, anxiety and schizoaffective disorder, bipolar type. Further review revealed Resident #3 had impaired cognitive function related to dementia and a communication problem. Observation and attempted interview on 2/25/26 at 4:45 PM with Resident #3 revealed she was lying in bed. She answered yes or no questions but did not answer open-ended questions. Resident #3 presented as being alert to self with confusion. Resident #3 was unable to answer any questions related to her health condition. Interview on 2/27/26 at 1:58 PM with MDS Coordinator revealed he would look at a resident's health chart for any diagnoses that would trigger mental illness. He stated when completing a PASARR 1 screening he would add any diagnoses reflecting mental illness and it would then trigger for the local authority to complete a PASRR II evaluation. The LIDDA (Local Intellectual and Development Disability Authorities) would determine if a resident qualified for services. The MDS Coordinator stated a diagnosis of Dementia would not negate an evaluation. Upon reviewing Resident #3's diagnosis of schizoaffective disorder, bipolar type and the initial PASRR 1 screening he stated the diagnosis was not added so it did not trigger for a PASARR II evaluation. He stated Resident #3's PASSAR 1 screening was completed prior to him assuming his position and stated he had not checked any of the residents PASSR screenings for accuracy. The MDS Coordinator stated if Resident #3 qualified for PASSAR services she would lose out on benefits such as money follows the resident, psychiatric services, habilitative services (healthcare programs designed to help individuals acquire, maintain, or improve skills necessary for daily living and independence), returning to the community, getting specialized medical equipment and any other benefits that PASSAR services provided. Review of a facility policy, PASRR, dated 7/29/25, read The PASRR aims to ensure that individuals with mental illness or intellectual disabilities receives appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs. 2. a) Level I screening: This initial screening determines if the individual may have a mental illness or intellectual disability. it is generally by the nursing facility prior to admission. b) Level II Evaluation: If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation is conducted. This comprehensive assessment is performed by a mental health professional and evaluates the individual's needs and whether nursing home placement is appropriate. The findings included: Record review of Resident #4's face sheet, dated 02/26/2026, revealed he was admitted to the facility on [DATE], original admission date 03/21/2025 diagnoses which included: major depressive disorder, single episode, severe with psychotic features, and bipolar disorder, current episode depressed, mild or moderate severity, unspecified. Record review of resident #4's Quarterly MDS assessment, dated 12/17/2025, revealed the resident's BIMS score of 14 noting resident with intact cognition. Quarterly MDS assessment revealed with diagnoses of bipolar disorder and depression (other than bipolar). Record review of Resident #4's care plan, initiated date 12/10/2025, revealed Resident #4's care plan had a focus of The resident has depression. Record review of Resident #4's PASRR screening dated 04/10/2025, noted an answer of 0 (No) in section C0100 Mental Illness in response to the question, Is there evidence or an indicator this is an individual with a Mental Illness? Observation and interview on 02/24/2026 at 10:22 a.m. revealed Resident #4 sitting up in a tall back wheelchair watching television. Resident #4 stated the staff responded to his needs when he requested and shaved him when he allowed them to. Record review of Resident #23's face sheet, dated 02/26/2026, revealed he was admitted to the facility on [DATE] with diagnoses which included: post-traumatic stress disorder, unspecified, and depression, unspecified. Record review of Resident #23's Quarterly MDS assessment, dated 02/20/2026, revealed the resident's BIMS score of 9 noting resident with moderate cognitive impairment. Quarterly MDS assessment revealed diagnoses of depression and post-traumatic stress disorder. Record review of Resident #23's care plan, initiated date 03/10/2025, revealed Resident #23's care plan had a focus of Risk for Depression. Record review of Resident #23's PASRR screening dated 08/14/2024, noted an answer of 0 (No) in section C0100 Mental Illness in response to the question, Is there evidence or an indicator this is an individual with a Mental Illness? Observation and interview on 02/24/2026 at 10:35 a.m. revealed Resident #23 lying across his bed with his rolling walker with a bench at bedside. Resident #23 stated he did not really have any concerns. During an interview on 02/26/2026 at 2:29 p.m. MDS Coordinator stated Resident #4 did have a diagnosis of major depressive disorder upon admission and this should have been added to PASRR I which would have triggered the local authority to come out for an evaluation. The MDS Coordinator stated Resident #23's diagnosis of PTSD should have been added to his PASRR I screen. During an interview on 02/27/2026 at 4:03 p.m. the MDS Coordinator stated by not coding the PASRR I accurately and not referring for an evaluation a resident could possibly not get the benefits from the PASRR if they qualified, such as rehabilitative services or possibly discharge assistance. During an interview on 02/27/2026 at 5:09 p.m. the Administrator stated the MDS Coordinator was responsible for ensuring PASRR was accurate. Record review of Texas Health and Human Services (THHSC)'s Detailed Item by Item Guide for Local Authorities and Nursing Facilities to Complete the PASRR Level 1 Screening Form guidelines, dated June 2023, read, Section C.1: PASRR Screening: Steps for Assessment: 1. Identify diagnoses: Review the medical record, if available, for an MI, ID, and/or DD/RC diagnoses. Medical record sources can include but are not limited to: verbal interview with the individual, family members or LAR, observation, progress notes, annual physical exam, the most recent History and Physical, hospital discharge summaries or diagnosis list. 2. If you cannot locate a diagnosis, but suspect that an individual does have an MI, ID, and/or DD/RC, then document that information in this section of the form. C0100 Mental Illness-Is there evidence or an indicator this is an individual that has Mental Illness? 0. No 1. Yes. Examples of MI diagnoses are: Schizophrenia, Mood Disorder (Bipolar Disorder, Major Depressive Disorder or other mood disorder) .

Based on record review and interview, the facility failed to ensure that the resident has the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Resident #5) out of 24 residents reviewed for resident rights. The facility failed to obtain informed consent for the use of Risperdal (an antipsychotic medication) for Resident #5. These failures could place residents who receive psychotropic medications at risk of receiving medications without consent, knowledge of possible side effects of the medications, or other treatment options.Findings included: Record review of Resident #5's face sheet, dated 02/27/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of epilepsy (a brain disorder that causes people to have recurring seizures), restlessness and agitation (sudden, distressing state of intense restlessness), and schizoaffective (exhibiting symptoms of both schizophrenia and a mood disorder such as bipolar disorder). Record review of Resident #5's admission MDS assessment, dated 02/16/2026 reflected that she was assessed to have a BIMS score was 3 out of 15 indicating she had severe cognitive impairment. Resident #5 was assessed to not have verbal and other behavioral symptoms. However, Resident #5 was assessed to have psychiatric / mood disorder: schizoaffective and restlessness and agitation, and Resident #5 was further assessed to be on an antipsychotic medication. Record review of Resident #5's comprehensive care plan, dated 02/24/2026, reflected the resident had the care plan of The resident uses psychotropic medications. For intervention - Administer PSYCHOTROPIC medications as ordered by a physician. Monitor for side effects and effectiveness every shift. Record review of Resident #5's physician's orders, dated 02/09/2026, reflected the resident had the order of risperiDONE Oral Tablet 0.5 MG (Risperidone) Give 1 tablet by mouth every 24 hours as needed for as needed related to RESTLESSNESS AND AGITATION. Record review of Resident #5's medication administration record from 02/01/2026 to 02/28/2026 revealed the resident received her risperidone 0.5 mg one tablet by mouth on 02/12/2026 at 7:20 PM for restlessness and agitation. Interview on 02/27/2026 at 9:51 a.m. with the DON stated there was no consent in Resident #5's medical record regarding the resident's Risperidone, and the facility should have obtained the consent from the resident's responsible party before starting the psychotropic medication. The DON said she did not know why the facility nurses did not obtain the consent. The DON stated it was a charge nurse's responsibility to get the consent, and not obtaining the consent before starting the medication might affect the resident who could receive the medication to which the resident's responsible party did not agree. Record review of the facility policy, titled Resident Right, revised 02/2021, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be informed of, and participate in, his or her care planning and treatment.

Based on interview and record review, the facility failed to ensure PRN (as needed) orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication for 1 (Resident #5) of 24 residents reviewed for chemical restraint, in that: The facility failed to ensure Resident #5 was prescribed Risperidone for restlessness and agitation, no longer than 14 days PRN (as needed). This failure could place residents at risk of receiving unnecessary psychotropic medications. The findings were: Record review of Resident #5's face sheet, dated 02/27/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of epilepsy (a brain disorder that causes people to have recurring seizures), restlessness and agitation (sudden, distressing state of intense restlessness), and schizoaffective (exhibiting symptoms of both schizophrenia and a mood disorder such as bipolar disorder). Record review of Resident #5's admission MDS assessment, dated 02/16/2026 reflected that she was assessed to have a BIMS score was 3 out of 15 indicating she had severe cognitive impairment. Resident #5 was assessed to not have verbal and other behavioral symptoms. However, Resident #5 was assessed to have psychiatric / mood disorder: schizoaffective and restlessness and agitation, and Resident #5 was further assessed to be on an antipsychotic medication. Record review of Resident #5's comprehensive care plan, dated 02/24/2026, reflected the resident had the care plan of The resident uses psychotropic medications. For intervention - Administer PSYCHOTROPIC medications as ordered by a physician. Monitor for side effects and effectiveness every shift. Record review of Resident #5's physician's orders, start dated 02/09/2026, reflected the resident had the order of risperiDONE Oral Tablet 0.5 MG (Risperidone) Give 1 tablet by mouth every 24 hours as needed for as needed related to RESTLESSNESS AND AGITATION. Further record review of the resident's physician order revealed there was no stop date of risperidone. Record review of Resident #5's medication administration record from 02/01/2026 to 02/28/2026 revealed Resident #5 had received Risperidone 0.5 MG on 02/12/2026 at 7:20 PM as ordered. Interview with the DON on 02/27/2026 at 9:51 a.m., it was confirmed Resident #5 had an order for risperiDONE Oral Tablet 0.5 MG (Risperidone) Give 1 tablet by mouth every 24 hours as needed for RESTLESSNESS AND AGITATION, and the order should have only been for 14 days. The DON stated she did not know why the order was written over 14 days, as overuse could place Resident # 5 at risk for respiratory depression. The DON said she was responsible for overseeing antipsychotic medications daily and currently monitored it at random, and it might affect that Resident #5 could receive unnecessary medications without re-evaluations. Record review of the facility's policy titled, Psychotropic Medication Use Policy, dated 2001, revised July 2022, revealed, .PRN orders for psychotropic medication are limited to 14 days.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #3) out of 24 residents reviewed for dignity. When LVN-M administered a medication to Resident #3 via the resident's gastrostomy tube on 02/26/2026, the nurse did not provide privacy, and as a result, the resident's roommate saw everything regarding how the nurse gave a medication via gastrostomy tube. These failures could place the residents at risk of not having their right to privacy and to a dignified existence maintained. Findings included: Record review of Resident #3's face sheet, dated 02/27/2026, revealed the resident was an 87-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms affecting memory, thinking, and social abilities), gastrostomy tube status (tube inserted through the belly that brings nutrition or medications directly to the stomach), and cerebral infarction (brain tissue death due to the blood vessel blockage). Record review of Resident #3's quarterly MDS assessment, dated 02/18/2026, revealed the resident's BIMS score was 3 out of 15 which indicated the resident had severe cognitive impairment, and the resident had a feeding tube. Record review of Resident #3's comprehensive care plan, dated 11/19/2025, revealed I [Resident #3] require tube feeding related to dysphasia (difficulty in swallowing) and have memory loss related to dementia. For intervention - Team members will listen and respond with empathy. Observation on 02/26/2026 at 11:29 a.m. revealed when LVN-M entered Resident #3's room and started administering one medication via the resident's gastrostomy tube, the resident's roommate was sitting on the wheelchair and watching TV in the room. LVN-M did not pull the curtain for privacy and did not close the blinds of the window beside the resident's bed, and as a result Resident #3's roommate saw everything regarding how the nurse gave the medication to the resident via gastrostomy tube. Interview on 02/26/2026 at 11:30 a.m. with Resident #3 revealed the resident was unable to interview. Interview on 02/26/2026 at 11:31 a.m. with LVN-M stated she should have used the curtain for privacy because Resident #3's roommate was in the room and closed the window blind to prevent possible privacy problems. LVN-M said she forgot to provide privacy to Resident #3 because she was very nervous, and it was her mistake. Interview on 02/26/2026 at 3:49 p.m. with DON stated LVN-M should have used the curtain for privacy because Resident #3's roommate was in the room when the nurse administered medication to the resident via gastrostomy tube and closed the window blind to prevent possible privacy problems, such as somebody in the courtyard could see Resident #3. DON said it was violation to Resident #3's right to privacy. Record review of the facility policy, titled Resident Right, revised 02/2021, revealed Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality.

Based on observation, interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 10 Residents (Resident #3 and Resident 42 whose records were reviewed for assessments. Nursing staff failed to code Resident #3 had an anxiety disorder on her MDS assessment. Nursing staff failed to code Resident #42 had an anxiety disorder on his MDS assessment. This deficient practice could place residents at risk of not identifying care areas and result in residents not receiving needed care and services. The findings were:1. Review of Resident #3's face sheet, dated 2/27/26, revealed she was admitted to the facility on [DATE] with diagnoses including anxiety and schizoaffective disorder bipolar type (Schizoaffective disorder is a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania. Bipolar type includes bouts of hypomania or mania and sometimes major depression.). Review of Resident #3's quarterly MDS, dated [DATE], revealed Resident #3 did not have an anxiety disorder. Further review revealed her BIMS score was 3 of 15 reflecting severe cognitive impairment. Review of Resident #3's Care Plan dated 2/18/26 revealed it did not include history of mental illness including depression, anxiety and schizoaffective disorder, bipolar type. Further review revealed Resident #3 had impaired cognitive function related to dementia and a communication problem. Observation and attempted interview on 2/25/26 at 4:45 PM with Resident #3 revealed she was lying in bed. She answered yes or no questions but did not answer open-ended questions. Resident #3 presented as being alert to self with confusion. Resident #3 was unable to provide any specific answers to her health condition. 2. Review of Resident #42's face sheet, dated 2/26/26, revealed he was admitted to the facility on [DATE] with diagnosis to include anxiety. Review of Resident #42's quarterly MDS, dated [DATE], reflected that Resident #42 did not have anxiety disorder. Further review revealed Resident #42's BIMS score was 15 of 15 reflecting he did not have cognitive impairment. Review of Resident #42's Care Plan dated 12/10/25 revealed The resident uses anti-anxiety medications (Buspirone). Interventions included administer anti-anxiety medication as ordered per physician. Observation and interview on 2/24/26 at 2:54 PM with Resident #42 revealed he was lying in bed. He engaged in conversation and shared his experiences while at the facility. Resident #42 was fixated on discussing his dissatisfaction with services and the food. He did not answer any other questions related to his health condition. Interview on 2/27/26 at 1:58 PM with MDS Coordinator revealed an MDS assessment should accurately reflect a resident's status otherwise the care areas might not be transferred onto the Care Plan and nursing staff would not know the resident's care areas. He stated ultimately, the resident, would not receive the care and services as needed. Interview on 2/7/26 at 6:56 PM with the DON revealed Resident #3's MDS assessment, dated 2/19/26, and Resident #42's MDS assessment, dated 1/2/26, did not reflect each resident had a diagnosis of anxiety disorder. She stated an MDS assessment should accurately reflect a resident's status to ensure they received the care and services the resident needed. Review of a facility policy, Comprehensive Assessment, dated February 2025, read 1. A comprehensive assessment is conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. Review of the RAI, dated October 2025 read Facilities must ensure that the documentation reflects the resident's status during the look-back period which directly impacts resident care, quality measures and reimbursement.

Based on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's care planning for 1 of 2 Residents (Resident #42) reviewed for PASARR services. The MDS Coordinator failed to include Resident #42 had chosen to continue with habilitative services on his Care Plan. This deficient practice could place residents at risk of not receiving services identified by the local authority. The findings were: Review of Resident #42's face sheet, dated 2/26/26, revealed he was admitted to the facility on [DATE] with diagnoses including anxiety, depression, schizoaffective disorder, bipolar type (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania) and mood disorder due to known physiological condition with depressive features (represents a significant clinical challenge within the realm of organic mental disorders. Defined as a mood disturbance that directly stems from a recognized physiological condition.) Review of Resident #42's quarterly MDS, dated [DATE], revealed Resident #42 had depression and Schizophrenia. Further review revealed Resident #42's BIMS score was 15 of 15 reflecting he did not have cognitive impairment. Review of Resident #42's Care Plan dated 12/10/25 revealed The resident uses psychotropic medications (Risperidone), and the resident has a mood problem. Interventions included administer medications as ordered per physician. Further review revealed there was no indication that Resident #42 was PASARR positive (Identification of individuals with MI or IID) or that he was receiving habilitative services (healthcare programs designed to help individuals acquire, maintain, or improve skills necessary for daily living and independence). Review of a quarterly meeting dated 12/5/25, between the local authority and the resident and facility staff, revealed Resident #42's service plan was updated and Resident #42 chose to continue habilitative services. Observation and interview on 2/24/26 at 2:54 PM with Resident #42 revealed he was lying in bed. He engaged in conversation and shared his experiences while at the facility. Resident #42 was fixated on discussing his dissatisfaction with other services and the food. Attempts were made to inquire about PASRR services; however, he did not answer any questions pertaining to PASRR. Interview on 02/26/2026 at 2:08 PM with the MDS Coordinator revealed Resident #42's Care Plan did not include a focused area related to PASRR habilitative services identified in the PASARR service plan for coordination of care. He stated the impact on Resident #42 could result in Resident #42 not receiving the services he was entitled to and required to receive through PASARR. Further interview with the MDS Coordinator revealed he had worked at the nursing facility for about one year and as an MDS Coordinator since September 2025 which included coordinating the residents care plan meetings with the local authority. He stated a resident's Care Plan should reflect a resident's care needs and services identified by the local authority. Review of facility policy, PASRR, dated 7/29/25, read The PASRR aims to ensure that individuals with mental illness or intellectual disabilities receives appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs.2. a) Level I screening: This initial screening determines if the individual may have a mental illness or intellectual disability. it is generally by the nursing facility prior to admission.b) Level II Evaluation: If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation is conducted. This comprehensive assessment is performed by a mental health professional and evaluates the individual's needs and whether nursing home placement is appropriate.4. Care planning: Based on the findings of the Level II evaluation, a care plan is developed that may include specialized services or living arrangements tailored to the individual's needs. Collaboration with mental health professionals and Local Authority to ensure continuity of care.

Based on observation, interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 2 of 2 residents (Resident #4 and Resident #70) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours from admission for Resident #4 and Resident #70. This deficient practice could place newly admitted residents at risk for not receiving care and services as needed. The findings were:Review of Resident #70's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including unspecified atrial fibrillation (irregular heartbeat, or arrhythmia. Can lead to blood clots, stroke, heart failure and other heart-related complications), essential hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Review of 5-day MDS Care Plan, dated [DATE], revealed Resident #70's ethnicity revealed another Hispanic, Latino/a, Spanish origin, her BIMS score was 9 of 15 reflective of moderate cognitive impairment, her ability to hear was adequate and she required partial to moderate assistance for most ADL's. Review of Resident #70's electronic health chart revealed a baseline Care Plan had not been completed at all. Observation and interview on [DATE] at 11:22 AM revealed Resident #70 was lying in bed with the bed in the low position. There was a water jug on top of the bedside table. Further observation revealed Resident #70 was Spanish speaking and the surveyor had to repeat questions because Resident #70 did not appear to hear the surveyor clearly. The surveyor noted Resident #70's upper and lower teeth were decaying, they were a dark brown color. Resident #70 stated she was doing ok. Interview on [DATE] at 12:00 PM with LVN D revealed Resident #70 was a new admission but did not know too much about her. He stated she was Spanish speaking and believed she required minimal assistance with ADL's. LVN D stated Resident #70 ate in her room. Observation and interview on [DATE] at 3:45 PM revealed Resident #70 was sitting on her bed. She presented as being anxious and stated she did not understand why she was in this place. Resident #70 spoke Spanish. She stated a family member died and was not allowed to return home until she cleaned it. She stated she was from another country where all her remaining family lived. Resident #70 stated she did not want to call them because they were all elderly as well and had their own problems. Resident #70 stated staff wanted her to walk like she was normal and stated just standing up from the bed took all her energy. She stated she did not have the leg strength. Resident #70 stated staff also wanted her to eat in the dining room, but she preferred to eat in her room. Observation and interview on [DATE] at 4:55 PM with the DON revealed there were at least four (4) staff who spoke Spanish including herself. She stated Resident #70 understood basic English, but staff was able to communicate with her to determine her basic needs. The DON stated she oriented Resident #70 to the facility community. She stated she noted Resident #70 had decaying teeth and asked Resident #70 if she had any pain. The DON stated Resident #70 denied any pain. She stated they would add her for dental services as a new admission, but she had not talked to the SW about a dental referral for Resident #70. The DON stated either she or the ADON completed baseline care plans and stated they had not completed Resident #70's baseline care plan. She stated it was important because it identified Resident #70's basic needs and it provided staff with guidance related to the care and services Resident #70 needed. She stated without a baseline care plan, they might not provide the care and services Resident #70 needed. Review of facility policy, Care Plans - Baseline, dated [DATE] read A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care. Record review of Resident #4's face sheet, dated [DATE], revealed Resident #4 was admitted to the facility on [DATE], original admission date [DATE] with diagnoses which included: other spondylosis with radiculopathy, lumbar region, bipolar disorder, current episode depressed, mild or moderate severity, unspecified, senile degeneration of brain, not elsewhere classified, chronic pain syndrome, dysphagia, oropharyngeal phase, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, polyneuropathy, unspecified. Record review of Resident #4's Quarterly MDS assessment, dated [DATE], revealed Resident #4's BIMS score was 14 indicating intact cognition. Record review of Resident #4's electronic medical record revealed Resident #4 did not have a baseline care plan completed at all. Observation and interview on [DATE] at 10:22 a.m. revealed Resident #4 sitting in a tall back wheelchair watching his television with some hair stubble to his face. Resident #4 stated the staff take care of him and they shave him when he let them. During an interview on [DATE] at 4:16 p.m. the MDS Coordinator stated Baseline Care Plans were done by the RNs on admission. The MDS Coordinator stated the DON or ADON initiated the baseline care plan. The MDS Coordinator stated his understanding was the baseline care plans were done on admission or within 2 days of admission. During an interview on [DATE] at 5:05 p.m. the Administrator stated care plans were the responsibility of the MDS Coordinator and the Social Worker. The Administrator stated the Social Worker was responsible, making sure that all the needs were addressed and voiced. The Administrator stated the MDS Coordinator was responsible for documenting information and addressing the MDS assessment. The Administrator stated the purpose of the care plan was to know what the residents needed. The Administrator further stated by not care planning the staff might not correctly give care to a resident.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 2 residents (Resident #52) reviewed for mechanical lift transfers and for 1 of 2 Residents (Resident 19) reviewed for smoking assessments. 1. Nursing staff failed to lock the wheelchair, the base of the mechanical lift and failed to widened the base of the mechanical lift when transferring Resident #52 from the wheelchair to the bed.2. The facility failed to ensure conducting Resident #19's smoking assessment quarterly. This deficient practice could place residents at risk of having avoidable falls and or accidents.2. Record review of Resident #19's face sheet, dated 02/27/2026, revealed the resident was a 65-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem), cystitis (inflammation of the bladder), and psychosis (losing some contact with reality). Record review of Resident #19's quarterly MDS assessment, dated 01/17/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive was intact, and the resident required Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to sit to stand and chair to bed. Record review of Resident #19's smoking assessment, dated 08/21/2025, revealed Resident #19 was smoking and Supervision during smoking at all times / Facility will store cigarettes and lighters / Resident is safe to hold and smoke cigarettes. Further record review of Resident #19's medical record from 08/22/2025 to 02/27/2026 revealed there was no more smoking assessments. Record review of Resident #19's comprehensive care plan, undated, revealed there was no care plan regarding Resident #19's smoking. Interview on 02/24/2026 at 10:32 a.m. Resident #19 stated she was smoking at the scheduled smoking times at the designated smoking area, and she did not have any accidents related to smoke. Interview on 02/27/2026 at 8:33 a.m. the DON stated Resident #19 was smoking since she was admitted to the facility on [DATE], and the facility nurse conducted smoking assessment on 08/21/2025 and did not conduct any smoking assessment since 08/21/2025. However, the facility nurses should have conducted the smoking assessment quarterly. The DON said the facility nurses had responsibility to do the smoking assessment and the DON should oversee it. Further interview with the DON stated Resident #19 did not have any accident related to smoke, and not conducting smoking assessment might affect the resident could have some accidents while the resident was smoking. Record review of the facility policy, titled Smoking Policy - Residents, dated 10/2022, revealed 9. a resident's ability to smoke or chew tobacco safely will be re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. 1.Review of Resident #52's face sheet, dated 2/27/26, revealed she was admitted to the facility on [DATE] with diagnoses including transient cerebral ischemic attack (brief blockage of blood flow to the brain), morbid, (severe) obesity due to excess calories (severe chronic condition characterized by a BMI (Body Mass Index) of 40 or higher, significantly increasing the risk of serious health complications), muscle wasting and atrophy (wasting or thinning of muscle mass), not elsewhere classified, right upper arm and muscle wasting and atrophy, not elsewhere classified, left upper arm. Review of Resident #52's annual MDS assessment, dated 11/22/25, revealed her BIMS score was 15 of 15 reflecting no cognitive impairment and she was dependent on nursing staff for chair/bed-to-chair transfer. Review of Resident #52's Care Plan, dated 12/11/25, revealed she had a Risk for Self-Care Deficit; however, it did not address transfers or how many staff should assist during a transfer. Observation and interview on 02/24/2026 at 2:47 PM revealed CNA E and MA F transferred Resident #52 from the wheelchair to the bed using a mechanical lift. MA F operated the lift. She never applied the brakes when lifting Resident #52 from the wheelchair and then when lowering Resident #52 onto the bed. MA F narrowed the base of the lift while Resident #52 was suspended in the air and while positioning the lift under the bed. MA F then lowered Resident #52 onto the bed. Further observation revealed CNA E guided Resident #52 while being transferred. He did not lock the wheelchair before MA F lifted Resident #52 from the wheelchair. Interview with CNA E revealed he did not lock the wheelchair and should have locked it to prevent it from rolling. He stated Resident #52 could hit the wheelchair with her arms or legs and it would cause an injury or Resident #52 could fall if she was not positioned correctly on the sling. Interview with MA F revealed she did not lock the base of the lift at any point during the transfer, and she narrowed the base of the lift when positioning the lift under the bed while Resident #52 was suspended in the air. MA F stated she should have widened the base of the lift for stability. She further stated she should have also locked the base of the lift when lifting Resident #52 from the wheelchair and lowering Resident #52 onto the bed for stability otherwise the lift could tilt and Resident #52 could fall. MA F stated it could cause serious bodily harm. Both CNA E and MA F stated they started working at the facility during [DATE] and they did not receive training for operating a mechanical lift. Interview on 2/27/25 at 5:20 PM with the DON revealed nursing staff reported details about Resident #52's transfer using a mechanical lift. The DON stated Resident #52 was transferred via mechanical lift by two (2) staff because Resident #52 was unable to bear weight. The DON stated nursing staff should always lock the wheelchair when lifting residents from the wheelchair via mechanical lift. She stated nursing staff should always lock the mechanical lift when coming to a stop for stability. The DON stated the wheelchair could roll and the resident could sustain injuries if any body parts hit the wheelchair. She stated the base of the lift should also be widened while transferring a resident from point A to point B and while positioning the lift under the bed to lower the resident onto the bed. The DON stated these were all safe techniques used so that the mechanical lift did not tilt causing the resident to fall. The DON stated Resident #52 was a heavy resident and if she fell, she would likely sustain serious bodily injuries. Review of facility policy Lifting Machine, Using a Mechanical, dated July 2017 read The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift device. It is not a substitute for manufacturer's training or instructions. General Guidelines At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices used in the facility. Make sure the lift is stable and locked.

Based on observation, interview and record review the facility failed to ensure the facility acted upon the pharmacist drug regimen report of any irregularities reported to the attending physician for 1 of 2 Residents (Resident #42) reviewed for gradual dose reductions. The DON failed to follow the pharmacist recommendation to change Resident #42's order for Fluoxetine from 50 mg to 40 mg administered QD per pharmacist recommendation. This deficient practice could place residents at risk for not receiving gradual dose reductions per pharmacist recommendations. The findings were: Review of Resident #42's face sheet, dated 2/26/26, revealed he was admitted to the facility on [DATE] with diagnoses including depression and schizoaffective disorder bipolar type (Schizoaffective disorder is a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania. Bipolar type includes bouts of hypomania or mania and sometimes major depression.). Review of Resident #42's quarterly MDS, dated [DATE], reflected that Resident #42 had a diagnosis of depression and schizophrenia. Further review revealed Resident #42's BIMS score was 15 of 15 reflecting he did not have cognitive impairment. Review of Resident #42's Care Plan dated 12/10/25 revealed The resident uses antidepressant medication (Fluoxetine) Interventions included administer anti-depressant medication as ordered by physician. Review of Resident #42's physician orders for February 2026 revealed an order for FLUOXETINE 10MG CAP W Give 1 tablet orally one time a day related to DEPRESSION UNSPECIFIED (F32.A) Give (1) 40mg cap with (1) 10mg cap to equal 50mg-Start Date-08/02/2025 0800 (8:00 AM). and an order for FLUOXETINE HCL 40 MG CAPSULE Give 1 tablet orally one time a day related to DEPRESSION, UNSPECIFIED (F32.A) Give (1) 40mg cap with (1) 10mg cap to equal 50mg-Start Date-08/02/2025 0800 (8:00 AM). Review of a pharmacy consultant recommendation, dated 1/25/26, revealed a recommendation for a gradual dose reduction for Fluoxetine. Further review revealed Resident #42's physician agreed and provided a new order for Fluoxetine, to discontinue the 50 mg daily dose and to start 40 mg daily dose on 2/5/26. Review of Resident #42's MAR for February 2026 revealed Resident #42 received the order for Fluoxetine 10 mg and Fluoxetine 40 mg to equal 50 mg daily from 2/1/26 to 2/27/26. Observation and interview on 2/24/26 at 2:54 PM with Resident #42 revealed he was lying in bed. He engaged in conversation and shared his experiences while at the facility. Resident #42 was fixated on discussing his dissatisfaction with services not received at the facility and his dissatisfaction with the food. Interview on 2/27/26 at 5:20 PM with the DON revealed she and the ADON reviewed all pharmacy consultant recommendations and ensured they were followed up on. She stated ultimately, she was responsible. The DON reviewed the pharmacist recommendation for a gradual dose reduction and the physician's new orders to discontinue the 50 mg dose of Fluoxetine and to start an order of 40 mg dose to be administered daily. The DON reviewed Resident #42's MAR for February 2026 and stated Resident #42 was still receiving 50 mg of Fluoxetine daily. The DON stated it was important to follow the pharmacist recommendations and physician orders to ensure Resident #42 received the accurate dose of Fluoxetine. She stated the purpose of a gradual dose reduction was to ensure residents received a therapeutic regimen. Review of a facility policy, Psychotropic Medication Use, dated July 2022, read Residents will not receive medications that are not clinically indicated to treat a specific condition.1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior.2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications:b. Anti-depressants.11. Residents on psychotropic medications receive gradual pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications.

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 2 of 8 residents (Resident #15 and Resident #65) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #15 and Resident #65. This deficient practice could place residents at risk of not being able to call for help as needed.The findings included: Record review of Resident #15's face sheet, dated 02/25/2026, revealed she was admitted to the facility on [DATE] with original admission date 10/21/2025 with diagnoses which included: mild intellectual disabilities, chronic pain syndrome, chest pain, cerebral palsy (group of conditions that affect movement and posture), and other lack of coordination. Record review of Resident #15's Quarterly MDS assessment, dated 01/13/2026, revealed the resident's BIMS score was 7, which indicated severe cognitive impairment. The Quarterly MDS assessment further revealed Resident #15 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to lying, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of Resident #15's care plan, target date of 03/16/2026, revealed Resident #15's care plan did not address the use of a call light.Record review of Resident #65's face sheet, dated 02/25/2026, revealed she was admitted to the facility on [DATE] with original admission date 09/19/2025 with diagnoses which included: Alzheimer's disease (a progressive, irreversible brain disorder that damages neurons causes memory loss, cognitive decline, and behavioral changes), generalized anxiety, polyneuropathy (the widespread damage of multiple peripheral nerves, causing symmetric numbness, tingling, burning pain, and muscle weakness, typically starting in the feet and hands), unspecified, and pain in unspecified joint.Record review of Resident #65's Quarterly MDS assessment, dated 01/01/2026, revealed the resident's BIMS score was 5, which indicated severe cognitive impairment. The Quarterly MDS assessment further revealed Resident #65 required substantial/maximal assistance (helper does more than half the effort) for putting on/taking off footwear, shower/bathe self and required supervision or touching assistance (helper provides verbal cues and /or touching/steadying and /or contact guard assistance as resident completes activity) with toileting hygiene, upper body dressing, lower body dressing, personal hygiene, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of Resident #65's care plan, initiated date 10/06/2025, revealed, Focus: Fall with injury. Intervention: Remind me to use call device (call light) for assistance as needed. Observation and interview on 02/24/2026 at 10:40 a.m. revealed Resident #15 lying in bed with the bed in the lowest position, head of bed elevated and call light hanging from the dresser next to the foot of Resident #15's bed. Resident #15 stated she did not think her call light worked as she looked around her bed unable to find her call light.Observation and interview on 02/24/2026 at 10:40 a.m. revealed Resident #65 lying in her bed with bed in the lowest position, head of bed elevated and call light on the dresser near the foot of her bed. Resident #65 stated she had her call light then felt around the bed and stated she could not reach the call light or find it. Resident #65's call light was observed on top of Resident #65's dresser hanging on the opposite side of the bed. Resident #65 pointed at her cellphone and stated she did not think her phone would call the facility. Observation on 02/24/2026 at 11:01 a.m. revealed Resident #15 was heard calling for assistance and calling for the nurse. Resident #15 was heard yelling; she had pain in her leg. Three staff members were to be at the end of the hallway unable to hear resident. Observation on 02/24/2026 at 11:04 a.m. revealed Resident #15 continued to yell out periodically for the nurse. Observation on 02/24/2026 at 11:05 a.m. revealed LVN entered the room and knocked on the door. LVN adjusted the bed and offered Resident #15's pain medication. LVN left Resident #15's room to get her medication from the medication cart. LVN left the room not noticing the call light on the dresser when she exited the room. During an interview and observation on 02/24/2026 at 11:10 a.m. CNA A stated they had showered Resident #15 that morning. When asked about Resident #15's call light she walked over and got the call light and placed it on Resident #15's lap. CNA A also assisted Resident #65 with her call light placing it on her stomach. CNA A stated the call light should be placed near the resident. CNA A further stated she was just helping on the hall but was working on the other hall. During an interview on 02/24/2026 at 11:15 a.m. CNA B stated they had showered both Resident #15 and Resident #65. CNA B stated they assisted hospice with shower of Resident #65 and she was placed back in bed. CNA B further stated she had assisted Resident #15 from the wheelchair to her bed. CNA B stated they forgot to give the residents their call light. CNA B stated residents did use their call lights. CNA B stated the call lights were used by residents to ask for medication, to be changed and it was how they communicated. During an interview on 02/27/2026 at 12:13 p.m. the DON stated the call light should always be within reach of the resident. The DON stated call lights were how the residents communicate with the staff. The DON stated everybody should make sure call lights were in reach, but CNAs have more interactions, and everyone should be looking out for it. The DON stated the residents would not be able to address a need, ask for help or communicate with the staff if they did not have their call lights. During an interview on 02/27/2026 at 4:54 p.m. the Administrator stated nursing was responsible for call lights and that they were important so the resident could ask for help when they needed it. The Administrator stated that by not having the call light residents would not be able to get assistance. Record review of facility's Call System, Residents policy, updated January 2025, read Policy Statement: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs without adequate indications for its use for 1 of 2 residents (Resident #5) reviewed for psychotropic use. Nursing staff failed to indicate an appropriate indication for Resident #5's use of Trazadone, an anti-depressant. This deficient practice could place residents at risk for the use of unnecessary medications. The findings were:Review of Resident #5's annual MDS assessment, dated 2/21/26, revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease and her BIMS score was 0 of 15 reflecting severe cognitive impairment. Review of Resident #5's consent, dated 7/31/25, for the use of Trazadone 150 mg QHS for depression. Review of Resident #5's physician orders for February 2026 revealed an order for traZODone HCl Oral Tablet 150 MG (Trazodone HCl)[NAME] with the start date, 02/18/2026. Further review revealed the order indicated to give 1 tablet by mouth at bedtime related to ALZHEIMER'S DISEASE, UNSPECIFIED. Review of Resident #5's MAR for February 2026 revealed an order for traZODone HCl Oral Tablet 100 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED -Start Date-01/09/2026 1900(7:00 PM) -D/C Date-02/18/2026 1557(3:57 PM). Further review revealed Resident #5 received the medication from 2/1/17 and then she started receiving an order for traZODone HCl Oral Tablet 150 MG (Trazodone HCl) [NAME]. Give 1 tablet by mouth at bedtime related to ALZHEIMER'S DISEASE, UNSPECIFIED with the Start Date-02/18/2026 1900 (7:00 PM). Interview on 2/27/26 at 5:20 PM with the DON revealed Resident #5 was taking Trazadone for depression and not for Alzheimer's. She reviewed Resident #5's orders and stated it reflected the indication for the use was Alzheimer's which was incorrect. The DON stated the nurse who received the order was responsible for entering it correctly. She stated that she and the DON would review all orders every morning for accuracy. She stated she did not remember reviewing Resident #5's orders. The DON stated the indication could place Resident #5 at risk for staff not monitoring for potential side effects as required for the use of psychotropic medications. Review of facility policy, Psychotropic Medication Use, dated July 2022, read Residents will not receive medications that are not clinically indicated to treat a specific condition.1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior.2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications:b. Anti-depressants.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #5 and #56) of 3 residents reviewed for incontinence care. 1. When CNA-O was providing incontinent care to Resident #5 on 02/26/2026, the CNA-O did not open the resident's labia area. 2. When CNA-J was providing incontinent care to Resident #56 on 02/26/2026 and the resident was uncircumcised, CNA-J did not pull back the foreskin of the resident's penis, cleaned the perineal area with multiple pass of one wipe. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #5's face sheet, dated 02/27/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses of epilepsy (a brain disorder that causes people to have recurring seizures), restlessness and agitation (sudden, distressing state of intense restlessness), and schizoaffective (exhibiting symptoms of both schizophrenia and a mood disorder such as bipolar disorder). Record review of Resident #5's admission MDS assessment, dated 02/16/2026 reflected that she was assessed to have a BIMS score was 3 out of 15 indicating she had severe cognitive impairment. Resident #5 was assessed to always incontinence to bowel and bladder. Record review of Resident #5's comprehensive care plan, dated 02/24/2026, reflected the resident had the care plan of The resident has bowel and bladder incontinence. For intervention - Clean peri-area with each incontinence episode. Observation on 02/26/2026 at 2:04 p.m. revealed CNA-O opened Resident #5's old and dirty brief, cleaned the resident's right and left groin areas, and cleaned the resident's genital area (middle area) without opening the resident's labia area, then cleaning the resident's buttock areas. Interview on 02/26/2026 at 2:12 p.m. CNA-O stated when she cleaned Resident #5's genital area, she did not open the resident's labia area. Further interview with the CNA-O said she should have opened Resident #5's labia area. Interview on 02/26/2026 at 3:54 p.m. the DON said CNA-O should have opened Resident #5's labia area to prevent possible infection. 2. Record review of Resident #56's face sheet, dated 02/27/2026, revealed the resident was a 38-years-old male and admitted to the facility on [DATE] with diagnosis of encounter for other orthopedic aftercare (intensive physical rehabilitation), fracture of part of neck of right femur (fracture to right thigh bone), and infection following a procedure deep incisional surgical site (infection to surgical site). Record review of Resident #56's admission MDS assessment, dated 02/13/2026, revealed the resident's BIMS score was 0 out of 15 which indicated the resident had severe cognitive impairment, required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to chair to bed and toilet transfer, and always incontinent to bowel and bladder. Record review of Resident #56's comprehensive care plan, dated 02/16/2026, revealed the resident had the care plan of self-care deficit for bathing, dressing, and feeding. For intervention - provide assistance with activities of daily livings. Observation on 02/26/2026 at 1:25 p.m. revealed when CNA-J opened Resident #56's old and dirty brief, the resident was uncircumcised. CNA-J cleaned the resident's right and left groin area, then cleaned the resident's penis area without pulling back the foreskin of the resident's penis, with multiple pass of one wipe, then turned the resident to side and cleaned the resident's buttock area. Interview on 02/26/2026 at 1:32 p.m. CNA-J stated when she was providing incontinent care to Resident #56, she did not pull back the foreskin of the resident's penis, cleaned with multiple pass of one wipe when cleaning the resident's penis because she was very nervous. Further interview, CNA-J said she should have pulled back the foreskin of Resident #56's penis because the resident was uncircumcised, and should have used a new wipe with each stroke to prevent infection. Interview on 02/26/2026 at 3:52 p.m. the DON said CNA-J should have pulled back the foreskin of Resident #56's penis because the resident was uncircumcised and should have used a new wipe with each stroke to prevent infection. Record review of the facility policy, titled Perineal Care, revised 02/2018, revealed Female - cleanse the peri area with wipes going front to back to dirty and separate the labia and use a new wipe with each stroke. Male - if the resident is uncircumcised gently pull back the foreskin and wipe the head of the penis beginning at the urethral opening working outward and away from the penis head.

Based on interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 out of 8 residents (Resident #1) reviewed for abuse/neglect. 1.The facility failed to ensure Resident #1 was free from abuse when RN A verbally abused Resident #1 by calling her a whore and a slut.2. The facility failed to ensure Resident #1 was free from abuse when RN A physically abused by forcefully pushing the resident's wheelchair and forcefully removing her clothes on 10/4/25 around 5:20 a.m. The noncompliance was identified as PNC. The IJ began on 10/4/25 and ended on 10/8/25. The facility had corrected the noncompliance before the investigation began. This deficient practice could place residents at risk injury and psychosocial harm. Findings included: Record review of Resident #1's admission record, dated 1/7/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included diffuse traumatic brain injury with loss of consciousness of unspecified duration (injury to multiple areas of the brain from a traumatic event), mood disorder due to known physiological condition with mixed features (mood disorder that is directly linked to a physiological condition such as a stroke), anxiety disorder (mental health condition characterized by intense, excessive, and persistent fear or worry), unsteadiness on feet, cognitive communication deficit, insomnia (sleep disorder that makes it hard to fall asleep or stay asleep), conversion disorder with seizures (a condition where psychological stress leads to abnormal neurological symptoms that cannot be explained by medical condition), other speech and language disorder following cerebral infarction, cerebral infarction (occurs when blood flow to a part of the brain is obstructed, typically by a blood clot, brain tissue begins to die), and hemiplegia (complete paralysis of one side of your body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting left non-dominant side. Resident #1 was discharged on 11/5/25. Record review of Resident #1's discharge MDS assessment, dated 11/5/25, revealed the resident had moderately impaired cognition for daily decision-making skills with a BIMS score of 10. Record review of Resident #1's care plan, initiated 9/15/25, reflected Resident #1 had a history of claiming no care had been provided when it had been provided, and staff was tossing her down the hallways when no evidence of injury had occurred. She would throw herself out of bed, and when she was questioned, she claimed someone else threw her. Record review of a statement dated 10/4/25, LVN B wrote at approximately 5:20 [a.m.] I was at my desk.I heard [CNA C] calling from [Resident #1's] room, she stated [Resident #1] was kicking and punching her and needed me to witness [Resident #1's] Behaviors. Behaviors were documented in a nurses note at approximately 0535. [RN A] arrived at that time and [Resident #1] tried taking off her shirt, [CNA C] put on a shirt and Resident # 1 came out of her room shirtless with her breasts out, [RN A] shouted with [CNA C] as a witness What is this a fucking whore house, out hear [sic] for everybody to see your tits and wheeled her to her room when and I followed her to [Resident #1's] room, [RN A] pulled [Resident #1's] shirt off [sic] aggressively and continued the verbal abuse saying Your [sic] being a fucking whore showing your fucking tits off this is a place of business not a whore house. [CNA C] and I witnessed that and [RN A] saw our face of concern and surprise and stated maybe I went a little overboard, I know that was verbal abuse, but you know how [Resident #1] is. [CNA C], [RN A], and I (LVN B) walked outside to the front where we sat for a few minutes while [RN A] smoked. While talking we see in the window [Resident #1] was again without her shirt and her breast exposed. [RN A] put her cig out and said Oh fuck no, I'm done got up and I followed. She pushed [Resident #1] to her room really fast and aggressively leaning to [Resident #1's] ear and told her you're a fucking whore showing your fucking tits acting like a slut, this is why your husband left you here because he doesn't want a whore she then at full force pushed her into her room and let go of the wheelchair like threw her in the wheelchair to roll into the room at full force. I heard [Resident #1] scream and heard a loud thud and ran into the room. I thought [Resident #1] crashed and fell into the floor but it was her wheelchair that slammed into her bed from [RN A] throwing her into the room. [RN A] ripped off the shirt off her contracted arm and [Resident #1] stated stop that hurts you bitch [RN A] aggressively and forcefully ripped off the sweater and put on her other shirt she had on prior and continued the verbal abuse calling [Resident #1] a slut and whore. [RN A] just looked at me and didn't say anything, left [Resident #1] in her room, walked out and slammed the door shut behind her. Record request for the facility's investigation report of the incident that occurred on 10/4/25 revealed one was not completed for this incident. Record review of Resident #1's nursing progress note, dated 10/4/25, at 5:47 a.m. stated Resident hitting and kicking CNA. Nurse and another CNA there to assist and witness. Resident changed into clean clothes and yelling at staff. Resident came out of room naked with breasts showing because she took off her clean shirt. Resident instructed to keep clothes on, Resident is now wearing clothes at this time. Written by LVN B. Record review of Resident #1's nursing progress note, dated 10/4/25, at 8:36 a.m. stated digging on trays taken from rooms after those residents have eaten. Written by RN A. Record review of Resident #1's nursing progress note, dated 10/5/25, at 8:04 a.m. stated res seen taking large amt of sugar packets from coffee cart and putting them in her shirt. when told not to do that she said it is paidfor by her so she can do what she wants with it. When told it is for everyone to use and she is not even using it she says to hell with them it ishers to take. Written by RN A. Record review of Resident #1's skin assessment, dated 9/30/25, revealed no alteration in skin integrity noted. The assessment was completed by RN A. Record review of Resident #1's skin assessment, dated 10/7/25, revealed the resident had no new or unusual markings or bruises to any part of her body. The assessment was completed by LVN D. Record review of the nursing staff schedule from 10/4/25 revealed RN A worked the 6 a.m. shift to 6 p.m. shift on the A hallway where Resident #1 resided on 10/4/25. Record review of the nursing staff schedule from 10/5/25 revealed RN A worked the 6 a.m. shift to 6 p.m. shift on the A hallway where Resident #1 resided on 10/5/25. Record review of RN A's employee file revealed she was rehired on 7/1/23, her last day worked was on 10/5/25, and she was terminated on 10/8/25 without being eligible for rehire. The file also contained 3 corrective actions: -10/31/17- Stated RN was informed that any resident-to-resident altercations are to be reported to the Administrator. -1/12/24- Stated RN A was heard by 2 CNAs making inappropriate comments about another staff member. -1/15/25- Stated RN A made a statement in a public area with Residents around stating she had a 380 and could just blow away others. Record review of document titled Safe Survey-Abuse dated 10/7/25, revealed 2 Residents were interviewed and stated they felt safe. One resident stated they heard loud voices on 10/4/25 but did not know what they were saying. During an interview on 1/7/26 at 10:06 a.m. LVN B confirmed the events in her statement are what she witnessed on the morning of 10/4/25. LVN B stated she checked the resident for injuries after the incident, and none were found but she forgot to document it in a nursing note or assessment. LVN B stated after the incident she had not have any one-on-one coaching or training but did receive an in service on 10/7/25 over abuse and neglect reporting. She stated she also had annual abuse training in December of 2025. During an interview on 1/7/25 at 3:05 p.m. the Administrator stated the incident was reported to him the morning of 10/7/25 by LVN B. The Administrator confirmed The alleged perpetrator explained that the resident was not cooperative the morning of the incident and kept taking off their shirt. The Administrator then asked the alleged perpetrator (RN A) did you call the resident [Resident #1] a Whore? The alleged perpetrator responded that she told the resident that 'she was acting like a whore,' but insisted she did not call the resident a whore. The Administrator then asked if the alleged perpetrator shoved the resident in their wheelchair into their room. The alleged perpetrator stated she didn't push the resident hard, but she did push the resident into their room without controlling the wheelchair. Following the conversation with the alleged perpetrator the administrator terminated the employee, due to them confirming the allegations of abuse. The Administrator stated staff were expected to immediately report incidents like this to him. The Administrator stated after the incident they completed an in-service on reporting abuse and neglect, and all staff also completed annual abuse and neglect training in December of 2025, and he interviewed residents who had good cognition and would have maybe over heard the incident. The Administrator stated the residents reported feeling safe and only heard loud voices but not what was said. During an interview on 1/7/25 at 6:03 p.m. CNA C stated on the morning of 10/4/25 Resident #1 was combative and agitated. She stated she saw RN A get aggressive with Resident #1 by pushing her into her room, calling her a slut, and shutting her door. CNA C stated she had checked on Resident #1 and she stated RN A always treated her like that and was a bitch to her. CNA C stated her and LVN B agreed LVN B would report the incident. CNA C stated she received an in-service after the incident on 10/4/25 over reporting abuse and neglect and had annual training for abuse and neglect in December of 2025. During an interview on 1/9/26 at 10:20 a.m. the DON stated she interviewed the Resident on 10/7/25 the day after she was informed because the resident was already asleep when she was told on 10/6/25. The DON stated they had a video visit with a psychiatric provider on 10/7/25, but could not provide any notes. The DON stated a skin assessment was completed on 10/7/25, and the resident had no injuries. The DON stated she could not recall what the resident stated happened, but that she was not affected by the incident because she was seen socializing during dining service as she normally would. The DON stated this incident could have mentally affected the resident. During an interview on 1/9/25 at 4:17 p.m. Resident #3 stated on 10/4/25 she was woken up to RN A yelling at an unknown resident. She stated she heard RN A calling someone a whore and a slut. Resident #3 stated later she asked RN A who she was yelling at, and she stated she was talking to Resident #1 because she was naked. Resident #3 stated RN A was never abusive to her, but she was vulgar with other residents. Record review of the facility's policy, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 2001, revised April 2021, stated Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: l. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:a. facility staff;b. other residents;c. consultants;d. volunteers;e. staff from other agencies;f. family members;g. legal representatives;h. friends;i. visitors; and/orj. any other individual.2. Develop and implement policies and protocols to prevent and identify:a. abuse or mistreatment of residents;b. neglect of residents; and/orc. theft, exploitation or misappropriation of resident property.4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has:a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; orc. a disciplinary action in effect against his or her professional license by a state Ii censure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.5. Establish and maintain a culture of compassion and caring for al\ residents and particularly those with behavioral, cognitive or emotional problems. 6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 7. Implement measures to address factors that may lead to abusive situations, for example:a. adequately prepare staff for caregiving responsibilities;b. provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation;c. instruct taff regarding appropriate ways to address interpersonal conflicts; andd. help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.8. Identify and in estigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident prope1ty.9. Investigate and report any allegations within timeframes required by federal requirements .10. Protect residents from any further ham, during investigations . This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 10/4/25 and ended on 10/8/25. The facility had corrected the noncompliance before the investigation began. The facility took the following actions to correct the non-compliance:-10/7/25 Incident reported to HHSC. -10/7/25 Inservice over abuse and neglect of all staff was started.-10/7/25 Head to toe Assessment completed by nursing for Resident #1.-10/7/25 RP of Resident #1 was notified of incident. -10/7/25 Resident safe interviews were conducted. -10/8/25 RN A was terminated on.-10/16/25 Resident #1 was evaluated by a mental health professional. During interviews with the staff, from various shifts, 2 LVNs, 1 RN and 2 CNAs on 1/6/26-1/9/26, all staff stated they were in-serviced on abuse and neglect, they were able to define the types of abuse, and they stated they would immediately report any abuse, neglect, or exploitation to the abuse coordinator, the Administrator. Review of Resident #1's Administration notes revealed a note, dated 10/7/25, The administrator spoke with the family of the resident to speak with them about an incident that occurred with the resident. The administrator told the family of the reported issue that occurred, and notified them of the active investigation and the outcome. Record review of an Inservice dated, 10/7/25, revealed the topic was Abuse and Neglect presented by the DON. The in-service was signed by 42 of 43 staff. One housekeeper did not sign the in-service. Record review of Resident #1's skin assessment, dated 10/7/25, revealed the resident had no new or unusual markings or bruises to any part of her body. The assessment was completed by LVN D. Record review of RN A's employee file revealed she was rehired on 7/1/23, her last day worked was on 10/5/25, and she was terminated on 10/8/25 without being eligible for rehire. Record review of document titled Safe Survey-Abuse dated 10/7/25, revealed 2 Residents were interviewed and stated they felt safe. One resident stated they heard loud voices on 10/4/25 but did not know what they were saying. Review of Resident #1's progress notes date range 10/07/25 to 11/07/25 revealed the resident was seen for a psychiatric periodic evaluation on 10/16/25 and noted patient is not in acute danger to self or others. An Immediate Jeopardy (IJ) existed from 10/4/2025 - 10/08/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused result in serious bodily injury for 1 of 8 residents (Resident #1) whose records were reviewed for abuse and neglect: The facility failed to ensure verbal and physical abuse that occurred on 10/4/25 at 5:20 a.m. of Resident #1 by RN A was immediately reported to the abuse coordinator. The abuse was reported to the administrator on 10/7/25.The noncompliance was identified as PNC. The IJ began on 10/4/25 and ended on 10/8/25. The facility had corrected the noncompliance before the investigation began.These deficient practices could affect residents by contributing to further abuse and neglect. The findings were: Record review of Resident #1's admission record, dated 1/7/26, reflected a [AGE] year-old female who was admitted to the facility on 3/21/23. Resident #12 had diagnoses which included diffuse traumatic brain injury with loss of consciousness of unspecified duration (injury to multiple areas of the brain from a traumatic event), mood disorder due to known physiological condition with mixed features (mood disorder that is directly linked to a physiological condition such as a stroke), anxiety disorder (mental health condition characterized by intense, excessive, and persistent fear or worry), unsteadiness on feet, cognitive communication deficit, insomnia (sleep disorder that makes it hard to fall asleep or stay asleep), conversion disorder with seizures (a condition where psychological stress leads to abnormal neurological symptoms that cannot be explained by medical condition), other speech and language disorder following cerebral infarction, cerebral infarction (occurs when blood flow to a part of the brain is obstructed, typically by a blood clot, brain tissue begins to die), and hemiplegia (complete paralysis of one side of your body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting left non-dominant side. Resident #1 was discharged on 11/5/25. Record review of Resident #1's discharge MDS assessment, dated 11/5/25, revealed the resident had moderately impaired cognition for daily decision-making skills with a BIMS score of 10. Record review of Resident #1's care plan, initiated 9/15/25, reflected Resident #1 had a history of making false accusations against staff/other residents. Resident had a history to claim no care had been provided while it had been provided, staff is tossing her down the hallways when no evidence of injury had occurred, and would throw self out of bed. When she was questioned she claimed someone else threw her. Record review of a statement dated 10/4/25, LVN B wrote at approximately 5:20 [a.m.] I was at my desk.I heard [CNA C] calling from [Resident #1's] room, she stated [Resident #1] was kicking and punching her and needed me to witness [Resident #1's] Behaviors. Behaviors were documented in a nurses note at approximately 0535. [RN A] arrived at that time and [Resident #1] tried taking off her shirt, [CNA C] put on a shirt and Resident # 1 came out of her room shirtless with her breasts out, [RN A] shouted with [CNA C] as a witness What is this a fucking whore house, out hear [sic] for everybody to see your tits and wheeled her to her room when and I followed her to [Resident #1's] room, [RN A] pulled [Resident #1's] shirt off [sic] aggressively and continued the verbal abuse saying Your [sic] being a fucking whore showing your fucking tits off this is a place of business not a whore house. [CNA C] and I witnessed that and [RN A] saw our face of concern and surprise and stated maybe I went a little overboard, I know that was verbal abuse, but you know how [Resident #1] is. [CNA C], [RN A], and I (LVN B) walked outside to the front where we sat for a few minutes while [RN A] smoked. While talking we see in the window [Resident #1] was again without her shirt and her breast exposed. [RN A] put her cig out and said Oh fuck no, I'm done got up and I followed. She pushed [Resident #1] to her room really fast and aggressively leaning to [Resident #1's] ear and told her you're a fucking whore showing your fucking tits acting like a slut, this is why your husband left you here because he doesn't want a whore she then at full force pushed her into her room and let go of the wheelchair like threw her in the wheelchair to roll into the room at full force. I heard [Resident #1] scream and heard a loud thud and ran into the room. I thought [Resident #1] crashed and fell into the floor but it was her wheelchair that slammed into her bed from [RN A] throwing her into the room. [RN A] ripped off the shirt off her contracted arm and [Resident #1] stated stop that hurts you bitch [RN A] aggressively and forcefully ripped off the sweater and put on her other shirt she had on prior and continued the verbal abuse calling [Resident #1] a slut and whore. [RN A] just looked at me and didn't say anything, left [Resident #1] in her room, walked out and slammed the door shut behind her. Record request for the facility's investigation report of the incident that occurred on 10/4/25 revealed one was not completed for this incident. Record review of Resident #1's nursing progress note, dated 10/4/25, at 5:47 a.m. stated Resident hitting and kicking CNA. Nurse and another CNA there to assist and witness. Resident changed into clean clothes and yelling at staff. Resident came out of room naked with breasts showing because she took off her clean shirt. Resident instructed to keep clothes on, Resident is now wearing clothes at this time. Written by LVN B. Record review of Resident #1's nursing progress note, dated 10/4/25, at 8:36 a.m. stated digging on trays taken from rooms after those residents have eaten. Written by RN A. Record review of Resident #1's nursing progress note, dated 10/5/25, at 8:04 a.m. stated res seen taking large amt of sugar packets from coffee cart and putting them in her shirt. when told not to do that she said it is paid for by her so she can do what she wants with it. When told it is for everyone to use and she is not even using it she says to hell with them it is hers to take. Written by RN A. Record review of Resident #1's skin assessment, dated 9/30/25, revealed no alteration in skin integrity noted. The assessment was completed by RN A. Record review of Resident #1's skin assessment, dated 10/7/25, revealed the resident had no new or unusual markings or bruises to any part of her body. The assessment was completed by LVN D. Record review of the nursing staff schedule from 10/4/25 revealed RN A worked the 6 a.m. shift to 6 p.m. shift on the A hallway where Resident #1 resided on 10/4/25. Record review of the nursing staff schedule from 10/5/25 revealed RN A worked the 6 a.m. shift to 6 p.m. shift on the A hallway where Resident #1 resided on 10/5/25. Record review of RN A's employee file revealed she was rehired on 7/1/23, her last day worked was on 10/5/25, and she was terminated on 10/8/25 without being eligible for rehire. Record review of document titled Safe Survey-Abuse dated 10/7/25, revealed 2 Residents were interviewed and stated they felt safe. One resident stated they heard loud voices on 10/4/25 but did not know what they were saying. During an interview on 1/7/26 at 10:06 a.m. LVN B confirmed the events in her statement are what she witnessed on the morning of 10/4/25. LVN B stated she checked the resident for injuries after the incident, and none were found but she forgot to document it in a nursing note or assessment. LVN B stated she had training and knew she was supposed to report the incident to the Administrator but she was in shock and had to sit with what happened. She stated she also wanted to follow her chain of command and decided to try to reach the DON first. LVN B stated she thought the incident occurred on 10/5/25. LVN B stated she called the DON on the morning of 10/5/25 but the DON had not return her call. LVN B stated she was not sure but she thought she informed the DON later that evening on 10/5/25 when she returned for her 6 p.m. shift. LVN B stated after she spoke to the DON she informed the Administrator after her shift on 10/6/25 in the morning (10/7/25). LVN B stated after the incident she had not had any one-on-one coaching or training but did receive an in service on 10/7/25 over abuse and neglect reporting. She stated she also had annual abuse training in December of 2025. LVN B stated not reporting the abuse immediately meant the resident could be abused again. During an interview on 1/7/25 at 3:05 p.m. the Administrator stated the incident was reported to him the morning of 10/7/25 by LVN B. The Administrator confirmed The alleged perpetrator explained that the resident was not cooperative the morning of the incident and kept taking off their shirt. The administrator then asked the alleged perpetrator (RN A) did you call the resident [Resident #1] a Whore? The alleged perpetrator responded that she told the resident that 'she was acting like a whore,' but insisted she did not call the resident a whore. The administrator then asked if the alleged perpetrator shoved the resident in their wheelchair into their room. The alleged perpetrator stated she didn't push the resident hard, but she did push the resident into their room without controlling the wheelchair. Following the conversation with the alleged perpetrator the administrator terminated the employee, due to them confirming the allegations of abuse. The Administrator stated staff were expected to immediately report incidents like this to him. The Administrator stated after the incident they completed an in-service on reporting abuse and neglect, and all staff also completed annual abuse and neglect training in December of 2025. The Administrator stated he made all staff aware they could contact him at anytime for abuse and neglect concerns. The Administrator stated by delaying reporting the incident the resident was at risk of something potentially happening. During an interview on 1/7/25 at 6:03 p.m. CNA C stated on the morning of 10/4/25 Resident #1 was combative and agitated. She stated she saw RN A get aggressive with Resident #1 by pushing her into her room, calling her a slut, and shutting her door. CNA C stated she had checked on Resident #1, and she stated RN A always treated her like that and was a bitch to her. CNA C stated her and LVN B agreed LVN B would report the incident. CNA C stated she received an in-service after the incident on 10/4/25 over reporting abuse and neglect and had annual training for abuse and neglect in December of 2025. CNA C stated the Administrator was the abuse coordinator and all abuse concerns should immediately be reported to him. CNA C stated however she felt she had done her part by talking with the charge nurse LVN B and agreed LVN B would report the abuse. LVN B stated she did not know what could have happened in the few days RN A continued to work with Resident #1. During an interview on 1/9/26 at 10:20 a.m. The DON stated she was informed of the incident late on 10/6/25 and was not given all the details of the incident until 10/7/25. The DON stated this incident occurred over the weekend and she had not worked that weekend. The DON stated she could not recall what the resident stated happened but that she was not affected by the incident because she was seen as she normally would. The DON stated this incident could have mentally affected the resident. During an interview on 1/9/25 at 4:17 p.m. Resident #3 stated on 10/4/25 she was woken up to RN A yelling at an unknown resident. She stated she heard RN A calling someone a whore and a slut. Resident #3 stated later she asked RN A who she was yelling at, and she stated she was talking to Resident #1 because she was naked. Resident #3 stated RN A was never abusive to her, but she was vulgar with other residents. Resident #3 stated the Administrator had interviewed her about the incident but she had not disclosed to him the exact details of what she heard at that time. Record review of the facility's policy, titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated 9/22, stated Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation. Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines.3. Immediately is defined as:a. within two hours of an allegation involving abuse or result in serious bodily injury; or . This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 10/4/25 and ended on 10/8/25. The facility had corrected the noncompliance before the investigation began. The facility took the following actions to correct the non-compliance: -10/7/25 Incident reported to HHSC. -10/13/25 3613-A report was sent to HHSC with the investigation findings. -10/7/25 Inservice over abuse and neglect of all staff was started. -10/7/25 Head to toe Assessment completed by nursing for Resident #1. -10/7/25 RP of Resident #1 was notified of incident. -10/7/25 Resident safe interviews were conducted. -10/8/25 RN A was terminated on. -10/16/25 Resident #1 was evaluated by a mental health professional. During interviews with the staff, from various shifts, 2 LVNs, 1 RN and 2 CNAs on 1/6/26-1/9/26 all staff stated they were in-serviced on abuse and neglect, they were able to define the types of abuse, they stated they would immediately report any abuse, neglect, or exploitation to the abuse coordinator, the Administrator. Review of Resident #1's Administration notes revealed a note, dated 10/7/25, The administrator spoke with the family of the resident to speak with them about an incident that occurred with the resident. The administrator told the family of the reported issue that occurred, and notified them of the active investigation and the outcome. Record review of an Inservice dated, 10/7/25, revealed the topic was Abuse and Neglect presented by the DON. The in-service was signed by 42 of 43 staff (LVN B and CNA C signed the in-service). One housekeeper did not sign the in-service. Record review of Resident #1's skin assessment, dated 10/7/25, revealed the resident had no new or unusual markings or bruises to any part of her body. The assessment was completed by LVN D. Record review of RN A's employee file revealed she was rehired on 7/1/23, her last day worked was on 10/5/25, and she was terminated on 10/8/25 without being eligible for rehire. Record review of document titled Safe Survey-Abuse dated 10/7/25, revealed 2 Residents were interviewed and stated they felt safe. One resident stated they heard loud voices on 10/4/25 but did not know what they were saying. Review of Resident #1's progress notes date range 10/07/25 to 11/07/25 revealed the resident was seen for a psychiatric periodic evaluation on 10/16/25 and noted patient is not in acute danger to self or others. An Immediate Jeopardy (IJ) existed from 10/4/2025 - 10/08/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation.

Based on interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 5 of 16 residents (Resident #9, Resident #21, Resident #36, Resident #40 and Resident #48) reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident #36 after Resident #36 was suspected to be under the influence of illicit substances. Resident #9, Resident #21, Resident #36, and Resident #40 all tested positive for amphetamines. The facility did not lock and adequately supervise the back door. Further observation revealed Resident #9 and Resident #48 were smoking outside unattended. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:10 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility needed to monitor the implementation of the plan of removal. The failure placed all residents at risk for serious injury, harm, and/or death. The findings included: 1. Record review of Resident #9's Admission record revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses of chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe. It's caused by damage to the lungs that reduces airflow.), vascular dementia (a type of dementia that occurs when blood vessels in the brain are damaged, reducing the flow of oxygen and nutrients to the brain), mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, extrapyramidal and movement disorder (are a group of movement disorders that can occur as a side effect of certain drugs, particularly antipsychotics), nicotine dependence (a chronic disease that occurs when the body becomes addicted to nicotine, a stimulant found in tobacco products), schizophrenia (a chronic mental disorder that affects how people think, perceive reality, and interact with others), and insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep). Record review of Resident #9's quarterly MDS, dated [DATE], revealed the resident had fully intact cognition for daily decision making. Record review of Resident #9's care plan contained a care area, last edited on [DATE], that stated the resident had a history of alcohol or drug abuse as evidenced by recently tested positive with interventions to MD/RP will be notified of any changes in residents behavior / mental state. Also, a care area for Resident #9 smokes cigarettes and he set a fire at the last placement due to hearing what he thought was a gun being loaded. He will have strictly supervised smoking breaks; no lighter will be in his possession with interventions to All smoking materials are kept at the nurse's station between smoke breaks, [Resident #9] will be given two cigarettes a break and offered a light-he will be supervised at all times during the break. Record review of a nursing note written by LVN B, dated [DATE], stated It had been noted by staff that res had been acting abnormally. This nurse was given an order to test urine for drugs. Urine came up positive for amphetamines . Record review of Resident #9's Psychotherapy progress notes, dated [DATE], stated Focus of Session: individual psychotherapy session with patient in his room and [nursing facility]. Patient was reportedly involved in an incident over the weekend but did not bring it up during the therapy session. The issue was not pressed. Patient reports that he is doing OK and that he is getting ready to go on his smoke break once this session is over. Patient reports good sleep, good appetite and patient reports that he is no longer depressed. He reports that he is still tired and lethargic most of the time. Encourage patient to be patient with adjustment. Period for new medications 2. Record review of Resident #21's Admission record revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses of hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease (the high blood pressure has damaged both the heart and kidneys, leading to significant impairment in kidney function and the heart's ability to pump blood effectively), cognitive communication deficit, insomnia (a sleep disorder that makes it difficult to fall asleep, stay asleep, or get enough quality sleep), depression, presence of coronary angioplasty implant and graft, secondary hyperaldosteronism (a patient has had a coronary angioplasty (procedure that uses a balloon to widen a blocked or narrowed coronary artery) procedure and a stent placed in their coronary artery), alcohol dependence, in remission, bipolar disorder, anxiety disorder, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a type of coronary artery disease (CAD) that occurs when plaque builds up in the walls of the heart's arteries. This buildup, also known as atherosclerosis, narrows the arteries and makes them less flexible. The narrowing can reduce blood flow to the heart, which can lead to angina pectoris, or chest pain.), and heart failure. Record review of Resident #21's quarterly MDS, dated [DATE], revealed the resident had mildly impaired cognition for daily decision making. Record review of Resident #21's care plan contained a care area, last edited on [DATE], that stated the resident had a history of alcohol or drug abuse as evidenced by recently tested positive with interventions to MD/RP will be notified of any changes in residents behavior / mental state. Record review of Resident #21's nursing note written by RN A, dated [DATE], stated res was very anxious and agitated. Pacing repeatedly. NP was notified and /her order a urine test for drugs was done He tested positive on our test her for amphetamines. A sample of his urine was also sent to the lab where it again came back positive for amphetamines. NP was notified by DON. Pending NP recommendations at this time Record review of Resident #21's Psychotherapy Progress note, dated [DATE], stated Focus of Session: individual therapy session with [Resident #21] in his room and [Nursing Facility]. Patient was referred for a follow up session today due to an incident that happened over the weekend. Patient was given opportunities to bring up anything that might've happened during the weekend, but he denied any significant event. Patient did discuss his chemo and the fact that it does make him nauseated at times. Patient reports he is not sleeping well and is only getting about five hours of sleep per night. Patient's appetite is good. Patient reports that he is doing OK, however, he presented with flat affect in this current session . Resident #21 Interview on [DATE] at 10:30 am - Resident was observed laying in his bed in his room, he refused to answer or talk about the drug use incident. 3. Record review of Resident #36's Admission record revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnoses of schizoaffective disorder (a chronic mental illness that involves symptoms of both schizophrenia and a mood disorder, such as bipolar disorder or depression), bipolar type, unspecified atrial fibrillation (a heart condition that causes the upper chambers of the heart to beat irregularly), unspecified convulsions (nerve cell activity in the brain is disrupted, causing muscles to involuntarily contract and spasm), extrapyramidal and movement disorders (a group of movement disorders that can occur as a side effect of antipsychotic and other drugs), bipolar disorder (a serious mental illness that causes extreme mood swings, along with changes in energy, thinking, behavior, and sleep), unspecified, recurrent depressive disorders, and major depressive disorder (a serious mood disorder that can affect how someone feels, thinks, and acts). Record review of Resident #36's quarterly MDS, dated [DATE], revealed the resident had mild cognitive impairment for daily decision making. Record review of Resident #36's care plan contained a care area, last edited on [DATE], that stated the resident had a history of alcohol or drug abuse with interventions to MD/RP will be notified of any changes in residents' behavior / mental state. Also, a care area for potential for safety hazards, injury related to smoking with an intervention to encourage resident to keep all smoking material at nurse's station after smoke break. Record review of Resident #36's nursing note written by LVN G, dated [DATE] stated As this nurse was administering morning medications, residents' vitals measured @ (BP),d+[DATE] and (P)134. Resident was observed as being overly skittish, could not stop moving while in the bed and acting paranoid that someone was trying to break into her closet and rest room, however there are no locks on her door handles. This nurse performed neuro check on resident and noted left pupil measuring at 6 mm and right pupil measuring at 4 mm. Resident admitted to this nurse that she had been drinking wine, smoking cigars and vaping throughout the night, resident was reminded that she should not be smoking outside of designated smoke times and she should not be holding cigarettes, lighters or vapes on her person. NP [D] notified of residents' condition; order given to have resident sent out to ER. 911 called, EMS arrived, and resident refused to go to hospital. EMS personnel stated that since she is alert enough to answer their questions and is refusing to be transported to hospital, they cannot take her. NP [D] notified of residents' refusal, NP gave orders for STAT labs CBC, BMP and blood drug panel, also monitor vitals every 30 mins for 3 hours. Record review of Resident #36's progress note, dated [DATE], written by NP D stated Seen today per request from Charge Nurse reporting that resident was up all night long on back outdoor patio unsupervised with other residents and has since had erractic behavior, AMS, jerking of arms and legs, twitching of neck, exhibiting paranoid behavior that someone was breaking into her closet. Nurse reported that pupils dilated to 6 mm at 05:37am. Resident admitted to drinking alcohol after she was told 2 weeks prior that this would have adverse effect to her mental status and serious health consequences due to all psychoactive medications, antidepressants, and anxiolytics. Patient made comment to nurse at 05:37 am that she was not doing drugs. Requested patient to be transferred to hospital for evaluation due to severe AMS but when EMS arrived, patient refused to go. Patient seen this afternoon and she is complaining rapid heart rate, SOB, chest tightness. She is still having constant movement of arms and legs, worming around in bed. She made the comment again that I have not done any drugs when patient questioned about chest pain. Record review of Resident #36's nursing note written by LVN G, dated [DATE], stated At beginning of this shift, during report, resident observed in wheelchair at nurses' station having erratic behavior and movement. Resident requested to have staff assist her to her room, once in room resident was heard yelling I'm too high, oh God help me. This nurse and day shift nurse assessed resident; resident admitted she had taken a pill that a man had given to her. 911 called. EMS arrived and resident taken to [hospital]. Resident did ask for staff to notify her sister before leaving facility. NP/DON/Administrator/[family member]. Record review of Resident #36 nursing note written by LVN B, dated [DATE], stated Res had been sent to hospital for erratic behavior on the 15th. This nurse came to work on the 16th and PA had given orders for urine drug screening. Urine collected and res tested positive for amphetamines . Record review of CNA C's statement dated [DATE] on stated I was in the bathroom and heard some people talking and heard a man (Resident #40) asking the lady (Resident #36) in the bathroom which one do you want and I guess she took whatever he gave her. Record review of Resident #36's Psychiatric progress note, dated [DATE], stated Patient is being seen today as a follow up on psychiatric services due to her psychotropic medication management, and psychiatric diagnosis of bipolar disorder, insomnia, major depressive disorder She has a pertinent history of bipolar disorder, multiple mental health hospitalization s, and suicide attempts .Trauma History: reported positive, was a prostitute, was incarcerated, can become physically violent. Substance Use: remote history, was in recover program. illicit drug use: remote history, was in recover program. Tobacco use: quit .Diagnosis #4 substance use disorder -patient had a sponsor in Houston, went to a 12-step program. It's not currently using Record review of Resident #36's hospital documents, dated [DATE], stated [AGE] year-old female brought n by EMS from [NAME] winds skilled nursing facility due to altered mental status. She has a history of schizophrenia. There was concern the patient had taken an unknown medication but EMS reports it was her Xanax. Patient had been complaining of feeling like she had bugs in her hair and on her body. When I went to evaluate her she was sleeping soundly but upon awakening she states that she still feels like she has bugs in her hair, Patient was easily redirectable XXX[AGE] year-old female with history of schizophrenia presenting having an episode of difficult control at the skilled nursing facility. She had taken her Xanax prior to departure and upon, arriving here was calm and directable. She was sleeping comfortably. Vital signs were normal. No indication for further diagnostic evaluation or therapeutic intervention. Patient appears to be at her baseline. Do not suspect sepsis, intracranial hemorrhage, or other acute organic condition. Will discharge patient back to her skilled nursing facility for ongoing care of her underlying condition, currently stable and safe for discharge Record review of Resident #36's Psychotherapy Progress note, dated [DATE], stated .Focus of Session: individual psychotherapy session with [Resident #36] in her room and [Nursing Facility]. Patient was reportedly involved in a situation over the weekend that was potentially compromising. Met with the patient to observe and assess for emotional unrest. Patient did not indicate any out of the ordinary occurrence over the weekend. The issue was not pressed. Patient reports that she needs her eyeglasses fixed and she feels sick to her stomach. Patient reports that she sleeps. OK, maybe too much. Patient denies having a good appetite and report she is not doing as much in the facility as she used to . During an interview on [DATE] at 2:44 p.m. Resident #36 stated Resident #40 and her snorted white powder off her phone last Friday the 15th of November. Resident #36 stated Residents #9, #21 #40, and #48 would smoke drugs from a pipe on the back patio when staff were not around. 4. Record review of Resident #40's Admission record revealed a [AGE] year-old male admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, disruption of external operation (surgical) wound, acquired absence of right leg below knee, acquired absence of left leg above knee, and depression. Record review of Resident #40's care plan contained a care area, last edited on [DATE], that stated the resident had a history of illicit drug use/abuse with interventions to MD/RP will be notified of any changes in resident's behavior/mental state. Also, a care area for potential for safety hazard, injury related to smoking. Resident assessed to be a supervised smoker. Resident smokes traditional cigarettes. Interventions included Encourage resident to keep all smoking material at nurse's station after smoke break. Record review of Resident #40's progress notes, revealed a note dated [DATE] for [DATE], written by NP F, stated Questionable activities reported that pt may be bringing unknown substance and giving it to other residents, his drug screen is pending . Record review of Resident #40's Psychotherapy Progress note, dated [DATE], stated .History of Present Illness: Patient came to the facility following an amputation of leg. Patient has a dx of .depression unspecified in his history. Patient was referred for assessment an reduction of inappropriate behaviors. Staff description of Patient Behavior: noncompliant uncooperative. Substance Misuse: client denies substance abuse Risk factors and summary of findings. Narrative: individual psychotherapy session with patient in his room. Patient was alert and presented as dysphoric and with flat or sad effect. Patient is in the facility due to amputation of legs. Patient reports that he is depressed most every day and anxiety is present some days. Patient has some issues with appetite and sleep. Patient denies any suicidal ideation or psychiatric inpatient care. Patient is a current smoker and denies alcohol or drug abuse. Patient is Patient PHQ9 score (is a depressive symptom scale and diagnostic tool) at present time is a nine. Patient is divorced. Has three girls, obtain an associate's degree on electronics, and was a delivery driver most of his life Record review lab results collected on [DATE] and ran on [DATE] showed urine drug screen results for Resident #9, Resdient #21, Resident #36, and Resident #40, were all positive for amphetamine. [DATE] at 10:40 am - Resident #40 interview - resident refused to answer or talk about the drug abuse incident. He just shook his head no. 5. Record review of Resident #48 face sheet dated [DATE] for Resident #48 showed an admitted [DATE] with diagnosis of Cerebral Infarction (mini stroke), Epilepsy (chronic brain disease that causes seizures), and Diabetes (chronic disease where the body doesn ' t produce enough insulin). Record review of Resident #48 ' s MDS dated [DATE] showed a BIMS score of 14 indicating the resident has normal cognitive functioning. Record review of Resident #48 ' s Care Plan dated [DATE] revealed, Potential for safety hazard, injury related to smoking. Record review of Resident #48 ' s Smoking assessment dated [DATE] revealed a score of 13 which indicated resident is Potentially unsafe smoker. During an observation on [DATE] at 11:07 am - Resident #48 and Resident #9 were observed smoking unsupervised for about 15 minutes. No staff were present at the time. During an interview on [DATE] at 11:09 am, Resident #48 - when asked where he got his cigar and how he lit it, he stated that he had it previously and that sometimes he doesn ' t smoke it all and saves it. He stated that he already had the old cigar and that a guy walking by lit it for me. During an interview on [DATE] at 11:00 am with the DON, she stated that smoke breaks are timed. Residents go about 6 times a day. Staff should be present when residents smoke. Staff keep the residents ' cigarettes and lighters. Policy stated they will be discharged if they are unsupervised. Told by corporate not to lock the doors anymore which allows residents to go outside whenever they want. Potential for harm could be an injury. During an interview on [DATE] at 11:43 am with the Administrator, he stated that residents who go outside alone to smoke, we are addressing it with the ombudsman. They are re-educating residents regarding smoking rules. He had a meeting with all the resident who smoke, and they signed the smoking policy about a month ago. Smoking residents should always be supervised regardless of whether they are deemed safe or not. Regarding residents who go out to smoke by themselves, it is frustrating because it does happen due to the doors not being locked. During an observation on [DATE] at 11:07 a.m. Resident #48 and Resident #9 were observed smoking unsupervised for about 15 minutes. No staff were present at the time. Observation on [DATE] at 4:34 p.m. revealed an unlocked door lead to the smoking area on the back side of the facility. There was no fence around the perimeter of the facility. The smoking area had open access to a sidewalk, neighborhood street, and houses across the street. The back door was unlocked for entry at any time. During an interview on [DATE] at 9:50 a.m. RN A revealed she would observe Residents #9, #21, #36, and #40 on the smoking patio huddled down and outside of designated smoking times. RN A stated Resident #40 had a visitor who would enter through an unlocked door in the back of the facility at any time - usually late in the evenings. Shortly after this visitor came, the above residents would begin to act differently with exaggerated movements and posturing, odd behaviors, and more aggression. RN A stated she was concerned about the unlocked doors at the facility because strangers would sometimes just sit inside the facility. RN A stated she had reported these concerns to management, but they never addressed them. During an interview on [DATE] at 10:11 a.m. LVN B stated she began to notice Resident #36 was having behaviors that were not normal for her. LVN B stated she noticed it was always after she was hanging out with a group of residents that included Resident #9, #21, and #40. LVN B stated they would go out on the smoking patio outside of smoking hours unsupervised and smoke. LVN B stated on [DATE] Resident #36 began acting strange and she notified NP D who ordered a blood panel to test for drugs. LVN B said there was a long delay in obtaining the blood panel drug test results and they still did not have those. LVN B stated while she had no proof that Resident #40 was suppling drugs to other resident's she suspected it was him because other residents would always visit him in his room, and he sometimes had a late-night visitor who would enter through the back unlocked door. LVN B stated Resident #36 had a history of Angina and recently had an abnormal EKG and had been a resident there for a long time and never behaved like this before. LVN B stated on [DATE] she observed Resident #36 run into the hallway and yell that she was too high. LVN B stated Resident #36 was tested along with Resident #9, #21, and #40 on [DATE] and they all tested positive for amphetamines. LVN B stated Resident #36 initially tested positive for MDMA, meth, and amphetamines. During an interview on [DATE] at 3:32 p.m. NP D stated she was informed on [DATE] that Residents #9, #21, #36, and #40 were out on the patio all night on [DATE] unsupervised. NP D stated they became suspicious that drug use was going on because resident #36's behaviors and mannerisms were different, and she stated she was not using drugs during her assessment of the resident. NP D stated she told facility staff she did not want patients under her care outside unsupervised all night because they have access to the community. NP D stated it was unhealthy for them to be up all night because many of them are on medications to help them sleep, are on psychiatric medications, and will miss out on ADLs, activities, and meals during the day. NP D stated these Residents were in a nursing home for a reason and should not be left unsupervised in the middle of the night. NP D stated she knew Resident #36 had a history of drug use and inquired why resident #36 used drugs again after a long period of sobriety and Resident #36 stated because of who she was hanging out with and because she had access to the drugs at the facility. NP D stated Resident #36 had a history of angina but in the past few months had an increase in chest pain complaints. NP D stated she had since educated the resident that amphetamines are bad for her heart and could lead to a heart attack or death. NP D stated Resident #36 had an abnormal EKG on [DATE] when she was sent to the ER after suspected drug use and seen for chest pain. During an interview on [DATE] at 10:40 a.m. the DON stated on [DATE] Resident #36 began acting erratic but denied any drug use. The DON stated they did collect a blood sample for drug testing but had issues with getting results from the lab. The follow week Resident #36 was again acting erratic and they sent her to the hospital for chest pain. The DON stated CNA C told staff she overheard Resident #40 was this what you want and Resident #36 said yes. The DON stated after that Resident #36 was heard yelling in the hallway that she was too high. The DON said later the NP ordered urine drug screening on all residents who were hanging out in the group together (Resident #9, #21, #36, and #40). The DON stated they did in house ones that showed multiple drugs in their systems and also sent the urine to the lab that showed just amphetamines in their systems. The DON stated she notified the Administrator. The DON stated they did call the police to come search for drugs and none were found on any of the residents involved. The DON stated she did not think the Administrator reported the drug use to the stated because the ombudsman told them they did not need to report it. During an interview on [DATE] at 11:35 a.m. the Administrator stated corporate and the ombudsman came on Monday [DATE] to discuss what to do about all the residents who tested positive for amphetamines. He was planning to reach out to the PM because they were unsure what this would be reported under if necessary to report to the state. The Administrator stated they used the SUD policy for guidance on how to handle the residents who were using amphetamines. The Administrator stated they could not find anywhere that stated they needed to report this to the state because the residents took the drugs because they wanted to and it was not coercion. The Administrator stated the company used to lock the doors but they since had changed the policy and that was why they do not accept wanderers at the facility. The Administrator stated they prefer to keep the doors unlocked to keep a home like environment and so they can have visitors. The Administrator stated he felt it was safe to have the doors unlocked because they are always watching them. The Administrator stated he has heard of times that residents are on the back patio smoking unsupervised and him and the ombudsman have reviewed the smoking policy with the residents and had them sign on [DATE]. The Administrator stated all residents should be supervised while smoking per policy and if they are unsupervised it was because they are sneaking out. The Administrator stated it was a constant issue that residents smoke unsupervised and he has asked the ombudsman if he can do a 30 day discharge or immediate if they are violating the smoking policy. The Administrator stated he did not think locking the doors would make a difference on residents having access to areas unsupervised because if they want to do something they are going to find a way to do it. The Administrator stated after the 4 residents tested positive for amphetamines on [DATE] they called law enforcement to investigate the drug use on [DATE] and no drugs or paraphernalia were found. Record review of the facility's policy titled Safety for Residents with Substance Use Disorder, dated ,d+[DATE], stated It is the policy of this facility to create an environment as free of accident hazards as possible for residents with a history of substance use disorder. Definitions: Substance Use Disorder (SUD) is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Policy Explanation and Compliance Guidelines: 1. Residents with a history of SUD will be assessed for risks including the potential to leave the facility without notification and use of illegal/prescription drugs. Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors. 2. When substance use is suspected, (in the facility or upon return from an absence from the facility) which could lead to overdose, facility staff should implement the care plan interventions, which includes notification of the resident's physician or non-physician practitioner. 3. Care planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the resident's health and/or safety . 6. Residents with SUD may try to continue using substances during their stay in the nursing home. Facility staff will assess the resident for the risk for substance use in the facility and have knowledge of signs and symptoms of possible substance that include, but are not limited to: a. Frequent leaves of absence with or without facility knowledge b. Odors c. New needle marks d. Changes in resident behaviors, especially after interaction with visitors of absences from facility . 7. The facility will make an effort to prevent substance use which may include providing substance use treatment services, such as behavioral health services, medication-assisted treatment (MAT), alcoholic/narcotics anonymous meetings, working with the resident and the family, if appropriate, to address goals related to their stay in the nursing home, and increased monitoring and supervision. 8. Staff will be prepared to address emergencies related to substance use by maintaining and having knowledge of administering opioid reversal agents like naloxone, initiating CPR as appropriate, and contacting emergency medical services as soon as possible. Record review of a facility policy titled Smoking policy, dated ,d+[DATE], showed Residents may not have or keep any smoking articles ., The facility may impose smoking restrictions on a resident at anytime if it is determined that the resident cannot smoke safely or use smokeless tobacco with the available levels of support and supervision. An Immediate Jeopardy was identified on [DATE]. The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 1:10 p.m. and were given a copy of the IJ template and a Plan of Removal (POR) was requested. The facility's Plan of Removal for the Immediate Jeopardy was accepted on [DATE] at 10:45 a.m. and reflected the following: Summary of Details which lead to outcomes. On [DATE], during a standard survey [facility]. A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the facility constitute immediate jeopardy to resident health. Problem: Failed to provide adequate supervision (F689) Plan: 1). [DATE]: Administrator/Designee re-educated residents who smoke individually on the smoking policy. The facility has an updated list of residents who smoke and once re-educated it is documented in the resident's electronic health record. Completion date [DATE] 2). [DATE]: DON/Designee presented re-education individually to each licensed and certified staff on substance use disorder to include signs of substance abuse using the facility policy to include notifying the Charge Nurse/Supervisor resident exhibiting signs of substance abuse. Facility is utilizing an employee roster to track licensed and certified staff in-service. Completion date [DATE] 3). [DATE]: DON/Designee presented In-service to all staff on supervised smoking policy to include smoking times, locations, and what to do when a resident is observed smoking unattended. Any staff not currently working will be contacted via phone. Completion date [DATE]. DON/designee will monitor to ensure staff have received the in-service training. [DATE] at 11:00 am - Observation of residents #9, #48, #21, #31, #41, #40 were observed smoking with staff present. No discrepancies noted. 4. [DATE]: DON/Designee re-educated the four residents identified on the IJ template (Resident [TRUNCATED]

26869 Based on observations, interviews and record reviews the facility failed to ensure receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 9 (Resident #1) reviewed for quality of care, in that: 1. On 04/17/2023, nursing staff found Resident #1's left heel/ankle wound had a strong foul odor and purulent drainage on the wound dressing. Resident #1 was sent to the hospital and admitted on [DATE] for a wound evaluation. At the hospital Resident #1 was intubated, went septic on 04/26/2023 and while at the hospital, an emergency left lower extremity amputation was performed on 04/26/2023 a. Resident #1 had 4 maggots on a heel/ankle wound removed by LVN B on 4/14/2023. An order for treatment solution was not entered correctly and the supply was not sent to the facility resulting in treatment not being provided to the resident. On 4/17/23 the resident was sent out to the hospital. b. Resident #1 was not seen/assessed by the Wound care team for 2 weeks. c. The facility-initiated trainings/in-services on 04/14/2023 nursing staff on proper entries but on 04/28/2023 not all nursing staff had been education and additional in-service training was needed. d. LVN J found 1 maggot on 4/17/2023. This failure to put measures in place could result in residents' physical needs not being met, diminished quality of life and medical complications. This failure resulted in identification of an Immediate Jeopardy (IJ) situation; an IJ was identified on 04/29/2023. The IJ template was provided to the facility on [DATE] at 5:52 p.m. While the IJ was removed on 05/01/2023 at 7:50 p.m.,the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of pattern due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal. The finding was: 1. Record review of Resident #1's admission record revealed dated 4/28/2023 revealed he was admitted on [DATE] and discharged on [DATE] at 11 AM with diagnoses of sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), dependence on renal dialysis, open wound foot, cognitive communication deficit, need for assistance for personal care, muscle weakness, muscle wasting and atrophy, heart disease, peripheral vascular disease ( systemic disorder that involves the narrowing of peripheral blood vessels (vessels situated away from the heart or the brain). This happens as a result of arteriosclerosis, or a buildup of plaque, and can happen with veins or arteries), acquired absence of right leg below the knee, acquired absence of right leg above knee, end stage renal disease, pain, limitations of activity due to disability and anxiety. Record review of Resident #1's telephone order dated 4/14/2023 at 6: 19 PM for Dakin solution (OTC) 0.5% amount 30 cc topical twice a day for diagnoses of unspecified open wound, unspecified food, created by LVN B, transmission status-not requested, Pharmacy directive-substitution permitted. This telephone order was discontinued on 4/17/2023 at 7:20 PM by Regional Nurse. Record review of Resident #1's consolidated orders for April 2023 revealed DTI (deep tissue injury) wound of the left ankle, cleanse with wound cleanser, pat dry, apply skin prep, monitor for signs and symptoms of infection once a day; cleanse left heel wound with normal saline and pat dry, apply betadine, painting wound and per-wound area and apply Santyl and Lepto honey and cover with boarded dressing, offload heel at all times while in bed once a day; Dakin Solution 0.5%, 30 cc topical twice a day for unspecified open wound; dialysis treatment on Tuesdays, Thursdays and Saturdays. No hydrogen peroxide and water order for wound treatment on Resident #1. Record review of Resident #1's admission MDS dated [DATE] revealed Section C-Cognitive Patterns BIMS score was 14/15 (cognitively intact), Section G-Functional Status ADL Bed mobility, transfers, dressing, personal hygiene he required extensive assistance with one person assistance, bathing he required total dependence with two person assistance, Functional limitations in range of motion was impaired on one side lower extremity, he required a wheelchair for mobility devices; Section H -Bladder and Bowel he was always incontinent of bowel/bladder; Section M-Skin Conditions he was at risk for pressure ulcers/injuries, he had unhealed pressure ulcers/injuries, a stage 4, 3 venous and arterial ulcers (Arterial ulcers develop as the result of damage to the arteries due to lack of blood flow to tissue. Venous ulcers develop from damage to the veins caused by an insufficient return of blood back to the heart. Unlike other ulcers, these leg wounds can take months to heal, if they heal at all) and surgical wound, Treatments included pressure ulcer/injury care, application of non-surgical dressing and applications of ointment/medications. Section O-Special Treatments, Procedures, and Programs included J. Dialysis. Record review of Resident #1's wound evaluation and management summary dated 1/25/2023 revealed Resident #1 had an arterial wound of the left heel for at least 1 day duration. Record Review of wound management on left heel full thickness stated diabetes and PVS were relevant conditions that contributed to wound healing and were considered. Wound measurement was 7x10x not measurable, reason for debridement non-infected heel necrosis and dressing and interventions. Record review of Resident #1's wound physicians, specialty physician wounds evaluation and management summary dated 3/29/2023. During review VOHRA revealed on 3/29/2023 at the request of the referring provider Dr K, wound care assessment and evaluation was performed today. Past Medical History: dependence on renal dialysis, coronary artery disease, diabetes II and Peripheral Arterial Disease (PVD). The VOHRA wound management evaluated and assessed Resident #1's multiple wounds to include, site 4 Arterial wound of the left heel full thickness, surgical excisional debridement was performed today on this wound, wound size 11x12x0.8 centimeters, 90% necrotic tissue, 10% slough, wound progress- no change. Will continue to monitor weekly. The VOHRA visit on 3/29/2023 was Resident #1's last visit from the wound management group. Record review of Resident #1 received wound care treatments, cleaning with hydrogen peroxide wound cleanser and covering the wound, from facility staff in the period between 03/29/2023 and 04/14/2023. Facility staff were not measuring or assessing the resident's wound during this period. Record review of Resident #1's MAR dated April 2023 revealed DTI wound of the left ankle cleanse with wound cleanser, pat dry, apply skin prep and cleanse left heel wound with normal saline and pat dry, apply betadine, painting wound and per-wound area and apply Santyl and Lepto honey and cover with boarded dressing off-load heel at all times while in bed once a day; no Dakin's solution on the MAR was administered. Record review of Resident #1's MAR for April 2023 revealed for wound care on left ankle 4/14/2023 was LVN B on 4/15/2023 was DON I , on 4/16/2023 was RN H and on 4/17/2023 was LVN J. Record review of Resident #1's care plan dated 4/14/2023 revealed arterial wound to left heel and interventions were to offload wounds and float heels, administer medications as ordered and monitor side effects, administer treatments as ordered and monitor effectiveness, provide supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing and provide with pressure relieving cushion while up in wheelchair. Record review of Resident #1's progress note dated 4/14/2023 at 6:24 PM revealed while doing wound care to the left ankle this nurse noticed maggots in the wound. Cleansed with hydrogen peroxide and removed 4 maggots. This nurse contacted NP G about the wound, NP G gave a new order to cleanse wounds with Dakin's solution (a dilute sodium hypochlorite (NaClO) solution commonly known as bleach, Dakin's Full-Strength Solution is an antibiotic that fights bacteria. Dakin's Full-Strength Solution was used to treat or prevent infections caused by cuts or abrasions, skin ulcers, pressure ulcers, diabetic foot ulcers, or surgery. New order for vascular consult in one week created by LVN B. Record review of Resident #1's progress note dated 4/17/2023 at 2:09 PM revealed left ankle wound care done around 9 AM. wound had extremely strong odor and purulent drainage was noted on old dressing (from day before). Area cleaned and redressed as ordered. Resident #1 denies any pain or discomfort to the area as it was being cleansed and redressed. Notified NP G about progression of wound, and writer was instructed to send to emergency room for evaluation and treatment. Resident #1 left facility on stretcher via ambulance at 10:40 AM by LVN J. Observation on 4/27/2023 at 2:27 PM at the hospital bed of Resident #1 revealed he was lying in bed, was intubated, had tube feeding, had catheter and had both legs amputated. Interview on 4/27/2023 at 2:28 PM with Resident #1's spouse stated Resident #1 had his leg amputated, had not awoken, since the surgery and was intubated this morning. Interview on 4/27/2023 at 2:00 PM with RN Q-hospital nurse caring for Resident #1 stated he was admitted on [DATE] at 11:01 AM to hospital due to wound evaluation and foul odor (infection). RN Q stated on 4/21/2023 at 1 PM Resident #1 had a left leg lower amputation. RN Q stated Resident #1 had surgery for amputation to left lower leg, he was ICU on 4/26/2023 at 1:07 PM, he was septic and was intubated this morning on 4/27/2023. RN Q stated Resident #1 was intubated due to altered mental status and failure to thrive. Interview on 4/28/2023 at 11:23 AM with LVN B stated Resident #1 was admitted with the right leg amputated, she was treating the surgical site and the left foot/ankle it looked discolored, he had vascular issues, he had poor circulation. LVN B stated the last day she treated was on the week Resident #1 went to hospital, she stated LVN J was assisting her that Monday, 4/17/2023. LVN B stated Resident #1 was seen by wound management weekly and the nurses will administer the treated as ordered by the wound management. LVN B stated Resident #1 went to dialysis treatment three times a week. LVN B stated Resident #1 had to be reminded and re-directed often to off load his foot to keep the swelling down. LVN B stated she found maggots and removed them on 4/14/2023 had order and referred Resident #1 to vascular MD in one week, then when she returned to work on 4/17/2023., Monday during treatment for Resident #1, LVN J sent Resident #1 to emergency room per order for wound evaluation. LVN B stated during treatment on 4/17/2023, LVN J found 1 maggot in his wound. Interview on 4/28/2023 at 3:34 PM the Regional Nurse stated she started reviewing Resident #1's chart when he went out to the hospital on 4/17/2023., she stated LVN B had notified the MDS nurse, and she then notified her (Regional Nurse) about finding maggots on Resident #1's wound during treatment. The Regional Nurse stated the order for Dakin's solution was placed in the wrong area, so the incoming nurse did not see the pending order for Dakin's solution, the order should have been under treatments event. The Regional Nurse stated the Dakin's solution was never delivered from pharmacy and Resident #1 was not administered Dakin's solution by the facility as ordered. The Regional Nurse stated staff had called local pharmacies to get Dakin's solution but it was not available. The Regional Nurse stated she did not report that Resident #1 had maggots in his wound because she did not feel that it was harm and instructed by corporate, and there was no change in wound due to maggots (Some flies deposit their eggs on or near a wound or sore, the larvae that hatch burrow into the skin. Certain species' larvae will move deeper in the body and cause severe damage.). Regional Nurse stated. Interview on 4/28/2023 at 4:31 PM the Regional Nurse stated she asked staff where the VOHRA wound management had come in to assess residents wound, the staff stated the previous VOHRA MD D had left and the new VOHRA wound management DR C was supposed to start back up on 4/18/2023. Surveyor asked Regional Nurse why VOHRA wound managements had not visited the facility to care for resident wounds from 3/29/2023 to 4/19/2023. The Regional Nurse stated, she could not answer why the residents did not have their wounds assessed. The Regional Nurse stated it was the responsibility of the DON to ensure that residents wounds was assessed weekly by wound management, VOHR. The Regional Nurse stated if residents were on VOHRA wound management case, then nurses do not do the wound assessments or measurements. Interview on 4/28/2023 at 5:55 PM with the Regional Nurse stated she had started in-servicing staff on 4/14/2023 at 2 PM, on skin orders, this was in a booklet. This in-service included 9 nurses. Interview on 4/28/2023 at 7:34 PM NP G stated Resident #1 was seen by VOHRA wound management once a week. NP G stated staff did call him in regard to Resident #1's during wound treatment when the nurse found maggots and she sent an image to him. NP G stated he was not able to see maggots, and he ordered Dakin's solution. NP G stated the staff had not called him to let him know Resident #1 was not administered the Dakin's solution. NP G stated he did not get to visit with Resident #1 because he had gone to hospital. NP G stated the hydrogen peroxide and water was not enough treatment for Resident #'s maggots. NP G stated his expectation of the facility was to follow the medical orders. NP G stated he did have remoted access to resident records. NP G stated he was not able to see wound managements notes and was not made aware that VOHRA wound managements did not visit facility for 2 weeks. Interview 4/29/2023 at 11:18 AM with previous DON I stated she now works as needed at the facility. DON I stated when conducting wound treatment for Resident #1 she did not see maggots in his wound. DON I stated when she starts her shift on the floor, she looks at the previous reports to the next shift, look at progress notes, the previous nurse did not alert to any maggots in Resident #1's wounds. DON I stated the nurses work 12 hr. shift. DON I stated she did the wound treatment for 4/15/2023. She revealed Resident #1's wound looked pretty bad, but she does not do treatment daily. DON I stated the previous wound care management-VOHR MD D came to visit on Wednesdays to assess resident wounds, there was no documentation of magots in his wound. DON I stated Resident #1 goes out to dialysis and he does go out on pass at times with family. DON I stated when nurse's input orders for residents in the computer software, they were automatically sent to the pharmacy and nurses should document a progress note of the order. DON I stated the pharmacy delivers the resident medications and, depending on the medication, for example if it is the weekend the medications sometimes does not get to facility until Monday, it takes 1-3 days for the medications to be delivered. DON I stated VOHR wound management does the measurements of the wound, nurses do not do measurements and MD's keeps track for wound system. DON I stated the nurse follows the wound care orders from VOHR wound management. DON I stated the VOHR wound management assesses resident wounds with nurse for the day and nurse takes the verbal orders, the nurse's document progress note in regard to VOHR wound management MD orders and any interventions. DON I stated she was trained on the computer system for inputting order in the correct area example if it is a treatment order it goes in the treatment event (flow log) when she first started working and received training on 4/29/2023. She stated she was pretty knowledgeable with the computer system, and she stated she received training since she last worked on 4/15/2023. Interview on 4/29/2023 at 11:31 AM with previous MDS A she now had a regional position now. MDS A stated she did not observe the maggots that day on 4/14/2023. MDS A stated there was no facility DON at the time. MDS A stated she was not at facility at the time when LVN B notified her during wound care treatment for Resident #1 that she found maggots, so MDS A called Regional Nurse and they suggested to call NP G. MDS A stated they did not have Dakin's in house, so flushed out hydrogen peroxide and wound cleanser, then LVN B told her there were 4 maggots and she removed them all. MDS A stated the next day she worked was Monday at 9a.m. staff had already sent out Resident #1 to the hospital. MDS A stated she was not sure if the Dakin's order was ever delivered or administered to Resident #1, because she was not there. MDS A stated the Regional Nurse was at the facility and reviewing orders on Monday, 4/17/2023. MDS A stated the Regional Nurse had been at facility due not having a DON at the time. MDS A stated she was trained on inputting in orders and wound care, recently. MDS A stated the process (flow log) for wound orders and orders was automatically sent to pharmacy, then medications are delivered and can vary on when the medications are delivered. MDS A stated when the order was transcribed in the computer system, it automatically shows up on MAR for the nurse to administer order. MDS A stated VOHR wound management had not been at facility for about a couple of weeks. MDS A stated the Regional Nurse called VOHR wound management on the second week, they stated a new MD would visit next week and they should visit once a week to assess residents wounds. Interview on 4/29/2023 at 12:36 PM the Regional Nurse stated she only found out about the flow log (process to input orders in software system) yesterday when I questioned DON I. She said she did not see the order so it prompted to investigate that and I noticed, the order was on the wrong flow log on a flow log that really does not exist for us. My clinical VP was on with matrix right now trying to get rid of that flow log, but it prompted me to educate the nurses and that was an in-service I started right away last night, and we got two signatures today from nurses that did not sign yesterday they were not here and will be training nurses. Interview on 4/29/2023 at 12:37 PM with RN H stated she did not observe any maggots on Resident #1's wounds during wound treatment on 4/16/2023. RN H stated she would see flies in resident rooms at times and resident rooms had to be cleaned and she would make the housekeeper aware. RN H stated when she started her shift at work she would see Resident #1's wounds looked bad and smelled bad, Resident #1 would not wear socks and have his foot on the floor and not wrapped. She would make sure Resident #1 had socks on and elevated his foot. RH H sated she did not see any maggots when she did the wound treatment for Resident #1. RN H sated she did not see any flies in Resident #1's room when doing wound treatment. RN H stated she did follow orders to treat his wounds, Resident #1 was so fragile, she remembers there was multiple areas, she was an agency nurse and did not see wounds on a daily basis. RN H stated she did receive training on how to input skin orders for resident wounds into the computer system. RN H stated she recently received training on orders, supplies (call management), wound assessments and change of condition-notifying MD, MD order-documentation on progress note and put in chart, put TO for management, when put treatment goes under treatment, etc., so each shift can see, pharmacy gets orders electronically and see if still not in, she should call the pharmacy and to notify MD and family of any change of conditions with residents that day. RN H stated she had seen Resident #1 go to dialysis and family would come to facility to visit him. Interview on 4/29/2023 at 1:27 PM with MD D VOHRA wound management stated she worked for VOHRA and left in March 2023. MD D stated her last wound assessment visit was on 3/29/2023 and she stated she discussed last day with the previous Administrator, RN A and MDS A know when her last day was at the facility, she remembers there was a lot of transition of managements staff at the time. MD D stated Resident #1 had multiple wounds that were difficult to heal due to poor blood circulation on leg (arterial doppler) and treated the best way, talked with resident about situation and tried to manage, no sign of infections in the last visit. MD D stated Resident #1's heel was a tough wound to heal, long-term the leg was eventually heading towards amputation. She could not fully heal wound due to vascular issues. MD D stated she never ordered magot therapy and had not seen magots on Resident #1's wounds during assessment and treatments. MD D stated during her visit she rounded with the nurse and verbally told them the orders to follow for wound treatment. MD D stated at end of the visit she would document a summary of resident wounds and treatment for the week and place them on the VOHRA site, that staff at facility had access too. Interview on 4/29/2023 at 1:59 PM with LVN B confirmed she did see and remove 4 magots from Resident #1's ankle/heel wound on 4/14/2023. LVN B confirmed she did notify NP G during Resident #1's wound treatment she removed 4 maggots; she followed orders and for wound and covered it. LVN B stated NP G order Dakin solution and vascular referral. LVN B stated she called local pharmacies to see if they had Dakin's solution, but no local pharmacies did, so she input order into system, so it would be processed through the pharmacy and delivered. LVN B stated she did not administer Dakin's solution to Resident #1's because she could not find at a local pharmacy that day, 4/14/2023. LVN B stated Dakin should come in next drop and reported to the oncoming nurse, Nurse L, about the magots in the wounds and the Dakin order from NP G. LVN B stated she did receive training on inputting orders and notifying MD for change of condition, supplies, treatment orders should go under orders for treatments (flow/events), prn medications, go to right spot and populate for nurse to see on next shift. In an interview on 04/30/2023 at 11:55 a.m., the Regional Nurse stated the facility did not have a policy on how frequently residents with pressure ulcers would be seen by a physician from Wound Care Physician's Group E. An Immediate Jeopardy (IJ) situation was identified on 4/29/2023. While the IJ was removed on 5/1/2023, the facility remained out of compliance at a scope of a pattern and a severity level of actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The Regional Nurse was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 04/29/2023 at 5:52 PM; and a plan of removal was requested. On 4/30/23, the facility provided a POR, and it was accepted on 5/1/2023 at 8 PM. It was documented as follows: Plan to remove immediate jeopardy. The facility failed to put measures in place to meet the needs for Resident #1. Resident #1 was found to have maggots in a left heel/ankle wound on 4/14/2023. F684 Resident #1 is not currently residing at the facility. On 4/29/2023 DON and Nursing team completed skin checks on all residents in the facility and checked wound care orders for proper locations on EHR to make sure they are on treatment flowsheet. Medical Director was notified of the Immediate Jeopardy on 4/29/2023 by RNC (Regional Nurse Consultant). On 4/29/23, the regional nurse consultant (RNC) educated the DON/ADON/MDS on measuring wounds weekly, completing an assessment, and entering the information into the EMR wound system if VOHRA is not available for a weekly visit. ON 4/29/23, DON/Designee initiated education with nurses on measuring wounds weekly, completing an assessment, and entering the information into the EMR wound system if [NAME] wound management is not available for a weekly visit and will be completed on 4/30/2023. Staff will not be allowed to work until they receive training. Ad-Hoc QAPI meeting was held on 4/29/2023, with the Medical Director, NHA (Nursing Home Administrator), Regional Nurse Consultant, DON, RDO (Regional Director of Operations) regarding the action plan for Wound care documentation of orders and completing weekly measurements, if [NAME] physician has not assessed and measured wounds. 4/29/2023 RNC will provide physical oversight at facility weekly x 4 weeks and then monthly reviews after. The Regional Nurse Consultant initiated audit of VOHRA orders for completion and correct flow log entry as well as entry into the EMR wound management system starting on 4/29/23, then weekly for one (1) month and monthly for two (2) months. Any concerns will be corrected immediately, and education given. New employees will receive training on the EMR including flow logs upon hire by DON/Designee. The administrator/designee will bring any concerns to the monthly quality assurance performance improvement meeting for tracking, trending, and further interdisciplinary team recommendations. Confirmation of Trainings: Eight out of the twelve nurses scheduled to work were trained on the POR and in-serviced in detail of what that looks like on the computer system. The staff were trained to ask management/MDs if they were unsure of any order. Interviews: Interviews between on 4/30/2023 at 4:45 PM to and 5/1/2023 at 12:05 PM with RN H, RN I, LVN J, RN O, RN A, MDS F, LVN B, Nurse L and LVN M confirmed they were trained on in-services for skin orders, wound/skin assessments and Management staff were trained on assessing wound if VOHRA wound management was not able to visit that week. The staff were all trained on how to input orders in computer system, EMR, weekly skin assessments, ordering supplies, how to create Event (flow log), completing weekly wound management assessment (wound measurements), notifying MD. The DON or designee responsible for reviewing weekly VOHRA wound management assessments, validating EMRs, ensure the wounds are care planned and the regional nurse will be notified of any concerns. Interview on at 5/1/2023 at 11:24 PM- with Regional Nurse stated she called the pharmacy and said it was OTC (over the counter) medication and if medications are OTC move to different profile and they do not send it. Regional Nurse stated the pharmacy should have sent the Dakin's solution. The Regional Nurse stated the pharmacists told her it would have had to be requested and approved to deliver an OTC medication. Regional Nurse stated they fill the weekly staffing schedule with 3 agency company nurses, and they own one of the agency nursing companies. Regional Nurse stated they had 10 in-house nurses and 4 outside agency nurses, which work as needed (prn). Regional Nurse stated the DON they hired resigned on 4/28/2023. Regional Nurse stated RN H, RN I, LVN J, and RN O our in-house agency and work as needed; RN A and MDS F are in-house and work 8-5 pm daily; and LVN B, Nurse L and LVN M are from another agency staffing company and work as needed. Interview on 5/1/2023 at 11:37 AM with LVN J revealed when doing wound care for Resident #1 on Monday, 4/17/2023/ LVN J described Resident #1's wound treatment to heel/ankle smelled a pungent odor on foot/ankle wound, looked necrotic tissue, white strands, maybe tendon, further up 6 inches above the ankle bone, dark spot, white sticking out, sprayed and wiggle, she saw 1 maggot, immediately called NP G, and he gave order to send Resident #1 to hospital to evaluate and treat. LVN J told Resident #1 she was sending him to emergency room due to severe breakdown and concerned it was a tendon LVN J stated Resident #1 started to cry and called family when discussed LVN J's concern of smell and he had a bug in the wound. LVN J stated during wound care for Resident #1 she discovered his ankle/heel wound was upper part was tunneled from heel, but thought it was 2 wounds LVN J stated when smelled Resident #1's wound she knew something was wrong, not sure why others did not smell, usually indicates rot or severe infection, dead tissue. Attempted Interview 5/1/2023 at 1:52 PM with New MD C VOHRA wound management left a voicemail with no return call before exit. Attempted Interview on 5/1/2023 at 2:23 PM with nurse L left a message with no return call before exit. Interview on 5/1/2023 at 2:24 PM with Pharmacist P stated the orders were automatically sent from facility via computer/fax, they can be verbal as well. The delivery times were 1pm and 9pm, within 2-hour delivery and weekends 5 pm delivery. Pharmacist P stated they could do a stat delivery run. Pharmacist P confirmed they did receive a Dakin's solution order for Resident #1 on 4/15/2023 processed, never filled and stuck on billing section and 4/19/2023 it was discontinued. Pharmacist P stated Dakin's was an OTC product and they do not send OTC medications, unless SNF specifies. Pharmacist P stated he did not revied receive a call from the facility about the Dakin's solution to be delivered as a request. Pharmacist P revealed the Dakin's solution was for an unspecified wound, usually means to clean wounds. Pharmacist P stated hydrogen peroxide would not be the same solution, it is a small portion of bleach. Interview on 5/1/2023 at 5:51 PM with interim Administrator stated he started work at facility on 4/10/2023, Monday -Friday. The interim Administrator stated he was notified on 4/14/2023 of Resident #1's wound and the LVN B found magots during wound treatment. The interim Administrator stated he did not feel Resident #1 was neglected and the nurse was treating wounds, and that is how they found it, the nurse flushed the wounds. The interim Administrator stated the Dakin's solution would not have helped he had poor circulation. The interim Administrator stated he was not aware that the VOHRA wound management was not visiting/assessing resident wounds weekly. The interim Administrator stated they had started an action plan binder with staff in-services, QAUPI and spoke to Medical Director K. The interim Administrator stated the action taken to prevent an incident again was that staff were trained on action plan, better plan for wound assessments, orders and VOHRA wound management back assessing residents weekly. Record review of Resident #1's chart was sent to the hospital on 04/17/2023 due the worsening of a left heel/ankle wound. While at the hospital an emergency left lower extremity amputation was performed. Confirmation- Record Review Interview with Medical Director K confirmed he was notified of the IJ and attended the QUAPI on 4/29/2023. Record review of the facility resident list revealed Resident #1 was not present at the facility. Record review of Resident #1's chart revealed MDS and care plan were verified that he had wounds with interventions. Record review of facility's resident list revealed that a 100 % audit was verified by nursing management from 04/29/2023 on skin audits. Record review of in-service training from 4/14/2023-4/29/2023 (ongoing until all nurses received training, to include outside agency nurse) for all nurses and management nurse on skin/wound orders, measuring wounds, completing assessments, entering information on EMR wound system if VOHRA is not available for a weekly visit, including new residents with newly identified wounds including hospice residents, completing an assessment, and entering the information into the EMR wound system if VOHRA is not available for a weekly visit, and verified new employees will receive training on the EMR including flow logs upon hire by DON/Designee. Record review of QAPI sign-in sheet on 04/29/2023 revealed signatures: Interim Administrator, Regional Nurse, Regional Director of Operations, and MD K. While the IJ was removed on 05/01/2023 at 7:50 p.m.,the facility remained out of compliance at a severity leve[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 5 residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to ensure Resident #1 was being supervised during the evening shift resulting in the resident eloping from the facility and being found on the side of the road by a community member. Resident was unaccounted for during the 2-10 p.m. shift for approximately 2.5 hrs. and the resident eloped from the facility. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 8/30/2021 at 6:45 p.m. While the IJ was removed on 9/1/21 at 4:45 p.m. , the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy isolated identified due to the facility's need to evaluate the effectiveness of the corrective systems, complete training, and approve the draft wander-guard( device worn on the resident which triggers alarms and can lock monitored doors to prevent the resident leaving unattended.) policy . The IJ template was provided to the facility staff at that time. This failure could have the potential to affect the residents in the facility by placing them at risk for elopement resulting in serious injury, serious impairment or death. Findings were: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included: unspecified [CONDITION(S)], mood disorder, cognitive communication deficit (a person with a cognitive-communication disorder may have difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions) , [CONDITION(S)] [CONDITION(S)] (a thickening and hardening of arterial walls), dementia, Gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), and Diabetes Mellitus. Record review of Resident #1's MDS (Minimum Data Set) dated 8/8/21 revealed a BIMS (Brief interview for mental status) score of 3, which indicated severe cognitive impairment. Initial admitted d 8/8/2021 section P, restraints and alarms- documented not used. 8/27/21- behavior wandering occurred, documented in behavior; section P - wander-guard used daily documented in section P. Reord review revealed no physcian order for wander-guard placement prior to elopement on 8/25/2021. Resident #1 removed a wander-guard device moments prior to elopement on 8/25/2021. Record review of Resident #1's Care-plan dated 8/26/21 revealed Potential/ high risk for injury R/T identified elopement risk factors and or exit seeking behavior AEB (as evidenced by): _x___ elopement history __x__ independent locomotion __x__ decreased safety awareness __x__ exit seeking/elopement history/ episodes Category: Behavioral Symptoms Start Date:08/26/2021 Care Conference Date: 08/11/2021 Type: Admission Attendee: Social Worker. Notes: Care plan with family member reviewed medications, has had a fall. Fall on 8/5/2021 staff observed Resident#1 lying on the floor next to A side bed. Resident #1 stated, she was sleeping and rolled to the floor from bed. Resident #1 complained of pain to Right posterior aspect of shoulder and Right ear. Physician notified .X rays done of right shoulder. No injuries reported. Adm. Weight 148 lbs. Has not had an MD visit at this time. Resident is a full code. Has order for Psychiatric services to evaluation. Resident ambulates around building and yesterday was seen outside standing came back in with nurse. Resident has a good appetite. No record of a physcian order for a wander-guard device prior 8/25/2021. The physican order for wander-guard device for Resident #1 issued on 8/26/2021 post return of Resident # 1 elopement. Record review of Resident #1's nurses note written by Registered Nurse, dated 8/25/2021, revealed, at approx. 8:00 p.m. staff were unable to locate resident in the building, or outside of facility. A person called the at approximately 8:15 p.m. facility as staff was searching for resident and informed this nurse that there was a female sitting outside near our facility sign, this nurse located the resident to be sitting outside at edge of property by our facility sign, where the person had stated she was. PT (patient) was sitting on the ground, this nurse sat beside her and informed her that I would help her back into the building. PT with no injuries upon observation, she stated that she did not want to get up because she was afraid, she might fall. Another staff member approached at that time as well as a police officer that had passed by and saw resident sitting, he had turned around and parked and approached to make sure everything was alright, which he saw it was and left. Assisted resident back into building and assisted with changing, assessed skin and no injuries or marks noted, patient denies pain. During an interview on 8/30/2021 at 11:45 a.m. Administrator confirmed she was notified of Resident #1 leaving the building unattended and was found outside by the facility sign, which is on the main busy with traffic road. She further revealed Resident #1 had a wander-guard on but lately she has been non-compliant with it. She stated the resident would walk around the facility and wander in other residents rooms and look out the windows and check the door like she was trying to open them. So they felt that she might be trying to leave. The Adminsitrator stated that Resident #1 would attempt to remove the wanderguard and was succesful in removing the wanderguard with a knife on the day of the elopement. During an interview on 8/30/2021 at 1:13 p.m. with the DON (director of nursing) revealed, she was notified of elopement of Resident #1 on 8/25/21 at about 8 PM. DON stated the nurse reported the resident had removed her wander-guard with a plastic knife from her meal tray. During an interview on 8/30/2021 at 2:00 p.m., LVN A (Licensed Vocational Nurse) revealed she is charge nurse for hall A on the 6 a.m. to 2 p.m. shift. LVN A stated Resident #1 wandered about the facility. LVN A further revealed, she had heard Resident #1 had left the faciity on [DATE] in the evening hours after removing her wander-guard from her ankle. LVN A stated, I think she had used a plastic knife from her meal tray. When asked how long Resident #1 had had a wander-guard had on, LVN A stated she did not know for sure when it was first placed. She stated, we know to watch her, so she does not leave the building. LVN A stated we are to document each shift that the wander-guard is checked. When asked how do you check it, she stated, I look to see if it is on the resident. When asked how she knows if the wander-guard is working, LVN A stated, the maintenance man checks them. Or if it gets near the door it alarms. During an interview on 8/30/2021 at 3:26 p.m. with Resident Aide revealed she was working on 8/25/21 during the 2:00 p.m.-10 p.m. shift, and was assigned to Resident #1, when Resident #1 had eloped. She stated, I had seen her last around dinner which was about 5:30p.m. to 6:00p.m. I then got busy with my residents. We did not realize she was gone until around 8:00 p.m. Then we (staff in building) started looking for her and I heard the nurse receiving a call on the facility phone Resident #1 was outside. I did go with the nurse to get the Resident who was outside sitting by the big sign by the road. The Resident told me she was looking for her daughter. When asked if she had her wander-guard on, she said, I think she did not, I think she had cut it off. When asked if she knew what the wander-guard was for Resident Aide said, yes to alarm the staff when a resident leaves the building. She further revealed she did not hear the wander-guard alarm go off in the front door. When asked often Resident Aide checks the residents, she stated, at least every 2 hours. When asked how often the residents with wander-guards how often they are checked. She stated, more frequently but I could not give you an exact time frame. She further revealed she did not know how the resident got out of the facility. When asked if she had any training on the wander-guards she stated, no, I just know they are on residents who may try to leave the building. During an interview on 8/30/2021 at 4:00 p.m. with RN (Registered Nurse) revealed she worked on 8/25/21 on the 2p.m.-10 p.m. shift when Resident #1 eloped. She stated she had seen Resident #1 last around dinner which was about 5:30p.m- 6:00 p.m. We did not realize she was gone until around 8:00p.m. Then we (the staff) started looking for her and as we were looking for her, I had got a call around 8:15 p.m. that she was outside. I went to the end of property on the hill by the sign and she was sitting on the ground with a passerby who had seen her. The Resident told us she was looking for her daughter. When asked if she had her wander-guard on, she said I think she did not that she had cut it off. When asked if she knew what the wander-guard was for RN said, yes, to alarm the staff when a resident leaves the building. She stated she did not know how the resident had gotten out that if she cut it off, she would have had to walk out with someone, or the alarm door would have gone off. We document every shift and check the wander guard to see if it is on the resident. In an interview attempted on 8/30/2021 at 1:30 p.m. with Resident #1, the resident declined. Observed wander-guard on Resident #1's left lower leg. During an observation of Resident #2 on 8/30/21 at 1:35 p.m. at front door revealed wander guard usage. Maintenance Supervisor revealed by moving resident with wander-guard close to front door, it alarmed if Resident #2 attempted to leave. He stated the door will alarm if an attempt to go out is made without using a code. Record review of the facilities policy and procedure Elopement policy: titled Elopements, dated 2001, revised February 2014, read: Staff shall investigate and report all cases of missing residents.1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. On 8/31/2021 the facility Administrator in Training and the Regional Director of Operations were requested to provide a Wander-guard policy. The Regional Director of Operations stated there was no Wander-guard policy in place at the facility. The facility Administrator in Training and Regional Director of Operations were notified of the IJ on 8/30/2021 at 6:45 p.m.; they were given the IJ template, and a plan of removal was requested. On 8/31/21 at 5:00 p.m., the facility provided a plan of removal and it was accepted on 9/1/21 at 9:18 a.m. It was documented as follows: Surveyor through observation, interview and record review, confirmed and monitored the POR (Plan of Removal) action items. The surveyor's observations, interviews, and record reviews are contained within the POR and were: The facility has found appropriate secured unit placement at a sister facility for resident #1 and she has been relocated on 8/30/21 after receiving responsible party approval. 1. On 8/30/21, residents with wander guards have had their bracelet checked by the director of nursing for placement and the facility maintenance log checked for the monitoring of function; logs were up to date and no concerns were identified. Record review of DON daily check of wander guard placement revealed placement was checked on 8/31/21. For all Residents on wander guards (only 4 residents). Record review of maintenance log dated 9/1/21 revealed functioning checked done on 9/1/21. Checks were done at the door of the 4 residents with wander guards. 2. The regional nursing consultant checked orders for residents with a wander guard bracelet to validate that they had orders for every shift placement check and any verbiage that was not consistent was updated so that all were the same. Record review by surveyor on 8/31/21 revealed General Orders were present in the EMR. Record review of General Order for resident #5, dated 7/13/21, revealed, wander guard ordered 7/13/21. Record review of General Odder, dated 6/10/20, for Resident #3 revealed, wander guarded ordered on 6/10/20. Record review of General Odder, dated 8/3/21, for Resident #2 revealed, wander guarded ordered on 8/3/21. Record review of MD General Orders dated 4/30/21 revealed, order for wander guard. 3. No other residents have been identified as having a history of removing their wander guard bracelet. During an interview on 9/1/21 at 9:54 AM, DON stated .No other residents have been identified as having a history of removing their wander guard bracelet based on documented behaviors and BIMS . Record review of sample residents (R#2, #3 and #5) did not reveal any recorded incident of wander guard removal for the month of August 2021. 4. The maintenance director was re-educated on 8/31/21 regarding his responsibility to check the individual bracelet functioning for each individual resident with a wander guard. Record review of in-service dated 8/31/21 revealed maintenance director received training on wander guard procedures. During an interview on 9/1/21 at 10:05 AM, Maintenance Director confirmed he received the above training. He stated, .I will check, keep a log, and give a list to the DON . 5. On 8/30/21, a signage was placed inside and outside the facility entrance door regarding visitors not letting residents follow them out of the facility when leaving. Observation on 9/01/21 at 10:11 AM revealed signage present in and out of the visitor door stating: Please check with Nurses Station before letting any Resident Outside. 6. Residents who have a history of wandering have the potential to be affected by this deficient practice. On 8/30/21, the administrator and the director of nursing-initiated education to nursing staff on being observant for residents with increased pacing or exit seeking behaviors and notifying the executive director and the director of nursing immediately with any concerns. Included in this education was completing checks on residents at the beginning, mid-shift, and end of shift, to quickly identify any resident that might be missing. Record review of sign-in sheets for the above education revealed that 57 total staff was the target audience and 7 staff members are still pending the education. During an interview on 9/1/21 at 10;16 AM, the Administrator in Training stated, .I will attempt to complete the training for the remaining staff today . During a joint interview on 9/1/21 at 10:21 AM with three staff members (day shift) ( LVN C, HR D, and Activity Director stated, .(LVN C) wander guards need consents, the wander guard is working .if the alarm goes off re-direct and notify the charge nurse .(HR D) .added, the doors will trigger the alarm .then the resident needs to be re-directed .and document the exit seeking .(Activity Director) .any time you see a resident exit seeking .re-direct seek help .notify the charge nurse document . 7. The director of nursing educated the licensed nursing staff on the daily every shift documentation of wander guard bracelet placement checks on the treatment administration record and on entering orders in a consistent manner whenever a resident receives a new wander guard bracelet to include every shift placement documentation to be entered onto the treatment administration record. During an interview on 9/1/21 at 10:31 AM, DON confirmed, I educated the license nursing staff on the daily shift documentation . During an interview on 9/1/21 at 10:34 AM, [NAME], LVN, stated, I initial that the wander guard is on .and check the wander is working at the door .this is done every shift . During an interview on 9/1/21 at 10:37 AM, LVN F stated, .I enter that the wander guard is working .and it is in place .and when document any orders given and seek consent from either the resident or the RP How do they verify it is working? (Verification is done by taking the resident by the wander door and observing whether the wander light is working and the door locks). 8. The maintenance director will conduct weekly function checks for each resident who has a wander guard bracelet, per the facility policy of checking functioning of all residents [facility will make correction to check the functioning of the wander guard rather than the resident]wearing a wander guard and keeping documentation utilizing the wander guard log. Any concerns in the functioning of the wander guards will be brought to the immediate attention of the executive director and the director of nursing. During an interview on 9/1/21 at 10:43 AM, the Maintenance Director stated, .I will keep a log of all the residents with wander guard .making sure they work by taking the resident to the door .any concerns will tell the administrator . Record review of maintenance log for wander guard revealed it was documented on 9/1/21. Record review of policy, Wander Guard, dated 9/1/21, revealed the policy was drafted on 9/1/21 in response to the POR. 9. Staff not receiving this education will be required to receive it before beginning their next work shift. Record review of sign-in sheets for the above education revealed that 57 total staff was the target audience and 7 staff members are still pending the education. During an interview on 9/1/21 at 10;16 AM, the Administrator in Training stated, .I will attempt to complete the training for the remaining staff today . Did you verify those staff have not worked? 10. The director of nursing/designee will monitor the wander guard bracelet documentation, daily for one (1) week and randomly thereafter. The weekend supervisor will monitor the wander guard bracelet documentation on the weekends. Any concerns will be corrected immediately and brought to the attention of the administrator. During an interview on 9/1/21 at 10:51 AM, the DON confirmed that .I will monitor the wander guard bracelet documentation, daily for one (1) week and randomly thereafter. The weekend supervisor will monitor the wander guard bracelet documentation on the weekends. Any concerns will be corrected immediately and brought to the attention of the administrator. Record review of sample residents' TAR (Resident # 2, #5, #4, , and 5) for 9/01/21 revealed documentation that wander was in place for the day shift (6 AM-2 PM). Also, record review of sample residents' TAR for August 2021 revealed, the TAR was documented that the wander guard was in place. 11. The administrator will bring any concerns to the monthly quality assurance performance improvement meeting for tracking, trending, and further interdisciplinary team recommendations. During an interview on 9/1/21 at 10:54 AM, the Administrator in Training stated, .we will make the IJ a focus of next QAPI meeting schedule for September 8, 2011. Based on observation and verification of facility plan of removal on 9/1/2021, the facility met satisfaction of the plan or removal. The Administrator in Training and the Regional Director of Operations were notified on 9/1/2021 at 4:45 p.m. that the IJ was removed.

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free from accident and hazards as was possible for 13 of 29 residents (Residents #5, 11, 14, 15, 19, 21, 28, 41, 42, 43, 55, 56 and 72), in that: 1. The hot water in the 200 Hall was not being regulated, which resulted in hot water temperatures that ranged from 130 degrees Fahrenheit (F) to 153.6 degrees F. (Hot water for resident use must be reliably controlled to not exceed 110 degrees F. and not less than 100 degrees F). 2. Thirteen residents (Residents #5, 11, 14, 15, 19, 21, 28, 41, 42, 43, 55, 56 and 72) in the 200 Hall had [DIAGNOSES REDACTED]. In addition, 7 out of the 13 residents (Residents # 5, 10, 29, 42, 56, 69, 72) had [DIAGNOSES REDACTED]. 3. The facility had been aware of issues with the regulation of hot water temperatures above 110 degrees F. on the 200 Hall, since April 04, 2019 These failures resulted in an Immediate Jeopardy (IJ) situation identified on 03/10/20. While the IJ was removed on 03/12/20, the facility remained out of compliance at a level of potential harm with a scope of a pattern until the water heater and regulator was repaired and all staff were in-serviced. These deficient practices can place residents with altered mental status or lack of sensation at risk for burns. The findings were: Record review of Resident's in the 200 Hall medical records revealed 13 residents (Residents #5, 11, 14, 15, 19, 21, 28, 41, 42, 43, 55,56 and 72) had [DIAGNOSES REDACTED]. Observations on 03/10/20 at 3:40 pm revealed the hot water in room [ROOM NUMBER]'s bathroom sink was hot to touch by bare hand. Further observation revealed surveyors hand turned red in less than a minute. Observation on 03/10/20 at 3:58 pm revealed the hot water in room [ROOM NUMBER]'s bathroom sink registered 148.6 F. as per surveyor's thermometer. Observation on 03/10/20 at 4:00 pm reveled the hot water in room [ROOM NUMBER]'s bathroom sink registered 151.6 degrees F. as per surveyor's thermometer. On 03/10/20 at 4:05 pm the Maintenance Supervisor was informed of the temperatures on the 200 Hall. Surveyor requested temperatures be checked with the Facility's thermometer. Observation on 03/10/20 at 4:11 pm, revealed Maintenance Supervisor tested the hot water temperature in room [ROOM NUMBER] and it registered 130 degrees F (maintenance's thermometer) to 152.6 degrees F (surveyor's thermometer). Observation on 03/10/20 at 4:15 p.m., revealed Maintenance Supervisor tested the hot water in room [ROOM NUMBER] and it registered 130 degrees F. (maintenance's thermometer) to 153.6 degrees F. (surveyor's thermometer). In an interview on 03/10/20 at 4:16 pm the Maintenance Supervisor, confirmed his thermometer was not registering correctly. He further stated the hot water was too hot and knew it should not be over 110 degrees F. The Maintenance Supervisor stated the hot water in the 200 Hall was regulated by one water heater. In an interview on 03/10/20 at 4:30 pm, Medication Aide O revealed she had to mix cold water with the hot water, so the water was not as hot. Medication Aide O stated she had not told anyone. In an interview on 03/10/20 at 4:31 pm, Hospitality Aide P revealed the water temperatures on the 200 Hall get too hot. She stated it had been that way about a week. Further interview revealed she had not told anyone about the water being too hot. In an interview on 03/10/20 at 4:35 pm, Therapy Assistant N revealed the water has always been extremely too hot on the 200 Hall, since he had been working in the facility and that was almost a year. Further interview with Therapy Assistant N revealed he had not told anyone about the hot water. In an interview on 03/10/20 at 4:57 pm, the Maintenance Supervisor confirmed the hot water temperatures on the 200 Hall were registering high at 130 degrees F to 150 degrees F. During further interview the Maintenance Supervisor revealed he had only been there four days and been working on beds. He stated he had not looked to see if there were any water temperature logs. In an interview on 03/10/20 at 4:58 pm, the ADON revealed Residents #5, 11, 14, 15, 19, 21, 28, 41, 42, 43, 55,56 and 72 on the 200 Hall were ambulatory and had access to the water in the bathroom sinks. The ADON further stated these residents may not have the mental capacity and/or the sensation to know the water was hot. In an interview on 03/10/20 at 5:10 pm, Resident #59 revealed the water was weird and it needs to be fixed, because it gets very hot no matter what you do you cannot regulate it. Resident # 59 further stated he did not tell anyone. In an interview on 03/10/20 at 5:11 pm, Resident # 23's responsible party stated she does not wash her hands in Resident #23's sink (in 200 Hall), but goes down to the restroom at the 200 Hall nurse's station. The RP revealed the water had been very hot and it had been that way since Resident #23 was admitted to the facility 2 years ago. In an interview on 03/10/20 at 5:42 pm the Administrator revealed he was in the process of trying to contact the former Maintenance Supervisor, to see where the water temperature logs were. The Administrator stated Maintenance Supervisor H and him were unable to locate the temperature logs in the maintenance office. The Administrator stated they had adjusted water temperatures with the mixing valves weekly since he started at the facility in June 2019, because the temperatures were high. After surveyor intervention: Observation on 03/10/20 from 5:44 pm to 6:01 pm revealed Maintenance Supervisor used a different thermometer and took water temperatures on the 200 Hall: room [ROOM NUMBER]- 101.7 degrees F Shower Room- 94.6 degrees F room [ROOM NUMBER]- 95.7 degrees F room [ROOM NUMBER]- 90.0 degrees F room [ROOM NUMBER]-96.3 degrees F room [ROOM NUMBER]- 94.0 degrees F Observation with the Maintenance Supervisor on 03/10/20 at 6:02 pm of the 200 Hall hot water heater revealed the hot water temperature gauge registered 94.0 degrees F. In an interview on 03/10/20 at 6:03 pm, the Maintenance Supervisor revealed he had the Maintenance Assistant M adjust the hot water, after the temperatures were checked the first time. The Maintenance Supervisor stated apparently he turned the hot water completely off and just had cold water running into the 200 Hall. Observation on 03/10/20 at 6:05 pm revealed the Maintenance Supervisor manipulated the hot water mixing valves (mixes hot and cold water together) that provided the water to the 200 Hall with a screw driver and then raised the hot water. Further observation revealed the temperature gauge on the hot water heater registered just under 110 degrees F. Observation with the Maintenance Supervisor on 03/10/20 at 6:20 to 6:28 pm revealed the water temperatures on the 200 Hall were: Shower Room- 100.7 degrees F room [ROOM NUMBER]- 104.7 degrees F room [ROOM NUMBER]- 101.4 degrees F room [ROOM NUMBER]- 103.4 degrees F room [ROOM NUMBER]- 104.5 degrees F In an interview on 03/11/20 at 10:46 am, Maintenance Assistant M revealed he had worked at the facility for almost [AGE] years. He stated the Maintenance Supervisor told him there was a problem with the water temperatures on the 200 Hall. Further interview revealed it had been an ongoing problem for a long time. Maintenance Assistant M confirmed he had adjusted the hot water almost all the way up. He further stated he had adjusted the water many times for at least a year. He stated the old Administrator was aware and had tried to get it fixed. In an interview on 03/12/20 at 3:14 pm, the ADON revealed she had informed the Administrator that the hot water in the 200 Hall shower room was too hot and it took a long time for the water to come down (cool) . The ADON further stated the Administrator told her the former maintenance man would go and adjust the gauges to bring the temperature down. In an interview on 03/13/20 at 7:15 am, the Maintenance Supervisor revealed he had taken the water temperatures on 03/12/20 from 5:40 pm to 6:50 pm in rooms 201, 202, 206, 207, 210, 211, 213, 214, 218, 217, 221, 222 and the shower. The temperatures ranged from 101.8 degrees F to 107.4 degrees F. The Maintenance Supervisor stated water temperatures were checked again in the same rooms on the 200 Hall on 03/13/20 from 6:23 am to 7:07 pm and the hot water temperatures ranged from 103.1 degrees F to 108.5 degrees F. On 03/10/20 at 7:35 am the Administrator was informed of an Immediate Jeopardy (IJ) situation for the above failures, a completed IJ template was provided and a plan of removal was requested. The Plan of Removal was approved on 03/12/20 at 3:34 pm with immediate actions taken to be taken by the facility: Plan of Removal - Immediate Jeopardy March 10, 2020 Immediate Action: The water was shut off to the B-hall resident rooms and the sink in the dining room. 100% of residents on the 200-hall were assessed for injury from hot water temps. There were no concerns or injuries from hot water temps. Staff were immediately notified to provide hand sanitation to residents by using hand sanitizer and/or if hands are visibly soiled to use the public restroom to wash their hands until the problem was corrected. Warm washcloths were provided for bedtime hygiene. A licensed plumber was called immediately upon discovery and the problem will be remediated as of March 11, 2020 to bring the water temperatures to a safe and acceptable range of 100 - 110 degrees for residents. New mixing valves will be placed on the 200 hall water heater, as well as the water heater supplying water to the dining room sink. Water temperatures in the rest of the facility were taken and there were no concerns identified. Continued Compliance with Water Temperatures: 1. The maintenance director will monitor water temperatures in the affected areas; hourly until compliance on 200 hall rooms; twice a day for one week, once daily for one week, and following the regular established routine of weekly thereafter. 2. The Administrator will monitor water temperatures in the affected areas; twice a week for one week and randomly thereafter. 3. The Vice President will randomly check water temperatures in the affected areas during routine visits. 4. The Vice President initiated education with nursing staff (nurses and CNAs) regarding reporting water temperatures that appears too hot to the Administrator or designee and Maintenance Director, immediately. Staff not attending the initial education will be required to receive the education before working their next assigned shift. 5. The results of water temperature logs will be reviewed in the monthly Quality Assurance Performance Improvement meeting for three months for tracking, trending, and further recommendations, when needed. On 03/12/20 the Survey Team confirmed the Plan of Removal had been implemented sufficiently to remove the IJ. The surveyor verification of the POR was as follows: Interviews were conducted with staff The questions asked were: 1. Have you had any issues with the hot water on the 200 Hall/B Hall? 2. If yes- Did you tell anyone? 3. Have you had any in- services since 03/10/20? If yes- What In services? 4. What did you learn? Staff interviewed on the 100 Hall and the 200 Hall to include, the DON and ADON, 4 LVN Charge Nurses,(B, Z, AA, DD), 6 CNAs,(D,R, S, T, U, V), 2 Laundry/Housekeeper,(W, EE), 3 Food Service Aides, (Q, X, Y), Dietary Manager, 1 RN (BB) and HR/ABOM. stated they were not aware of the hot water issues on the 200 Hall. They were in-serviced and instructed if the water was too hot to report it to the Charge Nurse, ADON, DON or the Administrator. The In-services provided to the staff were reviewed from 03/10/20 to 03/12/20 at 7:30 am. On 3/12/2020 at 3:34 p.m. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at severity level of potential for harm with a scope identified as a pattern until the water heater and regulator was repaired and all staff were in-serviced.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision to prevent accidents for 5 of 10 residents (Resident #s 12, 13, 14, 15, and 20) reviewed for accidents/supervision in that: 1. The facility did not provide the supervision necessary to prevent Resident #20 from wandering into the living spaces of Residents #14, 15, and 12. a. Resident #20 wandered into Resident #14's room during the night and woke her up. b. Resident #20 wandered into Resident #15 room during the night and woke her up. c. Resident #20 wandered into Resident #12's room, picked up Resident's 12's pet turtle and pulled on its limbs. 2. There was a bottle of [MEDICATION NAME] in Resident #12's room. 3. There was a bottle [MEDICATION NAME] Advanced eye drops in Resident #13's room. These deficient practices could affect all residents on the B hall by contributing to ingestion of medication at an inappropriate dose, drug/drug interactions, loss of a sense of security, and/or injury from a wandering unsupervised resident. The findings were: 1. Record review of Resident #20's facesheet, dated 12/19/2019, revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's Quarterly MDS, dated [DATE], revealed he had no speech and was rarely/never understood. A staff assessment for mental status revealed he had short-term and long-term memory problems, his cognitive skills for daily decision making were severely impaired, he experienced delusions and continuous inattention. Further review revealed the resident exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) between one and three days during the seven day period prior to the assessment date, exhibited other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), and the resident wandered every day of the seven day period prior to the assessment date. During an interview with CNA [NAME] on 12/18/2019 at 2:06 p.m., CNA [NAME] stated Resident #20 wanders almost constantly, goes in and out of other residents' rooms, and is especially aggressive toward female residents and staff members. CNA [NAME] confirmed Resident #20 has exhibited physical aggression with staff, visitors, and other residents. CNA [NAME] stated Resident #20 had thrown or attempted to throw furniture in his room and in the dining room. CNA [NAME] confirmed no other residents were present during Resident #20's episodes of furniture throwing/attempts to throw furniture. During an interview with LVN C on 12/19/2019 at 11:53 a.m., LVN C confirmed Resident #20 had wandered in and out of other residents' rooms on multiple occasions, and confirmed residents on B Hall had expressed anxiety about Resident #20's wandering. LVN C confirmed Resident #20 has exhibited physical aggression with staff, visitors, and other residents. During an interview with LVN D on 12/19/2019 at 4:48 p.m., LVN D confirmed Resident #20 had wandered in and out of other residents' rooms on multiple occasions, and confirmed residents on B Hall had expressed anxiety about Resident #20's wandering. LVN D stated she spends approximately 70% of her time each shift redirecting Resident #20. LVN D confirmed Resident #20 has exhibited physical aggression with staff, visitors, and other residents, and had thrown or attempted to throw furniture. During an interview with RN L on 12/18/2019 at 11:37 a.m., RN L confirmed Resident #20 had wandered in and out of other residents' rooms on multiple occasions, and confirmed residents on B Hall had expressed anxiety about Resident #20's wandering. RN L confirmed Resident #20 has exhibited physical aggression with staff, visitors, and other residents, and had thrown or attempted to throw furniture at staff. During an interview with the DON on 12/19/2019 at at 12:02 p.m., the DON confirmed Resident #20 had wandered in and out of other residents' rooms on multiple occasions and had exhibited physical aggression with staff, visitors, and other residents, and had thrown or attempted to throw furniture. a. Record review of Resident #14's facesheet, dated 12/19/2019, revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's clinical record revealed an incident report, dated 07/19/2019, which stated, Resident went into female resident's room (Resident #14) and urinated in her trash can. Record review of Resident #14's Comprehensive MDS, dated [DATE], revealed she had a BIMS score of 15, indicating intact cognition. During an interview with Resident #14 on 12/19/2019 at 2:36 p.m., Resident #14 stated that Resident #20 had entered her room, uninvited, while she was asleep and caused her to awaken. Resident #14 stated she was afraid at the time of the incident and stated she still felt concerned that Resident #20 would come back. During an interview with LVN D on 12/19/2019 at 4:48 p.m., LVN D confirmed Resident #20 had wandered into Resident #14's room. During an interview with RN L on 12/18/2019 at 11:37 a.m., RN L confirmed Resident #20 had wandered into Resident #14's room. Record review of Resident #20's care plan, revised 07/22/2019, revealed a problem which stated, Resident went in to another resident's room and urinated in trash can, an associated goal which stated, No further behaviors will occur, and an approach/intervention which stated, Staff education to ensure resident not wandering in other resident's rooms. Check where resident is during Q 2 (every 2) hour checks. During an interview with LVN D on 12/19/2019 at 4:48 p.m., LVN D reported she had not received explicit instructions from the facility regarding how to redirect Resident #20. b. Record review of Resident #15's facesheet, dated 12/19/2019, revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's clinical record revealed an incident report, dated 05/22/2019, which stated, Resident in another resident room, hitting and poking her .He (Resident #20) was in another resident's room (Resident #15) and now that resident (Resident #15) is afraid he will keep coming into the room. Record review of Resident #15's Quarterly MDS, dated [DATE], revealed she had a BIMS score of 09, indicated moderate cognitive impairment. During an interview with Resident #15 at on 12/19/2019 3:21 p.m., Resident #15 stated that Resident #20 had come into her room, uninvited, and woke her up by touching her (in a non-sexual manner) while she was asleep in her bed. Resident #15 stated she was afraid at the time of the incident and stated she still felt afraid that Resident #20 would come back. During an interview with LVN D on 12/19/2019 at 4:48 p.m., LVN D confirmed Resident #20 had wandered into Resident #15's room. During an interview with LVN C on 12/19/2019 at 11:53a.m., LVN C confirmed Resident #20 had wandered into Resident #15's room. Record review of Resident #20's care plan, revised 05/28/2019, revealed a problem which stated, Resident became aggressive with another resident, an associated goal which stated, No further aggression will occur, and an approach/intervention which stated, Sent to ER (emergency room ) to evaluate. Psych (psychiatric services) for medication review upon readmission. c. Record review of Resident #12's facesheet, dated 12/19/2019, revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident #12's Quarterly MDS, dated [DATE], revealed his BIMS score was 15, indicating intact cognition. Record review of Resident #20's clinical record revealed an incident report, dated 11/17/2019, which stated, Resident #20 refusing vitals, refusing care, Resident #20 has disrobed and urinating in floor but will not allow staff to assist, striking staff .continuously ambulating about facility and in and out of other resident rooms .taking belongings out of other Resident #12's room and causing increased anxiety for other patient. During an interview with Resident #12 at 1:54 p.m. on 12/18/2019, Resident #12 stated that Resident #20 had come into his room uninvited, picked up Resident #12's pet turtle and tried to pull it apart, causing Resident #12 concern for the safety of his pet. During an interview with LVN D on 12/19/2019 at 4:48 p.m., LVN D confirmed Resident #20 had wandered into Resident #12's room. Record review of Resident #20's care plan, revised 11/19/2019, revealed a problem which stated, Resident became aggressive towards staff, an associated goal which stated, No further aggression will be noted, and an approach/intervention which stated, Care plan with resident's family regarding moving resident to a locked unit/behavioral unit. During an interview with the DON on 12/19/2019 at 4:30 p.m., the DON confirmed facility representatives had met with Resident #20's spouse to discuss moving the resident to a behavioral unit. The DON confirmed facility representatives had contacted three facilities with behavioral units and Resident #20 had been rejected by all three. The DON confirmed the facility had not made further attempts to assist Resident #20 in moving to another facility. Record review of the facility's policy, Safety and Supervision of Residents, revised (MONTH) 2007, revealed that it stated, Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Systems Approach to Safety: 2. Resident supervision is a core component of the systems approach to safety .Resident Risks and Environmental Hazards: include .e. Unsafe Wandering. 2. Record review of Resident #12's face sheet (dated 12/19/19) revealed that he was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #12's quarterly MDS assessment (ARD 9/25/19) revealed that he scored a 15 on the BIMS (indicating that he was cognitively intact), had no short-term or long-term memory problems, had no hallucinations/delusions/disorganized thinking, and did not reject care. Record review of Resident #12's care plan (last reviewed/revised 12/11/19) revealed no address of noncompliance, rejection of care, and/or self-medication. Record review of Resident #12's (MONTH) of 2019 physician orders [REDACTED]. Observation of Resident #12 in bed in his room at 9:04 a.m. on 12/18/19 revealed that he was asleep. Observation of Resident #12's room at 1:43 p.m. on 12/18/19 revealed that there was a bottle of [MEDICATION NAME] 200 milligram tablets on a night stand by the window. The bottle was over ¾-full. Resident #12 was not in his room. During observation/interview with Resident #12 at 1:54 p.m. on 12/18/19, he said that he was not supposed to have the [MEDICATION NAME] 200 milligram tablets in his room and that he was surprised staff had not taken them from him yet. Resident #12 said that he went to the store at the beginning of every month and bought the [MEDICATION NAME] 200 milligram tablets then. Resident #12 appeared to be drowsy and said that he had not been sleeping well. During an interview with RN I at 1:43 p.m. on 12/18/19 (she was going into Resident #12's room as the surveyor was coming out), she said that Resident #12 was in therapy. Observation of Resident #12's room at 1:48 p.m. on 12/18/19 revealed that RN I and Central Supply K were coming out of Resident # 12's room. The bottle of [MEDICATION NAME] 200 milligram tablets was still on the night stand by his window. During an interview with RN I and LVN J at 2:25 p.m. on 12/18/19, they said that Resident #12 did not self-medicate and was not supposed to have [MEDICATION NAME] in his room. LVN J took the [MEDICATION NAME] out of Resident #12's room at this time. RN I said that therapy staff had informed her of Resident #12 being groggy during his time there. 3. Record review of Resident #13's face sheet (dated 12/19/19) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #13's quarterly MDS assessment (ARD 9/16/19) revealed that he scored a 3 on the BIMS (indicating severe cognitive impairment), was usually understood/could understand, and did not reject care. He had other behavioral symptoms not directed toward others 1 to 3 days within the 7-day lookback period. Record review of Resident #13's care plan (last reviewed/revised 12/13/19) revealed he wandered into other resident rooms, needed redirection, and had taken food from other resident's refrigerators and that he had verbally threatened to take his medication from a nurse. Resident #13's elopement risk and smoking were addressed with intervention of close supervision. Record review of Resident #13's physician's orders [REDACTED]. There were no orders [MEDICATION NAME] Advanced eye drops. Observation of Resident #13 in bed in his room at 9:07 a.m. on 12/18/19 revealed that his right eye was red. There was a bottle [MEDICATION NAME] Advanced eye drops in bed next to Resident #13. During an interview with Resident #13 at 9:07 a.m. on 12/18/19, when asked about his eye being red, he said I might have gotten too much in there - why it's red. During an interview with CNA G at 9:08 a.m. on 12/18/19 CNA G stated she did not know anything about Resident # 13 [MEDICATION NAME] at the bedside. She stated I have no idea. I work the A wing all the time. CNA G continued to walk past the nursing station and down the hall without informing anyone about the eye drops or trying to get the eye drops from Resident #13. During an interview with LVN C at 9:10 a.m. on 12/18/19, she said that Resident #13 did not self-medicate and was not supposed to [MEDICATION NAME] Advanced eye drops in his room. LVN C said that Resident #13 had a behavior of picking up items that were not his and immediately retrieved [MEDICATION NAME] Advanced eye drops from his room. LVN C said that [MEDICATION NAME] Advanced eye drop bottle she took from Resident #13's room did not have a resident's name on them and that Resident #13 did not leave the facility. Record review of the facility's Storage of Medications policy (revised (MONTH) 2007) revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . 1. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received . 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing . 5. Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Record review of the Resident Handbook (not dated) revealed The facility uses a unit dose system provided by a pharmacy independent of the facility. Residents may use the pharmacy of their choice, but it must conform to the system in use. It is critical that medication not be brought into the facility for the resident's use without the appropriate physician's approval. Failure to observe this prohibition could result in the following potential problems: 1. Unauthorized drugs may cause reactions with prescribed medications; 2. Unauthorized medications may cause faulty laboratory tests; 3. They may be detrimental to the resident's well-being; and 4. Accurate records cannot be kept of the residents are medicating themselves.

Based on observation, interview and record review, the facility failed to develop and implement policies and procedures that prohibit the neglect of 1 of 15 residents (#2) whose care was reviewed for neglect in that: Resident #2 was not identified for safety interventions to prevent her from leaning forward in her wheelchair. The wheelchair was not provided with footrests to prevent her from falling out of her wheelchair while being pushed. Resident #2 fell forward when her feet dropped to the floor and the feet were caught under the wheelchair. The resident sustained [REDACTED]. These failures resulted in an identification of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 10/14/16. While the IJ was removed on 10/17/16, the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. These deficient practices placed 17 residents at risk for injuries due to not having footrests attached to their wheelchairs when being pushed by direct care staff. The findings were: Review of Resident #2's undated admission face sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a fall risk assessment dated [DATE] revealed Resident #2 was at risk for falls due to poor safety awareness and spent most of her time in a wheelchair due to arthritic knees. The approaches include wearing non-skid footwear. A fall risk assessment dated [DATE] scored the resident a 15 (10 or above indicates a risk for falls) due to confusions at times and receiving 2 or more medications ([MEDICATION NAME], antihypertensive and narcotics). Review of a care plan dated 3/9/16 for falls did not include the use of assistive devices such as wheelchair or footrests. Review of a re-admission nursing assessment by LVN T dated 8/15/16 revealed that the resident was severely (cognitively) impaired and never or rarely made decisions and usually understood others but missed the intent of their message. The assessment area for wheelchair-use was checked to indicate the resident was able to self-propel. Review of a history and physical dated 8/16/16 revealed the resident had been hospitalized from [DATE] to 8/15/16 for a urinary tract infection. Review of a nursing note dated 8/20/16 post re-admission revealed that Physical/Speech/Occupational Therapy was required due to the resident's requirement for extensive assistance with transfers, bed mobility and toileting. Review of a quarterly MDS dated [DATE] assessed Resident #2's BIMS (a brief cognitive assessment with a scoring from 1-15, 15 indicating most oriented and memory intact) at a level 7. Section G, Functional Status, assessed the resident as needing extensive assistance with locomotion on the unit and in her room and utilized a wheelchair as a mobile device. Review of the facility's investigation report dated 10/17/16 revealed that Resident #2 was being pushed in her wheelchair on 10/10/16 at 6:30 p.m. to the dining room by a staff member employed as a Hospitality Aide (HA D) down A wing hall and fell forward out of the wheelchair hitting her head on the floor. HA D reported he had instructed Resident #2 to pick up her feet and lean back in the chair and instead Resident #2 put her feet down on the rug and fell forward hitting her forehead, resulting in a severe abrasion and laceration to the forehead. Review of hospital ER record dated 10/11/16 confirmed that Resident #2 was admitted to ICU with an avulsion fracture (a fragment of bone tears away from the main mass of bone as a result of physical trauma) of the C-2 to the neck at the base of the head. A radiology review dated 10/11/16 documented that the resident had been wheelchair bound for over a year due to knee pain and difficulty ambulating. A CT-SCAN (computed tomography) ruled out cerebral injuries. A plastic surgery consult dated 10/11/16 revealed the resident had a 6 cm linear laceration of the temporal and lateral orbital and supraorbital soft tissue, which was repaired in the ER. Review of a nursing notes dated 10/10/16, 4:42 p.m. revealed social service was unable to complete a BIMS assessment as the resident was not able to wake up and speak. On 10/10/16, at 6:37 p.m., the resident was sitting in wheelchair and being pushed in the wheelchair by HA D and leaned forward and fell on the floor hitting her head and sustaining a large gash 3-4 inch in length to the forehead. During an interview on 10/12/16 at 2:55 p.m., Hospitality Aide (HA) D reported that he was working on the A hall wing on the evening of 10/10/16 and had removed Resident #2 from the library area in front of the nurses' station by pushing her in her wheelchair to her room for incontinent care. There were no footrests attached to the wheelchair and HA D instructed Resident #2 to lift her feet. CNA C lifted the resident onto her bed and performed incontinent care and then transferred her back to the wheelchair. HA D then pushed the resident out of the room and into the hallway. HA D stated that he had taken about 18 steps into the hallway and was talking to the resident asking her how her day going. He stated that he had to maneuver around another resident in a wheelchair in the hallway and that was when he heard Resident #2 drop her feet down. He stated that he had not seen her feet drop. Review of the facility's undated job description for hospitality assistance revealed the hospitality assistant worked under the direction of the charge nurse, ADON and DON and duties included providing fresh water and encouraging fluid intake; answering call lights within 5 minutes; making beds and escorting residents to and from activities and dining area. The job description did not include pushing residents in wheelchairs. During an interview on 10/12/16 at 5:00 p.m., CNA C reported that he was working on the A hall wing on the evening of 10/10/16 and had performed incontinent care on Resident #2 after HA D had brought the resident into her room and transferred her to her bed. He stated that after performing incontinent care, he had transferred Resident #2 back to the wheelchair. He stated that he did not attach footrests to the wheelchair, because there were none in the room. During an interview on 10/13/16 at 10:40 a.m., the Rehabilitation Director, E, reported that whenever he picked up Resident #2 for therapy he always applied footrests to her wheelchair. He stated that the resident was limited in her ability to propel. He stated that the resident had bad and good days and was often lethargic or seemed sedated and therapy was limited due to a lack of participation. He stated that on the morning of 10/10/16, the resident was too lethargic to complete therapy. During an interview on 10/13/16 at 11:55 a.m., Resident #2's POA stated that Resident #2 did not propel in her wheelchair and that the wheelchair was always locked whenever she or her sisters visited. Sometimes the resident was found asleep in the wheelchair and leaning forward. During an observation on 10/13/16 at approximately 1:10 p.m., Resident #2 was observed at a local hospital ICU unit. The resident was unresponsive to verbal stimuli and touch. A nasal gastric tube extended from a nostril and an indwelling urinary catheter was draining yellow clear urine. The resident had an IV running and a solid neck brace was in place. A large discolored closed laceration extended to the right temporal area. The right shoulder was discolored and appeared to be bruised. During an interview on 10/17/16 at 2:30 p.m., LVN N, CN, reported that she was working the evening shift on 10/10/16 on A hall wing and was told in report by the previous nurse that Resident #2 was having a good day. She stated that she observed Resident #2 sitting in her wheelchair with glasses and shoes and fully dressed. She stated that the resident was heard yelling and observed her leaning forward. LVN N stated that when she worked the shift she kept an eye on Resident #2 and when sitting in her wheelchair, the chair was always locked. Occasionally, Resident #2 would unlock the wheels and propel to the nurses station, but the resident never propelled anywhere else. LVN N reported that when pushing the resident, the staff would place a hand on her chest to prevent her from falling forward and the resident often placed her feet on the floor. LVN N stated that she gave an in-service a couple of weeks before the fall (10/10/16) which included preventing Resident #2 from leaning forward when pushed in the wheelchair by placing a hand on the chest. She stated that CNA C was present, but HA D was not at the in-service. She stated that HA D was not sufficiently oriented for care of residents on the A wing hall as he was oriented on B wing hall. During the end of the day conference on 10/12/16 at 5: 30 p.m., the Administrator stated that she had thought the footrests had been discontinued because Resident #2 could propel herself. The Administrator referred to the re-admission nursing assessment of 8/17/16 as evidence. The DON and LVN T were also present during the conference and reported that the POC computers used by the direct care staff also listed the care needs of each resident on the profile icon and each direct care staff could access the profile. During an interview on 10/14/16 at 8:50 a.m., the DON reported that she had instructed the staff that any resident that had to be pushed in a wheelchair was to have footrests. During an interview on 10/17/16 at approximately 3:50 p.m., the RN Consultant reported that prior to this week, the facility had not established a post fall interdisciplinary team (IDT) program to evaluate and recommend interventions in reducing the fall rate within the facility. During interview on 10/14/16 at approximately 8:50 a.m., the DON reported that she had a QA (quality assurance) nurse conducting assessments of all the residents in the facility for the use of wheelchairs and footrests. She stated that the residents had not been assessed until Resident #2 fell on [DATE]. A copy of the assessment list was provided to the surveyor and revealed that the assessments were conducted on 10/11/14 and as off 10/13/16 seventeen (17) residents had been assessed. Review of the facility's operational/resident care policy on abuse and neglect dated December 2013 revealed that neglect meant failure to provide goods and services to avoid physical harm and mental anguish. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Along with other staff and management, the Medical Director will help identify situations that micht constitute or could be construed as neglect. Review of the facility's operational/resident care policy on management of fall prevention dated 2007 revealed that: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The Administrator was notified on 10/14/16 at 4:00 p.m. of an Immediate Jeopardy for the above failures and a Plan of Removal was requested. The facility's Plan of Removal was provided by the Administrator on 10/17/16 and included the following steps to be taken by the facility: a. In-service of all staff were to be educated on not pushing residents in wheelchairs until the leg-rests were attached for transport. Part of the education will be to encourage residents to self-propel whenever possible as to not promote a decline in their ADLs. The education will be included in orientation and facility staff was not to beginning their shifts until receiving the education. b. The Interdisciplinary Team was to be educated by the Regional Director of Operations to identify resident safety concerns and compliance with residents requiring wheelchair mobility. c. All 83 residents were to be screened for wheelchair use and footrests. A list with the names of each resident requiring a wheelchair and footrests was to be completed. Residents on the list were to be identified and observed for compliancy. All wheelchairs were to be labeled with the resident's name and wheelchairs were affixed with footrests. d. The facility's computerized Point Of Contact Resident Profile care plan was to be updated to reflect changes in resident care needs. Direct care staff was to be in-serviced individually by the DON to access the resident POC profile icon and identify the care plans. e. The DON was to conduct between shift reports on residents with on-coming direct care staff prior to starting their shifts. Verification of the Plan of Removal was as follows: Observations conducted on 10/15/16, 10/16/16 and 10/17/16 confirmed that footrests were being utilized by residents being pushed in wheelchairs. Interviews with staff on 10/16/16 and 10/17/17 confirmed that the education of the staff had been completed prior to starting their shifts. Observations on 10/17/16 during the 3:00 p.m. change of shift confirmed that the DON was attending change of shift reports between the charge nurses and CNA's for the evening shift. On 10/17/16 at 3:50 p.m., the Administrator was informed that the IJ was removed. However, the facility remained out of compliance with a severity of actual harm with a scope identified as pattern. The facility was continuing to educate staff and monitor resident at risk for falls. The facility reported that 17 residents were assessed at risk for falls and required wheelchairs with footrests.

Based on observation, interview and record review, the facility failed to implement the facility's written policies and procedures that prohibit the neglect of 1 of 15 residents (#2) whose care was reviewed for neglect in that: Resident #2 was not identified for safety interventions to prevent her from leaning forward in her wheelchair. The wheelchair was not provided with footrests to prevent her from falling out of her wheelchair while being pushed. Resident #2 fell forward when her feet dropped to the floor and the feet were caught under the wheelchair. The resident sustained [REDACTED]. These failures resulted in an identification of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 10/14/16. While the IJ was removed on 10/17/16, the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. These deficient practices placed 17 residents at risk for injuries due to not having footrests attached to their wheelchairs when being pushed by direct care staff. The findings were: 1. Review of the facility's operational/resident care policy on abuse and neglect dated December 2013 revealed that neglect meant failure to provide goods and services to avoid physical harm and mental anguish. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Along with other staff and management, the Medical Director will help identify situations that micht constitute or could be construed as neglect. Review of the facility's operational/resident care policy on management of fall prevention dated 2007 revealed that: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. 2. Review of Resident #2's undated admission face sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a fall risk assessment dated [DATE] revealed Resident #2 was at risk for falls due to poor safety awareness and spent most of her time in a wheelchair due to arthritic knees. The approaches include wearing non-skid footwear. A fall risk assessment dated [DATE] scored the resident a 15 (10 or above indicates a risk for falls) due to confusions at times and receiving 2 or more medications ([MEDICATION NAME], antihypertensive and narcotics). Review of a care plan dated 3/9/16 for falls did not include the use of assistive devices such as wheelchair or footrests. Review of a re-admission nursing assessment by LVN T dated 8/15/16 revealed that the resident was severely (cognitively) impaired and never or rarely made decisions and usually understood others but missed the intent of their message. The assessment area for wheelchair-use was checked to indicate the resident was able to self-propel. Review of a history and physical dated 8/16/16 revealed the resident had been hospitalized from [DATE] to 8/15/16 for a urinary tract infection. Review of a nursing note dated 8/20/16 post re-admission revealed that Physical/Speech/Occupational Therapy was required due to the resident's requirement for extensive assistance with transfers, bed mobility and toileting. Review of a quarterly MDS dated [DATE] assessed Resident #2's BIMS (a brief cognitive assessment with a scoring from 1-15, 15 indicating most oriented and memory intact) at a level 7. Section G, Functional Status, assessed the resident as needing extensive assistance with locomotion on the unit and in her room and utilized a wheelchair as a mobile device. Review of the facility's investigation report dated 10/17/16 revealed that Resident #2 was being pushed in her wheelchair on 10/10/16 at 6:30 p.m. to the dining room by a staff member employed as a Hospitality Aide (HA D) down A wing hall and fell forward out of the wheelchair hitting her head on the floor. HA D reported he had instructed Resident #2 to pick up her feet and lean back in the chair and instead Resident #2 put her feet down on the rug and fell forward hitting her forehead, resulting in a severe abrasion and laceration to the forehead. Review of hospital ER record dated 10/11/16 confirmed that Resident #2 was admitted to ICU with an avulsion fracture (a fragment of bone tears away from the main mass of bone as a result of physical trauma) of the C-2 to the neck at the base of the head. A radiology review dated 10/11/16 documented that the resident had been wheelchair bound for over a year due to knee pain and difficulty ambulating. A CT-SCAN (computed tomography) ruled out cerebral injuries. A plastic surgery consult dated 10/11/16 revealed the resident had a 6 cm linear laceration of the temporal and lateral orbital and supraorbital soft tissue, which was repaired in the ER. Review of a nursing notes dated 10/10/16, 4:42 p.m. revealed social service was unable to complete a BIMS assessment as the resident was not able to wake up and speak. On 10/10/16, at 6:37 p.m., the resident was sitting in wheelchair and being pushed in the wheelchair by HA D and leaned forward and fell on the floor hitting her head and sustaining a large gash 3-4 inch in length to the forehead. During an interview on 10/12/16 at 2:55 p.m., Hospitality Aide (HA) D reported that he was working on the A hall wing on the evening of 10/10/16 and had removed Resident #2 from the library area in front of the nurses' station by pushing her in her wheelchair to her room for incontinent care. There were no footrests attached to the wheelchair and HA D instructed Resident #2 to lift her feet. CNA C lifted the resident onto her bed and performed incontinent care and then transferred her back to the wheelchair. HA D then pushed the resident out of the room and into the hallway. HA D stated that he had taken about 18 steps into the hallway and was talking to the resident asking her how her day going. He stated that he had to maneuver around another resident in a wheelchair in the hallway and that was when he heard Resident #2 drop her feet down. He stated that he had not seen her feet drop. Review of the facility's undated job description for hospitality assistance revealed the hospitality assistant worked under the direction of the charge nurse, ADON and DON and duties included providing fresh water and encouraging fluid intake; answering call lights within 5 minutes; making beds and escorting residents to and from activities and dining area. The job description did not include pushing residents in wheelchairs. During an interview on 10/12/16 at 5:00 p.m., CNA C reported that he was working on the A hall wing on the evening of 10/10/16 and had performed incontinent care on Resident #2 after HA D had brought the resident into her room and transferred her to her bed. He stated that after performing incontinent care, he had transferred Resident #2 back to the wheelchair. He stated that he did not attach footrests to the wheelchair, because there were none in the room. During an interview on 10/13/16 at 10:40 a.m., the Rehabilitation Director, E, reported that whenever he picked up Resident #2 for therapy he always applied footrests to her wheelchair. He stated that the resident was limited in her ability to propel. He stated that the resident had bad and good days and was often lethargic or seemed sedated and therapy was limited due to a lack of participation. He stated that on the morning of 10/10/16, the resident was too lethargic to complete therapy. During an interview on 10/13/16 at 11:55 a.m., Resident #2's POA stated that Resident #2 did not propel in her wheelchair and that the wheelchair was always locked whenever she or her sisters visited. Sometimes the resident was found asleep in the wheelchair and leaning forward. During an observation on 10/13/16 at approximately 1:10 p.m., Resident #2 was observed at a local hospital ICU unit. The resident was unresponsive to verbal stimuli and touch. A nasal gastric tube extended from a nostril and an indwelling urinary catheter was draining yellow clear urine. The resident had an IV running and a solid neck brace was in place. A large discolored closed laceration extended to the right temporal area. The right shoulder was discolored and appeared to be bruised. During an interview on 10/17/16 at 2:30 p.m., LVN N, CN, reported that she was working the evening shift on 10/10/16 on A hall wing and was told in report by the previous nurse that Resident #2 was having a good day. She stated that she observed Resident #2 sitting in her wheelchair with glasses and shoes and fully dressed. She stated that the resident was heard yelling and observed her leaning forward. LVN N stated that when she worked the shift she kept an eye on Resident #2 and when sitting in her wheelchair, the chair was always locked. Occasionally, Resident #2 would unlock the wheels and propel to the nurses station, but the resident never propelled anywhere else. LVN N reported that when pushing the resident, the staff would place a hand on her chest to prevent her from falling forward and the resident often placed her feet on the floor. LVN N stated that she gave an in-service a couple of weeks before the fall (10/10/16) which included preventing Resident #2 from leaning forward when pushed in the wheelchair by placing a hand on the chest. She stated that CNA C was present, but HA D was not at the in-service. She stated that HA D was not sufficiently oriented for care of residents on the A wing hall as he was oriented on B wing hall. During the end of the day conference on 10/12/16 at 5: 30 p.m., the Administrator stated that she had thought the footrests had been discontinued because Resident #2 could propel herself. The Administrator referred to the re-admission nursing assessment of 8/17/16 as evidence. The DON and LVN T were also present during the conference and reported that the POC computers used by the direct care staff also listed the care needs of each resident on the profile icon and each direct care staff could access the profile. During an interview on 10/14/16 at 8:50 a.m., the DON reported that she had instructed the staff that any resident that had to be pushed in a wheelchair was to have footrests. During an interview on 10/17/16 at approximately 3:50 p.m., the RN Consultant reported that prior to this week, the facility had not established a post fall interdisciplinary team (IDT) program to evaluate and recommend interventions in reducing the fall rate within the facility. During interview on 10/14/16 at approximately 8:50 a.m., the DON reported that she had a QA (quality assurance) nurse conducting assessments of all the residents in the facility for the use of wheelchairs and footrests. She stated that the residents had not been assessed until Resident #2 fell on [DATE]. A copy of the assessment list was provided to the surveyor and revealed that the assessments were conducted on 10/11/14 and as off 10/13/16 seventeen (17) residents had been assessed. The Administrator was notified on 10/14/16 at 4:00 p.m. of an Immediate Jeopardy for the above failures and a Plan of Removal was requested. The facility's Plan of Removal was provided by the Administrator on 10/17/16 and included the following steps to be taken by the facility: a. In-service of all staff were to be educated on not pushing residents in wheelchairs until the leg-rests were attached for transport. Part of the education will be to encourage residents to self-propel whenever possible as to not promote a decline in their ADLs. The education will be included in orientation and facility staff was not to beginning their shifts until receiving the education. b. The Interdisciplinary Team was to be educated by the Regional Director of Operations to identify resident safety concerns and compliance with residents requiring wheelchair mobility. c. All 83 residents were to be screened for wheelchair use and footrests. A list with the names of each resident requiring a wheelchair and footrests was to be completed. Residents on the list were to be identified and observed for compliancy. All wheelchairs were to be labeled with the resident's name and wheelchairs were affixed with footrests. d. The facility's computerized Point Of Contact Resident Profile care plan was to be updated to reflect changes in resident care needs. Direct care staff was to be in-serviced individually by the DON to access the resident POC profile icon and identify the care plans. e. The DON was to conduct between shift reports on residents with on-coming direct care staff prior to starting their shifts. Verification of the Plan of Removal was as follows: Observations conducted on 10/15/16, 10/16/16 and 10/17/16 confirmed that footrests were being utilized by residents being pushed in wheelchairs. Interviews with staff on 10/16/16 and 10/17/17 confirmed that the education of the staff had been completed prior to starting their shifts. Observations on 10/17/16 during the 3:00 p.m. change of shift confirmed that the DON was attending change of shift reports between the charge nurses and CNA's for the evening shift. On 10/17/16 at 3:50 p.m., the Administrator was informed that the IJ was removed. However, the facility remained out of compliance with a severity of actual harm with a scope identified as pattern. The facility was continuing to educate staff and monitor resident at risk for falls. The facility reported that 17 residents were assessed at risk for falls and required wheelchairs with footrests.

Based on observation, interview and record review, the facility failed to ensure residents were free of accident hazards as is possible for 1 of 15 residents (#2) whose care was reviewed for accidents in that: Resident #2 was not identified for safety interventions to prevent her from leaning forward in her wheelchair. The wheelchair was not provided with footrests to prevent her from falling out of her wheelchair while being pushed. Resident #2 fell forward when her feet dropped to the floor and the feet were caught under the wheelchair. The resident sustained [REDACTED]. These failures resulted in an identification of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 10/14/16. While the IJ was removed on 10/17/16, the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. These deficient practices placed 17 residents at risk for injuries due to not having footrests attached to their wheelchairs when being pushed by direct care staff. The findings were: Review of Resident #2's undated admission face sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a fall risk assessment dated [DATE] revealed Resident #2 was at risk for falls due to poor safety awareness and spent most of her time in a wheelchair due to arthritic knees. The approaches include wearing non-skid footwear. A fall risk assessment dated [DATE] scored the resident a 15 (10 or above indicates a risk for falls) due to confusions at times and receiving 2 or more medications (antihistamine, antihypertensive and narcotics). Review of a care plan dated 3/9/16 for falls did not include the use of assistive devices such as wheelchair or footrests. Review of a re-admission nursing assessment by LVN T dated 8/15/16 revealed that the resident was severely (cognitively) impaired and never or rarely made decisions and usually understood others but missed the intent of their message. The assessment area for wheelchair-use was checked to indicate the resident was able to self-propel. Review of a history and physical dated 8/16/16 revealed the resident had been hospitalized from [DATE] to 8/15/16 for a urinary tract infection. Review of a nursing note dated 8/20/16 post re-admission revealed that Physical/Speech/Occupational Therapy was required due to the resident's requirement for extensive assistance with transfers, bed mobility and toileting. Review of a quarterly MDS dated [DATE] assessed Resident #2's BIMS (a brief cognitive assessment with a scoring from 1-15, 15 indicating most oriented and memory intact) at a level 7. Section G, Functional Status, assessed the resident as needing extensive assistance with locomotion on the unit and in her room and utilized a wheelchair as a mobile device. Review of the facility's investigation report dated 10/17/16 revealed that Resident #2 was being pushed in her wheelchair on 10/10/16 at 6:30 p.m. to the dining room by a staff member employed as a Hospitality Aide (HA D) down A wing hall and fell forward out of the wheelchair hitting her head on the floor. HA D reported he had instructed Resident #2 to pick up her feet and lean back in the chair and instead Resident #2 put her feet down on the rug and fell forward hitting her forehead, resulting in a severe abrasion and laceration to the forehead. Review of hospital ER record dated 10/11/16 confirmed that Resident #2 was admitted to ICU with an avulsion fracture (a fragment of bone tears away from the main mass of bone as a result of physical trauma) of the C-2 to the neck at the base of the head. A radiology review dated 10/11/16 documented that the resident had been wheelchair bound for over a year due to knee pain and difficulty ambulating. A CT-SCAN (computed tomography) ruled out cerebral injuries. A plastic surgery consult dated 10/11/16 revealed the resident had a 6 cm linear laceration of the temporal and lateral orbital and supraorbital soft tissue, which was repaired in the ER. Review of a nursing notes dated 10/10/16, 4:42 p.m. revealed social service was unable to complete a BIMS assessment as the resident was not able to wake up and speak. On 10/10/16, at 6:37 p.m., the resident was sitting in wheelchair and being pushed in the wheelchair by HA D and leaned forward and fell on the floor hitting her head and sustaining a large gash 3-4 inch in length to the forehead. During an interview on 10/12/16 at 2:55 p.m., Hospitality Aide (HA) D reported that he was working on the A hall wing on the evening of 10/10/16 and had removed Resident #2 from the library area in front of the nurses' station by pushing her in her wheelchair to her room for incontinent care. There were no footrests attached to the wheelchair and HA D instructed Resident #2 to lift her feet. CNA C lifted the resident onto her bed and performed incontinent care and then transferred her back to the wheelchair. HA D then pushed the resident out of the room and into the hallway. HA D stated that he had taken about 18 steps into the hallway and was talking to the resident asking her how her day going. He stated that he had to maneuver around another resident in a wheelchair in the hallway and that was when he heard Resident #2 drop her feet down. He stated that he had not seen her feet drop. Review of the facility's undated job description for hospitality assistance revealed the hospitality assistant worked under the direction of the charge nurse, ADON and DON and duties included providing fresh water and encouraging fluid intake; answering call lights within 5 minutes; making beds and escorting residents to and from activities and dining area. The job description did not include pushing residents in wheelchairs. During an interview on 10/12/16 at 5:00 p.m., CNA C reported that he was working on the A hall wing on the evening of 10/10/16 and had performed incontinent care on Resident #2 after HA D had brought the resident into her room and transferred her to her bed. He stated that after performing incontinent care, he had transferred Resident #2 back to the wheelchair. He stated that he did not attach footrests to the wheelchair, because there were none in the room. During an interview on 10/13/16 at 10:40 a.m., the Rehabilitation Director, E, reported that whenever he picked up Resident #2 for therapy he always applied footrests to her wheelchair. He stated that the resident was limited in her ability to propel. He stated that the resident had bad and good days and was often lethargic or seemed sedated and therapy was limited due to a lack of participation. He stated that on the morning of 10/10/16, the resident was too lethargic to complete therapy. During an interview on 10/13/16 at 11:55 a.m., Resident #2's POA stated that Resident #2 did not propel in her wheelchair and that the wheelchair was always locked whenever she or her sisters visited. Sometimes the resident was found asleep in the wheelchair and leaning forward. During an observation on 10/13/16 at approximately 1:10 p.m., Resident #2 was observed at a local hospital ICU unit. The resident was unresponsive to verbal stimuli and touch. A nasal gastric tube extended from a nostril and an indwelling urinary catheter was draining yellow clear urine. The resident had an IV running and a solid neck brace was in place. A large discolored closed laceration extended to the right temporal area. The right shoulder was discolored and appeared to be bruised. During an interview on 10/17/16 at 2:30 p.m., LVN N, CN, reported that she was working the evening shift on 10/10/16 on A hall wing and was told in report by the previous nurse that Resident #2 was having a good day. She stated that she observed Resident #2 sitting in her wheelchair with glasses and shoes and fully dressed. She stated that the resident was heard yelling and observed her leaning forward. LVN N stated that when she worked the shift she kept an eye on Resident #2 and when sitting in her wheelchair, the chair was always locked. Occasionally, Resident #2 would unlock the wheels and propel to the nurses station, but the resident never propelled anywhere else. LVN N reported that when pushing the resident, the staff would place a hand on her chest to prevent her from falling forward and the resident often placed her feet on the floor. LVN N stated that she gave an in-service a couple of weeks before the fall (10/10/16) which included preventing Resident #2 from leaning forward when pushed in the wheelchair by placing a hand on the chest. She stated that CNA C was present, but HA D was not at the in-service. She stated that HA D was not sufficiently oriented for care of residents on the A wing hall as he was oriented on B wing hall. During the end of the day conference on 10/12/16 at 5: 30 p.m., the Administrator stated that she had thought the footrests had been discontinued because Resident #2 could propel herself. The Administrator referred to the re-admission nursing assessment of 8/17/16 as evidence. The DON and LVN T were also present during the conference and reported that the POC computers used by the direct care staff also listed the care needs of each resident on the profile icon and each direct care staff could access the profile. During an interview on 10/14/16 at 8:50 a.m., the DON reported that she had instructed the staff that any resident that had to be pushed in a wheelchair was to have footrests. During an interview on 10/17/16 at approximately 3:50 p.m., the RN Consultant reported that prior to this week, the facility had not established a post fall interdisciplinary team (IDT) program to evaluate and recommend interventions in reducing the fall rate within the facility. During interview on 10/14/16 at approximately 8:50 a.m., the DON reported that she had a QA (quality assurance) nurse conducting assessments of all the residents in the facility for the use of wheelchairs and footrests. She stated that the residents had not been assessed until Resident #2 fell on [DATE]. A copy of the assessment list was provided to the surveyor and revealed that the assessments were conducted on 10/11/14 and as off 10/13/16 seventeen (17) residents had been assessed. Review of the facility's operational/resident care policy on management of fall prevention dated 2007 revealed that: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The Administrator was notified on 10/14/16 at 4:00 p.m. of an Immediate Jeopardy for the above failures and a Plan of Removal was requested. The facility's Plan of Removal was provided by the Administrator on 10/17/16 and included the following steps to be taken by the facility: a. In-service of all staff were to be educated on not pushing residents in wheelchairs until the leg-rests were attached for transport. Part of the education will be to encourage residents to self-propel whenever possible as to not promote a decline in their ADLs. The education will be included in orientation and facility staff was not to beginning their shifts until receiving the education. b. The Interdisciplinary Team was to be educated by the Regional Director of Operations to identify resident safety concerns and compliance with residents requiring wheelchair mobility. c. All 83 residents were to be screened for wheelchair use and footrests. A list with the names of each resident requiring a wheelchair and footrests was to be completed. Residents on the list were to be identified and observed for compliancy. All wheelchairs were to be labeled with the resident's name and wheelchairs were affixed with footrests. d. The facility's computerized Point Of Contact Resident Profile care plan was to be updated to reflect changes in resident care needs. Direct care staff was to be in-serviced individually by the DON to access the resident POC profile icon and identify the care plans. e. The DON was to conduct between shift reports on residents with on-coming direct care staff prior to starting their shifts. Verification of the Plan of Removal was as follows: Observations conducted on 10/15/16, 10/16/16 and 10/17/16 confirmed that footrests were being utilized by residents being pushed in wheelchairs. Interviews with staff on 10/16/16 and 10/17/17 confirmed that the education of the staff had been completed prior to starting their shifts. Observations on 10/17/16 during the 3:00 p.m. change of shift confirmed that the DON was attending change of shift reports between the charge nurses and CNA's for the evening shift. On 10/17/16 at 3:50 p.m., the Administrator was informed that the IJ was removed. However, the facility remained out of compliance with a severity of actual harm with a scope identified as pattern. The facility was continuing to educate staff and monitor resident at risk for falls. The facility reported that 17 residents were assessed at risk for falls and required wheelchairs with footrests.

Based on observation, interview and record review, the Administrator and Director of Nurses failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 1 of 15 residents (#2) whose care was reviewed in that: The Administrator and DON did not implement the facility's policies and procedures to protect Resident #2 from falling out of a wheelchair while being pushed. The DON did not supervise that all residents were assessed for wheelchairs and residents at risk for falls in wheelchairs of the need for footrests when being pushed in wheelchairs. The DON failed to supervise the charge nurse on A wing to include HA D in training on how to prevent Resident #2 from leaning forward. These failures resulted in an identification of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 10/14/16. While the IJ was removed on 10/17/16, the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. These deficient practices placed 17 residents at risk for injuries due to not having footrests attached to their wheelchairs when being pushed by direct care staff. The findings were: Review of Resident #2's undated admission face sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a fall risk assessment dated [DATE] revealed Resident #2 was at risk for falls due to poor safety awareness and spent most of her time in a wheelchair due to arthritic knees. The approaches include wearing non-skid footwear. A fall risk assessment dated [DATE] scored the resident a 15 (10 or above indicates a risk for falls) due to confusions at times and receiving 2 or more medications ([MEDICATION NAME], antihypertensive and narcotics). Review of a care plan dated 3/9/16 for falls did not include the use of assistive devices such as wheelchair or footrests. Review of a re-admission nursing assessment by LVN T dated 8/15/16 revealed that the resident was severely (cognitively) impaired and never or rarely made decisions and usually understood others but missed the intent of their message. The assessment area for wheelchair-use was checked to indicate the resident was able to self-propel. Review of a history and physical dated 8/16/16 revealed the resident had been hospitalized from [DATE] to 8/15/16 for a urinary tract infection. Review of a nursing note dated 8/20/16 post re-admission revealed that Physical/Speech/Occupational Therapy was required due to the resident's requirement for extensive assistance with transfers, bed mobility and toileting. Review of a quarterly MDS dated [DATE] assessed Resident #2's BIMS (a brief cognitive assessment with a scoring from 1-15, 15 indicating most oriented and memory intact) at a level 7. Section G, Functional Status, assessed the resident as needing extensive assistance with locomotion on the unit and in her room and utilized a wheelchair as a mobile device. Review of the facility's investigation report dated 10/17/16 revealed that Resident #2 was being pushed in her wheelchair on 10/10/16 at 6:30 p.m. to the dining room by a staff member employed as a Hospitality Aide (HA D) down A wing hall and fell forward out of the wheelchair hitting her head on the floor. HA D reported he had told Resident #2 to pick up her feet and lean back in the chair and instead Resident #2 put her feet down on the rug and fell forward hitting her forehead, resulting in a severe abrasion and laceration to the forehead. Review of hospital ER record dated 10/11/16 confirmed that Resident #2 was admitted to ICU with an avulsion fracture (a fragment of bone tears away from the main mass of bone as a result of physical trauma) of the C-2 to the neck at the base of the head. A radiology review dated 10/11/16 documented that the resident had been wheelchair bound for over a year due to knee pain and difficulty ambulating. A CT-SCAN (computed tomography) ruled out cerebral injuries. A plastic surgery consult dated 10/11/16 revealed the resident had a 6 cm linear laceration of the temporal and lateral orbital and supraorbital soft tissue, which was repaired in the ER. Review of a nursing notes dated 10/10/16, 4:42 p.m. revealed social service was unable to complete a BIMS assessment as the resident was not able to wake up and speak. On 10/10/16, at 6:37 p.m., the resident was sitting in wheelchair and being pushed in the wheelchair by HA D and leaned forward and fell on the floor hitting her head and sustaining a large gash 3-4 inch in length to the forehead. During an interview on 10/12/16 at 2:55 p.m., Hospitality Aide (HA) D reported that he was working on the A hall wing on the evening of 10/10/16 and had removed Resident #2 from the library area in front of the nurses' station by pushing her in her wheelchair to her room for incontinent care. There were no footrests attached to the wheelchair and HA D instructed Resident #2 to lift her feet. CNA C lifted the resident onto her bed and performed incontinent care and then transferred her back to the wheelchair. HA D then pushed the resident out of the room and into the hallway. HA D stated that he had taken about 18 steps into the hallway and was talking to the resident asking her how her day going. He stated that he had to maneuver around another resident in a wheelchair in the hallway and that was when he heard Resident #2 drop her feet down. He stated that he had not seen her feet drop. Review of the facility's undated job description for hospitality assistance revealed the hospitality assistant worked under the direction of the charge nurse, ADON and DON and duties included providing fresh water and encouraging fluid intake; answering call lights within 5 minutes; making beds and escorting residents to and from activities and dining area. The job description did not include pushing residents in wheelchairs. During an interview on 10/12/16 at 5:00 p.m., CNA C reported that he was working on the A hall wing on the evening of 10/10/16 and had performed incontinent care on Resident #2 after HA D had brought the resident into her room and transferred her to her bed. He stated that after performing incontinent care, he had transferred Resident #2 back to the wheelchair. He stated that he did not attach footrests to the wheelchair, because there were none in the room. During an interview on 10/13/16 at 10:40 a.m., the Rehabilitation Director, E, reported that whenever he picked up Resident #2 for therapy he always applied footrests to her wheelchair. He stated that the resident was limited in her ability to propel. He stated that the resident had bad and good days and was often lethargic or seemed sedated and therapy was limited due to a lack of participation. He stated that on the morning of 10/10/16, the resident was too lethargic to complete therapy. During an interview on 10/13/16 at 11:55 a.m., Resident #2's POA stated that Resident #2 did not propel in her wheelchair and that the wheelchair was always locked whenever she or her sisters visited. Sometimes the resident was found asleep in the wheelchair and leaning forward. During an observation on 10/13/16 at approximately 1:10 p.m., Resident #2 was observed at a local hospital ICU unit. The resident was unresponsive to verbal stimuli and touch. A nasal gastric tube extended from a nostril and an indwelling urinary catheter was draining yellow clear urine. The resident had an IV running and a solid neck brace was in place. A large discolored closed laceration extended to the right temporal area. The right shoulder was discolored and appeared to be bruised. During an interview on 10/17/16 at 2:30 p.m., LVN N, CN, reported that she was working the evening shift on 10/10/16 on A hall wing and was told in report by the previous nurse that Resident #2 was having a good day. She stated that she observed Resident #2 sitting in her wheelchair with glasses and shoes and fully dressed. She stated that the resident was heard yelling and observed her leaning forward. LVN N stated that when she worked the shift she kept an eye on Resident #2 and when sitting in her wheelchair, the chair was always locked. Occasionally, Resident #2 would unlock the wheels and propel to the nurses station, but the resident never propelled anywhere else. LVN N reported that when pushing the resident, the staff would place a hand on her chest to prevent her from falling forward and the resident often placed her feet on the floor. LVN N stated that she gave an in-service a couple of weeks before the fall (10/10/16) which included preventing Resident #2 from leaning forward when pushed in the wheelchair by placing a hand on the chest. She stated that CNA C was present, but HA D was not at the in-service. She stated that HA D was not sufficiently oriented for care of residents on the A wing hall as he was oriented on B wing hall. During the end of the day conference on 10/12/16 at 5: 30 p.m., the Administrator stated that she had thought the footrests had been discontinued because Resident #2 could propel herself. The Administrator referred to the re-admission nursing assessment of 8/17/16 as evidence. The DON and LVN T were also present during the conference and reported that the POC computers used by the direct care staff also listed the care needs of each resident on the profile icon and each direct care staff could access the profile. During an interview on 10/14/16 at 8:50 a.m., the DON reported that she had instructed the staff that any resident that had to be pushed in a wheelchair was to have footrests. During an interview on 10/17/16 at approximately 3:50 p.m., the RN Consultant reported that prior to this week, the facility had not established a post fall interdisciplinary team (IDT) program to evaluate and recommend interventions in reducing the fall rate within the facility. During interview on 10/14/16 at approximately 8:50 a.m., the DON reported that she had a QA (quality assurance) nurse conducting assessments of all the residents in the facility for the use of wheelchairs and footrests. She stated that the residents had not been assessed until Resident #2 fell on [DATE]. A copy of the assessment list was provided to the surveyor and revealed that the assessments were conducted on 10/11/14 and as off 10/13/16 seventeen (17) residents had been assessed. Review of the facility's operational/resident care policy on management of fall prevention dated 2007 revealed that: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The Administrator was notified on 10/14/16 at 4:00 p.m. of an Immediate Jeopardy for the above failures and a Plan of Removal was requested. The facility's Plan of Removal was provided by the Administrator on 10/17/16 and included the following steps to be taken by the facility: a. In-service of all staff were to be educated on not pushing residents in wheelchairs until the leg-rests were attached for transport. Part of the education will be to encourage residents to self-propel whenever possible as to not promote a decline in their ADLs. The education will be included in orientation and facility staff was not to beginning their shifts until receiving the education. b. The Interdisciplinary Team was to be educated by the Regional Director of Operations to identify resident safety concerns and compliance with residents requiring wheelchair mobility. c. All 83 residents were to be screened for wheelchair use and footrests. A list with the names of each resident requiring a wheelchair and footrests was to be completed. Residents on the list were to be identified and observed for compliancy. All wheelchairs were to be labeled with the resident's name and wheelchairs were affixed with footrests. d. The facility's computerized Point Of Contact Resident Profile care plan was to be updated to reflect changes in resident care needs. Direct care staff was to be in-serviced individually by the DON to access the resident POC profile icon and identify the care plans. e. The DON was to conduct between shift reports on residents with on-coming direct care staff prior to starting their shifts. Verification of the Plan of Removal was as follows: Observations conducted on 10/15/16, 10/16/16 and 10/17/16 confirmed that footrests were being utilized by residents being pushed in wheelchairs. Interviews with staff on 10/16/16 and 10/17/17 confirmed that the education of the staff had been completed prior to starting their shifts. Observations on 10/17/16 during the 3:00 p.m. change of shift confirmed that the DON was attending change of shift reports between the charge nurses and CNA's for the evening shift. On 10/17/16 at 3:50 p.m., the Administrator was informed that the IJ was removed. However, the facility remained out of compliance with a severity of actual harm with a scope identified as pattern. The facility was continuing to educate staff and monitor resident at risk for falls. The facility reported that 17 residents were assessed at risk for falls and required wheelchairs with footrests.

Based on interviews and record reviews, the facility failed to provide or obtain laboratory services to meet the needs of 1 of 6 residents (Resident #1) whose labs were reviewed in that: Resident #1 was ordered to have PT/INR lab draws on [DATE] and on [DATE]. The [DATE] lab draw was missed. The [DATE] lab draw was rejected. Resident #1's [MEDICATION NAME] (a blood thinner) was not held on [DATE] and [DATE] and should have been held secondary to abnormal results. Resident #1 was admitted to the hospital on [DATE] with a GI hemorrhage and had to have a blood transfusion. An immediate jeopardy was identified that existed from [DATE] to [DATE] at a scope of pattern. This was determined to be past non-compliance. The facility implemented actions that corrected the non-compliance prior to the beginning of the investigation survey. This deficient practice could affect 4 residents at the facility with prescribed [MEDICATION NAME] by contributing to inappropriate administration based on missing lab results. The findings were: Record review of Resident #1's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's consolidated physician orders (dated [DATE] through [DATE]) revealed that she was to be administered [MEDICATION NAME] (a blood thinner) 40 milligrams every day. Record review of Resident #1's physician telephone order (dated [DATE] and received by LVN B) revealed that she was to have a PT/INR lab draw Friday ([DATE]) morning, [MEDICATION NAME] 5 milligrams every day at 6:00 p.m., and continued [MEDICATION NAME] until her PT/INR was 2. Record review of Resident #1's physician telephone order (dated [DATE] and received by the DON) revealed that she was to have PT/INR lab draws every Monday, that her [MEDICATION NAME] was to be held on [DATE] and [DATE], and that her [MEDICATION NAME] was to be discontinued. Record review of Resident #1's July of 2016 MARs revealed that [MEDICATION NAME] was initialed as being given at 6:00 p.m. on [DATE], [DATE], and [DATE]. On [DATE], the initials were circled and the order was changed. On [DATE], the medication was held. Record review of Resident #1's August of 2016 MARs revealed that [MEDICATION NAME] was initialed as being given at 8:00 p.m. on [DATE] and that PT/INR every Monday morning was initialed as well. Record review of Resident #1's [DATE] INR lab result revealed that it was abnormal. Her INR was 4.8, and the therapeutic range was .8 to 1.2. Record review of Resident #1's [DATE] INR lab result revealed that it was abnormal. Her INR was 7.3, and the therapeutic range was .8 to ,[DATE]. Record review of Resident #1's physician telephone order (dated [DATE]) revealed that she was to be sent to the hospital for evaluation and treatment. Record review of Resident #1's [DATE] transfer form revealed that she was transferred from the facility to the hospital for evaluation and treatment of [REDACTED]. During an interview with the DON at 9:56 a.m. on [DATE], she reported that she worked from Saturday ([DATE]) 6:30 p.m. to Sunday ([DATE]) 7:00 a.m. The DON reported that Resident #1 was scheduled to have a PT/INR lab draw on Friday ([DATE]). On Saturday morning, QA Nurse G caught that the [DATE] PT/INR lab for Resident #1 was not drawn, so the PT/INR lab was drawn on Saturday morning. The results were obtained at approximately 11:30 p.m. Saturday evening and indicated that Resident #1's INR was 4.8 (above the therapeutic range of .8 to 1.2). The DON called Resident #1's nurse practitioner and got orders to hold her [MEDICATION NAME] Saturday evening and Sunday and resume it Monday depending on her Monday morning PT/INR lab draw results. The DON reported that, early Monday ([DATE]) morning, Resident #1's PT/INR lab was drawn again. The ,[DATE] shift nurse on Monday administered Resident #1's 6:00 p.m. [MEDICATION NAME] without getting her PT/INR results from that morning. Resident #1's PT/INR lab draw for Monday morning was rejected and there were no results to be had. On Tuesday ([DATE]) morning, Resident #1's PT/INR lab was again drawn. By this time, blood clots were observed in Resident #1's [MEDICAL CONDITION] bag and there was bleeding at her stoma site. Resident #1 was sent to the hospital. Her lab results (from the Tuesday morning lab draw - results obtained after her transfer to the hospital) indicated that her INR was 7.3 (above the therapeutic range of .8 to 1.2). During an interview with the DON at 1:11 p.m. on [DATE], she reported that there were no physician orders for [MEDICATION NAME] parameters for Resident #1. However, the DON stated It's just best practice. If a PT/INR lab is drawn, you wait for the results before administering [MEDICATION NAME]. The DON confirmed that LVN B actually administered Resident #1 [MEDICATION NAME] twice when Resident #1's [MEDICATION NAME] should have been held - on [DATE] and again on [DATE]. During a phone interview with LVN B at 2:48 p.m. on [DATE], she reported that Resident #1 was sent to the hospital at approximately 3:00 p.m. on [DATE] because she had blood clots coming out of her ostomy site. LVN B stated I should have asked for more information in report. LVN B reported that she worked the ,[DATE] shift on [DATE] and didn't work again until the ,[DATE] shift on [DATE]. LVN B reported that she should have logged into the computer to access Resident #1's lab results, that she should have called Resident #1's doctor and got a hold order, and that she should have held Resident #1's [MEDICATION NAME]. She stated I got her results the night she went to the hospital and my heart dropped. Her INR levels were critical. She could have died . Record review of Resident #1's hospital records revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. During an interview with the DON at 5:37 p.m. on [DATE], she was asked about the facility's procedure for making sure labs were drawn when ordered and for staff response when lab results were not in. The DON reported that, during change-of-shift reports, the offgoing nurse should tell the incoming nurse which labs have been drawn, which labs the facility was waiting for, pertinent lab results, etc. The DON reported that QA Nurse G caught Resident #1's missing [DATE] PT/INR lab draw when reviewing charts. She reported that the facility had no specific lab policy. The DON stated The lab company signs off on requisition for labs so we know that they were drawn. When asked why Resident #1's PT/INR lab draw was not done, the DON stated The lab group said it was staffing problems - that's the reason I was given. If there are no lab results, the nurses have been told to seek out lab results - 1) check the computer 2) call the lab company 3) call the lab company managers and 4) call me. Record review of the facility's Anticoagulant Monitoring Form (not dated) revealed PT/INR Guidelines and Tracking Log 1. If lab (PT/INR) is within therapeutic range, continue with same [MEDICATION NAME] dose and repeat PT/INR at routine interval as ordered. No need to call the practitioner. 2. If PT/INR is less than therapeutic range, call practitioner for new orders. 3. If PT/INR is greater than 3.5 and less than 5, hold [MEDICATION NAME] and contact practitioner within 24 hours. 4. If PT/INR is 5 or higher, hold [MEDICATION NAME] and contact practitioner STAT and be prepared to administer Vitamin K 2.5 milligrams to 10 milligrams subcutaneously. Will also need to repeat PT/INR STAT in 6 hours if Vitamin K given. The surveyor exited the facility on [DATE] and re-entered on [DATE] after administrative review. On [DATE], the administrator was notified that an immediate jeopardy at past non-compliance had been identified. The immediate jeopardy occurred [DATE] to [DATE] at a scope of pattern. The facility began and completed corrective action on [DATE]. Eight LVNs/RNs were in-serviced on [MEDICATION NAME] safety by the DON on [DATE]. LVN B received one-on-one counseling from the DON on [DATE]. LVN B signed the in-service on [DATE]. The DON reviewed all [MEDICATION NAME] logs to ensure that they were up to date and that treatment was appropriate. During the exit interview at 6:20 p.m. on [DATE], the DON reported that the facility currently had 4 residents with prescribed [MEDICATION NAME].

Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for 1 of 6 residents (Resident #1) whose care was reviewed in that the facility failed to provide goods and services necessary to avoid physical harm. Resident #1's [MEDICATION NAME] (a blood thinner) was not held by LVN B when PT/INR lab draw results were unavailable. Resident #1's [MEDICATION NAME] should have been held twice secondary to abnormal PT/INR lab draw results. Resident #1 was admitted to the hospital on [DATE] with a GI hemorrhage and had to have a blood transfusion. An immediate jeopardy was identified that existed from [DATE] to [DATE] at a scope of pattern. This was determined to be past non-compliance. The facility implemented actions that corrected the non-compliance prior to the beginning of the investigation survey. This deficient practice could affect 4 residents at the facility with prescribed [MEDICATION NAME] by contributing to inappropriate [MEDICATION NAME] administration based on missing/unreviewed lab results. The findings were: Record review of the facility's Reporting Abuse to Facility Management policy (revised in December of 2013) revealed . 2. f. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Record review of the facility's provider investigation report for Resident #1's [DATE] alleged neglect revealed that LVN B failed to review a [MEDICATION NAME] flow log resulting in Resident #1 receiving medication when the medication should have been held. Investigation findings were confirmed. Record review of Resident #1's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's consolidated physician orders (dated [DATE] through [DATE]) revealed that she was to be administered [MEDICATION NAME] (a blood thinner) 40 milligrams every day. Record review of Resident #1's physician telephone order (dated [DATE] and received by LVN B) revealed that she was to have a PT/INR lab draw Friday ([DATE]) morning, [MEDICATION NAME] 5 milligrams every day at 6:00 p.m., and continued [MEDICATION NAME] until her PT/INR was 2. Record review of Resident #1's physician telephone order (dated [DATE] and received by the DON) revealed that she was to have PT/INR lab draws every Monday, that her [MEDICATION NAME] was to be held on [DATE] and [DATE], and that her [MEDICATION NAME] was to be discontinued. Record review of Resident #1's July of 2016 MARs revealed that [MEDICATION NAME] was initialed as being given at 6:00 p.m. on [DATE], [DATE], and [DATE]. On [DATE], the initials were circled and the order was changed. On [DATE], the medication was held. Record review of Resident #1's August of 2016 MARs revealed that [MEDICATION NAME] was initialed as being given at 8:00 p.m. on [DATE] and that PT/INR every Monday morning was initialed as well. Record review of Resident #1's [DATE] INR lab result revealed that it was abnormal. Her INR was 4.8, and the therapeutic range was .8 to 1.2. Record review of Resident #1's [DATE] INR lab result revealed that it was abnormal. Her INR was 7.3, and the therapeutic range was .8 to ,[DATE]. Record review of Resident #1's physician telephone order (dated [DATE]) revealed that she was to be sent to the hospital for evaluation and treatment. Record review of Resident #1's [DATE] transfer form revealed that she was transferred from the facility to the hospital for evaluation and treatment of [REDACTED]. During an interview with the DON at 9:56 a.m. on [DATE], she reported that she worked from Saturday ([DATE]) 6:30 p.m. to Sunday ([DATE]) 7:00 a.m. The DON reported that Resident #1 was scheduled to have a PT/INR lab draw on Friday ([DATE]). On Saturday morning, QA Nurse G caught that the [DATE] PT/INR lab for Resident #1 was not drawn, so the PT/INR lab was drawn on Saturday morning. The results were obtained at approximately 11:30 p.m. Saturday evening and indicated that Resident #1's INR was 4.8 (above the therapeutic range of .8 to 1.2). The DON called Resident #1's nurse practitioner and got orders to hold her [MEDICATION NAME] Saturday evening and Sunday and resume it Monday depending on her Monday morning PT/INR lab draw results. The DON reported that, early Monday ([DATE]) morning, Resident #1's PT/INR lab was drawn again. The ,[DATE] shift nurse on Monday administered Resident #1's 6:00 p.m. [MEDICATION NAME] without getting her PT/INR results from that morning. Resident #1's PT/INR lab draw for Monday morning was rejected and there were no results to be had. On Tuesday ([DATE]) morning, Resident #1's PT/INR lab was again drawn. By this time, blood clots were observed in Resident #1's [MEDICAL CONDITION] bag and there was bleeding at her stoma site. Resident #1 was sent to the hospital. Her lab results (from the Tuesday morning lab draw - results obtained after her transfer to the hospital) indicated that her INR was 7.3 (above the therapeutic range of .8 to 1.2). During an interview with the DON at 1:11 p.m. on [DATE], she reported that there were no physician orders for [MEDICATION NAME] parameters for Resident #1. However, the DON stated It's just best practice. If a PT/INR lab is drawn, you wait for the results before administering [MEDICATION NAME]. The DON confirmed that LVN B actually administered Resident #1 [MEDICATION NAME] twice when Resident #1's [MEDICATION NAME] should have been held - on [DATE] and again on [DATE]. During a phone interview with LVN B at 2:48 p.m. on [DATE], she reported that Resident #1 was sent to the hospital at approximately 3:00 p.m. on [DATE] because she had blood clots coming out of her ostomy site. LVN B stated I should have asked for more information in report. LVN B reported that she worked the ,[DATE] shift on [DATE] and didn't work again until the ,[DATE] shift on [DATE]. LVN B reported that she should have logged into the computer to access Resident #1's lab results, that she should have called Resident #1's doctor and got a hold order, and that she should have held Resident #1's [MEDICATION NAME]. She stated I got her results the night she went to the hospital and my heart dropped. Her INR levels were critical. She could have died . Record review of Resident #1's hospital records revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. During an interview with the DON at 5:37 p.m. on [DATE], she was asked about the facility's procedure for making sure labs were drawn when ordered and for staff response when lab results were not in. The DON reported that, during change-of-shift reports, the offgoing nurse should tell the incoming nurse which labs have been drawn, which labs the facility was waiting for, pertinent lab results, etc. The DON reported that QA Nurse G caught Resident #1's missing [DATE] PT/INR lab draw when reviewing charts. She reported that the facility had no specific lab policy. The DON stated The lab company signs off on requisition for labs so we know that they were drawn. When asked why Resident #1's PT/INR lab draw was not done, the DON stated The lab group said it was staffing problems - that's the reason I was given. If there are no lab results, the nurses have been told to seek out lab results - 1) check the computer 2) call the lab company 3) call the lab company managers and 4) call me. Record review of the facility's Anticoagulant Monitoring Form (not dated) revealed PT/INR Guidelines and Tracking Log 1. If lab (PT/INR) is within therapeutic range, continue with same [MEDICATION NAME] dose and repeat PT/INR at routine interval as ordered. No need to call the practitioner. 2. If PT/INR is less than therapeutic range, call practitioner for new orders. 3. If PT/INR is greater than 3.5 and less than 5, hold [MEDICATION NAME] and contact practitioner within 24 hours. 4. If PT/INR is 5 or higher, hold [MEDICATION NAME] and contact practitioner STAT and be prepared to administer Vitamin K 2.5 milligrams to 10 milligrams subcutaneously. Will also need to repeat PT/INR STAT in 6 hours if Vitamin K given. The surveyor exited the facility on [DATE] and re-entered on [DATE] after administrative review. On [DATE], the administrator was notified that an immediate jeopardy at past non-compliance had been identified. The immediate jeopardy occurred [DATE] to [DATE] at a scope of pattern. The facility began and completed corrective action on [DATE]. Eight LVNs/RNs were in-serviced on [MEDICATION NAME] safety by the DON on [DATE]. LVN B received one-on-one counseling from the DON on [DATE]. LVN B signed the in-service on [DATE]. The DON reviewed all [MEDICATION NAME] logs to ensure that they were up to date and that treatment was appropriate. During the exit interview at 6:20 p.m. on [DATE], the DON reported that the facility currently had 4 residents with prescribed [MEDICATION NAME].

Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for 1 of 6 residents (Resident #1) whose care was reviewed in that the facility failed to provide goods and services necessary to avoid physical harm. Resident #1's [MEDICATION NAME] (a blood thinner) was not held by LVN B when PT/INR lab draw results were unavailable. Resident #1's [MEDICATION NAME] should have been held twice secondary to abnormal PT/INR lab draw results. Resident #1 was admitted to the hospital on [DATE] with a GI hemorrhage and had to have a blood transfusion. An immediate jeopardy was identified that existed from [DATE] to [DATE] at a scope of pattern. This was determined to be past non-compliance. The facility implemented actions that corrected the non-compliance prior to the beginning of the investigation survey. This deficient practice could affect 4 residents at the facility with prescribed [MEDICATION NAME] by contributing to inappropriate [MEDICATION NAME] administration based on missing/unreviewed lab results. The findings were: Record review of the facility's provider investigation report for Resident #1's [DATE] alleged neglect revealed that LVN B failed to review a [MEDICATION NAME] flow log resulting in Resident #1 receiving medication when the medication should have been held. Investigation findings were confirmed. Record review of Resident #1's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's consolidated physician orders (dated [DATE] through [DATE]) revealed that she was to be administered [MEDICATION NAME] (a blood thinner) 40 milligrams every day. Record review of Resident #1's physician telephone order (dated [DATE] and received by LVN B) revealed that she was to have a PT/INR lab draw Friday ([DATE]) morning, [MEDICATION NAME] 5 milligrams every day at 6:00 p.m., and continued [MEDICATION NAME] until her PT/INR was 2. Record review of Resident #1's physician telephone order (dated [DATE] and received by the DON) revealed that she was to have PT/INR lab draws every Monday, that her [MEDICATION NAME] was to be held on [DATE] and [DATE], and that her [MEDICATION NAME] was to be discontinued. Record review of Resident #1's July of 2016 MARs revealed that [MEDICATION NAME] was initialed as being given at 6:00 p.m. on [DATE], [DATE], and [DATE]. On [DATE], the initials were circled and the order was changed. On [DATE], the medication was held. Record review of Resident #1's August of 2016 MARs revealed that [MEDICATION NAME] was initialed as being given at 8:00 p.m. on [DATE] and that PT/INR every Monday morning was initialed as well. Record review of Resident #1's [DATE] INR lab result revealed that it was abnormal. Her INR was 4.8, and the therapeutic range was .8 to 1.2. Record review of Resident #1's [DATE] INR lab result revealed that it was abnormal. Her INR was 7.3, and the therapeutic range was .8 to ,[DATE]. Record review of Resident #1's physician telephone order (dated [DATE]) revealed that she was to be sent to the hospital for evaluation and treatment. Record review of Resident #1's [DATE] transfer form revealed that she was transferred from the facility to the hospital for evaluation and treatment of [REDACTED]. During an interview with the DON at 9:56 a.m. on [DATE], she reported that she worked from Saturday ([DATE]) 6:30 p.m. to Sunday ([DATE]) 7:00 a.m. The DON reported that Resident #1 was scheduled to have a PT/INR lab draw on Friday ([DATE]). On Saturday morning, QA Nurse G caught that the [DATE] PT/INR lab for Resident #1 was not drawn, so the PT/INR lab was drawn on Saturday morning. The results were obtained at approximately 11:30 p.m. Saturday evening and indicated that Resident #1's INR was 4.8 (above the therapeutic range of .8 to 1.2). The DON called Resident #1's nurse practitioner and got orders to hold her [MEDICATION NAME] Saturday evening and Sunday and resume it Monday depending on her Monday morning PT/INR lab draw results. The DON reported that, early Monday ([DATE]) morning, Resident #1's PT/INR lab was drawn again. The ,[DATE] shift nurse on Monday administered Resident #1's 6:00 p.m. [MEDICATION NAME] without getting her PT/INR results from that morning. Resident #1's PT/INR lab draw for Monday morning was rejected and there were no results to be had. On Tuesday ([DATE]) morning, Resident #1's PT/INR lab was again drawn. By this time, blood clots were observed in Resident #1's [MEDICAL CONDITION] bag and there was bleeding at her stoma site. Resident #1 was sent to the hospital. Her lab results (from the Tuesday morning lab draw - results obtained after her transfer to the hospital) indicated that her INR was 7.3 (above the therapeutic range of .8 to 1.2). During an interview with the DON at 1:11 p.m. on [DATE], she reported that there were no physician orders for [MEDICATION NAME] parameters for Resident #1. However, the DON stated It's just best practice. If a PT/INR lab is drawn, you wait for the results before administering [MEDICATION NAME]. The DON confirmed that LVN B actually administered Resident #1 [MEDICATION NAME] twice when Resident #1's [MEDICATION NAME] should have been held - on [DATE] and again on [DATE]. During a phone interview with LVN B at 2:48 p.m. on [DATE], she reported that Resident #1 was sent to the hospital at approximately 3:00 p.m. on [DATE] because she had blood clots coming out of her ostomy site. LVN B stated I should have asked for more information in report. LVN B reported that she worked the ,[DATE] shift on [DATE] and didn't work again until the ,[DATE] shift on [DATE]. LVN B reported that she should have logged into the computer to access Resident #1's lab results, that she should have called Resident #1's doctor and got a hold order, and that she should have held Resident #1's [MEDICATION NAME]. She stated I got her results the night she went to the hospital and my heart dropped. Her INR levels were critical. She could have died . Record review of Resident #1's hospital records revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. During an interview with the DON at 5:37 p.m. on [DATE], she was asked about the facility's procedure for making sure labs were drawn when ordered and for staff response when lab results were not in. The DON reported that, during change-of-shift reports, the offgoing nurse should tell the incoming nurse which labs have been drawn, which labs the facility was waiting for, pertinent lab results, etc. The DON reported that QA Nurse G caught Resident #1's missing [DATE] PT/INR lab draw when reviewing charts. She reported that the facility had no specific lab policy. The DON stated The lab company signs off on requisition for labs so we know that they were drawn. When asked why Resident #1's PT/INR lab draw was not done, the DON stated The lab group said it was staffing problems - that's the reason I was given. If there are no lab results, the nurses have been told to seek out lab results - 1) check the computer 2) call the lab company 3) call the lab company managers and 4) call me. Record review of the facility's Anticoagulant Monitoring Form (not dated) revealed PT/INR Guidelines and Tracking Log 1. If lab (PT/INR) is within therapeutic range, continue with same [MEDICATION NAME] dose and repeat PT/INR at routine interval as ordered. No need to call the practitioner. 2. If PT/INR is less than therapeutic range, call practitioner for new orders. 3. If PT/INR is greater than 3.5 and less than 5, hold [MEDICATION NAME] and contact practitioner within 24 hours. 4. If PT/INR is 5 or higher, hold [MEDICATION NAME] and contact practitioner STAT and be prepared to administer Vitamin K 2.5 milligrams to 10 milligrams subcutaneously. Will also need to repeat PT/INR STAT in 6 hours if Vitamin K given. Record review of the facility's Reporting Abuse to Facility Management policy (revised in December of 2013) revealed . 2. f. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . The surveyor exited the facility on [DATE] and re-entered on [DATE] after administrative review. On [DATE], the administrator was notified that an immediate jeopardy at past non-compliance had been identified. The immediate jeopardy occurred [DATE] to [DATE] at a scope of pattern. The facility began and completed corrective action on [DATE]. Eight LVNs/RNs were in-serviced on [MEDICATION NAME] safety by the DON on [DATE]. LVN B received one-on-one counseling from the DON on [DATE]. LVN B signed the in-service on [DATE]. The DON reviewed all [MEDICATION NAME] logs to ensure that they were up to date and that treatment was appropriate. During the exit interview at 6:20 p.m. on [DATE], the DON reported that the facility currently had 4 residents with prescribed [MEDICATION NAME].

Based on interviews and record reviews, the facility failed to ensure that each resident's drug regimen was free from unneccesary drugs for 1 of 6 residents (Resident #1) whose care was reviewed in that: Resident #1's [MEDICATION NAME] (a blood thinner) was not held by LVN B when PT/INR lab draw results were unavailable. Resident #1's [MEDICATION NAME] should have been held twice secondary to abnormal PT/INR lab draw results. Resident #1 was admitted to the hospital on [DATE] with a GI hemorrhage and had to have a blood transfusion. An immediate jeopardy was identified that existed from [DATE] to [DATE] at a scope of pattern. This was determined to be past non-compliance. The facility implemented actions that corrected the non-compliance prior to the beginning of the investigation survey. This deficient practice could affect 4 residents at the facility with prescribed [MEDICATION NAME] by contributing to inappropriate administration based on missing lab results. The findings were: Record review of Resident #1's facesheet (dated [DATE]) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's consolidated physician orders (dated [DATE] through [DATE]) revealed that she was to be administered [MEDICATION NAME] (a blood thinner) 40 milligrams every day. Record review of Resident #1's physician telephone order (dated [DATE] and received by LVN B) revealed that she was to have a PT/INR lab draw Friday ([DATE]) morning, [MEDICATION NAME] 5 milligrams every day at 6:00 p.m., and continued [MEDICATION NAME] until her PT/INR was 2. Record review of Resident #1's physician telephone order (dated [DATE] and received by the DON) revealed that she was to have PT/INR lab draws every Monday, that her [MEDICATION NAME] was to be held on [DATE] and [DATE], and that her [MEDICATION NAME] was to be discontinued. Record review of Resident #1's July of 2016 MARs revealed that [MEDICATION NAME] was initialed as being given at 6:00 p.m. on [DATE], [DATE], and [DATE]. On [DATE], the initials were circled and the order was changed. On [DATE], the medication was held. Record review of Resident #1's August of 2016 MARs revealed that [MEDICATION NAME] was initialed as being given at 8:00 p.m. on [DATE] and that PT/INR every Monday morning was initialed as well. Record review of Resident #1's [DATE] INR lab result revealed that it was abnormal. Her INR was 4.8, and the therapeutic range was .8 to 1.2. Record review of Resident #1's [DATE] INR lab result revealed that it was abnormal. Her INR was 7.3, and the therapeutic range was .8 to ,[DATE]. Record review of Resident #1's physician telephone order (dated [DATE]) revealed that she was to be sent to the hospital for evaluation and treatment. Record review of Resident #1's [DATE] transfer form revealed that she was transferred from the facility to the hospital for evaluation and treatment of [REDACTED]. During an interview with the DON at 9:56 a.m. on [DATE], she reported that she worked from Saturday ([DATE]) 6:30 p.m. to Sunday ([DATE]) 7:00 a.m. The DON reported that Resident #1 was scheduled to have a PT/INR lab draw on Friday ([DATE]). On Saturday morning, QA Nurse G caught that the [DATE] PT/INR lab for Resident #1 was not drawn, so the PT/INR lab was drawn on Saturday morning. The results were obtained at approximately 11:30 p.m. Saturday evening and indicated that Resident #1's INR was 4.8 (above the therapeutic range of .8 to 1.2). The DON called Resident #1's nurse practitioner and got orders to hold her [MEDICATION NAME] Saturday evening and Sunday and resume it Monday depending on her Monday morning PT/INR lab draw results. The DON reported that, early Monday ([DATE]) morning, Resident #1's PT/INR lab was drawn again. The ,[DATE] shift nurse on Monday administered Resident #1's 6:00 p.m. [MEDICATION NAME] without getting her PT/INR results from that morning. Resident #1's PT/INR lab draw for Monday morning was rejected and there were no results to be had. On Tuesday ([DATE]) morning, Resident #1's PT/INR lab was again drawn. By this time, blood clots were observed in Resident #1's [MEDICAL CONDITION] bag and there was bleeding at her stoma site. Resident #1 was sent to the hospital. Her lab results (from the Tuesday morning lab draw - results obtained after her transfer to the hospital) indicated that her INR was 7.3 (above the therapeutic range of .8 to 1.2). During an interview with the DON at 1:11 p.m. on [DATE], she reported that there were no physician orders for [MEDICATION NAME] parameters for Resident #1. However, the DON stated It's just best practice. If a PT/INR lab is drawn, you wait for the results before administering [MEDICATION NAME]. The DON confirmed that LVN B actually administered Resident #1 [MEDICATION NAME] twice when Resident #1's [MEDICATION NAME] should have been held - on [DATE] and again on [DATE]. During a phone interview with LVN B at 2:48 p.m. on [DATE], she reported that Resident #1 was sent to the hospital at approximately 3:00 p.m. on [DATE] because she had blood clots coming out of her ostomy site. LVN B stated I should have asked for more information in report. LVN B reported that she worked the ,[DATE] shift on [DATE] and didn't work again until the ,[DATE] shift on [DATE]. LVN B reported that she should have logged into the computer to access Resident #1's lab results, that she should have called Resident #1's doctor and got a hold order, and that she should have held Resident #1's [MEDICATION NAME]. She stated I got her results the night she went to the hospital and my heart dropped. Her INR levels were critical. She could have died . Record review of Resident #1's hospital records revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. During an interview with the DON at 5:37 p.m. on [DATE], she was asked about the facility's procedure for making sure labs were drawn when ordered and for staff response when lab results were not in. The DON reported that, during change-of-shift reports, the offgoing nurse should tell the incoming nurse which labs have been drawn, which labs the facility was waiting for, pertinent lab results, etc. The DON reported that QA Nurse G caught Resident #1's missing [DATE] PT/INR lab draw when reviewing charts. She reported that the facility had no specific lab policy. The DON stated The lab company signs off on requisition for labs so we know that they were drawn. When asked why Resident #1's PT/INR lab draw was not done, the DON stated The lab group said it was staffing problems - that's the reason I was given. If there are no lab results, the nurses have been told to seek out lab results - 1) check the computer 2) call the lab company 3) call the lab company managers and 4) call me. Record review of the facility's Anticoagulant Monitoring Form (not dated) revealed PT/INR Guidelines and Tracking Log 1. If lab (PT/INR) is within therapeutic range, continue with same [MEDICATION NAME] dose and repeat PT/INR at routine interval as ordered. No need to call the practitioner. 2. If PT/INR is less than therapeutic range, call practitioner for new orders. 3. If PT/INR is greater than 3.5 and less than 5, hold [MEDICATION NAME] and contact practitioner within 24 hours. 4. If PT/INR is 5 or higher, hold [MEDICATION NAME] and contact practitioner STAT and be prepared to administer Vitamin K 2.5 milligrams to 10 milligrams subcutaneously. Will also need to repeat PT/INR STAT in 6 hours if Vitamin K given. The surveyor exited the facility on [DATE] and re-entered on [DATE] after administrative review. On [DATE], the administrator was notified that an immediate jeopardy at past non-compliance had been identified. The immediate jeopardy occurred [DATE] to [DATE] at a scope of pattern. The facility began and completed corrective action on [DATE]. Eight LVNs/RNs were in-serviced on [MEDICATION NAME] safety by the DON on [DATE]. LVN B received one-on-one counseling from the DON on [DATE]. LVN B signed the in-service on [DATE]. The DON reviewed all [MEDICATION NAME] logs to ensure that they were up to date and that treatment was appropriate. During the exit interview at 6:20 p.m. on [DATE], the DON reported that the facility currently had 4 residents with prescribed [MEDICATION NAME].