Every finding on record at Avir at Western Hills

Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 1of 3 residents (Resident #64) reviewed for infection control. MA failed to disinfect the blood pressure cuff between use on Resident #79 and Resident #64 while performing medication administration. This failure places residents at risk for cross contamination and development of infections.Findings include: 1.Record Review of Resident #79's updated face sheet reflected she was an [AGE] year old female admitted to the facility on [DATE] with diagnosis of Hypertension (high blood pressure). 2.Record Review of Resident #64's updated face sheet reflected she was an [AGE] year old female admitted to the facility on [DATE] with diagnosis of Acute Posthemorrhagic anemia (sudden drop in red blood cells), Dementia, Iron Deficiency, Duodenal ulcer ( Ulceration in the intestines), Polyp in colon (growth in intestine), Lesion of Sciatic Nerve of Left leg. In observation of medication administration on 7/15/2026 at 8:20 AM MA utilized the automatic blood pressure cuff on Resident #70 and Resident #64 and failed to disinfect the blood pressure cuff between residents. In an interview on 7/15/2026 at 8:58AM with MAA she stated that she was frequently in serviced on infection control. She stated that it was policy to disinfect the blood pressure cuff between each use. She stated that she did not know why she did not clean the cuff. She stated that by not cleaning the blood pressure cuff between residents they could get a rash or something could spread from another resident. In an interview on 7/16/2026 at 1:20 PM with ADM he stated that staff are frequently in-serviced on infection control. He stated this training included the disinfection of reusable medical equipment between residents. He stated that he expects staff to clean the blood pressure cuff between residents. He stated if the cuff is not cleaned it could spread infections to the residents. In an interview on 7/16/2026 with DON and RNC they stated that staff are frequently in-serviced on infection control. They stated that the policy included the disinfection of reusable medical equipment between residents. The DON stated she expected her staff to clean the blood pressure cuff between each resident to prevent the spread of germs. Record review of facility provided policy Standard Precautions Revised September 2022 reflected, policy statements: Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. The section titles Resident-Care Equipment stated, Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed.

During Observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; for 1 of 6 residents (Resident #1) reviewed for quality of care.-The facility failed to ensure the ADON did not leave Resident #1 without providing incontinent care, when the resident had an BM on 06/11/2026 at 2:35 pm.This failure could result in skin breakdown, infection, and a significant decline in Resident #1's health.Findings included:Record review of Resident #1's face sheet revealed she is a forty-three-year-old woman with a diagnosis of cerebral palsy, aphasia, dysphagia, muscle weakness, muscle wasting and atrophy, epilepsy, and quadriplegia.Record review of Resident #1's care plan revealed she is dependent on staff etc. for meeting emotional, intellectual, physical, and social needs r/t Disease process (cerebral palsy), Immobility, Physical Limitations. Resident #1 is at high risk for falls related to Cerebral Palsy, muscle weakness, Quadriplegia, Epilepsy, lack of coordination, medication use and incontinence. (Resident #1) I am unable to voice my needs.On 6/11/26 at 2:35pm an observation/interview with the ADON (no other staff or family present) revealed the ADON checking Resident #1 for skin breakdown on her buttock. Skin was pink and blanchable with white cream visible on skin. Resident #1's brief was soiled with a fresh BM. She said she would tell an aide. She said it could cause skin breakdown leaving someone sitting in a soiled brief, but it didn't look like Resident #1 was done with the BM and an aide would be there shortly, so Resident #1 will be ok.On 6/11/26 at 3:30pm an interview/observation with Resident #1's family revealed Resident #1 had not had her brief changed and was still sitting in a soiled brief from earlier observation with the ADON. Resident #1's brief, bedding and clothing were wet. Resident #1's family was upset and stated that she frequently comes into visit and finds the resident in this condition. She pointed out that the call light was on prior to me entering the room and nobody had come in to check on the resident.In an observation on 6/11/26 at 3:55pm at the nurses' station for the 200 and 300 hall the call light was heard buzzing, and 2 lights were lit up. The MA was seen standing at the medication cart talking to another staff member. The ADMIN walked up to nurses' station standing right in front of the call light and started talking to MA. Both the MA and the ADMIN walked off in opposite directions. Neither of them checking on the residents whose call lights were going off including Resident #1. In an interview on 6/11/26 at 4:00pm, the MA stated they are always short-staffed but reported today they have 4 nurses, 3 aids, 2 trainees, and 1 MA on 200 and 300 halls. She said call light turnaround time was long because they did not have enough staff. She stated it can take 40-60 minutes sometimes to get to a call light. She said it is everyone's responsibility ensuring incontinence care is provided. She said the ADON did not tell anyone Resident #1 needed to be changed prior to her leaving for the day that she knew of.In an observation on 6/11/26 at 4:05 pm LVN was seen entering Resident #1's room and the call light went off.In an interview on 6/11/26 at 4:10pm, LVN stated the facility does seem to be short-staffed and call lights do tend to linger for a bit but everyone helped out and answered them as quickly as possible. She stated the ADON did tell her Resident #1 needed to be changed. She said she told her aide, but she did not know where that aid was, what her name was, or if she went in there to change Resident #1. She said she assumed that she did not go since Resident #1's family stated she had to change Resident #1 by herself. She said it was everyone's responsibility to ensure incontinence care was provided.In an interview on 6/11/26 at 5:15pm, the ADMIN stated it was the facility's fault that Resident #1 was not changed in a timely manner. He said he could not specify a time frame of what timely manner meant. He stated he was disappointed with the communication failure that led to Resident #1 not being changed in a timely manner.The facility did not have a policy that specified when a resident should be changed, who was responsible for changing a resident, or a time frame for answering call lights.

Based on observation, interview and record review the facility failed to ensure a resident was treated with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 2 residents (Resident # 1) reviewed for resident rights. The facility failed to ensure Resident #1 was treated with dignity and respect when her foley bag was uncovered and exposed, and was 1/4 full of urine. This failure could place residents at risk of lack of comfortability and respect, as well as a decline in self-worth. Findings include: Record review of Resident #1's face sheet, dated 05/27/26, reflected a [AGE] year-old female who was admitted to the facility 12/30/24. Resident #1 had diagnoses which included cerebral palsy (abnormal brain development), obstructive (blockage) and reflux (travels wrong way) uropathy (disease of urinary tract), unspecified, retention of urine, unspecified and presence of other specified devices (catheter). Record review of Resident #1's quarterly MDS, dated [DATE], reflected, Section GG. Functional Abilities: Toileting hygiene: 01. Dependent: Helper does all of the effort. Resident does none of the effort to complete the activity, or, the assistance of 2 or more helpers is required of the resident complete the activity; Toilet transfer: 88. Not attempted due to medical condition. Section H. Bladder and Bowel. Appliances A. Indwelling catheter. Urinary Toileting Program: 0. No. Urinary Continence: 9. Not rated, resident had a catheter (indwelling condom). Section I. Active Diagnoses: Obstructive Uropathy Record review of Resident #1's care plan, dated 04/03/26, reflected Focus: [Resident #1] has Foley Catheter related to Neurogentic Bladder Assoc with CP Retention. Goal: Resident #1 will be/remain free from catheter-related trauma through review date. [Resident #1] will show no s/sx of urinary infection through review date. Interventions/Tasks: Catheter: [Resident #1] has indwelling Foley Catheter, Position catheter bag and tubing below the level of the bladder and away from entrance room door. Record review of Resident #1's NMAR, dated 05/2026, reflected s/p catheter site: cleanse with soap and water, dry and apply t-sponge dressing daily and PRN at bedtime for s/p catheter; secure catheter with leg strap every shift Observation of Resident #1's room on 05/27/26 at 10:29 AM revealed a urine bag that was 1/4 full of yellow urine. The bag was uncovered and visible to passersby from the hallway. During an interview with CNA A on 05/27/26 at 01:15 PM, she stated foley bags had to be covered when residents were in their rooms. She also stated it was the responsibility of the CNA's to ensure they were covered. CNA A stated Resident #1's bag was uncovered because she was in her room. She stated an exposed urinary bag could negatively affect a resident's dignity or self-respect if visitors passed by the room and saw it. She stated there was a policy, but she could not recall it. During an interview with CNA B on 05/27/26 at 01:24 PM, he stated privacy bags were to be utilized at all times because it was a HIPAA violation. He stated all residents who had a urinary bag were supposed to have a privacy cover on them. CNA B stated resident dignity was affected by the bags not being covered. He stated all nursing staff were responsible for ensuring the bags were covered. He was asked why the bag was not covered, and he stated he did not know. During an interview with CNA C on 05/27/26 at 01:31 PM, she stated the facility policy was that urinary privacy covers were to always be utilized on the foley bags, even when a resident was in their room. She stated there was no time when it was okay for a resident to have an exposed urinary bag. She stated all nursing staff/caregivers were responsible for making sure they were utilized at all times. During an interview with CNA D on 05/27/26 at 01:26 PM, she stated she did not recall her most recent training on catheter bags. She stated nursing staff had always known urinary bags were supposed to be covered with privacy bags. She stated there was a policy regarding this but added she could not quote it. During an interview with the DON on 05/27/26 at 01:45 PM, she stated the facility's expectation was for foley bags to be covered with a privacy bag because it was a dignity issue for residents. She stated staff were in-serviced on 05/26/26 about foley bags so they should have known to have them covered. She stated all members of the nursing department were responsible for ensuring privacy bags were in effect, and added ultimately, she was responsible for them all. Record review of the facility's policy Resident Rights, dated 02/2001, reflected Employees shall treat all residents with kindness, respect and dignity.

Based on interview, and record review the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for 1 (Resident #1) of 5 residents reviewed for food preferences and allergies. The facility failed on 10/20/25, 10/22/25, 11/17/25, 12/8/25, and 12/27/25 to serve Resident #1 meals that excluded foods she was allergic to or foods that aligned with her religious beliefs. This failure placed residents at risk of food-related medical emergencies and did not honor their religious preferences. Findings included: Review of Resident #1's quarterly MDS dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: anemia (deficiency of red blood cells), neurogenic bladder (a condition where neurological conditions affect bladder function, leading to issues with bladder control), anxiety (feelings of worry, nervousness or unease), bipolar disorder (mental disorder characterized by wide mood swings), schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking or behavior), respiratory failure (inability of the respiratory system to perform adequate gas exchange), colostomy malfunction (complications that can arise after a colostomy surgery, which diverts waste from the rectum to an opening in the abdominal wall), and morbid obesity (BMI of 40 or higher). In Section K - Swallowing/Nutritional Status, Resident #1 was indicated as being on a therapeutic diet (e.g., low salt, diabetic, low cholesterol). Resident #1 had a BIMS score of 15, indicating intact cognition. Review of Resident #1's comprehensive care plan dated 11/25/25 reflected in the allergies list, and allergy of tomatoes. Resident #1 had a 'no salt on tray' diet with regular texture and consistency. Interventions were to provide and serve diet as ordered. Review of Resident #1's food preferences assessment dated [DATE] reflected that she did not like pork on 5 different spaces provided. The tomato allergy was also printed. Review of meal photos revealed the following items were severed to the resident:*12/27/25 Resident #1 was served 3 slices of pork, meal ticket stated dislikes of pork and no raw tomatoes *12/8/25 Resident #1 was served a dinner salad with raw tomatoes*11/17/25 Resident #1 was served a dinner salad with tomato seeds visible*10/22/25 Resident #1 was served raw tomatoes on her tray, meal ticket read, two turkey sandwiches, lettuce, pickles, mayo, ketchup, mustard*10/20/25 Resident #1 was served a turkey sandwich with a plate of lettuce, onion, and raw tomato on the side, meal ticket stated a dislike of pork and no raw tomatoes, 2 turkey sandwiches, lettuce, pickle, mayo Review of Resident #1's November MAR revealed a Benadryl was administered on 11/19/25 at 2100 (9:00PM). In an interview/observation on 12/29/2025 at 9:18 AM with Resident #1 she stated she had an allergy to raw tomatoes, but that she could eat cooked tomatoes. She stated that it was her religious preference not to eat pork, but that the facility continued to serve it to her. She stated the facility did not go over her food preferences until February 2025. She told the facility at that time that she could eat beef, chicken, and/or turkey. Resident #1 provided pictures of meals that she had been served that contained tomatoes and/or pork and her meal tickets were visible in some of the photos. A picture showing tomato seeds on her plate dated 11/17, Resident #1 informed the surveyor she had to take Benadryl that day due to ingesting the tomato seeds in her salad. She stated her mouth would swell and she got hives on her back if she ingested raw tomato. In an interview on 12/29/2025 at 9:42 AM with [NAME] A, she stated that there was a new cook aide that could have been responsible for serving tomatoes to Resident #1 because they did not have resident preferences memorized. She stated that she had informed the new aide to pay attention to the resident meal tickets, because it was on the counter in front of them as they prepared trays. She stated that the cook was responsible for ensuring what was on the ticket was being served accurately. She stated they started that process about a couple weeks ago, ensuring plates were accurate before sending out. In an interview on 12/29/2025 at 9:45 AM with the DA, she stated that she was well aware of Resident #1's allergy and preferences because Resident #1 would often write things on her meal tickets and send them back to the kitchen. She stated that on 12/24/25, [NAME] A had to leave due to getting sick at work, and the DA had to take over food preparation. She stated that it was an emergency and if she were responsible for any food mistakes she was horribly mistaken and apologetic. She stated that she had been in-serviced about a month ago on resident preferences and she knew how to look at resident tickets before making their side dishes. In an interview on 12/29/2025 at 11:27 AM with the DM, she stated she became the DM in October 2025 and prior to that, she was the cook for about 5 years. She stated she was aware of the preferences of Resident #1. She stated that she had been working on going around and completing all the residents' food preferences and that sometimes the nurses would send her communication slips pertaining to diet changes. She stated she was in the process of doing every resident's food preference while also learning her role. She stated that it was important to honor allergies because it could affect the resident's health, and they honor preferences so residents could enjoy their food. She stated that on 12/27/25 Resident #1 was served sliced ham. She stated that she talked to her cook and the cook stated that agency staff were giving residents the wrong trays, and trays were having to be re-made that day. She stated that agency was only to blame on that one occurrence. She provided the surveyor with a copy of employee counseling she had done with the new cook aide that may have been responsible for passing tomatoes to Resident #1 on multiple occasions. In an interview on 12/29/2025 at 12:23 PM with the ADM, he stated that the food on 12/27/25 should not have left the kitchen to go to Resident #1 due to there being pork on the plate. He stated that he, nursing staff, and kitchen staff were aware of Resident #1's allergies and preferences and that the DM had conducted an in-service before on accuracy in meal service. He stated that trays should be checked before leaving the kitchen and ensuring the right tray is given to the right residents. He stated that it was a resident right to eat what they wanted and adhering to resident allergies would prevent adverse health reactions. Review of an in-service dated 11/18/25, titled [Resident #1] and conducted by the DM reflected, Staff was in serviced of not putting tomatoes on Resident food. 3 cooks and 2 dietary aide signatures were visible. Review of 2 records of employee counseling dated 12/10/25 and 11/27/25 reflected that the DM had provided education/counseling to a dietary aide pertaining to reviewing meal tickets prior to trays leaving the kitchen. Review of the facility's 'Food and Nutrition Services' policy dated October 2017 reflected, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident

Based on interviews, and record review, the facility failed to ensure prompt resolution of grievances regarding the resident's right to file a grievance for 4 of 4 confidential residents interviewed for grievances. The facility failed to notify residents in writing of the findings and actions of the grievances they filed. This failure could affect resident's right to a written decision regarding the resolution of their grievance. Findings included: Review of the November and December 2025 grievance logs revealed 5 grievances in November, all which had documented follow up dates and resolutions noted. 7 grievances were documented in December which had follow up dates and resolutions noted. In confidential interviews on 12/29/2025 with residents who had filed grievances with the facility revealed none of them had received written findings of their grievances. Some stated that they never received verbal investigation findings and were not aware if staff they had complained about had received education, or disciplinary action. The confidential residents all recalled being spoken to by the ADM, who served as the grievance official, for him to gather additional information pertaining to their grievance, but not all of them recalled him coming back to inform them of the outcome of their complaint and what the actions would be taken to correct and identified problems pertaining to their grievances. In an interview on 12/29/2025 at 12:23 PM with the ADM who served as the grievance official, he stated that he communicated the findings of grievance investigations verbally to the complainants. He stated that he did not give them written results because he was not aware the Grievance policy stated that he needed to give the griever something in writing. He stated that the policies were all new due to the company change. He stated that it would be important to deliver written resolutions, so the griever had something to refer to later. He later stated that none of the administrators he had spoken with gave out written resolutions, and his boss was not familiar with that process either. Review of the facility's 'Grievances/Complaints, Filing' policy dated April 2017, revealed The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.

Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (Resident #1) reviewed for supervision:The facility failed to put effective measures in place to prevent Resident #1 from eloping. Resident #1 was found outside the facility across the street in the parking lot of the convenience store on Saturday, 11/12/25 at 7:45 AM. The facility had a plan in place to monitor the front door, but the lock was not working to prevent Resident #1's elopement. The noncompliance was identified as PNC. The IJ began on 11-12-2025 and ended on 11-14-2025. The facility had corrected the noncompliance before the survey began.The findings included:Record review of Resident #1s chart reflected he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of acute respiratory failure with hypercapnia, unspecified dementia, unspecified severity, with other behavioral disturbance. Record review of the MDS dated [DATE] reflected Resident #1 had a BIMS score of 10, indicating cognitive impairment, ambulating in a wheelchair and risk of elopement. Record review of the Care plan for Resident #1, dated 9/13/2025, reflected that Resident #1 was an elopement risk/wanderer and has a lack of understanding of the need for inpatient services. The resident has impaired cognitive function/dementia or impaired. thought processes related to orientation. status of to self and the location only, short and long-term memory issues. This was care planned before the elopement. In an interview on 11/19/2025 at 10:59 AM with the DM, the DM stated that doors are checked weekly. The DM said there were mag locks on the front and back doors. Resident #1 has a code alert bracelet, so when he gets close to the door, the alarm goes off and the door locks. The DM said on 11-12-2025, around 7:45 AM, Resident #1 made it to the front door. The alarm went off, but the door did not lock . The DM said the door when the door was inspected on 11-10-25, the door was working. DM said after Resident #1 left the facility, the door was checked, and the magnets on the lock were not lining up because the screw had come loose, causing the door not to lock. After the incident, the door was repaired the same day. In an interview on 11/19/2025 at 11:12 AM with the SW, SW said she heard the alarm going off at 7:45 AM, and she immediately went to the closest nurses' station to find out which door the alarm was going off at. The SW was told it was the front door where the alarm was going off, and Resident #1 was not in their room. The SW went out the front door to look for Resident #1 and saw he was across the street at the convenience store. The street was not busy at the time and the speed limit was unknown. Resident #1 was away from the facility for approximately 15 minutes. The SW stated she brought Resident #1 back to the facility. In an interview on 11/19/2025 at 12:12 PM with the AD, she said on 11-12-2025 at 7:50 AM, she stopped by the convenience store before work and saw Resident #1 in the parking lot. The AD stated there was some gravel in the parking lot, and Resident #1 was stuck in his wheelchair. The AD said she helped Resident #1 get the wheelchair unstuck and left. The AD did not know Resident #1 was an elopement risk. AD said there are some residents who were allowed to go to the convenience store. When she was leaving, the SW was coming out of the facility and came to get Resident #1 and took him back to the facility. In an interview on 11/19/2025 at 12:30 PM with the ADM, the ADM stated there was no specific policy/procedure for what to do when the alarm goes off. They had a policy if a resident leaves the building, the ADM stated a resident with a code system alert bracelet who went outside without supervision could get injured.In an interview on 11/20/2025 at 9:50 AM with the CMA. The CMA stated if she hears the door alarm go off, she will go to the nurses' station to look at the control box and find out which door was opened. Then she will check the room of the resident with a code alert bracelet on. The CMA knows which residents have a code alert bracelet on because there were only two in the facility. The CMA will then go find the resident. The CMA stated when she sees a resident with a code alert bracelet going to the door, she will redirect them. The CMA said if a resident with a code alert bracelet makes it outside, they could be hit by a car, fall and get injured, or tip out of the wheelchair. The CMA stated she was in-serviced on elopements last week.In an interview on 11/20/2025 at 10:30 AM with the LVN, the LVN said when the alarm goes off, she will try to find the resident. The LVN said that when a resident with a code-alert bracelet gets close to the door, the door alarm goes off and should lock. When they cross the barrier, the alarm goes off. The LVN said they check the control box at the nurses' station to see what door was open, then she will go find the resident. LVN said that she works with Residnet #1 and if she sees him going to to the door she will redirect him. The resident was then assessed for injuries. The ADM was made aware of the incident. She said that she has been in-service on elopement and what she is supposed to do if a resident elopes from the facilityRecord reviewResident Monitoring System log for residents with the wandering system revealed the test done on 11-10-2025, which showed the door was working. The test was completed weekly and daily since the elopement on 11-12-2025, after Resident #1 left the facility, showing that the door was not working. The facility took the following PNC Corrective actions before the surveyor's entrance: The facility was repaired on 11-13-2025 by [NAME] Fire and Safety before the investigation. The facility had in-service training on elopement with all staff in the facility and the training was signed by all staff prior to the investigation being done on 11/19/2024 MD has been checking the door daily since the incident took place on 11/12/2025 to make sure the door is working and that residents with. The facility policy on Wandering and Elopements is as follows. The policy does not have a date when it was updated. The resident with a risk of wandering will be identified in the care plan with strategies and interventions. If an employee should prevent them from leaving, they and get help if needed.

Based on interview, and record review, the facility failed to ensure that resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #2) reviewed for elopement.On 06/11/2025 Resident #2 eloped from the facility; On 06/25/2025 a Record Review of the Facility Incident report was completed. According to the Report, it was estimated that Resident #2 left the facility between 5:30PM and 6:00PM, was found on the grounds of a nearby apartment complex, and taken to the ER with an admission time around 7:10PM. The noncompliance was identified as PNC . The Immediate Jeopardy began on 6/11/25 and ended on 6/12/25. The facility had corrected the noncompliance before the survey began.This failure placed residents at risk of physical injury.Findings include: Review of Resident #2’s face sheet reflected he was a [AGE] year-old man admitted to the facility on [DATE]. Resident #2 was admitted with a diagnosis of secondary malignant neoplasm of the brain (cancer cells that have spread to the brain from a primary tumor in another part of the body). Review of the Wander Risk assessment dated [DATE] revealed Resident #2 scored at high risk for wandering. The facility reported this was the assessment that they used to determine if a person was at risk for elopement. Review of Resident #2’s Baseline Care Plan dated 06/11/2025 did not reflect any interventions for wandering or elopement. Review of Resident #2’s MDS initial assessment dated [DATE] reflected a BIMS score of 7 which indicated severe cognitive impairment. Record Review of the Facility Incident Report dated 06/11/2025 reflected how Resident #2 was discovered missing and the immediate facility-wide response. The Report described that a facility -wide search was implemented and when Resident #2 was not found, EMS was notified at 8:50PM on 06/11/2025. The Report documentation reflected that the Administrator, DON, Resident Representative, and Medical Director were notified on 06/11/2025. Documentation in the Report described that Resident #2 was discovered to be in the local Emergency Room. The Facility Incident Report outlined the activities implemented in response to the elopement. According to the Report, the following was implemented:• Administrator immediately conducted a headcount of all residents in the facility and no other residents were found to be missing• DON and ADONs conducted an audit on all residents and updated all wandering risk assessments on the night of 06/11/2025. On 06/25/2025 Record Review of the audit was completed to verify the Wandering Risk Assessment were completed and Care Plans updated as needed.• Administrator audited elopement binder to ensure all resident at high risk of elopement was included.• Administrator immediately began in serving all staff on the policies and procedures o wandering and elopements. On 06/25/2025 Record Review of the in-service sign in sheets was conducted. Interviews were conducted with 10 staff beginning on 06/27/2025 and ending 07/02/2025 to assess receipt and understanding of the in-service material.• Ad-hoc QAPI was implemented on 06/12/2025. Record Review of the QAPI Sign in Sheet and minutes was conducted on 06/25/2025 to confirm.• Administrator and DON collected statement from all staff who proved direct care to Resident #2. Record Review of the statements was performed on 06/25/2025. • Daily monitoring and discussion in Morning Meeting were implemented to identify residents at risk for safety concerns. Record Review conducted of Daily Monitoring Form on 06/25/2025 Review of ER hospital records dated 6/11/2025 reflected Resident #2 was brought into the hospital for assessment and the chief complaint was that he had fallen while walking through some tall grass and had some bumps and bruises but nothing that warranted hospitalization. The records reflected that Resident #2 stated he lost his balance while walking. Vitals were stable. Resident had complaints of right collar bone pain and T6 (sixth thoracic vertebra) region pain. Xray results were negative. CT Head negative for any acute findings. CT Cervical-spine, and Lumbar -spine all negative. CTA chest negative for PE and acute findings. CT abdomen negative for acute findings. On 06/25/2025 at 2:35PM during an interview with the Administrator, he stated Resident #2 was admitted on [DATE] due to a significant decline in physical and cognitive function due to radiation. The Administrator further stated the facility received little clinical information on Resident #2 as he was admitted from home. The Administrator stated the nurse who did the wandering assessment stated Resident #2 was high risk because she observed him walking around the halls. The Administrator stated management was never notified of the high risk for elopement. On 06/25/2025 at 3:01PM during an interview the DON stated on 6/11/2025 she was notified by ADON A on duty that Resident #2 was missing. The DON stated the staff immediately started a search of the facility and they contacted LE at approximately 7:50PM on 06/11/2025 and reported Resident # 2 as missing. The DON stated upon admission, residents are assessed for the risk of elopement and the Wander Risk Assessment is documented in the electronic medical record. If the resident scored high based on the Wandering Risk Assessment, their process was to notify the Administrator and or DON. The DON stated she was not notified that Resident #2 scored high on the Wandering Risk Assessment. The DON stated there was no specific policy for follow up actions after a resident scored high on the risk assessment for elopement. The DON stated the facility process was to place at risk residents on one-to-one monitoring and the Administrator and DON should have been notified for further interventions. On 06/25/2025 at 3:41PM during an interview with MA A she stated she discovered Resident #2 missing when she went to his room to give him his night pills at about 6:50PM. MA A stated she notified ADON A that she could not find Resident #2 and then the staff searched the building attempting to locate the resident. MA A further stated she did observe the resident in the afternoon while he was in his room visiting with his family. She reported that she never observed any behaviors that gave her concern about him being at risk for wandering away from the facility. On 06/25/2025 at 3:51PM during an interview with ADON-A she stated on 6/11/2025 she observed Resident #2 as his family walked in the building around 5:30PM or 5:45 PM. ADON A then stated she did not see anything else of them. ADON A stated she was notified around 6:50PM, by MA A that Resident #2 was missing. ADON A stated she called Resident #2’s family member to see if the resident was with him. The Resident’s family member stated the resident was not with him. ADON A reported during the call the family was very apologetic and stated they neglected to tell the staff he had an issue with wandering. ADON A stated, “They knew and didn’t tell us.” ADON A stated the staff started their search of the building, called LE, and notified the DON and Administrator. On 06/27/2025 at 10:10AM during an interview with LVN A she stated she completed the original wandering assessment on 6/11/2025. LVN A stated she had observed Resident #2 wandering around but did not think that it was exit seeking behavior but rather attempting to get familiar with surroundings. LVN A stated she did not know how to score the assessment. LVN A stated “I wanted him to be on the radar for his safety. My concern was that we might find him in someone else’s room not because Resident #2 was a flight risk.” She stated she did not obtain any history from the family for this assessment. On 06/27/2025 at 2:49PM during a phone interview with Resident #2’s family member, she stated the nurses were fantastic and were very good. Everything was fine. She had no complaints or concerns about the resident’s care when he was in the facility. On 06/27/2025 at 4:14PM received an email from the Regional Clinical Director. She stated the process for prevention of elopement is the IDT convenes and identifies individualized interventions that are appropriate for that resident if a resident is identified as being at risk for wandering. Those would then be added to their care plan and/or physician's orders as indicated.On 07/01/2025 at 3:28PM a phone interview with LE. The detective reported that on 06/11/2025 they received a report from EMS indicating they had transported Resident #2 to the hospital for further assessment. LE reported the facility called in a missing person report at approximately 8:40PM on 06/11/2025. Post event actions documented in the facility investigation and report detail the following completed 6/12/2025 prior to surveyor entrance on 06/25/2025• Administrator conducted a head count of all residents in the facility. No other residents were missing. This was confirmed per record review of the resident count documented on the resident roster and per interview with the Administrator on 06/25/2025 at 2:35PM.• The DON, ADONs, and other nurses conducted an audit on all Resident Wandering Risk Assessments. Completion of audit confirmed via Record Review of the audit documentation and per interview with the DON on 06/25/2025 at 3:01PM.• Administrator immediately began in-services to staff regarding policy/procedure of wandering/elopements. Confirmed by record review of the in-service sign in sheets, interview with the Administrator on 06/25/2025 at 2:35PM. Further confirmation obtained via individual staff interviews to include:• During an interview with RN A on 07/02/2025 at 11:46AM she stated she was shown on the computer how to assess the risk and how to complete the document. RN A also stated if someone was determined to be at high risk, they were to call Administrator and DON and monitor the resident. • During an interview with LVN A on 07/02/2025 at 11:51AM she stated on 06/12/2025 she was trained on how to complete the assessment and how to sign and save so the document automatically recorded the risk level. If the resident was identified at risk, they were to contact the Administrator and the DON immediately. • During an interview with LVN B on 07/02/2025 at 11:57AM she stated she was in serviced the day following the event. She verbally verified her signature on the Inservice sign in sheet. She stated she was trained on completing the assessments and what and how to do follow up for residents determined to be high risk. If at risk, they notify the DON and /or the Admin. There will be a determination of the intervention to be implemented such as a wander guard. LVN B stated if the resident was actively exiting seeking, they would be monitored on a one to one. • During an interview with ADON B on 07/02/2025 at 12:03PM she stated she received training the day of the event. She stated the training included a review of the wander assessments and how to score and document them properly. She stated the training also included what to do if a resident scored at high risk which was to notify Admin/DON. If the resident was exiting seeking, they would be placed on one-to-one monitoring. ADON B stated she keeps the resident with her for supervision while the calls are being made. • During an interview with RN B on 07/02/2025 at 12:10PM she stated she was in serviced the night of the event. The training included completion of the wandering risk assessment and what interventions to take depending on how the resident was scored. She stated if the resident scored high, the staff were to notify the Administrator/DON. • During an interview on 06/25/2025 at 3:43PM MA A stated she received training on responding to missing residents to include notifying the ADON and performing a search of the building and grounds. MA A’s signature is found on Record Review of the in-service sign in sheet dated 06/11/2025. • During an interview on 06/27/2025 at 3:16PM CNA A stated he recalled having had training on elopement and the training included instructions to respond with three step process. The staff were instructed to try to find the resident, perform a head count, and notify administration. Per Record Review on 06/25/2025 CNA A’s signature is located on the in-service sign in sheet dated 06/11/2025. • During an interview on 06/27/2025 at 3:24PM with CNA B he stated he received training on what to do if a resident seems to be missing. He stated the process was to check all rooms and do a head count and notify the administrator. He stated the training included to prevent elopements by making sure to visualize the residents every 2 hours and make sure no one was near those exit doors. Record Review of the in-service sign in sheet dated 06/11/2025 showed his signature. • During an interview on 06/27/2025 at 3:28PM with CNA C she stated she has been in serviced on the prevention of elopement. CNA C stated she received training on /6/11/2025 and also at new hire orientation to prevent elopements . The training included the use of alarms, performing head counts, and checking exit doors. • During an interview on 06/27/2025 at 3:34PM with CNA D she stated she received training by the Administrator, and it contained instructions on recognizing wandering or if a resident wanted to leave. She stated the training included the need to check on the residents and let the nurse know if a resident seemed to be wandering. Record Review of the in-service sign in sheet dated 06/11/2025 revealed CNA D’s signature. • On 06/12/2025 an Ad Hoc QAPI meeting was held to identify the process breakdown and how the facility could prevent a future incident. This was validated via record review of the QAPI sign in sheet and per interview with the Administrator on 06/25/2025 at 2:35PM. • The DON or designee implemented continuous monitoring via review of the 24-Hour Report daily during clinical meeting to identify residents at risk of safety concerns. Record Review of the audit tool was completed on 06/25/2025 and found to be completed to date.• Nurses were in serviced by the Administrator and DON regarding the elopement policy and procedures and the steps to take after a resident was deemed high for elopement risk. This was confirmed by record review of the in-service sign in sheets dated 06/11/2025 and confirmed during interviews conducted on 07/02/2025 with licensed nursing staff. During an interview with the DON on 07/02/2025 at 12:27PM she stated in order to make sure all staff were educated, the administrator helped in monitoring the in-service list and if it was identified that a staff was scheduled to work that had not had the in-service, the ADON would stay over or come in on the weekends to in-service those staff. Findings include: Review of Resident #2’s face sheet reflected he was a [AGE] year-old man admitted to the facility on [DATE]. Resident #2 was admitted with a diagnosis of secondary malignant neoplasm of the brain (cancer cells that have spread to the brain from a primary tumor in another part of the body). Review of the Wander Risk assessment dated [DATE] revealed Resident #2 scored at high risk for wandering. The facility reported this was the assessment that they used to determine if a person was at risk for elopement. Review of Resident #2’s Baseline Care Plan dated 06/11/2025 did not reflect any interventions for wandering or elopement. Review of Resident #2’s MDS initial assessment dated [DATE] reflected a BIMS score of 7 which indicated severe cognitive impairment. Record Review of the Facility Incident Report dated 06/11/2025 reflected how Resident #2 was discovered missing and the immediate facility-wide response. The Report described that a facility -wide search was implemented and when Resident #2 was not found, EMS was notified at 8:50PM on 06/11/2025. The Report documentation reflected that the Administrator, DON, Resident Representative, and Medical Director were notified on 06/11/2025. Documentation in the Report described that Resident #2 was discovered to be in the local Emergency Room. The Facility Incident Report outlined the activities implemented in response to the elopement. According to the Report, the following was implemented:• Administrator immediately conducted a headcount of all residents in the facility and no other residents were found to be missing• DON and ADONs conducted an audit on all residents and updated all wandering risk assessments on the night of 06/11/2025. On 06/25/2025 Record Review of the audit was completed to verify the Wandering Risk Assessment were completed and Care Plans updated as needed.• Administrator audited elopement binder to ensure all resident at high risk of elopement was included.• Administrator immediately began in serving all staff on the policies and procedures o wandering and elopements. On 06/25/2025 Record Review of the in-service sign in sheets was conducted. Interviews were conducted with 10 staff beginning on 06/27/2025 and ending 07/02/2025 to assess receipt and understanding of the in-service material.• Ad-hoc QAPI was implemented on 06/12/2025. Record Review of the QAPI Sign in Sheet and minutes was conducted on 06/25/2025 to confirm.• Administrator and DON collected statement from all staff who proved direct care to Resident #2. Record Review of the statements was performed on 06/25/2025. • Daily monitoring and discussion in Morning Meeting were implemented to identify residents at risk for safety concerns. Record Review conducted of Daily Monitoring Form on 06/25/2025 Review of ER hospital records dated 6/11/2025 reflected Resident #2 was brought into the hospital for assessment and the chief complaint was that he had fallen while walking through some tall grass and had some bumps and bruises but nothing that warranted hospitalization. The records reflected that Resident #2 stated he lost his balance while walking. Vitals were stable. Resident had complaints of right collar bone pain and T6 (sixth thoracic vertebra) region pain. Xray results were negative. CT Head negative for any acute findings. CT Cervical-spine, and Lumbar -spine all negative. CTA chest negative for PE and acute findings. CT abdomen negative for acute findings. On 06/25/2025 at 2:35PM during an interview with the Administrator, he stated Resident #2 was admitted on [DATE] due to a significant decline in physical and cognitive function due to radiation. The Administrator further stated the facility received little clinical information on Resident #2 as he was admitted from home. The Administrator stated the nurse who did the wandering assessment stated Resident #2 was high risk because she observed him walking around the halls. The Administrator stated management was never notified of the high risk for elopement. On 06/25/2025 at 3:01PM during an interview the DON stated on 6/11/2025 she was notified by ADON A on duty that Resident #2 was missing. The DON stated the staff immediately started a search of the facility and they contacted LE at approximately 7:50PM on 06/11/2025 and reported Resident # 2 as missing. The DON stated upon admission, residents are assessed for the risk of elopement and the Wander Risk Assessment is documented in the electronic medical record. If the resident scored high based on the Wandering Risk Assessment, their process was to notify the Administrator and or DON. The DON stated she was not notified that Resident #2 scored high on the Wandering Risk Assessment. The DON stated there was no specific policy for follow up actions after a resident scored high on the risk assessment for elopement. The DON stated the facility process was to place at risk residents on one-to-one monitoring and the Administrator and DON should have been notified for further interventions. On 06/25/2025 at 3:41PM during an interview with MA A she stated she discovered Resident #2 missing when she went to his room to give him his night pills at about 6:50PM. MA A stated she notified ADON A that she could not find Resident #2 and then the staff searched the building attempting to locate the resident. MA A further stated she did observe the resident in the afternoon while he was in his room visiting with his family. She reported that she never observed any behaviors that gave her concern about him being at risk for wandering away from the facility. On 06/25/2025 at 3:51PM during an interview with ADON-A she stated on 6/11/2025 she observed Resident #2 as his family walked in the building around 5:30PM or 5:45 PM. ADON A then stated she did not see anything else of them. ADON A stated she was notified around 6:50PM, by MA A that Resident #2 was missing. ADON A stated she called Resident #2’s family member to see if the resident was with him. The Resident’s family member stated the resident was not with him. ADON A reported during the call the family was very apologetic and stated they neglected to tell the staff he had an issue with wandering. ADON A stated, “They knew and didn’t tell us.” ADON A stated the staff started their search of the building, called LE, and notified the DON and Administrator. On 06/27/2025 at 10:10AM during an interview with LVN A she stated she completed the original wandering assessment on 6/11/2025. LVN A stated she had observed Resident #2 wandering around but did not think that it was exit seeking behavior but rather attempting to get familiar with surroundings. LVN A stated she did not know how to score the assessment. LVN A stated “I wanted him to be on the radar for his safety. My concern was that we might find him in someone else’s room not because Resident #2 was a flight risk.” She stated she did not obtain any history from the family for this assessment. On 06/27/2025 at 2:49PM during a phone interview with Resident #2’s family member, she stated the nurses were fantastic and were very good. Everything was fine. She had no complaints or concerns about the resident’s care when he was in the facility. On 06/27/2025 at 4:14PM received an email from the Regional Clinical Director. She stated the process for prevention of elopement is the IDT convenes and identifies individualized interventions that are appropriate for that resident if a resident is identified as being at risk for wandering. Those would then be added to their care plan and/or physician's orders as indicated.On 07/01/2025 at 3:28PM a phone interview with LE. The detective reported that on 06/11/2025 they received a report from EMS indicating they had transported Resident #2 to the hospital for further assessment. LE reported the facility called in a missing person report at approximately 8:40PM on 06/11/2025. Post event actions documented in the facility investigation and report detail the following completed 6/12/2025 prior to surveyor entrance on 06/25/2025• Administrator conducted a head count of all residents in the facility. No other residents were missing. This was confirmed per record review of the resident count documented on the resident roster and per interview with the Administrator on 06/25/2025 at 2:35PM.• The DON, ADONs, and other nurses conducted an audit on all Resident Wandering Risk Assessments. Completion of audit confirmed via Record Review of the audit documentation and per interview with the DON on 06/25/2025 at 3:01PM.• Administrator immediately began in-services to staff regarding policy/procedure of wandering/elopements. Confirmed by record review of the in-service sign in sheets, interview with the Administrator on 06/25/2025 at 2:35PM. Further confirmation obtained via individual staff interviews to include:• During an interview with RN A on 07/02/2025 at 11:46AM she stated she was shown on the computer how to assess the risk and how to complete the document. RN A also stated if someone was determined to be at high risk, they were to call Administrator and DON and monitor the resident. • During an interview with LVN A on 07/02/2025 at 11:51AM she stated on 06/12/2025 she was trained on how to complete the assessment and how to sign and save so the document automatically recorded the risk level. If the resident was identified at risk, they were to contact the Administrator and the DON immediately. • During an interview with LVN B on 07/02/2025 at 11:57AM she stated she was in serviced the day following the event. She verbally verified her signature on the Inservice sign in sheet. She stated she was trained on completing the assessments and what and how to do follow up for residents determined to be high risk. If at risk, they notify the DON and /or the Admin. There will be a determination of the intervention to be implemented such as a wander guard. LVN B stated if the resident was actively exiting seeking, they would be monitored on a one to one. • During an interview with ADON B on 07/02/2025 at 12:03PM she stated she received training the day of the event. She stated the training included a review of the wander assessments and how to score and document them properly. She stated the training also included what to do if a resident scored at high risk which was to notify Admin/DON. If the resident was exiting seeking, they would be placed on one-to-one monitoring. ADON B stated she keeps the resident with her for supervision while the calls are being made. • During an interview with RN B on 07/02/2025 at 12:10PM she stated she was in serviced the night of the event. The training included completion of the wandering risk assessment and what interventions to take depending on how the resident was scored. She stated if the resident scored high, the staff were to notify the Administrator/DON. • During an interview on 06/25/2025 at 3:43PM MA A stated she received training on responding to missing residents to include notifying the ADON and performing a search of the building and grounds. MA A’s signature is found on Record Review of the in-service sign in sheet dated 06/11/2025. • During an interview on 06/27/2025 at 3:16PM CNA A stated he recalled having had training on elopement and the training included instructions to respond with three step process. The staff were instructed to try to find the resident, perform a head count, and notify administration. Per Record Review on 06/25/2025 CNA A’s signature is located on the in-service sign in sheet dated 06/11/2025. • During an interview on 06/27/2025 at 3:24PM with CNA B he stated he received training on what to do if a resident seems to be missing. He stated the process was to check all rooms and do a head count and notify the administrator. He stated the training included to prevent elopements by making sure to visualize the residents every 2 hours and make sure no one was near those exit doors. Record Review of the in-service sign in sheet dated 06/11/2025 showed his signature. • During an interview on 06/27/2025 at 3:28PM with CNA C she stated she has been in serviced on the prevention of elopement. CNA C stated she received training on /6/11/2025 and also at new hire orientation to prevent elopements . The training included the use of alarms, performing head counts, and checking exit doors. • During an interview on 06/27/2025 at 3:34PM with CNA D she stated she received training by the Administrator, and it contained instructions on recognizing wandering or if a resident wanted to leave. She stated the training included the need to check on the residents and let the nurse know if a resident seemed to be wandering. Record Review of the in-service sign in sheet dated 06/11/2025 revealed CNA D’s signature. • On 06/12/2025 an Ad Hoc QAPI meeting was held to identify the process breakdown and how the facility could prevent a future incident. This was validated via record review of the QAPI sign in sheet and per interview with the Administrator on 06/25/2025 at 2:35PM. • The DON or designee implemented continuous monitoring via review of the 24-Hour Report daily during clinical meeting to identify residents at risk of safety concerns. Record Review of the audit tool was completed on 06/25/2025 and found to be completed to date.• Nurses were in serviced by the Administrator and DON regarding the elopement policy and procedures and the steps to take after a resident was deemed high for elopement risk. This was confirmed by record review of the in-service sign in sheets dated 06/11/2025 and confirmed during interviews conducted on 07/02/2025 with licensed nursing staff. During an interview with the DON on 07/02/2025 at 12:27PM she stated in order to make sure all staff were educated, the administrator helped in monitoring the in-service list and if it was identified that a staff was scheduled to work that had not had the in-service, the ADON would stay over or come in on the weekends to in-service those staff.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food following professional standards for food service safety for 1 of 1 kitchen that was reviewed for kitchen sanitation in that: Food items were not labeled and/or dated. These failures could place all residents who received meals from the main kitchen at risk for food-borne illness. Findings include: Observation on 5/06/2025 at 7:50 am in the refrigerator reflected the following: o Sliced ham in a container with water in it dated 4-28-2025 with no discard date. o Sliced bread in a serving pan with no date. o 2-boiled eggs in a zip lock bag dated 4-25-2025 with no discard date. o 2-side serving bowls with appeared to be pureed chicken dated 4-30-2025 with no discard date. o A container of what appeared to be grits with no date and was still warmed. Observation on 5/06/2025 at 8:15 am in the pantry reflected the following: o An open bag of potato chips not wrapped up with no discard date. o An open bag of grits not wrapped up with no discard date. Interview on 05/08/25 at 9:23 AM the DM stated that it was the entire team's job to oversee making sure the food placed in the refrigerator was properly closed, and dated to reflect when it was open and used by dates. She stated that the shelf life of food cooked and placed in the refrigerator was three days, and that the shelf life of cold cut meat placed in a container and put in the refrigerator was 'a week. DM stated the dates were not placed on the container and another staff comes in and began to make sandwiches with the meat and it is bad, someone could get sick. When asked what could happen if a resident eats the sandwich, she said that the risk is high that they could have a reaction and become sick. Interview on 05/08/25 at 9:36 AM the CK stated it was everyone's responsibility to make sure the food placed in the refrigerator was properly closed, and dated to reflect when it was opened and used by date. She stated that the shelf life of food cooked and placed in the refrigerator was three days and the shelf life on cold cut meat placed in the refrigerator in a container was a week. The [NAME] stated that if the date was not placed on the container and another staff comes in and began to make sandwiches with the meat and it was bad, then the other staff won't know that the meat was bad if it's not dated properly. When asked what can happen if the resident eats that sandwich, she said the resident could get sick. Interview on 05/08/25 at 9:41 AM DA A stated it was the last person that used the product that was responsible for making sure the food placed in the refrigerator was properly closed, and dated to reflect when it was open and used by date. DA A stated the shelf life of cooked food placed in the refrigerator and cold cut meat placed in the refrigerator in a container was three days. She said that if the date was not placed on the container and another staff comes in and began to make sandwiches with the meat and it was bad, then the meat could be spoiled and become slimy. She said that if the resident eats that sandwich then the resident could get sick. Interview on 05/08/25 at 9:48 AM the DA B stated it was everyone's responsibility to make sure the food was dated to reflect when it was opened and to place a used by date on the food. She stated the shelf life of food cooked and placed in the refrigerator was three days and a week for cold cut meat placed in the refrigerator in a container. DA B stated that if the date was not placed on the container and another staff comes in and began to make sandwiches with the meat and it was bad, then someone can get sick, someone can also get sick if a resident eats the sandwich. Record Review Food Storage Policies dated October 1, 2018, and revised on June 1, 2019, stated: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guideline. 1. Dry Storage Rooms: D. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators: D. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 3. Refrigerators: E. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

Based on observation, interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerance's, and preferences for 2 of 3 residents (Resident #13 and Resident #46) reviewed for food allergies. The facility failed to honor Resident #13 and Resident #46's food preference of an alternative meal according to their meal ticket. This failure could place the residents at risk of not having their preference honored and a diminished quality of life. Findings included: Review of Resident # 13's face sheet, dated, 05/08/2025, reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #13 had diagnoses which included need for assistance with personal care (helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), anemia in chronic kidney disease (a common complication where the body has a deficiency of red blood cells or hemoglobin, which can lead to a reduced ability to carry oxygen throughout the body), type 2 diabetes mellitus without complications (chronic metabolic disorder characterized by consistently high blood glucose (sugar) levels, where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce), end stage renal disease (the most severe stage of kidney failure, where the kidneys are no longer able to filter waste and excess fluid from the blood.) Review of Resident #13's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 7, which indicated her cognition was severely impaired. Resident #13 did not have a weight loss or a weight gain. Review of Resident #13's Comprehensive Care Plan, with completion date of 04/27/2025 reflected Resident #13 had a potential nutritional problem related to diabetes mellitus. Resident #13 diet was on a liberalized renal regular texture, regular consistency, with no added salt packets on the tray. Resident #13 requested large portions. Intervention: Provide and serve diet as ordered. Review of Resident #13's Physician Orders, initiated on 11/07/2023, reflected Resident #13 was ordered regular diet, regular texture, and regular consistency (did not specify fluids). Review Resident #13's meal ticket on 05/07/2025 at 12:45 PM reflected Resident #13 was on a liberalized renal regular texture large portion diet. Resident #13's beverage texture was regular. Resident #13's entree was one serving regular portion of spaghetti and meatballs. She dislikes spaghetti. Her meal ticket specifies to have an entree of a hamburger on bun. Also, it noted to limit tomatoes. Observation and Interview on 05/07/2025 at 12:45 PM Resident #13 meal was not double or large portion. The meal served did not reflect what was on her meal ticket. She had normal portion size, and she did not have the meal she preferred. When Resident #13 was asked why she was not eating, she responded she does not like spaghetti. The meal ticket stated hamburger and she was asked would she like to have a hamburger and she stated she would. Review of Resident # 46's face sheet, dated, 05/08/2025, reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #46 had diagnoses which included need for assistance with personal care (helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), acute kidney failure unspecified (a sudden loss of kidney function that can happen within hours or days), type 2 diabetes mellitus without complications (chronic metabolic disorder characterized by consistently high blood glucose (sugar) levels, where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce), unspecified systolic (congestive) heart failure (a condition where the heart's left ventricle struggles to pump blood efficiently.) Review of Resident #46's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 12, which indicated her cognition was cognitively intact. Resident #46 did not have a weight loss or a weight gain. Review of Resident #46's Comprehensive Care Plan, with completion date of 02/20/2024 reflected Resident #46 had a potential nutritional problem related to diabetes mellitus. Resident #46 diet was on a liberalized renal regular texture, regular consistency, with no added salt packets on the tray. Intervention: Provide and serve diet as ordered. Observation and Interview on 05/07/2025 at 12:55 PM Resident #46 meal served did not reflect what was on her meal ticket. She did not have the meal she preferred. When Resident #46 was asked why she was not eating, and she responded she did not order spaghetti and she wanted a hamburger. The meal ticket stated hamburger and she was asked would she like to have a hamburger and she stated it was alright, and she ate the meatballs, and she would be fine until dinner. She denied wanting to receive the hamburger as ordered. Interview on 05/08/25 at 9:23 AM the DM stated all residents' meals was to reflect the physician order and the residents' preferences. She stated Resident #13 did have a preference of double portions. The DM stated if it was on Resident meal ticket it was expected to be served. She stated that if something that a resident requested was not on the menu then the resident must be notified three days in advance. She stated that if a resident requested an alternate meal, the kitchen staff was responsible for ensuring the resident gets the proper meal requested, and it must be signed off by a dietary aide. When asked what the purpose was of asking the resident if they were ok with the meal being served, she said so they know that they are satisfied and are aware of their likes and dislikes. If served a meal they did not ask for, she said the resident will complain and be dissatisfied, she that the resident may not finish the food, loss weight, and not eat until the next meal. She said that a liberal renal diet means you are limited to tomatoes, potatoes, and oranges. Interview on 05/08/25 at 9:36 AM the CK stated it was the DM responsibility to make sure the residents were aware what will be served at the menu times. She stated if a resident requested an alternate meal, it was the CNA on that resident's hallway will mark it in their meal ticket. She stated that the purpose of asking the resident if they were ok with the meal being served, was to make sure they get what they want to eat. She said that if the resident was served a meal they did not ask for, then the resident may not eat the food, or they may come to the kitchen staff and ask for something different. Interview on 05/08/25 at 9:41 AM the DA A stated the supervisor was responsible to make sure the residents were aware what will be served at the menu times. She said that if a resident requested an alternate meal, the supervisor and the aide were responsible for ensuring the resident gets the proper meal requested. She said that the purpose of asking the resident if they were ok with the meal being served, was to ensure that the resident gets to eat what they like. If the resident was served a meal they did not ask for, DA A said that they may complain. Interview on 05/08/25 at 9:48 AM the DA B stated the night staff prints out the menus sent to them from PFG. She stated if a resident requested an alternate meal, it was the DM responsibility to double check the trays. She stated the purpose of asking the resident if they were ok with the meal being served was to ensure that the resident gets what they want because the residents have preferences. She stated if a resident was served a meal, they did not ask for, the residents may complain to staff. Interview on 05/08/25 at 2:10 PM the ADM stated the CNA's typically goes around and see if the residents were aware of what was being served and if they would like that or an alternate meal. He stated if a requested an alternate meal, it was the collaboration of dietary to make sure the meal was made and the nurse to make sure the meal reflects the meal on the tray reflects what is on the meal ticket. He stated the purpose of asking the resident if they want the meal being served was because they have the right to have the food they want within their limitations. If they were served a meal they did not want, it could lead into malnourishment, and weight loss. It was the responsibility of everyone to make sure the residents have a full belly. Interview on 05/08/25 at 2:29 PM the DON stated it was the CNA's responsibility to make sure the residents were aware what will be served at mealtimes. She stated if the resident requested an alternate meal, it was both the nurses and dietary aids to make sure the resident gets the proper meal requested. Dietary was responsible for making sure the proper meal was on the tray and the nurses were to make sure the meal matched the meal ticket. She stated the purpose of asking a resident if they wanted the meal being severed was to ensure the resident received quality of life because food is important. They want to have a good meal and to be able to enjoy what they were eating. She stated this was their home and they should be able to have their diet within their limits. She stated they should be able to accommodate the residents. She stated if residents received a meal they did not asked for, it could result in them receiving the wrong texture and choke, not be able to chew and digested it. Some residents have fewer teeth and not able to chew it and the food consistency can be a little tougher than they can handle. She stated if they have food allergies, they can have an allergic reaction to the food. She stated all residents had a right to voice their meal preferences. Record review of the facility's Resident Right Policy, not dated, reflected a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Resident had a right to receive services and /or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #73) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when LVN A provided gastric tube feeding for Resident #73. This failure could place residents at-risk for spread of infection. Findings included: Record review of Resident #73's face sheet dated 07/10/2024 revealed she was a [AGE] year-old woman, with an initial admitted [DATE], with re-admission on 12/09/2024 and with diagnoses of Nontraumatic Intracerebral Hemorrhage, Unspecified (bleeding within the brain tissue that is not caused by head trauma). Record review of Resident #73's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, indicating the interview was not successfully completed. Further review revealed Resident #73 was assessed as having a PEG tube (a type of feeding tube that is placed through the skin and into the stomach, allowing for direct delivery of nutrition). Record review of Resident #73's Active Orders dated 05/07/2025 revealed orders which included: o Enhanced Barrier Precautions start date 02/24/2025. Observation on 05/07/2025 at 01:15 p.m., revealed there was a sign indicating Enhanced Barrier Precautions outside the door to Resident #73's room, and there was no supply of PPE available outside the door/room. Further observation revealed LVN A put on gloves but did not put on or wear a gown while performing PEG tube feeding for Resident #73. During an interview with LVNA on 05/07/2025 at 1:30 p.m., when asked to describe EBPs, she stated EBPs were to give you a warning to use gloves. Gowns were only used if there was an active infection. During an interview with the DON on 05/08/2025 at 11:01 a.m., the DON stated EBPs should be implemented when a resident has any type of implanted medical device or has wounds. The DON stated a negative outcome of failure to abide by EBPs would be the spread of infection. Record review of facility policy titled Enhanced Barrier Precautions reviewed March 2025 revealed: o Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. o EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: 1. dressing. 2. bathing/showering. 3. transferring. 4. providing hygiene. 5. changing linens. 6. changing briefs or assisting with toileting. 7. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and 8. wound care (any skin opening requiring a dressing).

Based on observation and interviews the facility failed to ensure the daily nurse staffing information, including the facility name, current date, total number and actual hours worked by Registered Nurses, Licensed Practical Nurses or Licensed Vocational Nurses, Certified Nurse Aides, and the resident census, was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors for one of one facility reviewed for posted nurse staffing. The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. Findings included: Observation on 05/06/2025 at 7:30 AM, revealed the daily staffing schedule dated 4/30/2025 was posted on the right side of the hallway, around the right corner from the reception area. During an interview on 5/7/2025 at 5:15 PM, the ADM stated the Human Resource Coordinator was responsible to post the nurse staffing data each day. She was out of the facility unexpectedly and there should have been a back-up to assume the responsibility. He stated the facility did not have a policy which addressed the posting of nurse staffing, and they follow CMS guidelines. During an interview on 5/8/2025 at 2:20 PM, the DON and the RNC both stated the facility does not have a specific policy which addresses the posting of nurse staffing and census.

Based on Observations, interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for one of three residents (Resident #1) reviewed for misappropriation. The facility failed to prevent a diversion (misappropriation) of Resident #1's oxycodone HCl Oral Tablet 5 MG, 16 tablets (an oxycodone pain reliever) received through hospice and reported missing on 04/18/2025. The noncompliance was identified as PNC. The non-compliance began on 04/10/2025 and ended on 04/28/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. Findings included: Review of Resident #1's face sheet printed 04/30/2025 reflected a [AGE] year-old female admitted to the facility 12/04/2023. Her diagnoses included pain unspecified, chronic kidney disease stage 5, and other osteoporosis with current pathological fracture of the femur (thigh bone). Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 08 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected she required maximal assistance with hygiene and bathing and only supervision with most other ADLs. Section J (Health Conditions) the resident did not complain pain during the assessment period and was on a scheduled pain medication regimen. Review of Resident #1's comprehensive care plan, revised 06/13/24, the resident had an ADL self-care performance deficit due to right femur fracture, weakness, comorbidities, osteoporosis, and was receiving hospice services due to terminal illness. Review of Resident #1's physician order reflected an order dated 08/28/2024 for oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth two times a day for Pain. Review of Resident #1's physician order reflected an order dated 12/07/2023 for oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 8 hours as needed for moderate to severe pain. Review of Resident #1's medication administration record for April 2025, reflected no PRN dose of Oxycodone was administered during the month. Review of the Provider Investigation Report dated 12/28/23 reflected, on 4/10/25, a nurse with Hospice came to the facility and counted all medications for [Resident #1] and identified that resident had 16 PRN 5mg Oxycodone left in blister pack. On 4/18/25 around 11:30am, the same nurse with Hospice returned to the facility and identified that the PRN 5mg oxycodone blister pack and respective narcotic count sheet was not in the narcotic box or the narcotic book. At this time, nursing management attempted to find the oxycodone blister pack and card count sheet but could not find the medication. Observation on 04/30/2025 of the 300-hall nurse's narcotics book and cart, 200-hall medication aide and nurse's narcotics book and cart were completed, all medications and blister packets were correct. Review of facility's narcotics count sheet for the 200-hall reflected on 04/11/2025, there were 33 narcotic blisters at the beginning of the 6am to 6 pm shift. The nurses removed a total of 7 medications blister packet from the medication cart and the math was not done correctly, it reflected 25 packets instead of 26 . During an interview on 04/30/2025 at 1:26 pm Resident #1 stated she was on routine pain medication. Resident #1 stated she always got her pain medication when she needed it. Resident #1 stated she did not have concerns with her pain medication. During an interview on 04/30/2025 at 1:56 pm, the DON stated after the medication was noticed to be missing, she counted all narcotics in the facility to verify counts. The DON stated Resident #1 was assessed for pain and there was no adverse reaction for Resident #1. She stated Resident #1 never went without pain medication because Resident #1's routine pain medication was on the medication aide cart. The DON stated Resident #1 did not ask for PRN pain medication. The DON stated she initiated in-services on the process on narcotics count and when the narcotics cart keys change hands. The DON stated she initiated daily narcotic count monitoring of all carts in the facility. The DON stated she contacted the pharmacy and narcotics reconciliation was done. The DON stated she was the only one who could remove empty medication blister packets or discontinued medications from the medication cart. The DON stated 2 nurses were required to sign whenever the pharmacy delivered narcotics. The DON stated she suspected Resident #1's oxycodone went missing on 4/11/2025 when there was mistake on the blister count. During an interview on 04/30/2025 at 4:00 PM the Administrator stated he was made aware of the drug diversion on 4/18/2025. The Administrator stated he called all staff who had access to the 200-hall medication cart from 04/10/2025 to 4/18/2025 and they were interviewed and drug tested on [DATE] and all were negative. The Administrator stated he notified the local police, but they did not show up. The Administrator stated Resident #1's family and the Medical Director were notified. The Administrator stated staff were in-serviced on 04/18/2025. He stated they were not able to identify a perpetrator but there was a suspect. The Administrator stated the facility reordered Resident #1's oxycodone 16 tablets and paid for it on 4/18/2025 . During interviews on 04/30/2025 starting at 11:25am through 3:41 pm with 3 LVNs, 2 RNs, and 1 MA, they all stated they were made aware there was drug diversion in the facility. They stated they were in-serviced on the process of narcotics count and when the narcotics cart keys changed hands, the carts and medications should be counted. They stated only the DON could remove empty medication blister packets or discontinued medications from the medication cart. They stated 2 nurses were required to sign whenever the pharmacy delivered narcotics . Review of the facility's investigation reflected the Quality Assurance Performance Improvement team met on 04/18/2025 at 4:18 pm. Review of facility's investigation folder reflected Police REPORT NUMBER: CL25040088 DATE: 04/18/2025 at 4:45 pm. Review of facility's in-services date 04/18/2025 reflected: In-Service for Narcotic Count and Medication Reconciliation For all Licensed Charge Nurses and Certified Medication Aides Beginning 4/18/25 and ongoing, all nurses and medication aides will continue the existing card count sheet and narcotic count sheet already in play. In addition, the following parameters will be put into action. Effective Immediately, medication cards need to remain in the medication cart, even if completely depleted, until the DON reviews the Narcotic Count and Narcotic Card Counts for these medications. If a Nurse or Medication Aide dispenses the final dose of a medication in the blister pack, the employee must put the card back into the medication cart and it will be counted in the card count completed at the end/beginning of the shift. Only the Director of Nursing may remove any card from the medication cart. All blister cards, full and empty, must remain on the cart and only the Director of Nursing may remove empty blister packs from the medication cart. Effective Immediately, all narcotics will require 2 nurse's signatures when accepting them from the pharmacy. When pharmacy brings narcotics to the nurse's station, two nurses must sign off on the Narcotic acceptance form (attached to this in-service). This is to ensure verification by two licensed nurses that the medication has been delivered and the quantity is accurately reported in the narcotic count sheet. All information must be filled in - Resident Name, medication name, dose, acceptance date, and quantity . Review of the facility's investigation folder reflected daily monitoring of narcotics count done by the DON for all carts in the facility initiated 04/18/2025 and was ongoing. Review of facility's investigation folder reflected: All 6 employees who were assigned to the 200-hall medication cart between 04/10/2025 and 04/18/2025 where the drug diversion occurred were suspended pending consensual drug screen. It was reflected all 6 staff were drug screened on 4/18/2025 and all came up negative. All 6 nurses were interviewed by the Administrator. Review of the facility's investigation folder reflected: Controlled Substance Audit-- A controlled substance audit was performed at the request of the facility. The audit included 8 medication/nurse carts, 4 from each wing. Medication orders were reconciled against all active orders dated 4/22/2025 from the nursing home EHR . Controlled substances were audited for expired medications, medication orders with discrepancies, residents with medication orders without medications on-hand, and medications found without an active order. Facility was notified of issues and concerns upon exiting with nurse supervisors, with specific details provided by the end of day completed with this report. Review of the facility's in-services reflected an in-service dated 4/28/2025 Card/Narcotic count when keys change hands which was on going. Review of the facility policy Identifying Exploitation, Theft, and Misappropriation of Resident Property dated April 2021 reflected in part, 1. Exploitation, theft, and misappropriation of resident property are strictly prohibited. 4. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 5. Examples of misappropriation of resident property include: f. drug diversion (taking the resident's medication). Review of the facility's policy titled Drug Discrepancies, Loss, or Diversion dated reflected: The facility will comply with all federal, state, and local laws as it pertains to dangerous drugs and controlled substances. The facility must have a system that records receipt, usage, and disposition of all controlled substances in sufficient detail that permits an accurate reconciliation. See sections 8.3 Schedule Medication Inventory Sheets and 8.4 Destruction of Scheduled Medication of the Policies and Procedures for Pharmacy Services for additional information regarding those processes. Drug diversion (as defined in The State Operating [NAME]): is the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use, as adapted from the Uniform Controlled Substances Act. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 (Resident #8) of 15 residents reviewed for accidents and hazards. The facility failed to ensure CNA G performed appropriate incontinent care on Resident #8 when she asked her to hold onto the bed, which subsequently led to Resident #8 losing grip of the bed, falling to the ground, and sustaining a skin tear to her right forearm and bump to the left side of her forehead. This deficient practice could place residents at risk of injuries. Findings include: Review of Resident #8's admission record, dated 01/22/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8 had diagnoses including unspecified Parkinsonism (a general term for a group of neurological disorders that affect movement), unspecified fall, unspecified pain, age-related physical debility (a symptom of frailty, which is a syndrome of physiological decline that occurs with aging), unspecified obesity, generalized anxiety disorder, major depressive disorder, pain in unspecified joint, carpal tunnel syndrome (a common condition that occurs when the median nerve in the wrist is compressed) in bilateral upper limbs, acute (a sudden, sharp pain caused by a tumor (neoplasm) that comes on quickly and lasts for a short period of time) and chronic (a persistent, ongoing pain associated with a tumor that can last for months or even years, often with varying levels of intensity and may be present even when not actively treated) neoplasm related pain, and encounter for palliative care. Review of Resident #8's quarterly MDS assessment, dated 08/08/24, reflected she had a BIMS score of 12 out of 15, which indicated she had moderate cognitive impairment. Resident #8 had no falls since admission. Resident #1 was dependent on toileting and required substantial/maximal assistance with bed mobility. Review of Resident #8's care plan, dated 09/17/24, reflected she was at risk for falls. Resident #8 also had an ADL self-care performance deficit and had right-handed resting hand splints, but she chose digit aluminum splints during the day. Staff were required to provide Resident #8 with total assistance to turn and reposition in bed and for toileting. Resident #8's speech was unclear at times and staff were required to allow adequate time for her to respond, repeat as necessary, to not rush her, and request clarification to ensure understanding. Review of Resident #8's admission fall risk evaluation, dated 10/13/24, reflected she was at high risk for falls, had no falls in the past three months, was independent and continent, was confined to chair in mobility status, not able to attempt testing without physical help for mobility, had 1-2 present risk factors/health conditions, and took 1-2 high risk medications at the time and/or within last seven days. Review of Resident #8's progress notes, dated 01/22/25, reflected the following: -A nurse's note on 11/04/24 at 6:43 a.m. by RN H: Resident fell out of bed while being changed by CNA G at approximately 3:45 a.m. Resident alert and oriented x4 and able to make needs known. Vitals within normal limits. Resident has bump to left forehead and a small skin tear to left forearm which I cleaned and covered with a bandage. Resident rated pain 10/10. 911 called and resident transported to hospital per EMT at 4:20 a.m. DON informed, on call informed, daughter informed, and on call provider informed. -A nurse's note on 11/04/24 at 2:52 p.m. LVN K: Resident returned from ER. CT and X-rays of bilateral forearms and left femur performed at ER. No new orders noted. Review of Resident #8's pain level summary, dated 01/22/25, reflected the following pain levels on 11/04/24: -10/10 pain level at 4:00 a.m. -8/10 pain level at 10:50 a.m. -8/10 pain level at 12:02 p.m. -8/10 pain level at 3:45 p.m. -10/10 pain level at 5:05 p.m. -3/10 pain level at 7:25 p.m. -3/10 pain level at 7:47 p.m. -5/10 pain level at 10:29 p.m. Review of the facility's Provider Investigation Report, dated 11/04/24, reflected on Resident #8's family reported on 11/04/24 that on 11/04/24 at 3:45 a.m. in Resident #8's room, CNA G was assisting Resident #8 with incontinent care in bed, CNA G asked Resident #8 to hold on to bed, Resident #8 lost grip and fell to floor from 2.5 feet. Resident #8's family alleges that CNA G was neglectful and resulted in fall. CNA G denied the allegations. RN H assessed Resident #8. Resident #8 was alert and oriented x4, able to make needs known, and vitals were within normal limits. RN H noted Resident #8 had a bump to the left forehead, a small skin tear to the left forearm, and cleaned and covered the left forearm with a bandage. Resident #8 rated her pain to her head 10/10. Resident #8 was transferred to the hospital for further evaluation. At the hospital ED, x-rays were obtained as followed: Pelvis: No acute displaced pelvic fracture; Left femur: No acute fracture or discoloration; Right femur: No acute right femur fracture of discoloration; CT cervical spine without contrast: Bones: No acute fracture. Mild degenerative anterolisthesis of C3 on C4; 2 views left forearm: Findings: No acute fracture or dislocation' CT head without contrast: No acute intracranial abnormality, left frontal scalp contusion; XR forearm 2 views right: No evidence of acute fracture or subluxation. Acetaminophen 1000mg was administered and subsequently, Fentanyl 50 mcg/ml injection 25 mcg dose intravenously. Pain medication administration frequency increased per physician order due to increased pain upon readmission. CNA G was immediately suspended pending investigation, staff were re-educated on 1 vs 2 person staff assistance with bed mobility and incontinent care and where/how to determine level of assistance per specified resident, abuse, neglect, and exploitation that were ongoing. Ombudsman, RP, and MD were notified. Resident safety surveys were initiated on Resident #8's hall. Staff ensured Resident #8 felt safe and comfortable in the environment, provided her with an electric bed with halos to assist with bed mobility, interviewed her to determine comfortability with 1 person vs 2-person bed mobility/incontinent care, updated care plan accordingly, and audited care plans to ensure Kardex accurately reflected appropriate care level for bed mobility/incontinent care. The facility did not find evidence to support the neglect allegation. Resident #8 was care-planned as a 1-person incontinent care service. Resident #8 felt comfortable with CNA G up until the incident occurred including several other brief changes throughout the same shift. Resident #8 experienced a fall while CNA G was providing incontinent care. Review of Resident #8's statement from the Provider Investigation Report, dated 11/04/24, reflected CNA G was changing her brief and was on the left side of her bed, CNA G turned her over with the drawsheet, her legs hung off the bed and she told CNA G such, CNA G told her to hold onto the bed, she told CNA G that she could not, CNA G told her that she did it before and could do it again, CNA G went to her right side and told her again to hold onto the bed, the mattress at some point gave way, she fell to the floor, staff came into her room, CNA G said, I'm out of here, and left her room, her legs and head hurt, she hit her head on her oxygen concentrator and her legs on the trash can. Review of CNA G's statement from the Provider Investigation Report, dated 11/05/24, reflected she changed Resident #8 several times during the night shift, she pulled Resident #8 toward her using the draw sheet, told Resident #8 to hold onto the bed like she usually did and asked her repeatedly if she had grip of the bed and assured her that she would get assistance if she did not have grip, Resident #8 told her that she had grip of the bed, she moved to the right side of Resident #8, she reached for a brief sitting on the top of Resident #8's headboard, Resident #8 slipped off the bed, Resident #8 did not cue her that she was ready to fall or felt like she was falling, Resident #8 did not hit anything, she notified RN H, LVN I, and CNA J to help her, they used a Hoyer to help put Resident #8 back in bed, Resident #8 started complaining of pain when she was back in the bed, EMS was notified and arrived, they tried to notify Resident #8's RP and there was no answer, and Resident #8's RP called in the morning of 11/05/24. Review of Resident #8's ED arrival information, dated 11/04/24 at 9:48 a.m., reflected she arrived at theER on [DATE] at 4:49 a.m. on a chief complaint of a fall. Resident #8's CT head without contrast final result was no acute intracranial abnormality and a left frontal scalp contusion (bruise). Resident #8's CT cervical spine without contrast findings were no acute fracture and mild degenerative anterolisthesis of C3 on C4 (the third cervical vertebra (C3) has slightly slipped forward onto the fourth cervical vertebra (C4) due to age-related wear and tear on the spine). Review of Resident #8's ED provider notes, dated 11/04/24 at 9:49 a.m., reflected on Resident #8 presented to the ED from the facility after a fall from her bed. Resident #8 reported CNA G rolled her, she was left unattended, rolled out of bed impacting her left-sided forehead, her bilateral forearms, and her left femur. Resident #8 was alert and oriented x4, had Parkinson's disease at normal baseline, had a left-sided hematoma on her left femur, bruising to her left forehead, and a small skin tear on her right forearm. An attempt to interview Resident #8 was made on 01/17/25 at 11:10 a.m. Resident #8 was difficult to understand when asking open ended questions about the incident, despite the surveyor asking her several different ways. Resident #8 was able to answer close ended questions. Resident #8 replied, No. She was let go, when asked if CNA G still worked with her. Resident #8 replied, No, when asked if she had any other falls after the incident on 11/04/24. Resident #8 replied, No, when asked if the staff continued to perform incontinent care in the manner CNA G did after the incident. Resident #8 replied, Yes, when asked if she felt safe . An attempt to interview CNA G was made on 01/22/25 at 10:07 a.m. A voicemail and call back number were left. CNA G did not return the surveyor's call before exit. During an interview on 01/22/25 at 10:21 a.m., Resident #8's RP stated she was not there when Resident #8's incident happened. Resident #8's RP stated she received a voicemail from Resident #8, who told her that she was going to the hospital on 11/04/24. Resident #8's RP stated she called the facility and spoke with an unknown staff member, who told her that Resident #8 fell out of bed and was going to the hospital. Resident #8's RP stated Resident #8 also told her that CNA G told her to hold onto the left side of the bed with her right hand. Resident #8's RP stated Resident #8's right arm was weak. Resident #8's RP proceeded to state that Resident #8 told her that she told CNA G that she could not hold on, CNA G told Resident #8 that she could, CNA G left Resident #8's weak side unattended, CNA G flipped Resident #8, Resident #8 fell out of the bed and hit her right thigh on a metal trash can and her knee on the AC unit. Resident #8's RP stated Resident #8 did not break any bones, but she struggled with experiencing pain for a while. Resident #8's RP stated she believed it was a blatant case of negligence on CNA G's part and that the DON agreed with her and told her that they would follow-up. Resident #8's RP stated Resident #8 required 1-person assistance with repositioning in bed. During an interview on 01/22/25 at 10:29 a.m., RN H stated she assessed Resident #8 on 11/04/24. RN H stated Resident #8 expressed that she was in pain, observed Resident #8 had a bump on her forehead and a skin tear on one of her forearms. RN H stated she cleaned and bandaged Resident #8's skin tear and contacted EMS and the DON because she believed Resident #8 had a change in condition. RN H was unable to provide more information due to being at the hospital and about to undergo surgery and ended the call. An attempt to interview LVN I was made on 01/22/25 at 10:44 a.m. A voicemail and call back number were left. LVN I did not return the surveyor's call before exit. An attempt to interview CNA J was made on 01/22/25 at 10:46 a.m. A voicemail and call back number were left. CNA J did not return the surveyor's call before exit. During an interview on 01/22/25 at 12:08 p.m., the DON stated CNAs had access to residents' Kardex (care summary), which showed how much level of assistance and how many staff were required to assist residents with their ADLs. The DON stated she taught staff how to access residents' Kardex during in-service on 11/04/24 after Resident #8's incident. The DON stated CNAs always had access to residents' care plans. The DON stated CNA G was terminated due to performance related issues. During an interview on 01/22/25 at 12:36 p.m., the DON stated CNA G was suspended after Resident #8's incident on 11/04/24. The DON stated she did not know how long CNA G was suspended for. The DON stated CNA G was reinstated and did not work with Resident #8 after she returned to work. The DON stated the ADON did 1:1 training with CNA G. The DON stated she did not know what kind of 1:1 training the ADON did with CNA G. During an interview on 01/22/25 at 1:40 p.m., LVN D stated Resident #8 was a 2-person assist with her ADLs. LVN D stated CNAs and LVNs performed incontinent care on residents. LVN D stated CNAs could not ask residents to hold onto their beds during incontinent care. LVN D stated CNAs were required to ask a charge nurse if they did not know how much assistance and how many staff were required to assist a resident with incontinent care. LVN D stated CNAs had access to residents' electronic health records. LVN D stated she did not know if CNAs had access to residents' care plans. LVN D stated nurses had access to residents' electronic health records, care plans, and assessments. LVN D stated she did not receive any grievances and complaints about CNA G from residents and visitors. LVN D stated she knew it was important to know the type of assistance a resident needed during incontinent care and bed mobility and proper techniques to be utilized and said, 100% safety. That is why care plan in place. For safety issue. To feel emotionally and physically safe with 2 staff. During an interview on 01/22/25 at 2:18 p.m., the RNC stated CNA G was suspended from 11/04/24 through 11/06/24 and was terminated on 12/09/24. The RNC stated CNA G was written up related to Resident #8's incident, received a second write up due to other resident concerns related to professionalism and failing to provide adequate incontinent care. The RNC explained CNA G would perform incontinent care, but she would leave BM. The RNC stated CNA G was terminated due to customer service issues and not being a team player. During an interview on 01/22/25 at 3:27 p.m., CNA F stated she could not recall if she received in-services related to Resident #8's incident. CNA F stated CNAs, RNs, and LVNs performed incontinent care. CNA F stated residents willingly held onto their beds out of fear of falling back and forward. CNA F stated CNAs could not ask residents to grab onto the bed during incontinent care. CNA F stated CNAs had access to residents' Kardex and care plans to determine their ADL status. CNA F stated she knew it was important to know the type of assistance a resident needs during incontinent care and bed mobility and proper techniques to be utilized and said, Because you can turn them wrong and to not hurt them. During an interview on 01/22/25 at 4:00 p.m., RN E stated she was in-serviced on resident safety, reporting, and notifying families. RN E stated CNAs changed briefs most of the time. RN E stated LVNs, and RNs also changed briefs. RN E stated RNs and LVNs had access to residents' care plans to verify ADL status. RN E stated CNAs could determine residents' ADL status on their plan of care. RN E stated CNAs could ask LVNs and RNs for assistance. RN E stated staff could not ask the resident to hold onto the bed if they were incapable. RN E stated she knew it was important to know the type of assistance a resident needs during incontinent care and bed mobility and proper techniques to be utilized and said, Resident safety. Want residents to be comfortable and progress. And for their well-being. During an interview on 01/22/25 at 5:32 p.m., the ADON stated she received concerns and complaints about CNA G's timeliness. The ADON stated CNA G was terminated for quality of care and working while intoxicated. The ADON stated she recalled in-servicing staff on 2 person ADL assistance and never walking to the opposite side of a resident's bed when a resident was rolled over to their side. The ADON stated nurses and CNAs performed incontinent care. The ADON stated CNAs mainly performed incontinent care. The ADON stated CNAs had access to residents' Kardex, which would tell them residents' ADL status. The ADON stated CNAs could ask residents to grab onto the bed during incontinent care. The ADON stated staff could not ask a resident to grab onto the bed if a resident had poor grip strength and one-sided weakness. The ADON stated she knew it was important to know the type of assistance a resident needs during incontinent care and bed mobility and proper techniques to be utilized and said, Safety first and foremost. Falls and injury could occur. During an interview on 01/22/25 at 6:43 p.m., the DON stated during Resident #8's investigation, she found that CNA G told her that Resident #8 was always able to hold onto the bed and that it was her normal behavior. The DON stated she interviewed Resident #8, who told her that she did not want CNA G to take care of her anymore after the incident on 11/04/24. The DON stated she asked Resident #8 whether she wanted more than be educated regarding determining residents' ADL status. The DON stated she did not see CNA G noted on the in-services. The DON stated CNA G was suspended from 11/04/24 through 11/06/24. The DON stated the ADM told her that CNA G could return on 11/06/24. The DON stated CNA G also refused to sign the 1:1 education. The DON stated CNA G was terminated in December 2024. The DON stated CNA G could not be terminated sooner because human resources told her that it was difficult to terminate staff despite CNA G refusing to sign the re-education and 1:1 training. The DON stated CNA G received a write up after the 11/04/24 incident on paper. The DON stated CNA G was terminated due to calling out of work at the last minute on two occasions. The DON stated she did not refer CNA G's license due to not being able to terminate CNA G at the time of the incident. The DON stated the nurses and CNAs performed incontinent care. The DON stated she personally would not rely on residents holding onto the bed when asked if staff could ask residents to hold onto the bed. The DON stated nurses accessed residents' care plans and CNAs accessed residents' Kardex for residents' ADL status. The DON stated she knew it was important to know the type of assistance a resident needs during incontinent care and bed mobility and proper techniques to be utilized and said, Safety. Safety for resident and safety for staff because do not want to drop or hurt a resident. Also, resident preference. The DON stated Resident #8 was x-rayed and had no fractures. The DON stated Resident #8 complained of pain later, staff sent her out to the hospital, they notified the physician, and the physician increased her pain medication. The DON stated when CNA G was reinstated, she no longer worked with Resident #8 and was re-educated on locating Kardex and performing bed mobility and incontinent care. The DON stated she did not believe there were any other grievances and concerns before and after Resident #8's incident. During an interview on 01/22/25 at 7:39 p.m., the ADM stated he did not find any substantiation for neglect due to CNA G being the only witness of the incident with Resident #8. The ADM stated CNA G told him that Resident #8 slid during incontinent care. The ADM stated CNA G told him that she asked Resident #8 to hold onto the bed. The ADM stated Resident #8 was care-planned for one-person assistance and still felt comfortable with 1-person during care after the incident on 11/04/24. The ADM stated Resident #8 did not feel CNA G was competent enough to perform ADL care. The ADM stated CNA G was suspended for 2-3 days. The ADM stated CNA G was instructed not to provide care to Resident #8 when she returned to work. The ADM stated other CNAs provided care to Resident #8 after the incident. The ADM stated CNA G was given re-education on staff assistance with bed mobility and incontinent care and abuse and neglect. The ADM stated CNA G had no allegations before and after the incident. The ADM stated CNA G was terminated due to poor customer service. The ADM stated he was unsure if nursing staff could ask residents to hold onto their beds during incontinent care. The ADM stated CNAs referred to residents' Kardex for ADL status information. The ADM stated he knew it was important to know the type of assistance a resident needs during incontinent care and bed mobility and proper techniques to be utilized and said, Care plan was created by licensed nursing staff and IDT team and was coordinated with family. It captures residents' daily needs. Adhering to the care plan ensures staff provide care according to resident, families, and providers preferences and recommendations. The ADM stated Resident #8 had no allegations against staff before and after the incident. The ADM stated Resident #8 had no fractures after the incident. The ADM stated he in-serviced staff on abuse and neglect, reporting, abuse and neglect definitions, examples of abuse and neglect, and had staff demonstrate examples. Review of the facility's in-services reflected staff were taught that some residents required one or two staff for bed mobility and incontinent care, the importance of providing residents with the appropriate level of care and assistance based on their individual needs, two staff members must participate to ensure the residents' safety if a resident required two staff assistance to perform bed mobility and incontinent care, checking the residents' Kardex and electronic health record when staff were unsure of a residents' abilities to perform bed mobility and incontinent care and how many staff were required to perform bed mobility and incontinent care, and how to locate the Kardex by the DON on 11/04/24. CNA G and RN E were not listed. Review of the facility's Perineal Care policy, revised in February 2018, reflected the following: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. There was nothing in the policy about whether a staff member could ask the resident to hold onto the bed during perineal care. Review of the facility's Falls and Fall Risk Managing policy, revised April 2022, reflected the following: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Definition: According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence sug gesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Fall Risk Factors: 2. Resident conditions that may contribute to the risk of falls include: c. delirium and other cognitive impairment; d. pain; e. lower extremity weakness; f. poor grip strength; i. functional impairments; k. incontinence 3. Medical factors that contribute to the risk of falls include: e. balance and gait disorders; etc.

Based on observations, interviews, and record reviews, the facility failed to provide each resident at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for five (Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) of 15 reviewed for timely meals. The facility failed to provide lunch according to the lunch meal service schedule on 01/17/25 to Residents #3, #4, #5, #6, and #7. This deficient practice could place residents at risk of low blood sugar levels, increased stress levels, slowed metabolism rates, weakened immune systems, malnutrition, weakened hearts, and organ failures. Findings include: Review of Resident #3's admission record, dated 01/17/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses including a wedge compression fracture, unspecified Parkinsonism, Hypokalemia (a condition where there are low levels of potassium in the blood), unspecified and recurrent major depressive disorder, generalized muscle weakness, age-related osteoporosis (a disease that weakens bones, making them more likely to break), unsteadiness on feet, other abnormalities of gait and mobility, other lack of coordination, and repeated falls. Review of Resident #3's comprehensive MDS assessment, dated 12/31/24, reflected she had a BIMS score of 8, which indicated she had moderate cognitive impairment. Review of Resident #3's care plan, dated 01/13/25, reflected she had no altered meal time preference listed. Review of Resident #4's admission record, dated 01/17/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses including hypertensive chronic kidney disease. Review of Resident #4's comprehensive MDS assessment, dated 01/17/25, reflected she had no BIMS score listed . Review of Resident #4's baseline care plan, dated 01/09/25, reflected she was alert, oriented, and had no altered meal time preference listed. Review of Resident #5's admission record, dated 01/17/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses including unspecified asthma (a chronic lung disease), chronic pulmonary edema (a long-term condition that causes fluid to build up in the lungs), type 2 diabetes, chronic systolic (congestive) heart failure, essential (primary) hypertension (a chronic condition where the force of blood pushing against artery walls is consistently too high), muscle wasting and atrophy, chronic kidney disease stage 2, unsteadiness on feet, other abnormalities of gait and mobility, other lack of coordination, cognitive communication deficit, and weakness. Review of Resident #5's quarterly MDS assessment, dated 12/19/24, reflected she had a BIMS score of 10, which indicated she had moderate cognitive impairment. Resident #5 required a therapeutic diet. Review of Resident #5's care plan, dated 01/07/25, reflected she had diabetes mellitus and staff were required to monitor, document and report as needed any signs and symptoms of hyperglycemia, hypoglycemia, and infection. Resident #5 also did not have an altered meal time preference listed. Review of Resident #6's admission record, dated 01/17/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses including chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus), moderate protein-calorie malnutrition (a state where a person is experiencing a moderate level of deficiency in both protein and calories), hyperlipidemia (a condition where there are high levels of fats, like cholesterol and triglycerides, in the blood), hypokalemia, unspecified anemia (a blood disorder that occurs when the body doesn't produce enough healthy red blood cells), essential hypertension, chronic diastolic congestive heart failure, generalized muscle weakness, chronic kidney disease stage 3A, unsteadiness on feet, other abnormalities of gait and mobility, and other lack of coordination. Review of Resident #6's comprehensive MDS assessment, dated 12/06/24, reflected she had a BIMS score of 10, which indicated she had moderate cognitive impairment. Resident #6 required a therapeutic diet. Review of Resident #6's care plan, dated 01/07/25, reflected she required a no salt on tray diet. Resident #6 also did not have an altered mealtime preference listed. Review of Resident #7's admission record, dated 01/17/25, reflected she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses including acute cystitis with hematuria (a condition where someone experiences a sudden onset of bladder inflammation (acute cystitis) accompanied by blood in the urine (hematuria)), unspecified sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection), other iron deficiency anemias, hyperlipidemia, vascular dementia, unspecified depression, other chronic pain, essential hypertension, generalized muscle weakness, chronic kidney disease stage 3B, and abnormal weight loss. Review of Resident #7's comprehensive MDS assessment, dated 12/23/24, reflected she had a BIMS score of 9, which indicated she had moderate cognitive impairment. Resident #7 required a therapeutic diet. Review of Resident #7's care plan., dated 01/10/25, reflected she had chronic pain and staff were required to monitor, record and report to the nurse loss of appetite, refusal to eat, and weight loss. Resident #7 also required a no salt on tray diet. Resident #7 did not have an altered mealtime preference listed. Review of the facility's Meal Times posting, undated, reflected the following: 6:45 a.m. -- Breakfast 11:45 a.m. -- Lunch 4:45 p.m. -- Dinner An observation of the dining room on 01/17/25 at 12:00 p.m. found there were sixteen residents sitting in the dining room and 3 staff members monitoring the residents and serving beverages. No meals had been served to residents. During an interview on 01/17/25 at 12:02 p.m., the DM stated she did not receive any complaints and grievances about meal service times. The DM stated if a resident complained about dietary, a grievance was filed, and she resolved the grievances. During an interview on 01/17/25 at 1:01 p.m., CNA C stated she often received complaints about meal service times. CNA C stated she notified dietary staff whenever she received dietary concerns and complaints. CNA C stated she knew it was important to serve residents' meals according to the meal service schedule. During an interview on 01/17/25 at 1:02 p.m., RN E stated lunch meal service was at 12:15 p.m . RN E stated she did not know why lunch meal service was late. RN E stated CNAs served residents' meal trays. RN E stated nurses sometimes served residents' meal trays. RN E stated she passed out snacks to residents at about 10:30 a.m. During an interview on 01/17/25 at 1:05 p.m., Resident #3 stated she had not been served her meal tray. Resident #3 stated she was usually served lunch around 1:00 p.m. and it was not her preferred mealtime. Resident #3 stated she was hungry. Resident #3 stated she was not served snacks around 10:30 a.m. Resident #3 stated she usually had to wait an hour after the scheduled lunch meal service start time to receive her lunch meal. Resident #3 stated she felt concerned and bothered that she did not receive her lunch meal tray. During a group interview on 01/17/25 at 1:09 p.m., Residents #4 and #5 stated they had not been served their meal trays. Residents #4 and #5 stated they were usually served lunch around 1:00 p.m. and it was not their preferred mealtime. Residents #4 and #5 stated they were both hungry. Residents #4 and #5 stated they were not served snacks around 10:30 a.m. Resident #5 stated she felt bothered that she did not receive her lunch meal tray because she was a diabetic and felt like her sugar levels were dropping. Resident #4 stated she did not feel bothered that she did not receive her lunch meal tray today (01/17/25), but she felt bothered at times. During a group interview on 01/17/25 at 1:13 p.m., Residents #6 and #7 stated they had not been served their meal trays. Residents #6 and #7 stated they were usually served lunch around 1:00 p.m. and it was not their preferred mealtime. Residents #6 and #7 stated they were both hungry. Residents #6 and #7 stated they were not served snacks around 10:30 a.m. Resident #7 stated she felt bad because she was hungry and did not have lunch yet. Resident #6 stated she did not know how she felt, but she was bothered that she did not get lunch yet. An observation on 01/17/25 at 1:23 p.m., the last meal tray was served . During an interview on 01/22/25 at 1:48 p.m., LVN D stated residents were supposed to be served lunch at 12:00 p.m. LVN D said, Residents could be served lunch between 12:00 p.m. and 12:30 p.m. at the latest. Sometimes lunch was served at 1:00 p.m. LVN D stated she received questions from residents about where their lunch was. LVN D stated CNAs and LVNs provided residents with snacks after lunch trays were returned to the kitchen. LVN D stated she knew it was important to serve residents' meals according to the meal service schedule and said, Because we have patients who have a specific nutrition plan. To help patients return home by attaining their required protein intakes. For dementia residents, it could throw their day off due to the inconsistency. Following scheduled meal services helped dementia residents feel staff are there for them and care about them. Having an off-schedule meal service was negligent to me . During an interview on 01/22/25 at 3:17 p.m., CNA F stated CNAs, LVNs, and RNs served residents' meal trays. CNA F stated she did not receive any concerns or complaints about meal service timeliness by residents or visitors. CNA F stated some residents complained to her about where their meal trays were. CNA F said, Lunch meal service trays were brought to residents' hallways and served to residents as soon as the meal tray carts get to the hallways around 12:30 p.m. and 12:45pm. It was not normal for lunch to be served after 1:00 p.m. CNA F stated meal service took place for one hour. CNA F stated residents were served snacks when the meal trays were returned to the kitchen after each meal service. CNA F stated she knew it was important to serve residents' meals according to the meal service schedule and said, Because nurses conduct blood pressure checks and residents got to eat. Residents could have their sugar levels drop and be hungry. Sometimes the kitchen ran late with getting meal trays out. During an interview on 01/22/25 at 3:55 p.m., RN E stated the kitchen prepared residents' meal trays. RN E stated CNAs served meal trays to residents. RN E stated residents who sat in the dining room were served their meals first. RN E stated lunch meal service was scheduled to start in the dining room at 11:30 a.m . and for residents' rooms at 12:30 p.m. RN E stated lunch meal service was late sometimes. RN E stated she received concerns about meal service timeliness a couple of times from residents. RN E explained residents would tell her that they were hungry and asked where their meals were. RN E stated she provided snacks to residents and informed residents that their meals were on their way if a resident told her that they were hungry and asked where their meal tray was. RN E stated dietary staff brought out snacks around 10:00 a.m., 3:00 p.m., on request, and as needed. RN E stated she knew it was important to serve residents' meals according to the meal service schedule and said, We have some residents who were medication dependent, who must follow provider orders for their digestive purposes, and who follow a routine. We also cannot let residents be hungry and uncomfortable. During an interview on 01/22/25 at 5:29 p.m., the ADON stated lunch meal service was served at 12:00 p.m. The ADON stated CNAs and nurses served meal trays to residents. The ADON stated she received concerns about the lack of meal service timeliness. The ADON stated she most recently received concerns about the lack of meal service timeliness sometime last week. The ADON stated dietary concerns were brought up and discussed during morning meetings and were addressed with dietary. The ADON stated she knew it was important to serve residents' meals according to the meal service schedule and said, Consistency is good for patients. Blood sugars could drop. Behaviors could occur. Patients could be over hungry. Main thing is it could affect medications. During an interview on 01/22/25 at 6:34 p.m., the DON stated she was told that residents were served lunch at 11:45 a.m. The DON did not indicate who told her that residents were served lunch at 11:45 a.m. The DON stated the dietary prepared residents' meals, and the CNAs and nurses served the meal trays to the residents. The DON stated she did not receive any concerns or grievances about the lack of meal service timeliness within the last 2 months. The DON said, However, if lunch was due at 12:00 p.m. and it's 12:05 p.m., then I consider meal service to be late. The DON stated she knew it was important to serve residents' meals according to the meal service schedule and said, Because of patient satisfaction. Disease processes. People are diabetic. If you go later than schedule, residents could have a hypoglycemic episode. It is a resident right to know what and when they are eating. It is also policy. Meal times are posted in the building. If a resident knows what time meals are to be served as with anything else, then we are supposed to accommodate them. During an interview on 01/22/25 at 7:31 p.m., the ADM stated he did not receive any concerns or grievances about the lack of meal service timeliness. The ADM said, Lunch was to be served at 11:45 a.m. in the dining room. Meal tray carts go to the hallways after the dining room was served. Dietary prepared the meals, CNAs, and nurses passed out the meals. The ADM stated he knew it was important to serve residents' meals according to the meal service schedule and said, They (Residents) should be expecting a regular day to day basis with their meals. There are nursing concerns. For example, if residents need to take medications with their food. Diabetics. There are also issues that could arise with that . Review of the facility's Meal Times policy, dated 2018, reflected the following: Policy: The facility provides three meals daily at regular times which are comparable to meal times in the community setting. Meals are served at the specified times except in emergency situations. Procedures: 1. Meals will be served according to the state and federal regulations, with no more than fourteen hours between the evening meal and breakfast the following day. 2. There will be at least a four-hour interval between breakfast and lunch and between lunch and dinner. .5 Standard meals must be offered as required by the regulations above, but altered meal times should be offered as requested by the resident(s). A plan of care must be developed to document the resident's altered meal times. Review of the facility's Resident Rights policy, revised December 2016, reflected the following: Policy Statement: Team members shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. b. be treated with respect, kindness, and dignity;

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 7 of 9 (Resident #10, #11, #12, #13, #14, #15, and #16) residents reviewed. A. The facility failed to ensure Resident #16 received Rifaximin (an antibiotic used to prevent hepatic encephalopathy). Ten doses of the medication were missed during the 34 days stay at the facility. B. The facility failed to prevent the misappropriation of Resident #10's Oxycodone (a schedule II controlled opioid medication used to treat moderate to severe pain) taken during the days of 10/17/24 through 10/21/24, and Residents #11, #12, #13, #14 and #15's hydrocodone/APAP tablets (a schedule II controlled opioid medication used to treat pain) taken on unknown dates. This deficient practice could place residents at risk for adverse effects by not receiving the therapeutic effects of the medication. Findings included: A. Review of Resident #16's admission record, undated, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Diagnoses included encephalopathy (loss of brain function when a damaged liver does not remove toxins from the blood.), hepatorenal syndrome (complication liver causing rapid kidney deterioration), altered mental status. Review of Resident #16's Admission MDS assessment, dated 12/18/2024, reflected based on Section C: Cognitive Patterns, the resident had a BIMs score of 13 which indicated cognition was intact. Review of Resident #16's care plan reflected a focused area, initiated on 12/15/2024, of Resident #16 received Rifaximin for cirrhosis on the liver. The goal was that the resident would be free of adverse effects of the antibiotic. The interventions included administer medication as ordered. Review of Resident #16's Order Summary Report, viewed on 1/18/2025, reflected the resident was ordered on 12/13/2024 to receive Rifaximin 550 mg twice a day for alcoholic cirrhosis. Review of Resident #16's MAR for December 2024 reflected Rifaximin was not administered on 12/30/2024 the MAR notes OT on both doses due which according to the Chart Codes means Other/See Nurses Notes. Review of Resident #16's Nurses Progress Note revealed on 12/30/2024 the nurse documented Rifaximin was on order. Review of Resident #16's MAR for January 2025 reflected Rifaximin was not administered on 1/04/2025 and 1/08/2025 the MAR notes OT on all four doses. On 01/13/2025 the evening dose is initialed OT which according to the Chart Codes means Other/See Nurses Notes. On 01/14/2025 the morning dose initial area is blank with no code; the evening dose contains a H meaning on hold. Review of Resident #16's Nurses Progress Note revealed on 1/04/2025 and 01/08/2025 there was no documentation indicating a reason the Rifaximin was not given. On 1/13/2025 the Rifaximin was not given due to being on order. On 01/15/2025 Resident #16 was noted to have been discharged home. During an interview on 01/18/2025 at 1:54 pm MA Q explained that writing OT on the MAR indicated that the medication was not given and the reason would be documented in the progress notes. MA Q stated she had intended to write the cause in the progress notes but had missed doing so on some days. MA Q stated there had been a problem with the pharmacy only sending 3 or 4 doses each time causing them to run out of the Rifaximin. During an interview on 01/18/2025 at 3:42pm with the facility DON revealed she was not aware of all the missed doses of Resident #16's Rifaximin. The DON stated MA Q should have notified her that the pharmacy was not sending enough to prevent running out of Rifaximin. The DON stated the notes written in progress notes each day were automatically transferred over to the 24-hour report which was reviewed by her or an ADON at the beginning of each day. If an issue needed to be addressed they would follow up. If the MA does not tell her personally or failed to write the issue in the progress notes she had no way of knowing. The DON stated the outcome of a resident not getting their Rifaximin could be and increase in ammonia levels which for a person with liver disease can be toxic. During an interview on 01/22/2025 at 12:21pm with the facility MD revealed he was uncertain if he had been notified of Resident #16's missed doses of Rifaximin but thinks he probably had been. He stated there was no substitution he could prescribe for Rifaximin. The MD explained the purpose of the antibiotic was to treat bacteria that builds up in the gut. The MD stated it was frequently common that Rifaximin can be scarce and difficult to obtain from pharmacies. An occasional missed dose would probably not affect the resident but too many missed doses can cause hepatic encephalopathy. B.1. Review of Resident #10's admission record, undated, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, stage 5 (kidney failure), congestive heart failure (heart cannot pump an adequate amount of blood for circulation), femur fracture (broken thighbone) and pain unspecified (uncertain cause) Review of Resident #10's Annual MDS assessment, dated 11/20/2024, reflected based on Section C: Cognitive Patterns, the resident had a BIMs score of 12 which indicated moderate cognitive impairment. Review of Resident #10's care plan reflected a focused area, revised on 1/16/2024, of generalized pain related to a femur fracture. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included administer medications as ordered. Review of Resident #10's Order Summary Report, viewed on 1/17/2025, reflected the resident was ordered 1 oxycodone tablet, 5mg by mouth every 8 hours PRN for pain; Ordered 12/7/2023. Review of Resident #10's MAR for October reflected a PRN oxycodone tablet was not requested during the month. 2. Review of Resident #11's admission record, undated, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Diagnoses included DM II, pain in unspecified knee, HTN (high blood pressure) and heart failure. Review of Resident #11's Quarterly MDS assessment, dated 10/17/2024, reflected based on Section C: Cognitive Patterns, the resident had a BIMs score of 15 which indicated cognition was intact. Review of Resident #11's care plan reflected a focused area, revised on 1/15/2025, of generalized pain related to a femur fracture. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included administer medications as ordered. Review of Resident #11's Order Summary Report, viewed on 1/18/2025, reflected the resident was ordered 1 hydrocodone-acetaminophen tablet, 10-325mg by mouth every 6 hours PRN for pain; Ordered 3/13/2024. Review of Resident #11's MAR for October reflected prn hydrocodone-acetaminophen tablets had been given 12 times from 10/1/2024 until 10/21/2024. 3.Review of Resident #12's admission record, undated, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, stage 5 (kidney failure), disorder of bone (medical conditions affecting the bones), HTN and chronic pain. Review of Resident #12's quarterly MDS assessment, dated 12/2/2024, reflected based on Section C: Cognitive Patterns, the resident had a BIMs score of 15 which indicated cognition was intact. Review of Resident #12's care plan reflected a focused area, revised on 3/3/2024, of generalized pain related to a femur fracture. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included anticipate the resident's need for pain relief and respond immediately. Review of Resident #12's Order Summary Report, viewed on 1/18/2025, reflected the resident was ordered 1 hydrocodone-acetaminophen tablet, 5-325mg by mouth every 8 hours PRN for pain; Ordered 2/16/2024. Review of Resident #12's MAR for October reflected PRN hydrocodone-acetaminophen tablets had been given 5 times from 10/1/2024 through 10/21/2024. 4. Review of Resident #13's admission record, undated, reflected a [AGE] year-old female, who was admitted to the facility on [DATE], with an original admission of 10/21/2022. Diagnoses included heart failure, DM II, and unspecified pain. Review of Resident #13's care plan reflected a focused area, revised on 8/13/2024, of pain. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included administer medications as ordered. Review of Resident #13's Order Summary Report, viewed on 1/18/2025, reflected the resident was ordered 1 hydrocodone-acetaminophen tablet, 5-325mg by mouth every 6 hours PRN for pain; Ordered 5/6/2024. Review of Resident #13's MAR for October 2024 reflected prn hydrocodone-acetaminophen tablets had been given 26 times from 10/1/2024 through 10/21/2024. 5. Review of Resident #14's admission record, undated, reflected a [AGE] year-old female, who was admitted to the facility on [DATE], with an original admitted [DATE]. Diagnoses included unspecified fractured neck (fracture of any of the seven cervical vertebrae in the neck), dementia (gradual decline of brain functions) and chronic pain syndrome. Review of Resident #14's quarterly MDS assessment, dated 10/18/2024, reflected based on Section C: Cognitive Patterns, the resident had a BIMs score of 12 which indicated moderate cognitive impairment. Review of Resident #14's care plan reflected a focused area, revised on 9/9/2024, of chronic pain. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included administer medications as ordered. Review of Resident #14's Order Summary Report, viewed on 1/18/2025, reflected the resident was ordered 1 hydrocodone-acetaminophen tablet, 10-325mg by mouth every 8 hours PRN for pain; Ordered 8/16/2024, updated 10/16/2024 to include PRN for moderate or greater pain. Review of Resident #14's MAR for October reflected PRN hydrocodone-acetaminophen tablets had been given 13 times from 10/1/2024 through 10/21/2024. 6. Review of Resident #15's admission record, undated, reflected a [AGE] year-old female, who was admitted to the facility on [DATE], with an original admitted [DATE]. Diagnoses included idiopathic aseptic necrosis of right and left femur (unknown cause of a bone disease causing bone death due to lack of adequate blood supply, in the thigh bone), dementia (gradual decline of brain functions) and pain cause unspecified. Review of Resident #15's care plan reflected a focused area, revised on 12/12/2024, of right leg pain. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included administer medications as ordered. Review of Resident #14's Order Summary Report, viewed on 1/18/2025, reflected the resident was ordered 1 hydrocodone-acetaminophen tablet, 10-325mg by mouth every 12 hours PRN for pain; Ordered 8/16/2024, updated 10/16/2024 to include PRN for moderate or greater pain. Review of Resident #14's MAR for October reflected PRN hydrocodone-acetaminophen tablets had been given 4 times from 10/1/2024 through 10/21/2024. Review of the facility provided investigation report, dated 10/29/2024, reflected on 10/21/2024, visiting hospice nurse, RN L, notified facility staff Resident #10's Oxycodone blister pack and the narcotic count sheet for the medication were missing. RN L reported the blister pack and the count sheet had been in the cart the week prior when she visited the facility. The facility DON began an investigation. The report notes Resident #10's Oxycodone were not located; the facility began drug testing the nursing staff who had access to the cart in which the drug had been located. Overnight nurse, RN M, was the final nurse needing to be drug tested . The other three nurses who had access to the cart had tested negative for the presence of oxycodone. RN M was scheduled to be tested prior to her shift; the DON arranged for LVN O to be available to work if the drug test results were positive for RN M. LVN O mentioned to the DON that a similar situation had occurred at a sister facility. LVN O stated RN M had worked at the sister facility and was suspected of being the one to take the narcotics missing. LVN O described that the blister packs containing narcotics had been slit in the back and replaced with a similar looking non-narcotic pill and put back in the cart. The report noted RN M was suspended pending the investigation. All medication cart blister packs were inspected for alterations. The facility discovered the Residents #11, #12, #13, #14 and #15 had hydrocodone blister packs containing methocarbamol (a non-narcotic muscle relaxant) in place of hydrocodone pills. Review of the facility RN M's personnel revealed she was hired on 08/12/2024 and her employment was terminated on 10/25/2024. RN M had received training on Abuse, Neglect and Exploitation on 9/13/2024. RN M's file contained a current RN nursing license with an expiration date of 9/30/2026. During an interview on 01/17/2025 at 12:21pm and 1/18/2025 at 3:42pm with the facility DON revealed she had been notified by LVN N that Hospice nurse, RN L, was at the facility and had reported she was unable to find Resident #10's PRN Oxycodone or the count sheet. The DON stated it was initially believed that the Oxycodone had been placed in a different cart than the PRN cart. She stated Resident #10 also had a blister pack of scheduled Oxycodone which she received as scheduled daily twice a day, in the schedule medications cart and was not missing. On 10/22/2024 all carts were checked, and the medication was not found. The DON stated she then started the drug testing of all nurses that had access to the PRN cart and discovered from LVN O that RN M had a history of working at a sister facility where narcotic medications had also been stolen. LVN O had described that narcotic blister packs had been tampered with and replace with a medication that looked similar. The DON stated that after the drug test, which was negative for narcotics, RN M was suspended. A search of all narcotics in all medication carts with a focus on whether the foil backing on the blister packs had been tampered with and if the pills were as labeled on the packs. The DON stated the additional missing narcotic were then found, the count sheets corresponding to the medication remained. The DON stated it had not been easy to detect the tampering as the foil was cut along the edge of the bubble and the medication was substituted with methocarbamol which looks the same other than the pill imprint. The DON stated since the RN M's urine tested negative, and the tampering was so hard to detect she wonders if it was being done to resale the narcotics on the street, but she does not have evidence of this theory . The DON stated since the misappropriation occurred, she had implemented a process in which she or an ADON were notified daily by the pharmacy of the facility narcotic reconciliation report and one of them has checked all carts daily and will continue to do so. During an interview on 01/18/2025 at 12:58pm with hospice RN L revealed each hospice nurse when they visit a facility is required to do a narcotic count. She had been visiting Resident #10, so she was counting the residents' narcotics. RN L stated she had been unable to locate Resident #10's PRN Oxycodone blister pack and the corresponding count sheet. She stated the previous hospice nurse that visited on 10/17/2024 had documented there was 29 tablets left in a blister pack and the count sheet had the correct count. RN L stated she notified the facility nurse who was working at the time, and she had also looked for the blister pack. When it was not found the facility DON was notified by the facility nurse and she had called her hospice supervisor to notify of the missing drug. RN L stated she had never experienced missing medications at the facility prior to this so she assumed the blister pack had been misplaced. During an interview on 01/18/2025 at 3:25pm with LVN O revealed she had worked at another facility owned by the same company. She stated she knew RN M had also worked at the facility as an agency nurse. She had not known her well but when she was called in to work and RN M came in she had recognized her. LVN O stated the sister facility had not known for certain that missing drugs were caused by RN M but they had requested she not be sent back to the facility from the Agency. During an interview on 01/22/2025 at 12:21pm with the facility MD revealed he had been notified of the missing medication for Resident #10 then again notified of the other residents possibly having received a muscle relaxant in place of the narcotic ordered. The MD stated assessments were completed on all residents involved that as with any medication there can be adverse reactions and or side effects, none were found. Review of the facility's policy Identifying Exploitation, Theft and Misappropriation of Resident Property, dated 4/2021, revealed misappropriation of resident property meant the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. According to the document, an example of misappropriation of property included, drug diversion (taking the resident's medication). Review of the facility Medication and Preparation Administration Policy, undated, reflected the following: Medication Administration- Facility staff should take all measures required by Facility Policy, Applicable Law, and the State Operations manual when administering medications. Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.

Based on interview and record review, the facility failed to ensure each resident had the right to be free from misappropriation of property for 6 of 10 residents ( Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, and Resident #15) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #10's Oxycodone (a schedule II controlled opioid medication used to treat moderate to severe pain) taking taken during the days of 10/17/24 through 10/21/24, and Residents #11, #12, #13, #14 and #15's hydrocodone/APAP tablets (a schedule II controlled opioid medication used to treat pain) taken on unknown dates. This failure placed residents at risk for not receiving prescribed medications for pain relief. Findings included: 1. Review of Resident #10's admission record, undated, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, stage 5 (kidney failure), congestive heart failure (heart cannot pump an adequate amount of blood for circulation), femur fracture (broken thighbone) and pain unspecified (uncertain cause) Review of Resident #10's Annual MDS assessment, dated 11/20/2024, reflected based on Section C: Cognitive Patterns, the resident had a BIMs score of 12 which indicated moderate cognitive impairment. Review of Resident #10's care plan reflected a focused area, revised on 1/16/2024, of generalized pain related to a femur fracture. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included administer medications as ordered. Review of Resident #10's Order Summary Report, viewed on 1/17/2025, reflected the resident was ordered 1 oxycodone tablet, 5mg by mouth every 8 hours PRN for pain; Ordered 12/7/2023. Review of Resident #10's MAR for October 2024 reflected a PRN oxycodone tablet was not requested during the month. 2. Review of Resident #11's admission record, undated, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Diagnoses included DM II, pain in unspecified knee, HTN (high blood pressure) and heart failure. Review of Resident #11's Quarterly MDS assessment, dated 10/17/2024, reflected based on Section C: Cognitive Patterns, the resident had a BIMs score of 15 which indicated cognition was intact. Review of Resident #11's care plan reflected a focused area, revised on 1/15/2025, of generalized pain related to a femur fracture. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included administer medications as ordered. Review of Resident #11's Order Summary Report, viewed on 1/18/2025, reflected the resident was ordered 1 hydrocodone-acetaminophen tablet, 10-325mg by mouth every 6 hours PRN for pain; Ordered 3/13/2024. Review of Resident #11's MAR for October reflected prn hydrocodone-acetaminophen tablets had been given 12 times from 10/1/2024 until 10/21/2024. 3.Review of Resident #12's admission record, undated, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, stage 5 (kidney failure), disorder of bone (medical conditions affecting the bones), HTN and chronic pain. Review of Resident #12's quarterly MDS assessment, dated 12/2/2024, reflected based on Section C: Cognitive Patterns, the resident had a BIMs score of 15 which indicated cognition was intact. Review of Resident #12's care plan reflected a focused area, revised on 3/3/2024, of generalized pain related to a femur fracture. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included anticipate the resident's need for pain relief and respond immediately. Review of Resident #12's Order Summary Report, viewed on 1/18/2025, reflected the resident was ordered 1 hydrocodone-acetaminophen tablet, 5-325mg by mouth every 8 hours PRN for pain; Ordered 2/16/2024. Review of Resident #12's MAR for October reflected PRN hydrocodone-acetaminophen tablets had been given 5 times from 10/1/2024 through 10/21/2024. 4. Review of Resident #13's admission record, undated, reflected a [AGE] year-old female, who was admitted to the facility on [DATE], with an original admission of 10/21/2022. Diagnoses included heart failure, DM II, and unspecified pain . Review of Resident #13's care plan reflected a focused area, revised on 8/13/2024, of pain. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included administer medications as ordered. Review of Resident #13's Order Summary Report, viewed on 1/18/2025, reflected the resident was ordered 1 hydrocodone-acetaminophen tablet, 5-325mg by mouth every 6 hours PRN for pain; Ordered 5/6/2024. Review of Resident #13's MAR for October 2024 reflected prn hydrocodone-acetaminophen tablets had been given 26 times from 10/1/2024 through 10/21/2024. 5. Review of Resident #14's admission record, undated, reflected a [AGE] year-old female, who was admitted to the facility on [DATE], with an original admitted [DATE]. Diagnoses included unspecified fractured neck (fracture of any of the seven cervical vertebrae in the neck), dementia (gradual decline of brain functions) and chronic pain syndrome. Review of Resident #14's quarterly MDS assessment, dated 10/18/2024, reflected based on Section C: Cognitive Patterns, the resident had a BIMs score of 12 which indicated moderate cognitive impairment. Review of Resident #14's care plan reflected a focused area, revised on 9/9/2024, of chronic pain. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included administer medications as ordered. Review of Resident #14's Order Summary Report, viewed on 1/18/2025, reflected the resident was ordered 1 hydrocodone-acetaminophen tablet, 10-325mg by mouth every 8 hours PRN for pain; Ordered 8/16/2024, updated 10/16/2024 to include PRN for moderate or greater pain. Review of Resident #14's MAR for October reflected PRN hydrocodone-acetaminophen tablets had been given 13 times from 10/1/2024 through 10/21/2024. 6. Review of Resident #15's admission record, undated, reflected a [AGE] year-old female, who was admitted to the facility on [DATE], with an original admitted [DATE]. Diagnoses included idiopathic aseptic necrosis of right and left femur (unknown cause of a bone disease causing bone death due to lack of adequate blood supply, in the thigh bone), dementia (gradual decline of brain functions) and pain cause unspecified. Review of Resident #15's care plan reflected a focused area, revised on 12/12/2024, of right leg pain. The goal was that the resident would not have an interruption in normal activities due to pain through the review date. The interventions included administer medications as ordered. Review of Resident #14's Order Summary Report, viewed on 1/18/2025, reflected the resident was ordered 1 hydrocodone-acetaminophen tablet, 10-325mg by mouth every 12 hours PRN for pain; Ordered 8/16/2024, updated 10/16/2024 to include PRN for moderate or greater pain. Review of Resident #14's MAR for October reflected PRN hydrocodone-acetaminophen tablets had been given 4 times from 10/1/2024 through 10/21/2024. Review of the facility provided investigation report, dated 10/29/2024, reflected on 10/21/2024, visiting hospice nurse, RN L, notified facility staff Resident #10's Oxycodone blister pack and the narcotic count sheet for the medication were missing. RN L reported the blister pack and the count sheet had been in the cart the week prior when she visited the facility. The facility DON began an investigation. The report notes Resident #10's Oxycodone were not located; the facility began drug testing the nursing staff who had access to the cart in which the drug had been located. Overnight nurse, RN M, was the final nurse needing to be drug tested . The other three nurses who had access to the cart had tested negative for the presence of oxycodone. RN M was scheduled to be tested prior to her shift; the DON arranged for LVN O to be available to work if the drug test results were positive for RN M. LVN O mentioned to the DON that a similar situation had occurred at a sister facility. LVN O stated RN M had worked at the sister facility and was suspected of being the one to take the narcotics missing. LVN O described that the blister packs containing narcotics had been slit in the back and replaced with a similar looking non-narcotic pill and put back in the cart. The report noted RN M was suspended pending the investigation. All medication cart blister packs were inspected for alterations. The facility discovered the Residents #11, #12, #13, #14 and #15 had hydrocodone blister packs containing methocarbamol (a non-narcotic muscle relaxant) in place of hydrocodone pills. Review of the facility RN M's personnel file revealed she was hired on 08/12/2024 and her employment was terminated on 10/25/2024. RN M had received training on Abuse, Neglect and Exploitation on 9/13/2024. RN M's file contained a current RN nursing license with an expiration date of 9/30/2026. During an interview on 01/17/2025 at 12:21pm and 1/18/2025 at 3:42pm with the facility DON revealed she had been notified by LVN N that Hospice nurse, RN L, was at the facility and had reported she was unable to find Resident #10's PRN Oxycodone or the count sheet. The DON stated it was initially believed that the Oxycodone had been placed in a different cart than the PRN cart. She stated Resident #10 also had a blister pack of scheduled Oxycodone which she received as scheduled daily twice a day, in the schedule medications cart and was not missing. On 10/22/2024 all carts were checked, and the medication was not found. The DON stated she then started the drug testing of all nurses that had access to the PRN cart and discovered from LVN O that RN M had a history of working at a sister facility where narcotic medications had also been stolen. LVN O had described that narcotic blister packs had been tampered with and replace with a medication that looked similar. The DON stated that after the drug test, which was negative for narcotics, RN M was suspended. A search of all narcotics in all medication carts with a focus on whether the foil backing on the blister packs had been tampered with and if the pills were as labeled on the packs. The DON stated the additional missing narcotics were then found, the count sheets corresponding to the medication remained. The DON stated it had not been easy to detect the tampering as the foil was cut along the edge of the bubble and the medication was substituted with methocarbamol which looks the same other than the pill imprint. The DON stated since the RN M's urine tested negative, and the tampering was so hard to detect she wonders if it was being done to resale the narcotics on the street, but she does not have evidence of this theory . The DON stated since the misappropriation occurred, she had implemented a process in which she or an ADON were notified daily by the pharmacy of the facility narcotic reconciliation report and one of them has checked all carts daily and will continue to do so. During an interview on 01/18/2025 at 12:58pm with hospice RN L revealed each hospice nurse when they visit a facility is required to do a narcotic count. She had been visiting Resident #10, so she was counting the residents' narcotics. RN L stated she had been unable to locate Resident #10's PRN Oxycodone blister pack and the corresponding count sheet. She stated the previous hospice nurse that visited on 10/17/2024 had documented there was 29 tablets left in a blister pack and the count sheet had the correct count. RN L stated she notified the facility nurse who was working at the time, and she had also looked for the blister pack. When it was not found the facility DON was notified by the facility nurse and she had called her hospice supervisor to notify of the missing drug. RN L stated she had never experienced missing medications at the facility prior to this so she assumed the blister pack had been misplaced. During an interview on 01/18/2025 at 3:25pm with LVN O revealed she had worked at another facility owned by the same company. She stated she knew RN M had also worked at the facility as an agency nurse. She had not known her well but when she was called in to work and RN M came in, she had recognized her. LVN O stated the sister facility had not known for certain that missing drugs were caused by RN M, but they had requested she not be sent back to the facility from the Agency. During an interview on 01/22/2025 at 12:21pm with the facility MD revealed he had been notified of the missing medication for Resident #10 then again notified of the other residents possibly having received a muscle relaxant in place of the narcotic ordered. The MD stated assessments were completed on all residents involved that as with any medication there can be adverse reactions and or side effects, none were found. Review of the facility's policy Identifying Exploitation, Theft and Misappropriation of Resident Property, dated 4/2021, revealed misappropriation of resident property meant the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. According to the document, an example of misappropriation of property included, drug diversion (taking the resident's medication ).

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident had the right to a safe, clean, comfortable, and homelike environment for 2 (Residents #1 and #2) of 15 residents reviewed for clean rooms. The facility failed to ensure Resident #1's and #2's rooms were clean and did not have a foul odors on 01/17/25. This deficient practice could place residents at risk of a diminished quality of life. Findings include: Review of Resident #1's admission record, dated 01/22/25, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses including unspecified nontraumatic intracerebral hemorrhage (a type of stroke that occurs when blood pools in the brain without trauma), other specified cardiac arrhythmias (abnormal heart rhythms), anoxic brain damage (occurs when the brain is completely deprived of oxygen), aphasia (loss of ability to understand and express speech), dysphasia (difficulty speaking), and weakness. Review of Resident #1's quarterly MDS assessment, dated 12/31/24, reflected a BIMS of 4, indicating a severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent and required total staff assistance on all ADLs. Review of Resident #1's care plan, dated 01/13/25, reflected she had a wound to her sacrum and required tube feeding. Resident #1 also had impaired cognitive function and psychosocial well-being problems. Review of Resident #2's admission record, dated 01/17/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses including hypomagnesemia (a condition where there was too little magnesium in the blood), dysarthria (a speech disorder that made it difficult to clearly speak), unqualified visual loss in both eyes, adjustment disorder with mixed anxiety and depressed mood, blindness in one unspecified eye, and age-related physical debility. Review of Resident #2's quarterly MDS assessment, dated 11/20/24, reflected he had an 8 a BIMS score of 8 out of 15, which indicated he had moderate cognitive impairment. Resident #2 was dependent on toileting and showering, required partial/moderate assistance with dressing, bed mobility and personal hygiene, and supervision/touching assistance with eating and oral hygiene. Review of Resident #2's care plan, dated 12/24/24, reflected he was blind. An observation of Resident #1's room on 01/17/25 at 9:53 a.m. found the inside of her room smelled of vomit. The floor had dried up spills. Resident #1's bedside table also had wet spills. Resident #21 was asleep. An observation of the hallway where Resident #1 resided on 01/17/25 at 9:56 a.m. found the hallway in front of her room smelled of vomit. HK A was cleaning another resident's room that was across from Resident #1's room. During an interview on 01/17/25 at 9:56 a.m., HK A stated she was re-educated about her job duties daily by the HS. HK A stated she cleaned and deep cleaned residents' rooms twice daily. HK A stated she documented on cleaning sheets whenever she cleaned residents' rooms daily. HK A stated the HS would spot check residents' rooms and her cleaning sheets daily. HK A stated she smelled the vomit odor in the hallway that was coming from Resident #1's room. HK A stated she often received foul odor complaints from residents and family members. HK A stated she notified the HS whenever she received complaints about foul odors. HK A stated she most recently notified the HS about the foul odor complaint a while back. HK A stated the HS told her to keep using the same cleaning products in her housekeeping cart whenever she notified the HS about the foul odor complaints. HK A stated she did not know what to do with the foul odors most of the time. HK A stated she knew it was important to keep the facility and residents' rooms clean and odorless and said, To maintain a healthy clean environment. HK A did not believe the foul odors could affect the residents . Review of HK A's Deep Clean Sheets, dated 11/05/24, 11/06/24, 11/15/24, 11/18/24, 11/18/24, 11/20/24, 11/22/24, 12/03/24, 12/03/24, 12/16/24, 12/23/24, 12/31/24, 12/31/24, 2 for 01/01/25, 2 for 01/02/25, 01/03/25, 01/06/25, 01/07/25, 01/09/25, and 01/13/25, reflected her name, date, and room number. None of the deep clean sheets that HK A filled out and provided the surveyor from her housekeeping cart indicated Resident #1's room received a deep cleaning. A deep clean sheet, dated 12/16/24 and 01/02/25, had Resident #2's room listed. Additionally, the check off the following areas completed section was blank on all of HK A's deep clean sheets. During an interview on 01/17/25 at 10:07 a.m., HK A stated the HS was supposed to sign off on her deep clean sheets after the HS spot checks the residents' rooms when asked why the check off section was blank on all her deep clean sheets. During an observation and interview on 01/17/25 at 10:42 a.m., Resident #2's room was two rooms next to Resident #1's room. The outside and inside of Resident #2's room smelled of urine and feces. There were crumpled up papers and dried up spills on Resident #2's room floor. Resident #2 stated he smelled the urine, feces, and vomit odors in his room and the hallway in front of his room. Resident #2 said, The facility smelled like that daily. Resident #2 stated he notified staff of the foul odors and said, They would do nothing. Resident #2 said, Housekeeping do not ever come around to my room. I have to smell this every damn day. Resident #2 stated the foul odors he smelled daily also aggravated him daily . An attempt to interview Resident #1 was made on 01/17/25 at 10:49 a.m. Resident #1 was unable to answer any questions. During an observation of Resident #2's room and the hallway outside Resident #2's room on 01/17/25 at 11:24 a.m., Resident #2's room and the hallway were in the same condition and had the same odors as the observation on 01/17/25 at 10:42 a.m . During an interview on 01/17/25 at 11:40 a.m., HK B, who was working on a hallway next to Residents #1 and #2's hallway, stated he was given orientation training two days ago on how to perform his job duties. HK B stated he cleaned residents' rooms once daily. HK B stated he was not required to document whenever he cleaned residents' rooms. HK B stated he deep cleaned residents' rooms according to the cleaning schedule. HK B stated he did not receive any complaints about foul odors and/or uncleaned rooms. HK B stated he would immediately clean the residents' rooms and report to the HS if he received complaints about foul odors and/or uncleaned rooms. HK B stated the HS checked behind him to ensure residents' rooms were cleaned every 20-30 minutes. HK B stated he knew it was important to keep the facility and residents' rooms clean and odorless and said, That way it's not contagious. During an interview on 01/17/25 at 1:01 p.m., CNA C stated she received complaints from residents and families about foul odors and uncleaned residents' rooms daily. CNA C stated she notified Housekeeping whenever she received complaints about the foul odors and uncleaned residents' rooms. CNA C stated she noticed the foul odors outside and inside Resident #1's and #2's room and the lack of cleanliness in Resident #1's and Resident #2's room. CNA C stated Housekeeping supposedly cleaned residents' rooms daily. During an interview on 01/17/25 at 4:24 p.m., the DMHK stated she oversaw the facility's housekeeping department for 2 years. The DMHK stated housekeepers cleaned residents' rooms once daily and twice daily if the rooms were still dirty during her spot check. The DMHK stated housekeepers documented deep cleanings they completed daily on deep clean sheets. The DMHK stated the HS notified the ADM whenever there were physical environment and housekeeping concerns. The DMHK stated the HS quit last Thursday (01/09/25). The DMHK stated she directly received physical environment and housekeeping concerns and complaints from 01/09/25 through 01/17/25. The DMHK stated she did not receive any complaints or concerns about foul odors and uncleaned residents' rooms. The DMHK stated she observed the foul odor coming from Resident #1's room when she took over the facility's housekeeping department on 01/09/25. The DMHK stated Resident #1's room smelled of vomit, urine, and feces. The DMHK could not recall if she smelled the same odors in Resident #2's room. The DMHK stated she never spoke with Resident #1 about the foul odors coming from her room and did not know why. The DMHK stated she asked the nursing staff who worked on the hallway and at the nursing station near Resident #1's room about the foul odors and they told her that they also smelled the odors and that it was normal. The DMHK could not indicate who the nursing staff members were and when she spoke with them about the foul odors from Resident #1's room. The DMHK stated she cleaned Resident #1's room sometime last week (sometime between 01/06/25 through 01/10/25). The DMHK stated she knew it was important to keep the facility and residents' rooms clean and odorless and said, So residents felt comfortable because it was their home. During an interview on 01/22/25 at 11:39 a.m., Resident #1's RP stated he visited Resident #1 anytime he was in town. Resident #1's RP stated he most recently visited Resident #1 last Sunday (01/19/25). Resident #1's RP stated he observed Resident #1's room had urine, feces and vomit odors and was uncleaned. Resident #1's RP stated there were times that Resident #1's room smelled of urine and feces because the nurses had not come and changed Resident #1. Resident #1's RP could not recall when he most recently smelled the urine and feces odors in Resident #1's room. Resident #1's RP stated Resident #1's room smelled of vomit due to her vomiting at times during her peg tube feedings. Resident #1's RP could not recall when he most recently smelled the vomit odor in Resident #1's room. Resident #1's RP stated he did not observe housekeeping staff clean Resident #1's room since 12/20/24. Resident #1's RP stated he did not file a grievance or report his concerns about the odors and lack of cleanliness in Resident #1's room because he did not want to get anyone in trouble. During an interview on 01//22/25 at 1:33 p.m., LVN D stated housekeeping cleaned residents' rooms once daily. LVN D stated she received complaints about the foul odors from Residents #1 and #2's hall. LVN D stated she smelled body odor and urine in Resident #1's room. LVN D stated she observed the foul odors from Resident #1's room on 1-2 occasions. LVN D stated she most recently observed the foul odors from Resident #1's room back in October 2024. LVN D stated she could not recall if she observed the foul odors from Resident #2's room. LVN D stated she would alert housekeeping whenever she received complaints about the foul odors. LVN D stated she would also ensure the CNAs performed brief changes, took out residents' food trays, and took out the trash whenever she smelled foul odors. LVN D stated Resident #1's room had foul odors despite cleaning Resident #1's linens and changing Resident #1's briefs. LVN D stated the foul odors from Resident #1's room were constantly brought up during morning meetings. LVN D stated she knew it was important to keep the facility and residents' rooms clean and odorless and said, For residents' rooms to be clean, and safety. It is a huge issue and concern. If there was clutter or a mess, residents could slip and fall. It is also the resident's home. Residents lived here. We would be denying residents if we let them live in filth. During an interview on 01/22/24 at 5:38 p.m., the ADON stated she received complaints about the foul odors coming from Resident #1's room from staff. The ADON stated she could not recall if she received any complaints about the foul odors coming from Resident #2's room. The ADON stated staff tried to upkeep Resident #1's room whenever there were foul odors, or it was dirty. The ADON stated CNAs and nurses would try and clean Resident #1's room and notify the housekeeping staff to deep clean the room. The ADON stated she could not recall when Resident #1's room was most recently deep cleaned. The ADON stated housekeeping staff cleaned residents' rooms daily. The ADON stated Resident #1 did barf a lot due to her peg tube and had poor bowel movements. The ADON stated she knew it was important to keep the facility and residents' rooms clean and odorless and said, For their health and dignity. So, there is no insects. To make sure they (residents) are not ingesting anything old. During an interview on 01/22/24 at 6:39 p.m., the DON stated housekeeping staff cleaned residents' rooms daily. The DON explained the facility outsourced the housekeeping department to a third-party entity. The DON stated she did not know how housekeeping staff divided and cleaned residents' rooms. The DON stated rounds were conducted daily on residents' rooms and given to the ADM. The DON stated staff discussed whenever there was an odor during morning meetings. The DON stated if she smelled an odor, she was trained to investigate the origins of the foul odor, discard any food material, and check residents for incontinence. The DON said she had not received any concerns or grievances about foul odors from Residents #1's and #2's hallway. The DON stated she observed the foul odors from Resident #1's room. The DON stated she could not recall if she observed foul odors from Resident #2's room. The DON stated she knew it was important to keep the facility and residents' rooms clean and odorless and said, Because it must be a pleasant, homelike environment. It is their (resident's) home. No one wants their home to stink. It is already hard enough to adjust to living with other people. Residents are also sensitive to odors and clutter. It is a resident's right. To live in a clean environment, not a foul-smelling environment. It would also be an infection control issue. If there was a smell, it might be an infection. During an interview on 01/22/25 at 7:36 p.m., the ADM stated the housekeepers cleaned residents' rooms once daily. The ADM stated the HS left employment sometime last week. The ADM stated he did not receive any grievances and concerns from residents and families about foul odors and uncleaned rooms. The ADM stated he occasionally had staff complain about the foul odors coming from Resident #1's room. The ADM stated he could not recall if he received grievances and concerns about Resident #2's room. The ADM stated he was unsure if Resident #1's room's foul odors came from Resident #1's peg tube. The ADM stated housekeeping staff also deep cleaned Resident #1's room. The ADM stated he knew it was important to keep the facility and residents' rooms clean and odorless and said, This is their home. We try to make it as accommodating as possible. We also do not want to disturb other residents with the odors. Review of the facility's Deep Clean Schedule that HK A provided the surveyor, dated November 2024, reflected Resident #2's room was required to be deep cleaned every fourth day of the month. Resident #1's room was required to be deep cleaned every 30th day of the month. Review of the facility's Daily Clean Requirements for Residents #1 and #2's hall, undated, reflected that housekeeping staff were required to vacuum and wipe down the handrails in their way in and out the hallway. Housekeeping staff were also required to always check the binder for deep cleans and focus areas for cleaning the rooms. Review of the facility's Daily Rounds sheets, dated 01/02/25, 01/07/25, 01/10/25, and 01/13/25, reflected Resident #1's and #2's rooms were checked by the ADON, who indicated on the sheets that the rooms were clean and there were no odors. There were no other dates provided and included. Review of the facility's Homelike Environment policy, revised February 2021, reflected the following: Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment . Policy Interpretation and Implementation: .2. The community team members and management maximize, to the extent possible, the characteristics of the community that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment . 3. The community team members and management minimize, to the extent possible, the characteristics of the community that reflected a depersonalized, institutional setting. These characteristics include: .b. institutional odors . Review of the facility's Resident Rights policy, revised December 2016, reflected the following: Policy Statement: Team members shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. b. be treated with respect, kindness, and dignity .

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to complete an accurate skin assessment on Resident #1 upon readmission from the hospital on 10/14/24 in which six insect bites were not noted to his right hip. These failures could place residents at risk of not receiving necessary medical care, skin breakdown, and pain. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type II diabetes, end-stage renal disease, paraplegia (a form of paralysis that mainly affects the lower body), and muscle weakness. Review of Resident #1's admission MDS assessment, dated 09/09/24, reflected a BIMS score of 15, indicating he was cognitively intact. Review of Resident #1's initial care plan, dated 10/03/24, reflected he had a skin impairment to the top of his right foot with an intervention of keeping the skin clean and dry. Review of Resident #1's readmission assessment, dated 10/14/24 and locked by the DON, reflected dryness to his feet. During an observation and interview on 10/16/24 at 12:12 PM, Resident #1 stated he had been bitten by ants. He stated when he was admitted to the hospital (on 10/09/24) he had ants falling out of his pants. He pulled down the sheet covering him which revealed six round insect bites on his right hip. He stated they were not causing him pain nor were they causing him to itch. During an observation and interview on 10/16/24 at 12:25 PM, the DON stated she only locked Resident #1's readmission assessment and she believed LVN A had completed the assessment. The DON and Surveyor went to Resident #1's room and she observed his right hip. She confirmed the insect bites and stated it would be her expectation that they would have been addressed in the readmission skin assessment. During a telephone interview on 10/16/24 at 12:33 PM, LVN A stated she did not conduct Resident #1's readmission assessment. She stated they had three residents being readmitted that night (on 10/14/24) and the ADON stated she would conduct his assessment. She stated if a resident had any kind of skin impairment, including insect bites, she would absolutely address it on the skin assessment upon readmission. During an interview on 10/16/24 at 12:37 PM, the ADON stated she did conduct Resident #1's readmission skin assessment on 10/14/24. She stated she did not notice any bites, blisters, or anything of that nature. She stated her main concern was the dryness to his feet. She stated if she had observed insect bites on him, she would have 100% document them on the assessment. During an interview on 10/16/24 at 1:51 PM, the DON stated accurate skin assessments were important so that any skin issues could be identified and treated immediately. She stated skin integrity issues could be indicative of an underlying problem. She stated not documenting all skin issues could lead to something going untreated and worsening. Review of the facility's Admission Assessment and Follow Up: Role of the Nurse Policy, revised September 2012, reflected the following: . 8. Conduct a physical assessment, including the following systems: . j. Skin. Review of the facility's Charting and Documentation Policy, Revised July 2017, reflected the following: . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 9 of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on 11/5/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23, 12/3/23, and 12/04/23. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatments. Findings include: Review of RN staffing for November 2023, revealed zero hours were worked by an RN on: 11/5/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, and 11/26/23. Review of RN staffing for December 2023, revealed zero hours were worked by an RN on 12/03/23, 12/04/23, and 12/28/23. In an interview on 3/21/2024 at 11:45 am, the MDS Nurse stated that she was an RN, but because she was salary, she did not clock in. She did not remember working any of the missing days (11/5/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23, 12/3/23, and 12/04/23.) In an interview on 3/21/2024 at 1: 45 PM with the DON, she stated she was not aware of the lack of 8-hour RN coverage for the dates of 11/5/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23, 12/3/23, and 12/04/23. The DON stated she thought the staffing coordinator would make sure the requirement was met. The DON did state that she was unable to remember if she was in the building for the dates that were missing 8-hour RN coverage. The DON stated that she was available by phone and lived 10-minutes away, so she did not see any potential for harm as she was available if needed. In an interview on 3/21/2024 at 2:00 pm with the ADM, she stated that she was not aware of the holes in RN coverage for the dates of 11/5/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23, 12/3/23, and 12/04/23. The ADM stated she was aware of the regulation that required 8 hours of RN coverage each day, 7 days a week. The ADM stated her expectations were that the facility met the requirement of RN coverage. The ADM stated that she could not confirm there was an RN in the building because both the DON and the MDS Nurse were salary employees and did not punch in. She stated that the DON was available by phone, and she felt that while there was always potential for harm to the residents because of the lack of coverage in the building, she felt there was no actual harm because the DON was always available by phone. Record Review on 3/21/2024 at 1:30pm of Policy titled Department Supervision, Nursing undated revealed 2. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #55) of 8 residents reviewed for care plans. The facility failed to ensure Resident #55's comprehensive care plan has non-approved abbreviations for problems which could result in the resident's actual needs not being met. This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs. The findings included: Review of Resident # 55's face sheet dated 3/20/24 revealed a [AGE] year old male, admitted on [DATE] with diagnosis that include unspecified atrial fibrillation (abnormal heart rate), acute on chronic congestive heart failure(a condition in which the heart does not as well as it should), cognitive communication deficit (difficulty with thinking and how someone uses language) and dysphagia, oropharyngeal phase(swallowing problems occurring the mouth and or the throat) . Review of Resident # 55's Quarterly MDS dated [DATE] revealed a BIM's score of 13 which indicated the resident was cognitively intact. Review of Resident # 55's Care plan revised 2/28/2024 revealed a problem dated 8/4/2023 the Reads I have STM impairment. Interview with MDS Nurse on 3/21/24 at 11:45 am stated the IDT was responsible for completing the care plan and any updates as part of the team, but that she does update the care plan. When asked about Resident #55's care plan that stated STM MDS Nurse stated she was not sure what STM means but given the context she would imagine it stood for Short Term Memory loss. When asked if the facility had an approved abbreviation list for care plans, MDS Nurse state she was not sure. Interview with the DON on 3/21/24 at 1:45 PM revealed her expectations were that care plans were resident centered and that the approved abbreviations were being used so that every care giver can understand the needs of the resident. The DON stated the IDT was responsible for keeping their portion of the care plan up to date and accurate. The DON stated she was unaware of an approved abbreviation list but has found one and STM was not on it. The DON stated she guessed STM may stand for Short Term Memory, but she was not sure. The DON stated she was not aware of who used that abbreviation as so many have access to care plans. Interview with the ADM on 3/24/2024 at 2:00 pm revealed her expectations were that the staff used approved abbreviations when documenting in the medical record, including the care plan. The ADM stated she was not familiar with the abbreviation STM and would not have a clue what it could mean. The ADM stated that an approved abbreviation list was found and will be placed where the staff will have access to it, and they will be educated on its use. The ADM stated her expectations were that care plans reflect an up-to-date reflection of resident's medical conditions and needs. Record Review of List of Approved abbreviations revised February 2014 on 3/21/2024 at 2:30 pm revealed that STM was not on the list.

Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for changes in condition, in that: The facility failed to ensure Resident #1's NP was notified that she had missed doses of her prescribed Prednisone (normally prescribed for a short term in order to control acute flare-ups of Chron's disease) for eight days which exacerbated her symptoms of pain, nausea, vomiting, and diarrhea. This failure placed residents at risk of illness, uncontrolled pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Crohn's disease (chronic inflammation of the digestive tract that leads to abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition) of both small and large intestine, fistula (abnormal connection) of intestine, and chronic pain syndrome. Review of Resident #1's quarterly MDS assessment, dated 05/31/23, reflected a BIMS of 15, indicating she was cognitively intact. Section H (Bladder and Bowel) reflected she had an ostomy (a procedure that creates an opening in the abdomen for waste or urine to exit the body). Review of Resident #1's quarterly care plan, revised 02/07/23, reflected she had an ostomy with an intervention of reporting redness, inflammation, or draining at ostomy site. Review of a Resident #1's physician order, dated 05/10/23, reflected Prednisone oral tablet, 10 MG, 4 tablets by mouth one time a day for Chron's for 7 days. Review of Resident #1's MAR, on 06/20/23, reflected she was administered Prednisone on 05/11/23 and 05/12/23, and not again until 05/20/23. On 05/13/23 and 05/14/23, OT was documented, meaning Other/See Nurse Notes. On 05/15/23 and 05/16/23, MA A documented the medication was administered. On 05/18/23 and 05/19/23, H was documented, meaning On Hold. Review of Resident #1's progress notes in her EMR, dated 05/13/23 and 05/14/23, documented by MA B, reflected the following: Note Text: Prednisone Oral Tablet 10 MG, give 4 tablets by mouth one time a day for Chron's for 7 days: waiting on delivery from pharmacy. Med not in e-kit (Emergency kit). c/n aware. Review of Resident #1's physician order list in her EMR, on 06/20/23, reflected the following: 05/11/23 - order for Prednisone given by the NP 05/13/23 - ADON made an order for Prednisone from the pharmacy 05/17/23 - the NP requested the medication be put on hold until received from pharmacy and then start over 05/18/23 - Prednisone was received from the pharmacy 05/19/23 - the administering of the Prednisone was resumed Review of a physician's order for Resident #1, dated 05/15/23, documented by LVN C, reflected the following: Lomotil Oral Tablet, 2.5 - 0.025 MG, give 2 tablets by mouth every 6 hours as needed for diarrhea. Review of Resident #1's MAR, on 06/20/23, reflected she was administered Lomotil by LVN C on 05/15/23, 05/16/23, and 05/17/23. Review of Resident #1's hospital discharge summary, on 06/20/23, reflected she had been hospitalized for a bowel obstruction from 05/25/23 - 05/29/23. During an interview on 06/20/23 at 1:15 PM, MA B stated they were out of Prednisone for Resident #1 on 05/12/23. She stated she notified the NP who instructed her to utilize the e-kit. She stated the e-kit only had enough for one dose, and she was administered the dose that day. She stated she notified the charge nurse at the time but could not remember who the nurse was. She stated she was not sure why it took so long to receive the medication, but from what she could understand, it had something to do with Resident #1's insurance. She stated Resident #1 had not seemed more nauseous or in pain more than normal during the time she went without the medication. During a telephone interview on 06/20/23 at 1:23 PM, Resident #1's NP stated she put in an order for Prednisone on 05/11/23 due to Resident #1's Chron's symptoms being exacerbated causing a flare-up. She stated this medication was used for short periods of time to help relieve the symptoms when someone was having a flare-up. She stated she was notified on 05/12/23 when the facility ran out of the prescribed Prednisone and instructed them to retrieve it from the e-kit. She stated she was never informed by the facility staff that there was only one dose in the e-kit. She stated she had believed they had been utilizing the e-kit the whole time (05/12/23 - 05/17/23) until 05/17/23 when she realized the e-kit was out of the medication. She stated it was Resident #1 who informed her she had not been receiving the Prednisone and had been having extreme bouts of nausea, vomiting, and diarrhea. She stated Resident #1 had not expressed increased pain to her that day (05/17/23). She stated she then placed the order on hold until the medication was delivered from the pharmacy so that the seven-day regimen could start over. She stated it would be her expectation that she be notified if the facility was unable to obtain a resident's medication. She stated she did not believe Resident #1 not receiving the medication caused the bowel obstruction (diagnosed in the hospital on 05/25/23), but definitely could have been uncomfortable for her and exacerbated her symptoms such as nausea, vomiting, and diarrhea. Observation and interview on 06/20/23 at 1:34 PM revealed Resident #1 in her room. She stated she went almost a week without Prednisone and because of that she ended up in the hospital for four days with a bowel obstruction. She stated during that time, her pain was a 10 out of 10 and she kept telling the staff. She stated she was constantly nauseous, was throwing up after each meal, and was experiencing diarrhea. She stated she was feeling better since she came back from the hospital. During an interview on 06/20/23 at 1:45 PM, LVN C stated she worked with Resident #1 when they were out of her prescribed Prednisone. She stated the NP was notified and she instructed them to use the e-kit. She stated the MAs did not notify her going forward that there was none left in the e-kit. She stated she could not remember how long she was off the medication. She stated she did not remember if Resident #1 had been experiencing more pain or other side effects during that time. She stated if she had put in an order for Lomotil, that would not have been out of the ordinary, as Resident #1 often had diarrhea. During an interview on 06/20/23 at 2:00 PM, the ADM stated she had not been aware Resident #1 had gone without Prednisone. She stated the DON that had worked during that timeframe was no longer working at the facility. She stated her expectation was when a medication ran out, the NP would be notified, and it would be reordered immediately. She stated if it was taking a while for the pharmacy to deliver the medication, the NP could order an alternative or put it on hold. She stated it was the nurses' responsibility to ensure medications were ordered in a timely manner. She stated there could be numerous negative outcomes if residents went without medication, but it would depend on what the medication was for. She stated she did not believe that was what caused Resident #1 to have a bowel obstruction. She stated although MA A documented the medication was given on 05/15/23 and 05/16/23, there was no way it would have been possible due to the medication not being in the facility and she must have falsified on Resident #1's MAR. She stated MA A no longer worked at the facility. The ADM stated they did not have a policy on reordering medications or physician orders. During an interview on 06/20/23 at 2:31 PM, the ADON stated no one notified him that the e-kit did not have any Prednisone or that Resident #1 had gone multiple days without it. He stated nurses and medication aides had the ability to call the pharmacy to refill medications or to follow-up on medications that had not been delivered. He stated it could be possible that Resident #1's symptoms were exacerbated due to not receiving the Prednisone. Review of the facility's undated Pharmacy Services Policy reflected the following: .The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without necessary interruptions. . Facility staff should take all measures required by Facility Policy, Applicable Law, and the State Operations Manual following administration of medications. Following resident medication administration, facility staff should appropriately document medication administration .

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care, in that: The facility failed to ensure Resident #1 received her prescribed Prednisone (normally prescribed for a short term in order to control acute flare-ups of Chron's disease) for eight days which exacerbated her symptoms of pain, nausea, vomiting, and diarrhea. This failure placed residents at risk of illness, uncontrolled pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Crohn's disease (chronic inflammation of the digestive tract that leads to abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition) of both small and large intestine, fistula (abnormal connection) of intestine, and chronic pain syndrome. Review of Resident #1's quarterly MDS assessment, dated 05/31/23, reflected a BIMS of 15, indicating she was cognitively intact. Section H (Bladder and Bowel) reflected she had an ostomy (a procedure that creates an opening in the abdomen for waste or urine to exit the body). Review of Resident #1's quarterly care plan, revised 02/07/23, reflected she had an ostomy with an intervention of reporting redness, inflammation, or draining at ostomy site. Review of a Resident #1's physician order, dated 05/10/23, reflected Prednisone oral tablet, 10 MG, 4 tablets by mouth one time a day for Chron's for 7 days. Review of Resident #1's MAR, on 06/20/23, reflected she was administered Prednisone on 05/11/23 and 05/12/23, and not again until 05/20/23. On 05/13/23 and 05/14/23, OT was documented, meaning Other/See Nurse Notes. On 05/15/23 and 05/16/23, MA A documented the medication was administered. On 05/18/23 and 05/19/23, H was documented, meaning On Hold. Review of Resident #1's progress notes in her EMR, dated 05/13/23 and 05/14/23, documented by MA B, reflected the following: Note Text: Prednisone Oral Tablet 10 MG, give 4 tablets by mouth one time a day for Chron's for 7 days: waiting on delivery from pharmacy. Med not in e-kit (Emergency kit). c/n aware. Review of Resident #1's physician order list in her EMR, on 06/20/23, reflected the following: 05/11/23 - order for Prednisone given by the NP 05/13/23 - ADON made an order for Prednisone from the pharmacy 05/17/23 - the NP requested the medication be put on hold until received from pharmacy and then start over 05/18/23 - Prednisone was received from the pharmacy 05/19/23 - the administering of the Prednisone was resumed Review of a physician's order for Resident #1, dated 05/15/23, documented by LVN C, reflected the following: Lomotil Oral Tablet, 2.5 - 0.025 MG, give 2 tablets by mouth every 6 hours as needed for diarrhea. Review of Resident #1's MAR, on 06/20/23, reflected she was administered Lomotil by LVN C on 05/15/23, 05/16/23, and 05/17/23. Review of Resident #1's hospital discharge summary, on 06/20/23, reflected she had been hospitalized for a bowel obstruction from 05/25/23 - 05/29/23. During an interview on 06/20/23 at 1:15 PM, MA B stated they were out of Prednisone for Resident #1 on 05/12/23. She stated she notified the NP who instructed her to utilize the e-kit. She stated the e-kit only had enough for one dose, and she was administered the dose that day. She stated she notified the charge nurse at the time but could not remember who the nurse was. She stated she was not sure why it took so long to receive the medication, but from what she could understand, it had something to do with Resident #1's insurance. She stated Resident #1 had not seemed more nauseous or in pain more than normal during the time she went without the medication. During a telephone interview on 06/20/23 at 1:23 PM, Resident #1's NP stated she put in an order for Prednisone on 05/11/23 due to Resident #1's Chron's symptoms being exacerbated causing a flare-up. She stated this medication was used for short periods of time to help relieve the symptoms when someone was having a flare-up. She stated she was notified on 05/12/23 when the facility ran out of the prescribed Prednisone and instructed them to retrieve it from the e-kit. She stated she was never informed by the facility staff that there was only one dose in the e-kit. She stated she had believed they had been utilizing the e-kit the whole time (05/12/23 - 05/17/23) until 05/17/23 when she realized the e-kit was out of the medication. She stated it was Resident #1 who informed her she had not been receiving the Prednisone and had been having extreme bouts of nausea, vomiting, and diarrhea. She stated Resident #1 had not expressed increased pain to her that day (05/17/23). She stated she then placed the order on hold until the medication was delivered from the pharmacy so that the seven-day regimen could start over. She stated it would be her expectation that she be notified if the facility was unable to obtain a resident's medication. She stated she did not believe Resident #1 not receiving the medication caused the bowel obstruction (diagnosed in the hospital on 05/25/23), but definitely could have been uncomfortable for her and exacerbated her symptoms such as nausea, vomiting, and diarrhea. Observation and interview on 06/20/23 at 1:34 PM revealed Resident #1 in her room. She stated she went almost a week without Prednisone and because of that she ended up in the hospital for four days with a bowel obstruction. She stated during that time, her pain was a 10 out of 10 and she kept telling the staff. She stated she was constantly nauseous, was throwing up after each meal, and was experiencing diarrhea. She stated she was feeling better since she came back from the hospital. During an interview on 06/20/23 at 1:45 PM, LVN C stated she worked with Resident #1 when they were out of her prescribed Prednisone. She stated the NP was notified and she instructed them to use the e-kit. She stated the MAs did not notify her going forward that there was none left in the e-kit. She stated she could not remember how long she was off the medication. She stated she did not remember if Resident #1 had been experiencing more pain or other side effects during that time. She stated if she had put in an order for Lomotil, that would not have been out of the ordinary, as Resident #1 often had diarrhea. During an interview on 06/20/23 at 2:00 PM, the ADM stated she had not been aware Resident #1 had gone without Prednisone. She stated the DON that had worked during that timeframe was no longer working at the facility. She stated her expectation was when a medication ran out, the NP would be notified, and it would be reordered immediately. She stated if it was taking a while for the pharmacy to deliver the medication, the NP could order an alternative or put it on hold. She stated it was the nurses' responsibility to ensure medications were ordered in a timely manner. She stated there could be numerous negative outcomes if residents went without medication, but it would depend on what the medication was for. She stated she did not believe that was what caused Resident #1 to have a bowel obstruction. She stated although MA A documented the medication was given on 05/15/23 and 05/16/23, there was no way it would have been possible due to the medication not being in the facility and she must have falsified on Resident #1's MAR. She stated MA A no longer worked at the facility. The ADM stated they did not have a policy on reordering medications or physician orders. During an interview on 06/20/23 at 2:31 PM, the ADON stated no one notified him that the e-kit did not have any Prednisone or that Resident #1 had gone multiple days without it. He stated nurses and medication aides had the ability to call the pharmacy to refill medications or to follow-up on medications that had not been delivered. He stated it could be possible that Resident #1's symptoms were exacerbated due to not receiving the Prednisone. Review of the facility's undated Pharmacy Services Policy reflected the following: .The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without necessary interruptions. . Facility staff should take all measures required by Facility Policy, Applicable Law, and the State Operations Manual following administration of medications. Following resident medication administration, facility staff should appropriately document medication administration .

Based on interview, and record review, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice and comprehensive person-centered care plan for two (2) (Residents #1 & #2) of ten (10) residents reviewed for Quality of Care. A. LVN A failed to adequately assess, provide appropriate timely interventions and monitor for significant changes to Resident #1. On [DATE] Resident #1 experienced a significant decrease in her oxygen levels, 87%, at 11:21 a.m., continued to have oxygen level of 87% at 4:06 p.m. Resident #1 was transferred to the hospital at about 4:42pm and died 7 days later. B. LVN B failed to adequately assess, provided appropriate timely interventions and monitor for significant changes to Resident #2 after being reported to have blood in her stool at approximately 3:30 p.m on [DATE], had a blood pressure reading of ,d+[DATE] at 4:30 and was found dead in her room at about 5:50pm. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 2:30 pm. While the IJ was removed on [DATE] at 1:40 pm, the facility remained out of compliance at a level of actual harm with the potential for more than minimal harm with a scope identified as isolated. These failures placed two residents at risk for unattended significant change in their health status and potentially contributed to their death. The failures could place residents who experience a change of condition at risk for not having their needs met, diminished health status or death. A. Review of Resident #1's face sheet revealed an [AGE] year-old female, DOB [DATE] with original admitted [DATE] and readmitted [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident#1's MDS assessment dated [DATE] revealed a BIMS score of 99 meaning the Resident #1 did not participate in the assessment, a staff interview was done indicating memory problems. Review of Resident#1's Care Plan with revision date of [DATE] revealed the resident has an ADL self-care performance deficit related to activity intolerance, impaired balance. Review of Resident #1's Nurse's notes dated [DATE] at 12:34 pm reflected resident remains on COVID 19 quarantine and is total care assist x2, has aggressive behavior. was unable to obtain O2 saturation on resident. resident nail bed was cyanic. administration is aware. Resident is alert and has spoken to this nurse today and stated that she was hungry. According to Nursing Intervention and Clinical Skills by Perry & Potter, sixth edition, cyanosis is a late sign of [CONDITION(S)]. Observe for behavioral changes (apprehension, anxiety, confusion, decrease ability to concentrate .), decrease level of oxygen ([CONDITION(S)]) affects a person's cognitive abilities, intrapersonal interaction and mood. Review of clinical records indicated Resident #2 was diagnosed with COVID-19 on [DATE]. Review of Resident #1's clinical record for oxygen levels reflected the follow: [DATE] 11:21 am 87.0 % Room Air [DATE] 4:06 pm 87.0 % Room Air According to Nursing Intervention and Clinical Skills by Perry & Potter, sixth edition, acceptable range for oxygen level is ,d+[DATE]%. Review of Resident #1's clinical records reflected there was no documentation regarding interventions for low oxygen level from 11:21 am to 4:06 pm on [DATE]. There was also no documentation of communication with the Nurse Practitioner or the Medical Doctor regarding Resident #1's oxygen level. In an interview on [DATE] at 4:14 pm, LVN A stated on [DATE] she was notified by CNA A that Resident #1's 02 saturation was low. She stated, she put Resident #1 on oxygen and the resident was sating at ,d+[DATE]%. She stated, the Resident was aggressive, I contacted ADON B and told him. As I am trying to chart CNA A told me to check on Resident#2, she had blood in her stool. I checked, and it was pasty with blood. I called for a second opinion, my coworker, LVN B came and confirmed. I called the NP and she ordered IV for both Residents, labs and asked me to find out if Resident #1's family wanted her to be treated in the facility. I called Resident #1's daughter and she said she wanted Resident #1 to go to the hospital. I called to cancel the x-ray and lab. I called for EMS for Resident #1, by the time I went to Resident #2 she had expired, it all happened within 10 minutes. Resident #1's oxygen went up to 91%, she was aggressive, we elevated her head, she would not keep the oxygen on. I was monitoring her continuously, but it was hard to document at the time. Resident #1's oxygen was back to normal ,d+[DATE]%, it was back to normal as soon as we sat her up. Her nail bed was cyanotic, this was the first time to see her like that. When EMS got here at about 4:30 pm, her oxygen was 91% was [NAME] oxygen. I was supposed to document all my interventions and I forgot to do so. Beyond the documentation I was monitoring her frequently. Her O2 dropped at 11:00 am and it was stable. Her O2 dropped again at about 4:30 pm. If it is not documented, it is not done. She was still the same all the time she was on the unit, both Resident #1 and Resident #2 were aggressive, bite, punching. LVN A did not give specific times for assessments or interventions. In an interview on [DATE] at 4:56 pm, ADON A stated, the nurses and the CNAs are responsible for doing vital signs, vital signs are done at least three times within 24 hours, and with medication pass, therapy takes their vital signs. She also stated, if a CNA takes a Resident's vital signs and it is not normal, the nurse has to go back to verify before documenting. She stated, It is my expectations for the nurses to go back and do the vitals themselves if something is out of the ordinary. The nurse is supposed to follow up and document every intervention. She then stated, when the HHSC Surveyor pointed it out on [DATE] about the documentation, I went back to Resident #1's documentation and realized the problem. I called LVN A back on Friday [DATE]) did late entry. Review of Resident #1's nurse's notes, late entry dated [DATE] at 2:55pm reflected, applied nasal cannula on resident got O2 saturation to 91%. resident is aggressive and will not leave nasal cannula on. In an interview on [DATE] at 4:43 pm CNA A stated, she checked Resident #1's vital signs and notified the nurse of the oxygen level being low and the nurse went to the room immediately. CNA A was unable to tell when she checked Resident #1's vital signs and the exact oxygen reading. She stated, I know to report any oxygen below 95%. When the nurse went to the room I went to another resident. She also stated she usually does vital signs in the morning at the beginning of the shift, after report and rounds and sometimes as needed by the nurses. In an interview on [DATE] at 5:09 pm, LVN A stated, the nurses do initial vital signs on the COVID unit, assess the residents as needed on every shift. She also stated there is not a specific time to assess the residents on the COVID unit, they are assessed for signs and symptoms of COVID, their baseline and SOB. She stated, CNA A checked Resident #1's oxygen level in the morning and in the afternoon. She stated, she told CNA A to keep Resident #1's head elevated and in an upright sitting position but when she got back, Resident #1 was lying flat. In an interview on [DATE] at 6:15 pm, NP A stated LVN A called her on [DATE] at about 4:30 pm to notify her about Resident #1's O2 saturation being low. She stated, she asked LVN A if Resident #1 was on oxygen, if so to turn it up, and to call the family and ask if they wanted the Resident sent out to the hospital. She stated, she told LVN A if the family wanted to keep Resident #1 in the facility, then the orders were to keep her comfortable. She also stated, staff should send a resident to the hospital by calling 911 first when in a critical situation based on nursing judgement and notify the NP/MD later. She stated, she assumed the decreased O2 saturation had just happened and that's why LVN A called her then, but she was not aware of it happening around 11:00 am that day. The NP stated, it is her expectation the nurses do full assessments and she also expects them to notify her immediately when there is a change of condition. B. Review of Resident #2's face sheet revealed an [AGE] year-old female, DOB [DATE] with original admitted [DATE] and readmitted [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident#2's MDS assessment dated [DATE] revealed a BIMS score of 99 meaning the Resident #1 did not participate in the assessment, a staff interview was done indicating memory problems. Review of Resident#2's Care Plan with revision date of [DATE] revealed the resident has an ADL self-care performance deficit related to dementia, have impaired cognitive function/dementia or impaired thought processes related to dementia, have short term and long-term memory impairment with revision date of [DATE], no history of rectal bleed noted and or hemorrhoid. Review of clinical records indicated Resident #2 was diagnosed with COVID on [DATE] Review of Resident #2's blood pressure records revealed the following: [DATE] 4:35 pm ,d+[DATE] mmHg Review of Nursing Intervention and Clinical Skills by Perry & Potter, sixth edition, acceptable range for blood pressure: Systolic---<120 Diastolic--<80 Record review of Resident #2's blood pressure in the last 7 days revealed the following: [DATE] at 4:35pm 78 / 40 mmHg [DATE] at 3:51pm 161 / 62 mmHg [DATE] at 10:19am 107/ 54 mmHg [DATE] at 10:56pm 118 / 72 mmHg [DATE] at 8:16pm 114 / 68 mmHg [DATE] at 00:20am 150 / 61 mmHg [DATE] at 9:11pm 136 / 64 mmHg [DATE] at 3:14pm 149 / 55 mmHg [DATE] at 01:22am 140 / 75 mmHg [DATE] at 7:13pm 137 / 75 mmHg [DATE] at 11:41am 134 / 55 mmHg [DATE] at 9:47pm 147 / 77 mmHg [DATE] at 9:42pm 147 / 77 mmHg [DATE] at 09:42am 108 / 60 mmHg [DATE] at 9:25pm 139 / 76 mmHg [DATE] at 9:22pm 139 / 76 mmHg [DATE] at 08:12am 137 / 74 mmHg [DATE] at 07:37am 170 / 117 mmHg [DATE] at 9:47pm 134 / 77 mmHg [DATE] at 8:09pm 134 / 77 mmHg [DATE] at 07:06am 169 / 74 mmHg [DATE] at 7:16pm 129 / 41 mmHg [DATE] at 06:22am 190 / 88 mmHg [DATE] at 03:05am 169 / 71 mmHg Review of Resident #2's nurse's notes dated [DATE] at 2:42 pm revealed the following: resident remains on COVID quarantine. resident is nonverbal total care assist x 2 Hoyer lift and medication is crushed. resident is aggressive and spit out food and medication on staff. resident is incontinent. Review of Resident #2's nurse's notes dated [DATE] at 3:47 pm revealed the following: resident was swabbed for COVID test today Review of Resident #2's nurse's notes dated [DATE] at 5:02 pm revealed the following: called RP of resident left message to return call. staff reported to this nurse that resident BM did not look right upon assessment from this nurse. resident feces had good amount of burgundy color mixed with feces, this nurse contacted NP. NP ordered CBC, BMP, UA CNS In an interview on [DATE] at 4:14 pm, LVN A stated she is not sure when Resident #2's blood pressure was taken. She also stated the blood in the stool was noted around 4:30 pm, she was notified the CNA A and she went and look at the stool. She later stated it is not ok to document blood pressure that low without rechecking and notifying the Nurse Practitioner. She stated, she notified the Nurse Practitioner, got orders and when she got back Resident #2 was found dead. When LVN A was asked about what the indication of blood being in a stool was, she stated, I do not know what the possible problems for blood in the stool that is why I notified the NP. In an interview on [DATE] at 4:45 pm, LVN B stated she was called by LVN A to take a look at Resident #2's stool, it looked like blood in her stool and she needed a second opinion. She stated, she could see there was some blood in Resident #2's stool along with some blood clots. She later stated, The only thing I know we both left the room at the same time, I know she was on the phone with the NP and I was heading down my hall. I don't know what happened after that. I will not be able to tell the exact time, maybe around 3:00 pm or so. In an interview on [DATE] at 4:53 pm, ADON A stated, the CNAs and nurses are responsible to do vital signs and document if it is baseline. She stated, if the vitals are not normal, it is concerning. She stated, she expects the nurses to reassess the residents and notify the NP. She then stated, in the case with Resident #2, she has never seen blood in her stool, so blood in a stool is concerning. Review of Nursing Intervention and Clinical Skills by Perry & Potter, sixth edition, blood in the stool can indicate a relatively mild condition, such as hemorrhoids or constipation, or it can be due to a serious, even life-threatening condition, such as [CONDITION(S)] or [CONDITION(S)]. In an interview on [DATE] at 2:30 pm, the Administrator stated, the facility did not have policies for change of condition, assessment and documentation, and decisions regarding resident care are based on the nursing judgement. In an interview on [DATE] at 4:43 pm CNA A stated, she was the one who saw the blood in Resident #2's stool and informed the nurse. She also stated it was about 3:30 pm to 4:00 pm on [DATE]. She stated the nurse looked at Resident #2's stool and called the other nurse to see the stool. She then stated she left the room because she had other Residents to attend to. She stated later, at about 5:00 pm while preparing for dinner, EMT arrived to get Resident #1 and the LVN A found Resident #2 already dead. In an interview on [DATE] at 5:09 pm, LVN A stated, the nurses do initial vitals on the COVID unit, assess the residents as needed and every shift. She also stated there is not a specific time to assess the residents on the COVID unit, they are assessed for signs and symptoms of COVID, their baseline and SOB. LVN A stated, she looked at Resident #2' body, she did not do vitals. She stated the medication aide did not notify her of Resident #2's blood pressure being low. She ended by saying, she did not know the possible problems for blood being in the stool. In an interview on [DATE] at 6:15 pm, NP A stated LVN A called her on [DATE] at about 4:30 pm told her about blood in Resident #2's stool. She said, she asked LVN A if she assessed Resident #2 and checked for internal hemorrhoids to see where the bleeding was coming from and LVN A told her no she did not assess. The NP stated, it is her expectation the nurses do full assessments and she also expects them to notify her immediately when there is a change of condition. In an interview on [DATE] at 10:07 am, ADON B stated he was working the day of the allegation, but not on the COVID unit. He remembers the supervisor having the day off for that unit. ADON B stated he was not aware of the blood in the stool for Resident #2 and that he heard about it afterwards and that CNA had notified the nurse on that unit. He stated his expectation is the nurses will assess the resident and call the NP. He also stated, before calling the provider, vital signs need to be taken because the NP will ask for those, assess how the resident is clinically, assess to see where the blood is coming from, and to call the provider with all gathered info unless she is already in the facility to go directly and see. He also stated, his expectation is to assess and gather all information and notify the NP for a change in condition as soon as possible, however if it's emergent they can send the resident to the hospital by calling 911 and then notify NP after the fact. He stated, he defines the critical residents as those on the COVID, those with comorbidities or infection. He stated there is no written or set policies after change in condition to go back and assess resident or to follow up or when to notify the NP. He stated we just have a relationship between the NP/MD and us to notify them of change of conditions and if it's after hours then we call the after-hours service to notify and get new orders. He stated when a resident has a change in condition, he expects someone to stay with the resident while the nurse goes to call and notify NP. He also stated he expected documentation of assessments on Resident#1's condition to have started when the resident first had decreased O2 sat and needing oxygen. In an interview on [DATE] at 12:55 pm, the administrator stated she is the Abuse & Neglect Coordinator and her expectation is to ensure the resident is safe and then reported. She stated, when she is not in the facility, staff still reports to her because her phone number is posted at each computer to reach her anytime and the DON is next in line if she is on vacation. Surveyor explained concern with decrease in O2 saturations occurring twice during a shift. The Administrator stated LVN A should have documented from the first episode around 11:30 am up to 4:30 pm when LVN A notified the NP regarding Resident#1's drop in oxygen. She also stated she thought LVN A contacted the NP and the resident took the oxygen off. She stated, the NP should have been notified around 11:30 am when Resident #1's oxygen level dropped instead of later. The administrator stated she didn't ask about the blood in the stool because she wasn't aware but was later told by her staff that the NP said the orders would have been the same no matter where the blood was coming from. In an interview on [DATE] at 2:45 pm, LVN A stated she does not remember how many times she went back to Resident #1's room to assess her. She stated, Resident #1's 02 saturation went back up when she put the nasal cannula on Resident #1, reassessed her and sat her up in bed. LVN A stated she didn't think she should have called the NP to notify her of change of condition because she was able to get Resident #1's 02 sats back up within 5 minutes or possibly sooner but Resident #1 would not leave her oxygen on. LVN A stated she did not do any other assessment on Resident #1, but she left the 02 monitor on her the whole time. LVN A then paused and said, I didn't do anything wrong and would not have wanted anything to happen to the resident. Yes, it's my fault I didn't document any of that. I did call the NP at 4:00 pm to let her know about the decreased O2, normally when a resident has a change in condition I would assess, take all their vital signs, and do a neurological exam. I should have called the NP earlier, but I thought the resident would be okay. I panicked and called the NP when I saw the blood in the stool, I did not take the Resident #2's vital signs prior to calling her or do any further assessment I panicked. The facility later presented the following Policy. Review of facility's policy titled Assessment, Charting and Documentation revised [DATE] reflected: All services provided to the resident, progress toward the care plan goals, or any changes in the Resident's medical, physical, functional or psychosocial condition, shall be documented in the Resident's medical records. The medical records should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy interpretation and Implementation: --Documentation in the medical record may be electronic, manual or a combination --The following information may be documented the resident medical record: ---------objective observation ---------medication administration ---------treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] --------changes in the resident's condition --------events, incidents or accidents involving the resident and --------progress toward or changes in the care plan goals and objective. --Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate --Documentation of assessment, procedures, and treatments will include care specific details including: ----------the date and time the assessment, procedure and, or treatment was provided ----------the name and title of the individual(s) who provided the care ----------the assessment data and or any unusual findings obtained during the procedure/treatment. ----------how the resident tolerated the procedure/treatment. ----------whether the resident refused the procedure/treatment ---------notification of family, physician or other staff, if indicated: and ---------the signature and titled of the individual documenting. An Immediate Jeopardy was identified on [DATE] at 1:25 pm. The Administrator was notified of the Immediate Jeopardy on [DATE] at 2:30 p.m. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 7:35 PM. The Plan of Removal reflected A) RN and, or APN to perform head to toe assessment for all residents on the COVID unit to determine any change of condition or instability by end of day [DATE]. RN and, or APN will document all assessment findings in resident EHR by end of day [DATE]. No other changes of condition have been identified. DON or designee will confirm all assessments completed and documented in EHR. B) ADHOC QAPI meeting with Medical Director to be completed by end of day [DATE] to review Immediate Jeopardy, interventions and plan of removal implemented by the facility. C) CEU360 education modules listed below to be assigned and completed by all fulltime licensed nursing staff currently on the schedule by end of day [DATE]. All licensed nursing staff on leave or PRN will complete prior to future scheduled shift. DON or designee will audit and monitor to ensure completion of the CEU 360 education modules are completed by end of day [DATE] for all full-time licensed nursing staff and prior to next shift for all nursing staff currently on leave or prn status. DON or designee will report audit results to QAPI committee times 3 months and as needed. Administrator or Designee will audit to ensure all new licensed nursing staff hired over the next 90 days have completed the above CEU360 training modules and will report findings to QAPI committee times 3 months and as needed. Nursing Documentation-Clinical records should be complete, thorough, accurate, truthful, easily accessible and organized. This course will discuss proper nursing documentation so that anyone reading your nurses notes (physician, billing department, insurance company, lawyer) will have a good understanding of your patient's history, current status, goals, capabilities, prognosis, plan of care, and any changes in status. Additionally, specific patient scenarios are discussed, in which nursing documentation is required. Changes in Patient/Resident Condition: Noticing, Detecting, and Recognizing-The ability to notice, detect, and recognize a deteriorating or improving patient/resident's condition is an important skill for the care team. (Nursing made Incredibly Easy, 2017, pp. 36) Everyone plays a role in noticing change, from registered nurses to environmental care staff. This course discusses becoming familiar with the patient/resident's baseline condition as well as changes you might see in a patient care environment. Communicating a Change in a Patient/Resident's Condition: Using the SBAR Tool to Communicate- Using an organized and systematic approach when communicating about changes in a patient/resident condition is important. It helps you organize the information in such a way that makes it easier to understand and communicate. A common tool used for this is the SBAR Tool. SBAR stands for situation, background, assessment, and recommendation. This course will discuss what is in each section of SBAR and will also discuss why workplace culture is important in effective communication. Observation, Reporting and Documentation-provides a general guideline to follow for accurate & effective Observation, Reporting, & Documentation for all healthcare workers. D) DON or designee will complete education of and provide copy of Assessment, Charting, and Documentation Policy and Change in Condition Policy for all fulltime licensed nursing staff currently on the schedule by end of day [DATE]. All licensed nursing staff currently on leave or PRN will complete prior to future scheduled shift. Administrator or Designee will audit to ensure all new licensed nursing staff hired over the next 90 days have completed the education on Assessment, Charting and Documentation Policy and Change in Condition Policy and will report findings to QAPI committee times 3 months and as needed. E) MD and, or RN and, or APN to perform education with all fulltime licensed nursing staff currently on schedule regarding the below topics will be completed by end of day [DATE]. All licensed nursing staff currently on leave or PRN will complete prior to future scheduled shift. DON or designee will ensure education completed and documented for all fulltime licensed nursing staff currently on the schedule by end of day [DATE] and prior to next shift for all nursing staff currently on leave or prn status. DON or Designee will audit to ensure all new licensed nursing staff hired over the next 90 days have completed the education on the below topics and will report findings to QAPI committee times 3 months and as needed. Documentation-When, what and how licensed nurses should document in resident EHR. Assessment- When and how licensed nurses should assess residents for change in condition to include E-interact process and clinical pathways resource. o When change of condition is reported to nurse, nurse will then validate the vital signs and do a complete assessment following the clinical pathways resources available prior to calling provider. Frequency of reassessment will be dependent on nature of the issue and will follow clinical pathways resources. o Hospitalist Internist of Texas will provide dedicated NP for COVID Unit to provide closer monitoring for critical residents. o Physical head to toe assessment will be conducted on all COVID residents daily. o All COVID residents will have vital signs assessed 3 times daily to include heart rate, blood pressure, respiratory rate and O2 sats. o Visual assessment for COVID Unit residents will be conducted at minimum every 2 hours to determine any possible change of condition. This will include cough, shortness of breath, rapid or labored breathing and overall appearance. o If evidence of low O2 sats below 90 are present the nurse will administer oxygen and immediately notify the provider with clinical findings. The nurse will remain with the resident until the O2 sat is 90 or above and reassessing O2 sats every 30 minutes until the resident is consistent at 90 or above for at least an hour. A direct care staff member will observe resident to ensure they remain stable while the nurse calls the provider, while the nurse get supplies to implement interventions or while the nurse implements anything otherwise directed by the provider. All residents on the COVID Unit will have a PRN order for oxygen due to critical status. o If evidence of blood in stool is identified the direct care staff member will notify the nurse immediately and the nurse will obtain a full set of vital signs and head to toe assessment and then immediately notified provider with clinical findings. A direct care staff member will observe resident to ensure they remain stable while the nurse calls the provider, while the nurse get supplies to implement interventions or while the nurse implements anything otherwise directed by the provider. Required Notification-What events and when licensed nurses should notify providers of changes in resident status. F) DON or designee will ensure E-interact Clinical Pathways resource will be available to all licensed nursing staff via EHR and physical binder at each nursing station for reference by end of day [DATE]. DON or Designee will audit to ensure all licensed nursing staff know where to find the e-interact form and clinical pathways resource and will report findings to QAPI committee times 3 months and as needed. G) Administrator or designee will ensure all fulltime staff currently on the schedule will be re-education on Abuse and Neglect by end of day [DATE]. Administrator or designee will ensure all staff currently on leave or PRN will complete prior to future scheduled shift. Administrator or Designee will audit to ensure all new staff hired over the next 90 days have completed the education on Abuse and Neglect and will report findings to QAPI committee times 3 months and as needed. The Survey Team monitored the current plan of removal as follows: Monitoring done on [DATE] through [DATE] reflected the following. During an interview on [DATE] at 1:00 pm the Administrator stated there is a binder of the POR and everything she has completed or will be completed. She stated an in-service for Abuse and Neglect has been completed on [DATE]. The Administrator completed a spreadsheet of all things that have been completed or that will be completed. The Administrator stated all areas should be completed by Monday [DATE]. Record review on [DATE] reflected the facility initiated an in-service on Abuse and Neglect on [DATE]. Observation on [DATE] revealed a binder at the nurse's station on the GCU as a guide for the nurses for follow in the event of a change of condition. During an interview on [DATE] at 2:20 pm, LVN C stated he received training on Abuse and Neglect on [DATE]. He also stated he was in-serviced of Change of Conditions for residents and how to document in E-Interact in PCC. LVN C was able to locate the Interact Care Pathway binder at the nurse's station on the GCU and showed how to look up different issues Residents may have and then the pathways to follow. LVN C was knowledgeable about the severity of documenting and noticing a change of conditions. He also stated, Resident's vitals are 3 times a day to include heart rate, blood pressure, respiratory rate and O2 levels. He then stated, if a resident's O2 levels dropped below 90 he would administer oxygen and notify the Medical Director/NP. He ended by saying, if he found blood in a Resident's stool he would notify DON immediately. During an interview on [DATE] at 2:40 pm, CNA B stated she received training on Abuse and Neglect on [DATE]. She also stated she was in-serviced on Change of Conditions for residents and how to document in E-Interact in PCC. She stated some signs of COVID are cough, shortness of breath, fever and body aches and if she notices any residents with these symptoms she would notify the DON. She stated she checks blood pressure on her residents who take BP medicine 2 times a day. She stated, if she noticed any changes in a resident she would notify the DON. During an interview on [DATE] at 2:50 pm, LVN D stated received training on Abuse and Neglect on [DATE]. She also stated she was in-serviced on Change of Conditions for residents and how to document in E-Interact in PCC. She showed the Interact Care Pathway binder located at the nurse's station, she then opened the binder and showed how to look up different issues residents may have and then the pathways to follow. She stated, if she noticed a change in resident she would notify the DON/Medical Director/Nurse Practitioner. She stated Residents vitals are checked 3 times a day to include heart rate, blood pressure, respiratory rate and O2 levels. She

Based on observation, interview and record review the facility failed to provide services in accordance with professional standards of care for one of three residents (Resident #1) reviewed for neglect. LVN C failed to thoroughly assess and stabilize Resident #1 prior to moving him from the floor to his bed. Resident #1 fell out of bed and sustained a cervical spine fracture, a left nasal bone fracture, a right nasal bone fracture, a maxillary sinus fracture, a laceration of the eyebrow and a frontal scalp hematoma. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/27/17. While the IJ was lowered on 10/30/17, the facility remained out of compliance at a level of actual harm with a scope identified as a isolated. This deficient practice could place 58 residents at risk for falls and 40 residents requiring a two person assist with personal hygiene at risk for serious injuries and/or death. Finding include: Review of The Standards of Nursing Practice on http://www.bne.state.tx.us/ retrieved on 10/30/17 (22 TAC §217.11) applicable to LVNs (as well as RNs) includes the following standards: (B) Implement measures to promote a safe environment for clients and others; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; Record review of Resident #1's face sheet revealed an initial admission date of [DATE] with the following Diagnoses: [REDACTED]. Observation on 10/26/17 at 9:25 a.m. revealed Resident #1 lying in bed with a cervical collar in place. In an interview on 10/26/17 at 9:25 a.m. Resident #1 stated his neck was hurting at a pain level of eight. (On a scale of 1-10 with ten being the worst pain) Review of Resident #1's Minimum Data Set (MDS) Section C -Cognitive Patterns dated 10/22/17 revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicates severe cognitive impairment. The MDS Section G-Functional Status revealed Resident #1 required two+ person physical assist for transfer and personal hygiene. Review of Resident #1's current care plan dated for the month of 10/2017 revealed resident had severe cognitive impairments and will need assistance with decision making; potential for falls due to limited mobility and cognition and require assistance with Activity of Daily Living (ADLs). Review of the facility's Accident/Incident report dated 10/6/17 revealed the following: Brief Description: Certified Nurse Aide (CNA) reports resident fell out of bed; noted resident lying face down on the floor mat at the back side of the bed; bed was in low position; noted two inch laceration to the right side of the nose; skin tear to the right hand; facial bruising; bleeding from nose and laceration. Review of Resident #1's medical chart progress notes dated 10/6/17 at 4:10 am revealed CNA reports resident fell out of bed; noted resident face down on floor mat at the back side of bed; bleeding from his face. Resident awake and answering questions appropriately; four staff members assisted by lifting mat to bed and log rolling resident for assessment. Noted two inch laceration to right inner nose with bruising; nose swollen with blood from nares and laceration; Bruising to right eye and skin tear to right hand; ice applied and pressure; 911 initiated. At 4:35 am Emergency Medical Services transported resident to the local emergency room . Record review of Resident #1's discharge progress notes from the local hospital revealed a CT cervical spine without contrast results of an acute nondisplaced [MEDICAL CONDITION] inferior body of C2 extending into the [DIAGNOSES REDACTED] of the anterior longitudinal ligament. The progress notes also revealed a CT head without contrast result of a mildly displaced left nasal bone fracture and probable nondisplaced right nasal bone fracture; closed fracture of nasal bone with nonunion and possibly maxillary sinus fracture, closed, initial encounter. In an interview on 10/26/17 at 6:12 pm CNA A stated she worked at this facility for the first time on 10/5/17 on the night shift. CNA A stated she went into Resident #1's room to check and see if he needed incontinent care. CNA A stated the resident's bed was in the lowest position. CNA A stated she raised the bed a little bit and saw the bed was wet, and decided to go to the linen closet to get clean linen for resident's bed. CNA A stated she lowered the bed back down to its lowest position left the room went down the hall to get clean linen, and when she returned Resident #1 was face down on the floor with blood on the mat. CNA A stated she called for the charge nurse, and the charge nurse came in to assess the resident. CNA A stated when she went into the room to provide care for Resident #1 she was alone, she did not have the assistance of another aide. CNA A stated she thought Resident #1 was a one person assist because he could roll in the bed to help with repositioning. CNA A stated she was not given any information or guidance on how to care for Resident #1 when she started the shift. CNA A stated she assumed Resident #1 was a one person assist with ADLs. In an interview on 10/27/17 at 11:20 am CNA B stated she was coming back from her break when she saw CNA A coming down the hallway stating the charge nurse on Hall 100 and 200 needed help because Resident #1 was on the floor and there was a lot of blood on the floor. CNA B stated CNA A went over to Hall 300 and 400 to get the other charge nurse on duty. CNA B stated she went into the room with Licensed Vocational Nurse (LVN) C to help with Resident #1. CNA B stated LVN C assessed resident, and she and three other staff members lifted Resident #1 from the floor using a sheet. CNA B stated she got a sheet that was in the room, rolled the sheet under the resident, rolled him over onto his back, there were two person at the head of the resident and two persons at the foot of the resident, they lifted the resident onto the bed and the EMS arrived shortly. In an interview on 10/27/17 at 12:02 p.m. LVN C stated she had provided care for Resident #1 for several months, was familiar with his individual needs and stated Resident #1 required extensive assistance with activities of daily living care. LVN C stated on 10/6/17 at approximately 4:10 a.m. she was called to Resident #1's room by CNA A. LVN C stated CNA A reported she was doing incontinence care and stepped out of the room to get additional supplies and when she returned to the room Resident #1 was on the floor. LVN C stated CNA A had never worked in the facility prior to that night and was in orientation shadowing CNA B. LVN C stated when she arrived in Resident #1's room he was on the floor between the bed and the wall, was awake and kept repeatedly asking how did I get down here. LVN C stated there was a very large amount of blood on the floor and because the bed was in the way she could not properly assess Resident #1. She further stated they were not able to move the bed far enough away from the wall and could not move the bed out of the room without moving the other resident's bed. LVN C stated she made the decision to move Resident #1 from the floor to the bed, with the assistance of two CNAs and another nurse, they rolled the resident onto the floor mat and lifted him to the bed. LVN C stated no one held Resident #1's head and neck in alignment because there were not enough staff to hold him and lift him off of the floor. LVN C stated she did not want to move him because of the potential for hip or spine injuries. LVN C further stated she felt it was important to see how bad the injuries were to determine if he needed 911. LVN C stated she could see he had injuries that included a laceration to his face/nose. Also, there was a large amount of blood on the floor and on the resident prior to moving him to the bed. LVN C further stated the only way that fall could have been prevented was if two CNAs where in the room to assist the resident with personal care. In an interview on 10/27/17 at 12:35 pm LVN D stated on 10/5/17 night shift he was asked to go help the charge on the other side of the building. LVN D stated when he got into Resident #1's room, resident was on the floor and there was a lot of blood. LVN D stated he helped lift the resident off of the floor while Resident #1 was still on the mat. LVN D stated he assisted with the lift and left the room. LVN D stated he helped with the lift because he thought LVN C did an assessment on Resident #1 and it was okay to lift him. LVN D further stated it was not best practiced to lift a person off of the floor when there is a head injury because moving them could make the injury worse. In four confidential interviews on 10/27/17 with four LVNs they all stated if a person or resident has sustained a head injury and there is a lot of blood, it is best practice to not move the person for fear of causing more damage and maybe death. They further stated a person or resident should be moved by EMS personnel. Review of The Standards of Nursing Practice on http://www.bne.state.tx.us/ retrieved on 10/12/17 (22 TAC §217.11) applicable to LVNs (as well as RNs) includes the following standards: (B) Implement measures to promote a safe environment for clients and others; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; . Review of the American College of Emergency Physician's publication titled 'Emergency 101' at this website address, http://www.emergencycareforyou.org/Emergency-101/Emergencies-A-Z/Neck-or-Back-Injury/ reflected the following: Neck or Back Injury Suspected neck or back (spinal cord) injuries should be taken seriously because of the risk of paralysis and even death. When someone has a head or neck injury, he or she should not be moved because movement may cause further damage to spinal cord nerves (which carry messages between the brain and body), resulting in possible paralysis below the site of the injury. The causes of neck or back injury include: Accidents or falls that cause direct trauma to the face, neck, head or back (e.g., car or bike accidents, diving). Any activities that result in landing on one's head. If any of the above causes or symptoms are involved, assume that the person has a spinal cord injury, and take the follow steps: Call 911 or the local emergency number. Immobilize the head, neck and shoulder area to prevent movement. Do not attempt to reposition, bend or twist the neck or body; and do not move or roll the person unless he or she is in danger (e.g., he or she is in a burning vehicle). Review of the Journal of Emergency Medical Services publication dated 11/2/15, titled 'Complexities of Geriatric Trauma Patients' reflected the following: RESTRICTING SPINAL MOTION/POSITIONING Fractures of the spine, ribs, hips and extremities are among the injuries more likely to occur in older patients. Elderly patients are more likely to sustain injuries that are usually considered rare. These include C1 or C2 C-spine fractures, which may result from minor mechanisms such as a simple fall . High cervical fractures (e.g., odontoid) are more common in the elderly. The Administrator and Director of Clinical Operations were notified on 10/27/17 at 2:15 p.m. an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator and Director of Clinical Operations on 10/27/17 at 6:05 p.m. The final Plan of Removal was accepted by the Survey Team on 10/27/17 at 6:15 p.m. The facility's Plan of Removal was as follows: On 10.26.17, a survey was initiated at the facility. At approximately 2:15pm, 10.27.17, a surveyor provided verbal notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health and safety. The notification of the alleged immediate jeopardy states as follows: 1. Failure to properly assess and treat as related to falls - Proper Assessment post fall in-service was began by nursing designee on 10/27/17 TARGET DATE for completion: 10/30/17. Interact assessment for falls will be re-inserviced on 10/27/2017 and completed by 10/30/2017. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. The following plan of action outlines immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: a. Nursing staff will be in-serviced not to lift or remove a resident who has fallen until a proper assessment has been completed. An in-service was began by nursing designee on 10/27/17 TARGET DATE for completion: 10/30/17. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. b. New staff members will be educated by the DON/nursing designee for proper protocol and procedure for resident falls. New nursing staff will be educated about at-risk residents. The education will also include how to use the Care Tracker system to obtain the plan of care of a resident (i.e. transfer, bathing, eating, etc.). c. Fall incident reports will be reviewed in the morning clinical meetings as an ongoing expectation by the DON and or designee for new or additional interventions, care plans will be updated with interventions following a fall by the DON/ADONS. WAR (Weekly at Risk) Meeting will be held weekly to include in depth discussion about interventions in place to determine if they are effective or need to be revisited. TARGET DATE for initial determinations: Continuous Process d. Nursing staff members will be educated by DON or nursing designee to call a member of nursing administration with falls when they occur to ensure care plan is initiated and interventions implemented-education by ADONS/DON/DCO. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. e. Nursing staff education to include: Fall Prevention Program, Abuse and Neglect (the Abuse and Neglect in-service will include the SCC Abuse and Neglect policy in full), Acute fall protocol and assessment of the resident in-service to be completed by DON, ADONS, and DCO on 10/27/2017- completed by 10/30/2017. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. f. An Ad Hoc QAPI meeting was held 10.27.17 with the Regional vice President, Director of clinical operations, Medical Director and Administrator to review plan of removal. g. On an ongoing basis, the IDT Team will discuss residents fall interventions during our WAR (Weekly at Risk) meeting. Care plans will be updated and staff trained on new measures. TARGET DATE: 10/30/17 h. DON/nurse designee will in-service all nursing staff prior to the start of their shift to ensure each nurse knows the correct protocol related to falls/assessing TARGET DATE 10/27/17. i. Staff will be required to call or notify nursing management when a fall occurs. To allow nursing management to ensure correct procedure was followed. If it is determined that protocol was not followed correctly immediate education and/or disciplinary action will occur. j. Random rounds will be completed by the DON/nurse designee to review assessment skills and protocol weekly for 90 days and randomly thereafter. Education will begin on 10.27.17 and continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 10.27.17. The survey team monitored the current plan of removal as follows: Observations and interviews on 10/27/17 between 6:05 p.m. and 7:45 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Observations and interviews on 10/28/17 between 4:20 p.m. and 5:46 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Observations and interviews on 10/30/17 between 1:55 p.m. and 2:30 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Review of a copy of the facility Quality Assurance Performance Improvement meeting reflected a meeting was conducted on 10/27/17 with the Administrator, Medical Director, Regional Vice President and Director of Clinical Operations. Review of the in-service/training sign-in documents for the following in-services were conducted with 9 of 24 nurses and 15 of 38 CNAs, dietary staff and social workers regarding the following: Proper Assessment Post Fall Fall Management-fall prevention policy and steps to do after a fall. Abuse/Neglect Policy and Procedure Interact Fall, utilizing the Interact Care Path for Falls System 8 employees Nurses/CNA were interviewed about the above trainings all were knowledgeable about the falls trainings and abuse/neglect training. Record review of in-services and training records conducted on 10/27/17 through 10/30/17 reflected all staff members completed the in-service. Observation on 10/30/17 at 2:50 pm revealed Resident #1 was in a low bed asleep and did not show any issues or concerns. On 10/30/17 at 3:07 pm the Administrator and Director of Nurses were informed the IJ was removed. However the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility requiring additional time to train all staff and monitor their plan of removal. According to the Director of Nurse's the facility has 58 resident at risk for falls, and 40 residents who requires two person assist.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit and prevent neglect for one (1) of three (3) residents (Resident #1) reviewed for neglect. Resident #1 required a two person assist during incontinent care. CNA A initiated incontinent care without assistance from another person. During care Resident #1 fell out of bed and sustained a cervical spine fracture, a left nasal bone fracture, a right nasal bone fracture, a maxillary sinus fracture, a laceration of the eyebrow and a frontal scalp hematoma. Following the fall, nursing staff moved Resident #1 from the floor to the bed before thoroughly assessing and stabilizing Resident #1. The facility failed to report the incident of Resident #1's fall to the proper authorities. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/27/17. While the IJ was lowered on 10/30/17, the facility remained out of compliance at a level of actual harm with a scope identified as a isolated. This deficient practice could place 58 residents at risk for falls and 40 residents requiring 2 person assist with personal hygiene at risk for serious injuries and/or death. Finding include: Record review of Resident #1's face sheet revealed an initial admission date of [DATE] with the following Diagnoses: [REDACTED]. Observation on 10/26/17 at 9:25 a.m. revealed Resident #1 lying in bed with a cervical collar in place. In an interview on 10/26/17 at 9:25 a.m. Resident #1 stated his neck was hurting at a pain level of eight (8). (On a scale of 1-10 with ten being the worst pain) Review of Resident #1's Minimum Data Set (MDS) Section C -Cognitive Patterns dated 10/22/17 revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicates severe cognitive impairment. The MDS Section G-Functional Status revealed Resident #1 required 2+ person physical assist for transfer and personal hygiene. Review of Resident #1's current care plan dated for the month of 10/2017 revealed resident had severe cognitive impairments and will need assistance with decision making; potential for falls due to limited mobility and cognition and require assistance with Activity of Daily Living (ADLs). Review of the facility's Accident/Incident report dated 10/6/17 revealed the following: Brief Description: CNA reports resident fell out of bed; noted resident lying face down on the floor mat at the back side of the bed; bed was in low position; noted 2 inch laceration to the right side of the nose; skin tear to the right hand; facial bruising; bleeding from nose and laceration. Review of Resident #1's medical chart progress notes dated 10/5/17 at 4:10 am revealed CNA reports resident fell out of bed; noted resident face down on floor mat at the back side of bed; bleeding from his face. Resident awake and answering questions appropriately; four (4) staff members assisted by lifting mat to bed and log rolling resident for assessment. Noted 2 inch laceration to right inner nose with bruising; nose swollen with blood from nares (nostril) and laceration; Bruising to right eye and skin tear to right hand; ice applied and pressure; 911 initiated. At 4:35 am Emergency Medical Services transported resident to the local emergency room . Review of the American College of Emergency Physician's publication titled 'Emergency 101' at this website address, http://www.emergencycareforyou.org/Emergency-101/Emergencies-A-Z/Neck-or-Back-Injury/ reflected the following: Neck or Back Injury Suspected neck or back (spinal cord) injuries should be taken seriously because of the risk of paralysis and even death. When someone has a head or neck injury, he or she should not be moved because movement may cause further damage to spinal cord nerves (which carry messages between the brain and body), resulting in possible paralysis below the site of the injury. The causes of neck or back injury include: Accidents or falls that cause direct trauma to the face, neck, head or back (e.g., car or bike accidents, diving). Any activities that result in landing on one's head. If any of the above causes or symptoms are involved, assume that the person has a spinal cord injury, and take the follow steps: Call 911 or the local emergency number. Immobilize the head, neck and shoulder area to prevent movement. Do not attempt to reposition, bend or twist the neck or body; and do not move or roll the person unless he or she is in danger (e.g., he or she is in a burning vehicle). Review of the Journal of Emergency Medical Services publication dated 11/2/15, titled 'Complexities of Geriatric Trauma Patients' reflected the following: RESTRICTING SPINAL MOTION/POSITIONING Fractures of the spine, ribs, hips and extremities are among the injuries more likely to occur in older patients. Elderly patients are more likely to sustain injuries that are usually considered rare. These include C1 or C2 C-spine fractures, which may result from minor mechanisms such as a simple fall . High cervical fractures (e.g., odontoid) are more common in the elderly. Record review of Resident #1's discharge 10/06/17 progress notes from the local hospital revealed a CT cervical spine without contrast results of an acute nondisplaced [MEDICAL CONDITION] inferior body of C2 extending into the [DIAGNOSES REDACTED] of the anterior longitudinal ligament. The progress notes also revealed a CT head without contrast result of a mildly displaced left nasal bone fracture and probable nondisplaced right nasal bone fracture; closed fracture of nasal bone with nonunion and possibly maxillary sinus fracture, closed, initial encounter. In an interview on 10/26/17 at 6:12 pm CNA A stated she worked at this facility for the first time on 10/5/17 on the night shift. CNA A stated she went into Resident #1's room to check and see if he needed incontinent care. CNA A stated the resident's bed was in the lowest position. CNA A stated she raised the bed a little bit and saw the bed was wet, and decided to go to the linen closet to get clean linen for resident's bed. CNA A stated she lowered the bed back down to its lowest position left the room went down the hall to get clean linen, and when she returned Resident #1 was face down on the floor with blood on the mat. CNA A stated she called for the charge nurse and the charge nurse came in to assess the resident. CNA A stated when she went into the room to provide care for Resident #1 she was alone, she did not have the assistance of another aide. CNA A stated she thought Resident #1 was a 1 person assist because he could roll in the bed to help with repositioning. CNA A stated she was not given any information or guidance on how to care for Resident #1 when she started the shift. CNA A stated she assumed Resident #1 was a 1 person assist with ADLs. In an interview on 10/27/17 at 11:20 am CNA B stated she was coming back from her break when she saw CNA A coming down the hallway. CNA A stated the charge nurse on Hall 100 and 200 needed help because Resident #1 was on the floor and there was a lot of blood. CNA B stated CNA A went over to Hall 300 and 400 to get the other charge nurse on duty. CNA B stated she went into the room with LVN C to help with Resident #1. CNA B stated LVN C assessed resident, and she and three other staff members lifted Resident #1 from the floor using a sheet. CNA B stated she got a sheet that was in the room, rolled the sheet under the resident, rolled him over onto his back, there were two persons at the head of the resident and two persons at the foot of the resident, they lifted the resident onto the bed and the EMS arrived shortly after. In an interview on 10/27/17 at 12:02 p.m. LVN C stated she had provided care for Resident #1 for several months, was familiar with his individual needs and stated Resident #1 required extensive assistance with activities of daily living care. LVN C stated on 10/5/17 at approximately 4:10 a.m. she was called to Resident #1's room by CNA A, LVN C stated CNA A reported she was doing incontinence care and stepped out of the room to get additional supplies and when she returned to the room Resident #1 was on the floor. LVN C stated CNA A had never worked in the facility prior to that night and was in orientation shadowing CNA B. LVN C stated when she arrived in Resident #1's room he was on the floor between the bed and the wall, was awake and kept repeatedly asking how did I get down here. LVN C further stated there was a very large amount of blood on the floor and because the bed was in the way she could not properly assess Resident #1. She then stated they were not able to move the bed far enough away from the wall and could not move the bed out of the room without moving the other resident's bed. LVN C stated she made the decision to move Resident #1 from the floor to the bed, with the assistance of two CNAs and another nurse, they rolled the resident onto the floor mat and lifted him to the bed. LVN C stated no one held Resident #1's head and neck in alignment because there were not enough staff to hold him and lift him off of the floor. LVN C stated she did not want to move him because of the potential for hip or spine injuries. LVN C further stated she felt it was important to see how bad the injuries were to determine if he needed 911. LVN C stated she could see he had injuries that included a laceration to his face/nose. Also, there was a large amount of blood on the floor and on the resident prior to moving him to the bed. In an interview on 10/27/17 at 12:35 pm LVN D stated on 10/5/17 night shift he was asked to go help the charge on the other side of the building. LVN D stated when he got into Resident #1's room, resident was on the floor and there was a lot of blood. LVN D stated he helped lift the resident off of the floor while Resident #1 was still on the mat. LVN D stated he assisted with the lift and left the room. LVN D stated he helped with the lift because he thought LVN C did an assessment on Resident #1 and it was okay to lift him. LVN D further stated it was not best practiced to lift a person off of the floor when there is a head injury because moving them could make the injury worse. In 4 confidential interviews on 10/27/17 with 4 LVNs they all stated if a person or resident has sustained a head injury and there is a lot of blood, it is best practice to not move the person for fear of causing more damage and maybe death. They further stated a person or resident should be moved by EMS personnel. In an interview on 10/27/17 at 6:30 pm the Administrator stated before CNA A went to assist Resident #1 she should have been orientated to the residents on 100 Hall because CNA A was not familiar with any of the residents. In an interview on 10/26/17 at 8:50 am the facility DON stated when a resident has a fall the nursing staff should assess the resident, notify the physician and family; do an incident report, provide neuro checks, send to the emergency room if needed, and provide interventions. The DON stated she did not report this incident to the state because Resident #1 had old spinal fractures and they knew how he was injured, she felt she did not need to report this incident to the state. In an interview on 10/26/17 at 8:50 am the Director of Clinical Operations stated Resident #1's injury was considered to be serious in nature and should have been reported to the state. Review of the facility's undated Abuse and Neglect Prohibition policy reflected the following: Abuse and Neglect Prohibition Information Our residents have the right to be free from abuse, neglect . The facility must develop and operationalize policies and procedures incorporating the following 7 components: 4. Identification of possible incidents or allegations which need investigation. Identification of occurrences and patterns of potential neglect/abuse. 5. Investigation of all alleged abuse/neglect .in accordance with state law. 7. Reporting of allegations, incidents and substantiated occurrences of abuse, neglect .to the state agency .as designated by state law. Facility response to the results of their investigation. Identification How do we identify events .that may constitute abuse and/or neglect? -Reporting of injuries of unknown source for investigation: An injury should be classified as an injury of unknown source when both the following conditions are met: -The source of the injury was not observed by any person or the source of the injury could not be explained by the resident AND -The injury is suspicious because of the extent of the injury or . Reporting/Response The facility policy and procedure on reporting is to follow state guidelines as outlined in the TDADS Provider Letter #14-13-Guidelines for Reporting Incidents and to answer all questions as outlined in the TDADS letter dated August 19, 2014. Upon completion of the investigation the 'Provider Investigation Report' will be faxed or mailed to TDADS within 5 working days. Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences. Review of the facility's Perineal Care policy, dated 10/2010, and reflected the following: Preparation 1. Review the resident's care plan to assess for any special needs of the resident. Review of a procedure titled Care Path Fall presented to surveyor by the facility's Corporate Clinical Nurse dated 2014 revealed the following: 'Initial nursing evaluation for injury and or mental status: DO NOT move off floor until complete exam has been performed.' The Administrator and Director of Clinical Operations were notified on 10/27/17 at 2:15 p.m. an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator and Director of Clinical Operations on 10/27/17 at 6:05 p.m. The final Plan of Removal was accepted by the Survey Team on 10/27/17 at 6:15 p.m. The facility's Plan of Removal was as follows: On 10.26.17, a survey was initiated at the facility. At approximately 2:15pm, 10.27.17, a surveyor provided verbal notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health and safety. The notification of the alleged immediate jeopardy states as follows: 1. Failure to properly assess and treat as related to falls - Proper Assessment post fall in-service was began by nursing designee on 10/27/17 TARGET DATE for completion: 10/30/17. Interact assessment for falls will be re-inserviced on 10/27/2017 and completed by 10/30/2017. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. The following plan of action outlines immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: a. Nursing staff will be in-serviced not to lift or remove a resident who has fallen until a proper assessment has been completed. An in-service was began by nursing designee on 10/27/17 TARGET DATE for completion: 10/30/17. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. b. New staff members will be educated by the DON/nursing designee for proper protocol and procedure for resident falls. New nursing staff will be educated about at-risk residents. The education will also include how to use the Care Tracker system to obtain the plan of care of a resident (i.e. transfer, bathing, eating, etc.). c. Fall incident reports will be reviewed in the morning clinical meetings as an ongoing expectation by the DON and or designee for new or additional interventions, care plans will be updated with interventions following a fall by the DON/ADONS. WAR (Weekly at Risk) Meeting will be held weekly to include in depth discussion about interventions in place to determine if they are effective or need to be revisited. TARGET DATE for initial determinations: Continuous Process d. Nursing staff members will be educated by DON or nursing designee to call a member of nursing administration with falls when they occur to ensure care plan is initiated and interventions implemented-education by ADONS/DON/DCO. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. e. Nursing staff education to include: Fall Prevention Program, Abuse and Neglect (the Abuse and Neglect in-service will include the SCC Abuse and Neglect policy in full), Acute fall protocol and assessment of the resident in-service to be completed by DON, ADONS, and DCO on 10/27/2017- completed by 10/30/2017. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. f. An Ad Hoc QAPI meeting was held 10.27.17 with the Regional vice President, Director of clinical operations, Medical Director and Administrator to review plan of removal. g. On an ongoing basis, the IDT Team will discuss residents fall interventions during our WAR (Weekly at Risk) meeting. Care plans will be updated and staff trained on new measures. TARGET DATE: 10/30/17 h. DON/nurse designee will in-service all nursing staff prior to the start of their shift to ensure each nurse knows the correct protocol related to falls/assessing TARGET DATE 10/27/17. i. Staff will be required to call or notify nursing management when a fall occurs. To allow nursing management to ensure correct procedure was followed. If it is determined that protocol was not followed correctly immediate education and/or disciplinary action will occur. j. Random rounds will be completed by the DON/nurse designee to review assessment skills and protocol weekly for 90 days and randomly thereafter. Education will begin on 10.27.17 and continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 10.27.17. The survey team monitored the current plan of removal as follows: Observations and interviews on 10/27/17 between 6:05 p.m. and 7:45 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Observations and interviews on 10/28/17 between 4:20 p.m. and 5:46 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Observations and interviews on 10/30/17 between 1:55 p.m. and 2:30 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Review of a copy of the facility Quality Assurance Performance Improvement meeting reflected a meeting was conducted on 10/27/17 with the Administrator, Medical Director, Regional Vice President and Director of Clinical Operations. Review of the in-service/training sign-in documents for the following in-services were conducted with 9 of 24 nurses and 15 of 38 CNAs, dietary staff and social workers regarding the following: Proper Assessment Post Fall Fall Management-fall prevention policy and steps to do after a fall. Abuse/Neglect Policy and Procedure Interact Fall, utilizing the Interact Care Path for Falls System 8 employees Nurses/CNA were interviewed about the above trainings all were knowledgeable about the falls trainings and abuse/neglect training. Record review of in-services and training records conducted on 10/27/17 through 10/30/17 reflected all staff members completed the in-service. Observation on 10/30/17 at 2:50 pm revealed Resident #1 was in a low bed asleep and did not show any issues or concerns. On 10/30/17 at 3:07 pm the Administrator and Director of Nurses were informed the IJ was removed. However the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility requiring additional time to train all staff and monitor their plan of removal. The Director of Nurses provided the information of 58 residents at high risk for falls and 40 residents identified as requiring two person assist for transfers and personal hygiene.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for one (1) of three (3) residents (Resident #1) reviewed for neglect related to falls and procedures for reporting incidents of abuse and neglect in that they: Resident #1 required a two person assist during incontinent care. CNA A initiated incontinent care without assistance from another person. During care Resident #1 fell out of bed and sustained a cervical spine fracture, a left nasal bone fracture, a right nasal bone fracture, a maxillary sinus fracture, a laceration of the eyebrow and a frontal scalp hematoma. Following the fall nursing staff moved Resident #1 from the floor to the bed before thoroughly assessing and stabilizing Resident #1. The facility failed to report the incident of Resident #1's fall to the proper authorities. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a isolated. This deficient practice could place 58 residents at risk for falls and 40 residents requiring a two person assist with personal hygiene at risk for serious injuries and/or death. The findings include: Review of the facility's undated Abuse and Neglect Prohibition policy reflected the following: Abuse and Neglect Prohibition Information Our residents have the right to be free from abuse, neglect . The facility must develop and operationalize policies and procedures incorporating the following 7 components: 4. Identification of possible incidents or allegations which need investigation. Identification of occurrences and patterns of potential neglect/abuse. 5. Investigation of all alleged abuse/neglect .in accordance with state law. 7. Reporting of allegations, incidents and substantiated occurrences of abuse, neglect .to the state agency .as designated by state law. Facility response to the results of their investigation. Reporting/Response The facility policy and procedure on reporting is to follow state guidelines as outlined in the TDADS Provider Letter #,[DATE]-Guidelines for Reporting Incidents and to answer all questions as outlined in the TDADS letter dated [DATE]. Upon completion of the investigation the 'Provider Investigation Report' will be faxed or mailed to TDADS within 5 working days. Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences. Record review of Resident #1's face sheet revealed an initial admission date of [DATE] with the following Diagnoses: [REDACTED]. Observation on [DATE] at 9:25 a.m. revealed Resident #1 lying in bed with a cervical collar in place. In an interview on [DATE] at 9:25 a.m. Resident #1 stated his neck was hurting at a pain level of eight (8). (On a scale of ,[DATE] with ten being the worst pain) Review of Resident #1's Minimum Data Set (MDS) Section C -Cognitive Patterns dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicates severe cognitive impairment. The MDS Section G-Functional Status revealed Resident #1 required 2+ person physical assist for transfer and personal hygiene. Review of Resident #1's current care plan dated for the month of ,[DATE] revealed resident had severe cognitive impairments and will need assistance with decision making; potential for falls due to limited mobility and cognition and require assistance with Activity of Daily Living (ADLs). Review of the facility's Accident/Incident report dated [DATE] revealed the following: Brief Description: CNA reports resident fell out of bed; noted resident lying face down on the floor mat at the back side of the bed; bed was in low position; noted 2 inch laceration to the right side of the nose; skin tear to the right hand; facial bruising; bleeding from nose and laceration. Review of Resident #1's medical chart progress notes dated [DATE] at 4:10 am revealed CNA reports resident fell out of bed; noted resident face down on floor mat at the back side of bed; bleeding from his face. Resident awake and answering questions appropriately; four (4) staff members assisted by lifting mat to bed and log rolling resident for assessment. Noted 2 inch laceration to right inner nose with bruising; nose swollen with blood from nares (nostril) and laceration; Bruising to right eye and skin tear to right hand; ice applied and pressure; 911 initiated. At 4:35 am Emergency Medical Services transported resident to the local emergency room . Review of the American Red Cross publication, dated 2016, titled 'Responding to Emergencies' reflected the following: Generally, you should not move an injured or ill person while giving care. However, it would be appropriate in the following three situations: 1. When you are faced with immediate danger, such as ?re, lack of oxygen, risk of explosion or a collapsing structure. 2. When you have to get to another person who may have a more serious problem. In this case, you may have to move a person with minor injuries to reach someone needing immediate care. 3. When it is necessary to give proper care. For example, if someone needed CPR, he or she might have to be moved from a bed because CPR needs to be performed on a ?rm, ?at surface. If the surface or space is not adequate to give care, the person should be moved Review of the American College of Emergency Physician's publication titled 'Emergency 101' at this website address, http://www.emergencycareforyou.org/Emergency-101/Emergencies-A-Z/Neck-or-Back-Injury/ reflected the following: Neck or Back Injury Suspected neck or back (spinal cord) injuries should be taken seriously because of the risk of paralysis and even death. When someone has a head or neck injury, he or she should not be moved because movement may cause further damage to spinal cord nerves (which carry messages between the brain and body), resulting in possible paralysis below the site of the injury. The causes of neck or back injury include: Accidents or falls that cause direct trauma to the face, neck, head or back (e.g., car or bike accidents, diving). Any activities that result in landing on one's head. If any of the above causes or symptoms are involved, assume that the person has a spinal cord injury, and take the follow steps: Call 911 or the local emergency number. Immobilize the head, neck and shoulder area to prevent movement. Do not attempt to reposition, bend or twist the neck or body; and do not move or roll the person unless he or she is in danger (e.g., he or she is in a burning vehicle). Review of the Journal of Emergency Medical Services publication dated [DATE], titled 'Complexities of Geriatric Trauma Patients' reflected the following: RESTRICTING SPINAL MOTION/POSITIONING Fractures of the spine, ribs, hips and extremities are among the injuries more likely to occur in older patients. Elderly patients are more likely to sustain injuries that are usually considered rare. These include C1 or C2 C-spine fractures, which may result from minor mechanisms such as a simple fall . High cervical fractures (e.g., odontoid) are more common in the elderly. Record review of Resident #1's discharge [DATE] progress notes from the local hospital revealed a CT cervical spine without contrast results of an acute nondisplaced [MEDICAL CONDITION] inferior body of C2 extending into the [DIAGNOSES REDACTED] of the anterior longitudinal ligament. The progress notes also revealed a CT head without contrast result of a mildly displaced left nasal bone fracture and probable nondisplaced right nasal bone fracture; closed fracture of nasal bone with nonunion and possibly maxillary sinus fracture, closed, initial encounter. In an interview on [DATE] at 6:12 pm CNA A stated she worked at this facility for the first time on [DATE] on the night shift. CNA A stated she went into Resident #1's room to check and see if he needed incontinent care. CNA A stated the resident's bed was in the lowest position. CNA A stated she raised the bed a little bit and saw the bed was wet, and decided to go to the linen closet to get clean linen for resident's bed. CNA A stated she lowered the bed back down to its lowest position left the room went down the hall to get clean linen, and when she returned Resident #1 was face down on the floor with blood on the mat. CNA A stated she called for the charge nurse and the charge nurse came in to assess the resident. CNA A stated when she went into the room to provide care for Resident #1 she was alone, she did not have the assistance of another aide. CNA A stated she thought Resident #1 was a 1 person assist because he could roll in the bed to help with repositioning. CNA A stated she was not given any information or guidance on how to care for Resident #1 when she started the shift. CNA A stated she assumed Resident #1 was a 1 person assist with ADLs. In an interview on [DATE] at 11:20 am CNA B stated she was coming back from her break when she saw CNA A coming down the hallway. CNA A stated the charge nurse on Hall 100 and 200 needed help because Resident #1 was on the floor and there was a lot of blood. CNA B stated CNA A went over to Hall 300 and 400 to get the other charge nurse on duty. CNA B stated she went into the room with LVN C to help with Resident #1. CNA B stated LVN C assessed resident, and she and three other staff members lifted Resident #1 from the floor using a sheet. CNA B stated she got a sheet that was in the room, rolled the sheet under the resident, rolled him over onto his back, there were two persons at the head of the resident and two persons at the foot of the resident, they lifted the resident onto the bed and the EMS arrived shortly after. In an interview on [DATE] at 12:02 p.m. LVN C stated she had provided care for Resident #1 for several months, was familiar with his individual needs and stated Resident #1 required extensive assistance with activities of daily living care. LVN C stated on [DATE] at approximately 4:10 a.m. she was called to Resident #1's room by CNA A, LVN C stated CNA A reported she was doing incontinence care and stepped out of the room to get additional supplies and when she returned to the room Resident #1 was on the floor. LVN C stated CNA A had never worked in the facility prior to that night and was in orientation shadowing CNA B. LVN C stated when she arrived in Resident #1's room he was on the floor between the bed and the wall, was awake and kept repeatedly asking how did I get down here. LVN C further stated there was a very large amount of blood on the floor and because the bed was in the way she could not properly assess Resident #1. She then stated they were not able to move the bed far enough away from the wall and could not move the bed out of the room without moving the other resident's bed. LVN C stated she made the decision to move Resident #1 from the floor to the bed, with the assistance of two CNAs and another nurse, they rolled the resident onto the floor mat and lifted him to the bed. LVN C stated no one held Resident #1's head and neck in alignment because there were not enough staff to hold him and lift him off of the floor. LVN C stated she did not want to move him because of the potential for hip or spine injuries. LVN C further stated she felt it was important to see how bad the injuries were to determine if he needed 911. LVN C stated she could see he had injuries that included a laceration to his face/nose. Also, there was a large amount of blood on the floor and on the resident prior to moving him to the bed. In an interview on [DATE] at 12:35 pm LVN D stated on [DATE] night shift he was asked to go help the charge on the other side of the building. LVN D stated when he got into Resident #1's room, resident was on the floor and there was a lot of blood. LVN D stated he helped lift the resident off of the floor while Resident #1 was still on the mat. LVN D stated he assisted with the lift and left the room. LVN D stated he helped with the lift because he thought LVN C did an assessment on Resident #1 and it was okay to lift him. LVN D further stated it was not best practiced to lift a person off of the floor when there is a head injury because moving them could make the injury worse. In 4 confidential interviews on [DATE] with 4 LVNs they all stated if a person or resident has sustained a head injury and there is a lot of blood, it is best practice to not move the person for fear of causing more damage and maybe death. They further stated a person or resident should be moved by EMS personnel. In an interview on [DATE] at 6:30 pm the Administrator stated before CNA A went to assist Resident #1 she should have been orientated to the residents on 100 Hall because CNA A was not familiar with any of the residents. In an interview on [DATE] at 8:50 am the facility DON stated when a resident has a fall the nursing staff should assess the resident, notify the physician and family; do an incident report, provide neuro checks, send to the emergency room if needed, and provide interventions. The DON stated she did not report this incident to the state because Resident #1 had old spinal fractures and they knew how he was injured, she felt she did not need to report this incident to the state. In an interview on [DATE] at 8:50 am the Director of Clinical Operations stated Resident #1's injury was considered to be serious in nature and should have been reported to the state. Identification How do we identify events .that may constitute abuse and/or neglect? -Reporting of injuries of unknown source for investigation: An injury should be classified as an injury of unknown source when both the following conditions are met: -The source of the injury was not observed by any person or the source of the injury could not be explained by the resident AND -The injury is suspicious because of the extent of the injury or . Reporting/Response The facility policy and procedure on reporting is to follow state guidelines as outlined in the TDADS Provider Letter #,[DATE]-Guidelines for Reporting Incidents and to answer all questions as outlined in the TDADS letter dated [DATE]. Upon completion of the investigation the 'Provider Investigation Report' will be faxed or mailed to TDADS within 5 working days. Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences. Review of the facility's Perineal Care policy, dated ,[DATE], and reflected the following: Preparation 1. Review the resident's care plan to assess for any special needs of the resident. Review of a procedure titled Care Path Fall presented to surveyor by the facility's Corporate Clinical Nurse dated 2014 revealed the following: 'Initial nursing evaluation for injury and or mental status: DO NOT move off floor until complete exam has been performed.' The Administrator and Director of Clinical Operations were notified on [DATE] at 2:15 p.m. an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator and Director of Clinical Operations on [DATE] at 6:05 p.m. The final Plan of Removal was accepted by the Survey Team on [DATE] at 6:15 p.m. The facility's Plan of Removal was as follows: On 10.26.17, a survey was initiated at the facility. At approximately 2:15pm, 10.27.17, a surveyor provided verbal notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health and safety. The notification of the alleged immediate jeopardy states as follows: 1. Failure to properly assess and treat as related to falls - Proper Assessment post fall in-service was began by nursing designee on [DATE] TARGET DATE for completion: [DATE]. Interact assessment for falls will be re-inserviced on [DATE] and completed by [DATE]. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by [DATE] will no longer be able to work until the completion of in-service/education. The following plan of action outlines immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: a. Nursing staff will be in-serviced not to lift or remove a resident who has fallen until a proper assessment has been completed. An in-service was began by nursing designee on [DATE] TARGET DATE for completion: [DATE]. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by [DATE] will no longer be able to work until the completion of in-service/education. b. New staff members will be educated by the DON/nursing designee for proper protocol and procedure for resident falls. New nursing staff will be educated about at-risk residents. The education will also include how to use the Care Tracker system to obtain the plan of care of a resident (i.e. transfer, bathing, eating, etc.). c. Fall incident reports will be reviewed in the morning clinical meetings as an ongoing expectation by the DON and or designee for new or additional interventions, care plans will be updated with interventions following a fall by the DON/ADONS. WAR (Weekly at Risk) Meeting will be held weekly to include in depth discussion about interventions in place to determine if they are effective or need to be revisited. TARGET DATE for initial determinations: Continuous Process d. Nursing staff members will be educated by DON or nursing designee to call a member of nursing administration with falls when they occur to ensure care plan is initiated and interventions implemented-education by ADONS/DON/DCO. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by [DATE] will no longer be able to work until the completion of in-service/education. e. Nursing staff education to include: Fall Prevention Program, Abuse and Neglect (the Abuse and Neglect in-service will include the SCC Abuse and Neglect policy in full), Acute fall protocol and assessment of the resident in-service to be completed by DON, ADONS, and DCO on [DATE]- completed by [DATE]. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by [DATE] will no longer be able to work until the completion of in-service/education. f. An Ad Hoc QAPI meeting was held 10.27.17 with the Regional vice President, Director of clinical operations, Medical Director and Administrator to review plan of removal. g. On an ongoing basis, the IDT Team will discuss residents fall interventions during our WAR (Weekly at Risk) meeting. Care plans will be updated and staff trained on new measures. TARGET DATE: [DATE] h. DON/nurse designee will in-service all nursing staff prior to the start of their shift to ensure each nurse knows the correct protocol related to falls/assessing TARGET DATE [DATE]. i. Staff will be required to call or notify nursing management when a fall occurs. To allow nursing management to ensure correct procedure was followed. If it is determined that protocol was not followed correctly immediate education and/or disciplinary action will occur. j. Random rounds will be completed by the DON/nurse designee to review assessment skills and protocol weekly for 90 days and randomly thereafter. Education will begin on 10.27.17 and continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 10.27.17. The survey team monitored the current plan of removal as follows: Observations and interviews on [DATE] between 6:05 p.m. and 7:45 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Observations and interviews on [DATE] between 4:20 p.m. and 5:46 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Observations and interviews on [DATE] between 1:55 p.m. and 2:30 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Review of a copy of the facility Quality Assurance Performance Improvement meeting reflected a meeting was conducted on [DATE] with the Administrator, Medical Director, Regional Vice President and Director of Clinical Operations. Review of the in-service/training sign-in documents for the following in-services were conducted with 9 of 24 nurses and 15 of 38 CNAs, dietary staff and social workers regarding the following: Proper Assessment Post Fall Fall Management-fall prevention policy and steps to do after a fall. Abuse/Neglect Policy and Procedure Interact Fall, utilizing the Interact Care Path for Falls System 8 employees Nurses/CNA were interviewed about the above trainings all were knowledgeable about the falls trainings and abuse/neglect training. Record review of in-services and training records conducted on [DATE] through [DATE] reflected all staff members completed the in-service. Observation on [DATE] at 2:50 pm revealed Resident #1 was in a low bed asleep and did not show any issues or concerns. On [DATE] at 3:07 pm the Administrator and Director of Nurses were informed the IJ was removed. However the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility requiring additional time to train all staff and monitor their plan of removal. The Director of Nurses provided the information of 58 residents at high risk for falls and 40 residents identified as requiring two person assist for transfers and personal hygiene.

Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three (Resident #1) reviewed for neglect. LVN C failed to thoroughly assess and stabilize Resident #1 prior to moving him from the floor to his bed. Resident #1 fell out of bed and sustained a cervical spine fracture, a left nasal bone fracture, a right nasal bone fracture, a maxillary sinus fracture, a laceration of the eyebrow and a frontal scalp hematoma. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/27/17. While the IJ was lowered on 10/30/17, the facility remained out of compliance at a level of actual harm with a scope identified as a isolated. This deficient practice could place 58 residents at risk for falls and 40 residents requiring a two person assist with personal hygiene at risk for serious injuries and/or death. Finding include: Record review of Resident #1's face sheet revealed an initial admission date of [DATE] with the following Diagnoses: [REDACTED]. Observation on 10/26/17 at 9:25 a.m. revealed Resident #1 lying in bed with a cervical collar in place. In an interview on 10/26/17 at 9:25 a.m. Resident #1 stated his neck was hurting at a pain level of eight. (On a scale of 1-10 with ten being the worst pain) Review of Resident #1's Minimum Data Set (MDS) Section C -Cognitive Patterns dated 10/22/17 revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicates severe cognitive impairment. The MDS Section G-Functional Status revealed Resident #1 required two+ person physical assist for transfer and personal hygiene. Review of Resident #1's current care plan dated for the month of 10/2017 revealed resident had severe cognitive impairments and will need assistance with decision making; potential for falls due to limited mobility and cognition and require assistance with Activity of Daily Living (ADLs). Review of the facility's Accident/Incident report dated 10/6/17 revealed the following: Brief Description: Certified Nurse Aide (CNA) reports resident fell out of bed; noted resident lying face down on the floor mat at the back side of the bed; bed was in low position; noted two inch laceration to the right side of the nose; skin tear to the right hand; facial bruising; bleeding from nose and laceration. Review of Resident #1's medical chart progress notes dated 10/6/17 at 4:10 am revealed CNA reports resident fell out of bed; noted resident face down on floor mat at the back side of bed; bleeding from his face. Resident awake and answering questions appropriately; four staff members assisted by lifting mat to bed and log rolling resident for assessment. Noted two inch laceration to right inner nose with bruising; nose swollen with blood from nares and laceration; Bruising to right eye and skin tear to right hand; ice applied and pressure; 911 initiated. At 4:35 am Emergency Medical Services transported resident to the local emergency room . Record review of Resident #1's discharge progress notes from the local hospital revealed a CT cervical spine without contrast results of an acute nondisplaced [MEDICAL CONDITION] inferior body of C2 extending into the [DIAGNOSES REDACTED] of the anterior longitudinal ligament. The progress notes also revealed a CT head without contrast result of a mildly displaced left nasal bone fracture and probable nondisplaced right nasal bone fracture; closed fracture of nasal bone with nonunion and possibly maxillary sinus fracture, closed, initial encounter. In an interview on 10/26/17 at 6:12 pm CNA A stated she worked at this facility for the first time on 10/5/17 on the night shift. CNA A stated she went into Resident #1's room to check and see if he needed incontinent care. CNA A stated the resident's bed was in the lowest position. CNA A stated she raised the bed a little bit and saw the bed was wet, and decided to go to the linen closet to get clean linen for resident's bed. CNA A stated she lowered the bed back down to its lowest position left the room went down the hall to get clean linen, and when she returned Resident #1 was face down on the floor with blood on the mat. CNA A stated she called for the charge nurse, and the charge nurse came in to assess the resident. CNA A stated when she went into the room to provide care for Resident #1 she was alone, she did not have the assistance of another aide. CNA A stated she thought Resident #1 was a one person assist because he could roll in the bed to help with repositioning. CNA A stated she was not given any information or guidance on how to care for Resident #1 when she started the shift. CNA A stated she assumed Resident #1 was a one person assist with ADLs. In an interview on 10/27/17 at 11:20 am CNA B stated she was coming back from her break when she saw CNA A coming down the hallway stating the charge nurse on Hall 100 and 200 needed help because Resident #1 was on the floor and there was a lot of blood on the floor. CNA B stated CNA A went over to Hall 300 and 400 to get the other charge nurse on duty. CNA B stated she went into the room with Licensed Vocational Nurse (LVN) C to help with Resident #1. CNA B stated LVN C assessed resident, and she and three other staff members lifted Resident #1 from the floor using a sheet. CNA B stated she got a sheet that was in the room, rolled the sheet under the resident, rolled him over onto his back, there were two person at the head of the resident and two persons at the foot of the resident, they lifted the resident onto the bed and the EMS arrived shortly. In an interview on 10/27/17 at 12:02 p.m. LVN C stated she had provided care for Resident #1 for several months, was familiar with his individual needs and stated Resident #1 required extensive assistance with activities of daily living care. LVN C stated on 10/6/17 at approximately 4:10 a.m. she was called to Resident #1's room by CNA A. LVN C stated CNA A reported she was doing incontinence care and stepped out of the room to get additional supplies and when she returned to the room Resident #1 was on the floor. LVN C stated CNA A had never worked in the facility prior to that night and was in orientation shadowing CNA B. LVN C stated when she arrived in Resident #1's room he was on the floor between the bed and the wall, was awake and kept repeatedly asking how did I get down here. LVN C stated there was a very large amount of blood on the floor and because the bed was in the way she could not properly assess Resident #1. She further stated they were not able to move the bed far enough away from the wall and could not move the bed out of the room without moving the other resident's bed. LVN C stated she made the decision to move Resident #1 from the floor to the bed, with the assistance of two CNAs and another nurse, they rolled the resident onto the floor mat and lifted him to the bed. LVN C stated no one held Resident #1's head and neck in alignment because there were not enough staff to hold him and lift him off of the floor. LVN C stated she did not want to move him because of the potential for hip or spine injuries. LVN C further stated she felt it was important to see how bad the injuries were to determine if he needed 911. LVN C stated she could see he had injuries that included a laceration to his face/nose. Also, there was a large amount of blood on the floor and on the resident prior to moving him to the bed. LVN C further stated the only way that fall could have been prevented was if two CNAs where in the room to assist the resident with personal care. In an interview on 10/27/17 at 12:35 pm LVN D stated on 10/5/17 night shift he was asked to go help the charge on the other side of the building. LVN D stated when he got into Resident #1's room, resident was on the floor and there was a lot of blood. LVN D stated he helped lift the resident off of the floor while Resident #1 was still on the mat. LVN D stated he assisted with the lift and left the room. LVN D stated he helped with the lift because he thought LVN C did an assessment on Resident #1 and it was okay to lift him. LVN D further stated it was not best practiced to lift a person off of the floor when there is a head injury because moving them could make the injury worse. In four confidential interviews on 10/27/17 with four LVNs they all stated if a person or resident has sustained a head injury and there is a lot of blood, it is best practice to not move the person for fear of causing more damage and maybe death. They further stated a person or resident should be moved by EMS personnel. Review of The Standards of Nursing Practice on http://www.bne.state.tx.us/ retrieved on 10/12/17 (22 TAC §217.11) applicable to LVNs (as well as RNs) includes the following standards: (B) Implement measures to promote a safe environment for clients and others; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; . Review of the American College of Emergency Physician's publication titled 'Emergency 101' at this website address, http://www.emergencycareforyou.org/Emergency-101/Emergencies-A-Z/Neck-or-Back-Injury/ reflected the following: Neck or Back Injury Suspected neck or back (spinal cord) injuries should be taken seriously because of the risk of paralysis and even death. When someone has a head or neck injury, he or she should not be moved because movement may cause further damage to spinal cord nerves (which carry messages between the brain and body), resulting in possible paralysis below the site of the injury. The causes of neck or back injury include: Accidents or falls that cause direct trauma to the face, neck, head or back (e.g., car or bike accidents, diving). Any activities that result in landing on one's head. If any of the above causes or symptoms are involved, assume that the person has a spinal cord injury, and take the follow steps: Call 911 or the local emergency number. Immobilize the head, neck and shoulder area to prevent movement. Do not attempt to reposition, bend or twist the neck or body; and do not move or roll the person unless he or she is in danger (e.g., he or she is in a burning vehicle). Review of the Journal of Emergency Medical Services publication dated 11/2/15, titled 'Complexities of Geriatric Trauma Patients' reflected the following: RESTRICTING SPINAL MOTION/POSITIONING Fractures of the spine, ribs, hips and extremities are among the injuries more likely to occur in older patients. Elderly patients are more likely to sustain injuries that are usually considered rare. These include C1 or C2 C-spine fractures, which may result from minor mechanisms such as a simple fall . High cervical fractures (e.g., odontoid) are more common in the elderly. The Administrator and Director of Clinical Operations were notified on 10/27/17 at 2:15 p.m. an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator and Director of Clinical Operations on 10/27/17 at 6:05 p.m. The final Plan of Removal was accepted by the Survey Team on 10/27/17 at 6:15 p.m. The facility's Plan of Removal was as follows: On 10.26.17, a survey was initiated at the facility. At approximately 2:15pm, 10.27.17, a surveyor provided verbal notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health and safety. The notification of the alleged immediate jeopardy states as follows: 1. Failure to properly assess and treat as related to falls - Proper Assessment post fall in-service was began by nursing designee on 10/27/17 TARGET DATE for completion: 10/30/17. Interact assessment for falls will be re-inserviced on 10/27/2017 and completed by 10/30/2017. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. The following plan of action outlines immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: a. Nursing staff will be in-serviced not to lift or remove a resident who has fallen until a proper assessment has been completed. An in-service was began by nursing designee on 10/27/17 TARGET DATE for completion: 10/30/17. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. b. New staff members will be educated by the DON/nursing designee for proper protocol and procedure for resident falls. New nursing staff will be educated about at-risk residents. The education will also include how to use the Care Tracker system to obtain the plan of care of a resident (i.e. transfer, bathing, eating, etc.). c. Fall incident reports will be reviewed in the morning clinical meetings as an ongoing expectation by the DON and or designee for new or additional interventions, care plans will be updated with interventions following a fall by the DON/ADONS. WAR (Weekly at Risk) Meeting will be held weekly to include in depth discussion about interventions in place to determine if they are effective or need to be revisited. TARGET DATE for initial determinations: Continuous Process d. Nursing staff members will be educated by DON or nursing designee to call a member of nursing administration with falls when they occur to ensure care plan is initiated and interventions implemented-education by ADONS/DON/DCO. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. e. Nursing staff education to include: Fall Prevention Program, Abuse and Neglect (the Abuse and Neglect in-service will include the SCC Abuse and Neglect policy in full), Acute fall protocol and assessment of the resident in-service to be completed by DON, ADONS, and DCO on 10/27/2017- completed by 10/30/2017. The in-service and education will continue until 100% of staff have completed required education. Staff who are on PTO will be sent a message requiring a phone call or in person visit to advise of in-service/education requirements before returning to work. Staff who are PRN will be required to complete the in-service/education before working another shift. Any staff member who has not completed the in-service/education by November 4, 2017 will no longer be able to work until the completion of in-service/education. f. An Ad Hoc QAPI meeting was held 10.27.17 with the Regional vice President, Director of clinical operations, Medical Director and Administrator to review plan of removal. g. On an ongoing basis, the IDT Team will discuss residents fall interventions during our WAR (Weekly at Risk) meeting. Care plans will be updated and staff trained on new measures. TARGET DATE: 10/30/17 h. DON/nurse designee will in-service all nursing staff prior to the start of their shift to ensure each nurse knows the correct protocol related to falls/assessing TARGET DATE 10/27/17. i. Staff will be required to call or notify nursing management when a fall occurs. To allow nursing management to ensure correct procedure was followed. If it is determined that protocol was not followed correctly immediate education and/or disciplinary action will occur. j. Random rounds will be completed by the DON/nurse designee to review assessment skills and protocol weekly for 90 days and randomly thereafter. Education will begin on 10.27.17 and continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 10.27.17. The survey team monitored the current plan of removal as follows: Observations and interviews on 10/27/17 between 6:05 p.m. and 7:45 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Observations and interviews on 10/28/17 between 4:20 p.m. and 5:46 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Observations and interviews on 10/30/17 between 1:55 p.m. and 2:30 p.m. revealed staff nurses and CNAs being trained regarding abuse/neglect protocol including notification/reporting, fall incident investigation/reporting, resident assessment and requesting assistance during an incident. The CNAs stated they would press the call like and wait until a nurse arrives. The LVNs stated they wouldn't move the resident until EMS arrives or the assessment reflected the resident didn't sustain any injuries. They further stated they wouldn't move the resident. The charge nurse would be responsible in conducting an investigation/fall report. During the interview the staff understood the fall and abuse/neglect policy and procedures. They all received in-service training prior to work their shifts. Review of a copy of the facility Quality Assurance Performance Improvement meeting reflected a meeting was conducted on 10/27/17 with the Administrator, Medical Director, Regional Vice President and Director of Clinical Operations. Review of the in-service/training sign-in documents for the following in-services were conducted with 9 of 24 nurses and 15 of 38 CNAs, dietary staff and social workers regarding the following: Proper Assessment Post Fall Fall Management-fall prevention policy and steps to do after a fall. Abuse/Neglect Policy and Procedure Interact Fall, utilizing the Interact Care Path for Falls System 8 employees Nurses/CNA were interviewed about the above trainings all were knowledgeable about the falls trainings and abuse/neglect training. Record review of in-services and training records conducted on 10/27/17 through 10/30/17 reflected all staff members completed the in-service. Observation on 10/30/17 at 2:50 pm revealed Resident #1 was in a low bed asleep and did not show any issues or concerns. On 10/30/17 at 3:07 pm the Administrator and Director of Nurses were informed the IJ was removed. However the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility requiring additional time to train all staff and monitor their plan of removal. According to the Director of Nurse's the facility has 58 resident at risk for falls, and 40 residents who requires two person assist.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent falls for 1 of 4 residents reviewed for accidents. (Resident # 2) On 7/12/13 CNA G attempted to transfer Resident #2 by himself. Resident #2 fell during the transfer and sustained a fracture of his left leg. The physician was not notified of the fall until the following day and the resident was transferred to the hospital where the fracture was surgically corrected. This failure contributed to Resident #2's fracture, hospitalization , and surgery. This failure could place the 17 residents who required total assistance with transfers at risk for falls or injury. Findings included: Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 was usually understood and his cognition was moderately impaired. The resident required extensive assistance of 2 or more persons for bed mobility and was totally dependent on 2 or more persons for physical assist with transfers. A Care Plan updated 6/27/13 indicated Resident #2 was unable to transfer independently. The plan indicated the resident required a Hoyer lift for transfers and the level of assistance required for transfers would be provided. The Nurse Aide Assignment Worksheet dated 5/30/12, 6/3/13 and 7/12/13 indicated that Resident # 2 required a Hoyer lift for transfers. Nursing notes dated 7/13/13 at 6:00 a.m. indicated Resident #2 had a knot on his right thigh. The right knee was swollen and the resident stated, "it hurts a little." A Provider Investigation Report dated 7/13/13 indicated on 7/12/13 at approximately 6:30 p.m. Resident #2 slid out of a wheelchair onto the floor during a transfer completed by CNA G. The report indicated CNA G violated the 2 person assist lift policy. An undated statement signed by CNA G indicated the CNA transferred Resident # 2 by himself from the shower bed to the wheelchair. The statement indicated the resident slid down out of the wheelchair onto the floor. The CNA documented that he did not ask for assistance from another staff or report the incident to the nurse. The statement indicated CNA G knew Resident #2 required 2 people for transfers. Nursing notes dated 7/13/13 at 9:30 a.m. indicated Resident #2's left leg was slightly turned inward with the foot resting on the bed. The resident's muscle tone was flaccid (soft and hanging loosely or limply). The nurse practitioner was called and a request was made to have an x-ray from the hip to the ankle. A Radiology Report dated 7/13/13 indicated Resident #2 had a fracture of the left femur (thigh). A nursing note dated 7/13/13 at 1:55 p.m. indicated emergency services were called to transport Resident #2 to the hospital. An undated Physician Discharge Summary indicated Resident #2 was discharged [DATE] to the emergency room . An emergency room note dated 7/13/13 indicated Resident #2 presented at the emergency room with left leg swelling and deformity. The note indicated the left leg was shortened and externally rotated. The thigh had an outward deformity in the midshaft of the thigh. The resident had swelling to his left thigh and knee. The resident was nontender to palpation due to the quadriplegia and lack of sensation throughout. An Operative Report dated 7/15/13 indicated Resident #2 had surgery that consisted of intramedullary (inter locking) nail fixation of his femur. During an interview on 7/25/13 at 11:48 a.m. CNA E said Resident #2 required a Hoyer lift for transfers. CNA E said the resident was totally dependent and required 2 people for transfers. CNA E said on 7/13/13 LVN A told her not to get Resident #2 up for breakfast because of a knot on his leg. CNA E said around 10:00 a.m. she turned the resident and noticed his leg did not look right. She said it looked broken. CNA E said she could not tell something was wrong with the resident's leg until she turned the resident. During an interview on 7/25/13 at 11:55 a.m. LVN A said Resident #2 required 2 people for transfers. LVN A said on 7/13/13 during report at 6:00 a.m. LVN B said Resident #2 had a knot on his left thigh. LVN A said she asked CNA C if anything happened on 7/12/13. LVN A said CNA C admitted they knew about the resident sliding out of his wheelchair during a shower on 7/12/13. During an interview on 7/25/13 at 12:25 p.m. CNA C said on 7/12/13 she worked with Resident #2. CNA C said Resident #2 was to receive a shower on that date. She said she talked with CNA G and they agreed to complete his shower last since it would require both of them to transfer him. CNA C said sometime after 6.00 p.m. she saw CNA G pushing Resident #2 down the hall. CNA C said CNA G told her he gave the resident a shower by himself. CNA C said CNA G told her the resident slid out of his wheelchair. CNA C said the incident was not reported to anyone. She said she should have reported the incident. CNA C said she had never used the Hoyer lift to transfer the resident. She said they transferred using 2 people. CNA C said the incident was avoidable; all CNA G had to do was transfer the resident with two people as they usually did. During an interview on 7/25/13 at 4:37 p.m. CNA F said on 7/13/13 at 6:00 a.m. she received report from CNA D. CNA F said she was told Resident #2 had a knot on his thigh. She said she looked at the resident's leg and it looked broken. CNA F said LVN A looked at the resident's leg. CNA F said Resident #2 required two people for transfers, but did not mention the Hoyer lift. During an interview on 7/25/13 at 3:01 p.m. the administrator said CNA G admitted he transferred Resident #2 by himself. The administrator said the resident was a two person transfer with the Hoyer lift. During an interview on 7/26/13 at 8:10 a.m. CNA D said he worked on the 10-6 shift with Resident #2 on 7/12/13. He said he changed Resident #2 around 5:00 a.m. on 7/13/13 and noticed his leg looked broken. He said he reported the injury to the charge nurse. He said the resident complained of pain. During a confidential interview a staff member said Resident #2 was not transferred with a Hoyer lift. The staff member said Resident #2 was dropped by CNA G. An Inservice Attendance sheet dated 7/13/13 at 12:30 p.m. indicated a mandatory meeting was held with staff regarding reporting all events and incidents, compliance with company policy and following the resident care plan. CNA G was not listed as attending the in-service. During an interview on 7/26/13 at 11:30 a.m. the administrator said she did not have documentation CNA G attended the in-service on 7/13/13 or any in-service regarding Hoyer lift transfers. The CMS 672 dated 7/25/13 indicated 17 residents were totally dependant for transfers.

Based on interview and record review the facility failed to consult with the physician about a change in condition for 1 of 4 residents reviewed for assessment. (Resident #2) Resident #2 had a fall on 7/12/13 and experienced pain. The physician was not consulted regarding the fall or pain. This failure contributed to a delay in treatment for [REDACTED]. Findings included: Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 was usually understood and his cognition was moderately impaired. The resident required extensive assistance of 2 or more persons for bed mobility and was totally dependent on 2 or more persons for physical assist with transfers. An undated Physician's Discharge Summary indicated Resident #2 was discharged to the emergency roiagnom on [DATE]. Nursing notes dated 7/13/13 at 6:00 a.m. indicated Resident #2 had a knot on his right thigh. The right knee was swollen and the resident stated "hurts a little." Nursing notes dated 7/13/13 at 8:20 a.m. indicated LVN A spoke with the nurse practitioner who stated the resident had muscle spasms in the past and would try icy hot. The note did not document the nurse practitioner was notified of pain. A Provider Investigation Report dated 7/13/13 indicated on 7/13/13 at approximately 9:30 a.m. a nurse aide reported to LVN A that Resident #2 had a possible incident on 7/12/13. An undated statement signed by CNA G indicated the CNA transferred Resident # 2 by himself from the shower bed to the wheelchair. The statement indicated the resident slid down out of the wheelchair onto the floor. The CNA documented that he did not ask for assistance from another staff or report the incident to the nurse. Nursing notes dated 7/13/13 at 9:30 a.m. indicated Resident #2's left leg was slightly turned inward with the foot resting on the bed. The resident's muscle tone was flaccid (soft and hanging loosely or limply). The nurse practitioner was called and a request was made to have an x-ray from the hip to the ankle. The note did not document the nurse practitioner was notified of a possible incident. A nursing note dated 7/13/13 at 1:55 p.m. indicated emergency services were called to transport Resident #2 to the hospital. A Radiology Report dated 7/13/13 indicated Resident #2 had a [MEDICAL CONDITION] femur (thigh). During an interview on 7/25/13 at 11:55 a.m. LVN A said on 7/13/13 during shift report at 6:00 a.m. LVN B said Resident #2 had a knot on his left thigh. She said she notified the nurse practitioner of the knot. LVN A said at 8:30 a.m. she noted the resident's left leg was flaccid. She said the resident had contractures and the leg usually had to be moved. LVN A said she called the nurse practitioner and requested an x-ray. LVN A said she asked CNA C if anything happened on 7/12/13. LVN A said CNA C admitted to knowing about the resident sliding out of his wheelchair during a shower on 7/12/13. LVN A said she did not notify the nurse practitioner of the possible fall. During an interview on 7/25/13 at 4:48 p.m. the nurse practitioner said on 7/13/13 she was notified that Resident #2 had a knot on his left thigh. She said she was not notified of a possible incident. The nurse practitioner said LVN A requested an x-ray. She indicated she was not told the resident's leg was flaccid. She said she did not recall if she was told that the resident had swelling in his knee or that he had pain. The nurse practitioner said when she arrived and saw the resident she did not touch the resident's leg as she knew immediately that it was broken. A physician progress notes [REDACTED].#2 had a lump on his left thigh with no pain or incidents reported. The Change in Condition Communication and Treatment policy dated 2/2010 indicated " ...Change in Condition reported by: 1. Staff ... Contact Attending Physician Immediately ... " The CMS 672 dated 7/25/13 indicated a census of 88.

Based on interview and record review the facility failed to ensure an incident of possible neglect was reported to the administrator immediately for 1 of 4 residents reviewed for neglect. (Resident #2) On 7/12/13 CNA G attempted to transfer Resident #2 by himself. Resident #2 fell during the transfer and sustained a fracture of his left leg. The administrator was not notified of the fall until the following day and the resident was transferred to the hospital where the fracture was surgically corrected. This failure contributed to a delay in treatment for [REDACTED]. Findings included: Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 was usually understood and his cognition was moderately impaired. The resident required extensive assistance of 2 or more persons for bed mobility and was totally dependent on 2 or more persons for physical assist with transfers. An undated Physician's Discharge Summary indicated Resident #2 was discharged to the emergency roiagnom on [DATE]. Nursing notes dated 7/13/13 at 6:00 a.m. indicated Resident #2 had a knot on his right thigh. The right knee was swollen and the resident stated "hurts a little." Nursing notes dated 7/13/13 at 8:20 a.m. indicated LVN A spoke with the nurse practitioner who stated the resident had muscle spasms in the past and would try icy hot. The note did not document the nurse practitioner was notified of pain. A Provider Investigation Report dated 7/13/13 indicated on 7/13/13 at approximately 9:30 a.m. LVN A notified the administrator that Resident #2 had a possible incident on 7/12/13. An undated statement signed by CNA G indicated the CNA transferred Resident # 2 by himself from the shower bed to the wheelchair. The statement indicated the resident slid down out of the wheelchair onto the floor. The CNA documented that he did not ask for assistance from another staff or report the incident to the nurse. Nursing notes dated 7/13/13 at 9:30 a.m. indicated Resident #2's left leg was slightly turned inward with the foot resting on the bed. The resident's muscle tone was flaccid (soft and hanging loosely or limply). The nurse practitioner was called and a request was made to have an x-ray from the hip to the ankle. The note did not document the nurse practitioner was notified of a possible incident. A nursing note dated 7/13/13 at 1:55 p.m. indicated emergency services were called to transport Resident #2 to the hospital. A Radiology Report dated 7/13/13 indicated Resident #2 had a [MEDICAL CONDITION] femur (thigh). During an interview on 7/25/13 at 11:55 a.m. LVN A said on 7/13/13 during shift report at 6:00 a.m. LVN B said Resident #2 had a knot on his left thigh. She said she notified the nurse practitioner of the knot. LVN A said at 8:30 a.m. she noted the resident's left leg was flaccid. She said the resident had contractures and the leg usually had to be moved. LVN A said she called the nurse practitioner and requested an x-ray. LVN A said she asked CNA C if anything happened on 7/12/13. LVN A said CNA C admitted to knowing about the resident sliding out of his wheelchair during a shower on 7/12/13. LVN A said she did not notify the nurse practitioner of the possible fall. During an interview on 7/25/13 at 3:01 p.m. the administrator said CNA G admitted he transferred Resident #2 by himself on 7/12/13. The administrator said the resident was a two person transfer with the Hoyer lift. The administrator said she was not notified that CNA G transferred the resident by himself and the resident fell until 7/13/13. During an interview on 7/25/13 at 4:48 p.m. the nurse practitioner said on 7/13/13 she was notified that Resident #2 had a knot on his left thigh. She said she was not notified of a possible incident. The nurse practitioner said LVN A requested an x-ray. She indicated she was not told the resident's leg was flaccid. She said she did not recall if she was told that the resident had swelling in his knee or that he had pain. The nurse practitioner said when she arrived and saw the resident she did not touch the resident's leg as she knew immediately that it was broken. A physician progress notes [REDACTED].#2 had a lump on his left thigh with no pain or incidents reported. The Reporting Abuse and Neglect Policy dated 2/2010 indicated, "Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been, or may be adversely affected by abuse, neglect, or exploitation caused by another person, is to report the abuse, neglect or exploitation immediately." The policy documented "...For staff notify Abuse/Neglect Coordinator, the administrator and DON immediately..." The CMS 672 dated 7/25/13 indicated a census of 88.