Every finding on record at Avir at Texarkana

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 6 residents (Resident #1 and Resident #2) reviewed for abuse and neglect. The facility failed to report, timely to Health and Human Services Commission, an alleged incident of physical abuse by Resident #1 towards Resident #2 on or about 07/31/2026 and 08/02/2026. This failure could place residents at risk for abuse, humiliation, intimidation, fear, shame, agitation, and a decreased quality of life.Findings include:Record review of Resident #1's face sheet dated 08/14/2026 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included COPD (difficulty breathing), dementia (decline in cognitive processes), schizoaffective disorder (hallucinations and delusion, depression and mania). Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated, Resident #1 was able to make himself understood and usually understood others. The MDS assessment indicated Resident 1 had a BIMS score of 7 which indicated Resident #1's cognition was severely impaired. The MDS assessment indicated Resident #1 required supervision for standing/sitting, transferring, moderate assistance for walking, set up assistance for eating and oral care. Record review of Resident #1's care plan with a target date of 09/30/2026 indicated he had a behavior problem related to disease process, and he did not like other residents in his room with the following interventions: 1. Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention to something more positive. 2. Monitor behavior episodes and attempt to determine underlying causes. Consider location, time of day, people involved, and situations. Document behavior and potential causes. Record review of Resident 1's Order Summary Report dated 08/14/2026 indicated a medication order for: Olanzapine Oral Tablet 5 MG (Olanzapine) (Antipsychotic medication) Give 1 tablet by mouth two times a day related schizoaffective disorder. Record review of Resident #1's electronic data record on 08/13/2026 indicated no risk management reports for 07/31/2026. Record review of Resident #2's face sheet dated 08/14/2026 indicated Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included COPD (difficulty breathing), dementia (decline in cognitive processes), depression, anxiety (intense, excessive and persistent worry and fear about everyday situations) and hallucinations. Record review of Resident #2's Comprehensive MDS assessment dated [DATE] indicated, Resident #2 was able to usually make himself understood and usually understood others. The MDS assessment indicated Resident #2 had a BIMS score of 0 which indicated Resident #2's cognition was severely impaired. The MDS assessment indicated Resident #2 had experienced physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) within the last 1 to 3 days. The MDS assessment indicated Resident #2 had experienced 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) within the last 1 to 3 days. The MDS assessment indicated Resident #2 was independent with eating and oral hygiene, required set up assistance with personal hygiene, supervision of dressing, and moderate assistance for toileting hygiene. Record review of Resident #2's care plan with a target date of 11/03/2026 indicated he was at risk of elopement/wanderer related to impaired safety and awareness with the following intervention - would reside on the secured unit with redirect resident with meaningful activity when wandering in other rooms. Record review of the Provider Investigation Report dated 08/05/2026 indicated an incident of a resident-to-resident altercation on 07/31/2026 and 08/02/2026 were reported to the state agency on 08/04/2026 at 06:17 PM. The following witness statements were included: Witness statement dated 08/01/2026 signed by CNA A stated, on 07-31-26 [Resident #2] had to be re-directed constantly from going into other residents' rooms. Towards the end of the shift [Resident #2] went into [Resident #1's] room again and [Resident #1} screamed and said get out of my room and hit [Resident #1] in his stomach. I [CNA A] removed [Resident #2] out of [Resident #1's] room and reported to the charge nurse immediately. Witness statement dated 08/02/2026 signed by CNA A stated, on 08/02/2026 I was changing a resident before lunch and heard [Resident #1] screaming you don't belong in here. I immediately went to check to see what was going on and saw [Resident #1] on the floor in front of his bed and [Resident #2] was in his closet taking all the clothes out of closet. [Resident #2's] shirt had been pulled on in the front of his shirt to where it was out of shape very loose and hanging down under his neck. I then immediately got the charge nurse to let her know what was going on. Record review of Resident #2's electronic data record indicated a risk management report labeled physical aggression received dated 07/31/2026 at 07:00 PM stated [Resident #2] was wandering around hall when he went in [Resident #2's room]. [Resident #1] then hit [Resident #2] in the stomach and was promptly removed to his room. [Resident #2] was unable to give description. Administrator notified 07/31/2026 at 07:51 PM. Record review of Resident #2's electronic data record on 08/13/2026 indicated no risk management reports for 08/02/2026. Record review of Resident #2's electronic data record indicated a progress note dated 08/02/2026 at 12:04 PM signed by LVN B that stated, [Resident #2] continue to wonder [sic] in and out other resident room. [Resident #2] appears to be disheveled after entering a resident's room going into their closet. [Resident #2] redirected after aide heard yelling to separate residents. No injuries noted at this time. Record review of Resident #1's electronic data record indicated a progress note dated 08/02/2026 at 12:04 PM signed by LVN B that stated CNA informed this nurse (sic) was on the floor in front of his bed sitting on his bottom. Upon entering resident's room [Resident #1] observed in sitting position with knees bent. [Resident #2] observed in resident closet removing his clothes. [Resident #2] promptly removed from room. [Resident #1] assessed for injury and assisted back in bed Vital signs wnl. Record review of Resident #1's electronic data record indicated a risk management report labeled unwitnessed fall dated 08/02/2026 that stated CNA informed this nurse (sic) was on the floor in front of his bed sitting on his bottom. Resident unable to give description. Resident was attempting to remove another resident from his room. [Family member] notified. [Physician] notified. During an interview on 08/13/2026 at 02:45 PM, CNA A said the first incident occurred around 05:30 PM on 07/31/2026. CNA A said she was assisting another resident on the opposite end of the memory care unit when she heard Resident #1 screaming you don't belong in here. CNA A said when she got to Resident #1's room, she saw Resident #1 punch Resident #2 in the stomach. CNA A said she separated Resident #1 and Resident #2 and notified LVN B immediately. CNA A said LVN B was doing an assessment on Resident #1 in the memory care unit as she exited the unit at change of shift. CNA A said the second incident with Resident #1 and Resident #2 occurred on 08/02/2026, before lunch time. CNA A said she was assisting another resident on the opposite end of the hall on the memory unit when she heard Resident #1 screaming you don't belong in here. CNA A said she found Resident #1 sitting on the floor in front of his bed. CNA A said Resident #2 was in Resident #1's closet taking all the clothes out of the closet. CNA A said that Resident #2's shirt was disheveled, torn, and stretched in the front and hung loosely around his neck. CNA A said she immediately notified LVN B for assistance. CNA A said Resident #1 remained on the floor while Resident #2 continued to be in Resident #1's closet getting out clothes. CNA A said she quickly stuck her head out the memory unit door, which was beside Resident #1's room, and called for LVN B. CNA A said LVN B came onto the memory care unit at that time and began to assess Resident #1, then Resident #2. CNA A said that RN C entered the memory care unit from an outside door, after hearing the noise, and had entered Resident #1's room while she had notified LVN B from the doorway of the memory care unit. CNA A said LVN B asked Resident #1, Are you hurt?. CNA A said Resident #1 would only reply just my pride. CNA A said it was important to report abuse immediately so the facility could do its part to protect the residents from more abuse, and to investigate timely and properly. CNA A said abuse should be reported to the Abuse Coordinator or immediate supervisor. CNA A said she gave the requested written statements to LVN B on 08/02/2026 regarding both incidents (07/31/2026 and 08/02/2026) before the end of her shift. During an interview on 08/13/2026 at 03:01 PM, LVN B said she was notified of the resident-to-resident altercation between Resident #1 and Resident #2 on 07/31/2026 at the change of shift as CNA A exited the building from her shift. LVN B said she was sitting at the nurses' station outside the memory care unit when CNA A walked by and told her about the incident. LVN B said she immediately contacted the Administrator by telephone after CNA A told her about the altercation prior to going into the memory care unit and assessing the resident. LVN B said she documented she notified the administrator on the risk management report that she completed prior to leaving the facility on 07/31/2026. LVN B said she notified the Administrator because the Administrator was the abuse coordinator and it was important to notify the abuse coordinator so that proper state reporting could be completed within the required timelines of 2 hours if abuse was suspected. LVN B said the reporting guidelines were important to protect the residents from further abuse. LVN B said she had not reported the second incident that occurred between Resident #1 and Resident #2 on 08/02/2026 to the abuse coordinator because she had to take care of the required documentation and other notifications to the physician and the family. LVN B said when she entered Resident #1's room he was on the floor sitting on his buttocks. LVN B said Resident #2 was in Resident #1's closet taking out clothes. LVN B said Resident #2 clothes were mangled and he looked disheveled. LVN B said that CNA A was assisting RN C redirect Resident #2 out of Resident #1's room while she performed the assessment on Resident #1. LVN B said that RN C was supposed to notify the Abuse Coordinator as the acting weekend supervisor since she had been present during the incident on 08/02/2026 and that was her job. LVN B said she was the charge nurse for the memory care unit where Resident #1 and Resident #2 resided on 07/31/2026 and 08/02/2026. LVN B said that she thought she documented both incidents between Resident #1 and Resident #2 under incidents in the risk management section of the electronic data system. LVN B said she was not aware she was supposed to document in the risk management section of the electronic data system about the resident who had been the aggressor (Resident #1) regarding the incident that occurred on 7/31/2026. LVN B said she had not documented in the resident's progress notes because that was considered double documentation and she had been instructed by one of the many people in charge around here not to double document like that. LVN B said her documentation reflected the same documentation that CNA A documented on her written witness statements because she had written her notes/reports directly from those statements. LVN B said she asked Resident #1 if he was hurt prior to attempting to move him and he said, no Hun. LVN B said Resident #1 nor Resident #2 was able to relay what had occurred during the incidents. LVN B denied Resident #1 replied that his pride was hurt. During an interview on 08/13/2026, the DON said she had just become the DON the previous week. The DON said she was the ADON prior to assuming the DON position. The DON said she was on vacation during the incidents that occurred on 07/31/2026 and 08/02/2026 with Resident #1 and Resident #2. The DON said she expected the charge nurse over the involved alleged residents to report to the Abuse Coordinator promptly regarding any abuse, resident to resident altercations to prevent any further abuse, allow proper and timely investigation as well as reporting to the state per the guidelines and policies. During an interview on 08/14/2026, the Administrator said she was the Abuse Coordinator. The Administrator said she was not aware of the incidents when they occurred on 07/31/2026 or on 08/02/2026. The Administrator said she did not receive calls from LVN B on 07/31/2026 or 08/02/2026. The Administrator said she did not receive a call from RN C on 08/02/2026. The Administrator said she thought she first learned of the incidents when she found CNA A's witness statements in the box on her door on 08/05/2026, and that was when she reported to HHSC, and started investigating the incidents. The Administrator stated allegations of abuse should have been reported to HHSC within 2 hours, and no later than 24 hours. The Administrator said it was important to ensure allegations of abuse were reported to HHSC to ensure a thorough investigation was completed and to protect the residents from further abuse. Record review of the facility's Abuse , Neglect, Exploitation and Misappropriation Prevention Program with a revised date of April 2021, indicated, Residents have the right to be free from abuse, neglect. Upon receiving an allegation of abuse committed against a resident, the staff member receiving the allegation must ensure the safety of the resident and immediately notify the supervisor on duty.Investigate and report all allegations within timeframes required by federal requirements.

Based on interviews and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 (Resident #1 and Resident #2) residents reviewed for quality of care. The facility failed to provide supervision and interventions as evidenced by Resident #2's wandering into Resident #1's room on 07/31/2026 and 08/02/2026 resulting in resident-to-resident altercation. This failure could place residents at an increased risk for injury, fear, and for future resident-resident altercation.The findings included: Record review of a face sheet dated 08/14/2026 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included COPD (difficulty breathing), dementia (decline in cognitive processes), schizoaffective disorder (hallucinations and delusion, depression and mania). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #1 was able to make himself understood and was usually understood by others. The MDS assessment indicated Resident #1 had a BIMS score of 7 which indicated Resident #1 was severely cognitively impaired. The MDS assessment indicated Resident #1 required supervision for standing/sitting, transferring, moderate assistance for walking, set up assistance for eating and oral care. Record review of Resident #1's care plan with a target date of 09/30/2026 indicated he had a behavior problem related to a disease process, and he did not like other residents in his room with the following interventions: 1. Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention to something more positive. 2. Monitor behavior episodes and attempt to determine underlying causes. Consider location, time of day, people involved, and situations. Document behavior and potential causes. Record review of Resident 1's Order Summary Report dated 08/14/2026 indicated: Olanzapine Oral Tablet 5 MG (Olanzapine) (antipsychotic) Give 1 tablet by mouth two times a day related schizoaffective disorder. Record review of Resident #1's electronic data record on 08/13/2026 indicated no risk management reports for 07/31/2026. Record review of a face sheet dated 08/14/2026 indicated Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included COPD (difficulty breathing), dementia (decline in cognitive processes), depression, anxiety (intense, excessive and persistent worry and fear about everyday situations) and hallucinations. Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #2 was able to usually make himself understood and usually understood others. The MDS assessment indicated Resident #1 had a BIMS score of 0 which indicated Resident #2 was severely cognitively impaired. The MDS assessment indicated Resident #2 had experienced physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) within the last 1 to 3 days. The MDS assessment indicated Resident #2 had experienced 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) within the last 1 to 3 days. The MDS assessment indicated Resident #2was independent with eating and oral hygiene, required set up personal hygiene, supervision of dressing, and moderate assistance for toileting hygiene. Record review of Resident #2's care plan with a target date of 11/03/2026 indicated he was at risk of elopement/wanderer related to impaired safety and awareness with the following intervention - will reside on the secured unit with redirect resident with meaningful activity when wandering in other rooms. Record review of the Provider Investigation Report dated 08/05/2026 indicated incidents of a resident-to-resident altercation on 07/31/2026 and 08/02/2026 were reported to the state agency on 08/04/2026 at 06:17 PM. The following witness statements were included: Witness statement dated 08/01/2026 signed by CNA A stated, on 07-31-26 [Resident #2] had to be re-directed constantly from going into other residents' rooms. Towards the end of the shift [Resident #2] went into [Resident #1's] room again and [Resident #1} screamed and said get out of my room and hit [Resident #1] in his stomach. I [CNA A] removed [Resident #2] out of [Resident #1's] room and reported to the charge nurse immediately. Witness statement dated 08/02/2026 signed by CNA A stated, on 08/02/2026 I was changing a resident before lunch and heard [Resident #1] screaming you don't belong in here. I immediately went to check to see what was going on and saw [Resident #1] on the floor in front of his bed and [Resident #2] was in his closet taking all the clothes out of closet. [Resident #2's] shirt had been pulled on in the front of his shirt to where it was out of shape very loose and hanging down under his neck. I then immediately got the charge nurse to let her know what was going on. Record review of Resident #2's electronic data record indicated a risk management report labeled physical aggression received dated 07/31/2026 at 07:00 PM stated [Resident #2] was wandering around hall when he went in [Resident #2's room]. [Resident #1] then hit [Resident #2] in the stomach and was promptly removed to his room. [Resident #2] was unable to give description. Administrator notified 07/31/2026 at 07:51 PM. Record review of Resident #2's electronic data record on 08/13/2026 indicated no risk management reports for 08/02/2026 Record review of Resident #2's electronic data record indicated a progress note dated 08/02/2026 at 12:04 PM signed by LVN B that stated, [Resident #2] continue to wonder in and out other resident room. [Resident #2] appears to be disheveled after entering a resident's room going into their closet. [Resident #2] redirected after aide heard yelling to separate residents. No injuries noted at this time. Record review of Resident #1's electronic data record indicated a progress note dated 08/02/2026 at 12:04 PM signed by LVN B that stated CNA informed this nurse [sic] was on the floor in front of his bed sitting on his bottom. Upon entering resident's room [Resident #1] observed in sitting position with knees bent. [Resident #2] observed in resident closet removing his clothes. [Resident #2] promptly removed from room. [Resident #1] assessed for injury and assisted back in bed Vital signs wnl. Record review of Resident #1's electronic data record indicated a risk management report labeled unwitnessed fall dated 08/02/2026 that stated CNA informed this nurse [sic] was on the floor in front of his bed sitting on his bottom. Resident unable to give description. Resident was attempting to remove another resident from his room. [Family member] notified. [Physician] notified. During an interview on 08/13/2026 at 02:45 PM, CNA A said the first incident occurred around 05:30 PM on 07/31/2026. CNA A said she was assisting another resident on the opposite end of the memory care unit when she heard Resident #1 screaming you don't belong in here. CNA A said when she got to Resident #1's room, she saw Resident #1 punch Resident #2 in the stomach. CNA A said she separated Resident #1 and Resident #2 and notified LVN B immediately. CNA A said LVN B was doing an assessment on Resident #1 in the memory care unit as she exited the unit at change of shift. CNA A said the second incident with Resident #1 and Resident #2 occurred on 08/02/2026 before lunch time. CNA A said she was assisting another resident on the opposite end of the hall on the memory unit when she heard Resident #1 screaming you don't belong in here. CNA A said she found Resident #1 sitting on the floor in front of his bed. CNA A said Resident #2 was in Resident #1's closet taking all the clothes out of the closet. CNA A said that Resident #2's shirt was disheveled, torn, and stretched in the front and hung loosely around his neck. CNA A said she immediately notified LVN B for assistance. CNA A said Resident #1 remained on the floor while Resident #2 continued to be in Resident #1's closet getting out clothes. CNA A said she quickly stuck her head out the memory unit door which was beside Resident #1's room and called for LVN B. CNA A said LVN B came onto the memory care unit at that time and began to assess Resident #1 and then Resident #2. CNA A said that RN C entered the memory care unit from an outside door after hearing the noise and had entered Resident #1's room while she had notified LVN B from the doorway of the memory care unit. CNA A said LVN B asked Resident #1, Are you hurt?. CNA A said Resident #1 would only reply just my pride. CNA A said she was the only CNA working the male memory care unit on 07/31/2026 and on 08/02/2026. CNA A said she voiced her concerns and requested help several times throughout the day on 07/31/2026 and 08/02/2026 to LVN B. CNA A said there were 10 residents on the male unit on those specific dates. CNA A said nearly all of the time the male memory care unit had 2 CNAs designated to the unit at all times. CNA A said Resident #2 was new to the facility and had not adjusted so he was wandering a lot. CNA A said Resident #2 was consuming all of her time as she attempted to divert and redirect his attention. CNA A said that LVN B had assisted her several times during the days of 07/31/2026 and 08/02/2026 but was unable to remain in the male memory care unit at all times. CNA A said LVN B said, she had notified everybody that she could that they need help. CNA A said the incidents with Resident #1 and Resident #2 could have been avoided if two staff members would have been in the male memory unit. During an interview on 08/13/2026 at 03:01 PM, LVN B said she was notified of the resident-to-resident altercation between Resident #1 and Resident #2 on 07/31/2026 at the change of shift as CNA A exited the building from her shift. LVN B said she was sitting at the nurses' station outside the memory care unit when CNA A walked by and told her about the incident. LVN B said when she entered Resident #1's room he was on the floor sitting on his buttocks. LVN B said Resident #2 was in Resident #1's closet taking out clothes. LVN B said Resident #2's clothes were mangled and he looked disheveled. LVN B said that CNA A was assisting RN C redirect Resident #2 out of Resident #1's room while she performed the assessment on Resident #1. LVN B said there was only on CNA, CNA A, assigned to the male memory unit on 07/31/2026 and 08/02/2026. LVN B said she assisted CNA A throughout the day when she had the opportunity, but she also had other responsibilities like giving medications and assessments on the other hall outside of the male memory care unit. LVN B said, who else was I going to inform about no staff because that was the day the DON had walked out of the building and quit!. LVN B said the scheduler was already informed that the male memory care unit was not covered with two staff members because the scheduler told her that everyone had turned the shifts down and she could not get the shift filled for 07/31/2026 or 08/02/2026. LVN B said she had not reached out to the Administrator because she guessed the Administrator already knew they did not have enough staff because the Scheduler should have reported it to the Administrator. LVN B said she contacted Resident #2's family to come and try to calm him down after the second incident on 08/02/2026. LVN B said CNA A had kept Resident #2 beside her until Resident #2's family arrived at the facility. LVN B said neither incident would have occurred if the male memory care unit would have been properly staffed. Attempted telephone contact to RN C on 08/13/2026 at 04:13 PM was unable to leave a message due to there was no voice mailbox setup. During an interview on 08/13/2026 at 04:30 PM, the DON said she had just become the DON the previous week. The DON said she was the ADON prior to assuming the DON position. The DON said she was on vacation during the incidents that occurred on 07/31/2026 and 08/02/2026 with Resident #1 and Resident #2. The DON said she expected the Scheduler to notify the ADON, herself and the Administrator when shifts were not filled appropriately to ensure all available resources were utilized to protect the wellbeing of the residents. The DON said the Scheduler is a CNA and she expected her to fill the gap in the event of a very last resort. During an interview on 08/14/2026 at 09:45 AM, the Scheduler said she had attempted to fill the vacancy on the shifts for 07/31/2026 and 08/02/2026 but was not able to. The Scheduler said the facility experienced a death of a long-term CNA that week and they had filled other vacant shifts and no one was able to work. The Scheduler said she notified the DON previously during the week that she was having difficulty getting the weekend shift covered and the DON told her to keep trying. The Scheduler said the DON had quit her position on 07/31/2026 unexpectedly. The Scheduler said she had not told the Administrator that 07/31/2026 and 08/02/2026 were not covered appropriately. The Scheduler said she was not aware of who was on call. The Scheduler said she did not cover the shift because she was not asked to cover the shift by the DON when she had previously reported the vacancy. The Scheduler said there had been a few times she had filled in when needed but 99.5 percent of the time she was able to get all shifts filled. Attempted telephone contact to RN C on 08/14/2026 at 10:00 AM was unable to leave a message due to there was no voice mailbox setup. During an interview on 08/14/2026 at 11:00 AM, the Administrator said she was not made aware of the shifts not being adequately staffed by the Scheduler, previous DON, or LVN B. The Administrator said she had made it very clear to the Scheduler, DON and ADON and all staff that she always wanted two staff members in the memory units at all times for proper safety and supervision to prevent any potential resident to resident interactions or accidents. The Administrator said she expected the Scheduler at the very least to notify her prior to a shift not being covered appropriately. The Administrator said the Scheduler could have covered the shift and she would have expected that to happen if no coverage was found. Record review of the Facility assessment dated [DATE] indicated, 2 CNA's per shift on locked unit. Record review of the facility's policy titled, Safety and Supervision of Residents, last revised July 2017, revealed, . Resident safety and supervision and assistance to prevent accidents are facility-wide priorities 1. Our facility-oriented approach to safety addresses risks of groups of residents. our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training as necessary; d. ensuring that interventions are implemented; and e. documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently; b. evaluating the effectiveness of interventions; c. modifying or replacing interventions as needed; and d. evaluating the effectiveness of new or revised interventions. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 10 residents (Resident #1) reviewed for abuse. 1. The facility failed to ensure Resident #1 was free from physical abuse on 01/30/26, when CNA A open-handed slapped Resident #1 in the face, which was witnessed by CNA B. 2. The facility failed to ensure Resident #1 was protected from further abuse by CNA A on 01/30/26, when CNA B briefly left the room to notify the nurse. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 01/30/26 and ended on 02/02/26. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of serious adverse psychosocial outcome such as fear, anxiety, shame or guilt, depression, withdrawal from activities, helplessness, low self-worth, and post-traumatic responses such as flashbacks, nightmares, or increased startle responses. The findings included: Record review of the face sheet, dated 04/29/26, reflected Resident #1 was an [AGE] year-old male who admitted to the nursing facility on 03/16/21 with a diagnoses of heart failure (the heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), unspecified dementia (memory loss) with agitation and other behaviors, and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, eventually impairing the ability to carry out the simplest tasks). Record review of the quarterly MDS assessment, dated 03/23/26, reflected Resident #1 had a BIMS score of 0, which indicated severe cognitive impairment. Resident #1 had no behaviors or refusal of care episodes during the look-back period. The MDS reflected Resident #1 required total staff assistance with hygiene, dressing, and bathing. Record review of the comprehensive care plan, dated 05/01/25, reflected Resident #1 had impaired cognitive function and became combative with staff at times. The interventions included: . do not attempt to care for resident when physically abusive, allow time and revisit task later. Staff do not attempt to care for resident when physically abusive, staff educated to allow time and revisit task later. staff educated on explaining care task the best they could prior to completing the task. Record review of the Email Self-Report Template, dated 01/30/26, reflected the Administrator reported an incident that occurred on 01/30/26 at 3:35 p.m., where [CNA A] slapped [Resident #1] across the face after he kicked her on the leg. The incident was witnessed by CNA B. Record review of CNA A's signed witness statement, dated 01/30/26, reflected, Me and [CNA B] was changing a [patient] and [Resident #1] hit me in the leg and I hit him back. I was not trying to it was reaction. Record review of CNA B's signed witness statement, undated, reflected . On 01/30/26 at approximately 3:35 p.m., myself and [CNA A] were working 200 Hall and were attempting to clean up [Resident #1]. [Resident #1] was laying down when we began working on him. After we secured his brief, he began to sit up and resist. He sat himself on the side of the bed facing [CNA A] and swung, hitting her in the leg. [CNA A] immediately slapped him in his face hard. I looked at her, shocked, and then headed to get help. [CNA A] was asking if I was going to report her and telling me she didn't mean to do it. I reported the abuse immediately. Record review of a typed statement, dated 02/06/26, reflected the Administrator interviewed CNA A on 01/30/26 at approximately 3:50 p.m. The conversation was as follows: [CNA A] started the conversation off describing what happened upon entering the room and why they went into [Resident #1's] room. The two CNAs [CNA A and CNA B] went to perform routine rounds prior to the end of the shift and according to [CNA A] [Resident #1] was asleep when they entered the room, they started talking to him and he opened his eyes. The resident's named was called, and they woke him up from his sleep. She then proceeded to say that they started taking off his clothing and brief. When asked if they explained what there were going to do,? [CNA A] said yes. [CNA A] then stated she started removing his brief and pants. [Resident #1] started swinging and they talked to him softly and slowly explaining what they were doing. [Resident #1] hit and kicked [CNA A's] left leg. [CNA A] then hit him on the forehead (right side). [Resident #1] then stopped hitting and swinging. We [CNA A and CNA B] stopped and [CNA B] ran out of the room and reported me to the nurse. [ADON D] and the nurse escorted me off of the hall/unit. When asked if [Resident #1] has ever hit her before she stated Yes, he has hit me before, but we just leave him alone until he calms down. [CNA A] was asked why [01/30/26] was any different and why she hit him back today. Per [CNA A], He kicked my hurt leg, and I reacted and hit him back. I fell during the ice storm and hurt my left leg and that kick really hurt my leg. [CNA A] was asked if she had ever hit a resident before and she denied hitting [Resident #1] or any of the other residents before. After the interview with the cops, [CNA A] changed her reason for her leg hurting and she said that she takes insulin and that is the leg that she used to inject her insulin. She was escorted to the front door after interviewing with [Administrator] and giving the police a statement on the events that led to her hitting [Resident #1]. [CNA A] has been informed that she is out pending the investigation and that she will be notified of the final decision in 3 working days.[CNA A] was informed not to come back to the facility nor enter the facility until Human Resources or Administrator notifies of the final decision regarding her employment status with the company in this facility. She voiced understanding and left the facility at approximately 5:30 p.m. Record review of Resident #1's progress notes, reflected the following:1. ADON D documented on 01/30/26 at 5:32 p.m., Reported that [Resident #1] was slapped on forehead on the right side by [CNA B] on hall. At that point [Resident #1] was assessed with no injuries or obvious distress noted. No fearful behavior. No increased anxious behavior noticed. Attempted to contact [responsible party] with no answer left [voicemail] for call back. Contacted [Nurse Practitioner] new orders to monitor for delayed injuries [times or for] 3 days, monitor for increased anxiousness or fearful behavior.2. ADON D documented on 01/30/26 at 5:40 p.m., Skin warm & dry, skin color [within normal limits] and turgor (skin's elasticity, or its ability to change shape and return to normal) is normal. Skin Issues Note: No obvious skin issues noted .3. LVN E documented on 01/31/26 at 12:20 a.m., No delayed injuries noted post altercation with [CNA A] on previous shift. Supine position (flat on back) in bed at this time; laying quietly awake on secured unit. No visible [signs or symptoms] of distress or discomfort noted. No skin break or bruising noted. Will report any changes. Record review of the comprehensive care plan, dated 01/30/26, reflected Resident #1 would remain free from injuries or mental anguish caused by the incident of being slapped on the face/forehead. The interventions included: . monitor for mental distress and increase anxiety. monitor his face for 72 hours for redness or abrasion. report any changes to the doctor. Record review of the Record of Employee Counseling form, dated 01/30/26, reflected CNA A was suspended after she slapped a resident in his face after resident kicked her on the left leg. The expectation/outcome was Restrain and to walk away from the situation. Record review of the in-service, dated and signed on 01/30/26 by CNA B, reflected she was provided 1:1 education on, If you witness a resident being physically abused or abused in any way do not leave resident with the person that is being abusive. Bring the person out into the open with you or if you are not safe yell, get someone's attention. Resident to resident altercation - remove resident from danger. Anytime a resident is in a potentially dangerous situation we removed them from danger first. Record review of the in-service, dated 01/30/26, reflected that all nursing staff were provided in-service education on making sure residents were safe, not leaving them alone if abuse was witnessed, behaviors, abuse and neglect policy and procedure, and unmanageable residents. There were 43 staff signatures. Record review of the Interview Statements, dated from 01/31/26 to 02/02/26, reflected MA F, CNA G, CNA H, CNA K, CNA L, NA M, CNA N, and LVN O had worked with CNA A and not witnessed any physical abuse to other residents. Record review of the Resident Safe Surveys, dated 02/02/26, reflected Resident #2, Resident #3, and Resident #4 felt safe in the facility, felt staff were helpful and responsive, and had reported no one at the facility had hurt or threatened them during their stay. Record review of the Provider Investigation Report, dated 02/05/26, reflected on 01/30/26 at 3:35 p.m., CNA B witnessed CNA A slap Resident #1 across the face after Resident #1 kicked CNA A in the leg. An assessment was completed by ADON D on 01/30/26 at 3:45 PM, which reflected Resident #1 had no redness, open areas, scratches, bruises, etc. to the area on his cheek or forehead. He had no changes in his normal behavior or signs of mental anguish. The incident was reported to the police department. The Nurse Practitioner, Ombudsman, and responsible party were notified. CNA A was immediately removed from the secured unit and taken to the business office manager's office. Statements were obtained from residents and staff. The allegation of abuse was confirmed, and CNA A was terminated post investigation. Record review of the Record of Employee Counseling form, dated 02/02/26, reflected CNA A was terminated after the investigation was completed. During an observation on 04/28/26 beginning at 11:15 AM, Resident #1 was lying in bed with eyes closed. He opened his eyes when the state surveyor knocked on the door but was unable to answer questions appropriately related to his disease process. Resident #1 did not appear nervous, or anxious. During an interview on 04/28/26 at 1:26 p.m., CNA B stated she vividly remembered the incident on 01/30/26 when CNA A slapped Resident #1 in the face. She said CNA A and herself were getting Resident #1 ready to get up from his nap. She said CNA A and herself sat Resident #1 up on the side of the bed when he became combative and kicked or hit CNA A in the leg. CNA B said Resident #1's hit or kick was more of a light tap and was not hard at all. She said CNA A reared back and slapped the dog [s-word] out of Resident #1, hard. She said CNA A hit the left side of his face and it was a little red. CNA B stated Resident #1 just looked stunned and froze in place. She stated he appeared nervous, like he was afraid to move. She stated she immediately left the room briefly to report the incident to the charge nurse. CNA B stated she returned with the charge nurse to Resident #1's room and CNA A was sitting on the opposite bed. She stated CNA A kept saying she did not mean to do it, was really sorry, and did not want to get into trouble. CNA B stated she had not witnessed CNA A physically abuse residents before. She said CNA A reacted so instinctively and did not hesitate in her reaction. CNA B stated Resident #1 had been resistive and combative with care prior to that incident, but it depended on the approach staff used. CNA B stated she was provided one on one in-service education on 01/30/26 about not leaving residents alone with an abuser. During an interview on 04/28/26 at 2:17 p.m., ADON D stated she used to be the ADON but no longer worked at the facility. ADON D stated she remembered the incident that occurred on 01/30/26 when CNA A slapped Resident #1. ADON D stated it was reported that CNA B had witnessed CNA A slap Resident #1 on the secured unit. ADON D said she immediately removed CNA A from the secured unit and escorted her to one of the offices. She stated the police department was notified and arrived at the facility to obtain statements. She said CNA A was suspended pending the investigation and was not allowed to return to work. She said she was the nurse who assessed Resident #1 after the incident. She said Resident #1 had no redness or marks that she observed. ADON D stated Resident #1 had no observed distress or changes in his behavior from baseline. ADON D said Resident #1 was normally combative or resistive during care. She said Resident #1 was observed 72 hours post incident for any delayed injuries and education was provided to the staff on abuse and neglect policies, resident behaviors, and unmanageable residents. During interviews on 04/28/26 between 1:58 p.m. - 3:54 p.m., with staff over all shifts, NA S, CNA B, CNA C, CNA H, CNA P, CNA R, CNA T, CNA U, CNA V, CNA W, CNA X, CNA Z, CNA BB, CNA CC, LVN Q, and LVN Y were able to verify they were provided in-service education after the incident on 01/30/26 when CNA A slapped Resident #1. The staff stated they were in-serviced on the types of abuse to include physical abuse. They were able to verbalize the abuse coordinator, and abuse should be reported immediately, after the resident was safe. They verbalized if a resident was combative the staff members should step away and let the resident calm down or have another staff member step in and try. The staff verbalized hitting a resident was considered physical abuse. During an interview on 04/29/26 at 9:36 a.m., the Administrator stated on 01/30/26 she was called on her lunch break that CNA B had witnessed CNA A slap Resident #1. She instructed ADON D to remove CNA A, assess Resident #1, and call the police department. The Administrator stated when she arrived at the facility, she immediately started interviewing CNA A, who admitted to hitting Resident #1. She stated the police department later arrived and obtained statements from CNA A, who changed her statement about why she hit Resident #1. She said she immediately suspended CNA A and verbally in-serviced CNA B about not leaving residents with an abuser. She said she reported the incident to the Nurse Practitioner, ombudsman, family, and the state department. She stated resident safe surveys and interviews with other staff members were conducted with no further issues identified. She stated she provided in-service education on not leaving a resident alone with the abuser, resident behaviors, abuse and neglect policies, and unmanageable residents. The Administrator stated CNA A was terminated on 02/02/26 after the investigation was completed and the termination was approved by corporate office. Record review of the Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, reflected Residents have the right to be free from abuse. This includes but is not limited to. physical abuse.The resident abuse. program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse. by anyone including. facility staff.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. The noncompliance began on 01/30/26 and ended on 02/02/26.

Based on interview, observation 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 of 4 residents (Resident #1 and Resident #2) reviewed for pharmacy services. The facility failed to administer Resident #1's ordered Topamax 25 mg (seizure prevention medication) by the physician from 02/10/2026 - 02/15/2026 (5 days). Resident #1 missed 15 dosages of Topamax resulting in Resident #1 being hospitalized for seizure like activity on 02/13/2026 and 02/15/2026. The facility failed to obtain Resident #1's ordered Topamax (medication used to decrease seizure activity) 25 mg from the pharmacy as instructed by the facility Nurse Practitioner on 02/13/2026. The facility failed to follow their policies on verifying and obtaining medications as ordered from their pharmacy when staff failed to follow up on the status of Resident #1's Topamax 25 mg, after it was not received on 02/10/2026. The facility failed to notify the MD/NP Resident #1 was out of Topamax from 02/10/2026-02/15/2026. The facility failed to obtain Resident #1's Topamax from an emergency source (pyxis or local pharmacy) to ensure Resident #1 received his Topamax medication as ordered for his seizures. The facility failed to ensure Resident #2 received his scheduled pain medication, hydrocodone-acetaminophen tablet 10-325 mg orally, three times a day as ordered by the physician from 1/28/26-2/5/26. Resident #2 missed 23 dosages of hydrocodone which resulted in Resident #2 experiencing uncontrolled pain. The facility failed to follow-up on Resident #2's hydrocodone when the triplicate for the hydrocodone was faxed to the pharmacy on 01/05/2026. The facility failed to notify Resident #2's MD of his uncontrolled pain and unavailable pain medication. An IJ was identified on 03/05/2026. The IJ template was provided to the facility on [DATE] at 09:49 AM. While the IJ was removed on 03/06/2026, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place other residents at risk of missed medications such as seizures and increased, uncontrolled pain levels resulting in harm or death.Findings included: 1. Record review of a face sheet dated 08/18/2025 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of epilepsy (seizures). Record review of the Annual MDS assessment dated [DATE], indicated Resident #1 was able to make was able to make himself understood and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 13, which indicated he was cognitively intact. The MDS assessment indicated Resident #1 was taking anticonvulsant medication. Record review of Resident #1's care plan initiated on 02/15/2026 indicated Resident #1 would remain free from injury related to seizure activity with the following interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness; Obtain and monitor lab/diagnostic work as ordered. Report results to doctor and follow up as indicated; Post seizure treatment: turn on side with head back, hyper-extended to prevent aspiration, keep airway open. After seizures take vital signs and neurological checks; Monitor for aphasia, headache, altered level of consciousness, paralysis, weakness, pupillary changes. Record review of Resident #1's Order Summary Report dated 03/04/2026 indicated he had an order for Topamax 25 milligram tablet give one tablet by mouth three times a day related to seizure or convulsions with a start date of 12/01/2025. Record review of Resident #1's medication administration record for the month of February 2026 indicated, Topamax 25 milligram give one tablet by mouth three times a day. Resident #1's medication administration record indicated: 02/10/2026 at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other 02/11/2026 at 7:00 AM and 12:00 PM were documented as administered by MA N, 5:00 PM was documented as not administered reason indicated other/see progress note signed by MA G. 02/12/2026 at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G. 02/13/2026 at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G. 02/14/2026 at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA B. 02/15/2026 at 07:00 AM PM not administered reason indicated other/see progress note signed by MA B, 12:00 PM was documented resident hospitalized signed by MA B. Record review of Resident #1's administration notes dated 02/10/2026-02/13/2026 indicated: 02/10/2026 at 08:44 AM, Topamax 25mg on order signed by MA B 02/10/2026 at 11:51 AM, Topamax 25mg on order signed by MA B 02/10/2026 at 5:11 PM, Topamax 25mg on order signed by MA B 02/11/2026 at 4:33 PM, Topamax 25mg waiting on arrival signed by MA G 02/12/2026 at 07:56 AM, Topamax 25mg waiting on arrival signed by MA G 02/12/2026 at 4:51 PM, Topamax 25mg waiting on arrival signed by MA G 02/13/2026 at 08:19 AM, Topamax 25mg on order signed by MA B 02/13/2026 at 4:28 PM, Topamax 25mg on order signed by MA B 02/14/2026 at 07:58 AM, Topamax 25mg on order signed by MA B 02/14/2026 at 11:08 AM, Topamax 25mg on order signed by MA B 02/14/2026 at 4:40 PM, Topamax 25mg on order signed by MA B 02/15/2026 at 8:09 AM, Topamax 25mg N/A signed by MA B Record review of Resident #1's progress notes dated 02/10/26-02/13/2026 did not indicate Resident #1's physician, NP or the pharmacy were notified he was out of his Topamax. Record review of Resident #1's progress note dated 02/13/2026 at 5:24 PM signed by LVN A indicated, Resident observed by staff shaking and not responding appropriately. Resident was unable to respond to verbal commands per baseline. Vitals signs taken and WNL (within normal limits). Resident noted to have fixed pupils at this time. [EMS provider] called for transport to [local hospital ER]. Responsible party [Name] notified of transport. Nurse Practitioner aware of change. Record review of Resident #1's discharged hospital note dated 02/13/2026 indicated, PT arrives to ED via EMS [name of ambulance] from [Facility name] due to seizure like activity witnessed by staff. EMS reports that PT was staring off on scene. PT arrives to ED room [number] with incomprehensible speech. EMS reports history of seizures. PT takes Keppra and Topamax but has not had Topamax since the 11th (02/11/2026) per the facility. The discharge note indicated Resident #1 reason for visit was seizures and his diagnosis was seizures. The discharge note indicated Resident #1 was given Keppra 1000 milligrams IV. The discharge note indicated Resident #1 had instructions to continue current medications as prescribed, seizure precautions and to return to the emergency room as needed. Record review of Resident #1's progress note dated 02/14/2026 at 3:03 AM signed by LVN C, indicated, Resident returned to the facility via [ambulance name] from [local hospital ER]. Discharge instructions given to resident to continue current medications and seizure precautions at this time, resident was given levetiracetam (Keppra) (a seizure medication) at 7:37 PM. Resident #1 showed no signs and symptoms of distress and was talking. Record review of Resident #1's progress note dated 02/15/2026 at 10:43 AM signed by LVN A indicated, Resident #1 in bed not responding to verbal stimuli, sternal rub performed and resident opened eyes but unable to respond per baseline, pupils not reacting to light unable to follow commands per usual. Notified Nurse Practitioner [Name] of condition. [EMS name] called for transport to ER for further eval (evaluation). Responsible Party made aware. Record review of a pharmacy invoice dated 02/15/2026 indicated 42 tablets of Topamax 25 mg were ordered by Nurse Practitioner and received by the facility on 02/16/2026 at 3:59 AM. During an interview on 03/04/2026 at 10:00 AM, MA B said she had to repeatedly tell the nurses (unknown who) about low quantities of medications. MA B said some nurses did not want to help follow up with the pharmacy. MA B said the residents needed the medications as the doctor has ordered or the doctor needed to be notified otherwise. MA B said somebody needed to get to the bottom of why the medications do not come to the facility in larger quantities. MA B said she ordered the medications off the MAR in the electronic records systems by pushing the reorder button approximately 7 days before the medication was depleted. MA B said when she tried to reorder Resident #1 Topamax from the MAR the button had already been pushed to reorder so she was not able to reorder again. MA B said if the medications did not arrive after ordering, she notified the charge nurse, the ADON and left notes to remind anybody and everybody. MA B said residents that had not gotten medications as ordered were at risk of many things such as seizures, increased behaviors, high blood pressure, depression and uncontrolled pain depending on what medication was missed. During an interview on 03/04/2026 at 09:35 AM, an anonymous person said some things at the facility were not working the way they should. The anonymous person said some of the staff (not identified) did not want to do what was needed to ensure the residents were taken care of right. The anonymous person said the medications were ordered in the system but for whatever reason the medications would not arrive to the facility timely or in the correct quantity. The problems started when the corporate pharmacy changed the facility to a different location and it had been a fight ever since to get what they needed. The anonymous person said she was aware Resident #1 had not received the ordered Topamax and had missed multiple dosages. An anonymous person said she had told the charge nurses (unable to identify who) several times that Resident #1 was out of Topamax. The anonymous person said not all nurses would follow up with the pharmacy regarding Resident #1 Topamax. The anonymous person said she did not call the pharmacy since they were not allowed and it was the responsibility of the nurse. The anonymous person said she had told the ADON on numerous occasions, and she thought the ADON had followed up on it by contacting the pharmacy and the doctor. The anonymous staff member said it was important for residents to receive their ordered medications as prescribed to prevent a decline in their health condition. During an interview on 03/03/2026 at 04:30 PM, the ADON said she was notified by MA G that Resident #1 was out of his Topamax but unable to recall what day she was notified. The ADON said she had called the pharmacy multiple times from 02/10/2026-02/15/2026 regarding Resident #1's Topamax medication. She said she had even faxed over Resident #1's Topamax order to the pharmacy. The ADON said she had followed up every day since 02/10/2026 repeatedly to ensure they medication was in the facility. The ADON said she had contacted the Nurse Practitioner prior to Resident #1 being sent out to the hospital for seizure activity, on 02/13/2026, and told the Nurse Practitioner there was no Topamax available. The ADON said she was unsure of the date she had notified the Nurse Practitioner. The ADON said she had informed the Nurse Practitioner Resident #1 had missed multiple dosages of the Topamax. The ADON said she could not recall how many dosages she had told the Nurse Practitioner that Resident #1 had missed. The ADON said the Nurse Practitioner just told her she needed to get the medication in the facility. The ADON said Topamax was not kept in the pyxis for emergency situations because she had tried to get it from there before. The ADON said the facility had struggled with getting the medications in the building timely when the corporate pharmacy took over and their pharmacy location changed. The ADON said there had not been a system in place for ordering and receiving medications since the corporate pharmacy took over in January 2026 The ADON said there were problems with which number to dial and the pharmacy staff saying it was now housed out of a different location and no longer covered by the pharmacy they had called. The ADON said, we never knew who we were talking to or where we were supposed to be calling. The ADON said she had not documented any of the requests, faxes, conversations or follow-ups on the needed medications for Resident #1 with the pharmacy. The ADON said she had not documented notifying the Physician or the Nurse Practitioner of Resident #1's missed medications. The ADON said, she kept thinking after she faxed or had a conversation with the pharmacy the medication would arrive, but it never did. The ADON said whenever a medication needed to be reordered, the medication aides reordered the medication through the electronic computer system from the Medication Administration Record page. The ADON said she thought the medication aides were ordering the medications too early and the reason why the pharmacy had not sent the medication to the facility. The ADON said if the medication aide was unable to resolve any issues with medications not being delivered then it was the responsibility of the nurse to follow up. The ADON said she expected the nurses to call the pharmacy and find out what the issue was regarding medications not being sent since they were able to contact the MD or NP for any new order needed. The ADON said if the pharmacy was not delivering the medication, then the nurse should have contacted MD or NP so the medication could have been ordered from a local pharmacy until the medication was able to be provided by the facility pharmacy. The ADON said if the nurse was unsuccessful at getting the medication in the building timely, that she and the DON should be notified. During an interview on 03/03/2026 at 10:30 AM, LVN B said she expected the MA to report to her directly if a medication was not available as ordered for a resident. LVN B said if a resident was out of medication, she would first follow up at the pharmacy by calling to see what was needed. During an interview on 03/03/2026 at 2:00 PM, LVN E said she would contact the Nurse Practitioner if needed. LVN E said if the resident was going to be without the ordered medication after those steps had been followed, she would then reach out to the ADON/DON. LVN E said she had not experienced any issues other than a phone call to the pharmacy or a required fax that she could recall. LVN E said it was important for all residents to receive their medications as the physician had ordered to prevent a decline in their health. LVN E said she could not recall that the MAs had reported to her directly regarding Resident#1's Topamax was not available. LVN E said she thought they had reported to the ADON but she could not be for certain. Attempted telephone call on 03/03/2026 at 10:40 AM to LVN C - left a voice message and requested a call back. During an interview on 03/03/2026 at 02:15 PM, the DON said this was her first day of employment with the facility and was not aware of any issues with medications not being delivered from the pharmacy. The DON said she did not have access to the residents' EMRs and was not able to run any reports. During an interview on 03/03/2026 at 5:35 PM, the Physician stated he expected the facility to contact him if a medication was not administered as ordered. The Physician stated he was not notified and was not aware that Resident #1 had not received the Topamax 25 milligrams one tablet by mouth three times daily as ordered and had missed doses for 5 days. The Physician said he was not aware the resident had been transported to the hospital twice for seizure like activity and irresponsiveness after not receiving the ordered Topamax as prescribed. The Physician said he was not aware Resident #1 was no longer in the facility. The Physician stated that it was important for Resident #1 to have received the Topamax as ordered to prevent seizure activity. The Physician stated that Topamax should not be stopped abruptly because it would or could cause a seizure. The Physician stated if the facility had contacted him about the Topamax not being available, he would have reached out to a local pharmacy for assistance to ensure Resident #1's medication needs were met timely and effectively. The Physician stated that the corporation had experienced some growing pains that had made it difficult for staff at times to get through to the proper location, but no residents should go without medications, and he or the Nurse Practitioner should had been contacted immediately to resolve the matter. During an interview on 03/04/2026 at 09:00 AM, the Corporate Regional Nurse said during an acute review call (meeting to discuss an issue) on 02/16/2026 it was identified that Resident #1's medication was missed due to being unavailable. The Corporate Regional Nurse said Resident #1's Topamax medication had originally been requested to be refilled on 01/25/2026. The Corporate Regional Nurse said the nursing staff, Nurse Practitioner and the ADON had made several follow up phone calls to the pharmacy between 01/25/2026 - 02/15/2026 but the medication had not arrived. The Corporate Regional Nurse stated the Nurse Practitioner, on 02/16/26, was educated to call a local pharmacy to fill any medications that were unavailable after completing a MAR to medication cart audit. The Corporate Regional Nurse said there were no other residents identified with medication needs during the audit. The Corporate Regional Nurse said it was not the facility's fault that the medications were not available for Resident #1 because the facility had notified the Nurse Practitioner (which was an extension of the Physician) and followed up with the pharmacy numerous times. The Corporate Regional Nurse said she had escalated the pharmacy issue up to the corporate offices as well. During an interview on 03/04/2026 at 02:15 PM, the Nurse Practitioner said she expected the staff to notify her if an ordered medications that were not available before the residents missed any medications. The Nurse Practitioner said if she was notified of a resident being out of medications, she would call the pharmacy immediately to verify the prescriptions or to find out what was needed to prevent any residents from having missed medications. The Nurse Practitioner stated she had no knowledge that Resident #1 was without medication prior to 02/15/2026. She stated that on 02/13/2026 she was notified by the facility that Resident #1 had seizure activity that was witnessed by staff. The Nurse Practitioner stated she instructed the staff to send Resident #1 out by EMS at that time due to Resident #1 being unresponsive to verbal and touch stimuli. The Nurse Practitioner stated she was not notified that Resident #1 had returned to the facility on [DATE]. The Nurse Practitioner stated she was notified on 02/15/2026 that Resident #1 had another episode of seizure activity followed by unresponsive to verbal and touch stimuli and she instructed the staff to send Resident #1 to the hospital again for further evaluation. The Nurse Practitioner stated that one of the staff mentioned Resident #1 had missed 5 days of the ordered Topamax on 02/15/2026. The Nurse Practitioner stated she contacted the pharmacy immediately that day and placed the prescribed order. The Nurse Practitioner stated she followed up the next day with the facility and confirmed the Topamax medication had been delivered for Resident #1. The Nurse Practitioner stated Resident #1 had not returned to the facility, but the medication was available upon his return. The Nurse Practitioner stated she expected the facility to notify her when a resident had returned to the facility from a hospital. The Nurse Practitioner stated that it was imperative to have accurate and timely communication with the staff to ensure coordination of care of the residents. The Nurse Practitioner stated that Topamax should not be stopped abruptly because it could cause seizures. The Nurse Practitioner stated ordered medications should be given appropriately to prevent a further decline in the resident's health and wellbeing. The Nurse Practitioner stated she expected notification of missed medications or unavailable medications so alternative actions could be made timely such as contacting a local pharmacy or prescribing another medication to prevent a negative outcome. During an interview on 03/04/2026 at 4:53 PM, the pharmacy representative stated the record of activity for Resident #1 indicated the following:1/25/2026 - An order request for Resident #1's Topamax was received from the facility1/26/2026 - The facility received 42 tablets of Topamax 25mg at 12:08 AM for Resident #1 with instructions to take one tablet by mouth three times a day. The medication sent was a 14-day supply to last Resident #1 until 2/9/2026.No other logged activity via faxes, telephone calls or computer request made until 2/15/2026 .2/15/2026 - An order was received from the facility's Nurse Practitioner at 10:45 AM for Resident #1's Topamax .2/16/2026 - The facility received 42 tablets of Resident #1's Topamax 25mg at 3:59 AM. Attempted telephone call on 03/04/2026 at 08:45 PM to LVN D - left a voice message and requested a call back. Attempted telephone call on 03/04/2026 at 08:56 PM to LVN C - left a voice message and requested a call back. During an interview on 03/05/2026 at 07:45 AM, LVN A stated she was the charge nurse for Resident #1 on 02/13/2026 -02/15/2026. LVN A stated she was aware Resident #1 did not have the Topamax as ordered. LVN A stated the facility was always lacking the medications needed. LVN A stated the corporate pharmacy was always sending 2 to 3 pills instead of sending the right amounts to last the entire month. LVN A stated she had to call the pharmacy a lot. LVN A stated she had no time to document all the calls she made to the pharmacy for medications. LVN A stated she made the calls when she walked down the halls providing care and doing other things. LVN A stated her cart had not run out of medications because she took care of her job and sent her medications needs in 6 - 7 days ahead of time so she did not run out of medications. But she had to follow up on the corporate pharmacy when they did not send the full months' worth of pills like they were supposed to do. LVN A said the MAs were responsible for stocking their own carts. LVN A said, there was no reason for MAs to come to her when their carts were low because they all had the same access she had and that was on them to get their stuff done on their own. LVN A said, the MAs could make calls to follow up on the medications, send faxes or whatever was needed. LVN A said, when she had time, she could help them. LVN A said, she was sure that she had helped them get medication out of the pyxis when they needed them but that was a long process to do and sometimes, they got to wait until I can get over to it. LVN A said it was important for Resident #1 to receive the Topamax to prevent seizures. LVN A said , that is why something has got to be done about the corporate pharmacy because there is not enough time to be backtracking all the time. LVN A said she could not recall if she had notified the Nurse Practitioner that Resident #1 had not had the Topamax when he was sent out of the facility on 12/13/2026 or on 12/15/2026LVN A said the ADON was in the facility when Resident #1 was sent out by EMS to the hospital so she would have known Resident #1 was out of medication. LVN A said, she guessed the MA told her and the ADON but that was not the problem - the problem was the corporate pharmacy. LVN A said it was important to notify the physician and or the Nurse Practitioner of resident needs or changes accurately and timely because of continuity of care. 2. Record review of a face sheet dated 03/04/2026 indicated Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including physical disability related to age, hypertension (high blood pressure), schizophrenia (hallucinations, delusions, disorganized speech/behavior), major depression disorder. Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #2 was able to make was able to make himself understood and understood others. The MDS assessment indicated Resident #2 had a BIMS summary score of 14, which indicated he was cognitively intact. The MDS assessment indicated Resident #2 was taking scheduled pain medication. Record review of Resident #2's care plan initiated on 05/28/2025 indicated Resident #2 would remain free from pain with the following interventions: Give pain medication and evaluation of pain. Record review of Resident #2's Order Summary Report dated 03/04/2026 indicated he had an order for Hydrocodone-Acetaminophen tablet 10-325 milligrams give one tablet by mouth three times a day for pain with a start date of 05/17/2025. Record review of Resident #2's medication administration record for the month of January 2026 indicated, hydrocodone 10-325mg give one tablet by mouth three times a day for pain. Resident #2's medication administration record indicated: 01/28/2026 at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G 01/29/2026 at 07:00 AM was documented as administered by MA G, at 12:00 PM, and 5:00 PM it was documented as not administered reason indicated other/see progress note signed by MA G 01/30/2026 at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G 01/31/2026 at 07:00 AM was documented as administered by MA B, at 12:00 PM, and 5:00 PM it was documented as not administered reason indicated other/see progress note signed by MA B Record review of Resident #1's medication administration record for the month of February 2026 indicated that hydrocodone 10-325mg give one tablet by mouth three times a day for pain. Resident #2's medication administration record indicated: 02/01/2026 at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA B 02/02/2026 at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G 02/03/2026 at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G 02/04/2026 at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G 02/05/2026 at 07:00 AM, 12:00 PM it was documented as not administered reason indicated other/see progress note and at 5:00 PM it was documented as given signed by MA G Record review of Resident #2's administration notes dated 01/28/2026-02/05/26 indicated: 01/28/2026 at 09:25 AM, hydrocodone 10-325mg waiting on arrival signed by MA G 01/28/2026 at 12:24 PM, hydrocodone 10-325mg waiting on arrival signed by MA G 01/28/2026 at 5:57 PM, hydrocodone 10-325mg waiting on arrival signed by MA G 01/29/2026 at 2:23 PM, hydrocodone 10-325mg waiting on arrival signed by MA G 01/29/2026 at 5:07 PM, hydrocodone 10-325mg waiting on arrival signed by MA G 01/30/2026 at 7:16 AM, hydrocodone 10-325mg waiting on arrival signed by MA G 01/30/2026 at 4:50 PM, hydrocodone 10-325mg waiting on arrival signed by MA G 01/31/2026 at 12:47 PM, hydrocodone 10-325mg on order signed by MA B 01/31/2026 at 4:50 PM, hydrocodone 10-325mg on order signed by MA B 02/01/2026 at 08:31 AM, hydrocodone 10-325mg N/A signed by MA B 02/01/2026 at 1:39 PM, hydrocodone 10-325mg on order signed by MA B 02/01/2026 at 5:02 PM, hydrocodone 10-325mg on order signed by MA B 02/02/2026 at 08:37 AM, hydrocodone 10-325mg waiting on arrival signed by MA G 02/02/2026 at 12:48 PM, hydrocodone 10-325mg waiting on arrival signed by MA G 02/02/2026 at 6:41 PM, hydrocodone 10-325mg waiting on arrival signed by MA G 02/03/2026 at 07:40 AM, hydrocodone 10-325mg waiting on arrival signed by MA G 02/03/2026 at 12:43 PM, hydrocodone 10-325mg waiting on arrival signed by MA G 02/03/2026 at 4:15 PM, hydrocodone 10-325mg waiting on arrival signed by MA G 02/04/2026 at 08:04 AM, hydrocodone 10-325mg on order signed by MA B 02/04/2026 at 12:32 PM, hydrocodone 10-325mg N/A signed by MA B 02/04/2026 at 4:03 PM, hydrocodone 10-325mg on order signed by MA B 02/05/2026 at 08:12 AM, hydrocodone 10-325mg on order signed by MA B 02/05/2026 at 12:38 PM, hydrocodone 10-325mg on order signed by MA B Record review of Resident #2's progress notes dated 01/28/2026-02/05/2026 did not indicate Resident #2's physician, NP or the pharmacy were notified he was out of his hydrocodone. Record review of Resident #2's Triplicate Request form dated 01/05/2026 for Hydrocodone-Acetaminophen tablet 10-325 milligrams give one tablet by mouth three times day indicated there was an unsigned and undated handwritten note which stated a new triplicate was required because they changed pharmacies. During an interview on 03/04/2026, at 08:35 AM Resident #2 stated that he had received his medications lately. Resident #2 stated that about a month ago he had not received his pain medication for 5 days. Resident #2 said the MA had tried to help him get his pain medication every day that she was at work. Resident #2 said the nurse (unable to recall who) was not helping the situation. Resident #2 said he was never told what happened and why he could not have his pain medication. Resident #2 said all he knew was that the MA said his pain medication was not in the building. Resident #2 said he could not sleep or get any rest due to the excessive pain he felt. He said he suffered excruciating pain in his back and neck and experienced numbness in his hands and fingers. Resident #2 stated that he had a fall prior to his admission into the facility. Resident #2 stated his pain in his back and neck since the fall could be unbearable without the pain medications. Resident #2 was tearful and anxious and said he was embarrassed by how he treated the staff due to being agitated and irritable from lack of sleep. Resident #2 said he felt off the chart in pain greater than 10 on a scale of 1 out of 10 with 10 being the greatest pain. Resident #2 said, the MA had offered to reposition and adjusted his pillows but at that point he denied anything and I wanted my real pain medication - nothing else was going to touch my pain. He said he prayed that he never had to experience that pain again. During an interview on 03/04/2026 at 09:35 AM. The anonymous person said she was aware Resident #2 had not received the ordered Hydrocodone-Acetaminophen tablet 10-325 milligrams and had multiple missed dosages. An anonymous person said she had told the charge nurses. The anonymous person said she could not recall which nurse she told. The anonymous person said not all nurses would follow through. The anonymous person said the ADON was aware and tried to assist. The anonymous person said she thought the ADON had done her part to follow up with the pharmacy by calling and faxing but nothing had changed. The anonymous person said it was important for residents to receive their ordered medications as prescribed by the physician to prevent a decline in their health condition or have increased pain. During an interview on 03/04/2026 at 10:00 AM, MA B said Resident #2 expressed pain to her that was uncontrolled. MA B said she noticed his frustration and immediately reported it to the charge nurse, LVN A on 2/15/2[TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for pain. The facility failed to ensure Resident #2 had his scheduled pain medication Hydrocodone-Acetaminophen tablet 10-325 mg by mouth three times daily from [DATE] - [DATE]. The facility failed to notify the Physician when Resident #2 was experiencing uncontrolled, excruciating pain with behavioral changes. The facility failed to ensure that Resident #2 received adequate pain medication management options. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 09:49 AM. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of experiencing unnecessary pain and a decreased quality of life.Findings included: Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including physical disability related to age, hypertension (high blood pressure), schizophrenia (hallucinations, delusions, disorganized speech/behavior), major depression disorder. Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #2 was able to make was able to make himself understood and understood others. The MDS assessment indicated Resident #2 had a BIMS summary score of 14, which indicated he was cognitively intact. The MDS assessment indicated Resident 2 was taking scheduled pain medication. Record review of Resident #2's care plan initiated on [DATE] indicated Resident #2 would remain free from pain with the following interventions: Give pain medication and evaluation of pain. Record review of Resident #2's Order Summary Report dated [DATE] indicated he had an order for Hydrocodone-Acetaminophen tablet 10-325 milligrams give one tablet by mouth three times a day for pain with a start date of [DATE]. Record review of Resident #2's medication administration record for the month of [DATE] indicated, hydrocodone 10-325mg give one tablet by mouth three times a day for pain. Resident #2's medication administration record indicated: [DATE] at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G [DATE] at 07:00 AM was documented as administered by MA G, at 12:00 PM, and 5:00 PM it was documented as not administered reason indicated other/see progress note signed by MA G [DATE] at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G [DATE] at 07:00 AM was documented as administered by MA B, at 12:00 PM, and 5:00 PM it was documented as not administered reason indicated other/see progress note signed by MA B Record review of Resident #1's medication administration record for the month of February 2026 indicated that hydrocodone 10-325mg, give one tablet by mouth three times a day for pain. Resident #2's medication administration record indicated: [DATE] at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA B [DATE] at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G [DATE] at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G [DATE] at 07:00 AM, 12:00 PM, and 5:00 PM not administered reason indicated other/see progress note signed by MA G [DATE] at 07:00 AM, 12:00 PM it was documented as not administered reason indicated other/see progress note and at 5:00 PM it was documented as given signed by MA G Record review of Resident #2's administration notes dated [DATE]-[DATE] indicated: [DATE] at 09:25 AM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 12:24 PM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 5:57 PM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 2:23 PM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 5:07 PM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 7:16 AM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 4:50 PM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 12:47 PM, hydrocodone 10-325mg on order signed by MA B [DATE] at 4:50 PM, hydrocodone 10-325mg on order signed by MA B [DATE] at 08:31 AM, hydrocodone 10-325mg N/A signed by MA B [DATE] at 1:39 PM, hydrocodone 10-325mg on order signed by MA B [DATE] at 5:02 PM, hydrocodone 10-325mg on order signed by MA B [DATE] at 08:37 AM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 12:48 PM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 6:41 PM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 07:40 AM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 12:43 PM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 4:15 PM, hydrocodone 10-325mg waiting on arrival signed by MA G [DATE] at 08:04 AM, hydrocodone 10-325mg on order signed by MA B [DATE] at 12:32 PM, hydrocodone 10-325mg N/A signed by MA B [DATE] at 4:03 PM, hydrocodone 10-325mg on order signed by MA B [DATE] at 08:12 AM, hydrocodone 10-325mg on order signed by MA B [DATE] at 12:38 PM, hydrocodone 10-325mg on order signed by MA B Record review of Resident #2's progress notes dated [DATE]-[DATE] did not indicate Resident #2's physician, NP or the pharmacy were notified he was out of his hydrocodone. Record review of Resident #2's Triplicate Request form dated [DATE] for Hydrocodone-Acetaminophen tablet 10-325 milligrams give one tablet by mouth three times day indicated there was an unsigned and undated handwritten note which stated a new triplicate was required because they changed pharmacies. During an interview on [DATE], at 08:35 AM Resident #2 stated that he had received his medications lately. Resident #2 stated that about a month ago he had not received his pain medication for 5 days. Resident #2 said the MA had tried to help him get his pain medication every day that she was at work. Resident #2 said the nurse (unable to recall who) was not helping the situation. Resident #2 said he was never told what happened and why he could not have his pain medication. Resident #2 said all he knew was that the MA said his pain medication was not in the building. Resident #2 said he could not sleep or get any rest due to the excessive pain he felt. He said he suffered excruciating pain in his back and neck and experienced numbness in his hands and fingers. Resident #2 stated that he had a fall prior to his admission into the facility. Resident #2 stated his pain in his back and neck since the fall could be unbearable without the pain medications. Resident #2 was tearful and anxious and said he was embarrassed by how he treated the staff due to being agitated and irritable from lack of sleep due to so much pain. Resident #2 said he felt off the chart in pain greater than 10 on a scale of 1 out of 10 with 10 being the greatest pain. Resident #2 said, the MA had offered to reposition and adjusted his pillows but at that point he denied anything and I wanted my real pain medication - nothing else was going to touch my pain. Resident #2 said he was not offered any other pain medication by the nurse or MA. He said he prayed that he never had to experience that pain again. Resident #2 said he was responsible for self and did not have any other family members to visit or check on him. During an interview on [DATE] at 09:35 AM, the anonymous person said she was aware Resident #2 had not received the ordered Hydrocodone-Acetaminophen tablet 10-325 milligrams and had multiple missed dosages. An anonymous person said she had told the charge nurses. The anonymous person said she could not recall which nurse she told. The anonymous person said not all nurses would follow through. The anonymous person said the ADON was aware and tried to assist. The anonymous person said she thought the ADON had done her part to follow up with the pharmacy by calling and faxing but nothing had changed. The anonymous person said the ADON had notified the physician to get a new triplicate ordered. The anonymous person said Resident #2 was irritable from not getting his scheduled pain medications, but she did not notice any excessive pain. The anonymous person said it was important for residents to receive their ordered medications as prescribed by the physician to prevent a decline in their health condition or have increased pain. During an interview on [DATE] at 10:00 AM, MA B said Resident #2 expressed pain to her that was uncontrolled. MA B said she noticed his frustration and immediately reported it to the charge nurse, LVN A, on [DATE] and also on several other occasions. MA B said LVN A said she called the pharmacy and the physician, but nothing changed. The next day, [DATE], there were still no pain medications for Resident #2. MA B said she had to repeatedly tell the nurses about low quantities of medications. MA B said some nurses do not want to help follow up with the pharmacy. MA B said the residents needed the medications as the doctor has ordered or the doctor needed to be notified otherwise. MA B said somebody needed to get to the bottom of why the medications do not come to the facility in larger quantities. MA B said she ordered the medications off the MAR in the electronic records systems by pushing the reorder button approximately 7 days before the medication is depleted. MA B said if the medications had not arrived soon after, she notified the charge nurse, notified the ADON, and left notes to remind anybody and everybody. MA B said residents that had not gotten medications as ordered were at risk of many things such as seizures, increased behaviors, high blood pressure, depression and uncontrolled pain depending on what medication is ordered. MA B said Resident #2 was distraught and he was so agitated. That he was past comforting at that point. MA B said she offered position changes, but he denied everything because he knew his medications and what he was supposed to get and that was what he wanted. During an interview on [DATE] at 01:40 PM, the ADON said they had been without a DON for two months. The ADON said she was aware that Resident #2 had not received the ordered Hydrocodone-Acetaminophen tablet 10-325 milligrams and had missed dosages. The ADON said she had called and faxed the pharmacy on numerous occasions during the dates of [DATE] - [DATE] and had followed up each day. The ADON said she had contacted the Nurse Practitioner to update the triplicates. The ADON said Hydrocodone-Acetaminophen tablet 10-325 milligrams was kept in the pyxis for emergency situations, but the problem was we had no idea the triplicate expired so it would not dispense the medication after a couple of times. The ADON said the facility had struggled with getting the medications in the building timely when the corporate pharmacy took over and made a location change from a major city in southern part of the state to a different city in the northern part of the state. The ADON said there had not been a system in place since the corporate pharmacy took over in January for a check and balance of medications ordered and the medications received. The ADON said there were problems with which number to dial and the pharmacy staff saying it was now housed out of a different location and no longer covered by the pharmacy they had called. The ADON said, we never knew who we were talking to or where we were supposed to be calling. The ADON said she had sent the Triplicate Request Form on [DATE]. The ADON said the triplicate had expired so then it had to be sent again. The ADON said she had not documented any of the requests, faxes, conversations or follow-ups on the needed medications for Resident #2 with the pharmacy. The ADON said she had not documented notifying the Physician or the Nurse Practitioner of Resident #2's missed medications. The ADON said, she kept thinking after she faxed or had a conversation with the pharmacy the medication would arrive, but it never had arrived. The ADON said the medication aides requested the medication through the electronic computer system from the Medication Administration Record page to reorder the medication. The ADON said she thinks the medication aides were ordering the medications too early and the pharmacy could not send the medication out yet to the facility. The ADON said the nurses would then follow - up with the pharmacy if the medication aide was unable to resolve the issue. The ADON said the nurse should attempt to call the pharmacy and find out the situation and see if they needed to contact the nurse practitioner for another order or if a local pharmacy could fill the medication temporarily until the medication was provided by the corporate pharmacy. The ADON said if the nurse was unsuccessful at getting the medication in the building timely, that she and the DON should be notified as well as the Administrator. The ADON said it was important for residents to be reassessed for pain to prevent the pain from getting out of control. The ADON said the physician/NP should be notified for alternate measures such as a different pain-relieving medication. During an interview on [DATE] at 02:15 PM, the Nurse Practitioner said she expected the staff to notify her if an ordered medication is not available. The Nurse Practitioner said she would always pick up the phone and contact the pharmacy immediately to verify the prescription or to find out what is needed to prevent any missed dosages. The Nurse Practitioner stated she had no knowledge that Resident #2 was without pain medication until weeks after the incident had occurred when Resident #2 mentioned this during a visit. The Nurse Practitioner stated the facility never told her that Resident #2 was out of pain medication or had a change in condition. The Nurse Practitioner stated that she could not write the Triplicate herself due to that was out of her scope of practice. However, she expected to be notified regarding the missed dosages and any changes in condition such as increased pain. The Nurse Practitioner stated that it was imperative to have accurate and timely communication with the staff to ensure coordination of care of the residents. The Nurse Practitioner stated that. The Nurse Practitioner stated ordered medications should be given appropriately to prevent a further decline in the resident's health and wellbeing. The Nurse Practitioner stated she expected notification of missed medications or unavailable medications so alternative actions could be made timely such as contacting a local pharmacy or prescribing another medication to prevent a negative outcome such as increased, uncontrolled pain. The Nurse Practitioner said she also had standing orders available for the staff to utilize as well. During an interview on [DATE] at 03:35 PM, the Corporate Regional Nurse stated she had not contacted the pharmacy to inquire on the facility follow-up attempts because she had not realized there were ongoing problems. The Corporate Regional Nurse stated the ADON had not reported the Resident #2 had missed dosages of pain medications because of the unavailability of medications. The Corporate Regional Nurse stated she expected the staff to have clear and effective communication and to follow the medication administration policy accurately. The Corporate Regional Nurse stated that a resident can experience a decline in health and increase of pain, seizure, blood pressure, behaviors when prescribed medications are not given as ordered. During an interview on [DATE] at 4:53 PM, the pharmacy representative stated the record of activity for Resident #2 indicated the following:[DATE] - facility requested order for 50 tablets of Hydrocodone-Acetaminophen tablet 10-325 milligrams[DATE] - facility received order for 16-day supply - last through [DATE]XXX[DATE] - Pyxis was accessed for 2 tablets Hydrocodone-Acetaminophen tablet 10-325 milligramsNo other logged activity via faxes, telephone calls or computer request made until [DATE]. During an interview on [DATE] at 07:45 AM, LVN A stated she was the charge nurse for Resident #2 on [DATE], [DATE]. LVN A stated she was aware Resident #2 did not have the Hydrocodone-Acetaminophen tablet 10-325 milligrams as ordered. LVN A stated the facility was always lacking the medications needed. LVN A stated the corporate pharmacy was always sending 2 to 3 pills instead of sending the right amounts to last the entire month. LVN A stated she had to call the pharmacy a lot but could not say for certain when she had call regarding Resident #2. LVN A stated she had no time to document all the calls she made to the pharmacy for medications. LVN A stated she made the calls when she walked down the halls providing care and doing other things. LVN A stated her cart had not run out of medications because she took care of her job and sent her medications needs in 6 - 7 days ahead of time so she did not run out of medications. But she had to follow up on the corporate pharmacy when they did not send the full months' worth of pills like they were supposed to do. LVN A said the MAs were responsible for stocking their own carts. LVN A said, there was no reason for MAs to come to her when their carts were low because they all had the same access she had and that was on them to get their stuff done on their own. LVN A said, the MAs could make calls to follow up on the medications, send faxes or whatever was needed. LVN A said, when she had time, she could help them. LVN A said, she was sure that she had helped them get medication out of the pyxis for Resident #2 when they needed them but that was a long process to do and sometimes, they got to wait until I can get over to it. LVN A said it was important for Resident #2 to receive the scheduled pain medications. LVN A said, that is why something has got to be done about the corporate pharmacy because there is not enough time to be backtracking all the time. LVN A said she could not recall if she had notified the Nurse Practitioner that Resident #2 had not had the Hydrocodone-Acetaminophen tablet 10-325 milligrams when the MA notified her that Resident #2 was out of medication. LVN A said the ADON was aware that Resident #2 was out of medication so she would have contacted the physician. LVN A said, she guessed the MA told her and the ADON but that was not the problem - the problem was the corporate pharmacy. LVN A said she did not recall the MAs reporting Resident #1 was in pain. LVN A said Resident #2 never reported to her that he had excessive pain. LVN A said she had not re-assessed Resident #2 for pain after the MA told her Resident #2 did not have the scheduled Hydrocodone-Acetaminophen tablet 10-325 milligrams available. LVN A said she had not noticed any differences in Resident #2 because he was not in need of the nurse, so she did not know him well. LVN A said it was important to notify the physician and or the Nurse Practitioner of resident needs or changes accurately and timely because of continuity of care. LVN A said she had not offered Resident #2 any other pain-relieving medications when the scheduled Hydrocodone-Acetaminophen tablet 10-325 milligrams were not available. LVN A said it was important for residents to receive their ordered medications as prescribed by the physician to prevent a decline in their health condition or have increased pain. LVN A said she should have notified the physician when the MA told her Resident #2 did not have the scheduled pain medications. LVN A said she should have reassessed Resident #2's pain levels to prevent his pain from getting out of control. During an interview on [DATE] at 08:15 AM, the administrator said she expected the clinical staff to ensure the residents received their medications as ordered by the physician in an accurate and timely manner. The Administrator said the MAs should reorder the medication approximately 6 days out to prevent medication not being available through the electronic record system and the resident's MAR. If the MAs could not receive a medication timely, they would report that to the charge nurse. The charge nurse would follow up with the pharmacy. If a resolution was not accomplished, it should move up to the ADON/DON and myself. The Physician should be notified before a dosage is missed for further orders to be received. The clinical staff should be running reports from the electronic record system daily to ensure no medications dosages were not missed. The Administrator said it was important to have effective and clear communication to meet the needs of the residents. The Administrator said missed dosages of ordered medications could cause harm by increasing the risk factors associated with the reason the resident required the medication such as high blood pressure, increased seizure activity, behavioral issues or uncontrolled pain. Record review of the facility policy titled, Pain Assessment Management with a revision date of [DATE] indicated, .Ask the resident if he/she is experiencing pain.review the medication administration record to determine how often the individual requests and receives pain mediation, and to what extent the administered mediation relieves the resident's pain.Assessing Pain.Assess the resident whenever there is a suspicion of new pain and the need for further assessment when there is a change of condition. Record review of the facility policy titled, Change in Resident's Condition or Status, with a revision date of February of 2021 indicated, our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The Administrator was notified on [DATE] at 09:15 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator provided the Immediate Jeopardy template on [DATE] at 09:51 AM. The facility's Plan of Removal was accepted on [DATE] at 12:25 PM and included: Plan of Removal:697: Pain Management Action: Resident #2 assessed for pain. Resident received pain medication as ordered on [DATE]. Person(s) Responsible: Charge Nurse Date: [DATE] Action: All residents were assessed for pain. Any pain noted during assessments will be treated for pain if medication is ordered. If residents complain of pain and do not have ordered pain medication, the physician will be notified and orders will be followed. Person(s) Responsible: Charge Nurse, Assistant Director of Nursing, Director of Nursing, and/or Designee Date: [DATE] Action: A medication cart to medication administration record audit performed to ensure no additional pain medication is noted unavailable. Any medications noted unavailable have been ordered from the pharmacy. Physician notified if the facility is unable to obtain medications for new orders. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and/or DesigneeDate: [DATE] Action: All licensed nurses educated on: Pain Assessment Management, Administering Pain Medication, Change in Resident Condition, & Medications Order & Reorder. Nurses key takeaway from this education will be to assess the resident for pain, notify the physician of pain, follow physician orders and administer pain medications as ordered, notify the nursing leadership and the physician if pain medication is unavailable, and the medication reordering process and to reorder medication per policy. All licensed nurses will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and/or Designee Date: [DATE] Action: Certified Medication Aides educated on: Administering Pain Medication, Change in Resident Condition, & Medications Order & Reorder. Certified Medication Aides key takeaway will be administering pain medications per physician orders, that when a resident complains of pain and they do not have ordered pain medications and/or PRN pain medications to immediately notify the charge nurse and nursing administration, and the medication reordering process and to reorder medication per policy. All certified medication aides will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and/or Designee Date: [DATE] Action: The facility will run their medication admin audit report from their electronic medical record, daily, to check for pain medications that were not administered per order, check to ensure the medication is available, notify the physician, and reorder, if necessary x4 weeks. Re-education will occur as necessary with adverse findings. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Weekend Supervisor, Regional Nurse Consultant, and/or Designee Date: [DATE] Action: Ad hoc QAPI performed with the Medical Director to review the template for F697- Pain Management and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator Date: [DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation and interview on [DATE] at 04:30 PM, Resident #2 was sitting up on side of bed and stated, I had my pain medication, and I am doing well at this time. Resident #2 said, the nurse had visited with him and re-evaluated his pain earlier today and spoke with him regarding the missed pain medication incident. Record Review of the completed facility's binder indicated all residents were assessed for pain. Any pain noted during assessments was e treated for pain. If residents complain of pain and do not have ordered pain medication, the physician was notified and orders were followed. Record review of completed current residents' medication reconciliation of medication cart to medication administration record audit completed by DON, ADON, Regional Nurse Consult. The audit report to the pharmacy indicated 10 inquiries regarding reordered medication to the pharmacy online through EMRs. The Pharmacy responded back to update each inquiry and further instructions to process the request. ) LVNs, and RNs over Pain Assessment Management, Administering Pain Medication, Change in Resident Condition, & Medications Order & Reorder. Nurses key takeaway from this education will be to assess the resident for pain, notify the physician of pain, follow physician orders and administer pain medications as ordered, notify the nursing leadership and the physician if pain medication is unavailable, and the medication reordering process and to reorder medication per policy. All licensed nurses will be educated prior to working their next shift. Record review of Inservice dated [DATE] initiated by the DON to clinical staff including, CMA's Administering Pain Medication, Change in Resident Condition, & Medications Order & Reorder. Certified Medication Aides key takeaway will be administering pain medications per physician orders, that when a resident complains of pain and they do not have ordered pain medications and/or PRN pain medications to immediately notify the charge nurse and nursing administration, and the medication reordering process and to reorder medication per policy. All certified medication aides will be educated prior to working their next shift. Record review of Inservice dated [DATE] initiated by the Regional Nurse Consult to DON, ADON, Weekend Supervisor or Designee over run their medication admin audit report from their electronic medical record, daily, to check for medications that were not administered per order, check to ensure the medication is available, notify the physician, and reorder, if necessary, x4 weeks. Record Review of the QAPI Committee Review -committee meeting was completed on [DATE] with the Administrator, DON and Medical Director (over the telephone). The QAPI meeting consisted of education and training on nursing staff to pain assessment management, administering pain medication, change in condition, medication order and reorder. The key focus for nurses is to assess the resident for pain, notify the physician of pain, follow physician orders and administer pain medications as ordered, notify the nursing leadership and the physician if pain medication or any medication is not available, and the medication reordering process and to reorder medication per the policy. The CMA were educated on administering pain medications, change in condition, medication order and reorder. The focus was administering pain medications per the physician orders, that when a resident complains of pain and they do not have ordered pain medications and/or prn pain medications to immediately notify the charge nurse and nursing administration, and the medication reordering process and to reorder medication per policy. The DON, ADON and weekend supervisor or designee will run their medication admin audit report from the EMR, daily to check for pain medications that were not administered per order, check to ensure the mediation is available, notify the physician, and reorder, if necessary, monitor for the next 4 weeks. Re- education will occur, as necessary. During the interviews on [DATE] at 08:30 AM - 10:30 AM, the nursing staff on the 6AM to 6PM schedule: DON, ADON, MDS Nurse, LVN A, MA B, LVN E, LVN D, MA G, RN K and the Nursing staff on the 6 PM to 6AM schedule: LVN F, RN L, LVN M, LVN H staff were able to correctly identify the steps for proper medication administration and what to do if a medication is unavailable such as (check the e-kit, notify the nursing administration, pharmacy, and MD that the medication is not available, ensure the medication is reordered and follow physician orders). assess the resident for pain, notify the physician of pain, follow physician orders and administer pain medications as ordered, notify the nursing leadership and the physician if pain medication is unavailable. The CMAs were educated on administering pain medications, change in condition, medication order and reorder. The focus was administering pain medications per the physician orders, that when a resident complains of pain and they do not have ordered pain medications and/or prn pain medications to immediately notify the charge nurse and nursing administration. During the interviews on [DATE] at 10:30 AM - 11:30 AM , the DON, ADON, RN L (Weekend Supervisor/designer) verbalized the expectation to run/monitor their medication admin audit report from their electronic medical record, daily, to check for medications that were not administered per order, check to ensure the medication is available, notify the physician, and reorder, if necessary, x4 weeks of monitoring On [DATE] at 11:35 AM, the Administrator was informed that the IJ was removed; ; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facilities need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical record maintained for each resident were complete and accurately documented for 1 of 11 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN C documented the incident/fall on 11/20/2025 reported by the hospice aide (CNA G). This failure could place residents at risk for delayed interventions, appropriate interventions, health complications and decreased quality of life. Findings include:Record review of Resident #1's face sheet dated 12/03/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #1 had diagnoses which included cerebral infarction (stroke-disruption of blood flow to the brain causing tissue damage), hemiplegia and hemiparesis (paralysis (unable to move) and/or muscle weakness on one side of the body) of right side, mood disorder, anxiety disorder, Alzheimer's (progressive brain disorder that causes gradual memory loss, abnormal thinking, difficulty with daily activities and leads to brain shrinkage and death), weakness lack of coordination, repeated falls, and abnormality of albumin (protein in blood).Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood and sometimes understood others. She was unable to complete the BIMS because she was rarely/never understood. Resident #1 required substantial/maximal assistance from staff for most ADLs. Resident #1 was always incontinent of bowel and bladder. Resident #1 had no falls since prior assessment. Resident #1 was receiving hospice services.Record review of Resident #1's undated Care Plan indicated she was receiving hospice services related to terminal diagnoses of Alzheimer's and decline was expected. Resident #1 used anti-anxiety medications (used to treat anxiety) and on 11/17/25 resident was noted flailing arms and constantly attempting to roll and scoot out of the bed. Resident #1 was an elopement risk and resided on the secured unit. Resident #1 was at risk for falls related to confusion, deconditioning, and gait/balance problems. Resident #1 had fall interventions including following the facility fall protocol, was noted with terminal restlessness and agitation, flailing in bed, and hospice was notified and medications reviewed dated initiated 11/19/25.Record review of Resident #1 nurse's notes dated 11/20/25 did not reveal any documentation of resident falling between 4:00 AM-4:30 AM or notification of Resident #1's RP of fall. LVN C was the nurse on duty during that time.During an interview on 12/03/2025 at 12:14 PM, Resident #1's RP said the morning of 11/20/2025 the hospice aide, CNA G came in to bathe Resident #1 and found Resident #1 in the floor thrashing around and CNA G hollered for twenty minutes trying to get help and there was not anyone else in the secured unit. Resident #1's RP said CNA G ended up moving Resident #1 to where she felt safe to leave her because there was a television on a bedside table that she was afraid would fall on Resident #1 and had to go outside the secured unit to get the nurse. Resident #1's RP said the night shift nurse (LVN C) did not document anything about the incident in Resident #1's chart. Resident #1's RP said she had reviewed Resident #1's chart on 11/20/2025 with the day shift nurse (LVN B) and there was no documentation from the night shift nurse (LVN C) of the incident or the fall.During an interview on 12/03/2025 beginning at 3:01 PM, Hospice Representative H said apparently the hospice aide, CNA G, had gone in early the morning of 11/20/2025 and found Resident #1 on the floor and CNA G called her after getting the facility nurse because CNA G thought the facility was mad at her for not getting the nurse sooner. Hospice Representative H said CNA G told her Resident #1 was thrashing and rolling around on the floor and CNA G did not think she could leave Resident #1 right then and moved the television away that was on a bedside table, so it did not fall on Resident #1. Hospice Representative H said CNA G told her she opened Resident #1's door and kind of hollered out for help but not too loud because she did not want to wake everyone up. Hospice Representative H said CNA G decided to get Resident #1's bed changed so it would be ready for her to get put back in as she waited for someone in the secured memory unit. Hospice Representative H said CNA G told her when she still did not find anyone, CNA G went outside the secured unit to get the nurse. Hospice Representative H said after CNA G told her what had gone on, she reported off to Hospice Representative J who reported off to Resident #1's RP and their hospice RN made a visit to assess Resident #1. Hospice Representative H brought Hospice Representative J into the call. Hospice Representative H and Hospice Representative J said they never suspected Resident #1 had been abused. Hospice Representative J said Resident #1 had behaviors they were trying to manage with medications, and they had multiple fall mats and a mat against the wall because she was very active and would flail her arms and legs and fall off the bed. Hospice Representative J said the bed was kept in a low position. Hospice Representative J said Resident #1 had been diagnosed with terminal restlessness and was nearing end of life. During an interview on 12/03/2025 at 3:15 PM, CNA G said she worked for the hospice agency and had come to the facility around 4:00 AM to give Resident #1 a bath and had gone to the linen closet to get her supplies prior to going to Resident #1's room. CNA G said when she entered Resident #1's room, Resident #1 was on the floor. CNA G said she did not remember seeing any staff in the secured unit when she entered, but they could have been in a resident's room. CNA G said Resident #1 was in the floor and was scooting around in circles in the floor and she put some pillows behind her and moved the bedside table with the television away from her so it would not fall on her if she hit it. CNA G said she then opened Resident #1's door and kind of said Hey, Hey but did not holler loud because she did not want to wake everyone up. CNA G said she did not see or hear anyone in the hallway. CNA G said she then went out in the hallway and looked in the dining area and did not see anyone and came back to make sure Resident #1 was safe and then went to the nurses' station outside the secured unit and got the nurse to come help. CNA G said the nurse got a CNA to help her, but she did not remember if the aide was in the secured unit or not when they went back to the secured unit. CNA G said Resident #1 was only in the floor, maybe 5 to 6 minutes from the time she found her, to when she went and got the nurse. During an interview on 12/03/2025 at 4:07 PM, LVN C said she worked for a nurse staffing agency. LVN C said she had documented a timeline of events the morning of 11/20/2025 and CNA G came in at 4:02 AM and went to the secured unit and came back to the nurses' station at 4:28 AM and said Resident #1 was on the floor when she went in her room. LVN C said CNA G had already made Resident #1's bed and everything. LVN C said something did not seem right because CNA G had waited over twenty minutes to come get help to get Resident #1 up off the floor. LVN C said she called DON E at 4:32 AM because it just did not feel right. LVN C said she asked DON E if she needed to do an incident report and DON E told her she did not need to do a report because Resident #1 was care planned for it. LVN C said she even had DON E repeat that she did not need to do an Incident Report. LVN C said next thing she knew, they took her off the schedule and DON E said it was because she did not notify the family of the fall. LVN C said what would she be notifying them of, if it was not a fall and did not need an incident report. LVN C said HA F was inside the secured unit just inside the nook of the secured unit when she went into the secured unit with CNA G and herself and HA F got Resident #1 up off the floor. LVN C said she assessed Resident #1, and she did not have any noted injuries. LVN C said she would take accountability for not calling the family. LVN C said she knew she was supposed to notify the physician, DON, and RP and do an incident report but since coming in, DON E was very adamant to call him about everything, and he would guide her on what to do since she was agency staff and DON E told her not to do an Incident Report. LVN C said she should have also documented the incident in the nurse's notes. LVN C said she did not document the incident/fall because DON E told her not too. During an interview on 12/03/2025 at 4:37 PM, DON E said he received a call from the LVN C early in the morning on 11/20/2025 and LVN C told him the resident was on the floor and had found some bruises. DON E said he told LVN C to do an Incident Report and contact the family and LVN C did not notify the family or document the incident/fall. During an interview on 12/04/2025 at 2:44 PM, the ADM said she had been the ADM at the facility since 11/19/2025. The ADM said the staff reported they had been told not to document incidents by the previous DON (DON E) and there was confusion on when/what to report. The ADM said she would expect the facility policies to be followed. Record review of the facility's policy titled Assessing Falls and Their Causes dated revised December 09, 2024, indicated . The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . After a Fall . 5. Notify the resident's attending physician and family in an appropriate time frame . 8. Complete an incident report for resident falls no later than 24 hours after the fall occurs . Defining Details of Falls . 2. For each individua, distinguish falls into the following categories . a. rolling, sliding, or dropping from an object, such as from bed or chair to floor . b. falling while attempting to stand up from a sitting or lying position . c. falling while already standing and trying to ambulate . Documentation . When a resident falls, the following information should be recorded in the resident's medical record . 1. The condition of the resident . 2. Assessment data . 3. Interventions . administered . 4. Notification of the physician and family, as indicated . 8. The signature and title of the person recording the data . Reporting . 1. Notify the following individuals when a resident falls . a. the resident's family b. the attending physician c. the Director of Nursing . 2. Report other information in accordance with facility policy and professional standards of practice .

Based on interviews and record review, the facility failed to notify the resident's representative and hospice services when there were changes in the resident's physical, mental, or psychosocial status for 1 of 11 residents (Resident #1) reviewed for notification of changes.The facility failed to notify Resident #1's hospice agency and her RP of a falls on [DATE] and [DATE] The facility failed to notify Resident #1's hospice agency and her RP of bruising to her hand and foot on [DATE]. The facility failed to notify Resident #1's RP of behavioral changes or medication changes on [DATE]. The facility failed to notify Resident #1's RP of two falls, behavioral changes, and medication changes on [DATE].The facility failed to notify Resident #1's RP of a fall on [DATE]. These failures could place residents at risk of not receiving adequate and timely intervention and a decline in condition. Findings included:Record review of Resident #1's face sheet dated [DATE] indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #1 had diagnoses which included cerebral infarction (stroke-disruption of blood flow to the brain causing tissue damage), hemiplegia and hemiparesis (paralysis (unable to move) and/or muscle weakness on one side of the body) of right side, mood disorder, anxiety disorder, Alzheimer's (progressive brain disorder that causes gradual memory loss, abnormal thinking, difficulty with daily activities and leads to brain shrinkage and death), weakness lack of coordination, repeated falls, and abnormality of albumin (protein in blood). Resident #1's RP was listed on the face sheet.Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood and sometimes understood others. She was unable to complete the BIMS because she was rarely/never understood. Resident #1 required substantial/maximal assistance from staff for most ADLs. Resident #1 was always incontinent of bowel and bladder. Resident #1 had no falls since prior assessment. Resident #1 was receiving hospice services.Record review of Resident #1's undated Care Plan indicated she was receiving hospice services related to terminal diagnosis of Alzheimer's and decline was expected. Resident #1 used anti-anxiety medications (used to treat anxiety) and on [DATE] resident was noted flailing arms and constantly attempting to roll and scoot out of the bed. Resident #1 was an elopement risk and resided on the secured unit. Resident #1 was at risk for falls related to confusion, deconditioning, and gait/balance problems; on [DATE] she scooted onto the floor, no injuries noted, on [DATE] she slid off the bed onto the fall mat with no injuries noted, on [DATE] resident rolled out of the bed, no injuries noted, on [DATE] resident rolled out of the bed onto the fall mat, no injuries noted, and [DATE] bruises noted to resident's body. Resident #1 had fall interventions including following the facility fall protocol, was noted with terminal restlessness and agitation, flailing in bed, and hospice was notified and medications reviewed dated initiated [DATE].Record review of Resident #1's nurse's note dated [DATE] at 6:42 PM indicated RN A documented she was notified by the CNA (not named) that resident slid off the bed in low position to fall mat before she could get to her. RN A assessed the resident, and she had no signs of pain, redness/bruising to any area and could move all extremities. There was no documentation that RN A notified Resident #1's RP or hospice service of the fall. Record review of Resident #1's nurse's note dated [DATE] at 10:30 AM indicated LVN B documented the resident slid onto the floor with no injury or concerns. There was no documentation that LVN B notified Resident #1's RP or hospice service of the fall.Record review of Resident #1's nurse's note dated [DATE] at 7:42 AM indicated LVN B documented the aide (not named) noticed bruising on resident's right hand pinky and middle finger knuckle and bruising on top of her left foot. LVN B documented she evaluated the rest of Resident #1's body and did not see anything else out of the way. There was no documentation LVN B notified Resident #1's RP or hospice services of the bruising. LVN B documented at 12:34 PM, Resident #1 was hitting her hands on the dining table, upset, trying to hit the CNAs, and acting out with other residents, and LVN B administered her anxiety and pain medication. LVN B documented an order was received from the hospice physician to give Ativan 2 mg (anti-anxiety medication) and hydrocodone 7.5 mg one hour before scheduled time if needed for increased agitation or mood swings. There was no documentation LVN B notified Resident #1's RP of behavior changes or medication changes. Record review of Resident #1's nurse's note dated [DATE] at 7:00 AM indicated LVN B documented resident rolled out of the bed onto the fall mat with pillow under her and there was no injury. LVN B documented there was no new bruising at that time. LVN B notified hospice service and was instructed to monitor resident. There was no documentation LVN B notified Resident #1's RP of fall. LVN B documented at 10:58 AM, Resident #1 was really agitated this morning trying to get out of the bed on her own, aides were having to watch her and sit with her because she would not stay in chair or bed, constantly moving and wanting up and out. There was no documentation LVN B notified Resident #1's RP of behaviors. LVN B documented at 12:45 PM, Resident #1 rolled out of the bed onto the fall mat with pillow, no injuries, resident will not stay in bed or chair today ([DATE]), very agitated even after medication. LVN B documented she notified hospice services but there was no documentation she notified Resident #1's RP of fall or increased behaviors. LVN B documented at 3:10 PM, Resident #1 was in bed and highly agitated and the hospice nurse came and assessed the resident, and orders were received to discontinue hydrocodone and Ativan (tablets) and added lorazepam (anti-anxiety) liquid every four hours as needed and morphine liquid every two hours for pain and shortness of breath medication as needed. There was no documentation LVN B notified Resident #1's RP of medication changes or behaviors.Record review of Resident #1 nurse's notes dated [DATE] did not reveal any documentation of resident falling between 4:00 AM-4:30 AM or notification of Resident #1's RP of fall. LVN C was the nurse on duty during that time.Record review of Resident #1's nurse's note dated [DATE] at 10:10 AM indicated LVN B documented the DON asked her to make sure the resident's family had been called about the fall and the RP said she was unaware until early this morning when hospice called her. LVN B documented there was no documentation of the fall, hospice was not called, and DON was not aware. LVN B documented there was no injury noted other than prior bruising.Record review of nurses' notes from [DATE]-[DATE] indicated the resident was on end-of-life comfort care and expired on [DATE].Record review of photograph's provided by Resident #1's RP dated [DATE] at 11:44 AM revealed multiple bruises to arms, legs, foot, and chin in multiple stages of healing from yellow (normally indicated 10-14 days old), green in color (normally indicated it 5-10 days old), to purple in color (normally indicated 1-2 days old), and red (normally indicated it was new).During an interview on [DATE] at 12:14 PM, Resident #1's RP said she knew Resident #1 had a change starting [DATE]-[DATE] because she had reviewed Resident #1's chart at the facility and she saw where Resident #1 had multiple falls, and the facility had not notified her nor hospice of the falls or of her thrashing in her bed and falling out and appearing restless. Resident #1's RP said finally a nurse notified hospice on [DATE] and said there was something wrong and hospice came and diagnosed her with terminal restlessness and that was when they decided to just do comfort care. Resident #1's RP said on [DATE] she came to the facility and spoke with DON E and asked why resident #1 was covered in bruises and why she nor hospice had been notified of her multiple falls and DON E said he did not know why, and he was unaware. Resident #1's RP said DON E and the ADM went to the secured unit and did a full body assessment and Resident #1 was covered in bruises in different stages of healing. Resident #1's RP said DON E and the ADM said they were very sorry and that was not what they expected of their staff, and she should have been notified. Resident #1's RP said she thought everything would be better after that, but the very next morning CNA G came in to bathe her and found Resident #1 in the floor thrashing around and CNA G hollered for twenty minutes trying to get help and there was not anyone else in the secured unit. Resident #1's RP said CNA G ended up moving Resident #1 to where she felt safe to leave her because there was a television on a bedside table that she was afraid would fall on Resident #1 and had to go outside the secured unit to get the nurse. Resident #1's RP said the night shift nurse (LVN C) did not document anything about the incident in Resident #1's chart and the facility did not notify her until the day shift nurse (LVN B) called her six hours later, but the hospice agency had already notified her. Resident #1's RP said the facility should have notified her sooner of the incident.During an interview on [DATE] beginning at 3:01 PM, Hospice Representative H said apparently the hospice aide, CNA G, had gone in early the morning of [DATE] and found Resident #1 on the floor and CNA G called her after getting the facility nurse because CNA G thought the facility was mad at her for not getting the nurse sooner. Hospice Representative H said CNA G told her Resident #1 was thrashing and rolling around on the floor and CNA G did not think she could leave Resident #1 right then and moved the television away that was on a bedside table, so it did not fall on Resident #1. Hospice Representative H said CNA G told her she opened Resident #1's door and kind of hollered out for help but not too loud because she did not want to wake everyone up. Hospice Representative H said CNA G decided to get Resident #1's bed changed so it would be ready for her to get put back in as she waited for someone in the secured memory unit. Hospice Representative H said CNA G told her when she still did not find anyone, CNA G went outside the secured unit to get the nurse. Hospice Representative H said after CNA G told her what had gone on, she reported off to Hospice Representative J who reported off to Resident #1's RP and their hospice RN made a visit to assess Resident #1. Hospice Representative H brought Hospice Representative J into the call. Hospice Representative J said they were not notified of the resident falling on [DATE] or [DATE]. She said they were notified related to behavioral issues on [DATE] and made medication changes. Hospice Representative J said they were also not notified on [DATE] of a fall. Hospice Representative J said their nurse made a routine visit on [DATE] and noted bruising on Resident #1's hands, arms and elbows but did not do a full skin assessment because the resident was up in the wheelchair and calm. Hospice Representative J said they were notified on [DATE] of the early morning fall and then made a visit later that day. Hospice Representative H and Hospice Representative J said they never suspected Resident #1 had been abused. Hospice Representative J said Resident #1 had behaviors they were trying to manage with medications, and they had multiple fall mats and a mat against the wall because she was very active and would flail her arms and legs and fall off the bed. Hospice Representative J said the bed was kept in a low position. Hospice Representative J said Resident #1 had been diagnosed with terminal restlessness and was nearing end of life. Hospice Representative H said during the times in question there were management changes going on at the facility and there had been a lack of communication, but the current management was working hard at changing that and it had definitely gotten better. Hospice Representative H and Hospice Representative J said they would expect to be notified when one of their hospice residents falls so, they could make the determination whether they needed to make a visit, to adjust frequency of visits, medication changes, and to be informed of what was going on with the resident.During an interview on [DATE] at 3:15 PM, CNA G said she worked for the hospice agency and had come to the facility around 4:00 AM to give Resident #1 a bath and had gone to the linen closet to get her supplies prior to going to Resident #1's room. CNA G said when she entered Resident #1's room, Resident #1 was on the floor. CNA G said she did not remember seeing any staff in the secured unit when she entered, but they could have been in a resident's room. CNA G said Resident #1 was in the floor and was scooting around in circles in the floor and she put some pillows behind her and moved the bedside table with the television away from her so it would not fall on her if she hit it. CNA G said she then opened Resident #1's door and kind of said Hey, Hey but did not holler loud because she did not want to wake everyone up. CNA G said she did not see or hear anyone in the hallway. CNA G said she then went out in the hallway and looked in the dining area and did not see anyone and came back to make sure Resident #1 was safe and then went to the nurses' station outside the secured unit and got the nurse to come help. CNA G said the nurse got a CNA to help her, but she did not remember if the aide was in the secured unit or not when they went back to the secured unit. CNA G said Resident #1 was only in the floor, maybe 5 to 6 minutes from the time she found her to when she went and got the nurse. CNA G said she bathed Resident #1 three days a week and had only been seeing her for about two weeks at the time of the incident. CNA G said Resident #1 had old bruises on her legs and arms, when she first started seeing her and did not know if they had been reported previously.During an interview on [DATE] at 4:07 PM, LVN C said she worked for a nurse staffing agency. LVN C said she had documented a timeline of events the morning of [DATE] and CNA G came in at 4:02 AM and went to the secured unit and came back to the nurses' station at 4:28 AM and said Resident #1 was on the floor when she went in her room. LVN C said CNA G had already made Resident #1's bed and everything. LVN C said something did not seem right because CNA G had waited over twenty minutes to come get help to get Resident #1 up out of the floor. LVN C said she called DON E at 4:32 AM because it just did not feel right. LVN C said she asked DON E if she needed to do an incident report and DON E told her she did not need to do a report because Resident #1 was care planned for it. LVN C said she even had DON E repeat that she did not need to do an Incident Report. LVN C said next thing she knew, they took her off the schedule and DON E said it was because she did not notify the family of the fall. LVN C said what would she be notifying them of, if it was not a fall and did not need an incident report. LVN C said HA F was inside the secured unit just inside the nook of the secured unit when she went into the secured unit with CNA G and herself and HA F got Resident #1 up out of the floor. LVN C said she assessed Resident #1, and she did not have any noted injuries. LVN C said DON E did not actually tell her not to call the family, but it was something that would usually be reported off to the day shift nurse because it was 4:00 AM in the morning and it was care planned. LVN C said she would take accountability for not calling the family. LVN C said she knew she was supposed to notify the physician, DON, and RP and do an incident report but since coming in, DON E was very adamant to call him about everything and he would guide her on what to do since she was agency staff and DON E told her not to do an Incident Report. LVN C said she should have also documented the incident in the nurse's notes. LVN C said Resident #1 had some minor bruises when she had worked with her before. LVN C said she relieved DON E on [DATE] and even did a walk through with him and DON E showed her Resident #1's heavily bruising in multiple areas of her body. LVN C said she felt the bruises were more from her disease process and end of life because of the inconsistencies of them, but some could have been from her falls. LVN C said she was following the direction of DON E however he did not say to not notify the family. LVN C said she did not document the incident because DON E told her not too. During an interview on [DATE] at 4:37 PM, DON E said he received a call from the LVN C early in the morning on [DATE] and LVN C told him the resident was on the floor and had found some bruises. DON E said he told LVN C to do an Incident Report and contact the family and LVN C did not notify the family. DON E said he had the day shift nurse, LVN B, call the family to ensure they had been called, and they had not but the hospice agency had called them already. DON E said hospice service and RP should be called once they ensure the resident was safe and taken care of. DON E said if staff did not notify hospice agencies or RPs, it could affect the care for the resident or how perceived by the family. DON E said the hospice agency diagnosed Resident #1 with terminal restlessness (intense physical and emotional distress, including confusion, anxiety, and inability to rest, often happening in the final days or hours of life) and she would flail her arms and legs hitting objects such as her bed or table, and fall from the bed, which resulted in bruises. DON E said Resident #1 was on a daily low dose aspirin, had protein malnutrition, and nearing end of life, which could have contributed to her bruising easily along with her falls and flailing of arms and legs.During an interview on [DATE] at 4:47 PM, CNA K said she reported bruising to Resident #1's legs and arms to the charge nurse but could not remember when, maybe a couple weeks, before she passed away. CNA K said Resident #1 would sling her legs out of the bed and sling her arms, hitting the bed or tables, and they struggled to keep her from falling out of the bed.During an interview on [DATE] at 4:52 PM, RN A said she was the ADON. RN A said she was not aware Resident #1 was on hospice services at the time of her fall on [DATE]. RN A said it was not an actual fall, Resident #1 just slid off the bed and it was in the lowest position. RN A said she was pretty sure she notified the family on the incident on [DATE]. RN A said she should had done an incident report and thought she did, but she could have forgotten to do it. RN A said the hospice agency and the resident's RP should be notified of any falls immediately, so they were aware and knew what was going on and sometimes the hospice agency may want to come assess the resident or determine whether to send them out to the hospital.During an interview on [DATE] at 4:59 PM, LVN B said Resident #1 was falling a lot and her RP was upset there was not a lot documented about her falls and bruises in her chart and not being notified of falls and bruising. LVN B said they were documenting, just not every day. LVN B said Resident #1 would roll out of bed a lot before she passed away. LVN B said the resident's hospice agency and RP should be notified of any incidents, falls, bruises, behavior changes, and/or medication changes. LVN B said there was confusion on when/what to document on Resident #1 because DON E had told her she did not have to document when she slid out of the bed and had no injuries because she was care planned for it. LVN B said Resident #1's RP should have been notified when Resident #1 slid out of the bed on [DATE], increased behaviors and medication changes on [DATE] and [DATE], and of falls on [DATE] and [DATE]. LVN B said Resident #1's hospice agency should have been notified on [DATE] of sliding onto the floor and [DATE] of bruising. LVN B said the resident's RP should be notified to ensure they know what was going on with the resident and the hospice agency should be notified so they can determine if they need to see the resident, review medications, or make changes to their treatment plan.During an interview on [DATE] at 2:21 PM, DON D said she had only worked at the facility since [DATE]. DON D said any incident staff were to notify herself, they should notify the physician, the resident's RP, and their hospice agency, and then she would report off to the ADM. DON D said there should be an incident report on all falls. DON D said there should be documentation on all falls and incident reports and there should be documentation that the appropriate persons were notified of the incidents. DON D said any bruising on a resident should be documented until they were gone and should have an incident report done. DON D said she would expect the facility's policies to be followed. DON D said the family could be upset and non-trusting if the facility was not notifying the RP when incidents occurred, bruising, behavior changes, or medication changes, and it could make the facility look bad or like they were trying to hide something, could be presumed as abuse if hospice or RP were not notified. DON D said not notifying hospice could potentially change the relationship between the hospice agency and the facility and could affect the resident's treatment. DON D said sliding off the bed onto a fall mat was a fall and should be documented as a fall and an incident report done. DON D said the resident's RP and hospice agency should be notified of any changes, including falls, bruises, behavioral changes, and medication changes.During an interview on [DATE] at 2:44 PM, the ADM said she had been the ADM at the facility since [DATE]. The ADM said the staff reported they had been told not to document incidents by the previous DON (DON E) and there was confusion on when/what to report. The ADM said the hospice agency and the resident's RP should be notified for all falls/incidents and bruises, and then if the hospice agency wanted to call the family again then that was on them. The ADM said she would expect the facility policies to be followed. The ADM said the risk to the resident of not notifying the hospice agency or resident's RP, really depended on the type of fall/incident and could potentially affect the resident's treatment with medication changes, etc. The ADM said it could cause the resident some anxiety if family was not notified but may not affect them as much if they had dementia. The ADM said she would expect all falls, incidents, bruising and anything should be reported to the appropriate persons, such as the physician, hospice agency, and the resident's RP. Record review of the facility's policy titled Change in a Resident's Condition or Status dated revised February 2021, indicated . Our facility promptly notifies the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status . 1. The nurse will notify the resident's attending physician or on-call physician when there has been . a. an accident or incident involving the resident . b. discovery of injuries of an unknown source . d. a significant change in the resident's physical/emotional/mental condition . e. need to alter the resident's medical treatment significantly . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions . c. requires interdisciplinary review and/or revision to the care plan . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when . a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source . b. there is a significant change in the resident's physical, mental, or psychosocial status .Record review of the facility's policy titled Assessing Falls and Their Causes dated revised [DATE], indicated . The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . After a Fall . 5. Notify the resident's attending physician and family in an appropriate time frame . 8. Complete an incident report for resident falls no later than 24 hours after the fall occurs . Defining Details of Falls . 2. For each individua, distinguish falls into the following categories . a. rolling, sliding, or dropping from an object, such as from bed or chair to floor . b. falling while attempting to stand up from a sitting or lying position . c. falling while already standing and trying to ambulate . Documentation . When a resident falls, the following information should be recorded in the resident's medical record . 1. The condition of the resident . 2. Assessment data . 3. Interventions . administered . 4. Notification of the physician and family, as indicated . 8. The signature and title of the person recording the data . Reporting . 1. Notify the following individuals when a resident falls . a. the resident's family b. the attending physician c. the Director of Nursing . 2. Report other information in accordance with facility policy and professional standards of practice .

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 in the facility's only kitchen reviewed for food safety requirements.1. The facility failed to ensure Dishwasher A wore a facial covering to cover facial hair while serving food in the kitchen on 11/05/25.2. The facility failed to ensure Dishwasher A wore a hairnet and facial covering to cover his hair and facial hair while in the kitchen area on 11/06/25.3. The facility failed to ensure [NAME] B wore a facial covering to cover facial hair while preparing food in the kitchen on 11/06/25.These failures could place residents at risk for food contamination.Findings included:During initial tour observations and interview of the kitchen on 11/05/25 beginning at 4:35 PM, revealed [NAME] G was plating food and Dishwasher A was adding drinks and desserts to the meal tray and covered the food with a plate cover. Dishwasher A was noted to have facial hair above his upper lip and on his chin approximately 1/2 inch long and was not wearing facial covering to cover facial hair. [NAME] G said they did not have a Dietary Manager at this time. [NAME] G said they did have an Assistant Dietary Manager, [NAME] E. During an observation and interviews on 11/06/25 beginning at 2:24 PM, revealed [NAME] B was in the kitchen preparing food for the next meal service. [NAME] B was noted to have approximately 1/4 to 1/2 inch facial hair covering his lower face and was not wearing a facial covering to cover his facial hair. [NAME] B said all staff should be wearing hair nets and a facial covering if they had facial hair while in the kitchen, which included anything behind the two doors and he pointed at the kitchen door and dishwashing side door, to prevent hair from getting in the residents' food. The was a plastic bag with hair nets in it hung just outside of the dishwashing side of the kitchen. Dishwasher A was in the dishwashing side of the kitchen washing dishes. Dishwasher A was noted to have facial hair above his upper lip and chin and was not wearing a hairnet or facial covering to cover his hair or facial hair. Dishwasher A said he had been working at the facility for a couple of months. Dishwasher A said he had been educated to wear a hair net and facial covering when serving food, but he did not know he needed to wear them while washing dishes. Dishwasher A said he knew he should have been wearing facial covering yesterday (11/05/25) while serving food and just forgot. Dishwasher A said wearing hair nets and facial coverings were to keep hair out of the resident's food. Dishwasher A said if he was not wearing a hair net or facial covering in the kitchen, anything could happen, like hair could get in the residents' food. Dishwasher A said he did not know how it could affect the residents.On 11/06/25 at 2:49 PM and at 5:15 PM, Interim Dietary Manager H was called. There was no answer and unable to leave a voicemail.During an interview on 11/06/25 at 3:33 PM, the ADM F said he was the Interim ADM and had been at the facility since 10/27/25 this time. ADM F said the facility had gone through a lot of staffing changes and the facility did not have a Dietary Manager at the time, but they had an Interim Dietary Manager. ADM F said Interim Dietary Manager H was currently on leave. ADM F said staff should be wearing hairnets and facial coverings for facial hair when behind the kitchen doors to prevent food contamination. ADM F said he expected staff to follow the policies of the facility.During an interview on 11/10/25 at 9:20 AM, [NAME] E said she had worked at the facility for over 30 years. [NAME] E said everyone that entered the kitchen area, including the dishwashing side, should be wearing a hairnet and if they had facial hair, then they would need facial covering. [NAME] E said kitchen staff should be wearing hairnets/facial covering because hair could fall in anything and get in the resident's food. [NAME] E said hair could contaminate the resident's food.Record review of the facility's policy titled Food Preparation and Service dated revised November 2022, indicated . Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices . food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness . Food Distribution and Service . 8. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food .

Based on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 memory care units and 2 of 9 residents (Resident #1 and Resident #2) reviewed for adequate supervision to prevent accidents.The facility failed to ensure the residents in the Unit 2 Memory Care were adequately supervised while CNA C was in another resident's room getting residents up for breakfast and there was no other staff in the memory unit on 10/09/25, which left residents unsupervised in the dining area resulting in Resident #1 and Resident #2 getting into an altercation.This failure could place residents at an increased risk of injury.Findings included:1. Record review of Resident #1's face sheet dated 11/05/25 revealed he was [AGE] years old and admitted to the facility initially on 1/22/21 and re-admitted [DATE]. Resident #1 had diagnoses including Alzheimer's disease (progressive neurodegeneration (brain deterioration) that affects memory, thinking, and behavior), dementia (forgetfulness), schizoaffective disorder (a mental health condition that combined symptoms of schizophrenia and a mood disorder, such as depression (persistent sadness) or bipolar (extreme mood swings), muscle weakness, lack of coordination, glaucoma (progressive eye disease that could lead to vision loss), hallucinations (a person perceived something that was not actually present in their environment), anxiety (nervousness), and repeated falls.Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he was understood and understood others. Resident #1 had impaired vision. Resident #1 had a BIMS of 1, which indicated he had severe cognitive impairment. The MDS indicated Resident #1 did not have behaviors. Resident #1 used a wheelchair for mobility. Resident #1 was dependent on staff or required substantial assistance in performing most ADLs. Resident #1 was able to wheel self in his wheelchair. Record review of Resident #1's undated Care Plan Report indicated he was at risk for elopement and resided on the secured unit. Resident #1 was at risk for falls. Resident #1 had impaired physical mobility. Resident #1 had impaired social interaction 10/09/25 as evidenced by resident was noted hitting another resident in the dining room. Resident #1 had impaired visual function. Record review of Resident #1's Progress Notes dated 10/09/25 indicated RN D was notified by CNA (not named in note) that Resident #2 and Resident #1 were in the dining room hitting each other. Resident #1 was sitting in his wheelchair wheeling himself into the dining room, Resident #2 was sitting in the chair at table right at the doorway and Resident #2 started hitting Resident #1. The resident was assessed, and no injuries were noted.2. Record review of Resident #2's face sheet dated 11/05/25 revealed he was [AGE] years old and admitted to the facility initially on 5/06/25 and re-admitted [DATE]. Resident #2 had diagnoses including cerebral infarction (stroke-disruption of blood flow to the brain, resulting in brain tissue damage or death), schizophrenia (chronic mental health condition characterized by a combination of symptoms that significantly impair a person's thinking, feeling, and behaving), abnormalities of gait and mobility, and lack of coordination.Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated he was understood and understood others. Resident #2 had a BIMS of 11, which indicated he had moderate cognitive impairment. The MDS indicated Resident #2 had physical behavioral symptoms directed toward others one to three days. The MDS did not indicate Resident #2 had behaviors. Resident #2 required supervision to moderate assistance for most ADLs but was independent with ambulation.Record review of Resident #2's undated Care Plan Report indicated he used psychotropic medication (medication that affects a person's mental state) for behavioral management and on 8/22/25 he was aggressive with staff, 10/03/25 hit a resident with a toy, and 10/09/25 was seen hitting another resident. Resident #2 was an elopement risk and was placed on the secured unit due to disruptive behaviors and would walk up to resident and start arguments. Record review of Resident #2's Progress Notes dated 10/09/25 indicated RN D was notified by CNA (not named in note) that Resident #2 and Resident #1 were in the dining room hitting each other. Resident #1 was sitting in his wheelchair wheeling himself into the dining room, Resident #2 was sitting in the chair at table right at the doorway and Resident #2 started hitting Resident #1. The resident was assessed, and no injuries were noted. During an interview on 11/06/25 at 9:06 AM, RN D said she had worked at the facility since June 2025 and normally worked the 6 AM - 2 PM shift until the facility changed to twelve-hour shifts. RN D said she usually was the nurse for 100 (Unit 1 Memory Care), 200 (Unit 2 Memory Care), and the left side of 300 hall. RN D said a few residents could be aggressive toward other residents, which included Resident #2. RN D said Resident #2 was pretty quiet and did his own thing. RN D said if they tried to redirect Resident #2, he could get mad and he would try to grab things in the air that were not there. RN D said he had been aggressive to other residents. RN D said CNA C came and got her and said Resident #1 was wheeling into the dining room and Resident #2 was sitting at the table just inside the door of the dining room. RN D said CNA C said Resident #2 just started hitting Resident #1. RN D said CNA C separated them. RN D said she called and reported the incident to the NP, DON, and RP. RN D said they kept both residents separated and had both on every 15-minute checks for 72 hours. RN D said when she assessed both residents, neither of them had any marks, bruising, no nothing. RN D said CNA C said they were hitting at each other but not hard. RN D said there were normally two staff members in the memory care units but thought it may have just been CNA C back there when the incident occurred. During an interview on 11/06/25 at 9:30 AM, CNA C said at the time of the altercation between Resident #1 and Resident #2, she was the only staff member in the memory care unit. CNA C said she was in another resident's room getting residents up and dressed for breakfast. CNA C said when she came out of a resident's room and was coming up the hall, she saw Resident #2 sitting in a chair just inside the dining room door and Resident #1 was wheeling himself into the dining room and they were swatting/slapping each other's hands. CNA C said she did not see Resident #1 get hit in the face and only saw them swatting/slapping each other's hands. CNA C said there were around nine or 10 residents in the men's memory care unit (Unit 2) at the time of the incident. CNA C said Resident #1 was already parked just inside the doorway of the dining room when she saw them and both residents were swatting/slapping at each other's hands. CNA C said she did not know how long they had been at it but did not think it had been long. CNA C said she did not see who started the incident, but she immediately intervened when she saw them and separated the residents, then notified the nurse and the nurse came and assessed both residents. CNA C said Resident #1 did not have any visible injuries. CNA C said there should be 2 staff present in the men's memory care unit (Unit 2) because of fights, incidents, and lots of residents that were combative and needed two people to deal with them. CNA C said if she had to take a resident to their room to perform incontinent care and change their brief, then there was no one to watch the other residents if there was only one staff member in the memory care unit. CNA C said Resident #1 was able to wheel himself in his wheelchair, feed himself, transferred with assistance, and was able to use both arms. CNA C said Resident #2 was ambulatory.During an interview on 11/06/25 at 3:08 PM, the DON said his first day on the job was 10/09/25 and it was orientation day. The DON said the memory care units had residents that wandered, had dementia, and behaviors, such as outbursts, aggressive toward staff, and resident-to-resident altercations. The DON said there should be two staff in the memory care units, especially on the men's side (Unit 2 Memory Care). The DON said there should be two staff members for resident safety. The DON said there could be an altercation and if one staff member was showering or changing a resident they may not be able to get to them in time. The DON said he did not know if there were two staff members on the memory care unit at the time of the incident with Resident #1 and Resident #2 because he had just started that day. The DON said one staff member could not adequately supervise the residents if the one staff member was in another room or showering and something happened. The DON said the resident could be affected both emotionally, physically and feel unsafe if not adequately supervised. The DON said since he had been at the facility, he made sure there were two staff members on the memory care units, and they were trying to get a third person approved. The DON said he was unable to locate the sign-in staffing sheets for the date of the incident on 10/09/25.During an interview on 11/06/25 at 3:33 PM, Interim ADM F said he had initially been at the facility from 9/10/25 to 10/10/25 and then he came back 10/27/25 and 11/06/25 would be his last day. Interim ADM F said they have had a lot of staffing changes, and the previous DON had left without fulfilling her two-week notice. Interim ADM F said he had only been at the facility briefly, but knew they had residents in the memory care units that were rambunctious, elopement risks, had psychiatric issues, behaviors, aggressive residents, resident-to-resident altercations, and could get aggressive toward staff too. Interim ADM F said there were always two staff members on the memory care units. Interim ADM F said they were working on hiring someone for activities as a third person, specifically for the memory care units. Interim ADM F said there should be two staff members, especially in the men's unit, because they were typically bigger, louder, stronger and too much for one person to handle. Interim ADM F said he did not remember if there were two staff members at the time of the incident with Resident #1 and Resident #2, but he did not remember a time when they were not fully staffed. Interim ADM F said they were also utilizing agency staff to fill any gaps in coverage. Interim ADM F said he did not have an answer for what the risk to the residents would be if there was only one staff member in the memory care units. Interim ADM F said he would expect staff members to follow the policies and procedures of the facility.During an interview on 11/06/25 at 3:56 PM, the Regional Nurse Consultant said she started with the facility 10/01/25 and was probably in the building approximately a week or two later. The Regional Nurse Consultantsaid the memory care unit had residents with behaviors and they had to try to manage the behaviors with medications, supervision, and psychiatric services. The Regional Nurse Consultant said she thought there were two staff on the unit at the time of the incident with Resident #1 and Resident #2. She said the goal was to have two staff members in the memory care units. She said there should be two staff members so if one was providing care, the other could be monitoring and meeting the needs of the other residents. The Regional Nurse Consultant said the risk of not being supervised could result in increased risk of incident and accidents for the residents.Record review of the facility's Resident Roster dated 11/05/25 indicated there were 9 residents on Unit 2 Memory Care.Record review of the facility's policy titled Secure Unit, dated July 2025 indicated . The Secure Unit was designed to provide a safe and structured environment for residents who were at risk of elopement or harm due to cognitive impairment (such as dementia, Alzheimer's disease, or other behavioral health concerns). This policy ensures that all residents' rights, safety, and dignity were protected while maintaining compliance with Federal and State regulations .

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 for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food stored in the kitchen refrigerator and freezer was labeled and dated on 6/9/25. 2. The facility failed to ensure food stored in the pantry was labeled and dated on 6/9/25. 3. The facility to ensure pitchers of prepared drinks were labeled and dated on 6/9/25, 6/10/25 and 6/11/25. 4. The facility failed to ensure the handwashing sink had paper towels on 6/9/25. 5. The facility failed to ensure refrigerators and freezers temperatures were recorded on 6/9/25. 6. The facility failed to ensure the refrigerator temperature did not get out of range and no record of interventions to correct the temperature on 6/4/25 (AM) and 6/11/25 (AM). 7. The facility failed to properly store raw meat in the refrigerator. 8. The facility failed to ensure the flour and sugar bins did not have cups stored in them on 6/9/25. 9. The facility failed to ensure the oven's stovetop was free of grease buildup on 6/9/25. 10. The facility failed to ensure the oven's splash guard was free of grease and grime buildup and not bent on 6/10/25. 11. The facility failed to ensure the holding area of the ice machine, stored in the kitchen area, was free from a pink film on 6/9/25. 12. The facility failed to ensure a black crate with plastic items was not stored directly on the floor on 6/9/25 and 6/11/25. 13. The facility failed to ensure the drink dispenser internal vent was free of darked colored particles. 14. The facility failed to ensure cookware stored in the dishwasher area was free of carbon build up on 6/9/25 and 6/10/25. 15. The facility failed to ensure the bottom shelves on two black plastic storage rack and one white metal storage rack, in the dishwasher area, were 6 inches from the floor. 16. The facility failed to maintain an appropriate temperature in the main kitchen area, and the thermostat above the handwashing sick, read HI on 6/10/25. The pantry was 92-degree Fahrenheit on 6/11/25. 17. The facility failed to ensure the back door, to the area behind the kitchen, near the garage bins, was not propped open on 6/9/25 and 6/10/25. 18. The facility failed to ensure flies were not in the kitchen on 6/10/25. 19. The facility failed to ensure a medium size, plastic trash can, near the preparation table was not opened during purees on 6/10/25. These deficient practices could place residents at risk for foodborne illness. Findings included: During an observation on 6/9/25 at 8:42 a.m., revealed the handwashing sink had no paper towels in the holder. During an observation on 6/9/25 at 8:43 a.m., revealed the back door, to the area behind the kitchen, near the garage bins, was propped open. The temperature in the kitchen was warm. During an observation on 6/9/25 at 8:44 a.m., revealed refrigerator #1 had no documented temperature on the temperature log posted on refrigerator #1 for June 9th, 2025. During an observation on 6/9/25 starting at 8:45 a.m., in refrigerator #1 the following was observed: *Ten packages of whipped topping were not dated. The container holding eight of the whipped toppings had a date of 1/20/23. *One box, with approximately 32 small cartons of strawberry flavored mighty shakes was not dated. *One container with approximately forty hard boiled eggs was not dated. *One turkey breast was not dated. *One log of raw meat was not labeled and dated. The log of raw meat was stored directly on the rack and not at the bottom of the refrigerator. Food items were stored underneath it. *One bag of opened salad mix was not dated. During an observation at 8:50 a.m., revealed freezer #1 had no documented temperature on the temperature log posted on freezer #1 for June 9th, 2025. During an observation on 6/9/25 starting at 8:50 a.m., in freezer #1 the following was observed: *Two unopened bags and one opened bag of pork toppings were not dated. During an observation at 8:51 a.m., revealed freezer #2 had no documented temperature on the temperature log posted on freezer #2 for June 9th, 2025. During an observation on 6/9/25 starting at 8:52 a.m., in freezer #2 the following was observed: *Three bags, of what appeared to be frozen tater tots, were not labeled, and dated. *Sixteen packages, of what appeared to be frozen pancakes, were not labeled, and dated. During an observation on 6/9/25 at 8:55 a.m., the milk refrigerator, in the pantry, had no documented temperature on the temperature log posted on the wall above the milk refrigerator for June 9th, 2025. During an observation on 6/9/25 starting at 8:56 a.m., the following was observed: *Three boxes of [NAME] buddies were not dated. *Seven bags of orange twist drink mix were not dated. *Two cups were noted in the flour bin. * One cup was noted in the sugar bin. During an observation on 6/9/25 at 9:07 a.m., revealed the ice machine located in the main area of the kitchen, had a pink film inside the area that held the ice. During an observation on 6/9/25 starting at 9:08 a.m., in the main kitchen area the following was observed: *Four pitchers of an orange-colored liquid, stored on a preparation table, were not labeled, and dated. *One black, plastic milk crate was directly on the floor with four plastic items inside. *The internal vent on the drink dispenser machine had dark-colored particles on it. During an observation on 6/9/25 starting at 9:11 a.m., in the dishwasher area the following was observed: *Three skillets with carbon build up (black, crusty layer) were hanging from a metal rack. * The bottom shelves on two black plastic storage racks and one white metal storage rack, did not appear to be 6 inches from the floor. During an observation on 6/10/25 starting at 10:39 a.m., the following was observed in the main area of the kitchen: *Grease buildup was noted on the edges of the stove top. *Grime and splatters of grease on to the splash guard, and it was bent at the edge. *One cookie sheet with carbon buildup was noted on a shelf. *One medium size, plastic trash can, near the preparation table was opened during purees performed by [NAME] K. During an observation on 6/10/25 at 11:58 a.m., revealed one medium size, plastic trash can, near the preparation table was propped opened by a large empty metal during temperature checks. During an observation on 6/10/25 at 12:05 p.m., revealed near the 500 hall, on the hydration cart, had a pitcher of orange colored liquid not labeled or dated. During an observation on 6/10/25 at 1:44 p.m., the following was observed in the main area of the kitchen: *The back door, to the area behind the kitchen, near the garbage bins, was propped open. Approximately four flies were noted in the kitchen. Two food items were uncovered. *The temperature in the kitchen was hot. The thermostat above the handwashing sink, read HI. During an observation and interview on 6/11/25 at 9:27 a.m., revealed one black, plastic milk crate was directly on the floor with four plastic items inside. [NAME] K said everyone was responsible for labeling and dating food items in the refrigerators, freezers, and the pantry. He said the food items should have a received and opened date. He said food items taken out of the original box or packaging should be labeled. He said some of the kitchen staff labeled and dated items differently when it was taken off the delivery truck. He said it was important to know how long it had been opened and if the food items were expired. He said when he arrived on Monday (6/9/25) at 6am, there were no napkins in the holder at the handwashing sink. He said he did not have the key to open the napkin holder. He said they had to wait for housekeeping to open the holder and to refill it. He said napkins at the handwashing sink were important to make sure staff were washing their hands to prevent contamination. He said the refrigerators and freezers temperatures were supposed to be checked and logged when the cook arrived. He said it was important to check the temperatures first thing in the morning to know if something was going on with the fridges and freezers. He said sometimes the evening kitchen staff did not close the fridge good which could cause the food to spoil. He said raw meat was supposed to be stored on a tray at the bottom of the fridge. He said it should be stored that way so if the meat leaked it would not get everywhere. He said whoever placed the raw meat in the fridge should have stored it correctly. He said scoops and cups should not be stored in the bins. He said it was not good because of cross contamination. He said everyone should make sure that was not happening, but the cooks were primarily responsible. He said the cooks were responsible for cleaning the stovetop and splash guard. He said grease buildup was a fire hazard and could cause a grease fire. He said the stovetop and splash guard should be cleaned after every use. He said the ice machine should not have pink residue in it. He said the DM had been cleaning it. He said he did not know why the ice machine should not have pink residue in it. He said the black milk crate should not be stored directly on the floor. He said the items in the crate could get contaminated. He said the drink machine did not work. He said but everyone should be checking the filter. He said when the vent was dirty, stuff could get in the drink line. He said cookware should not have carbon buildup. He said it was a fire hazard. He said the cooks were responsible to make sure cookware did not have carbon buildup. He said the temperature in the kitchen had been over 90 degrees Fahrenheit for about 4 months. He said 4 months ago, the window air conditioner units were placed in the kitchen windows. He said it was still hot with the window unit on. He said the kitchen staff opened the back door because it was so hot. He said when the back door was propped opened, it let flies in the kitchen and dining room. He said the flies could get in the residents food. He said the trash can lid should be closed. He said food items could get contaminated from things in the trash can. He said if the pantry got too hot, the bread molded faster. He said because the pantry was hot, the facility had to use stuff faster. During an observation on 6/11/25 at 10:01 a.m., a handheld thermostat was placed in the pantry at 9:27 a.m. by the surveyor. At 10:01 a.m., it read 92 degrees Fahrenheit. No bread items were noted in the pantry. During an observation and interview on 6/11/25 at 10:04 a.m., the temperature log on refrigerator #2 reflected documented temperatures of 43 degrees Fahrenheit on 6/3/25 on the AM shift, and 42 degrees Fahrenheit on 6/11/25 on the AM shift. [NAME] K said the door was not good when he arrived for his shift. He said now the temperature was 35 degrees Fahrenheit. During an observation on 6/11/25 at 10:05 a.m., revealed near the 500 hall, on the hydration cart, had a pitcher of purple colored liquid not labeled or dated. During an observation and interview on 6/11/25 at 10:13 a.m., Maintenance P measured the black plastic shelves and reported from the floor to the top part of shelf, was 4 inches. He measured and reported the white metal rack was 3 1/4 inches from the floor to the top part of shelf. During an interview on 6/11/25 at 10:16 a.m., the DM said, the cooks, DAs, and DM were responsible for labeling and dating food items. He said the food items should be labeled and dated when they arrived on the truck and when opened. He said it was important to make sure not to give something that was old. He said it was important to serve fresh food to the residents. He said spoiled food could make the residents sick and get food poisoning. He said the DM should ensure the staff labeled and dated food items. He said he normally went behind the staff to ensure they labeled and dated food items. He said the handwashing station should have soap and napkins. He said on Monday (6/9/25) when he arrived, housekeeping had just brought the kitchen some napkins. He said he had not had a chance to load the napkins in the holder. He said he and housekeeping were the only ones that had keys to the napkin holder. He said napkins at the handwashing station was important to make sure staff hands were clean and to turn off the faucet. He said the cooks and DM were supposed to do the temperatures for the fridge and freezers. He said the temperatures should be done at 6am for AM shift, and 5pm for the PM shift. He said he normally checked the temperature log when he arrived later in the morning to make sure they were done. He said if the temperature was 40 degrees Fahrenheit and not improving after correcting the issue, then the food should be pulled out and placed somewhere else. He said the dietary staff should immediately let the DM know if the fridge or freezer temperatures were out of range. He said the staff should be rechecking the temperatures until it reached the safe range. He said raw meat should be stored on the bottom of the fridge in a pan. He said the cooks and DM were responsible for properly storing raw meat. He said proper storage of raw meat made sure nothing dripped on other foods. He said he should be ensuring the cooks stored the meat properly. He said the DAs, Cooks, and DM should make sure scoops or cups were not in the bins. He said not leaving cups in the bins prevented cross contamination. He said leaving cups in the bins could make the residents sick. He said he should be ensuring staff did not leave cups in the bins. He said the cooks and DM manager was responsible for preventing grease buildup on the stove top and pink residue in the ice machine. He said not having grease build up prevented fires and not having pink residue made sure the ice was clean. He said grease buildup could cause a fire and contaminated ice could make the residents sick. He said he should be ensuring staff cleaned the ice machine. He said he cleaned the ice machine every day at 6pm and even on the weekends. He said items could not be stored directly on the floor. He said it made sure things could not crawl into the items. He said the Cooks, Dishwasher, and DAs were responsible for storage items off the ground. He said he should be ensuring the staff did not store things directly on the floor. He said the drink dispenser worked and was being used. He said he was responsible for cleanliness of the drink dispenser filter. He said he had not noticed the filter was dirty. He said a clean drink filter prevented fires and clogging of the machine. He said the Cooks should notify the DM when cookware had carbon buildup. He said carbon buildup could cause grease fires and make the resident sick. He said he should be ensuring the cooks notified him of cookware with carbon buildup. He said the shelves should be 6 inches from the ground. He said he had not noticed the racks being less than 6 inches from the ground. He said the shelves had been there since he started 5 years ago. He said 6 inches helped prevent spillage to contact the dishes. He said he was responsible for the shelf heights. He said yesterday (6/10/25) was the hottest day in the kitchen. He said he never looked at the thermostat to check the temperature. He said the kitchen should not be overly hot to make sure nothing spoiled and was safe to consume. He said the window units sometimes cooled the kitchen. He said the facility had been working on cooling the kitchen for the last month. He said the dietary consultant had also told the facility the kitchen was too hot. He said the facility got the window units after the dietary consultant told them that. He said the back door should not be opened in the kitchen. He said keeping the back door closed, prevented things from crawling into the kitchen and bugs flying in. He said the bugs could make the residents sick and lead to illnesses. He said the trash can lid should be closed during prep and meal services. He said it prevented smells and cross contamination. He said he and the cooks should make sure the trash can lid was closed. He said he should be ensuring the cooks closed the trash can lids. During an interview on 6/11/25 at 3:35 p.m., the ADM said she expected the DM to ensure there were no fire hazards in the kitchen. She said all staff were responsible for labeling and dating food items and kitchen sanitation. She said it prevented contamination of the food and ensured spoiled food was not served. She said residents could become sick with an upset stomach. She said the DM should ensure the kitchen staff protect the resident from sickness caused by unsanitary conditions or spoiled food. She said the back door and trash can lid should not be open. She said it created unsanitary conditions in the kitchen. She said pest in the kitchen could make the resident sick. She said proper handwashing etiquette included drying your hands. She said everyone was responsible for making sure soap and napkins were at the handwashing station. She said she expected the kitchen cleaning scheduled to be followed. She said the DM should be ensuring the designated kitchen staff completed the cleaning schedule. She said the DM should be doing this by inspecting the listed tasks to ensure they were completed. Record review of a Quality Assurance Monitor, Kitchen/Food Service Observation, completed by the Dietary Consultant on 3/13/24 indicated, .general sanitation and cleanliness .No .ice machine is clean with no lime, rust, or mildew .no .dumpster clean, plugged, and closed .no .trash cans in food prep clean and have lids .comments .oven door broken . Record review of a Quality Assurance Monitor Report, completed by the Dietary Consultant, dated 4/16/25 indicated, .general sanitation and cleanliness .No .ice machine is clean with no lime, rust, or mildew .comments .please clean ice machine .observed with some debris on the white guard . Record review of the Cooler Temperature Log-June 2025 indicated, .Day 4 .6AM .Temperature .43 .[DA W] .Day 11 .6AM .Temperature .42 .[Cook K] . Record review of the Daily Cleaning Schedule: 6/2/2025 to 6/9/25 indicated, .stove top, drip pan, back wall, and side .6/3/25 &6/4/25 .[Cook/DA U] .making sure everything has date on it .6/4/25 .[Cook/DA V] . The ice machine was the assigned to the DM. No date or initials noted. Record review of the Monthly Cleaning Schedule-June 2025 indicated, .remove ice from ice machine .clean and descale .management responsible .DM 6/2 . Record review of a facility's Food Storage policy revised 06/01/2019 indicated, .to ensure that all food served by the facility is of good quality and safe consumption .all food stored according to the state, federal .dry storage rooms .for maximum shelf-life, dry foods should be stored at 50-70 degrees .however, less than 85 degrees is adequate for most products .use a wall thermometer to check the temperature of the dry-storage facility regularly .store scoops covered in a protected area near the food container .date packages .store all items at least 6 above the floor .refrigerators .keep fresh meat, poultry .internal temperature of 41 degrees Fahrenheit or less .date, label .all refrigerated foods .store raw meat and eggs on the bottom shelf to prevent contamination of other foods .temperatures should be checked each morning .when temperature are outside of the designated range, notify maintenance immediately .freezers .labeled and dated . Record review of a facility, Sanitization policy revised 11/2022 indicated, .the food service is maintained in a clean and sanitary manner .all kitchen, kitchen areas .protected from rodents and insects .equipment are kept clean, maintained in good repair and free from .corrosions .ice machine .cleaned and sanitized per manufacturer's instructions . Record review of a Ice Machines policy dated 10/01/2018 indicated, .the facility will maintain the ice machine .in a sanitary manner to minimize the risk of food hazards .the ice machine will be cleaned once per month or more often as needed .

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 11 errors out of 32 opportunities, resulting in a 34.38 percent medication error rate for 3 of 4 residents reviewed for medication error. (Resident's #6, #16, and #25) The facility did not ensure the following: 1. Resident #25 was given calcium plus vitamin D3 500 mg, citalopram 20 mg (antidepressant), and MiraLAX 17 GM (laxative) as ordered by the physician during the medication pass on 06/10/25. 2. Resident #16 was given aspirin 81mg (delayed release), Senna-S (laxative), potassium 10 mEq, and primidone 50 mg (anticonvulsant) as ordered by the physician during the medication pass on 06/10/25. 3. Resident #16's atenolol (blood pressure medication) was held for a heart rate of 58, according to the ordered parameters of hold for heart rate less than 60 on 06/10/25. 4. Resident #6 was given famotidine 40 mg and Tums 1,000 mg, for indigestion, as ordered by the physician during the medication pass on 06/10/25. 5. Resident #6 was not given zinc 50 mg without a physician order, during the medication pass on 06/10/25. These failures could place residents at risk for adverse reactions or ineffective dosage related to inaccurate drug administration. The findings included: 1. During an observation and interview on 06/10/25 beginning at 07:22 AM, MA Q prepared Resident #25's medications for administration. MA Q placed one tablet from a bottle of calcium 600 mg + D3 in the medication cup. MA Q placed one tablet from a card of citalopram 40 mg into the medication cup. MA Q did not prepare Resident #25's ordered MiraLAX 17 GM. MA Q crushed Resident #25's medications, mixed with a small amount of pudding and administered the medication to Resident #25 with a small glass of ice water. MA Q stated she was finished administering Resident #25's morning medications. Record review of the order summary report, dated 06/10/25, reflected Resident #25 had the following orders: 1. calcium plus vitamin D3 oral 500mg-5mcg - give 1 tablet by mouth one time a day for vitamin replacement, which started on 04/11/25. 2. citalopram 20 mg - give 1 tablet by mouth one time a day related to other depressive episodes, which started on 04/11/2025. 3. MiraLAX 17GM/scoop - give 1 scoop by mouth one time a day for constipation, which started on 04/11/25. Record review of the MAR, dated June 2025, reflected Resident #25 received calcium plus vitamin D3 500 mg, citalopram 20 mg, and MiraLAX 17 GM daily. The MAR further revealed the medications were scheduled to have been given at 7 AM. 2. During an observation and interview on 06/10/25 beginning at 07:31 AM, MA Q obtained Resident #16's blood pressure and heart rate. Resident #16's heart rate was 58 beats per minute. MA Q prepared Resident #16's medications for administration. MA Q placed one tablet from a bottle of aspirin 81 mg - chewable into the medication cup. MA Q placed one tablet from a card of atenolol 25 mg - give 1 tablet by mouth daily, hold for . heart rate less than 60 into the medication cup. MA Q did not prepare Resident #16's ordered Senna-S, potassium chloride, and primidone. MA Q administered Resident #16's medication with a small cup of water. MA Q stated she was finished administering Resident #16's morning medications and had nothing further that was scheduled. Record review of the order summary report, dated 06/10/25, reflected Resident #16 had the following orders: 1. aspirin oral delayed release 81 mg - give one tablet orally one time a day related to cerebral infarction (stroke), which started on 04/11/25. 2. atenolol 25 mg - give 1 tablet by mouth one time a day related to high blood pressure, hold for . heart rate less than 60, which started on 04/11/25. 3. potassium chloride 10 mEq - give 1 tablet by mouth one time a day related to heart disease, which started on 04/11/25. 4. primidone 50 mg - give 1 tablet by mouth one time a day related to heart disease, which started on 04/11/25. 5. Senna-S - give 1 tablet orally two times a day for constipation, which started on 04/11/25. Record review of the MAR, dated June 2025, reflected Resident #16 received, aspirin 81 mg - delayed release, atenolol 25 mg, potassium chloride 10 mEq, primidone 50 mg, and Senna-S daily. Resident #16's documented heart rate was under parameters for the atenolol 25 mg, 3 out of 10 days during June 2025. The MAR further revealed the medications were scheduled to have been given at 8 AM. 3. During an observation and interview on 06/10/25 beginning at 07:48 AM, RN E prepared Resident #6's medication for administration. RN E placed 2 tablets from a bottle of omeprazole 20 mg - 24 hours into the medication cup. RN E placed one tablet from a bottle of zinc 50 mg into the medication cup. RN E did not prepare Resident #6's ordered Tums 1,000 mg. RN E crushed Resident #6's medications and administered them via gastrostomy tube (tube that goes directly into the stomach for eating or administering medication). RN E stated Resident #6 did not receive any more medications until noon. Record review of the order summary report, dated 06/10/25, reflected Resident #6 had the following orders: 1. famotidine 40 mg - give 1 tablet enterally one time a day, which started on 04/11/25. 2. Tums 500 mg - give 2 tablets enterally one time a day for indigestion, which started on 04/11/25. 3. There was no order for zinc 50 mg or omeprazole 40 mg. Record review of the MAR, dated June 2025, reflected Resident #6 received famotidine 40 mg and Tums 500 mg (2 tablets) daily. The MAR reflected the medications were scheduled to have been given at 9 AM. During an interview on 06/11/25 beginning at 1:58 PM, RN E stated the process for medication administration included opening the MAR and matching the orders with each medication. RN E stated she was nervous on 06/10/25 when the state surveyor was watching her. RN E stated she believed Resident #6 had an order for zinc because she had wounds. RN E stated the order must have only been for a certain number of days and had fallen off the MAR. RN E stated she realized she had forgotten to administer the Tums on 06/10/25 and went back later in the day to give them. RN E stated she substituted the famotidine with the omeprazole because Resident #6 was out of the famotidine, and she believed it was the same medication. RN E stated she should not have given any medication without clarifying it with the physician. RN E stated it was important to ensure the ordered medication was given and the medications were verified prior to administration to prevent medication errors and adverse effects. During an attempted telephone interview on 06/11/25 at 2:07 PM, MA Q did not answer the phone. A brief message was left with a call back number, but the call was not returned upon exit of the facility. During an interview on 06/11/25 beginning at 2:10 PM, the ADON stated she expected the facility staff to ensure they were following the physician orders and checking the medication with the orders to ensure accuracy during the medication pass. The ADON stated MA Q should have held the medication and notified the nurse for clarification if there were discrepancies noted. The ADON stated MA Q should have administered all prescribed medication during the appropriate time frames. The ADON stated MA Q should have held Resident #16's atenolol and notified the nurse if her heart rate was outside of the parameters. The ADON stated no medication should have been administered without an order. She said MA Q had reported being nervous during the medication pass observation. The ADON stated if MA Q was nervous, she should have asked to take a break or paused the medication pass. The ADON stated RN E should have notified the doctor for clarification and checked the medication with the MAR to ensure accuracy. The ADON stated medication administration skills checkoffs were completed once per year and as needed. The ADON stated the pharmacy consultant came in monthly and observed medication pass. The ADON stated it was important to ensure the medications were given accurately to prevent medication errors and adverse reactions. During an interview on 06/11/25 beginning at 2:20 PM, the DON stated she expected staff to notify the appropriate staff and receive clarification from the physician for any medication discrepancies. The DON stated she expected clarification to have been obtained prior to the administration of the medication. The DON stated the facility staff should have followed all parts of the medication order including hold parameters. The DON stated the facility staff should not have given medication without a physician order and expected staff to administer all prescribed medications per the orders. The DON stated the facility recently switched their electronic charting system and pharmacies. The DON stated she had placed all the orders in the electronic monitoring system by herself, so she expressed to the staff to pay attention to the orders and notify her if there were any discrepancies. The DON stated nursing management was responsible to ensure medications were administered accurately. The DON stated it was important to ensure medications were given accurately to prevent medication error and adverse effects. During an interview on 06/11/25 beginning at 2:30 PM, the Administrator stated she expected the facility staff to verify the medications given and follow the physician orders during medication pass. The Administrator stated the nursing management staff, ADON and DON, were responsible for monitoring to ensure medications were given accurately. The Administrator stated it was important to ensure medications were given accurately per the physician orders to protect the resident's well-being and ensure their disease processes were treated effectively. Record review of the Administering Medications policy, dated April 2019, reflected Medications are administered in a safe and timely manner, and as prescribed . medications are administered in accordance with prescriber orders, including any required time frame .the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before given the medication .

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 memory care units (Women's Memory Care) and 2 of 5 residents (Resident #39 and Resident #25) reviewed for adequate supervision and assistive device to prevent accidents. The facility failed to ensure the residents in the Women's Memory Care were supervised while CNA O was in a resident's room with the door closed and CNA B left the Women's Memory Care unit to go to the Men's Memory Care unit on 6/10/25 for at least five minutes. The facility failed to ensure Resident #39's wheelchair brakes engaged on 6/9/25 and 6/10/25. The facility failed to ensure Resident #25 had proper footwear on 6/9/25, 6/10/25 and 6/11/25. These failures could place residents at an increased risk for injury. Findings included: 1. Record review of Resident #1's face sheet dated 06/10/25 indicated Resident #1 was an 81-years-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere with daily life), severe with agitation (is a state of restlessness and uneasiness, often accompanied by physical and mental symptoms), age-related physician debility (physical weakness, especially as a result of illness), muscle weakness, abnormalities of gait and mobility, muscle wasting and atrophy (shortening), and mood disorder (is a mental health condition that primarily affects your emotional state). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and usually had the ability to understand others. Resident #1 had severely impaired vision. Resident #1 had a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #1's care plan dated 4/30/25 indicated Resident #1 was an elopement risk/wanderer as evidenced by impaired safety awareness, wandered aimlessly, impaired vision, and impaired cognition and resided on the secure unit due to behaviors such as loudly cursing and yelling at inappropriate times. Intervention included provide structured activities. Record review of Resident #1's care plan dated 05/28/25 indicated Resident #1 was/had potential to be verbally aggressive. Interventions included analyze key times, places, circumstance, triggers, and what de-escalates behavior and document. Record review of Resident #1's fall risk evaluation dated 6/6/25 indicated, .intermittent confusion .legally blind .requires use of assistive devices .fall risk score .11 . A score of 11 indicated at risk. Record review of Resident #9's face sheet dated 6/11/25 indicated Resident #9 was an [AGE] year-old female admitted on [DATE]. Resident #9 had diagnoses including age-related physical debility (physical weakness, especially as a result of illness), mood affective disorder (is a mental health condition that primarily affects your emotional state), dementia (is a term for several diseases that affect memory, thinking, and the ability to perform daily activities), muscle weakness, and muscle wasting and atrophy (shortening). Record review of Resident #9's quarterly MDS assessment dated [DATE] indicated Resident #9 was sometimes understood and sometimes had the ability to understand others. Resident #9 had impaired vision. Resident #9 had a BIMS score of 4 which indicated severe cognitive impairment. Record review of Resident #9's care plan dated 6/3/25 indicated Resident #9 had impaired cognitive function/dementia or impaired thought process. No interventions were indicated. Record review of Resident #9's care plan dated 11/12/24 indicated: *Resident #9 was at risk for falling related to unsteady gait, visual disturbances, and medication usage. Interventions included provide resident an environment free of clutter. *Resident #9 had a diagnosis of exit seeking and wandering related to dementia and currently resides in secure unit. Interventions included attempt to make resident feel secure/safe. Record review of Resident #10's face sheet dated 6/11/25 indicated Resident #10 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #10 had diagnoses including dementia (is a term for several diseases that affect memory, thinking, and the ability to perform daily activities) with psychotic disturbance (severe mental illnesses characterized by a disconnection from reality, involving symptoms like hallucinations, delusions, and disorganized thinking), muscle wasting and atrophy (shortening), and muscle weakness. Record review of Resident #10's annual MDS assessment dated [DATE] indicated Resident #10 was understood and had the ability to understand others. Resident #10 had a BIMS score of 5 which indicated severe cognitive impairment. Record review of Resident #10's care plan dated 2/15/25 indicated Resident #10 was at risk related to change in environment/new admission to facility. Interventions included provide resident an environment free of clutter. Record review of Resident #10's care plan dated 5/1/25 indicated: *Resident #10 was an elopement risk/wanderer as evidenced by disoriented to place, impaired safety awareness. Interventions included provide structured activities. *Resident #10 had impaired cognition function/dementia or impaired thought process related to dementia. Interventions included keep routine consistent and try to provide consistent care givers. Record review of Resident #10's fall risk evaluation dated 2/7/25 indicated, .intermittent confusion .fall risk score .6 . A score of 6 indicated at risk. Record review of Resident #18's face sheet dated 6/11/25 indicated Resident #18 was a 66-years-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #18 had diagnoses including muscle wasting and atrophy (shortening), muscle weakness, dementia (is a term for several diseases that affect memory, thinking, and the ability to perform daily activities), and age-related physical debility (physical weakness, especially as a result of illness). Record review of Resident #18's quarterly MDS assessment dated [DATE] indicated Resident #18 sometimes was understood and rarely/never had the ability to understand others. Resident #18 had short-and-long term memory recall problem. Resident #18 had severely cognitive skills for daily decision making. Resident #18 had a fall with injury since admission/reentry or prior assessment. Record review of Resident #18's care plan dated 5/1/25 indicated Resident #18 was an elopement risk/wanderer as evidenced by disoriented to place, impaired safety awareness. Interventions included to provide structured activities. Record review of Resident #18's care plan dated 6/5/25 indicated: *Resident #18 had impaired social interaction. Intervention included monitor interactions with others. *Resident #18 had impaired cognition function/dementia or impaired thought process related to dementia. Intervention included keep routine consistent and try to provide consistent care givers. Record review of Resident #18's quarterly fall risk assessment dated [DATE] indicated, .disoriented times 3, diminished safety awareness .poor visual impairment .one to two falls in the last 3 months .12 . indicated at risk . Record review of Resident #29's face sheet dated 6/11/25 indicated Resident #29 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #29 had diagnoses including dementia (is a term for several diseases that affect memory, thinking, and the ability to perform daily activities), muscle wasting and atrophy (shortening), muscle weakness, and age-related debility (physical weakness, especially as a result of illness). Record review of Resident #29's annual MDS assessment dated [DATE] indicated Resident #29 was understood and usually had the ability to understand others. Resident #29 was unable to complete the BIMS score assessment. Resident #29 had short-and-long term memory recall problem. Resident #29 had moderately impaired cognitive skills for daily decision making. Record review of Resident #29's care plan dated 1/22/25 indicated history of falling and was at risk for subsequent falls related to cognitive impairment, confusion, weakness, and care deficits. Interventions included observe frequently and place in supervised area when out of bed. Record review of Resident #29's care plan dated 5/1/25 indicated: *Resident #29 was an elopement risk/wanderer as evidence by disoriented to place, impaired safety awareness. Intervention included provide structured activities. *Resident #29 had impaired cognition function/dementia or impaired thought process related to dementia, impaired decision making and long-term memory loss. Interventions included keep routine consistent and try to provide consistent care givers. During an observation on 6/10/25 beginning at 3:42 p.m., the state surveyor entered the Women's Memory Care unit. Five residents (Resident #9, Resident #10, Resident #18, Resident #29, and Resident #32) were sitting in the main dining room. The television was on, but no residents were observed watching it. CNA B was outside, in the courtyard area, providing a smoke break for Resident #1. CNA B brought Resident #1 back into the main dining room then exited the courtyard door again. CNA B walked across the courtyard and entered the Men's Memory Care unit. Resident #1 started yelling loudly. Resident #10 and Resident #9 wandered in and out of the main dining room. There were several other residents that were lying in their beds. At 3:46 p.m., Hospice CNA N came from the shower room with Resident #39 and placed her at a table. At 3:47 p.m., CNA B returned to the Women's Memory Care unit through the courtyard door. At 3:51 p.m., CNA O came out of a resident's room. 2. Record review of Resident #39's face sheet dated 6/9/25 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #39 had diagnoses including muscle weakness, age related physical debility (physical weakness, especially as a result of illness), history of falls, repeated falls, and malignant neoplasm (is an abnormal growth of cells that invades and can spread to other parts of the body) of left lung and brain. Record review of Resident #39's annual MDS assessment dated [DATE] indicated Resident #39 was sometimes understood and usually had the ability to understand others. Resident #39 had adequate hearing and vision and unclear speech. Resident #39 was rarely/never understood, and a BIMS score was not able to be assessed. Resident #39 had short-and-long term memory recall issues. Resident #39 had moderately impaired cognitive skills for daily decision making. Resident #39 used a wheelchair. Resident #39 required partial assistance for shower/bathe self, dressing, personal hygiene, and supervision for toileting hygiene. Resident #39 had 1 fall with no injury and 1 fall with minor injury since prior assessment. Record review of Resident #39's care plan dated 4/27/25 indicated Resident #39 was at high risk for falls related to gait/balance problems, poor communication/comprehension, unaware of safety needs, vision/hearing problems. Resident #39 had a history of repeated falls and rolling out of bed. Interventions included apply soft helmet and dropped wheelchair seat on new wheelchair. Record review of Resident #39's fall risk evaluation dated 5/22/25 indicated, .1-2 falls in past 3 months .disoriented times 3 at all times (Not Oriented to Person, Place, and Time) .balance problem while standing .fall risk score .7 . During an observation on 6/9/25 at 2:26 p.m., revealed Resident #39 was sitting in her wheelchair at the dining room table. Resident #39's wheelchair brakes were engaged. Resident #39 started pushing back in the wheelchair with her feet. Resident #39's wheelchair moved after each push. During an observation on 6/10/25 at 1:37 p.m., revealed Resident #39 was sitting in her wheelchair at the dining room table with CNA A bedside her. Resident #39's wheelchair brakes were engaged. Resident #39 started pushing back in the wheelchair with her feet. Resident #39's wheelchair moved after each push. CNA A said, Why is your wheelchair moving if it is locked! During an interview on 6/10/25 at 3:06 p.m., COTA M said about a month ago she noticed Resident #39's wheelchair moved when locked. She said she reported the issue to the DOR. She said a resident's wheelchair should not move when it was locked. She said Resident #39 pushed back on her wheelchair when it was locked. She said she believed Resident #39 got a new wheelchair after she reported the issue. She said she recently noticed Resident #39's new wheelchair also moved when it was locked. She said when a resident's brakes did not lock, the resident could fall out of the chair or roll over other residents. She said it was a safety hazard. During an interview on 6/10/25 at 3:30 p.m., the DOR said COTA M reported Resident #39's wheelchair was moving when the lock was on. She said she normally verbally reported wheelchair issues to Maintenance P. She said she could not recall if Maintenance P was told about Resident #39's wheelchair brakes not working. She said wheelchair brakes locking was important for the safety of the residents. She said a resident's wheelchair needed properly maintained equipment. She said brakes on a wheelchair placed the residents at risk for falls. She said she should have reported Resident #39's wheelchair brake issue to Maintenance P or told hospice to fix it. During an interview on 6/10/25 at 3:48 p.m., Hospice CNA N said Resident #39 was new to her caseload. She said Resident #39 was restless in her wheelchair. She said she noticed Resident #39's wheelchair moved a little when the brakes were locked. She said it moved when Resident #39 had her tennis shoes on. She said she did not know if the facility had reported Resident #39's wheelchair to hospice. She said Resident #39's wheelchair should not move when the brakes were locked. She said it was a safety risk. She said the resident could hurt themselves and fall out of the wheelchair. During an observation on 6/10/25 at 3:58 p.m., the DOR arrived on the memory care unit and looked at Resident #39's wheelchair. She locked the brakes and Resident #39's wheelchair moved. Resident #39 started pushing back in the wheelchair with her feet. Resident #39's wheelchair moved after each push. During an interview and observation on 6/10/25 at 4:09 p.m., CNA O was sitting near Resident #39. Resident #39's wheelchair brakes were engaged. Resident #39 started pushing back in the wheelchair with her feet. Resident #39's wheelchair moved after each push. CNA O said Resident #39 could unlock her wheelchair but not lock it back. She said sometimes Resident #39 wiggled and her chair moved when it was locked. She said Resident #39 could fall but someone was always with her. She said if a resident had wheelchair issues, she would tell the nurse or maintenance. She said she did not know CNA B was off the floor and the residents were alone in the dining room on 6/10/25 at 3:42 p.m. She said the women's memory care unit usually had two CNAs so the residents would not be left alone. She said if one CNA was inside a room with the door closed, one CNA should be with most of the residents. She said the women's memory care unit residents needed supervision because something could happen. She said the residents could fight when they were unsupervised. During an observation on 6/10/25 at 4:28 p.m., revealed Maintenance P arrived on the women's memory care unit. Maintenance P wiggled Resident #39's wheelchair lock and it was loose on the frame. Resident #39 was removed from the chair so Maintenance P could work on it. During an interview on 6/10/25 at 4:30 p.m., CNA B said she noticed Resident #39's wheelchair moved even with the brakes locked. She said she noticed it about two weeks ago and reported it to the DON. She said the residents' wheelchair brakes should lock so they would not fall. She said the wheelchair could slip from under the residents when it was not locked. She said she took Resident #1 outside to smoke on 6/10/25, in the courtyard outside the women's memory care unit. She said CNA O was in the dining room when she took Resident #1 outside. She said the CNA should be in the area, where the majority of the residents were. She said the residents needed supervision so nothing would happen to them or get into anything. She said Resident #4, Resident #10, and Resident #9 were combative and should not be unsupervised for a long period of time. During an observation on 6/10/25 at 4:47 p.m., revealed Maintenance P demonstrated Resident #39's wheelchair brakes locked when engaged. During an interview on 6/10/25 at 4:49 p.m., Maintenance P said the last time Resident #39's wheelchair was placed in maintenance book, her wheelchair seat needed to be lowered. He said the request was made on 4/29/25 but there was no name on the request form. He said on 5/8/25, staff finally placed Resident #39's name on the request form. He said the staff never reported to him Resident #39 had wheelchair brake issues. He said the left brake on Resident #39's wheelchair was loose. He said he tightened it. He said the staff should verbally tell him or place the issue in the maintenance book. He said if a resident's wheelchair did not lock, they could injury themselves or roll around and injury other residents. During an interview on 6/11/25 at 11:42 a.m., RN E said she was made aware today of Resident #39's wheelchair issue. She said the facility had been constantly working on Resident #39's wheelchair. She said the brakes were on, the wheelchair should not move. She said the resident could fall out of the wheelchair. She said about two weeks ago, Resident #39 could unlock her brakes but not anymore. She said two CNAs were assigned on the memory care unit. She said the residents should not be left alone. She said the CNAs should communicate with each other to ensure the memory care unit resident were not left alone if someone needed to leave the floor. She said the residents could be injured if left unsupervised. She said Resident #1, Resident #10, Resident #4, and Resident #25 were aggressive and should not be left alone with other residents. She said Resident #1 hollered out a lot which agitated the other residents. She said the situation on Tuesday (6/10/25) was not okay. 3. Record review of Resident #25's face sheet dated 6/10/25 indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #25 had diagnosis including pseudobulbar affect (is a neurological condition characterized by sudden, involuntary outbursts of crying or laughter that are not connected to the person's actual mood), mood disorder (is a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind or feeling), manic episodes (is a period of abnormally elevated or irritable mood, increased energy, and activity levels), anxiety disorder (repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks)), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following infarction (stroke) affecting right dominant side, repeated falls, and Alzheimer's disease (is a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was sometimes understood and sometimes had the ability to understand others. Resident #25 had adequate hearing, unclear speech, and impaired vision with corrective lenses. Resident #25 was unable to complete the BIMS score assessment. Resident #25 had short-and-long term memory recall problem. Resident #25 had severely impaired cognitive skills for daily decision making. Resident #25 experienced inattention which changed in severity and disorganized thinking that was continuously present without fluctuation. Resident #25 required substantial/maximal assistance for all ADLs except toilet hygiene which she was dependent. Resident #25 required substantial/maximal assistance to walk 10 feet. Resident #25 had one fall with no injury and one fall with a minor injury since the prior assessment. Record review of Resident #25's care plan dated 5/9/25 indicated Resident #25 was at risk for falls related to confusion, deconditioning, and gait/balance problems. Interventions included follow facility fall protocol. During an observation on 6/9/25 starting at 9:48 a.m., revealed Resident #25 was sitting in a high back wheelchair in the dining room. Resident #25 had on white socks with a light gray heel. The socks did not appear non-skid. Resident #25 was crying, anxious, and made repeated attempts to get out of the wheelchair. During an observation on 6/9/25 at 11:57 a.m., revealed Resident #25 was sitting in a high back wheelchair, in the dining room at a table. Resident #25 was crying, anxious, and made repeated attempts to get out of the wheelchair. Resident #25 had on white socks with a light gray heel. The socks did not appear non-skid. During an observation on 6/10/25 at 9:02 a.m., revealed Resident #25 made repeated attempts to get out of the wheelchair. Resident #25 had on white socks with a light gray heel. The socks did not appear non-skid. During an observation on 6/10/25 at 11:31 a.m., revealed Resident #25 was in a high back wheelchair, sitting in the dining room at a table. Resident #25 was crying, anxious, and made repeated attempts to get out of the wheelchair. Resident #25 had on white socks with a light gray heel. The socks did not appear non-skid. During an interview on 6/11/25 at 12:46 p.m., CNA L said on Monday (6/9/25), hospice dressed Resident #25. She said Resident #25 should have on non-skid socks. She said the family had brought Resident #25 some regular socks. She said non-skid socks prevented falls. She said she did not notice Resident #25 wearing regular socks instead of non-skid ones. During an observation and interview on 6/11/25 at 2:14 p.m., revealed Resident #25 was lying in bed. CNA B lifted Resident #25's blanket to expose her feet. Resident #25 had on white socks with a light gray heel and a slightly discolored area on the bottom portion. The discolored area appeared to be dirt. The socks were not non-skid. CNA B said Resident #25 normally had on regular socks and tennis shoes. During an interview on 6/11/25 at 2:35 p.m., the DON said she was not aware Resident #39's wheelchair brakes did not work. She said the wheelchair should not move when the brakes were locked. She said brakes not locking could cause falls. She said she expected CNAs to report wheelchair issues to the nurse then placed in the maintenance book. She said the memory care unit residents should always be supervised. She said the CNAs should communicate if they need to leave the floor. She said the residents needed to be supervised due to behaviors and safety. She said the residents could fall, have resident to resident altercations, spills, and elopements. She said residents should have on non-skid socks or closed toe shoes. She said the CNAs and LVNs should make sure the residents were wearing proper footwear. She said the DON should ensure the staff were putting proper footwear on the residents. She said the resident could fall or slip if they were not wearing non-skid socks. During an interview on 6/11/25 at 3:35 p.m., the ADM said she was not aware Resident #39's wheelchair brake was not working. She said whoever saw the issue should have reported it. She said the CNAs should tell the nurse then they contacted maintenance. She said if a resident's wheelchair brakes did not work then they could fall and have injuries. She said she expected the nursing staff to ensure residents' wheelchair brakes worked. She said she expected the residents on memory care unit to always be supervised. She said the residents needed to be supervised because of behaviors, the safety of the residents, and the need for redirection. She said when the residents were not supervised, altercations and falls could happen. She said depending on the resident's care plan, what fall intervention were put in place for the resident. She said she expected the residents to wear non-skid socks. She said non-skid socks prevented falls. She said not wearing non-skid socks placed the resident at risk for injuries. She said the CNAs should make sure the resident's wore non-skid socks. She said the charge nurses to ensure the CNAs were putting proper footwear on the residents. Record review of a Fall Prevention in-service dated 3/29/25, conducted by the DON, indicated, .do not place slippers on resident .non-skid socks that fit and closed toe, closed heel shoes . Record review of a facility's Safety and Supervision policy revised 12/2007 indicated, .our facility strives to make the environment as free from accident hazards as possible .resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Record review of a facility's Fall and Fall Risk, Managing policy revised 4/2018 indicated, .based on previous evaluations and current data .the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling .environmental factors that contribute to the risk of falls included .improperly fitted or maintained wheelchairs .and footwear that is unsafe or absent .

Based on observation, interview, and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 4 (Resident #25, Resident #39, Resident #1 and Resident #13) of 15 residents reviewed for infection control. The facility failed to ensure CNA L performed hand hygiene between going back and forth, several times, feeding Resident #25 and Resident #39 lunch on 06/09/25. The facility failed to ensure COTA M performed hand hygiene between going back and forth, feeding Resident #1 and Resident #13 lunch on 06/09/25. These failures could place residents at risk for cross-contamination and the spread of infection. Findings included: 1. Record review of Resident #25's face sheet dated 6/10/25 indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #25 had diagnosis including pseudobulbar affect (is a neurological condition characterized by sudden, involuntary outbursts of crying or laughter that are not connected to the person's actual mood), mood disorder (is a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind or feeling), manic episodes (is a period of abnormally elevated or irritable mood, increased energy, and activity levels), anxiety disorder (repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks)), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following infarction (stroke) affecting right dominant side, repeated falls, and Alzheimer's disease (is a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was sometimes understood and sometimes had the ability to understand others. Resident #25 had adequate hearing, unclear speech, and impaired vision with corrective lenses. Resident #25 was unable to complete the BIMS score assessment. Resident #25 had short-and-long term memory recall problem. Resident #25 had severely impaired cognitive skills for daily decision making. Resident #25 experienced inattention which changed in severity and disorganized thinking that was continuously present without fluctuation. Resident #25 required substantial/maximal assistance for all ADL's except toilet hygiene which she was dependent. Record review of Resident #25's care plan dated 5/8/25 indicated Resident #25 nutritional status: Regular Diet, Puree Texture, Thin liquids. Intervention included assist with meals. 2. Record review of Resident #39's face sheet dated 6/9/25 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #39 had diagnoses including muscle weakness, age related physical debility (physical weakness, especially as a result of illness), history of falls, repeated falls, and malignant neoplasm (is an abnormal growth of cells that invades and can spread to other parts of the body) of left lung and brain. Record review of Resident #39's annual MDS assessment dated [DATE] indicated Resident #39 was sometimes understood and usually had the ability to understand others. Resident #39 had adequate hearing and vision and unclear speech. Resident #39 was rarely/never understood, and a BIMS score was not able to be assessed. Resident #39 had short-and-long term memory recall issues. Resident #39 had moderately impaired cognitive skills for daily decision making. Resident #39 used a wheelchair. Resident #39 required partial assistance for shower/bathe self, dressing, personal hygiene, and supervision for toileting hygiene and eating. The MDS did not reflect swallowing disorder. The MDS did not reflect mechanically altered diet. Record review of Resident #39's care plan dated 5/8/25 indicated: *Resident #39 had impaired nutrition related to terminal disease of lung cancer with metastasis (is the process where cancer cells break away from a primary tumor and spread to other parts of the body, forming new tumors) and at risk for weight loss and may be unavoidable. Interventions included ensure resident is in proper position for eating, evaluate resident's physical ability to eat, and eat meals in a monitored environment. *Resident #39's nutritional status regular diet, regular texture, thin liquids. Interventions include determine resident's ability to chew and swallow and modify diet as appropriate according to resident's food tolerance and preference. 3. Record review of Resident #1's face sheet dated 06/10/25 indicated Resident #1 was an 81-years-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere with daily life), severe with agitation (is a state of restlessness and uneasiness, often accompanied by physical and mental symptoms), age-related physician debility (physical weakness, especially as a result of illness), muscle weakness, abnormalities of gait and mobility, muscle wasting and atrophy (shortening), and mood disorder (is a mental health condition that primarily affects your emotional state). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and usually had the ability to understand others. Resident #1 had severely impaired vision. Resident #1 had a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #1's care plan dated 5/8/25 indicated Resident #1 nutritional status, regular diet, regular texture, thin liquids. Intervention included place food in bowls. 4. Record review of Resident #13's face sheet dated 6/11/25 indicated Resident #13 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13 had diagnoses including muscle wasting and atrophy (shortening), mild protein-calorie malnutrition (is a condition where protein intake is insufficient to meet the body's needs), and contracture (is a type of scarring in your soft tissues that causes them to tighten and stiffen). Record review of Resident #13's annual MDS assessment dated [DATE] indicated Resident #13 had was rarely/never understood and rarely/never the ability to understood others. Resident #13 was unable to complete the BIMS assessment. Resident #13 had short-and-long term memory recall problem. Resident #13 had severely impaired cognitive skills for daily decision making. Resident #13 required partial/moderate assistance for eating. Record review of Resident #13's care plan dated 5/8/25 indicated Resident #13 nutritional status regular diet, thin liquids. Intervention included assist with meals. During an observation on 6/9/25 starting at 12:06 p.m., revealed CNA L was assisting Resident #25 with her lunch tray. CNA L stopped feeding Resident #25 then assisted Resident #39 with her lunch. CNA L did not perform hand hygiene between assistance. COTA M had clear gloves on her hands and was assisting Resident #13 with her lunch tray. COTA M got up from the table with Resident #13 and walked over to Resident #1. COTA M, with the same gloves used for Resident #13, placed Resident #1's fork in her right hand. COTA M then touched Resident #1's bowl holding her meat. COTA M then took Resident #1's dinner roll from her meat and placed in on another bowl. COTA M did not remove her gloves and perform hand hygiene between residents. While CNA L was intermittently assisting Resident #39 with her magic cup, she took out Resident #1's cookie and gave it to her. CNA L did not perform hand hygiene between residents. During an interview on 6/10/25 at 3:06 p.m., COTA M said on Monday (6/9/25), she assisted Resident #13 with her lunch meal. She said she was working with Resident #13 to use her hands to eat meals. She said she remembered giving Resident #1 her fork to assist her with the meat served for lunch. She said she may have touched Resident #1's dinner roll. She said she remembered using one hand for each resident. She said if she used the same gloves on the residents then it would be unsanitary. She said using the same gloves could spread infection or body fluids. She said it was cross contamination. She said it could potentially expose the other resident to a food allergy they may have. During an interview on 6/11/25 at 11:42 a.m., RN E said she did not witness the exchanges between the staff and residents. She said staff were supposed to perform hand hygiene between residents. She said staff could spread an infection to the residents. She said it was cross contamination. During an interview on 6/11/25 at 12:46 p.m., CNA L she was supposed to wash her hands or use hand sanitizer between residents. She said it was important to perform hand hygiene because of germs. She said the germs could make the residents sick. During an interview on 6/11/25 at 2:35 p.m., the DON said she expected staff to use hand sanitizer and hand hygiene when assisting with resident's meals. She said hand hygiene was important because the facility did not want to mix and spread germs or put stuff in the resident's food. She said feeding different residents at the same time was an interruption of the resident's meal. She said it was cross contamination to feed different resident with wash your hands between contact. During an interview on 6/11/25 at 3:35 a.m., the ADM said she expected the staff to perform hand hygiene and use hand sanitizer between the residents. She said it was an infection control issue to not perform hand hygiene when assisting with meals. She said it was cross contamination. She said it could make the residents sick. Record review of a facility's Handwashing/Hand Hygiene policy revised on 04/2012 indicated, .all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection .employee must wash their hands .before and after direct resident contact .

Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for residents 1 of 1 secure unit reviewed for activities, in that: The facility failed to ensure there were organized activities available to secured unit residents on 6/9/25 and 6/10/25. The facility failed to ensure a current activities calendar was posted in the resident's room. The facility failed to ensure the posted activities calendar was followed. These failures placed residents at risk for a diminished quality of life, behaviors, isolation, and lack of stimulation. Findings included: During an observation of the women's secured unit on 6/9/25 starting at 9:48 a.m., eleven out of eleven residents had May 2025 calendar posted in their rooms. During an observation of the women's secured unit on 6/9/25 at 9:58 a.m., the centrally located group activities board indicated: *10am: Worship, 12pm: Lunch, 2pm: Puzzle, 4pm: Movie, 5pm: Music and Relaxation *7am: Breakfast, 10am: Sit N Be Fit, 12pm: Lunch, 2pm: Memory Game, 4pm: Bingo, 5pm: Music and Relaxation *10am: Daily Bread/Coffee, 12pm: Lunch, 2pm: Kick Ball, 4pm: Bucket Toss, 5pm: Music and Relaxation *10am: Sit N Be Fit, 12pm: Lunch, 2pm: Movie Time, 4pm: Bingo, 5pm: Music and Relaxation *7am: Breakfast, 10am: Worship, 12pm: Lunch, 2pm: Snack/Social, 4pm: Yahtzee, 5pm: Music and Relaxation *10am: Sit N Be Fit, 12pm: Lunch, 2pm: Sorting Activities, 4pm: Bingo, 5pm: Music and Relaxation *10am: Bored Boards, 12pm: Lunch, 2pm: Library, 4pm: Movies, 5pm: Music and Relaxation, 7am: Breakfast During an observation on 6/9/25 at 10:00 a.m., six Residents were in the dining room with CNA A. One resident had a baby doll and toy on a bedside table. One resident was sitting in a wheelchair with a baby doll. All of residents were sitting quietly in the dining room or wandering the hall. No scheduled activities were observed. During an observation on 6/9/25 at 2:26 p.m., four residents (Resident #13, Resident #25, Resident #39, Resident #10) were observed in the dining room. Resident #13 was quietly sitting at a table and then got up to wander. Resident #25 was asleep in her wheelchair. Resident #39 was initially asleep with her head on the table then woke up and started pushing her wheelchair in a circle. Resident #10 was wandering in and out of the dining room. No scheduled activities were observed. During an interview on 6/9/25 at 4:26 p.m., a family member of a women's secured unit resident said she visited her family 2-3 times a week. She said she made random visits to visit her family member. She said on the days she visited during the day shift, there were no observed activities provided to the residents. During an observation on 6/10/25 at 9:02 a.m., newer line dance music was playing, and a ball toss game was observed. Seven residents (Resident #25, Resident #10, Resident #29, Resident #1, Resident #4, Resident #39, and Resident #13) were observed in the dining room with CNA A. Resident #25 and Resident #10 were the only residents playing the ball toss game. Resident #29 was holding a baby doll in her wheelchair. Resident #1 was asleep in her wheelchair. Resident #4 and Resident #39 were quietly sitting in their wheelchairs. Resident #13 was wandering in and out of the dining room. During an observation on 6/10/25 at 11:31 a.m., six resident (Resident #4, Resident #10, Resident #25, Resident #13, Resident #29, and Resident #39) were observed in the dining room with CNA A. The television was on, but no residents were watching it. Resident #25 was tearful and holding a baby doll. During an observation on 6/10/25 at 1:37 p.m., four residents (Resident #29, Resident #39, Resident #10, and Resident #18) were in the dining room with CNA A. No activities were observed. During an observation on 6/10/25 at 3:56 p.m., residents sitting in quiet dining room with no activities observed. CNA B eventually pulled out cards and played a game with Resident #18. During an interview on 6/10/25 at 4:09 p.m., CNA O said she had been working at the facility for 3 weeks. She said she worked the 2-10pm shift. She said she did not know what activities were provided on the day shift. She said when she arrived for her shift things needed to be done to get the residents ready for dinner and bedtime. She said no one told the CNAs what activities to provide the residents. She said some of the residents would participant in structured activities. She said activities were important to help the residents with their memory. She said when activities were not provided residents could have increase in behaviors, hurt themselves, or falls. During an interview on 6/10/25 at 4:30 p.m., CNA B said she normally worked the 2pm-10pm shift. She said she occasionally worked the 6am-2pm shift. She said the activity calendar was posted in the secured unit hallway. She said the posted activity calendar was not update. She said the old AD never changed the posted activity calendar. She said the old AD would come to the secured unit and get certain residents for activities on the non-secured side. She said since the AD had recently quit, the CNAs were supposed to do activities with the women's secured unit residents. She said the facility had not instructed the CNAs on what activities to provide the residents or when to do the activities. She said she felt only 2 out of the 11 residents on the women's secured unit would do structured activities. She said Resident #25, Resident #1, and Resident #32 enjoyed music. She said it was important to do activities with the women's secured unit to keep them stimulated and their minds going. She said the secured unit residents could become depressed if activities were not provided. During an interview on 6/11/25 at 10:54 a.m., MR T said she was helping the facility provide activities for the residents on the non-secured side. She said since the AD quit, the CNAs were responsible for activities on the secured units. She said she was a certified AD. She said she had been providing the non-secured unit residents with activities from the old calendar for the last 2-3 days. She said activities were important for the resident's quality of life, keeping the residents active, upbeat, and positive mood, helped with socialization and hand and eye coordination. She said good activities for the dementia resident included music therapy, activity boards, ball toss, and dancing. She said when activities were not provided to the secured unit residents, they could become bored, idle, and isolated. She said scheduled activities should be provided to the secured unit residents three to four times a day. She said the staff members should review the secured unit resident's care plan and activity assessment to know what activities to provide. During an interview on 6/11/25 at 11:42 a.m., RN E said the AD left about a month ago. She said the CNAs were now responsible for providing activities to the secured unit residents. She said the secured unit had games and baby dolls to provide the secured unit residents for activities. She said some of the secured unit resident were able to attend the general population scheduled activities. She said the women's secured unit was not getting scheduled activities, but the staff put toys out for the resident to use. She said the CNAs should not play current generation music but oldies and worship music. She said activities for the secured unit were important to keep the resident occupied and stimulated. She said the residents could become depressed, sicker, and have behaviors. She said when a resident was admitted , the AD performed an activity assessment. She said Resident #13 enjoyed the numbered blocks, but she also wandered. She said Resident #25 and Resident #1 enjoyed gospel or worship music. She said Resident #39 would be passive interaction. She said Resident #10 had labile cognition. She said it depended on the time of day what activities interested Resident #10. During an interview on 6/11/25 at 12:46 p.m., CNA L said the CNAs tried to do activities on the women's secured unit. She said the facility had not told them what activities to provide and when to provide the scheduled activities. She said activities were important to keep the resident's mind occupied. She said the residents could have behaviors when activities were not provided. During an interview on 6/11/25 at 1:52 p.m., LVN D said on 6/9/25, MR T took some residents from the secured unit to do, activities in the main dining room. She said the secured unit had card games for the residents. She said some of the secured unit residents attended bingo with the general population residents. She said on Monday, 6/9/25, the men's secured unit had activities being provided by the CNAs but not the women's secured unit. She said scheduled activities were important so the residents stayed active, would not be bored, and made them feel purposeful. She said when activities were not provided to the residents, they could become depressed. During an interview on 6/11/25 at 2:35 p.m., the DON said the previous AD took some of the secured unit residents to the general population activities. She said the CNAs were responsible for the secured unit activities until another AD was hired. She said the residents should receive daily structured and non-structured activities. She said several of the secured unit residents enjoyed music. She said she expected the CNAs to engage with the residents unless ADLs were being provided. She said she expected the staff to follow the resident's activity preferences. She said she felt the secured unit residents benefited from structure activities. She said the secured unit residents could become bored and unstimulated when activities were not provided. She said it placed residents at risk for behaviors, wandering, and depression. During an interview on 6/11/25 at 3:35 p.m., the ADM said the AD quit in the middle of May 2025. She said she expected the CNAs to provided activities to the secured unit residents who did not attend outside activities. She said she expected the CNAs to look on the activity calendar board to know what and when activities needed to be provided, to the secured unit residents. She said the women's secured unit had an activity closet with things to provide the residents. She said activities helped with the resident's anxiety and engagement. She said not providing activities to the women's secured unit could cause behaviors. Record review of Resident #1's Activities-Quarterly/Annual Participation review dated 04/23/25 indicated Resident #1 attended and participated 50 percent of group activities. Resident #1 enjoyed morning worship, music, and social events. Record review of Resident #9's Activities-Quarterly/Annual Participation review dated 5/9/25 indicated Resident #9 did independent and group activities. Resident #9 enjoyed bingo, morning worship, music, and movie time. Record review of Resident #10's Activities-Quarterly/Annual Participation review dated 5/13/25 indicated Resident #10 attended and participated in 95 percent of activities. Resident #10 enjoyed bingo, arts and crafts, social/music table games, and worship service. Record review of Resident #13's Activities-Quarterly/Annual Participation review dated 5/13/25 indicated Resident #13 attended and participated in 50 percent of activities. Resident #13 sat at the table for short periods of time. Resident #13 enjoyed music, singing songs, conversations, and walks. Record review of Resident #25's Activities-Quarterly/Annual Participation review dated 5/9/25 indicated Resident #25 had 1:1 visits. Resident #25 enjoyed gospel music and bible reading. Record review of Resident #29's Activities-Quarterly/Annual Participation review dated 4/1/25 indicated Resident #29 attended and participated in activities 80 percent of the times. Resident #29 enjoyed bingo, nursery, sorting activities, and social. Record review of a facility's Programming for Residents with Cognitive Impairments and Other Special Needs policy revised 08/2006 indicated, .Activity programs are provided for the maintenance and enhancement of each resident's quality of life while promoting physical, cognitive, and emotional health. The facility will offer meaningful programs for residents with cognitive impairments that use reality and sensory awareness techniques .

Based on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 17 residents (Resident #28 and Resident #39) reviewed for resident rights. 1. The facility failed to ensure COTA G treated Resident #28 with respect, had a dignified existence, and was not pulled backwards in a geriatric reclining rolling chair. 2. The facility failed to ensure CNA L assisted Resident #39 with eating in a dignified manner on 6/09/25. These failures could place residents at risk of humiliation, diminished quality of life, loss of dignity and self-worth. Findings included: 1. Record review of Resident #28's face sheet dated 6/10/25 indicated she was [AGE] years old and was admitted to the facility on initially on 4/15/19 and re-admitted [DATE]. Resident #28 had diagnoses which included Parkinsonism (broad term referring to various neurodegenerative diseases (progressive loss of function and death of nerve cells affecting memory, movement, and/or thought) that manifest with motor symptoms such as rigidity (stiffness), tremors (involuntary shaking or movement affecting hands, legs, face, and head), and bradykinesia (slowness of movement), abnormality of gait, anxiety disorder (feeling of worry, dread, and uneasiness), dementia (progressive forgetfulness), repeated falls, age related physical debility, major depression disorder (persistent sadness), and lack of coordination. Record review of Resident #28's quarterly MDS assessment dated [DATE] indicated Resident #28 was rarely understood and rarely understood others. Resident #28 was unable to complete the BIMS because she was rarely understood. Resident #28 had severely impaired cognitive skills for daily decision making. Resident #28 had other behavioral symptoms not directed toward others. Resident #28 required a wheelchair for mobility. Resident #28 was dependent on staff for all ADL's. Record review of Resident #28's Care Plan indicated she used anti-anxiety medications related to anxiety and she was at risk for falls due to poor safety awareness and cognition. During an observation on 6/10/25 beginning at 2:42 PM, COTA G pulled Resident #28 backwards, with one hand on the handle on the back of her geriatric reclining rolling chair, out of the therapy room and down the hallway of Hall 6, around the nurses' station and down approximately ¾ of the hallway on Hall 4 to Resident #28's room. During an interview on 6/10/25 at 2:46 PM, COTA G said he had worked at the facility for approximately two months. COTA G said therapy with Resident #28 depended on her anxiety level and it depended on if she had received her anxiety meds. COTA G said Resident #28 got tight and anxious and needed rest periods during therapy. COTA G said the geriatric reclining rolling chair was easier to maneuver pulling backwards than it was pushing it forward and less likely to run over other residents. COTA G said he can see it could cause Resident #28 some discomfort, but he only did it when he knew there was obstacles and tight spaces. COTA G said if there were wide open spaces, he would push the geriatric reclining rolling chair forward to make sure to keep her safe. COTA G said Resident #28 would also kick her legs over the sides at times. COTA G said he could see where it could be an issue pulling the geriatric reclining rolling chair backwards, but he wanted to keep Resident #28 safe. During an interview on 6/11/25 at 10:34 AM, the MDS Coordinator said she had been the ADON prior to taking the MDS Coordinator position in February 2025. The MDS Coordinator said it would not be appropriate to pull a resident down the hallway backwards. The MDS Coordinator said they train the CNAs and nurses to not pull residents backwards because it was a dignity issue. The MDS Coordinator said the geriatric reclining rolling chair were able to be pushed forward. The MDS Coordinator said being pulled backwards could affect the resident's independence. The MDS Coordinator said the resident could not see where they were going and would not know where they were taking them if being pulled backwards. The MDS Coordinator said it could affect the resident emotionally. The MDS Coordinator said it was a dignity issue. During an interview on 6/11/25 at 11:12 AM, RN E said it was not appropriate, nor were you supposed to, pull a resident backwards in a geriatric reclining rolling chair or wheelchair. RN E said it was a dignity issue to her and did not look right. RN E said she would not want anyone doing her mom like that. RN E said if the resident had some awareness, it would be confusing and it would be upsetting to residents and they would be upset, she said I would be. RN E said the resident in a geriatric reclining rolling chair could be hurt if they turned sideways in the chair or could do anything and you would not see it because you were not visualizing the resident. RN E said not paying attention to resident, they could be doing something as you were pulling them and you would not know. During an interview on 6/11/25 at 11:24 AM, the ADON said staff were not supposed to pull residents backwards in a geriatric reclining rolling chair or wheelchairs. The ADON said if pulling the resident backwards it was a safety issue, and the resident could not see where they were going. The ADON said the geriatric reclining rolling chairs were sometimes hard to steer and staff may need to turn the chair backwards to maneuver through tight spaces, but then should turn it back to the forward position. The ADON said the resident could get hurt being pulled backwards. The ADON said the residents that had dementia could get agitated from not being able to see where they are going. The ADON said being pulled backwards could affect the resident's dignity just from not having control of where they were going. During an interview on 6/11/25 at 11:28 AM, CNA F said she had worked at the facility for approximately a month. CNA F said it was not appropriate to pull a resident backwards in a wheelchair or a geriatric reclining rolling chair. CNA F said it was a dignity issue. CNA F said being pulled backwards probably made the resident feel embarrassed or incapable. CNA F said if someone pulled her backwards in a wheelchair it would make her feel like a child. CNA F said it would affect the resident's dignity to be pulled backwards. During an interview on 6/11/25 at 1:02 PM, the DON said it was not appropriate to pull a resident backwards in a geriatric reclining rolling chair or wheelchair because you could not visualize the resident. The DON said it was a dignity thing and was like dragging them. The DON said if staff were pulling the resident backwards, they could not visualize the resident to ensure the safety of the resident, therefore, it was a safety issue. The DON said it was a safety issue and anything could happen to the resident if not visualizing the resident during transport. The DON said it was a dignity and safety issue. The DON said everyone was responsible for ensuring the residents were transported appropriately in a geriatric reclining rolling chair or wheelchairs and for promoting the residents' dignity. During an interview on 6/11/25 at 1:30 PM, the DOR said she had worked at the facility for about a year and had been the DOR for approximately six months. The DOR said it was not appropriate to pull residents backwards in a geriatric reclining rolling chair or wheelchairs. The DOR said residents should be transported facing forward, so the resident could see where they were going. The DOR said she had just always been taught to go forward when transporting residents in a geriatric reclining rolling chair or wheelchair. The DOR said it was important to transport a resident going forward because it was a dignity thing and so the resident could know where they were going. The DOR said it could take the resident's sense of knowing where they were going and acknowledgement of who they were and just being considered a human being person. The DOR said COTA G had only been working at the facility for a few months and had a background in home health and probably was unaware that pulling the resident backwards was a dignity issue. The DOR said all department heads were responsible for ensuring staff were transporting residents appropriately and promoting the resident's dignity. During an interview on 6/11/25 at 1:39 PM, the ADM said it was not appropriate to pull a resident backwards in a geriatric reclining rolling chair or wheelchair. The ADM said it was a dignity issue. The ADM said the resident did not know where they were going if being pulled backwards. The ADM said it could affect the resident emotionally and it could even put the resident at risk for injury. The ADM said department heads were responsible for in-servicing staff on appropriate transporting and dignity concerns. The ADM said she would expect staff to transport residents appropriately and promote their dignity. 2. Record review of Resident #39's face sheet dated 6/9/25 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #39 had diagnoses including muscle weakness, age related physical debility (physical weakness, especially as a result of illness), and malignant neoplasm (is an abnormal growth of cells that invades and can spread to other parts of the body) of left lung and brain. Record review of Resident #39's annual MDS assessment dated [DATE] indicated Resident #39 was sometimes understood and usually had the ability to understand others. Resident #39 had adequate hearing and vision and unclear speech. Resident #39 was rarely/never understood, and a BIMS score was not able to be assessed. Resident #39 had short-and-long term memory recall issues. Resident #39 had moderately impaired cognitive skills for daily decision making. Resident #39 required supervision for eating. Record review of Resident #39's care plan dated 2/5/25 indicated Resident #39 had experienced self-care deficit related to diagnosis and decline in physical function. Intervention included Resident #39 was able to feed self once tray was brought and set up. Resident #39 sometimes used hands to eat certain foods. During an observation on 6/9/25 at 12:06 p.m., Resident #39 was sitting in the dining room at a table. CNA L assisted Resident #39 with her magic cup (frozen, fortified nutritional snack). CNA L stood up next to Resident #39 and fed her the magic cup until it was finished. During an interview on 6/11/25 at 11:42 a.m., RN E said staff should be sitting eye level to the residents when assisting with meals. She said it was a dignity issues when staff stood over residents when feeding them. She said she would not want someone standing over her while eating. She said the resident could become anxious while being fed by staff member who was standing. She said she was not in the dining room when CNA L was feeding Resident #39. She said if she had witnessed the incident, she would have instructed CNA L to sit down to assist Resident #39. During an interview on 6/11/25 at 12:46 p.m., CNA L said staff should sit bedside the residents when assisting with meals. She said she may have stood up to feed Resident #39 when she passed by and noticed her not eating. She said it was important to sit bedside the resident to watch them swallow their food and to know if they were choking. She said standing over a resident while feeding them could make them feel uncomfortable. During an interview on 6/11/25 at 2:35 p.m., the DON said staff assisting a resident with meals should be sitting and, on the resident's, weak side. She said it was a dignity issue when staff stood over the residents while feeding. She said when the staff stood over the resident, it could make them feel inferior. She said the LVN on duty should ensure the CNAs sat down when assisting residents with meals. She said she was normally on the secure unit during meal service to help and monitor the staff and residents. During an interview on 6/11/25 at 3:35 p.m., the ADM said she expected the CNAs and LVNs to sit when assisting a resident with meals. She said she knew the table space was limited but they should still sit down next to the residents. She said when the staff sat down and assisted the resident, it made them feel secure, taken care of, and not rushed. She said the resident could feel rushed, hurt their dignity, and would not have eye contact with the staff member if they were standing. She said the nursing administration should ensure the staff members were sitting at eye level, with the residents when providing a service. Review of the facility's policy titled Resident Rights dated revised February 2021 indicated . 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 . a dignified existence . be treated with respect, kindness, and dignity . Review of the facility's policy titled Dignity dated revised February 2021 indicated . each resident shall be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . residents were treated with dignity and respect at all times . demeaning practices and standards of care that compromise dignity were prohibited . staff were expected to treat cognitively impaired residents with dignity and sensitivity . Record review of a facility's Assistance with Meals policy revised 10/2009 indicated, . residents shall receive assistance with meals in a manner that meets the individual needs of each resident . residents who cannot feed themselves will be fed with attention to safety, comfort and dignity .not standing over residents while assisting them with meals .

Based on observation, interview and record review, the facility failed to promote resident self-determination through support of resident choice for 1 of 15 residents reviewed for resident rights. (Resident #17) The facility failed to assist Resident #17 out of bed after he requested to be gotten out of bed. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Findings included: Record review of a face sheet dated 06/10/25 indicated Resident #17 was [AGE] years old and admitted to the facility on [DATE]. Resident #17 had diagnoses which included heart failure, anxiety disorder, and muscle weakness. Record review of an annual MDS assessment dated [DATE] indicated Resident #17 was understood and understood others. The MDS indicated Resident #17 had a BIMS of 07 which indicated she had severe cognitive impairment. The MDS indicated Resident #17 was dependent on staff for chair/bed-to-chair transfers. Record review of Care Plan last revised 03/21/25 indicated Resident #17 was able to propel self in his wheelchair, short distances and long distances with multiple stops and breaks. The care plan indicated Resident #17 had to be transferred using the mechanical lift with assistance from 2 staff member. During an observation on 06/09/25 at 11:28 a.m. revealed a housekeeping staff member telling CNA F that Resident #17 wanted to get out of bed. During an observation and interview on 06/09/25 at 11:31 a.m., Resident #17 was in bed. Resident #17 said he had asked to get out of bed. He said his wheelchair was broken and he had not been able to get out of bed. He said he wants to get out of the bed. He said before he was able to use someone else's wheelchair. During an observation on 06/09/25 at 12:41 p.m., Resident #17 was in bed. During an observation on 06/09/25 at 2:22 p.m., Resident #17 was in bed. During an observation and interview on 06/09/25 at 3:51 p.m., Resident #17 said he had not been out of bed all day. He said he did not know why they did not get him up out of bed this morning. I guess they are waiting on my wheelchair to get out of the shop. He said they did offer him a wheelchair but it will throw me out of the floor. He said he asked every single day to be gotten out of bed. He said, I have been tired of this bed. He said he had been in the bed for close to a month. During an observation on 06/10/25 at 8:28 a.m., Resident #17 was sleeping in bed. During an observation on 06/10/25 at 10:05 a.m., Resident #17 was sleeping in bed. During an interview on 06/10/25 at 1:50 p.m., CNA H said Resident #17 was usually gotten out of bed every day. She said the handrails to his usual wheelchair broke and it was sent out to be fixed. She said there was another wheelchair he could use but he had slid out of it in the past. She said his wheelchair had been broken 6 - 7 days. She said she did not work on 06/09/25 but if she had to guess the wheelchair was the reason he was not gotten out of bed. During an interview on 06/11/25 at 9:00 a.m., Resident #17 said he was assisted out of bed on 06/10/25. He said they put him in the wheelchair they normally used to take him to the hospital in. He said he never refused to get out of bed and if anyone said he had they were lying. He said he wanted to get up every day. During an interview on 06/11/25 at 9:18 a.m., CNA F said she was Resident #17's aide on 06/09/25. She said she did not get him up out of bed on 06/09/25. She said she did not get him up because he did not have a wheelchair. She said his wheelchair was being repaired. She said, he has been in the bed about a week now. She said they did have a wheelchair they used to transport him to the hospital. She said she was not sure if that wheelchair was available on 06/09/25 or not. During an interview on 06/11/25 at 10:20 a.m., LVN J said they did normally get Resident #17 up out of bed daily. She said on 06/09/25 his wheelchair was being worked on and he was told he could not get up . She said they had to make sure he had a stable chair so he would not slide out. She said he was told he could not get up because of this. She said he was gotten up on 06/10/25. She said the chair he used on 06/10/25 was not used on 06/09/25 because they had to make sure it was stable. She said there was no negative outcome because the resident was educated concerning his safety and wellbeing. During an interview on 06/11/25 at 12:47 p.m., the DON said Resident #17 had a custom chair and it was broken. She said it has been broken for approximately 9 days. She said they were waiting on the company to come to see if it could be repaired. She said he had another chair, but he had slid to the front of the chair when the chair did not have footrest. She said he had been mad and upset ever since his custom chair broke. She said on 06/10/25 they were able to get him up in the other chair he had with footrest. She said she would not have expected staff to have gotten him up 06/09/25 without the footrest on the chair they have. She said they had encouraged to sit him up on the side of the bed. She said he only sat up on the side of the bed one day. She said the negative effect for him not being gotten up was that he could not be mobile like he wanted to be. She said with his condition he needed to be up. She said he had congestive heart failure. She said they tried to offer alternatives such as using the one chair with the footrest and sitting up on the side of the bed and he was not agreeable to that. During an interview on 06/11/25 at 12:57 p.m., the Administrator she said they were having issues with Resident #17's wheelchair. She said the company was coming out the week of 06/09/25 and they had obtained a bid for a new wheelchair in case it could not be repaired. She said they had concerns about safety issues. She said with him asking to get up, staff should have put forth the effort to find a wheelchair that would have worked for him and at least attempted to have gotten him up. She said being left in the bed could cause depression and he it was not utilizing his physical abilities. Record review of a Resident Rights facility policy last revised in February 2021 indicated, .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 .self-determination .

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 17 residents (Resident #5) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #5's active diagnoses to not include a diagnosis of schizophrenia (a disorder that affected a person's ability to think, feel, and behave clearly) on her 3/07/25 MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #5's face sheet dated 6/09/25 indicated she was [AGE] years old and admitted to the facility on originally on 2/29/24 and re-admitted on [DATE]. Resident #5 had diagnoses which included dementia (progressive or persistent loss of intellectual functioning including impairment of memory, thinking, and personality changes due to disease of the brain), bipolar disorder (episodes of mood swings ranging from depressive (sadness) lows to manic highs(excitability with high energy)) with psychotic features (mental disorder characterized by a disconnection from reality with symptoms of delusions-false belief of reality; hallucinations-seen, heard, touched, tasted, or smelled something that was not really there; talking incoherently; and agitation) and depression (feelings of sadness, tearfulness, angry outbursts, irritability or frustration even over small matters). Record review of Resident #5's annual MDS assessment dated [DATE] indicated Resident #5 had a BIMS of 14 which indicated she was cognitively intact. The MDS indicated Resident #5 had an active diagnosis of schizophrenia. Record review of Resident #5's undated care plan indicated she required a psychotropic medication related to bipolar disorder. Resident #5 required an antidepressant related to depression. Resident #3 had memory problems related to dementia. Record review of Resident 5's Nurse Practitioner Visit Note dated 5/17/25 did not indicate Resident #5 had a diagnosis of schizophrenia. During an interview on 6/10/25 at 12:15 PM, the MDS Coordinator said she just took over the position of MDS nurse the middle of February 2025. The MDS Coordinator said she would have to look into why Resident #5 was being coded for schizophrenia on the MDS. The MDS Coordinator said she could see that a schizoaffective disorder diagnosis was inputted in May of 2024 but was deleted 6/11/24. The MDS Coordinator said she would have to research it and would get back to surveyor. During an interview on 6/11/25 at 9:33 AM, the ADM said her staff searched Resident #5's chart all day yesterday (6/10/25) for documentation of a diagnosis of schizophrenia and her staff could only find a diagnosis of bipolar disorder for Resident #5. The ADM said they think it was a mis-keyed item on the MDS assessment. During an interview on 6/11/25 at 10:34 AM, the MDS Coordinator said she had looked at Resident #5's documents and the only thing she had found was Resident #5 had a diagnosis of bipolar disorder. The MDS Coordinator said the purpose of the MDS assessment was for gathering information based off the assessment and based off the care the resident needed and it helped create the care plan. The MDS Coordinator said the MDS should be accurate to stay on top of what services the resident may or may not need and to get the right reimbursement. The MDS Coordinator said if the MDS assessment was not accurate, it could set the facility back with payment and if not correct, it could affect what the resident may or may not need. The MDS Coordinator said the MDS Coordinator would be responsible for ensuring the MDS assessment was accurate, but it was a collective effort from nursing, therapy, and all departments involved in the resident's care. During an interview on 6/11/25 at 1:02 PM, the DON said she had been the previous MDS Coordinator until sometime in February 2025. The DON said she guessed the schizophrenia on Resident #5's MDS assessment was a miscoded and was marked in error. The DON said the purpose of the MDS assessment was to paint an accurate picture of the resident and it showed what care and needs the resident required. The DON said the resident could possibly miss care and not get everything the resident needed to promote quality of life if the MDS assessment was not accurate. The DON said the RN was responsible for the accuracy of the MDS assessment and had to sign off on the MDS assessment. During an interview on 6/11/25 at 1:39 PM, the ADM said she would expect the MDS assessments to be accurate. The ADM said the MDS assessment should be accurate so they could address and treat all their residents' needs. The ADM said if the MDS assessment was not accurate, there was a risk of the resident not receiving services or care they needed. The ADM said the MDS Coordinator was responsible for ensuring the MDS assessments were accurate. Record review of the facility's policy titled Resident Assessments dated revised March 2022 indicated . a comprehensive assessment of every resident's needs was made at intervals designated by OBRA and PPS requirements . the resident assessment coordinator was responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements . the RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments all persons who have completed any portion of the MDS resident assessment form sign the document attesting to the accuracy of such information . Record review of the Resident Assessment Instrument 3.0 User's Manual (RAI) last revised October 2024, revealed . the RAI process was the basis for the accurate assessment of each resident . the RAI process has multiple regulatory requirements . the assessment accurately reflects the resident's status . with an accurate RAI completed periodically, caregivers have a genuine and consistent recorded look at the resident and can attend to that resident's needs with realistic goals in hand .

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 24 hours after the allegation was made, for 2 of 11 residents (Resident's #20 and #38) reviewed for abuse on the male secured unit. The facility failed to report an allegation of resident-to-resident physical abuse on 05/27/25 to HHSC within 24 hours. This failure could place the residents at increased risk for abuse and neglect. The findings included: 1. Record review of the face sheet, dated 06/10/25, reflected Resident #20 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of unspecified convulsions (seizures), bipolar disorder (mental health condition that causes extreme mood swings), severe dementia with anxiety (memory loss), history of alcohol abuse with alcohol-induced dementia (memory loss), paranoid schizophrenia (characterized by intense paranoia and delusional thinking), and panic disorder (anxiety disorder characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress). Record review of the quarterly MDS assessment, dated 05/14/25, reflected Resident #20 had clear speech and was understood by others. Resident #20 was usually able to understand others. The MDS reflected Resident #20 had a BIMS score of 5, which indicated severe cognitive impairment. The MDS reflected Resident #20 had disorganized thinking that did not fluctuate. Resident #20 had delusions (misconceptions or beliefs that are firmly held, contrary to reality). No other behaviors were included on the MDS assessment. Record review of the comprehensive care plan, initiated on 05/27/25, reflected Resident #20 had episodes of verbal and physical aggression. Resident #20 grabbed another resident's ear on 05/27/25. The interventions included: Administer medication per orders, anticipate behaviors and redirect, notify doctor and family, ensure staff is aware of behaviors and successful interventions, maintain calm environment, psychiatric consult per orders, every 15 minute checks, separate residents, and monitor right wrist bruising until resolved. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #20 walked into the main dining area and pulled another resident's ear and he bit her on the right wrist. The immediate action taken included: residents were separated from each and redirected, assessed for injury, small area noted to right wrist, no break in skin, resident denies pain at this time. Injuries included: hematoma to right wrist. The incident report reflected Resident #20 did not like it when Resident #38 talks loudly, which is his normal due to hearing impairment. The incident report reflected the family, physician, and DON were notified of the incident. Record review of the skin assessment, dated 05/27/25, reflected Resident #20 had bruising to her right wrist. The area was small, but no measurements were indicated. 2. Record review of the face sheet, dated 06/10/25, reflected Resident #38 was an [AGE] year-old male who initially admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (brain condition that progressively damages memory, thinking, and learning skills). Record review of the quarterly MDS assessment, dated 05/18/25, reflected Resident #38 had clear speech and was usually understood by others. Resident #38 was sometimes able to understand others. The MDS reflected Resident #38 had a BIMS score of 1, which indicated severe cognitive impairment. Resident #1 had inattention that did not fluctuate. The MDS reflected Resident #38 had no behaviors or refusal of care during the look-back period. Record review of the comprehensive care plan, initiated 05/27/25, reflected Resident #38 had episodes of verbal and physical aggression. Resident #38 bit another resident. The interventions included: Administer medications per orders, anticipate behaviors and redirect, encourage to attend social activities, maintain calm environment, monitor and chart behaviors every shift and report to doctor as needed, provide psychiatric consult per orders, refer to social services as needed, resident immediately separated, refer to psychiatric services at next visit, and 15 minute monitoring. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #38 was in the dining room and another resident pulled his ear and Resident #38 responded by biting her on the right wrist. The immediate action taken included: Residents were separated from each other immediately and assessed for injury, none found. The incident report reflected the doctor, DON, and responsible party were notified of the incident. Record review of the skin assessment, dated 05/27/25, reflected Resident #38 had no injuries or skin concerns. During an interview on 06/10/25 beginning at 3:48 PM, the DON stated it was brought to her attention on 05/27/25 that Resident #20 and Resident #38 had a physical altercation. The DON stated it was reported that Resident #20 pulled Resident #38's ear, and he bit her in response. The DON stated the Administrator was on vacation during the incident, so it was reported to her regional compliance nurse. The DON stated the Regional Compliance Nurse instructed her the incident was not reportable to HHSC. The DON stated the facility recently switched corporations, and she knew with the previous company, the incident would have been reportable to the state. The DON stated she did not report the incident but investigated the incident and kept a soft file just in case. The DON stated she believed the incident should have been reported. The Regional Compliance Nurse's phone number was requested. The DON stated her phone recently messed up and she was unable to find the Regional Compliance Nurse's phone number. She stated she would ask around for the number. The number was not provided upon exit of the facility. During an interview on 06/11/25 beginning at 2:30 PM, the Administrator stated the allegation of resident-to-resident physical abuse between Resident #20 and Resident #38 should have been reported to HHSC. The Administrator stated she was on vacation when the incident happened, and the new company made the decision to not report the incident. The Administrator stated it was important to ensure all incidents of abuse were reported to HHSC to maintain resident safety, prevent recurring incidents, and to ensure all regulatory requirements were met. Record review of the Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy, revised April 2021, reflected . investigate and report any allegations within timeframes required by federal requirement .

Based on interview and record review the facility failed to ensure residents were free from abuse for 2 of 11 residents (Resident's #20 and #38) reviewed for resident abuse. The facility failed to ensure Resident #20, and Resident #38 were free from physical abuse, when Resident #20 pulled Resident #38's ear, and Resident #38 bit Resident #20 on the right wrist, on 05/27/25. The non-compliance was identified as past non-compliance. The noncompliance began on 05/27/25 and ended on 05/27/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: 1. Record review of the face sheet, dated 06/10/25, reflected Resident #20 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of unspecified convulsions (seizures), bipolar disorder (mental health condition that causes extreme mood swings), severe dementia with anxiety (memory loss), history of alcohol abuse with alcohol-induced dementia (memory loss), paranoid schizophrenia (characterized by intense paranoia and delusional thinking), and panic disorder (anxiety disorder characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress). Record review of the quarterly MDS assessment, dated 05/14/25, reflected Resident #20 had clear speech and was understood by others. Resident #20 was usually able to understand others. The MDS reflected Resident #20 had a BIMS score of 5, which indicated severe cognitive impairment. The MDS reflected Resident #20 had disorganized thinking that did not fluctuate. Resident #20 had delusions (misconceptions or beliefs that are firmly held, contrary to reality). No other behaviors were included on the MDS assessment. Record review of the comprehensive care plan, initiated on 05/27/25, reflected Resident #20 had episodes of verbal and physical aggression. Resident #20 grabbed another resident's ear on 05/27/25. The interventions included: Administer medication per orders, anticipate behaviors and redirect, notify doctor and family, ensure staff is aware of behaviors and successful interventions, maintain calm environment, psychiatric consult per orders, every 15 minute checks, separate residents, and monitor right wrist bruising until resolved. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #20 walked into the main dining area and pulled another resident's ear and he bit her on the right wrist. The immediate action taken included: residents were separated from each and redirected, assessed for injury, small area noted to right wrist, no break in skin, resident denies pain at this time. Injuries included: hematoma to right wrist. The incident report reflected Resident #20 did not like it when Resident #38 talks loudly, which is his normal due to hearing impairment. The incident report reflected the family, physician, and DON were notified of the incident. Record review of the skin assessment, dated 05/27/25, reflected Resident #20 had bruising to her right wrist. The area was small, but no measurements were indicated. 2. Record review of the face sheet, dated 06/10/25, reflected Resident #38 was an [AGE] year-old male who initially admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (brain condition that progressively damages memory, thinking, and learning skills). Record review of the quarterly MDS assessment, dated 05/18/25, reflected Resident #38 had clear speech and was usually understood by others. Resident #38 was sometimes able to understand others. The MDS reflected Resident #38 had a BIMS score of 1, which indicated severe cognitive impairment. Resident #1 had inattention that did not fluctuate. The MDS reflected Resident #38 had no behaviors or refusal of care during the look-back period. Record review of the comprehensive care plan, initiated 05/27/25, reflected Resident #38 had episodes of verbal and physical aggression. Resident #38 bit another resident. The interventions included: Administer medications per orders, anticipate behaviors and redirect, encourage to attend social activities, maintain calm environment, monitor and chart behaviors every shift and report to doctor as needed, provide psychiatric consult per orders, refer to social services as needed, resident immediately separated, refer to psychiatric services at next visit, and 15 minute monitoring. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #38 was in the dining room and another resident pulled his ear and Resident #38 responded by biting her on the right wrist. The immediate action taken included: Residents were separated from each other immediately and assessed for injury, none found. The incident report reflected the doctor, DON, and responsible party were notified of the incident. Record review of the skin assessment, dated 05/27/25, reflected Resident #38 had no injuries or skin concerns. During an interview on 06/09/25 beginning at 11:39 AM, CNA A stated Resident #20 and Resident #38 were constantly yelling, cursing, or hitting at each other. CNA A stated when Resident #20 and Resident #38 started acting out, she notified RN E. CNA A stated these behaviors happened almost every day. CNA A stated she kept the residents separated and redirected them when the behaviors started. CNA A stated on 05/27/25, Resident #20 walked up to Resident #38 and pulled his ear. CNA A stated Resident #38 turned his head and bit Resident #20 on the wrist. CNA A stated both residents were separated and placed on 15 minute checks. CNA A stated Resident #20 had a small bruise to her wrist, but no further injuries occurred. CNA A stated Resident #20 and Resident #38 had no changes in their behaviors related to the incident. During an interview on 06/09/25 beginning at 2:50 PM, the Psychiatric Consultant stated she visited with several residents on the secured unit every month. The Psychiatric Consultant stated Resident #38 and Resident #20 were visited. The Psychiatric Consultant stated Resident #38 talks loudly because he was hard of hearing. She said she had never had any behavioral issues with either resident, but the staff reports they were non-cooperative with cares. During an interview on 06/10/25 beginning at 3:37 PM, LVN D stated she was hired in December of 2024 and recently switched to part time status. LVN D stated she normally worked 2-10 shift on the secured unit. LVN D stated Resident #20 and Resident #38 did not hit each other regularly. LVN D stated there was an incident approximately a few weeks ago. LVN D stated Resident #20 pulled Resident #38's ear, and Resident #38 bit Resident #20. LVN D stated it was documented and 15 minute checks were initiated. LVN D stated when resident to resident altercations happened, the staff documented in the electronic charting system, notified the DON, family, and doctor, and placed it on the 24 hour report sheet for continued monitoring. LVN E stated they were trained to separate the residents, attempt to redirect them, and usually place them on 15 minute checks. LVN D stated it had not been reported that Resident #20 and Resident #38 had verbal or physical altercations daily. During an interview on 06/10/25 beginning at 3:48 PM, the DON stated it was brought to her attention on 05/27/25 that Resident #20 and Resident #38 had a physical altercation. The DON stated it was reported that Resident #20 pulled Resident #38's ear, and he bit her in response. The DON stated it had not been reported that verbal or physical behaviors happened daily between Resident #20 and Resident #38. The DON stated if physical or verbal behaviors happened, she expected it to be reported. The DON stated on 05/27/25, Resident #20 and Resident #38 were separated immediately and placed on 15 minute checks. She stated they were assessed, and Resident #20 had a small bruise to her right wrist. The DON stated in-service education was provided to the staff to include abuse and neglect, and resident to resident altercations. The DON stated the Administrator was on vacation during the incident, so it was reported to her regional compliance nurse. The DON stated the family, doctor, and herself were notified after the incident. The DON stated no further incident has occurred. During an interview on 06/11/25 beginning at 7:14 AM, RN E stated it had not been reported Resident #20 and Resident #38 had verbal or physical altercations daily. RN E stated approximately a few weeks ago, Resident #20 pulled Resident #38's ear and Resident #38 bit her. RN E stated both residents were immediately separated and placed on 15 minute checks. RN E stated Resident #20 was aggressive and was moved off the female secured unit because she was hitting the other female residents. RN E stated staff were to ensure the residents were supervised and redirected as needed. RN E stated when resident to resident altercations happened, the staff documented in the electronic charting system, notified the DON, family, and doctor, and placed it on the 24 hour report sheet for continued monitoring. LVN E stated they were trained to separate the residents, attempt to redirect them, and usually place them on 15 minute checks. RN E stated no further incidents have occurred since 05/27/25. Record review of the Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy, revised April 2021, reflected residents have the right to be free from abuse .this includes but is not limited to freedom from . physical abuse . protect residents from abuse . by anyone including . other residents . Record review of the Resident-to-Resident Altercations policy, revised September 2022, reflected All altercations, including resident to resident abuse, are investigated and reported to DON and Administrator .if two residents are involved in an altercations, staff: separate the residents, and institute measure to calm the situation, identified what happened, notify family, doctor, and facility management, make any changes to care plan, document in the record, complete an incident report, consult with psychiatric services The facility had corrected the non-compliance on 05/27/25 by the following: 1. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #20 walked into the main dining area and pulled another resident's ear and he bit her on the right wrist. The immediate action taken included: residents were separated from each and redirected, assessed for injury, small area noted to right wrist, no break in skin, resident denies pain at this time. Injuries included: hematoma to right wrist. The incident report reflected Resident #20 did not like it when Resident #38 talks loudly, which is his normal due to hearing impairment. The incident report reflected the family, physician, and DON were notified of the incident. 2. Record review of the skin assessment, dated 05/27/25, reflected Resident #20 had bruising to her right wrist. The area was small, but no measurements were indicated. 3. Record review of the physical aggression incident report, dated 05/27/25, reflected Resident #38 was in the dining room and another resident pulled his ear and Resident #38 responded by biting her on the right wrist. The immediate action taken included: Residents were separated from each other immediately and assessed for injury, none found. The incident report reflected the doctor, DON, and responsible party were notified of the incident. 4. Record review of the skin assessment, dated 05/27/25, reflected Resident #38 had no injuries or skin concerns. 5. Record review of the 15 Minute Checks Sheet, dated 05/27/25, 05/28/25, and 05/29/25 reflected 15 minute checks were completed for Resident #20 and Resident #38. 6. Record review of the comprehensive care plan, initiated on 05/27/25, reflected Resident #20 grabbed another resident's ear on 05/27/25. The interventions included: . every 15 minute checks, separate residents, psychiatric referral, and monitor right wrist bruising until resolved. 7. Record review of the comprehensive care plan, initiated 05/27/25, reflected Resident #38 bit another resident. The interventions included: . resident immediately separated, refer to psychiatric services at next visit, and 15 minute monitoring. 8. Record review of the abuse and neglect in-service training, dated 05/27/25, reflected staff was provided education. There were approximately 34 staff signatures. 9. Record review of the resident to resident altercation in-service training, dated 05/27/25, reflected staff was provided education. There were approximately 34 staff signatures. 10. During interviews between 06/09/25 at 11:39 AM and 06/11/25 at 1:49 PM, Housekeeper R, CNA A, CNA B, CNA C, CNA F, CNA H, CNA S, MA Q, LVN D, LVN J, RN E, the Maintenance Supervisor, and the Housekeeping Supervisor (different shifts who worked in the secured unit) were able to verbalize the different types of abuse, when to report abuse, and the abuse coordinator. The staff were able to outline the policy and procedure for resident to resident altercations including separating the residents and notifying the abuse coordinator. The noncompliance was identified as PNC. The noncompliance began on 05/27/25 and ended on 05/27/25. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review, the facility failed to consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 15 residents (Resident #39) reviewed for quality of care. The facility failed to notify the NP/MD of Resident #39's swallowing difficulties observed on 6/9/25 and 6/10/25. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. Findings included: Record review of Resident #39's face sheet dated 6/9/25 indicated Resident #39 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #39 had diagnoses including muscle weakness, age related physical debility (physical weakness, especially as a result of illness), history of falls, repeated falls, and malignant neoplasm (is an abnormal growth of cells that invades and can spread to other parts of the body) of left lung and brain. Record review of Resident #39's annual MDS assessment dated [DATE] indicated Resident #39 was sometimes understood and usually had the ability to understand others. Resident #39 had adequate hearing and vision and unclear speech. Resident #39 was rarely/never understood, and a BIMS score was not able to be assessed. Resident #39 had short-and-long term memory recall issues. Resident #39 had moderately impaired cognitive skills for daily decision making. Resident #39 used a wheelchair. Resident #39 required partial assistance for shower/bathe self, dressing, personal hygiene, and supervision for toileting hygiene and eating. The MDS did not reflect a swallowing disorder. The MDS did not reflect a mechanically altered diet. Record review of Resident #39's care plan dated 4/28/25 indicated Resident #39 received hospice services from a local hospice company related to terminal disease process: malignant neoplasm of left lung. Intervention included notify hospice nurse and MD for any decline in resident's condition. Record review of Resident #39's care plan dated 5/8/25 indicated: *Resident #39 had impaired nutrition related to terminal disease of lung cancer with metastasis and at risk for weight loss and may be unavoidable. Interventions included ensure resident is in proper position for eating, evaluate resident's physical ability to eat, and eat meals in a monitored environment. *Resident #39's nutritional status regular diet, regular texture, thin liquids. Interventions include determine resident's ability to chew and swallow and modify diet as appropriate according to resident's food tolerance and preference. During an observation on 6/9/25 starting at 11:57 a.m., Resident #39 was sitting in a wheelchair with a cup of water in her hand. Resident #39 brought the cup of water to her mouth and as she tipped the cup, a lot of the water did not make it to her mouth. When Resident #39 swallowed some of water she started coughing. A nursing staff member handed Resident #39 some medication, unable to determine if it was pill or liquid form, and Resident #39 started coughing. The staff member asked CNA A what was going on. CNA A said she noticed Resident #39 did the same thing at breakfast but did not think anything of it. The nursing staff member instructed CNA A to notify RN E. RN E came to the dining room and told CNA A she would observe her at lunch. During an observation on 6/9/25 at 12:06 p.m., Resident #39 was sitting at the dining room table with her meal tray. Resident #39 had a regular tray with thin liquids. RN E sat bedside Resident #39 and observed her take a few bites of food. Resident #39 struggled to feed herself and used her fingers to eat. RN E told CNAs she would get Resident #39's meat changed to chopped meats. RN E observed Resident #39 drink one swallow of thin liquids and Resident #39 did not cough or choke. RN E stopped observing Resident #39 and left the dining room. Toward the end of Resident #39's lunch meal, she drank some more liquid and coughed. During an interview on 6/10/25 at 4:09 p.m., CNA O said on some days Resident #39 drank good and other days she spurted. She said she worked 4 days on and 2 off. She said in the four shifts she worked. Resident #39 spurted when drinking. She said she had not reported to the nurse Resident #39 sometimes spurted when drink thin liquids. She said it was important to report swallowing problems to the nurse because the resident could be aspirating. She said if a resident was aspirating and it was not addressed, they could develop pneumonia. During an interview on 6/10/25 at 4:30 p.m., CNA B said she noticed Resident #39 was spurting when she drank thin liquids. She said she reported in LVN D last week. She said last week Resident #39 drank something and then coughed the liquid on to her clothes. She said before the incident happened to her, other staff had warned her Resident #39 did that sometimes. She said coughing, choking, or spurting with thin liquids could indicate Resident #39 was aspirating. She said if the swallowing problem was not addressed Resident #39 could choke and get pneumonia. She said the nurses were the only staff members that could document swallowing problems in the resident's chart. She said CNAs should report the spurting to the nurses immediately. During an interview on 6/10/25 at 11:42 a.m., RN E said staff members had reported to her on Monday (6/9/25) that Resident #39 had choked of liquid. She said she observed Resident #39 drink and Resident #39 did not choke. She said Resident #39 functioning ability had recently declined. She said Resident #39 could feed herself but now needs assistance or used her fingers. She said if Resident #39 choked after she left on Monday (6/9/25), then CNAs should have told her. She said she did not know about other reported events of Resident #39 spurting with liquids. She said she expected the CNAs to tell her those types of things. She said if a nurse observed Resident #39 choking or coughing with food or liquids they should report it to hospice. She said hospice would possibly order a speech evaluation. She said coughing or choking while drinking or eating could indicate aspiration. She said if the swallowing problem was not reported or addressed, it placed the resident at risk for hospitalization. During an interview on 6/11/25 at 12:46 p.m., CNA L said she told RN E, Resident #39 was spilling liquid when she drank. She said she thought Resident #39 may need a swallow test or sippy cup to control the flow. She said coughing or choking on food or liquid could indicate a swallowing problem. She said RN E was supposed to change Resident #39's meat to chopped so she could pick it better. She said Resident #39's functional ability was declining. She said CNAs should report to the nurse immediately when they noticed swallow issues. During an interview on 6/11/25 at 1:52 p.m., LVN D said the last time she worked with Resident #39 was on Monday (6/9/25), the evening shift. She said no CNAs had reported to her that Resident #39 was coughing with thin liquids. She said Resident #39's health was declining. She said Resident #39 was having more falls and declining in her feeding ability. She said CNAs should have reported to her immediately if Resident #39 was coughing while drinking. She said it could indicate aspiration. She said Resident #39 needed a speech evaluation and possible diet change. She said untreated aspiration could lead to pneumonia. During an interview on 6/11/25 at 2:35 p.m., the DON said, the CNAs should notify the nurses if a resident had swallowing issues. She said the charge nurse should notify the NP or MD. She said Resident #39 could need a speech evaluation. She said coughing or spurting on food or liquid could indicate dysphagia (difficulty swallowing food or liquids). She said if the dysphagia was not addressed then the resident could aspirate or affect the resident's eating. During an interview on 6/11/25 at 3:35 p.m., the ADM said the CNAs should immediately report to the charge nurse any swallowing issues observed. She said the charge nurse should notify the NP/MD. She said she also expected the charge nurse to fully assess the resident's swallowing issues. She said Resident #39 needed a speech evaluation. She said Resident #39 could be aspirating. She said if left untreated, the resident could require hospitalization or develop pneumonia. During an interview on 6/12/25 at 1:08 p.m., Hospice RN X said she saw Resident #39 weekly. She said she was seeing Resident #39 today (6/12/25). She said Resident #39 had recently started requiring assistance with meals. She said she had not been notified of Resident #39's difficulty swallowing. She said she was okay with the facility monitoring the issues until her visit today. She said hospice needed to be notified of new issues, decline, and med changes. She said hospice would want to know if Resident #39 was having difficulty swallowing. She said hospice would possibly get an order for thickened liquid. She said she knew the facility was changing her meat to chopped for smaller pieces. She said Resident #39 had a primary care physician but they really worked with NP Y. During an interview on 6/12/25 at 1:31 p.m., NP Y said she could not answer questions about Resident #39 because she did not know my identity. She said she could answer general practitioner questions. She said if a resident was displaying dysphagia (difficulty swallowing) or mastication (is the process of chewing food, the mechanical breakdown of food in the mouth using teeth) issues, she expected the nurse to assess the resident. She said the nurse should auscultate the resident's lungs and watch the resident eat or drink. She said if the resident coughed or choked one time, the facility may not notify her. She said if the dysphagia or mastication issue continued, it could be a sign of a change of condition and should be notified immediately. She said she would need more information to determine if it was a change of condition. She said she would order a chest x-ray, speech consult, diet change, and change liquid consistency to nectar or honey until the speech consult was done. She said if the dysphagia or mastication was not treated it could lead to dehydration and aspiration. She said it could also indicate a urinary tract infection (is an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra). She said reporting to the NP/MD prevented further decline and to know what was going on. Record review of a facility's Guidelines for Notifying Physicians of Clinical Problems policy revised 04/2007 indicated, .to help ensure that .medical care problems are communicated to the medical staff in a timely, efficient and effective manner .all significant changes in resident status are assessed and documented in the medical record .the charge nurse or supervisor should contact the Attending Physician at any time if they feel a clinical situation requires immediate discussion and management .non-immediate notification situations .the following types of problems should be reported to the Physician, but not necessarily immediately .in general .any substantial change in physical condition or functional status that does not require immediate notification should be addressed with the Physician .decline in function .

Based on interview and record review the facility failed to follow the menu for a resident on mechanical soft diet for 1 of 7 (Resident #1) residents reviewed for therapeutic diets. The facility did not ensure Resident #1 was provided the proper therapeutic diet during an activity which resulted in him choking, having CPR performed, being sent to the hospital, and his death. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 4:25 p.m. on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of choking or death. Findings include: 1. Record review of the consolidated physician orders dated [DATE] indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including profound intellectual disabilities, autism, muscle weakness, and anxiety disorder. The physician orders indicated Resident #1 had a therapeutic diet order of mechanical soft foods with thin liquids starting [DATE]. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 was rarely understood and sometimes understood others. The MDS indicated did not have a BIMS score documented for Resident #1. MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required eating. The MDS indicated Resident #1 required a change in diet texture of food. Record review of the care plan revised on [DATE] indicated Resident #1 experienced a self-care deficit related to autism with interventions including he required supervision with eating. The care plan indicated Resident #1 had a diet order on [DATE] for mechanical soft texture. Record review of Resident #1's nursing progress note dated [DATE] at 2:53 p.m. indicated, Resident was observed walking up the hallway with the AD with noted bleeding from the mouth. The nurse assessed the resident's mouth and began to clean the area with gauze when resident decided to sit on the floor. Resident then proceeded to begin wheezing when the nurse began to assess current vital signs. Resident became unresponsive. The nurse promptly notified the DON and began CPR .2:23 p.m. other personnel notified EMS for transport. 2:27 p.m. resident noted blood-tinged sputum and suction started. 2:30 p.m. EMS arrived and took over CPR .2:46 p.m. EMS departed from facility transporting resident to ER. Record review of Resident #1's nursing progress note dated [DATE] at 3:45 p.m. indicated, At approximately 2:20 p.m. resident was noted sitting on floor against wall-unresponsive-immediately checked airway with small amount of blood noted. Pulse non palpable. CPR immediately started with crash cart and AED being retrieved by staff. After round of compressions pulse palpable and resident noted to move eyes and gargle. Resident then suctioned and Heimlich maneuver began with intermittent suctioning and oxygen given .During Heimlich maneuver resident was being checked for pulse by other nurse on duty. Pulse continued to be palpable but very faint. Heimlich maneuver continued until EMS arrived . Record review of Resident #1's hospital record dated [DATE] indicated, .Upon arrival patient was found to have a large meatball in his oropharynx (the part of the throat at the back of the mouth behind the oral cavity) occluding the airway. This was removed and patient was intubated without any further difficulty. Patient receive approximately 30 minutes of CPR in the emergency department . Record review of Resident #1's hospital records dated [DATE] at 8:31 p.m. indicated the resident had expired. Record review of the facility's Diet Summary dated 2017 indicated, Mechanical Soft Diet: This consistency modified diet is for individuals with limited or difficulty in chewing regular texture foods .Foods should be moist and fork tender. Meat is ground or chopped into bite-size pieces and should be mixed or served with gravy, broth, or another type of moistening agent . During an interview on [DATE] at 11:30 a.m. the AD said the facility had a Super Bowl party hosted by hospice on [DATE]. The AD said Resident #1 attended the activity. The AD said the Hospice Volunteer passed out food to the residents while she passed out drinks. The AD said Resident #1 got up and was redirected by AD. The AD said Resident #1 continued to get up and be redirected by AD. The AD said after several times of getting up AD took Resident #1 back towards to his room. The AD said in the hallway Resident #1 tried to sit down on the floor. The AD said she would think meatballs were mechanical soft. The AD said she was unaware of Resident #1's diet changing. The AD said Resident #1 had attended events in the past and had not had any diet restrictions last year. The AD said the was the Hospice Volunteer would know what a resident's diet was by AD telling her. The AD said she pretty much knows what diet everyone is on. The AD said she did not know Resident #1's diet had changed or she would have given him a chopped or mashed up meatball. The AD said she has a dietary list to tell what diet residents are on. The AD said she received a dietary summary for the DON on [DATE]. The AD said she received a dietary summary on [DATE]. The AD said she had not received a dietary summary since [DATE]. Record review on [DATE] at 11:40 a.m. the AD gave the surveyor the copy of the most recent dietary summary she had received of the resident's diet orders. The dry summary the AD provided was dated [DATE]. During an interview on [DATE] at 11:47 a.m. the DON said she had worked at the facility since [DATE]. The DON said during an activity with food served a nurse should be present to ensure residents were getting the proper diet. The DON said during the event on [DATE] the AD and Hospice Volunteer were all that were present with the residents. The DON said to her knowledge a facility nurse was not present during the event and a nurse should have been present. The DON said on [DATE] she was returning from lunch when she heard the MA call her. The DON said she saw Resident #1 was leaned up against the wall sitting in the floor, unresponsive. The DON said she and another nurse started CPR. The DON said she looked in Resident #1's mouth and did not see anything his mouth. The DON said when Resident #1 started gurgling and had a faint pulse then the Heimlich maneuver was performed. The DON said depending on the way a meatball is cooked depended on whether it is considered mechanical soft. The DON said she was unaware whether the meatballs served on the day of the event were mechanical soft. The DON said she has in-serviced the AD on having a nurse present during events with food. The DON said she put out dietary binders out for the staff. The DON said all the dietary binders were looked at daily by her and updated via handwriting. The DON said updated printed sheets were put in the dietary binders weekly. The DON said if she was out of the facility it would be the ADON's responsibility to update the dietary binders. During an interview on [DATE] at 1:49 p.m. the Hospice Volunteer said she hosted a Superbowl party at the facility on [DATE]. The Hospice Volunteer said she served meatballs with BBQ sauce, M&Ms, Pretzels, Tortilla Chips, and Queso at the party. The Hospice Volunteer she plated the food and put it on the table for the residents. The Hospice Volunteer said she was not informed that any residents were on specialized diets. The Hospice Volunteer said she and the AD were the only two people at the event other than the residents in the activity area. The Hospice Volunteer said she put a plate of food in front of Resident #1 with meatballs, M&M's, pretzels, tortilla chips, and queso on it. The Hospice Volunteer said she was unsure of what foods Resident #1 had eaten off his plate because she did not personally see him put anything in his mouth. The Hospice Volunteer said she had put 3 meatballs on Resident #1's plate and after the incident there were only 2 meatballs on the plate. Record review of the facility's Resident Nutrition Services policy dated [DATE] indicated, .Nursing personnel will ensure that residents are served the correct food tray . Record review of the facility's Therapeutic Diets policy dated ,d+[DATE] indicated, .Snacks will be compatible with the therapeutic diet . Record review of the facility's Foods Brought by Family/Visitors policy dated [DATE] indicated, .Staff must be aware of and approve food(s) brought to resident by family/visitors .The Dietician or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan .Foods that present a potential choking hazard for residents with impaired cognitive function or swallowing difficulty will be taken from the resident and returned to the family member or visitor . The Administrator was notified on [DATE] at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 4:45 p.m. The facility's Plan of Removal was accepted on [DATE] at 2:20 p.m. and included: Immediate actions The Medical Director was notified by the Director of Nursing on [DATE] at 6:00pm. Diet orders printed and placed in a binder for use during meal service, including during special events. Weekly, prn or as the order changes. New orders are reviewed in the daily care meeting. Orders are placed daily in binders and as needed any updates will be flagged by colored tabs to alert staff of any changes. Outside foods from visitors and vendors will be monitored by nursing staff before served. Education (provided by DON or ADON) All staff were in-serviced on ensuring proper diet consistencies / textures are served, including monitoring for compliance with diet orders during special events. Nurse will ensure the proper diet consistency is served. Nursing staff will monitor activities during activities when food is served. Inservice's will be completed by [[DATE] at 10:00 PM]. Staff will not be allowed to return to shift without this in-service. This in-service was completed by the Director of Nursing and Administrator. Dietitian will monitor diets monthly for accuracy. Staff will be in serviced on how to identify any diet changes completed by [DATE] at 10:00pm All staff were in-serviced on Cardiopulmonary Resuscitation including the Heimlich maneuver and use of the AED, this Inservice includes emphasis on early signs of chocking. This in-service will be completed by [[DATE] at 10:00 PM]. Staff will not be allowed to return to shift without this in-service. This in-service was completed by the Director of Nursing. All staff were in-serviced Abuse and Neglect to include prevention, screening, identification, training, and protection reporting/responding and investigation. This in-service will be completed by [[DATE] at 10:00 PM]. Staff will not be allowed to return to shift without this in-service. This in-service was completed by the Director of Nursing. Staff in serviced on how to identify any diet changes completed by [DATE] at 10:00pm QAPI Committee Review - An interim QAPI committee meeting was completed on ,d+[DATE]. 6:00 On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the Dietary Binders dated [DATE] indicated all resident's diet orders were up to date and residents with specialized diets were highlighted to alert staff of the difference in the diet. Interviews of staff (the DON, 1-DOR, 1-COTA, 1-Medical Records Personnel, 3-CNAs 6:00 a.m.-2:00 p.m. shift, 2-nurses 6:00 a.m.-2:00 p.m. shift, 1-MA, 1-ADON, 1-Treatment Nurse, 1-CNA 2:00 p.m.-10:00 p.m. shift, 1-Housekeeper, 1-Laundy Personnel, 1-AD, 1-DM, 2-Dietary Aides, 1-Business Office Manager, 1-Floor Tech, 2-CNAs 10:00 p.m.-6:00 a.m. shift, 2-Nurses 10:00 p.m.-6:00 a.m. shift, 2-Nurses Double Weekend Shift ) were performed. During these interviews staff were able to correctly identify where to find the appropriate diet orders for residents, signs, and symptoms of choking how to perform the Heimlich maneuver and CPR, and abuse and neglect prevention, screening, identification, training, and protection reporting/responding and investigation. Record review of the QAPI committee review indicated a QAPI meeting was held on [DATE] regarding the above failure. On [DATE] at 12:07 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 3 of 7 (Resident #1) residents reviewed for quality of care. 1. The facility did not ensure Resident #1 was provided the proper therapeutic diet during an activity which resulted in him choking, having CPR performed, being sent to the hospital, and his death. 2. The facility failed to keep the dietary binders up to date with the resident's diet orders putting residents at risk for choking. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 4:25 p.m. on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm or death related to receiving the wrong therapeutic diet resulting in choking and/or death. Findings include: 1. Record review of the consolidated physician orders dated [DATE] indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including profound intellectual disabilities, autism, muscle weakness, and anxiety disorder. The physician orders indicated Resident #1 had a therapeutic diet order of mechanical soft foods with thin liquids starting [DATE]. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 was rarely understood and sometimes understood others. The MDS indicated did not have a BIMS score documented for Resident #1. MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required eating. The MDS indicated Resident #1 required a change in diet texture of food. Record review of the care plan revised on [DATE] indicated Resident #1 experienced a self-care deficit related to autism with interventions including he required supervision with eating. The care plan indicated Resident #1 had a diet order on [DATE] for mechanical soft texture. Record review of Resident #1's nursing progress note dated [DATE] at 2:53 p.m. indicated, Resident was observed walking up the hallway with the AD with noted bleeding from the mouth. The nurse assessed the resident's mouth and began to clean the area with gauze when resident decided to sit on the floor. Resident then proceeded to begin wheezing when the nurse began to assess current vital signs. Resident became unresponsive. The nurse promptly notified the DON and began CPR .2:23 p.m. other personnel notified EMS for transport. 2:27 p.m. resident noted blood-tinged sputum and suction started. 2:30 p.m. EMS arrived and took over CPR .2:46 p.m. EMS departed from facility transporting resident to ER. Record review of Resident #1's nursing progress note dated [DATE] at 3:45 p.m. indicated, At approximately 2:20 p.m. resident was noted sitting on floor against wall-unresponsive-immediately checked airway with small amount of blood noted. Pulse non palpable. CPR immediately started with crash cart and AED being retrieved by staff. After round of compressions pulse palpable and resident noted to move eyes and gargle. Resident then suctioned and Heimlich maneuver began with intermittent suctioning and oxygen given .During Heimlich maneuver resident was being checked for pulse by other nurse on duty. Pulse continued to be palpable but very faint. Heimlich maneuver continued until EMS arrived . Record review of Resident #1's hospital record dated [DATE] indicated, .Upon arrival patient was found to have a large meatball in his oropharynx (the part of the throat at the back of the mouth behind the oral cavity) occluding the airway. This was removed and patient was intubated without any further difficulty. Patient receive approximately 30 minutes of CPR in the emergency department . Record review of Resident #1's hospital records dated [DATE] at 8:31 p.m. indicated the resident had expired. Record review of the facility's Diet Summary dated 2017 indicated, Mechanical Soft Diet: This consistency modified diet is for individuals with limited or difficulty in chewing regular texture foods .Foods should be moist and fork tender. Meat is ground or chopped into bite-size pieces and should be mixed or served with gravy, broth, or another type of moistening agent . During an interview on [DATE] at 11:30 a.m. the AD said the facility had a Super Bowl party hosted by hospice on [DATE]. The AD said Resident #1 attended the activity. The AD said the Hospice Volunteer passed out food to the residents while she passed out drinks. The AD said Resident #1 got up and was redirected by AD. The AD said Resident #1 continued to get up and be redirected by AD. The AD said after several times of getting up AD took Resident #1 back towards to his room. The AD said in the hallway Resident #1 tried to sit down on the floor. The AD said she would think meatballs were mechanical soft. The AD said she was unaware of Resident #1's diet changing. The AD said Resident #1 had attended events in the past and had not had any diet restrictions last year. The AD said the was the Hospice Volunteer would know what a resident's diet was by AD telling her. The AD said she pretty much knows what diet everyone is on. The AD said she did not know Resident #1's diet had changed or she would have given him a chopped or mashed up meatball. During an interview on [DATE] at 11:47 a.m. the DON said she had worked at the facility since [DATE]. The DON said during an activity with food served a nurse should be present to ensure residents were getting the proper diet. The DON said during the event on [DATE] the AD and Hospice Volunteer were all that were present with the residents. The DON said to her knowledge a facility nurse was not present during the event and a nurse should have been present. The DON said on [DATE] she was returning from lunch when she heard the MA call her. The DON said she saw Resident #1 was leaned up against the wall sitting in the floor, unresponsive. The DON said she and another nurse started CPR. The DON said she looked in Resident #1's mouth and did not see anything his mouth. The DON said when Resident #1 started gurgling and had a faint pulse then the Heimlich maneuver was performed. The DON said depending on the way a meatball is cooked depended on whether it is considered mechanical soft. The DON said she was unaware whether the meatballs served on the day of the event were mechanical soft. The DON said she has in-serviced the AD on having a nurse present during events with food. During an interview on [DATE] at 1:49 p.m. the Hospice Volunteer said she hosted a Superbowl party at the facility on [DATE]. The Hospice Volunteer said she served meatballs with BBQ sauce, M&Ms, Pretzels, Tortilla Chips, and Queso at the party. The Hospice Volunteer she plated the food and put it on the table for the residents. The Hospice Volunteer said she was not informed that any residents were on specialized diets. The Hospice Volunteer said she and the AD were the only two people at the event other than the residents in the activity area. The Hospice Volunteer said she put a plate of food in front of Resident #1 with meatballs, M&M's, pretzels, tortilla chips, and queso on it. The Hospice Volunteer said she was unsure of what foods Resident #1 had eaten off his plate because she did not personally see him put anything in his mouth. The Hospice Volunteer said she had put 3 meatballs on Resident #1's plate and after the incident there were only 2 meatballs on the plate. 2. Record review of the Dietary Binders on [DATE] indicated the Dietary Binders had last been updated on [DATE]. The Dietary Binder indicated Resident #2's diet order was for pureed food with thin liquids starting [DATE]. The Dietary Binder indicated Resident #3's diet order was for mechanical soft food with thin liquids, no solids with hard casings larger than bite size (Grapes, Peas, Diced Fruits) starting [DATE]. Record review of the Diet Order Report dated [DATE] indicated Resident #2 had a diet order for pureed foods and nectar thickened liquids with meals starting [DATE]. The Diet Order Report indicated Resident #3 had a diet order for mechanical soft food with thin liquids, no solids with hard casings larger than bite size (Grapes, Peas, Diced Fruits) with pureed desserts starting [DATE]. During an interview on [DATE] at 11:30 a.m. the AD said she has a dietary list to tell what diet residents are on. The AD said she received a dietary summary for the DON on [DATE]. The AD said she received a dietary summary on [DATE]. The AD said she had not received a dietary summary since [DATE]. Record review on [DATE] at 11:40 a.m. the AD gave the surveyor the copy of the most recent dietary summary she had received of the resident's diet orders. The dietary summary the AD provided was dated [DATE]. During an interview on [DATE] at 11:47 a.m. the DON said she put out dietary binders out for the staff. The DON said all the dietary binders were looked at daily by her and updated via handwriting. The DON said updated printed sheets were put in the dietary binders weekly. The DON said if she was out of the facility it would be the ADON's responsibility to update the dietary binders. Record review of the facility's Resident Nutrition Services policy dated [DATE] indicated, .Nursing personnel will ensure that residents are served the correct food tray . Record review of the facility's Therapeutic Diets policy dated ,d+[DATE] indicated, .Snacks will be compatible with the therapeutic diet . Record review of the facility's Foods Brought by Family/Visitors policy dated [DATE] indicated, .Staff must be aware of and approve food(s) brought to resident by family/visitors .The Dietician or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan .Foods that present a potential choking hazard for residents with impaired cognitive function or swallowing difficulty will be taken from the resident and returned to the family member or visitor . The Administrator was notified on [DATE] at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 4:45 p.m. The facility's Plan of Removal was accepted on [DATE] at 2:20 p.m. and included: Immediate actions The Medical Director was notified by the Director of Nursing on [DATE] at 6:00pm. Diet orders printed and placed in a binder for use during meal service, including during special events. Weekly, prn or as the order changes. New orders are reviewed in the daily care meeting. Orders are placed daily in binders and as needed any updates will be flagged by colored tabs to alert staff of any changes. Outside foods from visitors and vendors will be monitored by nursing staff before served. Education (provided by DON or ADON) All staff were in-serviced on ensuring proper diet consistencies / textures are served, including monitoring for compliance with diet orders during special events. Nurse will ensure the proper diet consistency is served. Nursing staff will monitor activities during activities when food is served. Inservice's will be completed by [[DATE] at 10:00 PM]. Staff will not be allowed to return to shift without this in-service. This in-service was completed by the Director of Nursing and Administrator. Dietitian will monitor diets monthly for accuracy. Staff will be in serviced on how to identify any diet changes completed by [DATE] at 10:00pm All staff were in-serviced on Cardiopulmonary Resuscitation including the Heimlich maneuver and use of the AED, this Inservice includes emphasis on early signs of chocking. This in-service will be completed by [[DATE] at 10:00 PM]. Staff will not be allowed to return to shift without this in-service. This in-service was completed by the Director of Nursing. All staff were in-serviced Abuse and Neglect to include prevention, screening, identification, training, and protection reporting/responding and investigation. This in-service will be completed by [[DATE] at 10:00 PM]. Staff will not be allowed to return to shift without this in-service. This in-service was completed by the Director of Nursing. Staff in serviced on how to identify any diet changes completed by [DATE] at 10:00pm QAPI Committee Review - An interim QAPI committee meeting was completed on ,d+[DATE]. 6:00 On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the Dietary Binders dated [DATE] indicated all resident's diet orders were up to date and residents with specialized diets were highlighted to alert staff of the difference in the diet. Interviews of staff (the DON, 1-DOR, 1-COTA, 1-Medical Records Personnel, 3-CNAs 6:00 a.m.-2:00 p.m. shift, 2-nurses 6:00 a.m.-2:00 p.m. shift, 1-MA, 1-ADON, 1-Treatment Nurse, 1-CNA 2:00 p.m.-10:00 p.m. shift, 1-Housekeeper, 1-Laundy Personnel, 1-AD, 1-DM, 2-Dietary Aides, 1-Business Office Manager, 1-Floor Tech, 2-CNAs 10:00 p.m.-6:00 a.m. shift, 2-Nurses 10:00 p.m.-6:00 a.m. shift, 2-Nurses Double Weekend Shift ) were performed. During these interviews staff were able to correctly identify where to find the appropriate diet orders for residents, signs, and symptoms of choking how to perform the Heimlich maneuver and CPR, and abuse and neglect prevention, screening, identification, training, and protection reporting/responding and investigation. Record review of the QAPI committee review indicated a QAPI meeting was held on [DATE] regarding the above failure. On [DATE] at 12:07 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Residents #1 and #2) reviewed for adequate supervision. 1. The facility failed to ensure Resident #1, who was a resident on the secured unit, did not elope from the facility in her wheelchair. 2. The facility failed to implement interventions for Resident #1 after elopement, to prevent reoccurrence. 3. The facility failed to implement measures to prevent elopement of other residents on the secured unit. 4. The facility failed to ensure Resident #2, who was a resident on the secured unit, did not elope from facility's courtyard. 5. The facility failed to identify and in-service staff on the root cause of elopements. An Immediate Jeopardy (IJ) situation was identified on 12/08/22 at 9:20 a.m. While the IJ was removed on 12/08/22 at 2:21 p.m., the facility remained out of compliance at a scope of an isolated with the potential for more than minimal harm, due to the facility's need evaluate the effectiveness of the corrective systems. These failures could place residents at risk for possible elopement, serious injuries, harm and death. Findings include: Record review of Resident #1's face sheet, dated 12/06/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, bipolar type (s a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder. Symptoms may include delusions, hallucinations, depressed episodes, and manic periods of high energy), age-related physical debility (frail), muscle weakness, anxiety (intense, excessive, and persistent worry and fear about everyday situations), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), current episodes hypomanic (milder version of mania; periods of over-active and excited behavior), recurrent depressive disorder (a persistent feeling of sadness and loss of interest), and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). The face sheet revealed Resident #1 was a current everyday smoker. Record review of Resident #1's consolidated physician orders, dated 07/01/22-07/31/22, revealed the resident continued to wander this shift, every shift 06:00 a.m.-02:00 p.m., Evening shift 02:00 p.m.-10:00 p.m. Night shift 10:00 p.m.-06:00 a.m. with start date of 11/12/21. Record review of Resident #1's care plan, with problem start date of 09/22/21, revealed the resident currently used tobacco. Intervention with date of 12/17/21 revealed provide supervision when smoking. Record review of Resident #1's care plan, with problem start date of 10/24/21, revealed behavioral symptoms of confusion, delusion, and hallucination related schizophrenia. Resident #1 had a potential for wandering and elopement and resided on the secured unit. The care plan revealed, on 03/02/22, the resident threw herself on floor, 05/12/22 refused medication, meals, ADL assist, shower, change clothes, and to come inside the building (05/16/22 refer to mental hospital for inpatient or long-term care), and 07/24/22 elopement. Intervention, with date of 12/17/21, revealed wander assessment every quarter and as needed, re-direct when exit seeking, encourage resident to become involved with preferred activities (she loves to go outside and smoke), determine resident's ability to relate to others and provide social opportunities based on resident ability. Intervention, with date of 07/25/22, revealed placed in memory care unit, resident under close observation. All activities were supervised, check status of mental hospital transfer, licensed psychologist to visit, and monitor for further behaviors. Intervention, with date of 07/25/22, revealed Resident #1 would be supervised for all smoking, would stay on the secured unit for all meals and activities. Record review of the annual MDS, dated [DATE], revealed Resident #1 was understood and understood others. Resident #1 had adequate hearing, clear speech, and adequate vision. Resident #1 had a BIMS of 07, which indicated severe cognitive impairment. Resident #1 had wandering behaviors that occurred daily. Resident #1 was independent for bed mobility, transfer, toilet use, and bathing, required supervision for dressing and eating, and limited assistance for personal hygiene, and locomotion on/off unit. Resident #1 used a wheelchair for mobility. Resident #1 was a current tobacco user. Record review of the quarterly MDS, dated [DATE], revealed Resident #1 was understood and understood others. Resident #1 had adequate hearing, clear speech, and adequate vision. Resident #1 had a BIMS of 04, which indicated severe cognitive impairment. Resident #1 did not have wandering behaviors. Resident #1 required supervision for all ADLs except bathing which was coded independent. Resident #1 used a wheelchair for mobility. Record review of Resident #1's elopement evaluation, dated 05/03/22, completed by the MDS Coordinator, revealed [Resident #1] was ambulatory or independent in wheelchair locomotion . is cognitively impaired, poor decision making skills, and/or pertinent diagnosis (example .delusions .hallucination .anxiety disorder, depression, manic depression, and schizophrenia), history of wandering (into unsafe areas) .elopement risk score 60 indicated at risk for elopement .if resident is at risk for elopement, continue with elopement protocol and interventions .comments: resides on a secured unit Record review of Resident #1's elopement evaluation, dated 06/14/22, completed by LVN J, revealed 2-10 readmit . was ambulatory or independent in wheelchair locomotion . none of the above was answered for new admission who has made statements questioning the need to be here or cognitively impaired, poor decision making skills, and/or pertinent diagnosis (example .delusions .hallucination .anxiety disorder, depression, manic depression, and schizophrenia), history of wandering (into unsafe areas) .elopement risk score 0 indicated not at risk for elopement no answered selected for 'does the resident exhibit any of the following?' Record review of the census report dated 05-18/22- 06/14/22, revealed Resident #1 resided on Unit 1 which was the memory care secured unit. Record review of Resident #1's progress note, written by LVN J, dated 07/15/22, revealed . [Resident #1] is currently outside yelling, will not come in at this time .stated she will come in later Record review of Resident #1's progress note, written by LVN J, dated 07/17/22, revealed . [Resident #1] was screaming and yelling early this morning .so she went outside into the courtyard to get some air Record review of the psychological services progress note, written by a Psy D, dated 07/19/22, revealed . [Resident #1] struggling with hallucinations .kept telling 'Kathy' to stop touching her hair and stop pushing her .the resident was sitting in the sun and had reportedly been out there for some time . Record review of Resident #1's progress note, written by LVN H, dated 07/24/22, revealed .upon making 9 pm rounds, [Resident #1] not observed in her room .upon further observation resident not found on unit .[LVN K] stated that she observed [Resident #1] sitting in wheelchair smoking outside 300 hall exit door at approximately 7 p.m.staff conducted search outside and inside facility .resident found outside 1/3 mile up the street .escorted back to facility via wheelchair by staff .refused vitals .resident combative .upset stated she will start throwing chairs if she is not let back out Record review of the elopement evaluation/incident report, dated 07/24/22, completed by LVN H, revealed .was ambulatory or independent in wheelchair locomotion . is cognitively impaired, poor decision making skills, and/or pertinent diagnosis (example .delusions .hallucination .anxiety disorder, depression, manic depression, and schizophrenia), history of wandering (into unsafe areas) .elopement risk score 60 indicated at risk for elopement .history of wandering (into unsafe areas) and make statements that they are leaving .resident is at risk for elopement initiate elopement care plan .resident under close observation .notes: 07/24/22 at 9:58 p.m.upon making 9 p.m. rounds, [Resident #1] not observed in her room .upon further observation resident not found on unit .[LVN K] stated that she observed [Resident #1] sitting in her wheelchair smoking outside 300 hall exit door at approximately 7 p.m .staff conducted search outside and inside facility .resident found outside 1/3 mile up the street .escorted back to facility via wheelchair by staff .refused vitals .resident combative .upset stated she will start throwing chairs if she is not let back out . Record review of the provider investigation report, completed by the ADM, dated 07/24/22, revealed .[Resident #1] was interviewable .history of wandering was not selected .other pertinent history: memory care unit .witnesses: [CNA B] and [CNA C] . Description of the allegation: [Resident #1] was sitting in the front lobby around 7:00 p.m. she was later in the courtyard seen by staff smoking a cigarette in the assigned smoking area .[CNA B] went to locate [Resident #1] and was unable to locate her .[CNA B] notified the charge nurse and a search of the entire building and surrounding area by all staff was conducted .[Resident #1] was found 100 feet from facility at an assisted living .she was safe and was found talking to an elderly couple .resident transferred back to facility safe .resident continues to reside on memory care unit with no concerns noted .staff will be serviced on elopement protocols and ensuring doors are locked whenever exiting the building .in service to ensure looking behind themselves before leaving the building . Investigation summary: on 07/24/22, around 7:00 p.m. [Resident #1] was seen in the courtyard with staff smoking a cigarette in the assigned smoking area .[Resident #1] had been supervised all day for smoking via [RN A] for her regular smoke breaks .although resident resides on memory care unit, she enjoys sitting in the front lobby interacting with staff and visitors, she is often allowed to remain out of unit during the day because she often asks to stay out and talk with staff .facility had not had had any issues in the past allowing her to sit in lobby .[RN A] states before he left for the day he escorted her back to the unit without problems .[Resident #1] later asked [CNA B] if she could go smoke for her break, she was again escorted to the smoke area and when finished she was escorted back into facility .[Resident #1] asked to sit in the front lobby and staff allowed her to .staff reports they were down the hall assisting other resident and noticed [Resident #1] sitting in the lobby .around 8:00 p.m., [CNA B] went to locate [Resident #1] to take back to unit and was unable to locate . Record review of a witness statement dated 07/24/22, written by CNA C, revealed .I was taken out trash at 9pm .one of my coworkers asked me had I seen [Resident #1] they were looking for her .I came back to my hall my nurse said she saw her out back smoking at 7pm .I found her around 9:30 pm down the street . Record review of a witness statement dated 07/25/22, written by CNA B, revealed .[Resident #1] was sitting out front in the lobby during my shift .I went to bring her back to unit and she was not there .I asked the charge nurse sitting at the nurse station if she saw her .she said no . Record review of an email, dated 07/26 /22, written by LVN K, sent to the DON, revealed .on 07/24/22 at approximately 7pm, I observed [Resident #1] sitting in her wheelchair, smoking a cigarette at the end of the sidewalk near the laundry room . [Resident #1] stated that another employee let her out during this time .I proceed to come back in building during that time . Record review of a witness statement dated 07/27/22, written by RN A revealed [Resident #1] was becoming loud and combative with another resident .I took her off the unit with me .she was under my watch until 3:00 p.m.went outside so she could smoke off 300 hallway as access was closed to 200 hall and courtyard due to quarantine . before I clocked out, I took her back to the unit without any objection .she was definitely in the unit 100 when I left and all staff knew I was watching her closely all day . Record review of the facility smoke break time revealed the following: 9:00 a.m. 11:00 a.m. 1:30 p.m. 3:00 p.m. 5:30 p.m. 7:00 p.m. 9:00 p.m. Record review of the weather conditions, on 07/24/22, according to the National Weather Service, revealed the high temperature was 103 degrees Fahrenheit and low temperature was 79 degrees Fahrenheit. At 7:00 p.m. the temperature was 90 degrees Fahrenheit. Record review of an in-service on 07/25/22 at 2:00 p.m., provided to 22 staff members addressed locking doors: Please ensure door leading out to laundry is locked at all times and please look behind you when leaving to ensure there are no residents in area. Record review of an in-service on 07/25/22 at 2:00 p.m., provided to 23 staff members (LVN J, LVN H, CMA D, AD, CNA C, LVN F, RN P, CNA R) addressed elopement prevention: what steps to take for missing resident .check building, closet, doors, outside grounds .drive around in radius to locate .notify all parties including police if unable to locate. During an observation on 12/07/22 at 8:30 a.m., the main street to the facility was heavily congested with traffic. The main street had 3 unhoused citizens asking for money. The street the facility resided on posted speed limited was 30 mile per hour and narrow. During an observation on 12/07/22 at 09:10 a.m., on the 100-hall unit, one of the secured units doors, which lead to the courtyard, was propped open. Six women residents were in the common area and left unsupervised for 2 minutes while the courtyard door was opened. During an observation on 12/07/22 at 09:17 a.m., on the 200-hall, one of the secured units doors, which lead to the courtyard was propped open. Five residents, which included Resident #2 was left unsupervised for 5 minutes while the courtyard door which led to the courtyard was opened. During an interview and observation on 12/07/22 at 11:35 a.m., Resident #1 was sitting in her wheelchair with a slouched posture on the memory care unit (100-hall). Resident #1 was sitting alone in a smaller common area. Resident #1 said she remembered getting out of the facility and everyone made a big deal about it. She said CNA B told her to go smoke and let her outside. She said she went out the laundry door and went to another building down and across the street. She said she was outside for about 1-2 hours. She said several people came looking for her. She said since the incident she could not sit in the lobby anymore. She said the facility had been letting her sit in the lobby for about 6 months before the incident. She said staff normally kept an eye on her when she sat it the lobby. During an interview on 12/07/22 at 4:00 p.m., CNA C said she was working the COVID-19 unit when Resident #1 eloped. She said she took out the laundry and trash from the 200-hall outside when she heard staff looking for Resident #1. She said after notifying the 200-hall nurse, she joined the search. She said she found Resident #1 at another building down and across the street (176 yards from facility). She said Resident #1 told her the facility kicked her out, so she left. She said she did not know how Resident #1 got out of the facility. During an interview on 12/07/22 at 4:45 p.m., CNA B said she knew about the incident involving Resident #1 who eloped from the facility in July of this year. She said she remembered the day very well. She said she was working the 100-hall (memory care unit) and Resident #1 was sitting in the lobby outside of the unit as she often did when she had a bad day on the unit. She said she was easily annoyed by the other residents on the memory care unit. She said the nurse at the nursing station was supposed to keep an eye on Resident #1. CNA B said about 7:00 p.m., she went out to the laundry room, which was out by the 300-hall door and Resident #1 was smoking in the designated area near the laundry room and 300-hall exit door. She said Resident #1 was alone outside and she did not think anything of it because she was a safe smoker. She said about 45 minutes later after seeing Resident #1 outside (7:45 p.m.), she went to see if she was ready to come back in the facility and get ready for bed and she was not in the lobby. She said went outside to see if Resident #1 was still smoking, and she was not there. She said she immediately notified the nurse who then called the DON, and they began looking for the resident. She said the CNAs working got in their cars and looked for the resident, the DON arrived and called the police, and she was finally found around 9:00 p.m. down at the building down and across the street. She said the building was where the mentally handicapped people lived and worked. She said Resident #1 was unharmed but, thought she had been kicked out of the facility. During an interview on 12/08/22 at 11:55 a.m., CNA G said she worked the night Resident #1 eloped from the facility. She said she worked the 300-hall and CNA B asked her if she had seen Resident #1. She said she had not seen the resident during her shift. She said they searched the facility then CNA B and CNA C got in their vehicles to look for her. She said she told CNA B to check the group home for Resident #1. She said around 9:30 p.m., she saw CNA B pushing Resident #1 towards the facility with the police. She said from her understanding Resident #1 got out of the facility from the side door. She said the facility did let Resident #1 out in the general population with supervision. She said the area near the 300-hall exit door was the designated smoking area due to COVID being on the 200-hall were secured resident normally smoked. During an interview on 12/08/22 at 12:25 p.m., RN A said she worked the day shift Resident #1 eloped from the facility. He said at the beginning of his shift, Resident #1 had behaviors on the memory care unit, so he took her off the unit and around the facility with him. He said Resident #1 was with him throughout his shift. He said he took her out smoke in the designated smoking area which was near the 300-hall exit door. He said Resident #1 had been going there to smoke for a while due to COVID being on the 200-hall where she normally could go smoke. He said the 300-hall door automatically shuts and locked after you open and close it. He said at 2:10 p.m., he took Resident #1 back to the secured unit and let staff know she was back there. He said he received a phone call around 7pm to let him know Resident #1 eloped from the facility. He said when he left from his shift, Resident #1 was where she was supposed to be, on the secured unit. During an interview on 12/08/22 at 1:55 p.m., LVN H said she was the nurse on duty the night Resident #1 eloped. LVN H said Resident #1 had some behavioral problems in the morning and RN A spent the day babysitting Resident #1. She said RN A wheeled Resident #1around the facility, visited with her and took her out to smoke. She said at 2:30 p.m., RN A went to the nursing station and told her he returned Resident #1 to the unit and was gone for the day. LVN H said around 7:00 p.m., she witnessed CNA B wheel Resident #1 out the ungated 300-hall exit door to smoke. She said a few minutes later, CNA B returned from outside with clean linen and no Resident #1. She said Resident #1 was considered a safe smoker and sometimes was left outside smoking unsupervised with her cigarettes for extended periods of time. She said sometimes the residents from the independent living apartments would visit Resident #1 outside. She said the residents from the independent living apartments would call the facility when Resident #1 was ready to come back into the facility because the 300-hall exit door automatically closed and locked. She said about 30 minutes later, CNA B alerted her that she could not find Resident #1. She said she the DON was notified immediately, and the facility began the process of looking for Resident#1. She said it took the DON less than 15 minutes to arrive at the facility and she called the police. She said facility staff all searched for Resident #1. She said the nurses stayed behind to search the facility. She said around 9:15 p.m., Resident #1 was found down and across the road at the MHMR house outside. She said she was assessed by the DON when she came back. She said all staff were immediately educated on not letting Resident #1 out of the unit any longer and she must always be supervised. 2. Record review of Resident #2's face sheet, dated 12/06/22, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia with other behavioral disturbance (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), epilepsy (a brain disorder that causes seizures), and muscle weakness. Record review of Resident #2's consolidated physician order, dated 03/16/21, revealed the resident was a wander risk. Record review of the quarterly MDS, dated [DATE], revealed Resident #2 was usually understood and usually understood others. Resident #2 had adequate hearing, clear speech, and adequate vision with corrective lenses. Resident #2 had a BIMS score of 03, which indicated severe cognitive impairment. Resident #2 was independent with bed mobility and transfer, supervision for walk in room/corridor, dressing, eating, and locomotion off unit, and required extensive assistance for bathing. Resident #2 did not use a mobility device and did not exhibit wandering behaviors. Record review of Resident #2's care plan problem, dated 08/31/21, revealed psychosocial well-being: resident resides in a secured unit due to wandering. On 08/12/22, Resident #2 hit another resident on the chin. On 08/15/22, Resident #2 eloped from facility-returned with no injury. Interventions, dated 08/31/21, allow Resident#2 to wander in a safe environment, redirect out of other resident rooms as needed, provide resident with cues and re-direction as necessary, secure unit due to exit seeking and wandering behaviors. Intervention, dated 08/15/22, brought back to memory care unit immediately, placed on every 15-minute checks, staff in serviced on elopements and resident safety during open gate times, lawn care staff in serviced on closing the gate, continue to monitor for further incidents. Long term goal, last edited 08/05/22, revealed Resident #2 was at the facility for LTC due to altered decision making skills and memory deficit related to Alzheimer's disease. Interventions, dated 08/15/22, obtain Urine analysis with culture and screen. The care plan was not updated after the elopement on 08/15/22 to address ways to prevent reoccurrence. Record review of the elopement evaluation, completed by ADON, dated 08/15/22, revealed [Resident #2] was ambulatory, is cognitively impaired, poor decision-making skills, and/or pertinent diagnosis (example .dementia .Alzheimer's .anxiety disorder, depression), exhibited history of wandering with confusion .elopement care plan initiated .resident housed on secure unit . Record review of Resident #2's progress notes, written by LVN F, revealed Resident exit facility through back gate while lawn being mowed, in less than 5 minutes resident was picked up by staff member. Resident has no injures noted, no evidence of pain or discomfort, resident is confused to situation and surroundings . new orders received .to obtain urinalysis with culture and screen . Record review of the provider investigation report, completed by ADM, dated 08/15/22, revealed Resident #2 had minimal functional ability, no boxes were selected for the level of supervision. The section marked other comment revealed: resides on memory care unit, history of wandering was not selected, other pertinent history documented: memory care unit, the investigation did not reveal presence of a witness. Description of the allegation documented: .exited the facility back gate after lawn service personnel failed to lock the gate behind them after cutting lawn .[Resident #2] was located at assisted living (150 yards from the facility) within five minutes of exiting by staff employee, MDS coordinator .ADM in-serviced lawn personnel to ensure they checked back gate before exiting courtyard and ensure the gate is locked and no resident were in the area before exiting .staff in-serviced on elopement precautions, and ensuring gate is locked before allowing residents back in the courtyard after lawn service . Record review of a statement written by CNA E, dated 08/15/22, revealed I [CNA E] was in room with another resident changing him, came out, went to shower room, and heard someone calling my name. I went to the door told me [Resident #2] went outside the gate the yard working didn't close the gate . Record review of a statement written by the MDS Coordinator, dated 08/15/22, revealed I [MDS coordinator] was driving into work and saw an older gentlemen that looked familiar walking on the street when I came to the parking lot at the facility, I saw employees on the front parking area, I asked them if they were looking for someone, they said yes and I indicated that I had seen the gentlemen on the street walking .I drove back and found [Resident #2] talking to people at the assisted living .I asked him [Resident #2] his name, he said correct name .I told him my name and asked him if he wanted to get into the car . Record review of the weather conditions on 08/15/22, according to the National Weather Service, revealed the high temperature was 98 degrees and low temperature was 80 degrees. At 9:00 a.m., the weather was 86 degrees. Record review of the in-service, dated 08/15/22, provided to 17 staff members (DON, LVN CC, CMA Z, CNA E, CNA B, CNA C, CNA X, CMA D, LVN F, LVN H, CNA G) addressed elopement precautions: follow policy, search facility, doors, outside grounds. Record review of the in-service, dated 08/15/22, provided to the lawn company, addressed please make sure that patio door leading to 100-200 hall was locked after every yard service. Failure will result in term of contract. Record review of the in-service, dated 08/15/22, provided to 17 staff members (DON, LVN CC, CMA Z, CNA E, CNA B, CNA C, CNA X, CMA D, LVN F, LVN H, CNA G) addressed whenever lawn service was being done in the courtyard off 100-200 hall, please ensure all residents were inside and check back gate before residents allowed in the courtyard. During an interview on 12/07/22 at 12:05 p.m., the maintenance supervisor said he had been employed at the facility for 4 months. He said the back gate to the courtyard had a keypad on both sides. He said the lawn company had the code to access the gate. He said the gate did not alarm if it was not closed after a certain time. He said the ADM instructed him to check the gate every morning to ensure it was locked. He said the facility did not keep a formal log of the gate checks. During an interview and observation on 12/07/22 at 12:10 p.m., Resident #2 was sitting in the dining room after eating lunch. He said he did not remember getting out or leaving the facility in August 2022. During an interview on 12/07/22 at 3:22 p.m., the MDS coordinator said she was on her way to work on 08/15/22 and saw a gentleman walking in the street. She said he looked familiar, but she continued to drive to work. She said when she arrived, she saw people looking for Resident #2 and immediately turned around. She said when she returned, she found Resident #2 in the parking lot of one of the assisted livings. She said Resident #2 was confused and looked relieved someone knew him. She said she told Resident #2 she would take him back home if he got in the care and he got in. An interview with the lawn company was attempted on 12/07/22 at 3:24 p.m., and was unsuccessful. During an interview on 12/07/22 at 4:04 p.m., CNA E said she was the aide working the secured unit where Resident #2 resided on 08/15/22. She said she was the only aide working the unit which was normal. She said it was a nice, sunny day so she let Resident #2 outside in the courtyard which was a common practice. She said the residents did not have to be supervised in the courtyard because it was locked and before the incident, we did not check the gate to ensure it was locked. She said she propped open the door with a rock so residents could come and go from the courtyard. She said the lawn company was not in the courtyard area but Resident #1 was in the courtyard. She said she guessed someone brought Resident #1 to smoke and left for a moment. She said Resident #1 was a resident who eloped the month before. She said she was in another resident room and came out the room to Resident #1 screaming that Resident #2 got out. She said it took about 15 minutes or less to locate Resident #2. She said the 200-hall only staffed 1 CNA and residents were left unsupervised for at least 15 minutes whenever the CNAs had to do incontinent care or help with showers. During an interview on 12/08/22 at 10:12 a.m., the ADM said maintenance had told this surveyor some wrong information regarding the courtyard gate. She said she never instructed the maintenance man to check the gate every morning. She said he was a new employee and was not at the facility when the residents eloped, so he did not know anything about the gate. She said the maintenance man was trying to impress the state surveyor by saying she told him to do that. During an interview on 12/08/22 at 10:17 a.m., CMA D said she helped search for Resident #2 after he eloped in August 2022. She said she heard he got out because the man who cut the grass left the gate open. She said after the incident, she was in serviced on elopement precautions. She said the gated courtyard was used for supervised and unsupervised smokers. She said some residents went out in the courtyard area to sit and enjoy the weather. She said she had always seen the residents being supervised. She said Resident #1 was allowed off the secured unit during that time but was supervised. She said Resident #1 did smoke out the 300-hall door but was supervised. She said Resident #1 hallucinated and had delusions and said the facility kicked her out when she eloped. During an interview on 12/08/22 at 11:47 a.m., the Activity Director said Resident #1 used sit in front lobby, outside of the memory care unit. She said Resident #1 came out of the memory care unit for activities and dining. She said after the activities, Resident #1 liked to sit in the front lobby instead of going back to the secured unit. She said when she was in the front lobby, the nurses at the nursing station were responsible for supervising her. The AD said she worked the day Resident #2 eloped from the secured unit courtyard in August 2022. She said someone told her Resident #2 got out of the facility and she went to help look for him. She said she got in her vehicle and drove around the nearest main street looking for Resident #2 but did not see him. She said when she returned to the facility, she heard Resident #2 was found by another coworker. During an observation on 12/08/22 at 12:40 p.m., the 300-hall exit door were delayed doors equipped with delayed-egress locking mechanisms (open within 15 to 30 seconds upon

Based on observation, interview and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for the facility related to COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older) for 1 of 14 residents reviewed for COVID-19. (Resident #6) The facility staff did not quarantine Resident #6 after his roommate tested positive for COVID-19. The facility did not isolate Resident #6 when he had a fever per their policy. The facility did not communicate to all staff or the survey team Resident #6's unknown COVID-19 status. The facility did not place signage on Resident #6's door alerting staff and survey team Resident #6 was under quarantine. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/22/20. While the IJ was removed on 10/23/20, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for being exposed to COVID-19, health complications, and death. Findings included: The Texas Health and Human Services COVID-19 RESPONSE FOR NURSING FACILITIES version 3.5 dated 08/18/2020 stated, .Quarantine residents with exposure or symptoms .communicate with residents, staff, and family when exposure to probable or confirmed cases of occur in the facility . Any roommates (of COVID-19 positive residents) should be moved and monitored for fever and symptoms twice daily for 14 days . The facility policy titled, Infection Control Guidelines Related to COVID-19, revised on 10/16/20 stated, .If resident (is) positive for fever (100.0 oral or 99.0 temporal) or symptoms, implement isolation protocols and move to a private room if available . Isolation Protocols and Signage *When a case is first identified, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 [DIAGNOSES REDACTED].*Implement Standard, Contact and Droplet Precautions for non-aerosol generating care and procedures .*These precautions apply to all persons who need to enter the resident's room. *Appropriate PPE supply should be placed outside of the room and routinely refilled to ensure availability to caregivers. *A trash container should be placed next to the exit from the room. *Signage should be placed on the outside of the resident's door notifying people that the resident is on isolation and indicating the type of PPE required, for whom it is required and under what circumstances . During an interview on 10/19/20 at 9:20 a.m., the DON indicated there were 8 COVID-19 positive residents and 6 residents with an unknown COVID-19 status. The DON indicated the 8 positive residents were located on the hot hall and the 6 unknown residents were on the warm hall. The consolidated physician orders [REDACTED].#6 was [AGE] years old readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #6 usually made himself understood and usually understood others. The MDS indicated Resident #6 had moderately impaired cognition. The MDS indicated Resident #6 required supervision with bed mobility, transfers, walking, dressing, and eating. The MDS indicated Resident #6 required limited assistance with toilet use. The MDS indicated Resident #6 required extensive assistance with personal hygiene. The MDS indicated Resident #6 was totally dependent on staff for bathing. The MDS indicated Resident #6 was always continent of bowel and occasionally incontinent of bladder. The care plan revised on 8/27/20 did not address Resident #6's unknown COVID-19 status or COVID-19 exposure. During an interview on 10/19/20 at 9:30 a.m., the administrator provided the facility census and indicated halls 100, 300 and 400 were cold (area with no COVID-19 infection) halls. The administrator indicated hall 500 was warm (area used to monitor residents probable of COVID-19 infection) and hall 600 was hot (area where COVID-19 infection was present). During an observation on 10/19/20 at 10:33 a.m., Resident #6 was sitting on his bed in room [ROOM NUMBER] (on the hall 400/cold hall). There was no sign on the outside of the door indicating Resident #6 was quarantined. There was no PPE (personal protective equipment) caddy (plastic bin containing PPE) outside of the room. There were no boxes for the disposal of PPE in Resident #6's the room. During an observation on 10/20/21 at 2:10 p.m., Resident #6 was laying on his bed in room [ROOM NUMBER]. There was no sign on the outside of the door indicating Resident #6 was quarantined. There was no PPE caddy (plastic bin containing PPE) outside of the room. There were no boxes for the disposal of PPE in Resident #6's the room. The surveyor did not change PPE after making observation of Resident #6 and before entering other resident rooms on the clean halls. During an observation on 10/21/20 at 11:15 a.m., Resident #6 was laying on his bed in room [ROOM NUMBER]. There was no sign on the outside of the door indicating Resident #6 was quarantined. There was no PPE caddy (plastic bin containing PPE) outside of the room. There were no boxes for the disposal of PPE in Resident #6's the room. The surveyor did not change PPE after making observation of Resident #6 and before entering other resident rooms on the clean halls. During an observation on 10/21/20 at 2:45 p.m., Resident #6's door was open to the hall way. Resident #6 was laying on his bed in room [ROOM NUMBER]. There was no sign on the outside of the door indicating Resident #6 was quarantined. There was no PPE caddy (plastic bin containing PPE) outside of the room. There were no boxes for the disposal of PPE in Resident #6's the room. A nursing note dated 10/18/20 at 6:28 p.m., indicated Resident #58 (Resident #6's roommate) was sent to the hospital for tremors and decreased level of consciousness. A nursing note dated 10/18/20 at 11:35 p.m., indicated there was a notification from the hospital that Resident #58 was positive for COVID-19. A nursing note dated 10/19/20 at 12:32 a.m., completed by LVN L, indicated Resident #6 was to remain in his room with the door shut until further notice, as instructed by the DON due to COVID-19 exposure. A nursing noted dated 10/19/20 at 1:57 p.m., written by LVN J, indicated Resident #6 was not getting out of bed and had not eaten breakfast or lunch. The note indicated an order for [REDACTED].> A nursing note dated 10/20/20 at 2:50 p.m., written by LVN G, indicated Resident #6's COVID-19 test results were pending. A nursing noted dated 10/21/20 at 2:01 a.m., written by LVN M, indicated Resident #6 had a temperature of 100.4 and his COVID-19 test results were pending. A nursing note dated 10/21/20 at 7:06 a.m., written by LVN F, indicated Resident #6's COVID-19 test results were pending. During an interview on 10/21/20 at 3:30 p.m., the DON said Resident #6 had been tested for COVID-19 because his roommate tested positive at the hospital. The DON said she had left Resident #6 on the cold hall because there was no room on the warm hall. The DON said she had instructed staff to change PPE after providing care to Resident #6 and to keep his door shut. The DON said she should have posted signage and PPE outside of Resident #6's room. During on interview on 10/22/20 at 11:00 a.m., the DON she said she did not have anything in writting regarding keeping Resident #6's shut and no documentaion of in-services she provided to staff regarding isolation of the resident. During an interview on 10/22/20 at 4:18 p.m., LVN G said staff were required to wear full PPE at all times while providing care to residents on the cold hall. LVN G said it was not necessary to change PPE (N95 and gown) after each resident interaction because the halls on which she cared for residents were considered cold. LVN G said she had taken care of Resident #6 for the past few days. LVN G said she had not changed PPE after she provided care for Resident #6 and before she provided care for other residents on the cold halls. LVN G said no one had instructed her Resident #6 was on quarantine and no one had instructed her to change PPE after providing care to Resident #6. During an interview on 10/22/20 at 4:57 p.m., CNA H said she had taken care of Resident #6 for the past few days. CNA H said she had not changed PPE after she provided care to Resident #6 and before she provided care to other residents on the cold halls. CNA H said she did not have to change her PPE between providing care to residents on the cold halls. CNA H said no one had instructed her Resident #6 was on quarantine and no one had instructed her to change PPE after providing care to Resident #6. A nursing note dated 10/22/20 at 12:29 a.m., indicated Resident #6 had a temperature of 101.3 and his COVID-19 test results were pending. The administrator was notified on 10/22/20 at 1:50 p.m. an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided the Immediate Jeopardy template on 10/22/20. The facility's Plan of Removal was accepted on 10/23/20 at 8:20 a.m. and included: Immediate actions: *The resident was transferred to the facility warm unit on 10/21 at 6:30 PM *Nurses will be educated to immediately quarantine any resident who: 1) has a roommate who tests positive; or, 2) shows signs/symptoms of COVID. Education will include: *Immediate notification of positive result / symptoms to the Director of Nursing. *Proper signage to place on the isolated resident's room door that informs staff of the isolation and required precautions. *Proper placement of PPE required for isolation. *Proper location of biohazard disposal boxes in the resident's room. *All staff who enter resident rooms will be re-educated proper donning / doffing and disposal of PPE. *Administrative staff will be re-educated on the Infection Control Policy and that surveyors should be notified of any newly exposed, positive or symptomatic residents. *DON or ADON will provide this training starting 10/21/2020 and will ensure all staff nurses and other required staff are educated by 10/22/2020. Monitoring *The Director of Nursing or Designee will monitor the following items 5 days per week for 2 weeks, weekly for 4 weeks and then monthly for 1 month and reported to the facility QAPI committee. *That proper isolation procedures are immediately put in place when a resident's roommate tests positive or a resident shows signs and symptoms of COVID. *Proper isolation signage is placed outside of the isolated resident's room. *That proper biohazard disposal supplies and requires isolation supplies are available and placed in the correct location. *That staff who enter isolation rooms are donning and doffing PPE properly. Medical Director *The Medical Director has been notified of the Immediate Jeopardy. QAPI Committee Review *The Director of Nursing/Designee will present findings to the Quality Assurance Performance Committee monthly for 3 months until the Quality Assurance Performance Committee deems it no longer necessary. Any recommendations will be implemented and monitored until compliance is achieved. On 10/23/20 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 10/23/20 at 8:30 a.m. Resident #6 was on the warm hall. The in-service sign in sheet dated 10/22/20 indicated staff had been educated regarding All residents that have a roommate that test positive for COVID or show signs and symptoms of COVID must be isolated immediately. Immediately notify the DON of any positives or (residents) with symptoms. Place proper signage of isolation status on the (resident's door to alert staff of quarantine. Place isolation caddy outside of the (resident's) door, place biohazard boxes in resident's room for PPE disposal. The in-service sign in sheet dated 10/22/20 indicated staff had been educated regarding proper donning/doffing and disposal of PPE. During interviews on 10/23/20 Five LVNs (2 on the 6 a.m.-2p.m. shift; 1 on the 2p.m.-10 p.m. shift and 2 from the 10p.m.-6 a.m. shift) 10 CNAs (6 on the 6 a.m.-2p.m. shift; 2 on the 2p.m.-10 p.m. shift and 3 from the 10p.m.-6 a.m. shift) and 1 CMA (on the 6a.m.-2 p.m. shift) were interviewed. Staff indicated they had received in-service over placing a resident in quarantine/isolation when the resident had a roommate who tested positive for COVID-19, or the resident had signs and symptoms of COVID-19. They indicated they would immediately place the resident in quarantine and place signage alerting all staff the resident was in quarantine. Staff said they would immediately notify the DON. Staff said they would place an isolation caddy outside of the resident's room and place disposal boxes in the resident's room. They said these actions would be taken to ensure all staff would be aware of the resident's quarantine status and ensure the same PPE was not worn into cold resident's rooms after providing care to the warm resident. During an interview on 10/23/20 at 9:10 a.m., the DON indicated she would be monitoring 5 days per week for 2 weeks, weekly for 4 weeks and then monthly for 1 month, for staff adherence to proper isolation procedures. The DON said these procedures would be immediately put in place when a resident's roommate tests positive or a resident shows signs and symptoms of COVID-19. The DON said she would ensure the procedures would include; proper isolation signage was placed outside of the isolated resident's room; staff properly donned/doffed PPE; and isolation supplies would be placed in the correct location. During an interview on 10/23/20 at 9:28 a.m., the administrator said the medical director had been notified and the QAPI meeting was scheduled for 10/30/20. On 10/23/20 at 10:20 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure adequate supervision to prevent accidents was provided for 1 of 5 residents reviewed for accidents. (Resident #1) The facility did not implement interventions to prevent Resident #1 who exhibited exit seeking behaviors from leaving the facility without staff knowledge. Resident #1 was placed at the nursing station for supervision. The resident was left unattended at approximately 3:15 a.m., and was found outside the facility at approximately 4:20 a.m. Resident #1 exited the facility, fell from her wheelchair and sustained a minimally displaced right nasal bone fracture and a large right frontal scalp hematoma (injury to a large blood vessel causing blood to leak into the surrounding tissue). The exit door alarms were not set properly. This was determined to be past non-compliance that existed on 8/18/19 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for injury or death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. An incomplete admission assessment dated [DATE] for Resident #1 indicated the wandering/elopement risk assessment was blank. A baseline care plan dated 8/9/19 indicated Resident #1 was alert and confused with difficulty communicating due to impaired speech. The care plan indicated the resident exhibited agitation and was totally dependent for bed mobility, transfer, toileting, locomotion, eating, grooming/hygiene and bathing. The care plan indicated she required a wheelchair and was non-ambulatory. A nursing progress note dated 8/10/19, completed by LVN C indicated Resident #1 self-propelled to the front door and started kicking the door attempting to get out. The note indicated the resident was re-directed. During an interview on 8/27/19 at 8:48 a.m., LVN C said Resident #1 self-propelled in her wheelchair all around the nursing station and up and down the halls. She said the resident was confused and had no safety awareness. LVN C said on 8/10/19 at approximately 10 a.m., Resident #1 self-propelled to the front lobby and repeatedly kicked the exit door and attempted to exit. LVN C said Resident #1 had attempted to go out the door a couple of times since then but had never exited and was easily redirected. She said she reported each incident to the DON and ADON. A baseline care plan updated 8/10/19 did not address Resident #1's wandering or exit seeking behavior. A baseline care plan updated 8/17/19 indicated Resident #1 fell with no injury and refused to stay in her bed, with interventions to allow the resident to stay in her wheelchair at the nursing station for supervision. The care plan did not address Resident #1's wandering or exit seeking behavior. An incident report dated 8/18/19 at 5:00 a.m., indicated Resident #1 went out of the facility through a door and fell out of her wheelchair. The report indicated she received an injury to her head and was sent to the hospital. The report did not indicate the time Resident #1 was sent to the hospital or time the physician and family were contacted. The report indicated Resident #1 was admitted to the hospital for treatment of [REDACTED]. A nursing progress note dated 8/18/19 at 7:20 a.m., indicated LVN B saw Resident #1 at 3:15 a.m., sitting at the nursing station in her wheelchair. The note indicated when LVN B returned to the nursing station, the resident was not there. The note did not indicate the time LVN B returned to the nursing station. The note indicated CNA J found the resident outside and it looked like she exited the door on hall 600. The note indicated LVN B called 911. The nursing progress note did not indicate the time Resident #1 was found or transported to hospital. During an interview on 8/27/19 at 12:08 p.m., LVN B said on 8/18/19 at 11:30 p.m., Resident #1 was found on the fall mattress beside her bed. She said the resident did not have an injury and refused to go back to bed. LVN B said she brought Resident #1 to the nursing station, so she could be monitored by staff. She said Resident #1 self-propelled herself around the nursing station and halls. LVN B said she last saw Resident #1 sitting at the nursing station at 3:15 a.m., and began a search for her at approximately 4:00 a.m. She said CNA J found the resident sitting on the sidewalk outside of the exit door on hall 600. LVN B was unable to state the time Resident #1 was found. LVN B said the resident was injured so she called 911. LVN B said she was not able to remember the time the resident was transported to the hospital. She said she did not hear the alarm on the exit door and did not know when Resident #1 exited the facility. LVN B said she had not witnessed Resident #1 exit seek since her admission and she was not aware of her previous attempts. LVN B said she admitted Resident #1 on 8/9/19 and did not complete the risk assessment paperwork because the resident arrived at the facility after 9:30 p.m., She said she got busy and did not go back to complete the paperwork. She said she should have completed the fall and wandering/elopement risk assessment at admission. LVN B said she had received counseling from the DON on completing the admission paperwork. A history and physical dated 8/18/19 indicated Resident #1 presented at the emergency department with a golf ball size hematoma on her right forehead, bruising all over her neck, blood all over her face and eyes and multiple abrasions on her face and scalp. The report indicated a CAT scan of the resident's face was obtained and indicated a minimally displaced right nasal bone fracture and a right frontal scalp hematoma. The report indicated Resident #1 was to receive [MEDICATION NAME] 2 mg intravenously every 6 hours for pain management, neurological checks every 4 hours and ice packs for swelling. A hospital progress note dated 8/20/19 indicated Resident #1 had a temperature of 101.5 and required 2 liters of supplemental oxygen which she had not required the day before. The note indicated the resident complained of headache, facial pain and shortness of breath. The note indicated the fever could be reactive due to the trauma that occurred leading to her hospital admission. A discharge summary dated 8/22/19 indicated Resident #1 was discharged from the hospital on [DATE] and the family did not wish her to return to the facility. During an interview on 8/27/19 at 5:36 a.m., CNA J said on 8/18/19 at approximately 11:30 p.m., she made rounds on hall 300 and Resident #1 was on the fall mattress on the floor. CNA J said the resident refused to go back to bed. CNA J said LVN B told her to bring Resident #1 to the nursing station, so she could be monitored. CNA J said Resident #1 was self- propelling all over the facility and wandering in and out of rooms, which was typical behavior for the resident. CNA J said at 3:37 a.m., LVN A asked her to take Resident #1 to the nursing station because she was on hall 400 wandering in and out of resident rooms. CNA J said she last saw Resident #1 at approximately 3:50 a.m., sitting in her wheelchair at the nursing station. CNA J said she had call lights to answer, LVN B was on 200 hall and CNA H was assisting other residents. CNA J said at 4:05 a.m., Resident #1 was not at the nursing station and was not on any of the halls. CNA J said at approximately 4:20 a.m., she found the resident sitting outside on the sidewalk near the 600 hall exit. She said Resident #1 was bleeding from her head and her wheelchair was across the parking lot turned over on its side. CNA J said she did not hear the door alarm on hall 600 when the resident exited the facility. She said the hall 600 door was opened after Resident #1 was found and the alarm sounded approximately 15 seconds before it went off. She said she had not witnessed the resident exit seek but was told she had tried to go out the front entrance on day shift. CNA J was unable to determine the date Resident #1 attempted to go out the front door. During an interview on 8/27/19 at 5:20 a.m., LVN A said on 8/18/19 she was not assigned to Resident #1, but all staff were supervising the resident because she had fallen out of bed earlier and was restless. LVN A said at approximately 3:30 a.m., she was on hall 400 passing medications and Resident #1 followed her and self-propelled in and out of resident rooms in her wheelchair. She said she asked CNA J to return the resident to the nursing station to prevent her from waking residents. LVN A said she did not see Resident #1 again until she was found outside. She said she did not hear the exit door on hall 600 alarm and did not know the time of Resident #1's elopement. LVN A said she had not witnessed Resident #1 exit seek but she was made aware the resident attempted to go out the door on hall 300 a few days prior. LVN A was unable to recall the date or details of the exit attempt. During an interview on 8/27/19 at 1:33 p.m., CNA H said on 8/18/19 she assisted in the search for Resident #1. She said she went outside after CNA J discovered Resident #1 sitting on the sidewalk. She said when asked how she got outside, Resident #1 gestured toward the exit on hall 600. CNA H said the resident was not far from the exit door on hall 600 and there was an incline from the door to the parking lot. CNA H said the resident's wheelchair was across the parking lot close to the trees on its side. CNA H said LVN B exited the door on hall 600 and the alarm sounded for approximately 10 to 15 seconds then went off. She said she did not hear the alarm sound when Resident #1 exited the building. She said since the resident's elopement the alarm was set to sound continuously. She said she had not observed Resident #1 exit seek during her shift. During an interview on 8/27/19 at 10:29 a.m., Resident #1's daughter said on 8/18/19 at 5:15 a.m., she was notified the resident exited the facility and fell outside. She said LVN B told her the resident went missing and when they searched the grounds she was found sitting on the sidewalk beside the building. Resident #1's daughter said the resident had a broken nose and her face was bruised. She said the staff were not able to tell her the exact time the resident was discovered missing and the time she was found. The daughter said the report she received from the emergency room staff indicated the resident's accident occurred at 4:33 a.m., Resident #1's daughter said she did not know if the resident had previous attempts to leave the facility, and if so, she had not been notified by staff. During an interview on 8/27/19 at 8:59 a.m., CNA [NAME] said Resident #1 attempted to leave the facility twice during her shift on 8/12/19. She said the resident went to the door and waited for someone to exit or enter and attempted to exit. CNA [NAME] said she redirected her after the first attempt and the resident circled the nursing station and headed back to the front door. CNA [NAME] said the resident self-propelled in her wheelchair and wandered the halls. CNA [NAME] said staff were aware Resident #1 required supervision. CNA [NAME] said she did not inform anyone of Resident #1's attempt to exit because all staff were aware she was going to the door to exit. During an interview on 8/27/19 at 9:13 a.m., LVN D said Resident #1 wandered all about the facility while in her wheelchair. She said the resident was confused and did not verbally communicate. LVN D said she was informed Resident #1 had attempted to go out the door after her admission, but she had not witnessed her exit seek. During an interview on 8/27/19 at 9:48 a.m., CNA G said Resident #1 wandered up and down halls and around the nursing station in her wheelchair. She said on 8/12/19 during the evening meal she was in the dining room and heard the exit alarm sound for a short period and shut off. She said she went to investigate and LVN K was pushing Resident #1 in her wheelchair toward the dining room. CNA G said LVN K told her the resident pushed open the exit door on hall 300. During an interview on 8/27/19 at 1:16 p.m., LVN K said on 8/12/19 during the evening meal she heard the alarm sound at the exit door on hall 300. She said she saw Resident #1 being re-directed by a CNA away from the door. LVN K said the CNA indicated the resident opened the door and caused the alarm to sound and was startled. She said Resident #1 did not go out the door and was easily re-directed. LVN K said she kept the resident at the nursing station to monitor her behavior the remainder of the shift and she did not go to the exit door. She said she informed the oncoming nurse of the incident in report. LVN K said the staff were aware she had exit seeking behavior and were checking on her frequently to monitor the behavior. LVN K said she could not recall the name of the CNA or the on-coming nurse and she did not document the incident or monitoring activity. During an interview on 8/27/19 at 1:42 p.m., the ADON said she was not aware Resident #1 had previous exit seeking behavior. She said a wandering/elopement risk assessment should have been completed for Resident #1 on admission and after each occurrence. The ADON said wandering/elopement risk assessments were completed on all residents since Resident #1's incident. The ADON said the staff should document exit seeking behavior and complete the wandering/elopement risk assessment at the time of occurrence. The ADON said the staff should communicate changes in resident's behavior to the DON. During an interview on 8/27/19 at 11:32 a.m., the DON said she was informed Resident #1 had attempted to get out the front entrance door on 8/10/19, the day after admission. She said she was told the resident's family visited and exited the front door with Resident #1 in the lobby. She said afterwards the resident went to the door and kicked it and attempted to open the door. The DON said she was told Resident #1 was easily re-directed and she had not been informed of her exit seeking incident on 8/12/19. She said the exit door on hall 600 had a malfunction on the night Resident #1 eloped. She said the door alarm should have sounded continuously when opened. The DON said the maintenance supervisor checked the door after the incident and the alarm timer was set at 30 seconds. She said he re-set the alarm timer on all the exit doors to sound continuously and staff were monitoring them daily. The DON said a fall risk assessment and a wandering/elopement risk assessment should be completed for every resident on admission and after each occurrence. She said all residents have been assessed for elopement. She said she was unaware the assessment was not completed for Resident #1 until after the elopement. During an interview on 8/27/19 at 8:08 a.m., the maintenance supervisor said he was informed on 8/18/19 the exit door alarm on hall 600 was not set properly. He said he set the alarm timer to continuously sound and require a key to shut off. The maintenance supervisor demonstrated the exit alarms and all exit door alarms were functioning properly. During an interview on 8/27/19 at 3:20 p.m., the administrator said she was not aware Resident #1 had exit seeking behavior prior to her exiting the facility. She said an elopement risk assessment should be completed on admission by the admitting nurse. The administrator said on 8/19/19 the DON and ADON completed wandering/elopement risk assessments on all residents and processes were put in place to assure the assessments were completed per the facility policy. The administrator said on 8/18/19 the staff were in-serviced on elopement risk and monitoring the door alarms. She said the hall 600 alarm had been re-set to sound continuously. A policy dated 08/15 and titled Elopement Protocol indicated . all residents will be assessed on admission, re-admission, quarterly and with changes in condition for risk factors that would place the resident at risk for elopement such as wandering, previous history of elopement or exit seeking behavior . changes in condition: any resident with changes of condition including elopement, elopement attempts or exit seeking behavior will be re-assessed for need of further intervention to reduce the risk of elopement .Interventions for residents at risk for elopement: all residents who are identified at risk for elopement will have their picture taken and be placed in the elopement book within 24 hours of admission/re-admission or change of condition . the care plan will be updated and staff will be advised of the resident's risk for elopement .Immediate Interventions for resident safety .the facility will ensure any monitoring devices are operational and maintained . the administrator or designee will check each door alarm periodically. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on 8/18/19. The facility took the following actions to correct the non-compliance on 8/18/19: The DON in-serviced staff on 8/18/19 on elopement risk, completing risk assessments, what to watch for and report to supervisor, fall management, monitoring the exit doors daily and reporting to maintenance immediately if the alarm timer was not set for continuous alarm. The doors were to be tested daily for proper alarm function. The DON and ADON audited all charts to ensure fall and elopements risk assessments were completed. On 8/27/19, the surveyor determined interventions were completed by: *10 resident charts were reviewed, and all contained current elopement risk assessments. *5 LVNs were interviewed and indicated they received training prior to the surveyor's entrance regarding completing elopement risk assessments, monitoring residents for elopement risk and ensuring interventions were in place. The nurses said they were in-serviced on responding to the door alarm immediately and door alarms were to be checked daily and if an issue was detected with the alarm timer they were to notify maintenance immediately. *5 CNAs were interviewed and indicated they received training prior to the surveyor's entrance regarding elopement prevention and supervision of residents at risk. The CNAs said they were in-serviced on monitoring the exit doors, responding to the door alarms immediately and if an issue was detected with the alarm timer they were to notify maintenance immediately. *A monitoring log dated 8/18/19 indicated staff began daily monitoring for exit doors. The document indicated the alarm on all exit doors were functional.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect, for 3 of 3 residents reviewed for neglect. (Resident #s 1, 8, and 10) The facility did not have replacement [MEDICAL CONDITION] and inner cannulas available in the event of accidental removal of the cannulas for Resident #s 1, 8, and 10. The facility did not have an ambu bag at bedside for Resident #s 8 and 10. The facility did not have an emergency supply of portable oxygen at the bedside for Resident #s 1, 8, and 10 in the event of a power outage. The facility did not ensure Resident #1's Trilogy (ventilator device) and Resident #'s 1 and 8 suction machines had an emergency direct power source. The facility did not have physician orders for the size of [MEDICAL CONDITION] (trach) tube, [MEDICAL CONDITION] care, oxygenation needs, or suctioning requirements for Resident #s 1, 8, and 10. The facility did not ensure nursing staff knew emergency procedures to implement related to [MEDICAL CONDITION]/ventilator care for Residents #s 1, 8, and 10. An Immediate Jeopardy situation was identified on 7/25/16. The Immediate Jeopardy was removed on 7/26/16. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 3 residents with tracheostomies at risk for neglect, serious injury and even death. Findings included: Findings included: 1. A face sheet dated 3/11/16 indicated Resident #1 was [AGE] years old, admitted [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 could understand others and usually made himself understood. He required extensive assistance of two staff for transfers. He was totally dependent on staff for dressing, bathing, and hygiene. The MDS indicated Resident #1 received specialty care including oxygen therapy, suctioning, and [MEDICAL CONDITION] care. An undated Care Plan indicated Resident #1 had a [MEDICAL CONDITION] in place and would [MEDICAL CONDITION] daily and PRN(as needed). The care plan indicated staff would apply the Trilogy ventilator (mechanical ventilator that provides both volume and pressure ventilation and delivers the therapy either invasively, via a trach, or noninvasively, via a mask) at night and PRN and an [MEDICAL CONDITION] be available for accidental dislodgement. The care plan indicated Resident #1 was suctioned and staff would record how the resident tolerated the procedure and notify the physician of any changes. The care plan indicated Resident #1 would have a speaking valve for [MEDICAL CONDITION] awake hours and would be removed at night to place the ventilator. Physician orders dated 7/7/16 indicated Resident #1 would [MEDICAL CONDITION] daily and he would receive oxygen at 4 liters per minute via [MEDICAL CONDITION]. There were no orders for the ventilator on the resident's active chart. During an observation on 7/25/16 at 9:07 a.m., Resident #1 was sitting upright in his recliner. Oxygen was being administered [MEDICAL CONDITION] at 4 liters per minute. The ventilator, oxygen concentrator and suction machine were plugged into regular power outlets. There was no red plug for emergency power located inside the room. There were two emergency red outlets located in the hallway. There was [MEDICAL CONDITION] portable oxygen at the bedside in case of an emergency. During an interview on 7/25/16 at 11:58 a.m., the RT said Resident #1 had a [MEDICAL CONDITION] and was hooked to a Trilogy [MEDICAL CONDITION] at night. He said the resident received breathing treatments and suctioning every 4 hours and received [MEDICAL CONDITION]. The RT said he was responsible for Resident #1's respiratory needs Monday through Friday from 8:00 a.m. to 5:00 p.m. He said the nurses were responsible evenings after 5:00 p.m., nights, weekends and when he was off. He said the nurses had received training [MEDICAL CONDITION], breathing treatments and suctioning. The RT said Resident #1's Trilogy was not plugged into a red outlet at night. He said the Trilogy had a 2 hour battery that automatically came on in the case of a power outage. The RT said Resident #1 would be moved into the hallway during an emergency and if the power was going to be out for very long Resident #1 would be transferred to the hospital. The RT said he believed, but was not certain, Resident #1 had a [MEDICATION NAME][MEDICAL CONDITION] 6. He said there was not an [MEDICAL CONDITION] bedside, but he had one in the supply closet. During an interview on 7/25/16 at 12:15 p.m., the RT said he was unaware the Trilogy orders for Resident #1 were not on the chart. He said he did not know why the orders were not there. The RT said it was the responsibility of the nurses and himself to assure respiratory orders were correct. During an interview on 7/25/16 at 3:25 p.m., the RT said there was a clarification order in April. He said after the clarification order the ventilator orders stopped appearing on the physician's orders. He said the orders were correct on the MAR. He said he was not sure why this was happening, but they were working to correct the problem. The respiratory therapist found the orders from the thinned chart from medical records. After surveyor intervention, physician orders dated 7/25/16 for the Trilogy were placed on the chart. The order included: oxygen at 4 liters per minute [MEDICAL CONDITION]; may use Passy-muir speaking valve during the awake hours and remove Passy-muir valve to apply Trilogy at night; Trilogy AVAPS-AE, IPAP 15, EPAP 5, rate 14 and pressure support to 5-20 CUP at night; Apply Trilogy at night and PRN via trach. Monitor every 2 hours while applied for proper functioning. During an observation on 7/25/16 at 3:54 p.m., Resident #1 had a [MEDICATION NAME] size 6 [MEDICAL CONDITION] in place. During an interview on 7/25/16 at 3:56 p.m., the RT said he did not have a replacement [MEDICAL CONDITION] set for Resident #1's trach. He said he would have to send the resident to the hospital if there was an accidental dislodgement of his trach. During an observation on 7/25/16 at 4:05 p.m., the supply closet contained Shiley #6 and #7 inner cannulas, and [MEDICATION NAME] #6 and #7 inner cannulas. There were no [MEDICATION NAME][MEDICAL CONDITION] or inner cannulas. During an interview on 7/26/16 at 2:19 p.m., LVN B said she was inserviced [MEDICAL CONDITION] by the RT. She said she was shown how to suction and administer Resident #1's breathing treatments. She said she was unsure of Resident #1'[MEDICAL CONDITION]. She said she believed there was an [MEDICAL CONDITION] Resident #1's bedside. LVN B said she had not been inserviced on [MEDICAL CONDITION] or accidental dislodgement. She said the RT was responsible for making sure respiratory orders were correct. During an interview on 7/27/16 at 9:20 a.m., the DON said she expected the RT to have the necessary [MEDICAL CONDITION] supplies at bedside. She said she expected the residents with tracheostomies to have an [MEDICAL CONDITION] the correct size as well as one size smaller. She said the RT was responsible for making sure orders were correct and up to date. 2. A face sheet dated July 2016 indicated Resident #8 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. There was no indicattion in the [DIAGNOSES REDACTED]. The most recent care plan dated 3/23/16 indicated Resident #8 had a potential for impaired respiratory function related to the disease process of [MEDICAL CONDITION] with [MEDICAL CONDITION]. The goal was Resident #8 would maintain a patent airway with no signs and symptoms of respiratory distress. The interventions included to monitor oxygen saturations as ordered, and keep a spare [MEDICAL CONDITION] available for accidental dislodgment. A recent history and physical dated 06/01/16 indicated Resident #8 had a hospital admission related to healthcare associated pneumonia, acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. The most recent MDS dated [DATE] indicated Resident #8 was rarely/never understood and rarely/never understands others. Her cognition was severely impaired and she was unable to make decisions. Resident #8 required extensive assistance with bed mobility, and total assistance with dressing, eating, personal hygiene and bathing. The MDS indicated Resident #8 had a suprapubic catheter and was incontinent of bowel. She received [MEDICAL CONDITION] (trach) care, suctioning, and oxygen therapy. Readmission physician orders dated 7/06/16 did not contain any orders oxygenation via the [MEDICAL CONDITIONS] care, oxygenation saturations, or suctioning. Physician orders dated 7/07/16 indicated Resident #8 had a [MEDICAL CONDITION] with a T bar with humidifier. Physician orders, obtained after surveyor intervention, dated 7/25/16 indicated Resident #8 received oxygen at 4 liters via the [MEDICAL CONDITION] each shift, suctioning as needed each shift, and [MEDICAL CONDITION] care daily and as needed . A Physicians telephone order dated 7/26/16 indicated Resident #8 would have a pulse oximetry check every six hours and as needed. The physician's order did not indicate Resident #8's required level of oxygenation needs. During an observation and interview on 7/25/16 at 11:32 a.m., Resident #8 was in bed with humidified oxygen at 5 liters to her [MEDICAL CONDITION] via a [MEDICAL CONDITION] collar. The suction machine was not battery operated and was not pulled up to an emergency supply source. There was not an ambu bag at bedside. In the top drawer of Resident #8's bedside table were 3 boxes containing Shiley size 8 [MEDICAL CONDITION] sets. The treatment nurse said these were the emergency [MEDICAL CONDITION] sets for Resident #8. She said she was unsure of the size of the [MEDICAL CONDITION] Resident #8 should have. The treatment nurse said the RT would have the information. During an interview on 7/25/16 at 11:35 a.m., the RT said Resident #8 required suctioning every 3 to 4 hours. He said he was unsure of the size of Resident #8's [MEDICAL CONDITION]. During an interview on 7/25/16 at 3:00 p.m., LVN M said she was unaware of Resident #8's [MEDICAL CONDITION] size. She said she relied on the RT to provide the needed respiratory care. During an observation and interview on 7/25/16 at 4:00 p.m., the RT said he was not sure of Resident #8's [MEDICAL CONDITION] size. The RT removed the [MEDICAL CONDITION] collar and after viewing the [MEDICAL CONDITION] he said Resident #8's [MEDICAL CONDITION] was a Shiley 6 LPC. The RT said Resident #8's emergency tracheostomies stored at bedside were Shiley 8 LPC. The RT said the emergency [MEDICAL CONDITION] sets should be Shiley 6. He said in the event of an emergency Resident #8 would be sent to the local hospital because he did not have the correct size [MEDICAL CONDITION] available. During an observation on 7/25/16 at 4:05 p.m., the supply closet contained Shiley #6 and #7 inner cannulas, and Biovana #6 and #7 inner cannulas. There were no Shiley #8. During an interview on 7/25/16 at 4:35 p.m., the RT said he was ordering the emergency [MEDICAL CONDITION] sets for residents. He said the supplies would be delivered on 7/26/16. During an interview on 7/25/16 at 4:40 p.m., LVN M said Resident #8's emergency [MEDICAL CONDITION] sets were stored in Resident #8's bedside table. She said she had not been trained on emergency situations regarding Resident #8's [MEDICAL CONDITION]. LVN M said the needed emergency supply would be sterile water and suction. LVN M said there was no red plugs for the suction machine, no battery operated suction machine or an ambu bag available for Resident #8. During an observation and interview on 7/25/16 at 5:55 p.m., the facility's lights blinked off and on. An alarm was sounding loudly on hall 400 (where Resident #8 lived). LVN M walked to check the exit door alarming device. LVN M said she was unfamiliar with what alarm was sounding. After surveyor intervention, LVN M went to Resident #8's room and found Resident #8's oxygen concentrator was alarming and not functioning. LVN M attempted to turn the concentrator off and then on again. She said she would need get another concentrator. There was no portable oxygen in Resident #8's room. During an observation on 7/25/16 at 6:02 p.m., LVN M applied a tank of oxygen at 4 liters to Resident #8 while she prepared another oxygen concentrator. 3. A face sheet dated 7/25/16 indicated Resident #10 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. A care plan dated 4/01/16 indicated Resident #10 had a potential for respiratory distress related to acute [MEDICAL CONDITION]. The goal was to maintain a patent airway and have a backup [MEDICAL CONDITION] available for displacement. The most recent MDS dated [DATE] indicated Resident #10 sometimes understood others and sometimes was understood. He was independent in making decisions. Resident #10 required total assistance with all his ADLs. He received suctioning and [MEDICAL CONDITION] care. The Medication Administration Record [REDACTED]. A history and physical dated 5/05/16 indicated Resident #10 was hospitalized with acute respiratory distress with [MEDICAL CONDITION]. He was provided humidified oxygen through his [MEDICAL CONDITION], aggressive [MEDICAL CONDITION] toileting, breathing treatments, and suctioning. Consolidated physician orders dated 6/28/16 indicated Resident #10 had oxygen at 2 liters per minute via the [MEDICAL CONDITION] collar as needed, apply Trilogy at hour of sleep and as needed via [MEDICAL CONDITION], and monitor Trilogy every two hours while applied for proper functioning and document adverse events and notify the physician. The consolidated orders did not include [MEDICAL CONDITION] care, suctioning, [MEDICAL CONDITION] size, or desired level of oxygenation. The order for the Trilogy did not include any settings. During an observation and interview on 7/25/16 at 9:30 a.m., Resident #10 was in bed with humidified oxygen applied via a [MEDICAL CONDITION] at 2 liters per minute. Resident #10 said he was readmitted Saturday 7/23/16. After a hospitalization for pneumonia Resident #10 did not have an emergency tank of oxygen at bedside, a spare [MEDICAL CONDITION] set, or an ambu bag. During an interview on 7/25/16 at 11:15 a.m., the RT said he and the nurses were responsible for obtaining the respiratory orders. He said he could not locate the physician orders for Resident #10. During an observation and interview on 7/25/16 at 4:15 p.m., Resident #10 had a Shiley # 6 LPC [MEDICAL CONDITION] in place. The RT said Resident #10 did not have an emergency [MEDICAL CONDITION] or oxygen at his bedside. During an interview on 7/27/16 at 9:20 a.m., the DON said she expected the RT to have the [MEDICAL CONDITION] supplies at bedside for Resident #s 1, 8, and 10. She said she expected the residents with tracheostomies to have one size smaller and the same [MEDICAL CONDITION] inner cannulas available at bedside. During an interview on 7/27/16 at 9:39 a.m., the RT said he was responsible for the respiratory care of Resident #s 1, 8, and 10. He said, We dropped the ball on having the emergency supplies on hand for these residents. During an interview on 7/27/16 at 9:45 a.m., The RDO (regional director of operations) said he expected the RT to have the needed supplies at the bedside and anticipate the needs of the residents who required respiratory care. The Abuse Prohibition policy and procedure dated 1/01/12 indicated the residents have the right to be free from abuse, neglect, and misappropriation of resident property, corporal punishment and involuntary seclusion. (1) Our facility's leadership is committed to protecting our residents from abuse, mental or physical, including involuntary seclusion, neglect, or misappropriation of property by anyone including, but not necessarily limited to facility staff. RULE §217.11 Standards of Nursing Practice indicated The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others. Medical-Surgical Nursing by(NAME)M. Black and(NAME)Hokanson Hawks 7th edition Volume 2: pages 1369-2512 Box 62-2 page1780 Accidental decannulation of [MEDICAL CONDITION] and the preparation for a potential decannulation. The literature indicated to keep the following equipment at the client's bedside: extra [MEDICAL CONDITION] of the same size and one size smaller, obturator belonging to the existing tube, tracheal [MEDICATION NAME], oxygen source, suction catheters and suction source, and a resuscitation bag. An undated [MEDICAL CONDITION] Care Policy indicated, [MEDICAL CONDITION] care would be provided by licensed nursing staff or a licensed respiratory staff in accordance to the facility guidelines for [MEDICAL CONDITION] care. An undated [MEDICAL CONDITION] Equipment at Bedside policy and procedure indicated to have emergency [MEDICAL CONDITION] equipment at bedside. Procedure (1) All [MEDICAL CONDITION] patients will have the following equipment at bedside upon admission and readmission: replacement [MEDICAL CONDITION] set, ambu bag with [MEDICAL CONDITION] attachment, replacement inner cannula and a [MEDICAL CONDITION] suction kit. The RDO and DON were notified on 7/25/16 at 4:50 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/25/16 at 7:55 p.m. and included: *Resident #'s 8 and 10 both have back up [MEDICAL CONDITION] supplies (current size and one size smaller) at bedside as of 7/25/16. *Resident #1 with the Trilogy was sent to the local hospital on [DATE]. *Resident #8 has [MEDICAL CONDITION] care orders and oxygen orders as 7/25/16. *Licensed nurses will be educated on emergency procedures by 8:00 a.m. on 7/26/16 by the DON and the RT. No nurse will work on the floor before being in-serviced. Monitoring will be by the DON daily until complete. *The following measures have been put into place to ensure the alleged deficiency will not recur: all emergency [MEDICAL CONDITION] supplies will be monitored daily by nursing administration, all orders will be reviewed daily by nursing administration to ensure they are entered into the system correctly and transcribed to the appropriate flow sheet, and resident will have their devices powered by emergency power in the event of a power outage. Emergency procedures for Respiratory Residents: *Residents on oxygen concentrators can be placed on oxygen tanks at the ordered liter flow or concentrators will be moved to a red electrical outlet in the hallway. *Trilogy residents have a two hour battery power that will alarm when battery reaches low. The trilogy must be plugged in to a red electrical outlet in the hallway if the resident must remain on a trilogy. *Residents requiring suctioning will require connecting suction unit to a red electrical outlet in the hallway to operate suction unit. *Residents with [MEDICAL CONDITION] much have a spare [MEDICAL CONDITION] of same brand and size at bedside at all times and one size down. *Residents requiring breathing treatments will have to be connected to a red electrical outlet in the hallway. *Emergency bedside equipment: [MEDICAL CONDITION], oxygen, suction kit, concentrator operation procedures, and ambu bag. On 7/26/16 the surveyors confirmed the POR had been implemented sufficiently remove the IJ by: 5 RNs, 6 LVNs, and 1 RT were interviewed and said they were in-serviced on the emergency needs of the respiratory resident and their responsibility to obtain orders for respiratory care. Resident #1 was sent to the local hospital to meet his respiratory needs. Resident #8 and #10 had physician orders, and emergency trachs, oxygen, and an ambu bag at their bedsides. On 7/26/16 at 11:30 a.m., the DON and RN E were informed the IJ was removed: however, the facility remained out of compliance at a pattern for potential for more than minimal harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 7/25/16 indicated 3 residents had a [MEDICAL CONDITION].

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for 3 of 3 residents reviewed for neglect. (Resident #s 1, 8, and 10) The facility did not have replacement [MEDICAL CONDITION] and inner cannulas available in the event of accidental removal of the cannulas for Resident #s 1, 8, and 10. The facility did not have an ambu bag at bedside for Resident #s 8 and 10. The facility did not have an emergency supply of portable oxygen at the bedside for Resident #s 1, 8, and 10 in the event of a power outage. The facility did not ensure Resident #1's Trilogy (ventilator device) and Resident #'s 1 and 8 suction machines had an emergency direct power source. The facility did not have physician orders for the size of [MEDICAL CONDITION] (trach) tube, [MEDICAL CONDITION] care, oxygenation needs, or suctioning requirements for Resident #s 1, 8, and 10. The facility did not ensure nursing staff knew emergency procedures to implement related to [MEDICAL CONDITION]/ventilator care for Residents #s 1, 8, and 10. An Immediate Jeopardy situation was identified on 7/25/16. The Immediate Jeopardy was removed on 7/26/16. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 3 residents with tracheostomies at risk for neglect, serious injury and even death. Findings included: The Abuse Prohibition policy and procedure dated 1/01/12 indicated the residents have the right to be free from abuse, neglect, and misappropriation of resident property, corporal punishment and involuntary seclusion. (1) Our facility ' s leadership is committed to protecting our residents from abuse, mental or physical, including involuntary seclusion, neglect, or misappropriation of property by anyone including, but not necessarily limited to facility staff. An undated [MEDICAL CONDITION] Care Policy indicated, [MEDICAL CONDITION] care would be provided by licensed nursing staff or a licensed respiratory staff in accordance to the facility guidelines for [MEDICAL CONDITION] care . An undated [MEDICAL CONDITION] Equipment at Bedside policy and procedure indicated to have emergency [MEDICAL CONDITION] equipment at bedside. Procedure (1) All [MEDICAL CONDITION] patients will have the following equipment at bedside upon admission and readmission: replacement [MEDICAL CONDITION] set, ambu bag with [MEDICAL CONDITION] attachment, replacement inner cannula and a [MEDICAL CONDITION] suction kit. 1. A face sheet dated 3/11/16 indicated Resident #1 was [AGE] years old, admitted [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 could understand others and usually made himself understood. He required extensive assistance of two staff for transfers. He was totally dependent on staff for dressing, bathing, and hygiene. The MDS indicated Resident #1 received specialty care including oxygen therapy, suctioning, and [MEDICAL CONDITION] care. An undated Care Plan indicated Resident #1 had a [MEDICAL CONDITION] in place and would [MEDICAL CONDITION] daily and PRN(as needed). The care plan indicated staff would apply the Trilogy ventilator (mechanical ventilator that provides both volume and pressure ventilation and delivers the therapy either invasively, via a trach, or noninvasively, via a mask) at night and PRN and an [MEDICAL CONDITION] be available for accidental dislodgement. The care plan indicated Resident #1 was suctioned and staff would record how the resident tolerated the procedure and notify the physician of any changes. The care plan indicated Resident #1 would have a speaking valve for [MEDICAL CONDITION] awake hours and would be removed at night to place the ventilator. Physician orders dated 7/7/16 indicated Resident #1 would [MEDICAL CONDITION] daily and he would receive oxygen at 4 liters per minute via [MEDICAL CONDITION]. There were no orders for the ventilator on the resident's active chart. During an observation on 7/25/16 at 9:07 a.m., Resident #1 was sitting upright in his recliner. Oxygen was being administered [MEDICAL CONDITION] at 4 liters per minute. The ventilator, oxygen concentrator and suction machine were plugged into regular power outlets. There was no red plug for emergency power located inside the room. There were two emergency red outlets located in the hallway. There was [MEDICAL CONDITION] portable oxygen at the bedside in case of an emergency. During an interview on 7/25/16 at 11:58 a.m., the RT said Resident #1 had a [MEDICAL CONDITION] and was hooked to a Trilogy [MEDICAL CONDITION] at night. He said the resident received breathing treatments and suctioning every 4 hours and received [MEDICAL CONDITION]. The RT said he was responsible for Resident #1's respiratory needs Monday through Friday from 8:00 a.m. to 5:00 p.m. He said the nurses were responsible evenings after 5:00 p.m., nights, weekends and when he was off. He said the nurses had received training [MEDICAL CONDITION], breathing treatments and suctioning. The RT said Resident #1's Trilogy was not plugged into a red outlet at night. He said the Trilogy had a 2 hour battery that automatically came on in the case of a power outage. The RT said Resident #1 would be moved into the hallway during an emergency and if the power was going to be out for very long Resident #1 would be transferred to the hospital. The RT said he believed, but was not certain, Resident #1 had a [MEDICATION NAME][MEDICAL CONDITION] 6. He said there was not an [MEDICAL CONDITION] bedside, but he had one in the supply closet. During an interview on 7/25/16 at 12:15 p.m., the RT said he was unaware the Trilogy orders for Resident #1 were not on the chart. He said he did not know why the orders were not there. The RT said it was the responsibility of the nurses and himself to assure respiratory orders were correct. During an interview on 7/25/16 at 3:25 p.m., the RT said there was a clarification order in April. He said after the clarification order the ventilator orders stopped appearing on the physician's orders. He said the orders were correct on the MAR. He said he was not sure why this was happening, but they were working to correct the problem. The respiratory therapist found the orders from the thinned chart from medical records. After surveyor intervention, physician orders dated 7/25/16 for the Trilogy were placed on the chart. The order included: oxygen at 4 liters per minute [MEDICAL CONDITION]; may use Passy-muir speaking valve during the awake hours and remove Passy-muir valve to apply Trilogy at night; Trilogy AVAPS-AE, IPAP 15, EPAP 5, rate 14 and pressure support to 5-20 CUP at night; Apply Trilogy at night and PRN via trach. Monitor every 2 hours while applied for proper functioning. During an observation on 7/25/16 at 3:54 p.m., Resident #1 had a [MEDICATION NAME] size 6 [MEDICAL CONDITION] in place. During an interview on 7/25/16 at 3:56 p.m., the RT said he did not have a replacement [MEDICAL CONDITION] set for Resident #1's trach. He said he would have to send the resident to the hospital if there was an accidental dislodgement of his trach. During an observation on 7/25/16 at 4:05 p.m., the supply closet contained Shiley #6 and #7 inner cannulas, and [MEDICATION NAME] #6 and #7 inner cannulas. There were no [MEDICATION NAME][MEDICAL CONDITION] or inner cannulas. During an interview on 7/26/16 at 2:19 p.m., LVN B said she was inserviced [MEDICAL CONDITION] by the RT. She said she was shown how to suction and administer Resident #1's breathing treatments. She said she was unsure of Resident #1'[MEDICAL CONDITION]. She said she believed there was an [MEDICAL CONDITION] Resident #1's bedside. LVN B said she had not been inserviced on [MEDICAL CONDITION] or accidental dislodgement. She said the RT was responsible for making sure respiratory orders were correct. During an interview on 7/27/16 at 9:20 a.m., the DON said she expected the RT to have the necessary [MEDICAL CONDITION] supplies at bedside. She said she expected the residents with tracheostomies to have an [MEDICAL CONDITION] the correct size as well as one size smaller. She said the RT was responsible for making sure orders were correct and up to date. 2. A face sheet dated July 2016 indicated Resident #8 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. There was no indicattion in the [DIAGNOSES REDACTED]. The most recent care plan dated 3/23/16 indicated Resident #8 had a potential for impaired respiratory function related to the disease process of [MEDICAL CONDITION] with [MEDICAL CONDITION]. The goal was Resident #8 would maintain a patent airway with no signs and symptoms of respiratory distress. The interventions included to monitor oxygen saturations as ordered, and keep a spare [MEDICAL CONDITION] available for accidental dislodgment. A recent history and physical dated 06/01/16 indicated Resident #8 had a hospital admission related to healthcare associated pneumonia, acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. The most recent MDS dated [DATE] indicated Resident #8 was rarely/never understood and rarely/never understands others. Her cognition was severely impaired and she was unable to make decisions. Resident #8 required extensive assistance with bed mobility, and total assistance with dressing, eating, personal hygiene and bathing. The MDS indicated Resident #8 had a suprapubic catheter and was incontinent of bowel. She received [MEDICAL CONDITION] (trach) care, suctioning, and oxygen therapy. Readmission physician orders dated 7/06/16 did not contain any orders oxygenation via the [MEDICAL CONDITIONS] care, oxygenation saturations, or suctioning. Physician orders dated 7/07/16 indicated Resident #8 had a [MEDICAL CONDITION] with a T bar with humidifier. Physician orders dated 7/25/16 indicated Resident #8 received oxygen at 4 liters via the [MEDICAL CONDITION] each shift, suctioning as needed each shift, and [MEDICAL CONDITION] care daily and as needed after surveyor intervention. A Physicians telephone order dated 7/26/16 indicated Resident #8 would have a pulse oximetry check every six hours and as needed. The physician's order did not indicate Resident #8's required level of oxygenation needs. During an observation and interview on 7/25/16 at 11:32 a.m., Resident #8 was in bed with humidified oxygen at 5 liters to her [MEDICAL CONDITION] via a [MEDICAL CONDITION] collar. The suction machine was not battery operated and was not pulled up to an emergency supply source. There was not an ambu bag at bedside. In the top drawer of Resident #8's bedside table were 3 boxes containing Shiley size 8 [MEDICAL CONDITION] sets. The treatment nurse said these were the emergency [MEDICAL CONDITION] sets for Resident #8. She said she was unsure of the size of the [MEDICAL CONDITION] Resident #8 should have. The treatment nurse said the RT would have the information. During an interview on 7/25/16 at 11:35 a.m., the RT said Resident #8 required suctioning every 3 to 4 hours. He said he was unsure of the size of Resident #8's [MEDICAL CONDITION]. During an interview on 7/25/16 at 3:00 p.m., LVN M said she was unaware of Resident #8's [MEDICAL CONDITION] size. She said she relied on the RT to provide the needed respiratory care. During an observation and interview on 7/25/16 at 4:00 p.m., the RT said he was not sure of Resident #8's [MEDICAL CONDITION] size. The RT removed the [MEDICAL CONDITION] collar and after viewing the [MEDICAL CONDITION] he said Resident #8's [MEDICAL CONDITION] was a Shiley 6 LPC. The RT said Resident #8's emergency tracheostomies stored at bedside were Shiley 8 LPC. The RT said the emergency [MEDICAL CONDITION] sets should be Shiley 6. He said in the event of an emergency Resident #8 would be sent to the local hospital because he did not have the correct size [MEDICAL CONDITION] available. During an observation on 7/25/16 at 4:05 p.m., the supply closet contained Shiley #6 and #7 inner cannulas, and Biovana #6 and #7 inner cannulas. There were no Shiley #8. During an interview on 7/25/16 at 4:35 p.m., the RT said he was ordering the emergency [MEDICAL CONDITION] sets for residents. He said the supplies would be delivered on 7/26/16. During an interview on 7/25/16 at 4:40 p.m., LVN M said Resident #8's emergency [MEDICAL CONDITION] sets were stored in Resident #8's bedside table. She said she had not been trained on emergency situations regarding Resident #8's [MEDICAL CONDITION]. LVN M said the needed emergency supply would be sterile water and suction. LVN M said there was no red plugs for the suction machine, no battery operated suction machine or an ambu bag available for Resident #8. During an observation and interview on 7/25/16 at 5:55 p.m., the facility's lights blinked off and on. An alarm was sounding loudly on hall 400 (where Resident #8 lived). LVN M walked to check the exit door alarming device. LVN M said she was unfamiliar with what alarm was sounding. After surveyor intervention, LVN M went to Resident #8's room and found Resident #8's oxygen concentrator was alarming and not functioning. LVN M attempted to turn the concentrator off and then on again. She said she would need get another concentrator. There was no portable oxygen in Resident #8's room. During an observation on 7/25/16 at 6:02 p.m., LVN M applied a tank of oxygen at 4 liters to Resident #8 while she prepared another oxygen concentrator. 3. A face sheet dated 7/25/16 indicated Resident #10 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. A care plan dated 4/01/16 indicated Resident #10 had a potential for respiratory distress related to acute [MEDICAL CONDITION]. The goal was to maintain a patent airway and have a backup [MEDICAL CONDITION] available for displacement. The most recent MDS dated [DATE] indicated Resident #10 sometimes understood others and sometimes was understood. He was independent in making decisions. Resident #10 required total assistance with all his ADLs. He received suctioning and [MEDICAL CONDITION] care. The Medication Administration Record [REDACTED]. A history and physical dated 5/05/16 indicated Resident #10 was hospitalized with acute respiratory distress with [MEDICAL CONDITION]. He was provided humidified oxygen through his [MEDICAL CONDITION], aggressive [MEDICAL CONDITION] toileting, breathing treatments, and suctioning. Consolidated physician orders dated 6/28/16 indicated Resident #10 had oxygen at 2 liters per minute via the [MEDICAL CONDITION] collar as needed, apply Trilogy at hour of sleep and as needed via [MEDICAL CONDITION], and monitor Trilogy every two hours while applied for proper functioning and document adverse events and notify the physician. The consolidated orders did not include [MEDICAL CONDITION] care, suctioning, [MEDICAL CONDITION] size, or desired level of oxygenation. The order for the Trilogy did not include any settings. During an observation and interview on 7/25/16 at 9:30 a.m., Resident #10 was in bed with humidified oxygen applied via a [MEDICAL CONDITION] at 2 liters per minute. Resident #10 said he was readmitted Saturday 7/23/16. After a hospitalization for pneumonia Resident #10 did not have an emergency tank of oxygen at bedside, a spare [MEDICAL CONDITION] set, or an ambu bag. During an interview on 7/25/16 at 11:15 a.m., the RT said he and the nurses were responsible for obtaining the respiratory orders. He said he could not locate the physician orders for Resident #10. During an observation and interview on 7/25/16 at 4:15 p.m., Resident #10 had a Shiley # 6 LPC [MEDICAL CONDITION] in place. The RT said Resident #10 did not have an emergency [MEDICAL CONDITION] or oxygen at his bedside. During an interview on 7/27/16 at 9:20 a.m., the DON said she expected the RT to have the [MEDICAL CONDITION] supplies at bedside for Resident #s 1, 8, and 10. She said she expected the residents with tracheostomies to have one size smaller and the same [MEDICAL CONDITION] inner cannulas available at bedside. During an interview on 7/27/16 at 9:39 a.m., the RT said he was responsible for the respiratory care of Resident #s 1, 8, and 10. He said, We dropped the ball on having the emergency supplies on hand for these residents. During an interview on 7/27/16 at 9:45 a.m., The RDO (regional director of operations) said he expected the RT to have the needed supplies at the bedside and anticipate the needs of the residents who required respiratory care. RULE §217.11 Standards of Nursing Practice indicated The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others. Medical-Surgical Nursing by(NAME)M. Black and(NAME)Hokanson Hawks 7th edition Volume 2: pages 1369-2512 Box 62-2 page1780 Accidental decannulation of [MEDICAL CONDITION] and the preparation for a potential decannulation. The literature indicated to keep the following equipment at the client's bedside: extra [MEDICAL CONDITION] of the same size and one size smaller, obturator belonging to the existing tube, tracheal [MEDICATION NAME], oxygen source, suction catheters and suction source, and a resuscitation bag. The RDO and DON were notified on 7/25/16 at 4:50 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/25/16 at 7:55 p.m. and included: *Resident #'s 8 and 10 both have back up [MEDICAL CONDITION] supplies (current size and one size smaller) at bedside as of 7/25/16. *Resident #1 with the Trilogy was sent to the local hospital on [DATE]. *Resident #8 has [MEDICAL CONDITION] care orders and oxygen orders as 7/25/16. *Licensed nurses will be educated on emergency procedures by 8:00 a.m. on 7/26/16 by the DON and the RT. No nurse will work on the floor before being in-serviced. Monitoring will be by the DON daily until complete. *The following measures have been put into place to ensure the alleged deficiency will not recur: all emergency [MEDICAL CONDITION] supplies will be monitored daily by nursing administration, all orders will be reviewed daily by nursing administration to ensure they are entered into the system correctly and transcribed to the appropriate flow sheet, and resident will have their devices powered by emergency power in the event of a power outage. Emergency procedures for Respiratory Residents: *Residents on oxygen concentrators can be placed on oxygen tanks at the ordered liter flow or concentrators will be moved to a red electrical outlet in the hallway. *Trilogy residents have a two hour battery power that will alarm when battery reaches low. The trilogy must be plugged in to a red electrical outlet in the hallway if the resident must remain on a trilogy. *Residents requiring suctioning will require connecting suction unit to a red electrical outlet in the hallway to operate suction unit. *Residents with [MEDICAL CONDITION] much have a spare [MEDICAL CONDITION] of same brand and size at bedside at all times and one size down. *Residents requiring breathing treatments will have to be connected to a red electrical outlet in the hallway. *Emergency bedside equipment: [MEDICAL CONDITION], oxygen, suction kit, concentrator operation procedures, and ambu bag. On 7/26/16 the surveyors confirmed the POR had been implemented sufficiently remove the IJ by: 5 RNs, 6 LVNs, and 1 RT were interviewed and said they were in-serviced on the emergency needs of the respiratory resident and their responsibility to obtain orders for respiratory care. Resident #1 was sent to the local hospital to meet his respiratory needs. Resident #8 and #10 had physician orders, and emergency trachs, oxygen, and an ambu bag at their bedsides. On 7/26/16 at 11:30 a.m., the DON and RN E were informed the IJ was removed: however, the facility remained out of compliance at a pattern for potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 7/25/16 indicated 3 residents had a [MEDICAL CONDITION].

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for 3 of 3 residents reviewed for [MEDICAL CONDITION] care. (Residents #s 1, 8, and 10) The respiratory therapist did not provide proper ventilator and [MEDICAL CONDITION] care; -did not have replacement [MEDICAL CONDITION] and inner cannulas available in the event of accidental removal of the cannulas for Resident #s 1, 8, and 10; -did not have an ambu bag at bedside for Resident #s 8 and 10; - did not have an emergency supply of portable oxygen at the bedside for Resident #s 1, 8, and 10 in the event of a power outage; -did not ensure Resident #1's Trilogy (ventilator device), and suction machines had an emergency direct power source for Resident #s 1 and 8; and - did not have physician orders [REDACTED].#s 1, 8, and 10. An Immediate Jeopardy situation was identified on 7/25/16. The Immediate Jeopardy was removed on 7/26/16. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 3 residents with tracheotomies at risk for neglect, serious injury and even death. Findings included: During an interview on 7/27/16 at 9:20 a.m., the DON said she expected the RT to have the necessary tracheotomy supplies at bedside. She said she expected the residents with tracheotomies to have an [MEDICAL CONDITION] the correct size as well as one size smaller. She said the RT was responsible for making sure orders were correct and up to date. The DON said to prevent the reoccurrence of the IJ findings she was ensuring physician orders [REDACTED]. During an interview on 7/27/16 at 9:39 a.m., the RT said he was responsible for the respiratory care of Resident #s 1, 8, and 10. He said, We dropped the ball on having the emergency supplies on hand for Resident #s 1, 8 and 10. The RT said to prevent the IJ findings from reoccurring he would ensure all staff were properly trained on the emergency supplies needed for each resident, ensure adequate supplies would be available for the residents, and physician orders [REDACTED]. The RT said if Resident #10 had orders to return to the use of the Trilogy he would be sent to the local hospital for a higher level of care. During an interview on 7/27/16 at 9:45 a.m., the RDO indicated he expected the previous administrator to have had better leadership of the facility. He said he believed the poor leadership contributed to the IJ situation. The RDO said he expected the RT to have the needed supplies at the bedside and anticipate the needs of the residents with respiratory care. The RDO said the DON and RT would ensure all training regarding the IJ would be ongoing with all nurses prior to starting their shifts. He said the DON and RT would ensure orders, emergency supplies, and all other supplies would be on hand for each resident to meet their needs. The RDO said this process would occur on a daily basis. 1. A face sheet dated 3/11/16 indicated Resident #1 was [AGE] years old, admitted [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 could understand others and usually made himself understood. He required extensive assistance of two staff for transfers. He was totally dependent on staff for dressing, bathing, and hygiene. The MDS indicated Resident #1 received specialty care including oxygen therapy, suctioning, and [MEDICAL CONDITION] care. An undated Care Plan indicated Resident #1 had a [MEDICAL CONDITION] in place and would [MEDICAL CONDITION] daily and PRN(as needed). The care plan indicated staff would apply the Trilogy (mechanical ventilator that provides both volume and pressure ventilation and delivers the therapy either invasively, via a trach, or noninvasively, via a mask) at night and PRN and an [MEDICAL CONDITION] be available for accidental dislodgement. The care plan indicated Resident #1 was suctioned and staff would record how the resident tolerated the procedure and notify the physician of any changes. The care plan indicated Resident #1 would have a Passy-muir speaking valve during awake hours and would be removed at night to place the Trilogy. Physician orders [REDACTED].#1 would [MEDICAL CONDITION] daily and the resident would receive oxygen at 4 liters per minute [MEDICAL CONDITION]. There were no orders for the Trilogy. The Respiratory Therapist found the orders from the thinned chart from medical records. After surveyor intervention, physician orders [REDACTED]. The order included: oxygen at 4 liters per minute [MEDICAL CONDITION]; may use Passy-muir speaking valve during the awake hours and remove Passy-muir valve to apply Trilogy at night; Trilogy AVAPS-AE, IPAP 15, EPAP 5, rate 14 and pressure support to 5-20 CUP at night; Apply Trilogy at night and PRN via trach. Monitor every 2 hours while applied for proper functioning. During an observation on 7/25/16 at 9:07 a.m., Resident #1 was sitting upright in his recliner. Oxygen was being administered [MEDICAL CONDITION] at 4 liters per minute. The Trilogy, oxygen concentrator, and suction machine were plugged into regular power outlets. There was no red plug for emergency power located inside the room. There were two emergency red outlets located in the hallway. There was [MEDICAL CONDITION] portable oxygen at bedside in case of an emergency. During an interview on 7/25/16 at 11:58 a.m., the RT said Resident #1 had a [MEDICAL CONDITION] and was hooked to a Trilogy [MEDICAL CONDITION] at night. He said he received breathing treatments and suctioning every 4 hours and received [MEDICAL CONDITION]. The RT said he was responsible for Resident #1's respiratory needs while he was there. He said the nurses were responsible when he was gone. He said the nurses had received training [MEDICAL CONDITION], breathing treatments and suctioning. The RT said Resident #1's Trilogy was not plugged into a red outlet at night. He said the Trilogy had a 2 hour battery that automatically came on in the case of a power outage. The RT said Resident #1 would be moved into the hallway during an emergency and if the power was going to be out for very long Resident #1 would be transferred to the hospital. The RT said he believed Resident #1 had a [MEDICATION NAME][MEDICAL CONDITION] 6. He said there was not an [MEDICAL CONDITION] bedside, but he had one in the supply closet. During an interview on 7/25/16 at 12:15 p.m., the RT said he was unaware the Trilogy orders for Resident #1 were not on the chart. He said he did not know why the orders were not there. The RT said it was the responsibility of the nurses and himself to assure orders were correct. During an interview on 7/25/16 at 3:25 p.m., the RT said there had been a clarification order in April. He said after the clarification order the Trilogy orders stopped appearing on the physician's orders [REDACTED]. He said he was not sure why this was happening, but they were working to correct the problem. During an observation on 7/25/16 at 3:54 p.m., Resident #1 had a [MEDICATION NAME] size 6 [MEDICAL CONDITION] in place. During an interview on 7/25/16 at 3:56 p.m., the RT said he did not have a replacement for Resident #1's trach. He said he would have to send the resident to the hospital if there was an accidental dislodgement of his trach. During an observation on 7/25/16 at 4:05 p.m., the supply closet contained Shiley #6 and #7 inner cannulas, and Biovana #6 and #7 inner cannulas. During an interview on 7/26/16 at 2:19 p.m., LVN B said she had been inserviced [MEDICAL CONDITION] by the RT. She said she was shown how to suction and administer Resident #1's breathing treatments. She said she was unsure of Resident #1'[MEDICAL CONDITION]. She said she believed there was an [MEDICAL CONDITION] Resident #1's bedside. LVN B said she had not been inserviced on [MEDICAL CONDITION] or accidental dislodgement. She said the RT was responsible for making sure orders were correct. During an interview on 7/27/16 at 9:20 a.m., the DON said she expected the RT to have the necessary [MEDICAL CONDITION] supplies at bedside. She said she expected the residents with tracheostomies to have an [MEDICAL CONDITION] the correct size as well as one size smaller. She said the RT was responsible for making sure orders were correct and up to date. 2) A face sheet dated July 2016 indicated Resident #8 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #8 was rarely/never understood and rarely/never understands others. Her cognition was severely impaired and she was unable to make decisions. Resident #8 required extensive assistance with bed mobility, and total assistance with dressing, eating, personal hygiene and bathing. The MDS indicated Resident #8 had a suprapubic catheter and was incontinent of bowel. She received [MEDICAL CONDITION] care, suctioning, and oxygen therapy. The most recent care plan dated 3/23/16 indicated Resident #8 had a potential for impaired respiratory function related to the disease process of [MEDICAL CONDITION] with [MEDICAL CONDITION]. The goal was Resident #8 would maintain a patent airway with no signs and symptoms of respiratory distress. The interventions included to monitor oxygen saturations as ordered, and keep a spare [MEDICAL CONDITION] available for accidental dislodgment. A recent history and physical dated 06/01/16 indicated Resident #8 had a hospital admission related to healthcare associated pneumonia, acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. A chest x-ray indicated bibasilar infiltrates and atelectasis with worsening on the right lung and enlarging right pleural effusion. Readmission physician orders [REDACTED]. Physician orders [REDACTED].#8 had a [MEDICAL CONDITION] with a T bar with humidifier each shift. Physician orders [REDACTED].#8 received oxygen at 4 liters via the [MEDICAL CONDITION] each shift, suctioning as needed each shift, and [MEDICAL CONDITION] care daily and as needed after surveyor intervention. A Physicians telephone order dated 7/26/16 indicated Resident #8 would have a pulse oximetry check every six hours and as needed. During an observation and interview on 7/25/16 at 11:32 a.m., Resident #8 was asleep resting in her bed. She had humidified oxygen at 5 liters to her [MEDICAL CONDITION] via a [MEDICAL CONDITION] collar. In the top drawer of Resident #8's bedside table were 3 boxes containing Shiley size 8 [MEDICAL CONDITION] sets. The treatment nurse said these were the emergency [MEDICAL CONDITION] sets for Resident #8. During an interview on 7/25/16 at 11:35 a.m., the RT said Resident #8 required suctioning every 3 to 4 hours and there were no ventilators in the facility. During an interview on 7/25/16 at 3:00 p.m., LVN M said she was unaware of Resident #8's [MEDICAL CONDITION] size. She said she relied on the RT to provide the needed respiratory care. During an observation and interview on 7/25/16 at 4:00 p.m., the RT said he was not sure of Resident #8's [MEDICAL CONDITION] size. The RT removed the [MEDICAL CONDITION] collar and after viewing the [MEDICAL CONDITION] he said Resident #8's [MEDICAL CONDITION] was a Shiley 6 LPC. The RT said Resident #8's emergency tracheostomies stored at bedside were Shiley 8 LPC. The RT said the emergency [MEDICAL CONDITION] sets should be Shiley 6. He said in the event of an emergency Resident #8 would be sent to the local hospital because he did not have the correct size [MEDICAL CONDITION] available. During an observation on 7/25/16 at 4:05 p.m., the supply closet contained Shiley #6 and #7 inner cannulas, and Biovana #6 and #7 inner cannulas. During an interview on 7/25/16 at 4:35 p.m., the RT said he was ordering the emergency [MEDICAL CONDITION] sets for Resident #'s 1, 8 and 10. He said the supplies would be delivered on 7/26/16. During an interview on 7/25/16 at 4:40 p.m., LVN M said Resident #8's emergency [MEDICAL CONDITION] sets were stored in Resident #8's bedside table. She said she had not been trained on emergency situations regarding Resident #8's [MEDICAL CONDITION]. LVN M said the needed emergency supply would be sterile water and suction. During an observation and interview on 7/25/16 at 5:55 p.m., the facility's lights blinked off and on. An alarm was sounding loudly on hall 400. LVN M went to check the exit door alarming device. LVN M said she was unfamiliar with what alarm was sounding. After surveyor intervention, LVN M was alerted to Resident #8's room. Resident #8's oxygen concentrator was alarming and not functioning. LVN M attempted to turn the concentrator off and then on again. She said I will have to get another concentrator. She said there was no portable oxygen in Resident #8's room. During an observation on 7/25/16 at 6:02 p.m., LVN M applied an E-tank of oxygen at 4 liters to Resident #8 while she prepared another oxygen concentrator. 3) A face sheet dated 7/25/16 indicated Resident #10 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #10 sometimes understood others and sometimes was understood. He was independent in making decisions. Resident #10 required total assistance with all his ADLs. He received suctioning and [MEDICAL CONDITION] care. A care plan dated 4/01/16 indicated Resident #10 had a potential for respiratory distress related to acute [MEDICAL CONDITION]. The goal was to maintain a patent airway and have a backup [MEDICAL CONDITION] available for displacement. The Medication Administration Record [REDACTED]. A history and physical dated 6/02/16 indicated Resident #10 was hospitalized with the [DIAGNOSES REDACTED]. A history and physical dated 5/05/16 indicated Resident #10 was hospitalized with acute respiratory distress with [MEDICAL CONDITION]. He was provided humidified oxygen through his [MEDICAL CONDITION], aggressive [MEDICAL CONDITION] toileting, breathing treatments, and suctioning. A telephone order dated 7/23/16 at 7:35 p.m., indicated Resident #10 was readmitted with resume all previous orders. Consolidated physician orders [REDACTED].#10 had oxygen at 2 liters per minute via the [MEDICAL CONDITION] collar as needed, apply Trilogy at hour of sleep and as needed via [MEDICAL CONDITION], and monitor Trilogy every two hours while applied for proper functioning and document adverse events and notify the physician. The consolidated orders did not include [MEDICAL CONDITION] care or suctioning, [MEDICAL CONDITION] size. The order for the Trilogy did not include any settings. During an observation and interview on 7/25/16 at 9:30 a.m., Resident #10 was resting in bed with humidified oxygen applied via a [MEDICAL CONDITION] at 2 liters per minute. Resident #10 said he had readmitted Saturday 7/23/16. He said he had pneumonia and was sent to the hospital. Resident #10 did not have an emergency E-tank of oxygen at bedside, a spare [MEDICAL CONDITION] set, or an ambu bag. During an interview on 7/25/16 at 11:15 a.m., the RT said he and the nurses were responsible for obtaining the respiratory orders. He said he could not locate the physician orders [REDACTED]. During an observation and interview on 7/25/16 at 4:15 p.m., Resident #10 had a Shiley 6 LPC [MEDICAL CONDITION] in place. The RT said Resident #10 did not have an emergency [MEDICAL CONDITION] or oxygen at bedside. During an interview on 7/27/16 at 9:20 a.m., the DON said she expected the RT to have the [MEDICAL CONDITION] supplies at bedside for Resident #s 1, 8, and 10. She said she expected the residents with tracheostomies to have one size smaller and the same size available at bedside. The Abuse Prohibition policy and procedure dated 1/01/12 indicated the residents have the right to be free from abuse, neglect, and misappropriation of resident property, corporal punishment and involuntary seclusion. (1) Our facility's leadership is committed to protecting our residents from abuse, mental or physical, including involuntary seclusion, neglect, or misappropriation of property by anyone including, but not necessarily limited to facility staff. An undated [MEDICAL CONDITION] Care Policy indicated, [MEDICAL CONDITION] care would be provided by licensed nursing staff or a licensed respiratory staff in accordance to the facility guidelines for [MEDICAL CONDITION] care. An undated [MEDICAL CONDITION] Equipment at Bedside policy and procedure indicated to have emergency [MEDICAL CONDITION] equipment at bedside. Procedure (1) All [MEDICAL CONDITION] patients will have the following equipment at bedside upon admission and readmission: replacement [MEDICAL CONDITION] set, ambu bag with [MEDICAL CONDITION] attachment, replacement inner cannula and a [MEDICAL CONDITION] suction kit. The RDO and DON were notified on 7/25/16 at 4:50 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/25/16 at 7:55 p.m. and included: *Resident #'s 8 and 10 both have back up [MEDICAL CONDITION] supplies (current size and one size smaller) at bedside as of 7/25/16. *Resident #1 with the trilogy was sent to the local hospital on [DATE]. *Resident #8 has [MEDICAL CONDITION] care orders and oxygen orders as 7/25/16. *Licensed nurses will be educated on emergency procedures by 8:00 a.m. on 7/26/16 by the DON and the RT. No nurse will work on the floor before being in-serviced. Monitoring will be by the DON daily until complete. *The following measures have been put into place to ensure the alleged deficiency will not recur: all emergency [MEDICAL CONDITION] supplies will be monitored daily by nursing administration, all orders will be reviewed daily by nursing administration to ensure they are entered into the system correctly and transcribed to the appropriate flow sheet, and resident will have their devices powered by emergency power in the event of a power outage. Emergency procedures for Respiratory Residents: *Residents on oxygen concentrators can be placed on oxygen tanks at the ordered liter flow or concentrators will be moved to a red electrical outlet in the hallway. *Trilogy residents have a two hour battery power that will alarm when battery reaches low. The trilogy must be plugged in to a red electrical outlet in the hallway if the resident must remain on a trilogy. *Residents requiring suctioning will require connecting suction unit to a red electrical outlet in the hallway to operate suction unit. *Residents with [MEDICAL CONDITION] much have a spare [MEDICAL CONDITION] of same brand and size at bedside at all times and one size down. *Residents requiring breathing treatments will have to be connected to a red electrical outlet in the hallway. *Emergency bedside equipment: [MEDICAL CONDITION], oxygen, suction kit, concentrator operation procedures, and ambu bag. On 7/26/16 the surveyors confirmed the POR had been implemented sufficiently remove the IJ by: 5 RNs, 6 LVNs, and 1 RT were interviewed and said they were in-serviced on the emergency needs of the respiratory resident and their responsibility to obtain orders for respiratory care. Resident #1 remained at the local hospital to meet his respiratory needs. Resident #8 and #10 had physician orders, emergency [MEDICAL CONDITION] and oxygen at bedside, and an ambu bag. On 7/26/16 at 11:30 a.m., the DON and RN E were informed the IJ was removed: however, the facility remained out of compliance at a pattern for potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 7/25/16 indicated 3 residents had a [MEDICAL CONDITION].

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment for [REDACTED].#s 1, 8 and 10) and 1 of 1 resident for proper ventilator management (Resident #1). The facility did not have replacement [MEDICAL CONDITION] and inner cannulas available in the event of accidental removal of the cannulas for Resident #s 1, 8, and 10. The facility did not have an ambu bag at bedside for Resident #s 8 and 10. The facility did not have an emergency supply of portable oxygen at the bedside for Resident #s 1, 8, and 10 in the event of a power outage. The facility did not ensure Resident #1's Trilogy (ventilator device), and Resident #'s 1 and 8 suction machines had an emergency direct power source. The facility did not have physician orders for the size of [MEDICAL CONDITION] (trach) tube, [MEDICAL CONDITION] care, oxygenation needs, or suctioning requirements for Resident #s 1, 8, and 10. The facility did not ensure nursing staff knew emergency procedures to implement related to [MEDICAL CONDITION]/ventilator care for Residents #s 1, 8, and 10. An Immediate Jeopardy situation was identified on 7/25/16. The Immediate Jeopardy was removed on 7/26/16. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 3 residents with tracheostomies at risk of not receiving the adequate respiratory care and services which could result in decreased oxygenation or death. Findings included: 1. A face sheet dated 3/11/16 indicated Resident #1 was [AGE] years old, admitted [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 could understand others and usually made himself understood. He required extensive assistance of two staff for transfers. He was totally dependent on staff for dressing, bathing, and hygiene. The MDS indicated Resident #1 received specialty care including oxygen therapy, suctioning, and [MEDICAL CONDITION] care. An undated Care Plan indicated Resident #1 had a [MEDICAL CONDITION] in place and would [MEDICAL CONDITION] daily and PRN(as needed). The care plan indicated staff would apply the Trilogy ventilator (mechanical ventilator that provides both volume and pressure ventilation and delivers the therapy either invasively, via a trach, or noninvasively, via a mask) at night and PRN and an [MEDICAL CONDITION] be available for accidental dislodgement. The care plan indicated Resident #1 was suctioned and staff would record how the resident tolerated the procedure and notify the physician of any changes. The care plan indicated Resident #1 would have a speaking valve for [MEDICAL CONDITION] awake hours and would be removed at night to place the ventilator. Physician orders dated 7/7/16 indicated Resident #1 would [MEDICAL CONDITION] daily and he would receive oxygen at 4 liters per minute via [MEDICAL CONDITION]. There were no orders for the ventilator on the resident's active chart. During an observation on 7/25/16 at 9:07 a.m., Resident #1 was sitting upright in his recliner. Oxygen was being administered [MEDICAL CONDITION] at 4 liters per minute. The ventilator, oxygen concentrator and suction machine were plugged into regular power outlets. There was no red plug for emergency power located inside the room. There were two emergency red outlets located in the hallway. There was [MEDICAL CONDITION] portable oxygen at the bedside in case of an emergency. During an interview on 7/25/16 at 11:58 a.m., the RT said Resident #1 had a [MEDICAL CONDITION] and was hooked to a Trilogy [MEDICAL CONDITION] at night. He said the resident received breathing treatments and suctioning every 4 hours and received [MEDICAL CONDITION]. The RT said he was responsible for Resident #1's respiratory needs Monday through Friday from 8:00 a.m. to 5:00 p.m. He said the nurses were responsible evenings after 5:00 p.m., nights, weekends and when he was off. He said the nurses had received training [MEDICAL CONDITION], breathing treatments and suctioning. The RT said Resident #1's Trilogy was not plugged into a red outlet at night. He said the Trilogy had a 2 hour battery that automatically came on in the case of a power outage. The RT said Resident #1 would be moved into the hallway during an emergency and if the power was going to be out for very long Resident #1 would be transferred to the hospital. The RT said he believed, but was not certain, Resident #1 had a [MEDICATION NAME][MEDICAL CONDITION] 6. He said there was not an [MEDICAL CONDITION] bedside, but he had one in the supply closet. During an interview on 7/25/16 at 12:15 p.m., the RT said he was unaware the Trilogy orders for Resident #1 were not on the chart. He said he did not know why the orders were not there. The RT said it was the responsibility of the nurses and himself to assure respiratory orders were correct. During an interview on 7/25/16 at 3:25 p.m., the RT said there was a clarification order in April. He said after the clarification order the ventilator orders stopped appearing on the physician's orders. He said the orders were correct on the MAR. He said he was not sure why this was happening, but they were working to correct the problem. The respiratory therapist found the orders from the thinned chart from medical records. After surveyor intervention, physician orders dated 7/25/16 for the Trilogy were placed on the chart. The order included: oxygen at 4 liters per minute [MEDICAL CONDITION]; may use Passy-muir speaking valve during the awake hours and remove Passy-muir valve to apply Trilogy at night; Trilogy AVAPS-AE, IPAP 15, EPAP 5, rate 14 and pressure support to 5-20 CUP at night; Apply Trilogy at night and PRN via trach. Monitor every 2 hours while applied for proper functioning. During an observation on 7/25/16 at 3:54 p.m., Resident #1 had a [MEDICATION NAME] size 6 [MEDICAL CONDITION] in place. During an interview on 7/25/16 at 3:56 p.m., the RT said he did not have a replacement [MEDICAL CONDITION] set for Resident #1's trach. He said he would have to send the resident to the hospital if there was an accidental dislodgement of his trach. During an observation on 7/25/16 at 4:05 p.m., the supply closet contained Shiley #6 and #7 inner cannulas, and [MEDICATION NAME] #6 and #7 inner cannulas. There were no [MEDICATION NAME][MEDICAL CONDITION] or inner cannulas. During an interview on 7/26/16 at 2:19 p.m., LVN B said she was inserviced [MEDICAL CONDITION] by the RT. She said she was shown how to suction and administer Resident #1's breathing treatments. She said she was unsure of Resident #1'[MEDICAL CONDITION]. She said she believed there was an [MEDICAL CONDITION] Resident #1's bedside. LVN B said she had not been inserviced on [MEDICAL CONDITION] or accidental dislodgement. She said the RT was responsible for making sure respiratory orders were correct. During an interview on 7/27/16 at 9:20 a.m., the DON said she expected the RT to have the necessary [MEDICAL CONDITION] supplies at bedside. She said she expected the residents with tracheostomies to have an [MEDICAL CONDITION] the correct size as well as one size smaller. She said the RT was responsible for making sure orders were correct and up to date. 2. A face sheet dated July 2016 indicated Resident #8 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. There was no indicattion in the [DIAGNOSES REDACTED]. The most recent care plan dated 3/23/16 indicated Resident #8 had a potential for impaired respiratory function related to the disease process of [MEDICAL CONDITION] with [MEDICAL CONDITION]. The goal was Resident #8 would maintain a patent airway with no signs and symptoms of respiratory distress. The interventions included to monitor oxygen saturations as ordered, and keep a spare [MEDICAL CONDITION] available for accidental dislodgment. A recent history and physical dated 06/01/16 indicated Resident #8 had a hospital admission related to healthcare associated pneumonia, acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. The most recent MDS dated [DATE] indicated Resident #8 was rarely/never understood and rarely/never understands others. Her cognition was severely impaired and she was unable to make decisions. Resident #8 required extensive assistance with bed mobility, and total assistance with dressing, eating, personal hygiene and bathing. The MDS indicated Resident #8 had a suprapubic catheter and was incontinent of bowel. She received [MEDICAL CONDITION] (trach) care, suctioning, and oxygen therapy. Readmission physician orders dated 7/06/16 did not contain any orders for oxygenation via the [MEDICAL CONDITIONS] care, oxygenation saturations, or suctioning. Physician orders dated 7/07/16 indicated Resident #8 had a [MEDICAL CONDITION] with a T bar with humidifier. Physician orders, obtained after surveyor intervention, dated 7/25/16 indicated Resident #8 received oxygen at 4 liters via the [MEDICAL CONDITION] each shift, suctioning as needed each shift, and [MEDICAL CONDITION] care daily and as needed . A Physicians telephone order dated 7/26/16 indicated Resident #8 would have a pulse oximetry check every six hours and as needed. The physician's order did not indicate Resident #8's required level of oxygenation needs. During an observation and interview on 7/25/16 at 11:32 a.m., Resident #8 was in bed with humidified oxygen at 5 liters to her [MEDICAL CONDITION] via a [MEDICAL CONDITION] collar. The suction machine was not battery operated and was not pulled up to an emergency supply source. There was not an ambu bag at bedside. In the top drawer of Resident #8's bedside table were 3 boxes containing Shiley size 8 [MEDICAL CONDITION] sets. The treatment nurse said these were the emergency [MEDICAL CONDITION] sets for Resident #8. She said she was unsure of the size of the [MEDICAL CONDITION] Resident #8 should have. The treatment nurse said the RT would have the information. During an interview on 7/25/16 at 11:35 a.m., the RT said Resident #8 required suctioning every 3 to 4 hours. He said he was unsure of the size of Resident #8's [MEDICAL CONDITION]. During an interview on 7/25/16 at 3:00 p.m., LVN M said she was unaware of Resident #8's [MEDICAL CONDITION] size. She said she relied on the RT to provide the needed respiratory care. During an observation and interview on 7/25/16 at 4:00 p.m., the RT said he was not sure of Resident #8's [MEDICAL CONDITION] size. The RT removed the [MEDICAL CONDITION] collar and after viewing the [MEDICAL CONDITION] he said Resident #8's [MEDICAL CONDITION] was a Shiley 6 LPC. The RT said Resident #8's emergency tracheostomies stored at bedside were Shiley 8 LPC. The RT said the emergency [MEDICAL CONDITION] sets should be Shiley 6. He said in the event of an emergency Resident #8 would be sent to the local hospital because he did not have the correct size [MEDICAL CONDITION] available. During an observation on 7/25/16 at 4:05 p.m., the supply closet contained Shiley #6 and #7 inner cannulas, and Biovana #6 and #7 inner cannulas. There were no Shiley #8. During an interview on 7/25/16 at 4:35 p.m., the RT said he was ordering the emergency [MEDICAL CONDITION] sets for residents. He said the supplies would be delivered on 7/26/16. During an interview on 7/25/16 at 4:40 p.m., LVN M said Resident #8's emergency [MEDICAL CONDITION] sets were stored in Resident #8's bedside table. She said she had not been trained on emergency situations regarding Resident #8's [MEDICAL CONDITION]. LVN M said the needed emergency supply would be sterile water and suction. LVN M said there was no red plugs for the suction machine, no battery operated suction machine or an ambu bag available for Resident #8. During an observation and interview on 7/25/16 at 5:55 p.m., the facility's lights blinked off and on. An alarm was sounding loudly on hall 400 (where Resident #8 lived). LVN M walked to check the exit door alarming device. LVN M said she was unfamiliar with what alarm was sounding. After surveyor intervention, LVN M went to Resident #8's room and found Resident #8's oxygen concentrator was alarming and not functioning. LVN M attempted to turn the concentrator off and then on again. She said she would need get another concentrator. There was no portable oxygen in Resident #8's room. During an observation on 7/25/16 at 6:02 p.m., LVN M applied a tank of oxygen at 4 liters to Resident #8 while she prepared another oxygen concentrator. 3. A face sheet dated 7/25/16 indicated Resident #10 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. A care plan dated 4/01/16 indicated Resident #10 had a potential for respiratory distress related to acute [MEDICAL CONDITION]. The goal was to maintain a patent airway and have a backup [MEDICAL CONDITION] available for displacement. The most recent MDS dated [DATE] indicated Resident #10 sometimes understood others and sometimes was understood. He was independent in making decisions. Resident #10 required total assistance with all his ADLs. He received suctioning and [MEDICAL CONDITION] care. The Medication Administration Record [REDACTED]. A history and physical dated 5/05/16 indicated Resident #10 was hospitalized with acute respiratory distress with [MEDICAL CONDITION]. He was provided humidified oxygen through his [MEDICAL CONDITION], aggressive [MEDICAL CONDITION] toileting, breathing treatments, and suctioning. Consolidated physician orders dated 6/28/16 indicated Resident #10 had oxygen at 2 liters per minute via the [MEDICAL CONDITION] collar as needed, apply Trilogy at hour of sleep and as needed via [MEDICAL CONDITION], and monitor Trilogy every two hours while applied for proper functioning and document adverse events and notify the physician. The consolidated orders did not include [MEDICAL CONDITION] care, suctioning, [MEDICAL CONDITION] size, or desired level of oxygenation. The order for the Trilogy did not include any settings. During an observation and interview on 7/25/16 at 9:30 a.m., Resident #10 was in bed with humidified oxygen applied via a [MEDICAL CONDITION] at 2 liters per minute. Resident #10 said he was readmitted Saturday 7/23/16. After a hospitalization for pneumonia Resident #10 did not have an emergency tank of oxygen at bedside, a spare [MEDICAL CONDITION] set, or an ambu bag. During an interview on 7/25/16 at 11:15 a.m., the RT said he and the nurses were responsible for obtaining the respiratory orders. He said he could not locate the physician orders for Resident #10. During an observation and interview on 7/25/16 at 4:15 p.m., Resident #10 had a Shiley # 6 LPC [MEDICAL CONDITION] in place. The RT said Resident #10 did not have an emergency [MEDICAL CONDITION] or oxygen at his bedside. During an interview on 7/27/16 at 9:20 a.m., the DON said she expected the RT to have the [MEDICAL CONDITION] supplies at bedside for Resident #s 1, 8, and 10. She said she expected the residents with tracheostomies to have one size smaller and the same [MEDICAL CONDITION] inner cannulas available at bedside. During an interview on 7/27/16 at 9:39 a.m., the RT said he was responsible for the respiratory care of Resident #s 1, 8, and 10. He said, We dropped the ball on having the emergency supplies on hand for these residents. During an interview on 7/27/16 at 9:45 a.m., The RDO (regional director of operations) said he expected the RT to have the needed supplies at the bedside and anticipate the needs of the residents who required respiratory care. RULE §217.11 Standards of Nursing Practice indicated The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others. Medical-Surgical Nursing by(NAME)M. Black and(NAME)Hokanson Hawks 7th edition Volume 2: pages 1369-2512 Box 62-2 page1780 Accidental decannulation of [MEDICAL CONDITION] and the preparation for a potential decannulation. The literature indicated to keep the following equipment at the client's bedside: extra [MEDICAL CONDITION] of the same size and one size smaller, obturator belonging to the existing tube, tracheal [MEDICATION NAME], oxygen source, suction catheters and suction source, and a resuscitation bag. An undated [MEDICAL CONDITION] Care Policy indicated, [MEDICAL CONDITION] care would be provided by licensed nursing staff or a licensed respiratory staff in accordance to the facility guidelines for [MEDICAL CONDITION] care. An undated [MEDICAL CONDITION] Equipment at Bedside policy and procedure indicated to have emergency [MEDICAL CONDITION] equipment at bedside. Procedure (1) All [MEDICAL CONDITION] patients will have the following equipment at bedside upon admission and readmission: replacement [MEDICAL CONDITION] set, ambu bag with [MEDICAL CONDITION] attachment, replacement inner cannula and a [MEDICAL CONDITION] suction kit. The RDO and DON were notified on 7/25/16 at 4:50 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/25/16 at 7:55 p.m. and included: *Resident #'s 8 and 10 both have back up [MEDICAL CONDITION] supplies (current size and one size smaller) at bedside as of 7/25/16. *Resident #1 with the Trilogy was sent to the local hospital on [DATE]. *Resident #8 has [MEDICAL CONDITION] care orders and oxygen orders as 7/25/16. *Licensed nurses will be educated on emergency procedures by 8:00 a.m. on 7/26/16 by the DON and the RT. No nurse will work on the floor before being in-serviced. Monitoring will be by the DON daily until complete. *The following measures have been put into place to ensure the alleged deficiency will not recur: all emergency [MEDICAL CONDITION] supplies will be monitored daily by nursing administration, all orders will be reviewed daily by nursing administration to ensure they are entered into the system correctly and transcribed to the appropriate flow sheet, and resident will have their devices powered by emergency power in the event of a power outage. Emergency procedures for Respiratory Residents: *Residents on oxygen concentrators can be placed on oxygen tanks at the ordered liter flow or concentrators will be moved to a red electrical outlet in the hallway. *Trilogy residents have a two hour battery power that will alarm when battery reaches low. The trilogy must be plugged in to a red electrical outlet in the hallway if the resident must remain on a trilogy. *Residents requiring suctioning will require connecting suction unit to a red electrical outlet in the hallway to operate suction unit. *Residents with [MEDICAL CONDITION] much have a spare [MEDICAL CONDITION] of same brand and size at bedside at all times and one size down. *Residents requiring breathing treatments will have to be connected to a red electrical outlet in the hallway. *Emergency bedside equipment: [MEDICAL CONDITION], oxygen, suction kit, concentrator operation procedures, and ambu bag. On 7/26/16 the surveyors confirmed the POR had been implemented sufficiently remove the IJ by: 5 RNs, 6 LVNs, and 1 RT were interviewed and said they were in-serviced on the emergency needs of the respiratory resident and their responsibility to obtain orders for respiratory care. Resident #1 was sent to the local hospital to meet his respiratory needs. Resident #8 and #10 had physician orders, and emergency trachs, oxygen, and an ambu bag at their bedsides. On 7/26/16 at 11:30 a.m., the DON and RN E were informed the IJ was removed: however, the facility remained out of compliance at a pattern for potential for more than minimal harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 7/25/16 indicated 3 residents had a [MEDICAL CONDITION].

Based on observation, interview, and record review, the facility failed to administer its resources effectively and efficiently to maintain the highest practicable level of well-being for 3 of 3 residents reviewed for [MEDICAL CONDITION] care. (Residents #s 1, 8, and 10) The administrator and DON did not monitor and supervise staff to ensure provision of correct [MEDICAL CONDITION]/ventilator care. They did not have replacement [MEDICAL CONDITION] and inner cannulas available in the event of accidental removal of the cannulas for Resident #s 1, 8, and 10. The facility did not have an ambu bag at bedside for Resident #s 8 and 10.The facility did not have an emergency supply of portable oxygen at the bedside for Resident #s 1, 8, and 10 in the event of a power outage. The administrator and DON did not recognize Resident #1's Trilogy machine when used in conjunction with a [MEDICAL CONDITION] functioned as a ventilator providing Resident #1 with positive pressure ventilation and required a direct emergency power source; and did not ensure Resident #'s 1 and 8 suction machines had an emergency direct power source. The administrator and DON did not ensure physician orders [REDACTED].#s 1, 8, and 10. The administrator and DON did not ensure nursing staff knew emergency procedures to implement related to [MEDICAL CONDITION]/ventilator care for Residents #s 1, 8, and 10. An Immediate Jeopardy situation was identified on 7/25/16. The Immediate Jeopardy was removed on 7/26/16. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 3 residents with tracheotomies at risk for neglect, serious injury and even death. Findings included: During an interview on 7/27/16 at 9:20 a.m., the DON said she expected the RT to have the necessary tracheotomy supplies at bedside. She said she expected the residents with tracheotomies to have an [MEDICAL CONDITION] the correct size as well as one size smaller. She said the RT was responsible for making sure orders were correct and up to date. The DON said to prevent the reoccurrence of the IJ findings she was ensuring physician orders [REDACTED]. During an interview on 7/27/16 at 9:39 a.m., the RT said he was responsible for the respiratory care of Resident #s 1, 8, and 10. He said, We dropped the ball on having the emergency supplies on hand for Resident #s 1, 8 and 10. The RT said to prevent the IJ findings from reoccurring he would ensure all staff were properly trained on the emergency supplies needed for each resident, ensure adequate supplies would be available for the residents, and physician orders [REDACTED]. The RT said if Resident #10 had orders to return to the use of the Trilogy he would be sent to the local hospital for a higher level of care. During an interview on 7/27/16 at 9:45 a.m., the RDO (regional director of operations) indicated he expected the previous administrator to have had better leadership of the facility. He said he believed the poor leadership contributed to the IJ situation. The RDO said he expected the RT to have the needed supplies at the bedside and anticipate the needs of the residents with respiratory care. The RDO said the DON and RT would ensure all training regarding the IJ would be ongoing with all nurse's prior to starting their shifts. He said the DON and RT would ensure orders, emergency supplies, and all other supplies would be on hand for each resident to meet their needs. The RDO said this process would occur on a daily basis. 1. A face sheet dated 3/11/16 indicated Resident #1 was [AGE] years old, admitted [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 could understand others and usually made himself understood. He required extensive assistance of two staff for transfers. He was totally dependent on staff for dressing, bathing, and hygiene. The MDS indicated Resident #1 received specialty care including oxygen therapy, suctioning, and tracheotomy care. An undated Care Plan indicated Resident #1 had a tracheotomy in place and would [MEDICAL CONDITION] daily and PRN(as needed). The care plan indicated staff would apply the Trilogy (mechanical ventilator that provides both volume and pressure ventilation and delivers the therapy either invasively, via a trach, or noninvasively, via a mask) at night and PRN and an [MEDICAL CONDITION] be available for accidental dislodgement. The care plan indicated Resident #1 was suctioned and staff would record how the resident tolerated the procedure and notify the physician of any changes. The care plan indicated Resident #1 would have a Passy-muir speaking valve during awake hours and would be removed at night to place the Trilogy. Physician orders [REDACTED].#1 would [MEDICAL CONDITION] daily and resident would receive oxygen at 4 liters per minute [MEDICAL CONDITION]. There were no orders for the Trilogy. The Respiratory Therapist found the orders from the thinned chart from medical records. After surveyor intervention physician orders [REDACTED]. The order included: oxygen at 4 liters per minute [MEDICAL CONDITION]; may use Passy-muir speaking valve during the awake hours and remove Passy-muir valve to apply Trilogy at night; Trilogy AVAPS-AE, IPAP 15, EPAP 5, rate 14 and pressure support to 5-20 CUP at night; Apply Trilogy at night and PRN via trach. Monitor every 2 hours while applied for proper functioning. During an observation on 7/25/16 at 9:07 a.m., Resident #1 was sitting upright in his recliner. Oxygen was being administered [MEDICAL CONDITION] at 4 liters per minute. The Trilogy, oxygen concentrator, and suction machine were plugged into regular power outlets. There was no red plug for emergency power located inside the room. There were two emergency red outlets located in the hallway. There was [MEDICAL CONDITION] portable oxygen at bedside in case of an emergency. During an interview on 7/25/16 at 11:58 a.m., the RT said Resident #1 had a tracheotomy and was hooked to a Trilogy [MEDICAL CONDITION] at night. He said he received breathing treatments and suctioning every 4 hours and received [MEDICAL CONDITION]. The RT said he was responsible for Resident #1's respiratory needs while he was there. He said the nurses were responsible when he was gone. He said the nurses had received training [MEDICAL CONDITION], breathing treatments, and suctioning. The RT said Resident #1's Trilogy was not plugged into a red outlet at night. He said the Trilogy had a 2 hour battery that automatically came on in the case of a power outage. The RT said Resident #1 would be moved into the hallway during an emergency and if the power was going to be out for very long Resident #1 would be transferred to the hospital. The RT said he believed Resident #1 had a [MEDICATION NAME][MEDICAL CONDITION] 6. He said there was not an [MEDICAL CONDITION] bedside but he had one in the supply closet. During an interview on 7/25/16 at 12:15 p.m., the RT said he was unaware the Trilogy orders for Resident #1 were not on the chart. He said he did not know why the orders were not there. The RT said it was the responsibility of the nurses and himself to assure orders were correct. During an interview on 7/25/16 at 3:25 p.m., the RT said there had been a clarification order in April. He said after the clarification order the Trilogy orders stopped appearing on the physician's orders [REDACTED]. He said he was not sure why this was happening but they were working to correct the problem. During an observation on 7/25/16 at 3:54 p.m., Resident #1 was observed to have a [MEDICATION NAME] size 6 [MEDICAL CONDITION] in place. During an interview on 7/25/16 at 3:56 p.m., the RT said he did not have a replacement for Resident #1's trach. He said he would have to send the resident to the hospital if there was an accidental dislodgement of his trach. During an observation on 7/25/16 at 4:05 p.m., the supply closet contained Shiley #6 and #7 inner cannulas, and Biovana #6 and #7 inner cannulas. During an interview on 7/26/16 at 2:19 p.m., LVN B said she had been inserviced [MEDICAL CONDITION] by the RT. She said she was shown how to suction and administer Resident #1's breathing treatments. She said she was unsure of Resident #1'[MEDICAL CONDITION]. She said she believed there was an [MEDICAL CONDITION] Resident #1's bedside. LVN B said she had not been inserviced on [MEDICAL CONDITION] or accidental dislodgement. She said the RT was responsible for making sure orders were correct. 2) A face sheet dated July 2016 indicated Resident #8 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #8 was rarely/never understood and rarely/never understands others. Her cognition was severely impaired and she was unable to make decisions. Resident #8 required extensive assistance with bed mobility, and total assistance with dressing, eating, personal hygiene and bathing. Resident #8 had a suprapubic catheter and was incontinent of bowel. She received [MEDICAL CONDITION] care, suctioning, and oxygen therapy. The most recent care plan dated 3/23/16 indicated Resident #8 had a potential for impaired respiratory function related to the disease process of [MEDICAL CONDITION] with [MEDICAL CONDITION]. The goal was Resident #8 would maintain a patent airway with no signs and symptoms of respiratory distress. The interventions included to monitor oxygen saturations as ordered, and keep a spare tracheotomy tube available for accidental dislodgment. A recent history and physical dated 6/01/16 indicated Resident #8 had a hospital admission related to healthcare associated pneumonia, acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. A chest x-ray indicated bibasilar infiltrates and atelectasis with worsening on the right lung and enlarging right pleural effusion. Readmission physician orders [REDACTED]. Physician orders [REDACTED].#8 had a [MEDICAL CONDITION] with a T bar with humidifier each shift. Physician orders [REDACTED].#8 received oxygen at 4 liters via the [MEDICAL CONDITION] each shift, suctioning as needed each shift, and [MEDICAL CONDITION] care daily and as needed after surveyor intervention. A Physicians telephone order dated 7/26/16 indicated Resident #8 would have a pulse oximetry check every six hours and as needed. During an observation and interview on 7/25/16 at 11:32 a.m., Resident #8 was asleep resting in her bed. She had humidified oxygen at 5 liters to her [MEDICAL CONDITION] via a [MEDICAL CONDITION] collar. In the top drawer of Resident #8's bedside table were 3 boxes containing Shiley size 8 [MEDICAL CONDITION] sets. The treatment nurse said these were the emergency [MEDICAL CONDITION] sets for Resident #8. During an interview on 7/25/16 at 11:35 a.m., the RT (respiratory therapist) said Resident #8 required suctioning every 3 to 4 hours and there were no ventilators in the facility. During an interview on 7/25/16 at 3:00 p.m., LVN M said she was unaware of Resident #8's [MEDICAL CONDITION] size. She said she relied on the RT to provide the needed respiratory care. During an observation and interview on 7/25/16 at 4:00 p.m., the RT said he was not sure of Resident #8's [MEDICAL CONDITION] size. The RT removed the [MEDICAL CONDITION] collar and after viewing the [MEDICAL CONDITION] he said Resident #8's [MEDICAL CONDITION] was a Shiley 6 LPC. The RT said Resident #8's emergency tracheostomies stored at bedside were Shiley 8 LPC. The RT said the emergency [MEDICAL CONDITION] sets should be Shiley 6. He said in the event of an emergency Resident #8 would be sent to the local hospital because he did not have the correct size [MEDICAL CONDITION] available. During an observation on 7/25/16 at 4:05 p.m., the supply closet contained Shiley #6 and #7 inner cannulas, and Biovana #6 and #7 inner cannulas. During an interview on 7/25/16 at 4:35 p.m., the RT said he was ordering the emergency [MEDICAL CONDITION] sets for Resident #s 1, 8 and 10. He said the supplies would be delivered on 7/26/16. During an interview on 7/25/16 at 4:40 p.m., LVN M said Resident #8's emergency [MEDICAL CONDITION] sets were stored in Resident #8's bedside table. She said she had not been trained on emergency situations regarding Resident #8's [MEDICAL CONDITION]. LVN M said the needed emergency supply would be sterile water and suction. During an observation and interview on 7/25/16 at 5:55 p.m., the facilities lights blinked off and on. An alarm was sounding loudly on hall 400. LVN M was observed walking to check the exit door alarming device. LVN M said she was unfamiliar with what alarm was sounding. After surveyor intervention LVN M was alerted to Resident #8's room. Resident #8's oxygen concentrator was alarming and not functioning. LVN M attempted to turn the concentrator off and then on again. She said I will have to get another concentrator. She said there was no portable oxygen in Resident #8's room. During an observation on 7/25/16 at 6:02 p.m., LVN M applied an E-tank of oxygen at 4 liters to Resident #8 while she prepared another oxygen concentrator. 3) A face sheet dated 7/25/16 indicated Resident #10 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #10 sometimes understood others and sometimes was understood. He was independent in making decisions. Resident #10 required total assistance with all his ADLs. He received suctioning and [MEDICAL CONDITION] care. A care plan dated 4/01/16 indicated Resident #10 had a potential for respiratory distress related to acute [MEDICAL CONDITION]. The goal was to maintain a patent airway and have a backup [MEDICAL CONDITION] available for displacement. The Medication Administration Record [REDACTED]. A history and physical dated 6/02/16 indicated Resident #10 was hospitalized with the [DIAGNOSES REDACTED]. A history and physical dated 5/05/16 indicated Resident #10 was hospitalized with acute respiratory distress with [MEDICAL CONDITION]. He was provided humidified oxygen through his [MEDICAL CONDITION], aggressive [MEDICAL CONDITION] toileting, breathing treatments, and suctioning. A telephone order dated 7/23/16 at 7:35 p.m., indicated Resident #10 was readmitted with resume all previous orders. Consolidated physician orders [REDACTED].#10 had oxygen at 2 liters per minute via the [MEDICAL CONDITION] collar as needed, apply trilogy at hour of sleep and as needed via [MEDICAL CONDITION], and monitor trilogy every two hours while applied for proper functioning and document adverse events and notify the physician. The consolidated orders did not include [MEDICAL CONDITION] care or suctioning, [MEDICAL CONDITION] size. The order for the trilogy did not include any settings. During an observation on 7/25/16 at 9:30 a.m., Resident #10 was resting in bed with humidified oxygen applied via a [MEDICAL CONDITION] at 2 liters per minute. Resident #10 said he had readmitted Saturday 7/23/16. He said he had pneumonia and was sent to the hospital. Resident #10 did not have an emergency E-tank of oxygen at bedside, a spare [MEDICAL CONDITION] set, or an ambu bag. During an interview on 7/25/16 at 11:15 a.m., the RT said he and the nurses were responsible for obtaining the respiratory orders. He said he could not locate the physician orders [REDACTED]. During an observation and interview on 7/25/16 at 4:15 p.m., Resident #10 was observed to have a Shiley 6 LPC [MEDICAL CONDITION] in place. The RT said Resident #10 did not have an emergency [MEDICAL CONDITION] or oxygen at bedside. During an interview on 7/27/16 at 9:20 a.m., the DON said she expected the RT to have the [MEDICAL CONDITION] supplies at bedside for Resident #s 1, 8, and 10. She said she expected the residents with tracheostomies to have one size smaller and the same size available at bedside. The Abuse Prohibition policy and procedure dated 1/01/12 indicated the residents have the right to be free from abuse, neglect, and misappropriation of resident property, corporal punishment and involuntary seclusion. (1) Our facility ' s leadership is committed to protecting our residents from abuse, mental or physical, including involuntary seclusion, neglect, or misappropriation of property by anyone including, but not necessarily limited to facility staff. An undated [MEDICAL CONDITION] Care Policy indicated, [MEDICAL CONDITION] care would be provided by licensed nursing staff or a licensed respiratory staff in accordance to the facility guidelines for [MEDICAL CONDITION] care . An undated [MEDICAL CONDITION] Equipment at Bedside policy and procedure indicated to have emergency [MEDICAL CONDITION] equipment at bedside. Procedure (1) All [MEDICAL CONDITION] patients will have the following equipment at bedside upon admission and readmission: replacement [MEDICAL CONDITION] set, ambu bag with [MEDICAL CONDITION] attachment, replacement inner cannula and a [MEDICAL CONDITION] suction kit. The RDO and DON were notified on 7/25/16 at 4:50 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 7/25/16 at 7:55 p.m. and included: *Resident # ' s 8 and 10 both have back up [MEDICAL CONDITION] supplies (current size and one size smaller) at bedside as of 7/25/16. *Resident #1 with the trilogy was sent to the local hospital on [DATE]. *Resident #8 has [MEDICAL CONDITION] care orders and oxygen orders as 7/25/16. *Licensed nurses will be educated on emergency procedures by 8:00 a.m. on 7/26/16 by the DON and the RT. No nurse will work on the floor before being in-serviced. Monitoring will be by the DON daily until complete. *The following measures have been put into place to ensure the alleged deficiency will not recur: all emergency [MEDICAL CONDITION] supplies will be monitored daily by nursing administration, all orders will be reviewed daily by nursing administration to ensure they are entered into the system correctly and transcribed to the appropriate flow sheet, and resident will have their devices powered by emergency power in the event of a power outage. Emergency procedures for Respiratory Residents: *Residents on oxygen concentrators can be placed on oxygen tanks at the ordered liter flow or concentrators will be moved to a red electrical outlet in the hallway. *Trilogy residents have a two hour battery power that will alarm when battery reaches low. The trilogy must be plugged in to a red electrical outlet in the hallway if the resident must remain on a trilogy. *Residents requiring suctioning will require connecting suction unit to a red electrical outlet in the hallway to operate suction unit. *Residents with [MEDICAL CONDITION] much have a spare [MEDICAL CONDITION] of same brand and size at bedside at all times and one size down. *Residents requiring breathing treatments will have to be connected to a red electrical outlet in the hallway. *Emergency bedside equipment: [MEDICAL CONDITION], oxygen, suction kit, concentrator operation procedures, and ambu bag. On 7/26/16 the surveyors confirmed the POR had been implemented sufficiently remove the IJ by: 5 RNs, 6 LVNs, and 1 RT were interviewed and said they were in-serviced on the emergency needs of the respiratory resident and their responsibility to obtain orders for respiratory care. Resident #1 remained at the local hospital to meet his respiratory needs. Resident #8 and #10 had physician orders, emergency [MEDICAL CONDITION] and oxygen at bedside, and an ambu bag. On 7/26/16 at 11:30 a.m., the DON and RN E were informed the IJ was removed: however, the facility remained out of compliance at a pattern for potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 7/25/16 indicated 3 residents had a [MEDICAL CONDITION].

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibit neglect for 1 of 7 residents reviewed for neglect (Resident #2). The facility did not prevent an injury during a mechanical lift transfer. Two CNAs allowed a mechanical lift bar to hit Resident #2 in the face, resulting in bruising and a hairline fracture. This failure could place 22 residents who were transferred by the Hoyer lift at risk of injury. Findings included: Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 could understand others, make herself understood, and required extensive assistance of two staff for transfers. Her cognition was intact and she did not have any signs or symptoms of [MEDICAL CONDITION] or behaviors. An incident report dated 3/14/16 indicated Resident #2 sustained a 4 centimeter (cm) bruise to her left cheek when the Hoyer lift bar hit her on the left side of her face. A CT scan of the facial bones dated 3/18/16 indicated there was a hairline [MEDICAL CONDITION] wall of the right maxillary sinus. During an observation and interview on 3/31/16 at 3:09 p.m., Resident #2 had a fading light green bruise to her left cheek, from the cheekbone down to the edge of her jaw. Resident #2 said on 3/14/16, CNA A performed her Hoyer lift transfer alone. Resident #2 said she hit the chair hard during the transfer, and afterwards, the swivel bar that held the straps, hit her on both sides of her face. She said the straps were still attached to the bar. She said the DON came and questioned her about the incident and kept saying two CNAs did the transfer, but Resident #2 said she kept correcting her and told her CNA A transferred her alone. Resident #2 said she moved to a different nursing facility after this incident, because she was scared and did not feel safe. Resident #2 said she had recurring headaches and both sides of her face still hurt from the incident on 3/14/16. During a telephone interview on 3/31/16 at 12:03p.m., CNA B said she assisted CNA A to transfer Resident #2 with the Hoyer lift on 3/14/16. She said they lowered Resident #2 into her chair, and were talking to each other and not paying attention. She said they took the lift straps off the swivel bar and the bar swung around and hit Resident #2 in the face (she could not recall which side of the face the bar hit). CNA B said if they had been paying attention, the incident would not have happened. During an interview on 3/31/16 at 2:25 p.m., CNA A said CNA B assisted her with transferring Resident #2 on 3/14/16. She said they were running their mouths and did not look at the straps as they took them off the swivel bar. She said if they had looked, the swivel bar would not have swung around and hit Resident #2 in the face. During a telephone interview on 3/31/16 at 11:52 a.m. the DON said two CNAs got Resident #2 up and when they released the lift straps on the swivel bar, the bar swung around and hit Resident #2 in the face. She said they did not report this incident to the regulatory agency because she did not consider this incident neglect because two staff members performed the transfer for Resident #2, and the incident was not intentional. During an interview on 3/31/16 at 12:16 p.m., the administrator said CNAs A and B told her they were taking the straps off the swivel bar on the lift, when the swivel bar swung around and hit Resident #2 in the face. She said Resident #2 said the incident was not done deliberately, and following the incident she had CNAs A and B demonstrate competency. At 4:43 p.m., the administrator said if she had known the CNAs were not paying attention at the time of the incident, she would have considered the incident neglect and would have reported it to the state agency. An Abuse Prohibition Policy dated 5/20/10 indicated the residents would be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This policy defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. A list provided by the MDS Coordinator on 3/31/16 indicated 22 residents were transferred with the Hoyer lift.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for 1 of 7 residents reviewed for neglect (Resident #2). The facility did not prevent or report an incident of neglect during a mechanical lift transfer. Two CNAs allowed a mechanical lift bar to hit Resident #2 in the face, resulting in bruising and a hairline fracture. This failure could place 22 residents who were transferred via mechanical lift (Hoyer) at risk of injury. Findings included: An Abuse Prohibition Policy dated 5/20/10 required the residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This policy defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy indicated the facility conducts an internal investigation and reports results of all investigations to the enforcement agency in accordance with state law including the State Survey and Certification Agency within five working days of the incident or according to state acceptable law. Physician orders [REDACTED].#2 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 could understand others, make herself understood, and required extensive assistance of two staff for transfers. Her cognition was intact and she did not have any signs or symptoms of [MEDICAL CONDITION] or behaviors. An incident report dated 3/14/16 indicated Resident #2 sustained a 4 centimeter (cm) bruise to her left cheek when the Hoyer lift bar hit her on the left side of her face. A CT scan of the facial bones dated 3/18/16 indicated there was a hairline [MEDICAL CONDITION] wall of the right maxillary sinus. During an observation and interview on 3/31/16 at 3:09 p.m., Resident #2 had a fading light green bruise to her left cheek, from the cheekbone down to the edge of her jaw. Resident #2 said on 3/14/16, CNA A performed her Hoyer lift transfer alone. Resident #2 said she hit the chair hard during the transfer, and afterwards, the swivel bar that held the straps, hit her on both sides of her face. She said the straps were still attached to the bar. She said the DON came and questioned her about the incident and kept saying two CNAs did the transfer, but Resident #2 said she kept correcting her and told her CNA A transferred her alone. Resident #2 said she moved to a different nursing facility after this incident, because she was scared, and did not feel safe. Resident #2 said she had recurring headaches and both sides of her face still hurt from the incident on 3/14/16. During a telephone interview on 3/31/16 at 12:03p.m., CNA B said she assisted CNA A to transfer Resident #2 with the Hoyer lift on 3/14/16. She said they lowered Resident #2 into her chair, and were talking to each other and not paying attention. She said they took the lift straps off the swivel bar and the bar swung around and hit Resident #2 in the face (she could not recall which side of the face the bar hit). CNA B said if they had paid attention, the incident would not have happened. During an interview on 3/31/16 at 2:25 p.m., CNA A said CNA B assisted her with transferring Resident #2 on 3/14/16. She said they were running their mouths and did not look at the straps as they took them off the swivel bar. She said if they had been looking, the swivel bar would not have swung around and hit Resident #2 in the face. During a telephone interview on 3/31/16 at 11:52 a.m., the DON said two CNAs got Resident #2 up and when they released the lift straps on the swivel bar, the bar swung around and hit Resident #2 in the face. She said they did not report this incident to the regulatory agency because she did not consider this incident neglect because two staff members performed the transfer for Resident #2, and the incident was not intentional. During an interview on 3/31/16 at 12:16 p.m., the administrator said CNAs A and B told her they took the straps off the swivel bar on the lift, when the swivel bar swung around and hit Resident #2 in the face. She said Resident #2 said the incident was not done deliberately, and following the incident she had CNAs A and B demonstrate competency. At 4:43 p.m., the administrator said if she had known the CNAs had not paid attention at the time of the incident, she would have considered the incident neglect and would have reported it to the state agency. The CMS 672 dated 3/31/16 indicated the census of the facility was 76.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibited neglect of 1 of 11 residents reviewed for neglect. (Resident #5) Staff did not administer Resident #5 the correct dose of [MEDICATION NAME] (anti-psychotic medication), resulting in the resident receiving excessive doses of the medication for 9 days. The facility did not identify and address a change of condition for Resident #5 which resulted in Resident #5 being admitted to the hospital for septic shock. This failure contributed to Resident #5's rapid decline in health and hospitalization for septic shock. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 44 residents residing on Halls 4, 5, and 6 at risk for not receiving timely assessments which could result in harm or death, Findings included: Abuse Prohibition dated dated [DATE] indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary exclusion. 5. Neglect- failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illenss. The undated Admission Protocols Process indicated the charge nurse admitting a resident would complete a head-to-toe assessment, complete nursing assessment, and risk assessments on all residents. The undated Resident change of Condition Policy and Procedure indicated if a resident has a change of condition, the nurse aide should notify the charge nurse of the slightest change in order for the nurse to assess and complete SBAR (INTERACT tool) document to ensure that they are monitoring an acute illness prior to being an emergency. The Acute Condition Changes-Clinical Protocol revised [DATE], indicated the nurse will notify the Physician about a resident with an acute change of condition. The nurse will make detailed observations and collect pertinent information, including the resident's current symptoms and status. The nurse will contact the Physician based on the urgency of the situation. The nursing staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. A computerized physician order [REDACTED].#5 was a [AGE] year old female admitted [DATE]. Her [DIAGNOSES REDACTED]. She was to receive [MEDICATION NAME] (anti-depressant) 15 mg by mouth at bedtime and [MEDICATION NAME] (anti-psychotic) 2.5 mg by mouth at bedtime. A care plan dated [DATE] indicated Resident #5 had an unsteady gait and was a fall risk. She required set-up and cueing assistance with meals. She had impaired cognition and one of the approaches was to check O2 saturation with changes in cognition. She was at risk for alteration in nutrition and was to be assisted with all meals. The care plan did not address the anti-psychotic medication. The MAR indicated [REDACTED]. The resident also received [MEDICATION NAME] 5 mg [DATE] through [DATE]. Nursing notes on [DATE] at 1:01 p.m. indicated LVN J was called to the shower room by CNA M. Resident #5 was calling the staff racial names and had slapped CNA M in the face. Resident continued to be combative and LVN J assisted in redirecting Resident # 5 and transferred her to the Geri-chair. A physician telephone order dated [DATE] indicated [MEDICATION NAME] 2.5 mg was to be discontinued. An order to increase [MEDICATION NAME] 5 mg one tablet by mouth at bed time was to be given. The MAR indicated [REDACTED]. Nursing notes dated [DATE] at 10:24 a.m. and [DATE] at 8:47 p.m. indicated Resident #5 was severely confused and combative with care . An MDS assessment dated [DATE] Indicated Resident #5 was severely cognitively impaired. She could sometimes make herself understood and could sometimes understand others. Resident #5 had signs of inattention and disorganized thinking. She had no [MEDICAL CONDITION] or psychotic behavior such as delusions or hallucinations. She had no signs and symptoms of depression. She was totally dependent on staff for assistance with all ADLs with one person and two persons for transfers. The Dietary Data Set & Progress Note dated [DATE] indicated Resident #5 weighed 135 pounds on admission ([DATE]) and weighed 128 pounds as of [DATE]. (7 pound loss in 12 days) On [DATE], she was seen by a dietitian who made no recommendations. During an interview on [DATE] at 12:13 p.m., LVN J said the physician assistant increased Resident #5's [MEDICATION NAME] to 5 mg for reported aggression. LVN J said there was no behavior monitoring or any specific target behavior addressed; or any non-pharmacological intervention attempted, prior to increasing the antipsychotic medication. During an interview on [DATE] at 4:33 p.m., MA N said she initialed the box for the [MEDICATION NAME] 2.5 mg. and initialed the box for the [MEDICATION NAME] 5 mg on [DATE] through [DATE], and on [DATE] and [DATE], so she must have given both. During an observation and phone interview on [DATE] at 4:55 p.m., MA H said she did not remember giving both the [MEDICATION NAME] 2.5 mg and [MEDICATION NAME] 5mg on [DATE] and [DATE], and again on [DATE] and [DATE]. She said she circles her initials if she does not give a medication. MA N said she did not know if she gave both medications or not. There were no circles on the MAR for the 2.5 mg [MEDICATION NAME] on the dates MA N worked. During an interview on [DATE] at 10:00 a.m., the DON said the process the nurses and MAs followed was if a medication was not given; the initialed box beside the medication was circled and an explanation of why the medication was not given was written on the back of the MAR. During an interview on [DATE] at 3:15 p.m., CNA F said upon admission, Resident #5 was alert, oriented to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. CNA F said Resident #5 was able to bear weight for transfers at times when she was more alert. She said now the resident was a two person transfer combative and resistant to care at times and could not stay awake to eat or drink. CNA F said the nurses were aware. During an observation and interview on [DATE] at 3:15 p.m., Resident #5 was in bed asleep. Resident #5 was not easily aroused. There was an untouched glass of a health shake sitting on her bedside table. CNA F said the resident did not wake up to drink it. The resident's left heel had a pressure sore with black eschar. There was a strong foul odor of urine and feces in the resident's room. The resident was lying on a draw sheet, on top of a comforter, on top of a cloth incontinent pad, on top of a fitted sheet. CNA F removed the resident's brief and Resident #5 was lying in a large puddle of loose feces and urine. Urine had soaked through to the mattress and there was a dry brown ring on the draw sheet. CNA F said they were instructed to double and triple pad if necessary. A large Stage III pressure sore approximately 7 inches long and 2 inches wide was uncovered on her left buttock close to the resident ' s gluteal fold. The sore was beefy red and bloody with cream colored slough in the center. There was a second Stage II pressure sore approximately 2 inches long and 0.5 inches wide on the upper right buttock close to the gluteal fold. CNA F said the pressure sore to Resident #5's right buttock was new because she had not seen it before. During an interview on [DATE] at 9:30 a.m., LVN D said she was responsible for wound treatments in the facility. LVN D said Resident #5 had one pressure sore on her left heel. She said the wound on Resident #5's left buttock was an abrasion . She said she was not confident in staging so she asked one of the other nurses to stage wounds. LVN D said she did not remember which nurse identified Resident #5's pressure sore to her left buttock as an abrasion. She said she had no training. LVN D said she was not told Resident #5 had another pressure sore to her right buttock. And, was not told there was no dressing on the pressure sore to the left buttock. LVN D said she did not notify the physician about the pressure sore. The Wound and Skin Status Report dated [DATE] identified the pressure sore to Resident #5's left buttock as an abrasion. The TAR (Treatment Administration Record) dated September indicated Resident #5 was admitted with the pressure sore on her left heel. The pressure sore to Resident #5 ' s Left buttock was identified on [DATE]. (4 days after the [MEDICATION NAME] was increased) During an interview on [DATE] at 1:44 p.m., CNA K said Resident #5 was alert, oriented to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. CNA K said over the past 10 days Resident #5 could no longer ambulate, she could no longer feed herself, she could no longer reposition herself in bed, and she could not converse. During an interview on [DATE] at 12:04 p.m., LVN J said when Resident #5 was admitted , she was not a big eater; however, she was able to feed herself and with prompting would eat ,[DATE]% of her meal. She said the resident was able to communicate clearly with periods of disorganized thinking. LVN J said when the [MEDICATION NAME] was increased to 5 mg, Resident #5 started to decline. She said the resident stopped eating, was very lethargic, and required extensive assistance with transfers and repositioning. LVN J said Resident #5's aggressive behavior worsened. LVN J said she did not review Resident #5's medical history and she did not review her medications. She said she did not assess Resident #5 for a UTI or infection and did not consider it could have contributed to the resident s behavior. She said she did not notify the resident ' s physician of her decline. During an interview on [DATE] at 2:10 p.m., RN O said on Saturday, [DATE], Resident #5 complained of her butt hurting; however, she did not assess the source of the pain or the pressure sore on the resident ' s left buttock. RN O said she was told the [MEDICATION NAME] was increased due to Resident #5's behavior. RN O said she did not monitor the resident ' s behavior or if the [MEDICATION NAME] was effective in reducing the behavior. The RN said she monitored medications for adverse reactions. RN O said she knew Resident #5 was sleeping all the time and not eating or drinking, but she did not consider the decline was caused by medication and did not notify the physician. During an interview on [DATE] at 10:25 a.m., CNA P said she worked the 6 a.m.-2:00 p.m. shift. She said Resident #5 had diarrhea on Sunday, [DATE]. She said she told the nurse, but did not know if anything was done. She said Resident #5 still had diarrhea today. CNA P said Resident #5 had not been eating or drinking for several days and the nurse was aware. During an interview on [DATE] at 11:00 a.m., LVN J said on [DATE] the CNA told her Resident #5 had diarrhea. She said she gave the resident Pepto Bismol. She said she did not document the diarrhea in the nursing note. LVN J said she did not assess Resident #5 after giving the anti-diarrheal medicine to see if it was effective. She said Resident #5 had been very lethargic and unable to arouse long enough to eat for at least a week. LVN J said Resident #5's son told her on [DATE] he wanted the [MEDICATION NAME] stopped so his mother would wake up. LVN J contacted the physician assistant after lunch on Sunday [DATE] and received an order to put the medication on hold for 3 days. LVN J did not document what time she contacted the physician assistant. LVN J said she was aware Resident #5 was not eating or drinking, but did not notify the physician of the diarrhea, the resident ' s decreased appetite, or of the pressure sores. A telephone order dated [DATE] indicated to Hold [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg x 3 days due to increased fatigue and decreased appetite. There was not an order regarding the [MEDICATION NAME] 5 mg which was the resident's current order. The [DATE] MAR indicated [REDACTED]. Nursing notes [DATE] to [DATE] did not contain documentation the physician was notified of a decline or change of condition with Resident #5. There was documentation Resident #5 had increased fatigue and was not eating, but the physician was not notified. During an interview on [DATE] at 1:56 p.m., CNA M said she was assigned to assist Resident #5 on [DATE] and she was unable to arouse the resident. She said she had not cared for Resident #5 in over a week. CNA M said the last time she cared for Resident #5, the resident was able to tell you when she need to go to the toilet. CNA M said she thought Resident #5 was much calmer when staff explained what they were going to do before doing it. She said when she took care of Resident #5 on [DATE]; the resident did not act out or become combative. During an interview on [DATE] at 11:25 a.m., Resident #5's physician said he saw Resident #5 around 9:00 a.m. that day ([DATE]) and she was much worse than when he saw her two weeks earlier. He said he was not consulted about Resident #5's decline. The physician said he did not know the resident was not eating and had lost weight. He said he did not know she had become very lethargic, developed new pressure sores, and had diarrhea. During an observation and interview on [DATE] at 11:30 a.m., Resident #5's sister asked to speak with the physician about her sister's decline. The physician went back to Resident #5's room and said she had worsened over the past two hours and he thought she was septic. The physician went to the nurses station and told the nurses standing there that he should have been notified of Resident #5 ' s condition and to call an ambulance to transport Resident #5 to the hospital. During an observation on [DATE] at 11:40 a.m., EMS arrived to transport Resident #5 to the hospital. The paramedic could not obtain a blood pressure or a pulse. Oxygen was applied because Resident #5's O2 saturation was 64%. Resident #5's physician was in the room. The physician said to the surveyor, Young lady if you had not come got me, she probably would have died . The Hospital Admitting Face sheet dated [DATE] indicated Resident #5 was admitted to ICU (Intensive Care Unit) with the [DIAGNOSES REDACTED]. A Wound Record from the hospital dated [DATE] at 1:30 p.m. indicated Resident #5 was admitted with a Stage II pressure sore on her left buttock, a Stage II pressure sore on her right buttock, a Stage II pressure sore on her coccyx, and an unstageable pressure sore on her heel. During an interview on [DATE] at 12:30 p.m., the DON said Resident #5's physician was never notified or consulted when Resident #5 declined. The DON said she was aware Resident #5 lost 7 pounds in 12 days. She said she knew something was going on with Resident #5, but did not assess her or contact the physician. The Administrator and DON were notified on [DATE] at 12:15 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted [DATE] at 10:45 a.m. and included: All licensed nurses in-serviced on [DATE] by the Regional Nurse. In services to be completed by [DATE], 11 PM, any staff on vacation or unavailable will be in serviced before returning to work: Physical assessment Changes of Condition procedures SBAR and STOP and WATCH Procedures before ordering Antipsychotics and appropriate DX Medication administration, documentation, ordering, D/C meds Physician notification, family notification All Medication Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH tool New meds and D/C meds on MARS Medication ordering procedures Medication administration All Certified Nurse Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH Pre and Post tests administered to all disciplines by the Unit Manager All current residents with an order for [REDACTED]. Nursing staff will use the [MEDICAL CONDITION] monitoring form to track behaviors and document behaviors in the nurses' notes. Interact Care Paths tool may be used to assess changes in behaviors and condition changes. The survey team confirmed the POR had been implemented sufficiently to remove the IJ on [DATE] between 9:00 a.m. and 10:35 a.m. 13 CNAs, 4 LVNs, 3 RNs, and 3 housekeepers, from all three shifts, were interviewed. During the interviews all staff were asked to identify signs and symptoms of a change in condition, procedures used to report a change of condition, signs and symptoms of hydration and dehydration, and what was Stop and Watch and how to use it. On [DATE] at 10:45 a.m. the administrator and corporate nurse were informed the IJ was lifted; however, the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on [DATE] at 4:00 p.m., RN E said 44 residents resided on Halls 4, 5, and 6.

Based on observation, interview, and record review, the facility failed to ensure the drug regimen was free from unnecessary medication for 1 of 5 residents reviewed for medications. (Resident #5) Staff did not administer the correct dosage of [MEDICATION NAME] (antipsychotic medication) resulting in Resident #5 receiving excessive doses of the medication. Staff did not ensure Resident #5 was adequately monitored, did not ensure Resident #5 had an appropriate [DIAGNOSES REDACTED].#5's behavior prior to increasing the antipsychotic medication. The resident's condition deteriorated and she was admitted to the hospital with [REDACTED]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #5's rapid decline in health and hospitalization for septic shock. This failure could place 5 other residents who received [MEDICATION NAME] at risk for adverse consequences from unnecessary drugs. Findings included: A computerized physician order [REDACTED].#5 was a [AGE] year old female admitted [DATE]. Her [DIAGNOSES REDACTED]. She was to receive [MEDICATION NAME] (anti-depressant) 15 mg by mouth at bedtime and [MEDICATION NAME] (anti-psychotic) 2.5 mg by mouth at bedtime. A care plan dated [DATE] indicated Resident #5 had an unsteady gait and was a fall risk. She required set-up and cueing assistance with meals. She had impaired cognition and one of the approaches was to check O2 saturation with changes in cognition. She was at risk for alteration in nutrition and was to be assisted with all meals. The care plan did not address the anti-psychotic medication. The MAR indicated [REDACTED]. Nursing notes on [DATE] at 1:01 p.m. indicated LVN J was called to the shower room by CNA M. Resident #5 was calling the staff racial names and had slapped CNA M in the face. Resident continued to be combative and LVN J assisted in redirecting Resident # 5 and transferred her to the Geri-chair. A physician telephone order dated [DATE] indicated [MEDICATION NAME] 2.5 mg was to be discontinued. An order to increase [MEDICATION NAME] 5 mg one tablet by mouth at bed time was to be given. The MAR indicated [REDACTED]. Nursing notes dated [DATE] at 10:24 a.m. and [DATE] at 8:47 p.m. indicated Resident #5 was severely confused and combative with care. An MDS assessment dated [DATE] Indicated Resident #5 was severely cognitively impaired. She could sometimes make herself understood and could sometimes understand others. Resident #5 had signs of inattention and disorganized thinking. She had no [MEDICAL CONDITION] or psychotic behavior such as delusions or hallucinations. She had no signs and symptoms of depression. She was totally dependent on staff for assistance with all ADLs with one person and two persons for transfers. During an observation and interview on [DATE] at 3:15 p.m., Resident #5 was in bed asleep. There was an untouched glass of a health shake sitting on her bedside table. Resident #5 was very lethargic and not easily aroused. CNA F said for the past week the resident did not wake up to eat or drink. CNA F said Resident #5 used to assist with turning and repositioning, but was unable to assist for the past week. CNA F said upon admission, Resident #5 was alert, orientated to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. During an interview on [DATE] at 12:13 p.m., LVN J said the physician assistant increased Resident #5's [MEDICATION NAME] to 5 mg for reported aggression. LVN J said there was no behavior monitoring or any specific target behavior addressed; or any non-pharmacological intervention attempted, prior to increasing the antipsychotic medication. During an interview on [DATE] at 4:33 p.m., MA N said she initialed the box for the [MEDICATION NAME] 2.5 mg. and initialed the box for the [MEDICATION NAME] 5 mg on [DATE] through [DATE], and on [DATE] and [DATE], so she must have given both. During an observation and phone interview on [DATE] at 4:55 p.m., MA H said she did not remember giving both the [MEDICATION NAME] 2.5 mg and [MEDICATION NAME] 5mg on [DATE] and [DATE], and again on [DATE] and [DATE]. She said she circles her initials if she does not give a medication. MA N said she did not know if she gave both medications or not. There were no circles on the MAR for the 2.5 mg [MEDICATION NAME] on the dates MA N worked. During an interview on [DATE] at 10:00 a.m., the DON said the process the nurses and MAs followed was if a medication was not given; the initialed box beside the medication was circled and an explanation of why the medication was not given was written on the back of the MAR. During an interview on [DATE] at 3:15 p.m., CNA F said upon admission, Resident #5 was alert, oriented to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. CNA F said Resident #5 was able to bear weight for transfers at times when she was more alert. She said now the resident was a two person transfer combative and resistant to care at times and could not stay awake to eat or drink. CNA F said the nurses were aware. During an interview on [DATE] at 1:44 p.m., CNA K said Resident #5 was alert, orientated to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. She said over the past 10 days Resident #5 could no longer ambulate, she could no longer feed herself, she could no longer reposition herself in bed and she could not converse. The Dietary Data Set & Progress Note dated [DATE] indicated Resident #5 weighed 135 pounds on admission and weighed 128 pounds [DATE]. She was seen by a dietitian on [DATE] that made no recommendation. During an interview on [DATE] at 12:04 p.m., LVN J said when Resident #5 was admitted , she was not a big eater; however, she was able to feed herself and with prompting would eat ,[DATE]% of her meal. She said the resident was able to communicate clearly with periods of disorganized thinking. LVN J said when the [MEDICATION NAME] was increased to 5 mg, Resident #5 started to decline. She said the resident stopped eating, was very lethargic, and required extensive assistance with transfers and repositioning. LVN J said Resident #5's aggressive behavior worsened. LVN J said she did not review Resident #5's medical history and she did not review her medications. She said she did not consider it could have contributed to the resident s behavior. She said she did not notify the resident's physician of her decline. During an interview on [DATE] at 2:10 p.m. RN O said she was told the [MEDICATION NAME] was increased due to Resident #5's behavior. RN O said she did not monitor the resident's behavior or if the [MEDICATION NAME] was effective in reducing the behavior. The RN said she monitored medications for adverse reactions. RN O said she knew Resident #5 was sleeping all the time and not eating or drinking, but she did not consider the decline was caused by medication and did not notify the physician. During an interview on [DATE] at 11:00 a.m. LVN J said Resident #5 had been very lethargic and unable to arouse long enough to eat. LVN J said Resident #5's son told her on [DATE], he wanted the [MEDICATION NAME] stopped so his mother would wake up. LVN J said she contacted the physician assistant on [DATE] and received an order to put the medication on hold for 3 days. A telephone order dated [DATE] indicated to Hold [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg x 3 days due to increased fatigue and decreased appetite. There was not an order regarding the [MEDICATION NAME] 5 mg which was the resident's current order. The [DATE] MAR indicated [REDACTED]. During an interview on [DATE] at 11:25 a.m., Resident #5's physician said he saw Resident #5 around 9:00 a.m. that day ([DATE]) and she was much worse than when he saw her two weeks earlier. He said he was not consulted about Resident #5's decline. The physician said he did not know the resident was not eating and had lost weight. He said he did not know she had become very lethargic, developed new pressure sores, and had diarrhea. During an observation and interview on [DATE] at 11:30 a.m., Resident #5's sister asked to speak with the physician about her sister's decline. The physician went back to Resident #5's room and said she had worsened over the past two hours and he thought she was septic. The physician went to the nurses station and told the nurses standing there that he should have been notified of Resident #5's condition and to call an ambulance to transport Resident #5 to the hospital. During an observation on [DATE] at 11:40 a.m., EMS arrived to transport Resident #5 to the hospital. The paramedic could not obtain a blood pressure or a pulse. Oxygen was applied because Resident #5's O2 saturation was 64%. Resident #5's physician was in the room. The physician said to the surveyor, Young lady if you had not come got me, she probably would have died . The Hospital Admitting Face sheet dated [DATE] indicated Resident #5 was admitted to ICU (Intensive Care Unit) with the [DIAGNOSES REDACTED]. During an interview on [DATE] at 12:30 p.m., the DON said Resident #5's physician was never notified or consulted when Resident #5 declined. The DON said she was aware Resident #5 lost 7 pounds in 12 days. She said she knew something was going on with Resident #5, but did not assess her or contact the physician. According to the website, http://www.drugs.com/dosage/[MEDICATION NAME], accessed [DATE], .[MEDICATION NAME] is an antipsychotic. It may increase the risk of death when used to treat mental problems caused by dementia in elderly patients. Most of the deaths were linked to heart problems or infection. [MEDICATION NAME] is not approved to treat mental problems caused by dementia . The undated [MEDICAL CONDITION] Medication Use and Consents Policy and Procedure indicated .Medication interventions will never be used for disciplinary, restraint, or convenience of the facility staff. Residents will never receive a medication that is used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state when treating symptoms of mental illness without their knowledge and consent . The Administrator and DON were notified on [DATE] at 12:15 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted [DATE] at 10:45 a.m. and included: All licensed nurses in-serviced on [DATE] by the Regional Nurse. In services to be completed by [DATE], 11 PM, any staff on vacation or unavailable will be in serviced before returning to work: Physical assessment Changes of Condition procedures SBAR and STOP and WATCH Procedures before ordering Antipsychotics and appropriate DX Medication administration, documentation, ordering, D/C meds Physician notification, family notification All Medication Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH tool New meds and D/C meds on MARS Medication ordering procedures Medication administration All Certified Nurse Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH Pre and Post tests administered to all disciplines by the Unit Manager All current residents with an order for [REDACTED]. Nursing staff will use the [MEDICAL CONDITION] monitoring form to track behaviors and document behaviors in the nurses' notes. Interact Care Paths tool may be used to assess changes in behaviors and condition changes. The survey team confirmed the POR had been implemented sufficiently to remove the IJ on [DATE] between 9:00 a.m. and 10:35 a.m. 13 CNAs, 4 LVNs, 3 RNs, and 3 housekeepers, from all three shifts, were interviewed. During the interviews all staff were asked to identify signs and symptoms of a change in condition, procedures used to report a change of condition, signs and symptoms of hydration and dehydration, and what was Stop and Watch and how to use it. On [DATE] at 10:45 a.m. the administrator and corporate nurse were informed the IJ was lifted; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on [DATE] at 3:00 p.m., the DON said there were 5 residents currently taking the medication [MEDICATION NAME].

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibited neglect of 1 of 11 residents reviewed for neglect. (Resident #5) Staff did not administer Resident #5 the correct dose of [MEDICATION NAME] (anti-psychotic medication), resulting in the resident receiving excessive doses of the medication for 9 days. The facility did not identify and address a change of condition for Resident #5 which resulted in Resident #5 being admitted to the hospital for septic shock. This failure contributed to Resident #5's rapid decline in health and hospitalization for septic shock. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 44 residents residing on Halls 4, 5, and 6 at risk for not receiving timely assessments which could result in harm or death, Findings included: A computerized physician order [REDACTED].#5 was a [AGE] year old female admitted [DATE]. Her [DIAGNOSES REDACTED]. She was to receive [MEDICATION NAME] (anti-depressant) 15 mg by mouth at bedtime and [MEDICATION NAME] (anti-psychotic) 2.5 mg by mouth at bedtime. A care plan dated [DATE] indicated Resident #5 had an unsteady gait and was a fall risk. She required set-up and cueing assistance with meals. She had impaired cognition and one of the approaches was to check O2 saturation with changes in cognition. She was at risk for alteration in nutrition and was to be assisted with all meals. The care plan did not address the anti-psychotic medication. The MAR indicated [REDACTED]. Nursing notes on [DATE] at 1:01 p.m. indicated LVN J was called to the shower room by CNA M. Resident #5 was calling the staff racial names and had slapped CNA M in the face. Resident continued to be combative and LVN J assisted in redirecting Resident # 5 and transferred her to the Geri-chair. A physician telephone order dated [DATE] indicated [MEDICATION NAME] 2.5 mg was to be discontinued. An order to increase [MEDICATION NAME] 5 mg one tablet by mouth at bed time was to be given. The MAR indicated [REDACTED]. Nursing notes dated [DATE] at 10:24 a.m. and [DATE] at 8:47 p.m. indicated Resident #5 was severely confused and combative with care. An MDS assessment dated [DATE] Indicated Resident #5 was severely cognitively impaired. She could sometimes make herself understood and could sometimes understand others. Resident #5 had signs of inattention and disorganized thinking. She had no [MEDICAL CONDITION] or psychotic behavior such as delusions or hallucinations. She had no signs and symptoms of depression. She was totally dependent on staff for assistance with all ADLs with one person and two persons for transfers. The Dietary Data Set & Progress Note dated [DATE] indicated Resident #5 weighed 135 pounds on admission ([DATE]) and weighed 128 pounds as of [DATE]. (7 pound loss in 12 days) On [DATE], she was seen by a dietitian who made no recommendations. During an interview on [DATE] at 12:13 p.m., LVN J said the physician assistant increased Resident #5's [MEDICATION NAME] to 5 mg for reported aggression. LVN J said there was no behavior monitoring or any specific target behavior addressed; or any non-pharmacological intervention attempted, prior to increasing the antipsychotic medication. During an interview on [DATE] at 4:33 p.m., MA N said she initialed the box for the [MEDICATION NAME] 2.5 mg. and initialed the box for the [MEDICATION NAME] 5 mg on [DATE] through [DATE], and on [DATE] and [DATE], so she must have given both. During an observation and phone interview on [DATE] at 4:55 p.m., MA H said she did not remember giving both the [MEDICATION NAME] 2.5 mg and [MEDICATION NAME] 5mg on [DATE] and [DATE], and again on [DATE] and [DATE]. She said she circles her initials if she does not give a medication. MA N said she did not know if she gave both medications or not. There were no circles on the MAR for the 2.5 mg [MEDICATION NAME] on the dates MA N worked. During an interview on [DATE] at 10:00 a.m., the DON said the process the nurses and MAs followed was if a medication was not given; the initialed box beside the medication was circled and an explanation of why the medication was not given was written on the back of the MAR. During an interview on [DATE] at 3:15 p.m., CNA F said upon admission, Resident #5 was alert, oriented to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. CNA F said Resident #5 was able to bear weight for transfers at times when she was more alert. She said now the resident was a two person transfer combative and resistant to care at times and could not stay awake to eat or drink. CNA F said the nurses were aware. During an observation and interview on [DATE] at 3:15 p.m., Resident #5 was in bed asleep. Resident #5 was not easily aroused. There was an untouched glass of a health shake sitting on her bedside table. CNA F said the resident did not wake up to drink it. The resident's left heel had a pressure sore with black eschar. There was a strong foul odor of urine and feces in the resident's room. The resident was lying on a draw sheet, on top of a comforter, on top of a cloth incontinent pad, on top of a fitted sheet. CNA F removed the resident's brief and Resident #5 was lying in a large puddle of loose feces and urine. Urine had soaked through to the mattress and there was a dry brown ring on the draw sheet. CNA F said they were instructed to double and triple pad if necessary. A large Stage III pressure sore approximately 7 inches long and 2 inches wide was uncovered on her left buttock close to the resident ' s gluteal fold. The sore was beefy red and bloody with cream colored slough in the center. There was a second Stage II pressure sore approximately 2 inches long and 0.5 inches wide on the upper right buttock close to the gluteal fold. CNA F said the pressure sore to Resident #5's right buttock was new because she had not seen it before. During an interview on [DATE] at 9:30 a.m., LVN D said she was responsible for wound treatments in the facility. LVN D said Resident #5 had one pressure sore on her left heel. She said the wound on Resident #5's left buttock was an abrasion . She said she was not confident in staging so she asked one of the other nurses to stage wounds. LVN D said she did not remember which nurse identified Resident #5's pressure sore to her left buttock as an abrasion. She said she had no training. LVN D said she was not told Resident #5 had another pressure sore to her right buttock. And, was not told there was no dressing on the pressure sore to the left buttock. LVN D said she did not notify the physician about the pressure sore. The Wound and Skin Status Report dated [DATE] identified the pressure sore to Resident #5's left buttock as an abrasion. The TAR (Treatment Administration Record) dated September indicated Resident #5 was admitted with the pressure sore on her left heel. The pressure sore to Resident #5's Left buttock was identified on [DATE]. (4 days after the [MEDICATION NAME] was increased) During an interview on [DATE] at 1:44 p.m., CNA K said Resident #5 was alert, oriented to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. CNA K said over the past 10 days Resident #5 could no longer ambulate, she could no longer feed herself, she could no longer reposition herself in bed, and she could not converse. During an interview on [DATE] at 12:04 p.m., LVN J said when Resident #5 was admitted , she was not a big eater; however, she was able to feed herself and with prompting would eat ,[DATE]% of her meal. She said the resident was able to communicate clearly with periods of disorganized thinking. LVN J said when the [MEDICATION NAME] was increased to 5 mg, Resident #5 started to decline. She said the resident stopped eating, was very lethargic, and required extensive assistance with transfers and repositioning. LVN J said Resident #5's aggressive behavior worsened. LVN J said she did not review Resident #5's medical history and she did not review her medications. She said she did not assess Resident #5 for a UTI or infection and did not consider it could have contributed to the resident s behavior. She said she did not notify the resident's physician of her decline. During an interview on [DATE] at 2:10 p.m., RN O said on Saturday, [DATE], Resident #5 complained of her butt hurting; however, she did not assess the source of the pain or the pressure sore on the resident ' s left buttock. RN O said she was told the [MEDICATION NAME] was increased due to Resident #5's behavior. RN O said she did not monitor the resident ' s behavior or if the [MEDICATION NAME] was effective in reducing the behavior. The RN said she monitored medications for adverse reactions. RN O said she knew Resident #5 was sleeping all the time and not eating or drinking, but she did not consider the decline was caused by medication and did not notify the physician. During an interview on [DATE] at 10:25 a.m., CNA P said she worked the 6 a.m.-2:00 p.m. shift. She said Resident #5 had diarrhea on Sunday, [DATE]. She said she told the nurse, but did not know if anything was done. She said Resident #5 still had diarrhea today. CNA P said Resident #5 had not been eating or drinking for several days and the nurse was aware. During an interview on [DATE] at 11:00 a.m., LVN J said on [DATE] the CNA told her Resident #5 had diarrhea. She said she gave the resident Pepto Bismol. She said she did not document the diarrhea in the nursing note. LVN J said she did not assess Resident #5 after giving the anti-diarrheal medicine to see if it was effective. She said Resident #5 had been very lethargic and unable to arouse long enough to eat for at least a week. LVN J said Resident #5's son told her on [DATE] he wanted the [MEDICATION NAME] stopped so his mother would wake up. LVN J contacted the physician assistant after lunch on Sunday [DATE] and received an order to put the medication on hold for 3 days. LVN J did not document what time she contacted the physician assistant. LVN J said she was aware Resident #5 was not eating or drinking, but did not notify the physician of the diarrhea, the resident ' s decreased appetite, or of the pressure sores. A telephone order dated [DATE] indicated to Hold [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg x 3 days due to increased fatigue and decreased appetite. There was not an order regarding the [MEDICATION NAME] 5 mg which was the resident's current order. The [DATE] MAR indicated [REDACTED]. Nursing notes [DATE] to [DATE] did not contain documentation the physician was notified of a decline or change of condition with Resident #5. There was documentation Resident #5 had increased fatigue and was not eating, but the physician was not notified. During an interview on [DATE] at 1:56 p.m., CNA M said she was assigned to assist Resident #5 on [DATE] and she was unable to arouse the resident. She said she had not cared for Resident #5 in over a week. CNA M said the last time she cared for Resident #5, the resident was able to tell you when she need to go to the toilet. CNA M said she thought Resident #5 was much calmer when staff explained what they were going to do before doing it. She said when she took care of Resident #5 on [DATE]; the resident did not act out or become combative. During an interview on [DATE] at 11:25 a.m., Resident #5's physician said he saw Resident #5 around 9:00 a.m. that day ([DATE]) and she was much worse than when he saw her two weeks earlier. He said he was not consulted about Resident #5's decline. The physician said he did not know the resident was not eating and had lost weight. He said he did not know she had become very lethargic, developed new pressure sores, and had diarrhea. During an observation and interview on [DATE] at 11:30 a.m., Resident #5's sister asked to speak with the physician about her sister's decline. The physician went back to Resident #5's room and said she had worsened over the past two hours and he thought she was septic. The physician went to the nurses station and told the nurses standing there that he should have been notified of Resident #5 ' s condition and to call an ambulance to transport Resident #5 to the hospital. During an observation on [DATE] at 11:40 a.m., EMS arrived to transport Resident #5 to the hospital. The paramedic could not obtain a blood pressure or a pulse. Oxygen was applied because Resident #5's O2 saturation was 64%. Resident #5's physician was in the room. The physician said to the surveyor, Young lady if you had not come got me, she probably would have died . The Hospital Admitting Face sheet dated [DATE] indicated Resident #5 was admitted to ICU (Intensive Care Unit) with the [DIAGNOSES REDACTED]. A Wound Record from the hospital dated [DATE] at 1:30 p.m. indicated Resident #5 was admitted with a Stage II pressure sore on her left buttock, a Stage II pressure sore on her right buttock, a Stage II pressure sore on her coccyx, and an unstageable pressure sore on her heel. During an interview on [DATE] at 12:30 p.m., the DON said Resident #5's physician was never notified or consulted when Resident #5 declined. The DON said she was aware Resident #5 lost 7 pounds in 12 days. She said she knew something was going on with Resident #5, but did not assess her or contact the physician. The Abuse Prohibition dated dated [DATE] indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary exclusion. 5. Neglect- failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illenss. The undated Admission Protocols Process indicated the charge nurse admitting a resident would complete a head-to-toe assessment, complete nursing assessment, and risk assessments on all residents. The undated Resident change of Condition Policy and Procedure indicated if a resident has a change of condition, the nurse aide should notify the charge nurse of the slightest change in order for the nurse to assess and complete SBAR (INTERACT tool) document to ensure that they are monitoring an acute illness prior to being an emergency. The Acute Condition Changes-Clinical Protocol revised [DATE], indicated the nurse will notify the Physician about a resident with an acute change of condition. The nurse will make detailed observations and collect pertinent information, including the resident's current symptoms and status. The nurse will contact the Physician based on the urgency of the situation. The nursing staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. The Administrator and DON were notified on [DATE] at 12:15 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted [DATE] at 10:45 a.m. and included: All licensed nurses in-serviced on [DATE] by the Regional Nurse. In services to be completed by [DATE], 11 PM, any staff on vacation or unavailable will be in serviced before returning to work: Physical assessment Changes of Condition procedures SBAR and STOP and WATCH Procedures before ordering Antipsychotics and appropriate DX Medication administration, documentation, ordering, D/C meds Physician notification, family notification All Medication Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH tool New meds and D/C meds on MARS Medication ordering procedures Medication administration All Certified Nurse Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH Pre and Post tests administered to all disciplines by the Unit Manager All current residents with an order for [REDACTED]. Nursing staff will use the [MEDICAL CONDITION] monitoring form to track behaviors and document behaviors in the nurses' notes. Interact Care Paths tool may be used to assess changes in behaviors and condition changes. The survey team confirmed the POR had been implemented sufficiently to remove the IJ on [DATE] between 9:00 a.m. and 10:35 a.m. 13 CNAs, 4 LVNs, 3 RNs, and 3 housekeepers, from all three shifts, were interviewed. During the interviews all staff were asked to identify signs and symptoms of a change in condition, procedures used to report a change of condition, signs and symptoms of hydration and dehydration, and what was Stop and Watch and how to use it. On [DATE] at 10:45 a.m. the administrator and corporate nurse were informed the IJ was lifted; however, the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on [DATE] at 4:00 p.m., RN E said 44 residents resided on Halls 4, 5, and 6.

Based on observation, interview, and record review, the facility failed to immediately consult with the physician for a serious change of condition for 1 of 11 residents reviewed for change of condition. (Resident #5) The facility did not consult with Resident #5's physician when the resident experienced a decrease in mental functions, a sudden weight loss, development of pressure sores, and she could no longer perform simple ADLs; all within a 3 week period. After surveyor intervention, on Monday [DATE], the physician assessed the resident and immediately gave an order to transfer her to the hospital. She was admitted to the intensive care unit with septic shock. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #5's rapid decline in health and hospitalization for septic shock. This failure could place 44 residents residing on Halls 4, 5, and 6 at risk for not receiving necessary medical intervention. Findings included: A computerized physician order [REDACTED].#5 was a [AGE] year old female admitted [DATE]. Her [DIAGNOSES REDACTED]. She was to receive [MEDICATION NAME] (anti-depressant) 15 mg by mouth at bedtime and [MEDICATION NAME] (anti-psychotic) 2.5 mg by mouth at bedtime. A care plan dated [DATE] indicated Resident #5 had an unsteady gait and was a fall risk. She required set-up and cueing assistance with meals. She had impaired cognition and one of the approaches was to check O2 (oxygen) saturation with changes in cognition. She was at risk for alteration in nutrition and was to be assisted with all meals. The care plan did not address the anti-psychotic medication. The MAR indicated [REDACTED]. Nursing notes on [DATE] at 1:01 p.m. indicated LVN J was called to the shower room by CNA M. Resident #5 was calling the staff racial names and had slapped CNA M in the face. Resident continued to be combative and LVN J assisted in redirecting Resident #5 and transferred her to the Geri-chair. A physician telephone order dated [DATE] indicated [MEDICATION NAME] 2.5 mg was to be discontinued. An order to increase [MEDICATION NAME] 5 mg one tablet by mouth at bed time was to be given. The MAR indicated [REDACTED]. Nursing notes dated [DATE] at 10:24 a.m. and [DATE] at 8:47 p.m. indicated Resident #5 was severely confused and combative with care. An MDS assessment dated [DATE] Indicated Resident #5 was severely cognitively impaired. She could sometimes make herself understood and could sometimes understand others. Resident #5 had signs of inattention and disorganized thinking. She had no [MEDICAL CONDITION] or psychotic behavior such as delusions or hallucinations. She had no signs and symptoms of depression. She was totally dependent on staff for assistance with all ADLs with one person and two persons for transfers. The Dietary Data Set & Progress Note dated [DATE] indicated Resident #5 weighed 135 pounds on admission ([DATE]) and weighed 128 pounds as of [DATE]. (7 pound loss in 12 days, 5%) On [DATE], she was seen by a dietitian who made no recommendations. The progress note did not indicate the physician was notified of the resident's weight loss. During an interview on [DATE] at 12:13 p.m., LVN J said the physician assistant increased Resident #5's [MEDICATION NAME] to 5 mg for reported aggression. LVN J said there was no behavior monitoring or any specific target behavior addressed; or any non-pharmacological intervention attempted, prior to increasing the antipsychotic medication. During an interview on [DATE] at 3:15 p.m., CNA F said upon admission, Resident #5 was alert, oriented to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. CNA F said Resident #5 was able to bear weight for transfers at times when she was more alert. She said now the resident was a two person transfer combative and resistant to care at times and could not stay awake to eat or drink. CNA F said the nurses were aware. During an observation and interview on [DATE] at 3:15 p.m., Resident #5 was in bed asleep. Resident #5 was not easily aroused. There was an untouched glass of a health shake sitting on her bedside table. CNA F said the resident did not wake up to drink it. The resident's left heel had a pressure sore with black eschar. There was a strong foul odor of urine and feces in the resident's room. A large Stage III pressure sore approximately 7 inches long and 2 inches wide was uncovered on her left buttock close to the resident's gluteal fold. The sore was beefy red and bloody with cream colored slough in the center. There was a second Stage II pressure sore approximately 2 inches long and 0.5 inches wide on the upper right buttock close to the gluteal fold. CNA F said the pressure sore to Resident #5's right buttock was new because she had not seen it before. During an interview on [DATE] at 9:30 a.m., LVN D said she was responsible for wound treatments in the facility. LVN D said Resident #5 had one pressure sore on her left heel. She said the wound on Resident #5's left buttock was an abrasion. LVN D said she was not told Resident #5 had another pressure sore to her right buttock. LVN D said she did not notify the physician about the pressure sores. The Wound and Skin Status Report dated [DATE] identified the pressure sore to Resident #5's left buttock as an abrasion. The TAR (Treatment Administration Record) dated September indicated Resident #5 was admitted with the pressure sore on her left heel. The pressure sore to Resident #5's left buttock was identified on [DATE] (4 days after the [MEDICATION NAME] was increased). During an interview on [DATE] at 1:44 p.m., CNA K said Resident #5 was alert, oriented to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. CNA K said over the past 10 days Resident #5 could no longer ambulate, she could no longer feed herself, she could no longer reposition herself in bed, and she could not converse. During an interview on [DATE] at 12:04 p.m., LVN J said when Resident #5 was admitted , she was not a big eater; however, she was able to feed herself and with prompting would eat ,[DATE]% of her meal. She said the resident was able to communicate clearly with periods of disorganized thinking. LVN J said when the [MEDICATION NAME] was increased to 5 mg, Resident #5 started to decline. She said the resident stopped eating, was very lethargic, and required extensive assistance with transfers and repositioning. LVN J said Resident #5's aggressive behavior worsened. She said she did not notify the resident's physician of her decline. During an interview on [DATE] at 2:10 p.m., RN O said on Saturday, [DATE], Resident #5 complained of her butt hurting; however, she did not assess the source of the pain or the pressure sore on the resident's left buttock. The RN said she monitored medications for adverse reactions. RN O said she knew Resident #5 was sleeping all the time and not eating or drinking, but she did not consider the decline was caused by the increased [MEDICATION NAME] and did not notify the physician. During an interview on [DATE] at 10:25 a.m., CNA P said she worked the 6 a.m.- 2:00 p.m. shift. She said Resident #5 had diarrhea on Sunday, [DATE]. She said she told the nurse, but did not know if anything was done. She said Resident #5 still had diarrhea today. CNA P said Resident #5 had not been eating or drinking for several days and the nurse was aware. During an interview on [DATE] at 11:00 a.m., LVN J said on [DATE] the CNA told her Resident #5 had diarrhea. She said she gave the resident Pepto Bismol. She said she did not document the diarrhea in the nursing note. She said Resident #5 had been very lethargic and unable to arouse long enough to eat for at least a week. LVN J said Resident #5's son told her on [DATE] he wanted the [MEDICATION NAME] stopped so his mother would wake up. LVN J said she contacted the physician assistant after lunch on Sunday [DATE] and received an order to put the medication on hold for 3 days. LVN J said she did not document what time she contacted the physician assistant. LVN J said she was aware Resident #5 was not eating or drinking, but did not notify the physician of the diarrhea, the resident's decreased appetite, or of the pressure sores. A telephone order dated [DATE] indicated to Hold [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg x 3 days due to increased fatigue and decreased appetite. There was not an order regarding the [MEDICATION NAME] 5 mg which was the resident's current order. The [DATE] MAR indicated [REDACTED]. Nursing notes [DATE] to [DATE] did not contain documentation the physician was notified of a decline or change of condition with Resident #5. There was documentation Resident #5 had increased fatigue and was not eating, but the physician was not notified. During an interview on [DATE] at 1:56 p.m., CNA M said she was assigned to assist Resident #5 on [DATE] and she was unable to arouse the resident. She said she had not cared for Resident #5 in over a week. CNA M said the last time she cared for Resident #5, the resident was able to tell you when she need to go to the toilet. During an interview on [DATE] at 11:25 a.m., Resident #5's physician said he saw Resident #5 around 9:00 a.m. that day ([DATE]) and she was much worse than when he saw her two weeks earlier. He said he was not consulted about Resident #5's decline. The physician said he did not know the resident was not eating and had lost weight. He said he did not know she had become very lethargic, developed new pressure sores, and had diarrhea. During an observation and interview on [DATE] at 11:30 a.m., Resident #5's sister asked to speak with the physician about her sister's decline. The physician went back to Resident #5's room and said she had worsened over the past two hours and he thought she was septic. The physician went to the nurses station and told the nurses standing there that he should have been notified of Resident #5's condition and to call an ambulance to transport Resident #5 to the hospital. During an observation on [DATE] at 11:40 a.m., EMS arrived to transport Resident #5 to the hospital. The paramedic could not obtain a blood pressure or a pulse. Oxygen was applied because Resident #5's O2 saturation was 64%. Resident #5's physician was in the room. The physician said to the surveyor, Young lady if you had not come got me, she probably would have died . The Hospital Admitting Face sheet dated [DATE] indicated Resident #5 was admitted to ICU (Intensive Care Unit) with the [DIAGNOSES REDACTED]. A Wound Record from the hospital dated [DATE] at 1:30 p.m. indicated Resident #5 was admitted with a Stage II pressure sore on her left buttock, a Stage II pressure sore on her right buttock, a Stage II pressure sore on her coccyx, and an unstageable pressure sore on her heel. During an interview on [DATE] at 12:30 p.m., the DON said Resident #5's physician was never notified or consulted when Resident #5 declined. The DON said she was aware Resident #5 lost 7 pounds in 12 days. She said she knew something was going on with Resident #5, but did not assess her or contact the physician. The Acute Condition Changes-Clinical Protocol revised [DATE], indicated the nurse will notify the Physician about a resident with an acute change of condition. The nurse will make detailed observations and collect pertinent information, including the resident's current symptoms and status. The nurse will contact the Physician based on the urgency of the situation. The nursing staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. The Administrator and DON were notified on [DATE] at 12:15 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted [DATE] at 10:45 a.m. and included: All licensed nurses in-serviced on [DATE] by the Regional Nurse. In services to be completed by [DATE], 11 PM, any staff on vacation or unavailable will be in serviced before returning to work: Physical assessment Changes of Condition procedures SBAR and STOP and WATCH Procedures before ordering Antipsychotics and appropriate DX Medication administration, documentation, ordering, D/C meds Physician notification, family notification All Medication Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH tool New meds and D/C meds on MARS Medication ordering procedures Medication administration All Certified Nurse Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH Pre and Post tests administered to all disciplines by the Unit Manager All current residents with an order for [REDACTED]. Nursing staff will use the [MEDICAL CONDITION] monitoring form to track behaviors and document behaviors in the nurses' notes. Interact Care Paths tool may be used to assess changes in behaviors and condition changes. The survey team confirmed the POR had been implemented sufficiently to remove the IJ on [DATE] between 9:00 a.m. and 10:35 a.m. 13 CNAs, 4 LVNs, 3 RNs, and 3 housekeepers, from all three shifts, were interviewed. During the interviews all staff were asked to identify signs and symptoms of a change in condition, procedures used to report a change of condition, signs and symptoms of hydration and dehydration, and what was Stop and Watch and how to use it. On [DATE] at 10:45 a.m. the administrator and corporate nurse were informed the IJ was lifted; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on [DATE] at 4:00 p.m., RN E said that the resident's were divided between two charge nurses. She said 44 residents resided on Halls 4, 5, and 6.

Based on observation, interview, and record review, the facility failed to ensure the residents were free from significant medications errors for 1 of 5 residents reviewed for medications. (Resident #5) Staff did not administer Resident #5 the correct dosage of [MEDICATION NAME] (an anti-psychotic medication) resulting in the resident receiving excessive doses of the medication. The resident's condition deteriorated and she was admitted to the hospital with [REDACTED]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #5's rapid decline in health and hospitalization for septic shock. This failure could place 5 other residents who received [MEDICATION NAME] at risk for adverse consequences from unnecessary drugs. Findings included: A computerized physician order [REDACTED].#5 was a [AGE] year old female admitted [DATE]. Her [DIAGNOSES REDACTED]. She was to receive [MEDICATION NAME] (anti-depressant) 15 mg by mouth at bedtime and [MEDICATION NAME] (anti-psychotic) 2.5 mg by mouth at bedtime. A care plan dated [DATE] indicated Resident #5 had an unsteady gait and was a fall risk. She required set-up and cueing assistance with meals. She had impaired cognition and one of the approaches was to check O2 saturation with changes in cognition. She was at risk for alteration in nutrition and was to be assisted with all meals. The care plan did not address the anti-psychotic medication. The MAR indicated [REDACTED]. Nursing notes on [DATE] at 1:01 p.m. indicated LVN J was called to the shower room by CNA M. Resident #5 was calling the staff racial names and had slapped CNA M in the face. Resident continued to be combative and LVN J assisted in redirecting Resident # 5 and transferred her to the Geri-chair. A physician telephone order dated [DATE] indicated [MEDICATION NAME] 2.5 mg was to be discontinued. An order to increase [MEDICATION NAME] 5 mg one tablet by mouth at bed time was to be given. The MAR indicated [REDACTED]. Nursing notes dated [DATE] at 10:24 a.m. and [DATE] at 8:47 p.m. indicated Resident #5 was severely confused and combative with care. An MDS assessment dated [DATE] Indicated Resident #5 was severely cognitively impaired. She could sometimes make herself understood and could sometimes understand others. Resident #5 had signs of inattention and disorganized thinking. She had no [MEDICAL CONDITION] or psychotic behavior such as delusions or hallucinations. She had no signs and symptoms of depression. She was totally dependent on staff for assistance with all ADLs with one person and two persons for transfers. During an observation and interview on [DATE] at 3:15 p.m., Resident #5 was in bed asleep. There was an untouched glass of a health shake sitting on her bedside table. Resident #5 was very lethargic and not easily aroused. CNA F said for the past week the resident did not wake up to eat or drink. CNA F said Resident #5 used to assist with turning and repositioning, but was unable to assist for the past week. CNA F said upon admission, Resident #5 was alert, orientated to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. During an interview on [DATE] at 12:13 p.m., LVN J said the physician assistant increased Resident #5's [MEDICATION NAME] to 5 mg for reported aggression. LVN J said there was no behavior monitoring or any specific target behavior addressed; or any non-pharmacological intervention attempted, prior to increasing the antipsychotic medication. During an interview on [DATE] at 4:33 p.m., MA N said she initialed the box for the [MEDICATION NAME] 2.5 mg. and initialed the box for the [MEDICATION NAME] 5 mg on [DATE] through [DATE], and on [DATE] and [DATE], so she must have given both. During an observation and phone interview on [DATE] at 4:55 p.m., MA H said she did not remember giving both the [MEDICATION NAME] 2.5 mg and [MEDICATION NAME] 5mg on [DATE] and [DATE], and again on [DATE] and [DATE]. She said she circles her initials if she does not give a medication. MA N said she did not know if she gave both medications or not. There were no circles on the MAR for the 2.5 mg [MEDICATION NAME] on the dates MA N worked. During an interview on [DATE] at 10:00 a.m., the DON said the process the nurses and MAs followed was if a medication was not given; the initialed box beside the medication was circled and an explanation of why the medication was not given was written on the back of the MAR. During an interview on [DATE] at 3:15 p.m., CNA F said upon admission, Resident #5 was alert, oriented to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. CNA F said Resident #5 was able to bear weight for transfers at times when she was more alert. She said now the resident was a two person transfer combative and resistant to care at times and could not stay awake to eat or drink. CNA F said the nurses were aware. During an interview on [DATE] at 1:44 p.m., CNA K said Resident #5 was alert, orientated to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. She said over the past 10 days Resident #5 could no longer ambulate, she could no longer feed herself, she could no longer reposition herself in bed and she could not converse. The Dietary Data Set & Progress Note dated [DATE] indicated Resident #5 weighed 135 pounds on admission and weighed 128 pounds [DATE]. She was seen by a dietitian on [DATE] that made no recommendation. During an interview on [DATE] at 12:04 p.m., LVN J said when Resident #5 was admitted , she was not a big eater; however, she was able to feed herself and with prompting would eat ,[DATE]% of her meal. She said the resident was able to communicate clearly with periods of disorganized thinking. LVN J said when the [MEDICATION NAME] was increased to 5 mg, Resident #5 started to decline. She said the resident stopped eating, was very lethargic, and required extensive assistance with transfers and repositioning. LVN J said Resident #5's aggressive behavior worsened. LVN J said she did not review Resident #5's medical history and she did not review her medications. She said she did not consider it could have contributed to the resident s behavior. She said she did not notify the resident's physician of her decline. During an interview on [DATE] at 2:10 p.m. RN O said she was told the [MEDICATION NAME] was increased due to Resident #5's behavior. RN O said she did not monitor the resident's behavior or if the [MEDICATION NAME] was effective in reducing the behavior. The RN said she monitored medications for adverse reactions. RN O said she knew Resident #5 was sleeping all the time and not eating or drinking, but she did not consider the decline was caused by medication and did not notify the physician. During an interview on [DATE] at 11:00 a.m. LVN J said Resident #5 had been very lethargic and unable to arouse long enough to eat. LVN J said Resident #5's son told her on [DATE], he wanted the [MEDICATION NAME] stopped so his mother would wake up. LVN J said she contacted the physician assistant on [DATE] and received an order to put the medication on hold for 3 days. A telephone order dated [DATE] indicated to Hold [MEDICATION NAME] 2.5 mg x 3 days due to increased fatigue and decreased appetite. There was not an order to discontinue the [MEDICATION NAME] 5mg. The [DATE] MAR indicated [REDACTED]. During an interview on [DATE] at 11:25 a.m., Resident #5's physician said he saw Resident #5 around 9:00 a.m. that day ([DATE]) and she was much worse than when he saw her two weeks earlier. He said he was not consulted about Resident #5's decline. The physician said he did not know the resident was not eating and had lost weight. He said he did not know she had become very lethargic, developed new pressure sores, and had diarrhea. During an observation and interview on [DATE] at 11:30 a.m., Resident #5's sister asked to speak with the physician about her sister's decline. The physician went back to Resident #5's room and said she had worsened over the past two hours and he thought she was septic. The physician went to the nurses station and told the nurses standing there that he should have been notified of Resident #5's condition and to call an ambulance to transport Resident #5 to the hospital. During an observation on [DATE] at 11:40 a.m., EMS arrived to transport Resident #5 to the hospital. The paramedic could not obtain a blood pressure or a pulse. Oxygen was applied because Resident #5's O2 saturation was 64%. Resident #5's physician was in the room. The physician said to the surveyor, Young lady if you had not come got me, she probably would have died . The Hospital Admitting Face sheet dated [DATE] indicated Resident #5 was admitted to ICU (Intensive Care Unit) with the [DIAGNOSES REDACTED]. During an interview on [DATE] at 12:30 p.m., the DON said Resident #5's physician was never notified or consulted when Resident #5 declined. The DON said she was aware Resident #5 lost 7 pounds in 12 days. She said she knew something was going on with Resident #5, but did not assess her or contact the physician. According to the website, http://www.drugs.com/dosage/[MEDICATION NAME], accessed [DATE], .[MEDICATION NAME] is an antipsychotic. It may increase the risk of death when used to treat mental problems caused by dementia in elderly patients. Most of the deaths were linked to heart problems or infection. [MEDICATION NAME] is not approved to treat mental problems caused by dementia . The undated [MEDICAL CONDITION] Medication Use and Consents Policy and Procedure indicated .Medication interventions will never be used for disciplinary, restraint, or convenience of the facility staff. Residents will never receive a medication that is used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state when treating symptoms of mental illness without their knowledge and consent . The Administrator and DON were notified on [DATE] at 12:15 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted [DATE] at 10:45 a.m. and included: All licensed nurses in-serviced on [DATE] by the Regional Nurse. In services to be completed by [DATE], 11 PM, any staff on vacation or unavailable will be in serviced before returning to work: Physical assessment Changes of Condition procedures SBAR and STOP and WATCH Procedures before ordering Antipsychotics and appropriate DX Medication administration, documentation, ordering, D/C meds Physician notification, family notification All Medication Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH tool New meds and D/C meds on MARS Medication ordering procedures Medication administration All Certified Nurse Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH Pre and Post tests administered to all disciplines by the Unit Manager All current residents with an order for [REDACTED]. Nursing staff will use the [MEDICAL CONDITION] monitoring form to track behaviors and document behaviors in the nurses' notes. Interact Care Paths tool may be used to assess changes in behaviors and condition changes. The survey team confirmed the POR had been implemented sufficiently to remove the IJ on [DATE] between 9:00 a.m. and 10:35 a.m. 13 CNAs, 4 LVNs, 3 RNs, and 3 housekeepers, from all three shifts, were interviewed. During the interviews all staff were asked to identify signs and symptoms of a change in condition, procedures used to report a change of condition, signs and symptoms of hydration and dehydration, and what was Stop and Watch and how to use it. On [DATE] at 10:45 a.m. the administrator and corporate nurse were informed the IJ was lifted; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on [DATE] at 3:00 p.m., the DON said there were 5 residents currently taking the medication [MEDICATION NAME].

Based on observation, interview, and record review, the facility failed to ensure care and services were provided in accordance with the comprehensive assessment and plan of care to maintain the highest practicable well-being for 1 of 11 residents reviewed for change in condition (Resident #5), to ensure indwelling urinary (Foley) catheter tubing was secured for 1 of 2 residents reviewed for indwelling Foley catheters (Resident #20), and to ensure residents were assessed and needs met to help with sleep deprivation for 1 of 1 residents reviewed for [MEDICAL CONDITION]. (Resident #13) Immediate Jeopardy Staff did not administer Resident #5 the correct dose of [MEDICATION NAME] (anti-psychotic medication), resulting in the resident receiving excessive doses of the medication for 9 days. The facility did not identify and address a change of condition for Resident #5 which resulted in Resident #5 being admitted to the hospital for septic shock. This failure contributed to Resident #5's rapid decline in health and hospitalization for septic shock. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed [DATE]; however, the facility remained out of compliance at a pattern of actual harm harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 44 residents residing on Halls 4, 5, and 6 at risk for not receiving timely assessments which could result in harm or death. Non-Immediate Jeopardy Staff did not secure Foley catheter tubing for Resident #20. Staff did not address Resident #13's inability to sleep. This failure could place 4 residents with an indwelling urinary catheter at risk for pain and urethral trauma and 3 residents with [MEDICAL CONDITION] at risk of impaired decision making and [MEDICAL CONDITION]. Findings included: 1. A computerized physician order [REDACTED].#5 was a [AGE] year old female admitted [DATE]. Her [DIAGNOSES REDACTED]. She was to receive [MEDICATION NAME] (anti-depressant) 15 mg by mouth at bedtime and [MEDICATION NAME] (anti-psychotic) 2.5 mg by mouth at bedtime. A care plan dated [DATE] indicated Resident #5 had an unsteady gait and was a fall risk. She required set-up and cueing assistance with meals. She had impaired cognition and one of the approaches was to check O2 (oxygen) saturation with changes in cognition. She was at risk for alteration in nutrition and was to be assisted with all meals. The care plan did not address the anti-psychotic medication. The MAR indicated [REDACTED]. Nursing notes on [DATE] at 1:01 p.m. indicated LVN J was called to the shower room by CNA M. Resident #5 was calling the staff racial names and had slapped CNA M in the face. Resident continued to be combative and LVN J assisted in redirecting Resident #5 and transferred her to the Geri-chair. A physician telephone order dated [DATE] indicated [MEDICATION NAME] 2.5 mg was to be discontinued. An order to increase [MEDICATION NAME] 5 mg one tablet by mouth at bed time was to be given. The MAR indicated [REDACTED]. Nursing notes dated [DATE] at 10:24 a.m. and [DATE] at 8:47 p.m. indicated Resident #5 was severely confused and combative with care. An MDS assessment dated [DATE] Indicated Resident #5 was severely cognitively impaired. She could sometimes make herself understood and could sometimes understand others. Resident #5 had signs of inattention and disorganized thinking. She had no [MEDICAL CONDITION] or psychotic behavior such as delusions or hallucinations. She had no signs and symptoms of depression. She was totally dependent on staff for assistance with all ADLs with one person and two persons for transfers. The Dietary Data Set & Progress Note dated [DATE] indicated Resident #5 weighed 135 pounds on admission ([DATE]) and weighed 128 pounds as of [DATE]. (7 pound loss in 12 days) On [DATE], she was seen by a dietitian who made no recommendations. The progress notes did not indicate the physician was notified about the weight loss. During an interview on [DATE] at 12:13 p.m., LVN J said the physician assistant increased Resident #5's [MEDICATION NAME] to 5 mg for reported aggression. LVN J said there was no behavior monitoring or any specific target behavior addressed; or any non-pharmacological intervention attempted, prior to increasing the antipsychotic medication. During an interview on [DATE] at 4:33 p.m., MA N said she initialed the box for the [MEDICATION NAME] 2.5 mg. and initialed the box for the [MEDICATION NAME] 5 mg on [DATE] through [DATE], and on [DATE] and [DATE], so she must have given both. During an observation and phone interview on [DATE] at 4:55 p.m., MA H said she did not remember giving both the [MEDICATION NAME] 2.5 mg and [MEDICATION NAME] 5mg on [DATE] and [DATE], and again on [DATE] and [DATE]. She said she circles her initials if she does not give a medication. MA N said she did not know if she gave both medications or not. There were no circles on the MAR for the 2.5 mg [MEDICATION NAME] on the dates MA N worked. During an interview on [DATE] at 10:00 a.m., the DON said the process the nurses and MAs followed was if a medication was not given; the initialed box beside the medication was circled and an explanation of why the medication was not given was written on the back of the MAR. During an interview on [DATE] at 3:15 p.m., CNA F said upon admission, Resident #5 was alert, oriented to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. CNA F said Resident #5 was able to bear weight for transfers at times when she was more alert. She said now the resident was a two person transfer combative and resistant to care at times and could not stay awake to eat or drink. CNA F said the nurses were aware. During an observation and interview on [DATE] at 3:15 p.m., Resident #5 was in bed asleep. Resident #5 was not easily aroused. There was an untouched glass of a health shake sitting on her bedside table. CNA F said the resident did not wake up to drink it. The resident's left heel had a pressure sore with black eschar. There was a strong foul odor of urine and feces in the resident's room. The resident was lying on a draw sheet, on top of a comforter, on top of a cloth incontinent pad, on top of a fitted sheet. CNA F removed the resident's brief and Resident #5 was lying in a large puddle of loose feces and urine. Urine had soaked through to the mattress and there was a dry brown ring on the draw sheet. CNA F said they were instructed to double and triple pad if necessary. A large Stage III pressure sore approximately 7 inches long and 2 inches wide was uncovered on her left buttock close to the resident's gluteal fold. The sore was beefy red and bloody with cream colored slough in the center. There was a second Stage II pressure sore approximately 2 inches long and 0.5 inches wide on the upper right buttock close to the gluteal fold. CNA F said the pressure sore to Resident #5's right buttock was new because she had not seen it before. During an interview on [DATE] at 9:30 a.m., LVN D said she was responsible for wound treatments in the facility. LVN D said Resident #5 had one pressure sore on her left heel. She said the wound on Resident #5's left buttock was an abrasion. She said she was not confident in staging so she asked one of the other nurses to stage wounds. LVN D said she did not remember which nurse identified Resident #5's pressure sore to her left buttock as an abrasion. She said she had no training. LVN D said she was not told Resident #5 had another pressure sore to her right buttock. She said she was not told there was not a dressing on the pressure sore to the left buttock. LVN D said she did not notify the physician about the pressure sores. The Wound and Skin Status Report dated [DATE] identified the pressure sore to Resident #5's left buttock as an abrasion. The TAR (Treatment Administration Record) dated September indicated Resident #5 was admitted with the pressure sore on her left heel. The pressure sore to Resident #5's left buttock was identified on [DATE]. (4 days after the [MEDICATION NAME] was increased) During an interview on [DATE] at 1:44 p.m., CNA K said Resident #5 was alert, oriented to person and place with intermittent confusion, ambulatory, could feed herself, and could carry on conversations. CNA K said over the past 10 days Resident #5 could no longer ambulate, she could no longer feed herself, she could no longer reposition herself in bed, and she could not converse. During an interview on [DATE] at 12:04 p.m., LVN J said when Resident #5 was admitted , she was not a big eater; however, she was able to feed herself and with prompting would eat ,[DATE]% of her meal. She said the resident was able to communicate clearly with periods of disorganized thinking. LVN J said when the [MEDICATION NAME] was increased to 5 mg, Resident #5 started to decline. She said the resident stopped eating, was very lethargic, and required extensive assistance with transfers and repositioning. LVN J said Resident #5's aggressive behavior worsened. LVN J said she did not review Resident #5's medical history and she did not review her medications. She said she did not assess Resident #5 for a UTI or infection and did not consider it could have contributed to the resident s behavior. She said she did not notify the resident's physician of her decline. During an interview on [DATE] at 2:10 p.m., RN O said on Saturday, [DATE], Resident #5 complained of her butt hurting; however, she did not assess the source of the pain or the pressure sore on the resident ' s left buttock. RN O said she was told the [MEDICATION NAME] was increased due to Resident #5's behavior. RN O said she did not monitor the resident's behavior or if the [MEDICATION NAME] was effective in reducing the behavior. The RN said she monitored medications for adverse reactions. RN O said she knew Resident #5 was sleeping all the time and not eating or drinking, but she did not consider the decline was caused by medication and did not notify the physician. During an interview on [DATE] at 10:25 a.m., CNA P said she worked the 6 a.m.-2:00 p.m. shift. She said Resident #5 had diarrhea on Sunday, [DATE]. She said she told the nurse, but did not know if anything was done. She said Resident #5 still had diarrhea today. CNA P said Resident #5 had not been eating or drinking for several days and the nurse was aware. During an interview on [DATE] at 11:00 a.m., LVN J said on [DATE] the CNA told her Resident #5 had diarrhea. She said she gave the resident Pepto Bismol. She said she did not document the diarrhea in the nursing note. LVN J said she did not assess Resident #5 after giving the anti-diarrheal medicine to see if it was effective. She said Resident #5 had been very lethargic and unable to arouse long enough to eat for at least a week. LVN J said Resident #5's son told her on [DATE] he wanted the [MEDICATION NAME] stopped so his mother would wake up. LVN J said she contacted the physician assistant after lunch on Sunday [DATE] and received an order to put the medication on hold for 3 days. LVN J said she did not document what time she contacted the physician assistant. LVN J said she was aware Resident #5 was not eating or drinking, but did not notify the physician of the diarrhea, the resident's decreased appetite, or of the pressure sores. A telephone order dated [DATE] indicated to Hold [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg x 3 days due to increased fatigue and decreased appetite. There was not an order regarding the [MEDICATION NAME] 5 mg which was the resident's current order. The [DATE] MAR indicated [REDACTED]. Nursing notes [DATE] to [DATE] did not contain documentation the physician was notified of a decline or change of condition with Resident #5. There was documentation Resident #5 had increased fatigue and was not eating, but the physician was not notified. During an interview on [DATE] at 1:56 p.m., CNA M said she was assigned to assist Resident #5 on [DATE] and she was unable to arouse the resident. She said she had not cared for Resident #5 in over a week. CNA M said the last time she cared for Resident #5, the resident was able to tell you when she need to go to the toilet. CNA M said she thought Resident #5 was much calmer when staff explained what they were going to do before doing it. She said when she took care of Resident #5 on [DATE]; the resident did not act out or become combative. During an interview on [DATE] at 11:25 a.m., Resident #5's physician said he saw Resident #5 around 9:00 a.m. that day ([DATE]) and she was much worse than when he saw her two weeks earlier. He said he was not consulted about Resident #5's decline. The physician said he did not know the resident was not eating and had lost weight. He said he did not know she had become very lethargic, developed new pressure sores, and had diarrhea. During an observation and interview on [DATE] at 11:30 a.m., Resident #5's sister asked to speak with the physician about her sister's decline. The physician went back to Resident #5's room and said she had worsened over the past two hours and he thought she was septic. The physician went to the nurses station and told the nurses standing there that he should have been notified of Resident #5's condition and to call an ambulance to transport Resident #5 to the hospital. During an observation on [DATE] at 11:40 a.m., EMS arrived to transport Resident #5 to the hospital. The paramedic could not obtain a blood pressure or a pulse. Oxygen was applied because Resident #5's O2 saturation was 64%. Resident #5's physician was in the room. The physician said to the surveyor, Young lady if you had not come got me, she probably would have died . The Hospital Admitting Face sheet dated [DATE] indicated Resident #5 was admitted to ICU (Intensive Care Unit) with the [DIAGNOSES REDACTED]. A Wound Record from the hospital dated [DATE] at 1:30 p.m. indicated Resident #5 was admitted with a Stage II pressure sore on her left buttock, a Stage II pressure sore on her right buttock, a Stage II pressure sore on her coccyx, and an unstageable pressure sore on her heel. During an interview on [DATE] at 12:30 p.m., the DON said Resident #5's physician was never notified or consulted when Resident #5 declined. The DON said she was aware Resident #5 lost 7 pounds in 12 days. She said she knew something was going on with Resident #5, but did not assess her or contact the physician. According to the website, http://www.drugs.com/dosage/[MEDICATION NAME], accessed [DATE], .[MEDICATION NAME] is an antipsychotic. It may increase the risk of death when used to treat mental problems caused by dementia in elderly patients. Most of the deaths were linked to heart problems or infection. [MEDICATION NAME] is not approved to treat mental problems caused by dementia . The undated Admission Protocols Process indicated the charge nurse admitting a resident would complete a head-to-toe assessment, complete nursing assessment, and risk assessments on all residents. The undated Resident change of Condition Policy and Procedure indicated if a resident has a change of condition, the nurse aide should notify the charge nurse of the slightest change in order for the nurse to assess and complete SBAR (INTERACT tool) document to ensure that they are monitoring an acute illness prior to being an emergency. The Acute Condition Changes-Clinical Protocol revised [DATE], indicated the nurse will notify the Physician about a resident with an acute change of condition. The nurse will make detailed observations and collect pertinent information, including the resident's current symptoms and status. The nurse will contact the Physician based on the urgency of the situation. The nursing staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. The Administrator and DON were notified on [DATE] at 12:15 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted [DATE] at 10:45 a.m. and included: All licensed nurses in-serviced on [DATE] by the Regional Nurse. In services to be completed by [DATE], 11 PM, any staff on vacation or unavailable will be in serviced before returning to work: Physical assessment Changes of Condition procedures SBAR and STOP and WATCH Procedures before ordering Antipsychotics and appropriate DX Medication administration, documentation, ordering, D/C meds Physician notification, family notification All Medication Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH tool New meds and D/C meds on MARS Medication ordering procedures Medication administration All Certified Nurse Aides in-serviced on [DATE] by the Unit Manager: Hydration and Dehydration Change of Condition procedures STOP and WATCH Pre and Post tests administered to all disciplines by the Unit Manager All current residents with an order for [REDACTED]. Nursing staff will use the [MEDICAL CONDITION] monitoring form to track behaviors and document behaviors in the nurses' notes. Interact Care Paths tool may be used to assess changes in behaviors and condition changes. The survey team confirmed the POR had been implemented sufficiently to remove the IJ on [DATE] between 9:00 a.m. and 10:35 a.m. 13 CNAs, 4 LVNs, 3 RNs, and 3 housekeepers, from all three shifts, were interviewed. During the interviews all staff were asked to identify signs and symptoms of a change in condition, procedures used to report a change of condition, signs and symptoms of hydration and dehydration, and what was Stop and Watch and how to use it. On [DATE] at 10:45 a.m. the administrator and corporate nurse were informed the IJ was lifted; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 2. The electronic physician orders [REDACTED].#20 was [AGE] years old admitted on [DATE] with [DIAGNOSES REDACTED]. The orders did not address securing the resident ' s indwelling urinary catheter. The most recent care plan dated [DATE] indicated Resident #20 was to have a leg strap in place to secure the indwelling urinary catheter tubing. The most recent MDS dated [DATE] indicated Resident #20 usually made his needs known and usually understood others. Resident #20 required extensive one to two person assist with all ADLs and had an indwelling Foley catheter. During an observation and interview on [DATE] at 3:40 p.m., Resident #20's indwelling Foley catheter tubing was not secured and pulled taut. Resident #20 said the indwelling Foley catheter tubing often pulled on his urethra causing it to hurt him. During an observation and interview on [DATE] at 5:00 p.m., Resident #20's Foley catheter tubing was not secured. RN E (unit manager) said Resident # 20 should always have his indwelling urinary catheter secured with a catheter secure. The urinary catheter care policy dated [DATE] indicated the following: Changing catheters: *ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. Complications: * .secure catheter tubing to leg or thigh to prevent potential injury . 3. Physician orders [REDACTED].#13 was [AGE] years old admitted [DATE] with [DIAGNOSES REDACTED]. Her orders indicated she received [MEDICATION NAME] 6 mg (natural hormone for sleep) by mouth at bedtime, started [DATE]. The most recent MDS dated [DATE] indicated Resident #13 usually understood others and usually made herself understood, she scored a 15 on her BIMS (brief interview for mental status),which indicated she was cognitively intact. The mood interview indicated she did not have any trouble with staying asleep and she had no behaviors except wandering. She required supervision for transfer and ambulation and required extensive assistance with bed mobility and personal care. Resident #13 was continent of bowel and bladder. The care plans dated [DATE] for Resident #13 did not address [MEDICAL CONDITION] (inability to sleep). Nursing notes for August- [DATE] indicated the following: * [DATE] at 8:00 p.m. - complains often of not sleeping well, but sleeps during the day. * [DATE] at 6:15 a.m. - Resident up walking, stating can't sleep. * [DATE] at 3:14 a.m. - Awake and wandering in hallway all night, states, I can't sleep. * [DATE] at 10:42 p.m. - Resident ambulatory, wandering about. * [DATE] at 10:54 p.m. - Resident is awake and alert. * [DATE] at 2:48 a.m. - Frequent wandering during the night. * [DATE] at 3:26 a.m. - Has problems falling to sleep and staying asleep. * [DATE] at 10:42 a.m. - Resident is awake and alert. * [DATE] at 1:58 a.m. - frequent wandering during the night. During a group interview on [DATE] at 2:00 p.m., Resident #13 said she had not slept in days. The resident said the facility tried a sleeping pill at one point, but the medication did not work. During an observation and interview on [DATE] at 9:15 p.m., Resident #13 was pacing and walking around the hallway. She said she could not sleep and rarely slept at all. During an observation and interview on [DATE] at 8:30 a.m., Resident #13 was sitting in the lobby with dark circles under her eyes and her hair was disheveled. She said she only slept a little the night before. During an observation and interview on [DATE] at 10:45 a.m., Resident #13 was walking the hallways and said since she was she was not able to sleep. During an interview on [DATE] at 1:40 p.m., CNA Q said Resident #13 did not sleep much. She said the resident occasionally napped during the day, but not enough to equal a full night's sleep. During an interview on [DATE] at 1:45 p.m., RT R said Resident did not sleep much, and seldom saw her sleeping during the day. He said when he worked on the night shift, she would be awake and wandering. During an interview on [DATE] at 1:50 p.m., the SW said Resident #13 had a sleep problem, and she discussed her concerns about Resident #13 not sleeping with the nurses. The SW said on the resident ' s last MDS assessment ([DATE]), she did not mark the sleep section because she did not think it affected the resident ' s mood. During an interview on [DATE] at 2:00 p.m., RN O said Resident #13 napped during the day sometimes after lunch. She said she did not know if she slept at night. During an interview on [DATE] at 10:00 a.m., Resident #13's daughter said the resident had a history of [REDACTED]. Internet accessed on [DATE] at 9:30 a.m., http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 25/ said the following: [MEDICAL CONDITION] is a potential cause of anxiety, depression, and anomalies of experience; separate research has shown that anxiety, depression and anomalies of experience are predictors of paranoia. Thus [MEDICAL CONDITION] may contribute to the formation and maintenance of persecutory ideation (delusion of persecution) There is evidence consistent with the idea that sleep disturbance has a role in the development of paranoia. [MEDICAL CONDITION] is a risk factor for the development of emotional disorder (Ford and Kamerow, 1989; Breslau et al., 1996; Morphy et al., 2007) and an association with daytime mood disturbance has been repeatedly demonstrated (Riedel and Lichstein, 2000; Buysse et al., 2007). During an interview on [DATE] at 4:00 p.m., RN E said 44 residents resided on Halls 4, 5, and 6. The CMS 672 dated [DATE] indicated 4 residents had indwelling urinary catheters. During an interview [DATE] at 4:30 p.m., RN E provided a list of 3 residents with [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services to promote healing and prevent the development of new pressure sores for 1 of 3 residents reviewed for pressure sores (Resident #5). Resident #5 was admitted with a pressure sore to her left heel. She developed 2 pressure sores on her buttocks and the pressure sore to her heel worsened. The facility did not appropriately assess and stage the pressure sores on her left buttock or left heel and was unaware of the second pressure sore on the resident's right buttock. This failure contributed to Resident #5 development of new and worsening pressure sores and placed 14 residents who were in bed all or most of the time at risk for development or worsening of pressure sores. Findings included: A computerized physician order [REDACTED].#5 was a [AGE] year old female admitted [DATE]. Her [DIAGNOSES REDACTED]. Left heel treatment to paint left heel with [MEDICATION NAME] daily and monitor until resolved. An MDS assessment dated [DATE] indicated Resident #5 was severely cognitively impaired. The MDS indicated she could sometimes make herself understood, could sometimes understand others and was totally dependent on staff for assistance with all ADLs with one person and two persons for transfers. The MDS indicated Resident # 5 had a stage IV pressure sore that was black eschar. A care plan dated 8/26/15 indicated Resident #5 had impaired cognition. The care plan did not address anti-psychotic medications or pressure sores. The nursing notes dated 8/26/15 to 9/14/15 indicated the physician was not notified of new pressure sores to the left and right buttock on Resident #5. There was no documented assessment of the pressure sores in the nurse ' s notes. During an observation and interview on 9/13/15 at 3:15 p.m., Resident #5 was in bed asleep. Resident #5 was not easily aroused. There was an untouched glass of a health shake sitting on her bedside table. CNA F said the resident did not wake up to drink it. The resident ' s left heel was open to air and had thick black eschar. There was no off-loading with pillows or cushions to eliminate pressure to the heel. There was a strong foul odor of urine and feces in the resident's room. The resident was lying on a draw sheet, on top of a comforter, on top of a cloth incontinent pad, on top of a fitted sheet. CNA F removed the resident's brief and Resident #5 was lying in a large puddle of loose feces and urine. Urine had soaked through to the mattress and there was a dry brown ring on the draw sheet. CNA F said they are instructed to double and triple pad if necessary. A large stage III pressure sore approximately 7 inches long and 2 inches wide was noted uncovered on her left buttock close to the resident ' s gluteal fold. The sore was beefy red and bloody with cream colored slough in the center. There was a second stage II pressure sore approximately 2 inches long and 0.5 inches wide on the upper right buttock close to the gluteal fold. When the surveyor identified the pressure sore, CNA F said the pressure sore to Resident #5's right buttock was new because she had not seen it before. A Wound and Skin Status Report dated 9/14/15 indicated Resident #5 had an abrasion to the left buttock that was identified on 9/8/15. During an interview on 9/14/15 at 9:30 a.m., LVN D said she was responsible for wound treatments in the facility. LVN D said Resident #5 had one pressure sore on her left heel. She said the wound on Resident #5's left buttock was an abrasion, but could be a pressure sore, she was not sure. LVN D said she did not know how to stage so sometimes she would ask one of the other nurses to stage wounds. LVN D said she did not remember which RN staged Resident #5's pressure sore to her left buttock as an abrasion. She said she had no training but used pictures as a guide in staging pressure sores. LVN D said she was not told Resident #5 had another pressure sore to her right buttock and she had not dressed the pressure sore to the left buttock. During an interview on 9/14/15 at 11:59 a.m., the DON said the treatment nurse had no training on pressure sores or wound care. She had been the treatment nurse for the past month. The DON said she did not look at Resident #5's pressure sores. The DON said she did not assess pressure sores on a regular basis. During an interview on 9/14/15 at 3:20 p.m., LVN D, the treatment nurse, said the last time she saw Resident #5's buttocks was Friday, 9/11/15. She said she did not consider the wound to the left buttock a pressure wound. The treatment nurse said Resident # 5 had a small black area on her left heel when she was admitted . She said the black eschar had increased in size and covered the entire left heel. She said she did not notify the physician about the pressure sore to the left buttock or that the pressure sore to the left heel was worsening. During an interview on 9/15/15 at 2:10 p.m., RN O said Resident #5 complained of her butt hurting after lunch when she was returning to her room. RN O said she did not assess the source of the pain or the pressure sore to the left buttock. She said, I don ' t mess with wounds . During an interview on 9/14/15 at 11:25 a.m., Resident #5's physician said he saw Resident #5 around 9:00 a.m. that day and she was much worse than when he saw her two weeks earlier. He said he had not been consulted about Resident #5's development of new pressure sores. A Wound Record from the hospital dated 9/15/15 at 1:30 p.m., indicated Resident #5 was admitted with a Stage II pressure sore on her left buttock, a Stage II pressure sore on her right buttock, a Stage II pressure sore on her coccyx, and an unstageable pressure sore on her heel. The pressure sore to the coccyx was not identified prior to the resident going to the hospital. The undated Skin System Policy & Procedure indicated All residents will be assessed on admission, with each change in condition, and quarterly for their individual risk for skin compromise. Historical medical records, family, resident and physician input will be used to assist the appropriate documentation of the kind of wound found such as stasis, diabetic, excoriation, or true pressure ulcer. Staging and measuring will be done exclusively by the Skin Management Nurse assigned to that resident. It is necessary to show all areas of compromise and use the facility reporting system to communicate the changes to the appropriate persons. Physician and family will be notified of any changes of skin condition according to the regulatory guideline . The CMS 672 dated 9/13/15 indicated 14 residents were in bed all or most of the time.