Every finding on record at Avir at Weston

Based on interview and observation the facility failed to have competent licensed staff to provide nursing care to all residents at all times. On 08/20/2026 CNA E was observed in the model room, sleeping, while CNA E should have been providing resident care.This failure placed residents at risk for unmet needs and/or injury. Findings included:An observation and interview was completed on 08/20/2026 at 3:30AM on the south side of the facility where 2 CNA's and 1 nurse were on site. During the observation, LVN A was at the nurse's station and was awake. CNA G was providing resident care while CNA C was on their break. LVN A stated he had not observed staff sleep on the job. LVN A also stated that he had heard that staff had been sleeping on the job previously. An observation was completed on 08/20/2026 at 3:50AM on the north side of the facility where 2 CNA's and 1 nurse were on site. During the observation, LVN B sat at the nurse's station and was awake. CNA E was not located, while CNA F was on their break. During the observation, there was an ADL cart stationed outside of a resident room. An observation was completed on 08/20/2026 at 4:15AM where the ADL cart was still stationed outside the same bedroom. During the observation, CNA E was observed to come out of the model room and appeared disheveled with her eyes partially closed. During the observation, the model room was observed to have a blanket on the floor, a laptop on the side table, and two cell phone chargers in the room. The lights were off and the door was cracked closed. An interview was completed on 08/20/2026 at 4:15AM with LVN B who stated that the facility would typically have 2 CNA's and 1 nurse scheduled for both sides of the building during the night shift. She stated that CNA E would often go into the model room in the hall, because the room was warm. LVN B stated they have not seen the staff asleep on the job. LVN B stated care could be missed if staff slept while on the job. An interview was completed on 08/20/2026 at 4:20AM with CNA E who stated she would go into the model room because it was warmer in the hallway. CNA E denied that she would sleep in the room and on the job. CNA E stated she would hear the call lights at the nurse station if a resident needed help. An interview was held on 08/21/2026 at 2:00PM with the DON who stated that staff should not be sleeping at work. The DON stated that she expected her staff to conduct work tasks while on the clock. She said that call lights could go unanswered and care could go missed if staff slept at work. She stated that she doesn't know how her staff would know if a resident needs assistance if they are asleep. She said that her staff are trained to not sleep while on the job. An interview was held on 08/21/2026 at 2:50PM with the ADM who stated that staff members should not be sleeping while at work. He stated that staff would not be aware of any situation that was going on if they were asleep at work. He stated that staff wouldn't know if residents needed help if they were asleep. Record review of the facility's policy staffing, Sufficient and competent Nursing dated August 2022 indicated the following:Licensed staff and CNA's are available 24 hours a day, seven days a week to provide competent resident care services including responding to resident's needs.

Based on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal care for 4 of 5 residents (Resident #1, Resident# 39, Resident# 49, and Resident#58) reviewed for ADL care. The facility failed to provide feeding to Resident #1 during mealtime leaving the resident without nourishment. The facility failed to provide shaving care to Resident's #39, #49, and #58 leaving facial hair on the Residents. Resident #39, Resident #49 and Resident #58 all had observable facial hair. This failure could place residents at risk of social embarrassment, isolation, infection, injury, pain, deterioration of health and a diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated 08/20/26, reflected Resident #1 was admitted [DATE]. She was an [AGE] year-old female diagnosed with epilepsy, unspecified, intractable, without status epilepticus (a form of epilepsy where seizures are recurrent but manageable with medication and do not involve prolonged, life-threatening episodes), Alzheimer's disease, unspecified (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia), vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a type of cognitive impairment caused by brain blood vessel problems, often resulting from stroke, infarction, or hypertensive cerebrovascular disease). Record review of Resident #1's initial MDS assessment, dated 05/28/26, reflected that an assessment for BIMS of 03, reflecting she had severe impairment. Resident #1 had a diagnosis of need for assistance with personal care. Further review revealed that she was fully dependent. Record review of Resident #1's care plan, dated 02/28/26 reflected that she required assistance for performing ADLs r/t dementia. The relevant intervention was that the resident requires substantial/maximum assistance from staff to eat and all ADL care. During an observation and interview with Resident#1's RP on 08/19/2026 at 10:50 a.m., RP stated she observed a nurse aide came in the room and asked Resident#1 if she wanted to eat on the resident's camera. RP stated Resident #1 cannot talk and did not provide any indications she answered her. RP provided video footage that revealed that CNA J entered Resident #1 room and asked Resident #1 if she wanted to eat. Resident #1 did not answer her, nor did Resident #1 show any signs of grimacing that indicated a yes answer. The nurse aid then advised the resident she will let the nurse know she refused to eat. The nurse aide did not attempt to try and feed the resident. RP stated she reviewed the footage and she then came to the facility and she fed Resident #1. Record review of Resident #39's face sheet, dated 08/20/26, reflected Resident #39 was admitted [DATE]. She was a [AGE] year-old female diagnosed with nontraumatic intracerebral hemorrhage in brain stem (a type of stroke characterized by sudden bleeding into the brain tissue, which can lead to serious neurological deficits and requires immediate medical attention), essential (primary) hypertension (a common condition where the force of blood against the artery walls is consistently too high), aphasia (a disorder that affects how you communicate), sciatica, unspecified side (is nerve pain from an injury or irritation to your sciatic nerve). Record review of Resident #39's initial MDS assessment, dated 07/30/2026, reflected that an assessment for Resident #39 had a BIMS of 15 which indicated no cognitive impairment. The assessment also reflected Resident #39 was dependent in the task of personal hygiene which included shaving. Dependent means that the helper does all of the effort, with no support from the residents. Record review of Resident #39's care plan, dated 02/28/26 reflected that she required assistance for performing ADLs r/t impaired cognition, hemiplegia, debility. The relevant intervention was that the resident requires extensive by 1-2 staff with shower and requires moderate assistance times 1 for personal hygiene care. Record review of Resident #49's face sheet, dated 08/20/26, reflected Resident #49 was admitted [DATE]. He was an [AGE] year-old male diagnosed with anxiety disorder (common mental health conditions that cause persistent, excessive fear, dread, or worry that interferes with daily life), multiple fractures of ribs, other fracture of base of skull. Record review of Resident #49's initial MDS assessment, dated 06/23/2026, reflected that Resident #49 had a BIMS of 03 which indicated severe cognitive impairment. The assessment reflected Resident #49 was dependent in the task of personal hygiene which included shaving. Dependent means that the helper does all of the effort, with no support from the residents. Record review of Resident #49's care plan, dated 06/25/2026 reflected that he required assistance for performing ADLs r/t hygiene which included shaving, with 1 person staff assist. Record review of Resident #58's face sheet, dated 08/20/26, reflected Resident #58 was admitted [DATE]. She was a [AGE] year-old female diagnosed with vascular dementia, mild, with anxiety (is characterized by cognitive impairment due to reduced blood flow to the brain, and it is often accompanied by anxiety, which can exacerbate cognitive symptoms), cognitive communication deficit (a condition where impairments in cognitive processes, rather than language or speech, disrupt a person's ability to communicate effectively), unspecified intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently). Record review of Resident #58's initial MDS assessment, dated 07/18/26, reflected that an assessment for BIMS of 14 which reveal minimal cognitive impairment. The assessment also reflected that the resident was independent in personal hygiene which includes shaving. Independent means the resident completes all activity by himself with no assistance. Record review of Resident #58's care plan, dated 02/28/26 reflected that she required assistance for performing ADL self-care performance deficit r/t vascular dementia. The relevant intervention was that the resident requires check nail length and trim and clean on bath day and as necessary; resident require standby assist by (1) staff with bathing and showering. An observation was held on 08/18/2026 at 11:10AM with Resident #39 revealed the resident had visible facial hair above the lip and on the chin. An observation was held on 08/18/2026 at 11:20AM with Resident #49 revealed the resident had visible facial hair on the chin which was approximately 2 inches long. An observation was held on 08/18/2026 at 11:30AM with Resident #58 revealed the resident had visible facial hair above the lip and on the chin. An observation and interview were held on 08/20/2026 at 2:30PM with Resident #49 revealed observable facial hair still present. Resident #49 stated that they had never been offered to shave. Resident #49 stated that the staff do not feel good about not shaving. An observation and interview were held on 08/20/2026 at 2:40PM with Resident #58 revealed observable facial hair still present. Resident #58 stated that they had not been offered to shave. Resident #58 stated that they don't want their facial hair to be visible to others. An interview was held on 08/21/2026 at 11:54AM with CNA H who stated that training on ADL care is done hands on and they get tested on it throughout the year. On our learning app, we must do tests throughout the year. It is the nursing staff responsibility to provide ADL care, especially the CNAs. ADL care consists of feeding, brushing teeth, bathing, shaving and changing the residents, along with ROM. Shaving is offered every shower day. There is one resident that requests to be shaved every day. If the resident requests, we always do it. She stated that not providing the shaving to a resident is neglected. Not shaving a female resident with facial hair, could affect the resident by having them feel embarrassed but it could also cause itchiness and scratchiness. CNA H stated residents that required assistance is fed by the nurse aide staff and the nurses assist also. They also provide them with drinks and make sure they are positioned correctly. If the residents are not provided with meal assistance, they could be hungry or starved. She stated that is extremely neglectful. She stated they are trained to communicate with nonverbal residents, but each resident is different. You watch their eyes and listen to their noises, and different behaviors. If they are non-verbal, they can't answer. I always offer their food to them. She stated you never just walk away because they physically cannot answer, we always go and get the nurse. An interview was held on 08/21/2026 at 12:27PM with CNA I and she stated she had ADL training upon new hire and annually thereafter. She stated CNAs are responsible for providing ADL care. ADL care included: Eating, bathing, feeding, showers, and letting the nurses know if there is a change in condition. She stated shaving is part of the ADLs. She stated shaving should be offered every shower day and then as residents asked. If residents aren't shaved, they could get ingrown toenails or infection. Hit cold affects a female's dignity having facial hair. CNA I stated if residents require feeding the staff is required to feed them. She stated anyone who is a nurse that is trained can feed the resident. If a resident is not provided with meal service they can develop weight loss, might need food to coat stomach with meds. CNA I stated they are trained to communicate with nonverbal residents regarding ADL care by looking for signs. She stated she will still offer them the food. She stated would could happen to a nonverbal resident and someone ask them if they want to eat and they were unable to respond is they could get sick from not being fed. She stated you should take the initiative and offered them food to see what their reaction will be. An interview was held on 08/21/2026 at 1:11PM with CNA J who stated training is conducted on ADLs by hands on and they get tested throughout the year. Nursing staff are responsible for providing ADL care to residents. She stated using a gait belt and things like that are included in ADL care. Shaving is a part of the ADL care, and it is offered on shower days or whenever they ask. If a resident is not shaved, it could cause a rash or infection. Not shaving can affect females with facial hair can cause them to be itchier, embarrassment or dignity. She stated if a resident requires feeding assistance, they need to be sitting up at a 90-degree angle, they should get their food last so it's still warm. Nursing staff are responsible for feeding residents. If you did not provide meal assistance, a resident could lose weight. They are trained to communicate with nonverbal residents regarding ADL care by their gestures once you learn the resident. If the resident is nonverbal and someone asks them if they wanted to eat, and they were unable to respond, you should try to feed them but if they don't open their mouth or try to refuse, report this to the nurse. An interview was held on 08/21/2026 at 1:35PM with LVN K who stated the nursing staff are responsible for providing ADL care. ADL care consists of showers, toileting, incontinent care, nail care, feeding, dressing, shaving, etc (etcetera, and so forth). He stated shaving is automatic with showers and then as needed upon request. If shaving is not done, it could become a dignity issue especially with female residents. If residents require feeding assistance, some require cues and some need physical assistance. LVN K stated CNA, nurses, and med aides are responsible for feeding residents. If a resident is not verbal and was not provided with meal assistance, they could go without a meal and begin to lose weight. Record review of the facility's policy dated February 2025 titled ADL supporting indicated the following:Residents will be provided with care, treatment, and services to ensure that their ADL's do not diminishAppropriate care and services will be provided to residents who are unable to carry out ADL's independently which include grooming.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 4 residents (Resident #60) reviewed for PASARR Level I screenings. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #60. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis major depressive disorder, recurrent, with severe with psychotic symptoms present upon Resident #60 admission. and the facility did not complete a 1012 form to update Resident #60 PASARR Level 1 with the new diagnosis. These failures could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #60's face sheet indicated a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of essential (primary) hypertension (a common condition where the force of blood against the artery walls is consistently too high), major depressive disorder, recurrent, with severe with psychotic symptoms (a serious mental health condition characterized by repeated episodes of intense depression accompanied by hallucinations or delusions), other abnormalities of gait and mobility (any unusual or unexpected patterns of movement or changes in the way an individual walks or moves). Record review of Resident #60's MDS record dated 06/04/2026 revealed a BIMS score of 15, reflecting she had no cognitive impairment. Resident #60 had a diagnosis of major depressive disorder. Record review of Resident #60's care plan does not reveal Resident #60's mental illness. Resident #60 care plan reveals the resident used antidepressant medication r/t DX of depression. Record review of Resident #60's level 1 PASARR dated 06/18/2020 indicated that Resident #60 had no evidence of a primary diagnosis for this individual, individual had no mental illness, no intellectual disability and/or evidence that this individual has a developmental disability. An interview was held on 08/21/2026 at 2:50PM with the ADM who stated MDS staff are responsible for PASSAR. The ADM stated that PASSAR should be completed before residents entered the facility, or if they were discharged and came back to the facility. He stated that the social worker is the one that completes all of the assessments and works with the MDSC. The ADM stated that major depressive disorder could be a diagnosis that triggered a positive PASSAR 1. He stated that if a PASSAR was incorrect the residents would not get the additional services that may be available to them. Record review of the facility's policy dated 01/20/2026 titled PASSAR revealed the following:When it is determined that a PL1 was filled out incorrectly, the MDSC or designee will reach out to the hospital caseworker and have them correct it.When it is determined that an individual's diagnosis was changed and/or a state surveyor determines the PL1 incorrect, the social worker designee will complete and submit a form 1012.

Based on interviews, observations and record review, the facility failed to ensure 2 of 6 residents (Resident #4 and Resident # 38) received services in the facility with reasonable accommodation of resident needs and preferences.The facility failed to respond to call lights in a timely manner on 08/19/2026 when Resident #4 had to wait 15 minutes for the call light to be answered, and on 08/20/2026 when Resident #38 had waited 22 minutes for the call light to be answered.This failure could place residents at risk of harm and/or isolation.Findings included: Record Review or Resident #4 face sheet revealed a [AGE] year-old male resident who admitted to the facility 05/04/2021 with diagnosis of acute combined systolic (congestive) and diastolic (congestive) heart failure (a severe condition where the heart's pumping and filling functions are simultaneously impaired, requiring urgent medical attention), other acute osteomyelitis, right ankle and foot (an infection in a bone. It can affect one or more parts of a bone. Infections can reach a bone through the bloodstream or from nearby infected tissue), type 2 diabetes mellitus with diabetic polyneuropathy (a chronic condition that occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin), acute pain due to trauma (sudden, intense pain that occurs immediately after an injury or physical insult to the body, serving as a protective warning signal of tissue damage). Record Review or Resident #4 MDS record date May 15, 2026, revealed that Resident #4 had a BIMS of 15, which indicated minimal cognitive impairment. The MDS also revealed that Resident #4 can independently complete the task of toileting and showering needs. Independent means to complete the activity by themselves with no assistance from a helper. An observation conducted on 08/19/2026 at 9:25AM to 9:40 AM revealed Resident #4's call light was activated above their door. No one came to answer the call light for 15 minutes. The state surveyor walked to the nurses' station to reveal 2 nurses sitting at the nurses' station. Record Review of Resident #38 face sheet revealed a [AGE] year-old male resident who admitted to the facility on [DATE] with diagnoses of unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), vascular dementia, mild with mood disturbance (is characterized by subtle cognitive decline due to reduced cerebral blood flow, often accompanied by depression, apathy, or emotional changes), difficulty in walking, not elsewhere classified (a gait or mobility impairment that cannot be attributed to a specific, previously defined medical condition), weakness (the quality or state of being weak). RR of Resident #38 MDS record dated 07/20/2026 revealed that Resident #38 had a BIMS of 15, which indicated minimal cognitive impairment. The record also indicated that Resident #38 can complete the task of toileting and showering needs with moderate assistance. Moderate assistance means the helper does less than half of the support. An observation conducted on 08/20/2026 at 3:45PM revealed Resident #38's call light was activated above their door. During the observation, the call light remained unanswered for 20 minutes, while staff were observed at the nurse's station. An interview was held on 08/21/2026 at 11:54AM with the CNA H who stated that training on call lights was given at new hire and then annually thereafter. If a call light goes off, answer it as soon as you can. You should always ensure it is in reach of the resident before you leave the room. In the training it stated anyone can answer a call light and the call light should be answered as soon as possible. She stated a reasonable amount of time the call light should be answered is no more than 5 minutes. CNA H stated no one should ever turn off a call light without providing help to the residents. A negative effect of not responding to a call light in a timely manner could be an emergency that they were left while they in need of help. It could be serious. An interview was held on 08/21/2026 at 12:27PM with the CNA I who stated that training on call lights was conducted for new hires and annually. The training included answering the call light as soon as possible but within 5 minutes. It also stated that anyone can answer the call light. CNA I stated no one should turn off a call light without providing help for the residents. If you don't respond to a call light in a timely manner, a resident could fall, die, they could be in distress. An interview was held on 08/21/2026 at 1:11PM with the CNA J who stated training is conducted on call lights upon hire and annually. In the training, it was stated to answer the call light within 5 minutes; if possible, anyone can answer a call light and answer it as soon as possible. CNA J stated she thinks 5 minutes is a reasonable amount of time to respond to a call light. She stated no one should enter a room and turn off the call light and not attend to the resident need. She stated the resident could have had a medical emergency and we couldn't get to it in time. An interview was held on 08/21/2026 at 1:35PM with the LVN D who stated training is conducted at hiring and periodically thereafter. Training included: it's everyone's responsibility to respond to the call light, call lights are within reach, call lights cannot be tied to the bed, promptness is expected, everyone can answer the call light. LVN D stated a couple of minutes is reasonable amount of time to respond to the call light. He stated no one should turn off a residents call light. LVN D stated that not responding to a call lights timely could be potentially life threatening. An interview was held on 08/21/2026 at 2:00PM with the DON who stated training is conducted at different frequencies, because of call light audits. Her expectations regarding answering call lights are for staff to answer them timely. DON stated everyone is responsible for answering call lights. DON stated the reason why staff would not answer the call light, is if the request was beyond what they could provide. She stated nobody should pass up a call light and no staff should turn off the call light without providing care. An interview was held on 08/21/2026 at 2:50PM with the ADM who stated that the facility policy for answering call lights was that anybody can answer a call light and should be done as soon as possible. The ADM stated that all employees are responsible for answering the call lights. He stated that the residents' needs would not be met if residents had to wait a long time for their call light to be answered. PUT THE POLICY INFORMATION ON HERERecord review of the facility's policy dated January 2025 indicated the following:1. Each resident is provided with a means to call staff from his/her bedroom or bathroom.2. Calls for assistance are answered timely.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of resident for 1 of 8 residents (Resident #1) reviewed for pharmacy services. LVN A failed to complete and document the administration of 10 separate physicians' orders for Resident #1 on 07/15/26 from 6PM to 1AM. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization. Findings include: Record review of Resident #1's face sheet, dated 07/22/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included epilepsy-unspecified-not intractable- without status epilepticus (chronic brain disorder characterized by recurrent unprovoked seizures caused by abnormal electrical activity in the brain), cerebral palsy (group of conditions that affect movement and posture caused by brain damage before birth), major depressive disorder- recurrent- severe without psychotic features (mood disorder that significantly impacts daily life marked by depressed mood lasting for at least 2 weeks), conversion disorder (psychiatric condition in which psychological stress manifests as real involuntary physical symptoms) with seizures or convulsions, intellectual disabilities, and gastritis (inflammation of the stomach lining). Record review of Resident #1's annual MDS assessment, dated 04/30/26, reflected a BIMS score of 0, which indicated severe cognitive impairment. Section I for active diagnosis reflected seizure disorder/ epilepsy and depression. Section J reflected a history of a scheduled pain medication regimen. Section K reflected Resident #1 had a feeding tube. Record review of Resident #1's care plan, last revised 05/08/26, reflected a focus on enhanced barrier precautions r/t requiring use of g-tube a focus of resident has consent on file for AEM, it is the resident/ representatives right to have the video monitoring in the facility a focus of the resident has impaired cognitive function/ dementia or impaired thought process r/t cerebral palsy a focus of [Resident #1] requires tube feeding r/t hx of choking, aspiration pneumonia, and decreased oral intake a focus of resident has dx gastritis a focus of Resident #1 uses mood stabilizer/ anticonvulsant medications r/t epilepsy with interventions that included administer mood stabilizer/ anticonvulsant medication as ordered by physician a focus of Resident #1 uses antidepressant medication with intervention administer antidepressant medications as ordered by physician a focus of Resident #1 has epilepsy with intervention give medications as ordered, monitor/document for effectiveness and side effects and a focus of the resident has potential for pain r/t chronic physical debility with intervention administer analgesia as per orders. Record review of Resident #1's physician orders reflected the following orders:Biofreeze External Cream 10 % (Menthol [Topical Analgesic]) Apply to right shoulder topically at bedtime for pain, with a start date of 05/27/26.Ascorbic Acid Tablet 500 MG Give 1 tablet via G-Tube two times a day for Supplement, with a start date of 06/03/23.CarBAMazepine Tablet Chewable 100 MG Give 3 tablet via PEG-Tube two times a day for Seizures, with a start date of 12/12/24.Keppra Oral Solution 100 MG/ML (Levetiracetam) Give 15 ml by mouth two times a day for Shake before use related to epilepsy, unspecified, not intractable, without status epilepticus, with a start date of 07/20/25.OcuSoft Lid Scrub Plus External Pad (Eyelid Cleansers) Apply to Both Eyes topically two times a day for removing debris, with a start date of 02/04/26.RisperDAL Oral Tablet 1 MG (Risperidone) Give 1 mg via PEG-Tube two times a day related to major depressive disorder, recurrent severe without psychotic features, with a start date of 02/10/26.Hot compress apply 1 to both eyes twice a day, two times a day, with a start date of 07/10/25.Simethicone Oral Tablet 80 MG (Simethicone) Give 1 tablet via G-Tube two times a day for gas/bloating, with a start date of 02/18/26.Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 1 tablet via PEG-Tube four times a day for mild pain, with a start date of 07/20/25.Check Gastric Residual Volume (GRV) every 4 hours and hold feedings if residuals are > than 250 ml. Return GRV to stomach and recheck in 4 hours. If enteral feedings was held for high GRV for 3 consecutive checks notify the physician for additional orders. every 4 hours with order start date of 06/02/23. Record review of Resident #1's medication administration record and the medication administration audit report provided by the DON for date 07/15/26, reflected the following medications were not documented as being administered:Biofreeze External Cream 10 % (Menthol [Topical Analgesic]) Apply to right shoulder topically at bedtime for pain, with a start date of 05/27/26. Not documented administered as scheduled ordered for 07/15/26 6p-1Ascorbic Acid Tablet 500 MG Give 1 tablet via G-Tube two times a day for Supplement, with a start date of 06/03/23. Not documented administered as scheduled ordered for 07/15/26 6p-1CarBAMazepine Tablet Chewable 100 MG Give 3 tablet via PEG-Tube two times a day for Seizures, with a start date of 12/12/24. Not documented administered as scheduled ordered for 07/15/26 6p-1Keppra Oral Solution 100 MG/ML (Levetiracetam) Give 15 ml by mouth two times a day for Shake before use related to epilepsy, unspecified, not intractable, without status epilepticus, with a start date of 07/20/25. Not documented administered as scheduled ordered for 07/15/26 6p-1OcuSoft Lid Scrub Plus External Pad (Eyelid Cleansers) Apply to Both Eyes topically two times a day for removing debris with a start date of 02/04/26. Not documented administered as scheduled ordered for 07/15/26 6p-1RisperDAL Oral Tablet 1 MG (Risperidone) Give 1 mg via PEG-Tube two times a day related to major depressive disorder, recurrent severe without psychotic features, with a start date of 02/10/26. Not documented administered as scheduled ordered for 07/15/26 6p-1Hot compress apply 1 to both eyes twice a day two times a day, with a start date of 07/10/25.Simethicone Oral Tablet 80 MG (Simethicone) Give 1 tablet via G-Tube two times a day for gas/bloating, with a start date of 02/18/26. Not documented administered as scheduled ordered for 07/15/26 6p-1Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 1 tablet via PEG-Tube four times a day for mild pain, with a start date of 07/20/25. Not documented administered as scheduled ordered for 07/15/26 early, bedtime 2 scheduled doses missed. Check Gastric Residual Volume (GRV) every 4 hours and hold feedings if residuals are > than 250 ml. Return GRV to stomach and recheck in 4 hours. If enteral feedings was held for high GRV for 3 consecutive checks notify the physician for additional orders. every 4 hours, with order start date of 06/02/23. Not documented administered as scheduled ordered for 07/15/26 1900 Record Review of Resident #1's progress notes reflected there was no evidence of the administration of refusal of the medications reviewed (listed above) by LVN A on 07/15/26. Record review of staffing schedule and hours worked reflected: LVN A clocked in on 07/15/26 from 17:55-06:28 (05:55 PM 07/15/26 -06:28 AM 07/16/26 working 11.5 hrs) agency LVN. During an interview on 07/22/26 at 11:38 AM with Resident #1's FM, he stated he monitored the resident via the in room camera and noticed the resident behaving differently on 07/16/26 to include an increase in shaking and agitation. He stated the only time this had happened in the past was when the resident missed medications and believed that medications were missed for 07/15/26. The FM stated he observed CNAs the night of 07/16/26 trying to calm him while performing incontinent care. The FM stated this was addressed with the ADM and DON, he did not believe they understood it was a concern with the medications and Resident #1's behavior changes as a result and not the care provided by the CNAs. During an interview and observation on 07/22/26 at 04:51 PM with the DON, she was asked to review the audit report with state surveyor and each of the orders missed (listed above). The DON was observed going through each of the orders and confirming through the review of the Medication Administration Audit report that they were not documented as administered on 07/15/26 by LVN A. The DON stated she was not aware the orders had not been administered for Resident #1 on 07/15/26. She stated she was alerted by Resident #1's FM that he had medication concerns, but she believed it was for medications on the weekend (07/18/26 to 07/19/26). She stated when she returned on 07/20/26 she did a medication audit for the weekend only (07/18/26 to 07/19/26) and it appeared those medications had been provided, she stated she did not review the ones for other days during that week to include the day they were missed on 07/15/26. The DON stated she expected medications to be administered per physician orders. She stated a potential negative outcome depended on the medication, she stated a negative outcome to missed carbamazepine could range from no issues to the potential for increased seizures, the negative outcome to Keppra could range from no negative effect to seizure she stated there would be no negative effect to missing the eye lid cleanser ordered because the resident has his face cleaned. She stated the Risperdal (antipsychotic) took 6-8 weeks to build in the system so she did not believe one dose would have a negative effect as it had reached therapeutic levels. She stated the missed simethicone negative effects could range from no effects to slight discomfort related to gas and bloating she stated missed acetaminophen doses could result in a range from no effects to the resident being in pain. The DON stated the purpose of the residual checks were to see how much stomach acid and content there was, depending on the amount it may need to be reported to the physician. She stated if they were not being completed it could result in discomfort or feeling of fullness. She once again reiterated it was the expectation staff were following the physician orders, double checking what was ordered and what is on hand, and making sure they have the correct documentation to include the right time, right resident, and if the medication required follow up to do so. She stated if there were behaviors or the resident refused the medication that would need to be documented as well. During an interview on 07/22/26 at 05:15 PM with LVN A, she stated she was an agency nurse. She stated she picked up quite a few shifts at the facility. She stated she recalled working with Resident #1 on 07/15/26 and stated she was assigned to him. She stated she believed she gave Resident #1 his medications and followed his order. She stated, I may not have clicked them off, but I know I passed those medications. She stated the facility had not personally done any training with her on medication administration or documentation requirements and said, I don't need that. She went on to say, we are human there's human errors. During an interview on 07/22/26 at 05:24 PM with the ADM, he stated it was his expectation that physician orders were followed and medications given when they were supposed to and stated they should also be documented. He stated a potential negative outcome to Resident #1's missed medications was the resident could have a seizure, pain and could have increased behaviors because of the medications not given. The ADM stated he had not heard concerns related to Resident #1's missed medications from the family, he stated he was alerted to the increased behaviors that occurred on 07/16/26 by the FM, and did see the room camera footage of the increased behaviors and CNAs working with him during incontinent care, but he stated he did not put those together and had not thought the increased behaviors could have been a result of the missed medications on 07/15/26. He stated he also did not get any alert from LVN A that they were not documented due to any resident refusal or behaviors. He stated he was not aware they were missed. He stated after seeing the video Resident #1's FM showed him, with the increased behaviors on 07/16/26, he did an in-service on the CNAs over incontinent care. He stated there had not been any in-services that he could recall on medication administration and none on documentation. Record review of the facility's policy Administering Medications last revised April 2019 reflected: Medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescribed orders, including any required time frame. Medication administration times are determined by resident need and benefit not staff convenience. Factors that are considered include enhancing optimal therapeutic effect of the medication, preventing potential medication or food interactions, and honoring resident choices and preferences consistent with his or her care plan. The individual administering the medication initials the residents MAR on the appropriate line after giving the medication and before administering the next one.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 1 facility reviewed for safe and homelike environment. The facility failed to ensure visitors or any unauthorized people did not have access to the facility at any time creating an unsafe environment for residents. The failure could place residents at risk of potential harm, and the resident feeling unsafe in the facility. Findings Included: Observation of the facility on 06/10/2026 at 3:45a.m., there were no staff in the front entrance of the facility or inside the lobby area. The surveyor rang the doorbell, and no one responded. The surveyor than called the after-hour number and did not identify herself. The surveyor asked the staff who answered the phone Can you open the door please? the staff on the phone did not ask the surveyor any questions she just gave the surveyor the code to the front door. The surveyor then entered the facility and was able to walk around the facility. No staff asked surveyor any questions. The surveyor went to the nurses station and Identified herself. Observation of the facility on 06/10/2026 at 7:00a.m., there were no staff in the front entrance or inside the lobby area. A nurse surveyor rang the doorbell, and no one answered. An employee with an outside lab service came from her car and entered the code to the door and let the nurse surveyor in. The lab staff member did not say anything to the nurse surveyor or ask her any questions before letting her in. The lab employee just opened the door let the surveyor in and walked away. During an interview with CNA G on 06/10/2026 at 3:50a.m., She said that she worked the overnight shift. She said there were normally two aides and a nurse on both sides of the building. During an interview with CNA H on 06/10/2026 at 4:06a.m., she said she worked the overnight shift. She said that the facility normally had two aides and a nurse on each side of the building. She said she thought there was enough staff on the overnight shift.During an interview with the ADM on 06/10/2026 at 6:02a.m., revealed he had been trained on resident rights. He said the policy for answering the door after hours was staff was to come to the front and ask the person their name and reason for visiting. He said staff were not to give the door code out. He said staff were the only ones authorized to have the code to the door. Homelike policy was requested. During interviews with confidential residents on 06/10/2026 between 5:23a.m., and 11:30a.m., revealed residents did not feel safe at the facility. One resident said, No I do not feel safe you never know who can walk in here. Another resident said No I do not feel safe because staff will open the door or give anyone the code to get in. Other residents also stated they did not feel safe. The residents said there are always people who come into the building day or night that should not have access. They said nothing has happened yet but they worry something will. During an interview with CNA C on 06/10/2026 at 9:32a.m., revealed she had been trained on resident rights. She said staff were responsible for keeping the residents safe. She said staff members were the only ones authorized to have the code to the door. She said the policy for visitors was staff were to greet them, ask who they were, and reason for visit. If after hours she said staff were to walk to the front entrance, ask the person their name and reason for visiting before letting them in. she said staff were not supposed to give the door code out. She said if staff gave the door code out it put the residents and staff in harm's way or a resident could get out. She said the ADM, DON and the nurse on duty was responsible for ensuring staff were not giving out the door code. She said they monitored by watching staff. She said she did not know who answered the phone or why the staff gave the surveyor the code. During an interview with MA F on 06/10/2026 at 5:14p.m., she said she had been trained on resident rights. She said all staff were responsible for keeping the residents safe. She said if someone was in the facility that she had never seen before she would greet them, ask the person if she can help them and see if she can find out the reason they were at the facility. She said only staff were authorized to have to code to the front door. She said if someone got the door code that was not authorized it could cause some dangerous things to happen. She also said a resident could get out. She said she did not know who monitored to ensure staff were not giving out the door code. She said she did not know why the staff member gave the surveyor the door code. During an interview with the DON on 06/10/2026 at 5:57p.m., she said she had been trained on resident rights. She said all staff were responsible for keeping the residents safe. She said the facility did not have a policy for giving out the door code. She said her expectation was for staff to greet the person and see if there was anything they could help the person with. She said staff should not give out the door code. She said if the door code was just given to anyone it could be someone off the streets that wanted to cause harm to staff and residents. She said she did not know what staff answered the phone and gave the code out. She did not know if anyone monitored to ensure the door code was not given out. She also said she did not know that residents did not feel safe due to people entering the building. During an interview with the ADM on 06/10/2026 at 7:01p.m., he said she had been trained on resident rights. He said all staff were responsible for keeping the residents safe. He said the facility did not have a policy for the door code. He said staff were to greet the visitor and ask their reason for visiting. He said staff should not give out the door code and staff were the only people who should have the door code. He said if the door code was given to unauthorized people who got access to the facility, someone could come in and harm residents and staff. He said staff were to walk to the front after hours and ask the person for the reason for the visit and their name. He added that if they had problems with the person they were to call the police. He said if the person did not want to give their name and reason for visiting staff should not allow the person inside. He said he did not find out what staff answered the phone and gave the code out. He said no one monitored to ensure the door code was not given out. He also said he did not know that residents did not feel safe due to people entering the building. Homelike policy was requested from the ADM on 06/10/2026 at 6:01a.m. and was not received upon exit. Record review of Visitation Policy dated 09/2022 revealed Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security, and/or rights of the facility's residents. Keeping the facility locked or secured at night with a system in place for allowing visitors approved by the resident. Record review of Resident Rights Policy dated 02/2021 revealed Residents had the right to be informed of safety or clinical restriction or limitations of visitation.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 10 residents (Resident #1, and Resident #2) reviewed for ADL care. The facility failed to ensure Resident #1 was not dirty and her hair was combed on 06/10/2026. The facility failed to ensure Resident #2 was changed every two hours on 06/10/2026. This failure could place residents at risk of embarrassment and diminished quality of life.Findings included: 1. Record review of Resident #1's face sheet dated 06/10/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included anemia (not healthy red blood cells), heart failure, muscle weakness, hemiplegia (paralysis and weakness on one side of the body that can affect the arms, legs, and facial muscles), respiratory failure, insomnia (difficulty sleeping), and cerebral edema (abnormal accumulation of fluid within the brain tissue.Record review of Resident #1's quarterly MDS assessment, dated 04/19/2026, reflected a BIMS score of 14, which indicated intact cognitive response. [Resident #1] was dependent on staff for personal hygiene (helper does all of the effort. Resident does none of the effort to complete the activity).Record review of Resident #1's care plan, dated 05/12/2026, reflected the following: Focus: [Resident #1] has an ADL self-care performance deficit related to debility.Goals: [Resident #1] will maintain current level of function in through the review date.Interventions: AM ROUTINE: [Resident #1] preferred dressing/grooming routine. BATHING/SHOWERING: Check and clean on bath day and as necessary. Report any changes to the nurse. [Resident #1] requires extensive assistance by (2) staff with shower. The care plan did not show the resident refused.During an observation of Resident #1 on 06/10/2026 at 08:10a.m., revealed she was lying in her bed. Her hands were dirty with a brown substance, her nails were unkept and her hair looked matted.Record review of Resident #1's shower log dated 06/2026 revealed Resident #1's shower days were Tuesday, Thursday and Saturday. The shower log also showed that her last shower was on 06/06/2026. The shower log did not show the resident refused her showers.During an interview with Resident #1 on 06/10/2026 at 08:11a.m., she said that she had been at the facility for five years. She said she had trouble with some of the aides, so she does not like to get up. She said she did not get her showers/bed bath regularly. She said her hair was matted and a rats nest and my anxiety is high lately. She said she would like to be cleaned and have her hair combed.2. Record review of Resident #2's face sheet dated 06/10/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included embolism and thrombosis (blood clots in blood vessels), chronic pain, weakness, heart failure, absences of right leg above knee, absence of left leg, sarcopenia (progressive and involuntary loss of skeletal muscle, mass, strength, and physical function) cognitive communication deficit (problems with communication), and malaise (feeling of general discomfort).Record review of Resident #2's quarterly MDS assessment, dated 03/18/2026, reflected a BIMS score of 13 which indicated intact cognitive response. The MDS revealed Resident #2 was Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity) for toileting hygiene. The MDS also revealed Resident #2 was not attempted on toileting transfer due to medical condition or safety concerns.Record review of Resident #2's care plan, dated 05/18/2026, reflected the following: Focus: [Resident #2] has an ADL self-care performance deficit related to Amputation, Limited Mobility.Goals: The resident will maintain current level of function in through the review date.Interventions: TOILET USE: The resident requires extensive to total assist by 1-2 staff for toileting.During an interview with Resident #2 on 06/10/2026 at 7:51a.m., he said the care was not so good. He said that there were times when the aides did not come to change him. He said on 05/28/2026 the aide took 3 1/2 hours to come change him. He said he did not like staying wet.During an interview with CNA B on 06/10/2026 at 8:18a.m., he said that he had been trained on ADL care. He said staff rounded on the residents every two hours. He said he was PRN and did not work at the facility very often to know if any residents complained about not getting hygiene or changed. He said he had only worked at the facility four times. He said if staff did not clean or change residents regularly the resident could have skin breakdown.During an observation of Resident #2 on 06/10/2026 at 1:34p.m., revealed CNA B was changing Resident #2. Resident #2's brief was soaked with urine.During an interview with CNA E on 06/10/2026 at 1:34p.m., she said she had been trained on ADL care. She said the policy for ADL care was the residents were supposed to get showers three times a week and be changed every two hours. She said she had residents who had complained about not getting their showers. She also said that the residents did complain about staff not changing their brief regularly especially at night. She said the CNA's were responsible for changing the residents every two hours and giving the residents their showers. She said if staff were not changing or giving the residents their showers the resident could have skin breakdown or an infection. She said the nurse monitored to ensure staff were changing the residents and giving the resident their showers. She said the nurse monitored by observations. She said she did not know why Resident #1 was dirty and her hair was matted. She said she did not know why Resident #2 had not been changed and was soaked with urine. During an interview with the DON on 06/10/2026 at 5:42p.m., said she had been trained on ADL care. She said her expectation was that the resident should be offered or given a shower three times a week. She added if the resident refused staff were to let the nurse know. She said staff were to change the residents every two hours or as needed. She said ultimately the CNAs were responsible for showering and changing the residents. She said if the residents were not getting showers or being changed it could potentially cause skin integrity issues or cause a UTI. She said the nurses monitored to ensure staff were showering and changing the residents. She said the nurses monitored by checking with the resident or checking the computer tasks page. She said that residents were still complaining about not getting showers and some were complaining they were not getting changed. She said she did not know why Resident #1 was dirty and her hair was matted. She added that Resident #1 did refuse showers at times. She said she did not know why Resident #2 was not changed and was soaked in urine when staff did change him. During an interview with the ADM on 06/10/2026 at 6:49p.m., he said he had been trained on ADL care. He said the policy was that the resident was to get a shower on their shower day and the resident should be changed every two hours. He said the aides should be checking the residents every couple of hours. He said the CNAs were responsible for giving the residents a shower and changing the residents every two hours. He added the nurses were to change the residents if the CNAs were not available. He said if the resident were not changed or showered like they were supposed to could cause the resident to have skin breakdown or other skin issues or wounds. He said the DON monitored to ensure staff were changing and showering the residents. He said the DON monitored by checking the computer for the shower documentation. He said showers and changing residents were discussed in the morning meetings. He said he had gotten complaints on residents not getting showers and being changed by staff recently. He said he did not know why the Resident #1 was not clean and had matted hair. He also said he did not know why Resident #2 was not changed and was soaked with urine. Record review of Activities of Daily Living (ADL), Supporting Policy dated 02/2025 revealed Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, including walking), and elimination (toileting).

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to 1 of 3 medication carts (MC #1) reviewed for drug storage and labeling.The facility failed to ensure MC #1, was locked, medications secured, and not accessible to other staff, residents, or visitors on 06/10/2026.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings include:During an Observation of the South Side Nurses Station on 06/10/2026 at 4:12a.m., revealed LVN A was in a resident's room and the medication cart was up against the nurses station unattended and unlocked.During an interview with LVN A on 06/10/2026 at 04:14a.m., she said she was trained on medication storage. She said the policy was staff must lock the medication carts any time the nurse walked away from the medication cart. She said the nurse or medication aide who was working on the cart was responsible for locking the medication cart. She said if staff left the medication cart unlocked and unattended a resident could get into the medication cart and take medication that did not belong to them. She said everyone monitored to ensure the medication carts were locked. She said everyone monitored the medication carts through observation. She said she left the medication cart unlocked because a residents kangaroo pump (medical device used for external feeding) was going off so she went to fix the pump.During an interview with the DON on 06/10/2026 at 05:23 p.m., she said she was trained on medication storage. She said the policy was the medication cart was to be locked when staff were not in sight or in reach of the medication cart. She said the nurse or the medication aide who was on the medication cart was responsible for ensuring the medication cart was locked. She said if the medication cart was left unlocked and unattended a resident could get into the medication cart and take medications. She said nurse leadership monitored to ensure staff locked the medication cart. She said nurse leadership were to monitor by doing observations and in-service training. She said she did not know why LVN A left the medication carts unlocked.During an interview with the ADM on 06/10/2026 at 06:49 p.m., revealed he was trained on medication administration. He said the policy for medication storage was that the medication cart was to always be locked. He said no matter what time of day the medication cart should be locked. He said the nurse or medication aide who was on the medication cart were responsible for ensuring the medication cart was locked. He said if the medication cart was left unlocked and unattended a resident could take medication that was harmful to them or an employee could steal medications. He said the DON or any management should be monitoring to ensure the staff were locking the medication cart. He said the DON and any management should be monitored by doing observations. He said she did not know why LVN A left the medication cart unlocked.Record review of Medication Labeling and Storage Policy, dated February 2023, reflected The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on record reviews and interviews, the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week and have a designated full time Registered Nurse to serve as the Director of Nursing on a full- time basis for 1 of 1 facility's reviewed for nurse staffing.1. The facility failed to have the services of an RN for 8 consecutive hours on 10/11/25, 10/12/25, 11/09/25, 11/22/25, 11/23/25, 11/27/25, 12/11/25, 12/14/25, 1/17/26, 1/18/26, 2/7/26, 2/8/26, 2/13/26, 3/1/26, 3/15/26, 3/24/26, 3/25/26, 3/27/26, 3/28/26, 3/29/26, 3/30/26, 3/31/26. 2. The facility failed to ensure they had a full-time DON licensed in Texas from 3/20/26-4/08/26.3. The facility failed to ensure a separate RN-serving as the charge nurse, was on duty for 8 consecutive hours on 1/2/26, 1/3/26, 1/4/26, 1/7/26, 1/8/26, 1/12/26, 1/13/26, 1/16/26, 1/20/26, 1/21/26, 1/22/26, 1/26/26, 1/27/26, 2/1/26, 2/9/26, 2/13/26, 2/16/26, 2/18/26, 2/20/26, 2/27/26, 3/4/26, 3/5/26, 3/16/26, 3/18/26, 3/20/26, when they utilized their DON as their RN on duty, and their census was above 60 residents. These failures could have placed residents at risk of not receiving adequate care or monitoring of staff that required the supervision or decision making of an RN. Findings included: Record review of the facility's FY Quarter 1 CASPER report revealed a trigger for No RN Hours for the following dates: 10/11/25, 10/12/25, 11/09/25, 11/22/25, 11/23/25, 11/27/25, 12/11/25, 12/14/25. Record review of the facility's timesheets for direct care staff payroll hours for the period from 10/11/25-12/14/25 revealed no evidence for the services of an RN for 8 consecutive hours on 10/11/25, 10/12/25, 11/09/25, 11/22/25, 11/23/25, 11/27/25, 12/11/25, 12/14/25. Record review of the facility's use of agency personnel revealed no RN's were utilized through an agency for shiftwork on 10/11/25, 11/09/25, 11/22/25, 11/23/25, 11/27/25, 12/11/25, 12/14/25.Record review of the facility's timesheets for direct care staff payroll hours for the period from 1/1/26 through 3/31/26 revealed no evidence for the services of an RN for 8 consecutive hours, on: 1/17/26, 1/18/26, 2/7/26, 2/8/26, 2/13/26, 3/1/26, 3/15/26, 3/24/26, 3/25/26, 3/27/26, 3/28/26, 3/29/26, 3/30/26, 3/31/26. Record review of a posted daily staffing sheet dated 3/27/26 with the facility name in the top right corner, revealed that for (RN) 6a-6p-0 Total Hours, 6p-6a-0 Total Hours indicated. In an interview on 4/7/26 at 6:59 PM with the ADM, he stated they had hired a DON who lasted for approximately 4 days, and they were currently in the process of interviewing for a new DON. He stated the CRN had been providing assistance to the facility, as well as serving as the infection preventionist, but was not serving as the DON, nor did they have an interim DON.In an interview on 4/7/26 at 8:36 PM the CRN stated that she was not serving as the facility's DON, rather she was overseeing the clinical systems to ensure things did not fall apart. She stated that she had physically been in the building on 3/20/26, 3/23-3/27/26, 3/30/26, 4/1-4/3/26, and 4/6/26. She stated prior to her being in the building there was a full-time DON employed. She stated that the only services she could think of that would not be provided because of no RN coverage onsite would be staging a wound. She stated that LVN's provided wound care at the facility and could administer IV medications.In an interview on 4/7/26 at 9:04 PM, LVN E stated she was an agency LVN, and she last worked at the facility about a month ago. She stated that not having an RN on duty did not affect her work, because she could call the RN. She stated she would be able to conduct assessments, and if it was something unusual, she would call the on-call NP. She stated if an RN was needed during her shift, she would just call them, and that it was just a nice comfort to have an RN there in person versus having to contact them. She stated she had not had any situations where she needed an RN or the DON onsite, they were always available by phone. In an interview on 4/7/26 at 9:25 PM RN D stated the RNs would do admission assessments and the LVN's were capable of doing other assessments. She stated initial education should be given by an RN, such as medication administration and then an LVN could do education after the initial RN education. She stated she reiterated to residents about using their call lights. She stated there had not been any new admits during the shifts she has picked up at this facility. She stated that a lot of times residents feel more confident, respected, or heard when they could request an RN and the RN goes to their room and gets what they need or supports them. In an interview on 4/8/26 at 10:47 AM the SC stated that she had worked at the facility for about 5 years and had been the SC for 1 year. She stated her responsibilities included staffing the building. She said if the facility was short staffed, she would work a shift as a CNA, as she was also a CNA. She said she also ensured the daily staffing sheets were filled out, and posted, kept up with absences, monitored the floors, and provided some training and competency check offs with CNA's. She stated the RN coverage was for supervising LVN's, CNA's, medication administration, breaks, and making sure everyone were doing what they were supposed to do, and making sure everyone was safe. She stated that the LVN's could pass medications, administer g-tube and peg tube medications, conduct skin assessments, and did charting. She stated they had a DON, and on 3/27/26 and 3/28/26 the facility did not have a DON. She said there were only LVN's, who were serving as charge nurses. She stated no RN had filled in for the DON since her departure on about 3/20/26. She stated the CRN physically worked in the building after the DON quit. She stated that they had just started utilizing agency RNs about 2 weeks ago. She stated if there was not an RN in the building, they could call the CRN and let her know. She stated a negative impact to residents could be that they did not feel confident in reporting their concerns due to there not being an RN supervisor. She stated nursing concerns were reported to the CRN. In an interview on 4/8/26 at 2:20 PM, the ADM said he began working at the facility on 2/9/26. He stated that he would be made aware that the facility would not have an RN on duty for at least 8 consecutive hours a day in the morning meetings daily where they went over staffing with the SC. They had realized that they skipped a couple days of reviewing staff once the DON left, but since then they had made sure they were doing everything they could to get an RN scheduled through agency. He stated he did not know if the company had a policy on having an RN serve as the DON when the facility was without one. When asked how often there were days, they had no RN available to provide care for residents, He stated that he was aware of 3/27/26 and 3/28/26 of days they had no RN on duty to provide care to residents. However, they had identified days from 2025 as well. He stated that PASRR care plan meetings had to have an RN present, and that they had about 10 PASRR positive residents, and did not identify any delays in PASRR care plans at the time. He stated that none of the care currently being provided in the facility was only doable by an RN.Review of the facility assessment dated 2026 revealed their overall staffing needs included 1 RN providing direct care. 2 RN's available to provide direct care-including DON and RNs with administrative duties. A staff to resident ratio of 1 RN to 30 residents, a RN coverage of 8 hours.

Based on interviews, observations, and record reviews, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 5 (Resident #1 and Resident #2) residents reviewed for dignity. The facility failed to ensure CMA A did not feed Resident #1 her medications from a pudding cup, while standing over her in the dining room on 4/7/26. The facility failed to ensure CNA B used person-centered language when she described Resident #2 as a feeder on 4/7/26. These failures could place residents at risk of shame and embarrassment.Findings included:Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who originally admitted to the facility on [DATE], with a re-entry date of 01/06/2026. Her diagnoses included pneumonia, hemiplegia or hemiparesis (paralysis or severe weakness affecting one side of the body), Traumatic Brain Injury, seizure disorder, respiratory failure, dysphagia (difficulty swallowing), cognitive communication deficit. Her functional ability of eating indicated she needed setup or clean-up assistance. Resident #1 had a BIMS score of 08, indicating moderately impaired cognition. Review of Resident #1's care plan revealed she had an ADL self-care performance deficit r/t TBI with hemiplegia and required supervision/setup assistance from staff, initiated 2/13/23. Her care plan also indicated she had a swallowing problem related to complaints of difficulty or pain with swallowing, coughing, or choking during meals or swallowing medications, difficulty with thin liquids initiated 5/5/23. Review of Resident #2's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included non-traumatic brain dysfunction, heart failure, Alzheimer's disease and seizure disorder. Her functional ability of eating indicated she needed setup or clean-up assistance. Resident #2 had a BIMS score of 03, indicating severe cognitive impairment. Review of Resident #2's care plan revealed she had an ADL self-care performance deficit r/t dementia and required substantial/maximum assistance from staff to eat, initiated 2/28/26.In an observation on 4/7/26 at 5:11 PM, CMA A was observed giving medication, while standing, to Resident #1, who was seated at a dining table in the dining room. CMA A was administering the whole medication using pudding, feeding Resident #1 the pudding until the cup was empty. In an interview on 4/7/26 at 5:15 PM CMA A stated it was not a typical practice to administer medications to residents while standing, and in the dining room during mealtimes. She stated she had been unable to locate Resident #1, so when she saw Resident #1 in the dining room, she decided to administer the medication, but that she should have been seated next to Resident #1 out of respect, until the entirety of the medication/pudding was administered.In an interview on 4/7/26 at 5:25 PM, CNA B stated that Resident #2 had already been fed, and she had fed Resident #2 because she was a feeder. CNA B acknowledged that was not a term she should have used to describe a resident, and that she should have used a more respectful term because that was not a dignified way to talk about a resident. In an interview on 4/7/26 at 9:25 PM, RN D stated staff should not be standing up while administering a medication that was given by way of food (pudding cup) or standing while feeding a resident. She stated typically staff should not be passing medications during meals, unless ordered, but it could also be a resident preference. She stated that it was a dignity issue to refer to residents as feeders because if residents, visitors, or family heard that it could upset them. In an interview on 4/8/26 at 2:20 PM, the ADM stated he began working at the facility on 2/9/26. He stated that staff should not be addressing residents by their diagnoses, and they should not be referring to residents as feeders, and it was important for dignity purposes, staff should not say personal information that others could hear. He stated that it could make someone feel ashamed, or embarrassed.Review of the facility's policy titled Dignity dated February 2021 reflected, .8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.

Based on, interview and record review, the facility failed to ensure residents are offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 1 (Resident # 1) reviewed for nutrition and hydration:The facility failed to follow Resident #1's physician orders for enteral feeding.This failure could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health. Findings include: Record review of Resident #1's face sheet dated, reflected an initial admission date of 6/02/2023 and a readmission date of 11/05/2024 with diagnosis that include UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION (Deficiency of protein and energy intake), DYSPHAGIA (difficulty swallowing), GASTRITIS, UNSPECIFIED, WITHOUT BLEEDING (Inflammation of the stomach lining), CEREBRAL PALSY(Abnormal brain development or injury),VITAMIN D DEFICIENCY, IRON DEFICIENCY. Record Review of Resident # 1's MDS assessment dated [DATE], reflected a BIMS of 99. The assessment reflected Resident # 1 required extensive assistance with ADLs. Resident # 1's weight was 161 pounds, and the resident's nutritional approach was feeding tube and mechanically altered diet. Record review of Resident #1's Order summary report dated 01/29/2026 reflected a physician order to administer at bedtime Nutren 2.0 @65ML/HR Continuously for 10 hours (8P-6A), providing 1300 kcal,55 gm protein, and 1650ml free water. The physical order had a start date of 11/26/2025 and no end date. Record review of Resident #1's weights from October 2025 to current reflected there was no weight loss for Resident # 1. Record review of progress note dated 1/28/2026 at 9:38am revealed the NP was notified that Resident #1's tube feeding was not done by night shift nurse. She ordered staff to encourage him to eat all his breakfast and to monitor any change in condition throughout day. Record review of meal intake dated 1/28/2026 reflected Resident #1 had eaten 75-100% of breakfast. In an Interview on 01/29/2026 at 1:15pm, the DON stated Resident #1 missed his nighttime tube feeding 1/27/2026 from 8pm-6am. She stated the night nurse did not give Resident # 1 his feeding. She stated the NP was notified and ordered staff to encourage Resident #1 to eat all his breakfast and monitor for any changes in his condition throughout the day. She stated her expectation was that the night nurse should have followed physician orders and given Resident #1 his nighttime tube feeding of Nutren 2.0 @65ML/HR continuously for 10 hours (8P-6A). She stated the potential risk of not following physician orders and not providing enteral feeding to a resident is weight loss or malnutrition. In an interview on 01/29/2026 at 3:20p.m., LVN A stated she did not follow physician orders for Resident #1 and failed to provide Resident #1's tube feeding of Nutren 2.0 @65ML/HR continuously for 10 hours (8P-6A) on 01/27/2026.She stated she got confused and thought Resident #1's feeding was to be done during the day shift. She stated that she should have double checked the physician orders. She stated that the potential risk of not following physician orders and not providing enteral feeding to a resident is the risk of malnutrition. She stated she has not worked in the facility since 01/27/2026 and had not received the in-service training yet.In an interview on 01/29/2026 at 5:23 p.m., the DON stated she was currently providing in-service training to staff over PEG tube, following physician orders and documentation. She stated to ensure Resident #1 did not miss anymore tube feedings, she was calling Resident #1's night nurse to ensure the tube feeding was done. She stated during the morning stand-up talks with staff she would remind them of tube feeding. In an Interview on 01/29/2026 at 5:42 p.m., LVN B stated he received in -service training over peg tube feeding, following physician orders, and documentation. He stated the negative outcome of not following physician orders and not providing tube feeding is the potential of weight loss. In an interview on 01/29/2026 at 6:00 p.m., LVN C she stated she received in -service training over PEG tube feeding, following physician orders, and documentation. She stated a negative outcome of not following physician orders and not providing tube feeding is the potential for weight loss and malnutrition. Record review of in-service records titled PEG tube, orders and documentation dated 01/29/2026 revealed LVN B, LVN #3 and DON completed the training. Record review of nutrition Risk assessment dated [DATE] at 10:02am reflected most recent weight of 168 pounds, Height of 64inches and BMI of 28.8. Record review of facility's current Enteral Nutrition policy and procedure dated November 2018 reflected Adequate nutritional support through enteral nutrition is provided to residents as ordered.

Based on observation, record review and interviews, the facility failed to ensure resident received adequate supervision to prevent accidents for 3 (Residents 1, 2, and 3) of 6 residents reviewed for supervision. The facility failed to ensure Resident #1 did not elope from the facility on March 26, 2022, February 1, 2025, and again on June 21, 2025. On June 21, 2025, resident #1 was seen on the corner of the facility near a stop sign of an unbusy street. The facility was unsure how the resident eloped. A root cause analysis was not completed to determine how the resident eloped. There were two other residents at the facility (Resident #2 and #3) who were at a high risk for elopement with no interventions to prevent the elopement. Intervention's not put in place include but are not limited to: Redirecting, placing on a one on one once staff has seen a behavior change until assist, and or talking to. This failure resulted in an identification of an (IJ) Immediate Jeopardy on July 22, 2025, at 08:25pm. The IJ Immediate Jeopardy template was provided to the ADM on July 22, 202 at 08:25pm. While the (IJ) Immediate Jeopardy was removed on July 23, 2025, at 3:45pm, the facility remained out of compliance at a scope of isolate and severity level scope of isolate and severity level of no actual harm because all staff had not been trained on elopement.This deficient practice could place residents at risk of elopements that could result in serious injury and death.Findings included: Resident #1A record review of Resident #1's face-sheet updated, reflected that he was a [AGE] year-old man admitted to the facility on [DATE], with a readmission on [DATE]. Resident 1 was admitted with diagnosis of Unspecified Dementia, Nontraumatic Intracerebral Hemorrhage, Unsteadiness on feet, Bradycardia, Heart Failure, Allergic Rhinitis, Cerebral Infraction, Vitamin D Deficiency, Benign Neoplasm of colon and Anima. A record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 6 which indicated severe cognitive impairment. Review of section GG- functional abilities indicated Resident #1 required moderate assistance for personal hygiene and was dependent for lower and upper body dressing, showering and toileting. Resident #1 required supervision or touching assistance to roll left and right, sit to lying, and lying to sit. Resident 1 required moderate assistance to sit to stand, chair to bed transfer, toilet transfer and tub/shower transfer. A record review of Resident #1's care plan from March,21,2025 reflected Resident #1 was an elopement risk. The goal was the resident's safety would be maintained through the review date. The Interventions were for staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. All CAN's will document wandering behavior and attempted diversional interventions in behavior log. All CNA's will Monitor resident for elopement attempts and for verbalizations of wanting to go home. A record review of Residents #1's Progress Notes reflected Resident #1 was an elopement risk and had over 21 wandering risk scale assessments completed throughout his stay at the facility. Resident 1 had eloped on March 2, 2022, February 2,2025 and June 21, 2025, while at the facility. A record review, of Residents #1's progress notes dated March 2, 2022, at 02:21pm entered by CNA B stated Appears that pt was let out of the building by someone entering as the door was locked but it was reported to this nurse that resident was outside in the parking lot. Initially he was not seen but he was near the end of the parking lot, looking out over the street. Asked if he was simply enjoying the sunshine he responded, No I'm trying to go home! Brought inside. Vitals assessed. ADON aware. Administrator aware. Phoned and spoke with [Residents #1's] [family member] who will come up to visit although I did make clear there were no injuries. Monitoring will be completed with resident location. A record review conducted on July 22, 2025, of residents #1'a progress notes dated June 21, 2025, entered by LVN A, resident #1 will discharged from the current facility and placed at a sister facility with a secure unit. A record review of Resident #1 progress notes dated June 22, 2025 at 02:21pm CNA B, reflected that Resident #1 was outside down the street at a stop sign by passerby who called facility to notify staff and also a residents family member from the North side notified staff of resident being outside. Resident brought back into facility by staff and assessed with no injuries.noted and vitals are 124/64,67,18,98.1. When asked where he was going, he stated to my brother's house. Resident taken to his room and placed into bed. 15-minute checks implemented at this time. DON, Administrator, and RP notified of incident. Plans in place to move resident to secure unit once consent from his daughter. Record review of the Wander Risk Scale assessment dated [DATE], at 06:31am reflected that Resident #1 score was a 9 indicating that Resident #1 is at a high risk to Wander. A telephone interview conducted on July 22,2025 at 3pm with LVN A reflected during shift change she received a call from a community member who had been passing by. A community member told her there was a man out by the stop sign sitting in a wheelchair with the facilities name on it. LVN A stated as she was talking to the community member on the phone, the TD A was approaching her pushing Resident #1. LVN A said she thanked the community member and disconnected the call. LVN A said TD A told her she was leaving from the facility when someone told her a resident was sitting in front of the facility near the stop sign. LVN A stated she asked Resident #1 where he was going and he responded, I was going to my [family member] house. LVN A said she completed a head-to-toe assessment and found no injuries or heat exhaustion. She said she then called RN A to inform her on what happened. LVN A said she also called Resident #1's family member, however she did not answer. LVN A was advised by RN A to put Resident #1 on 15min checks. LVN A said she was given an elopement and abuse and neglect in-service. LVN A stated Resident #1 could have received life threatening injuries from being unsupervised during his elopement. An interview conducted on July 22, 2025, at 03:36pm, with TD A reflected she was leaving for the day when she was told by a resident that a man was in a wheelchair was seen near the stop sign. She said she located the resident and seen that it was Resident #1. TD A said she then approached him and returned him to the south side, which was where his room was located. TD A said she took Resident #1 to LVN A who took Resident #1 to complete a head-to-toe assessment. She said that she has never seen Resident #1 elope before. TD A said she received an in-service the next day about elopement and what to do. She said the facility handled the situation in a timely matter and she had no concerns. An interview and observation on July 22,2025 at 11:57am with CN A reflected LVN A got a call from a community member saying they saw someone in a wheelchair with the facility's name on it. TD A and LVN A went to get the resident and completed assessment and found no injuries, his temperature was fine, and he was not over heated. She said that she instructed LVN A to place Resident # 1 on a one-on-one observation, until he was discharged to a sister facility, the next day around 1pm on June 24, 2025. CN A said LVN A informed her she notified the family. CN A said while she was reviewing residents #1's progress notes she noticed resident #1 has eloped before in February. CN A said she believed the resident was found under the awning in front of the building and brought back inside. She stated she did not know why he was not transferred out of the facility at that time. CN A said she was unable to discuss this with the ADM on site at that time because he was no longer the ADM at the facility. CN A said according to the notes she read after the elopement in February, there was no health concerns were found. CN A stated that during the morning meeting's staff discuss residents who are high wonder risk. She said that in the resident's care plans is where staff will find how long a one on one should be. She said the building was not equipped with a wonder guard or alarm system due to cost. CN A said the front door had a code that must be entered to exit and enter the building. She said both incidents took place after hours and at that time there was no one monitoring the doors. CN A stated thought Resident #1 may have eloped by a family member(visitor) letting him out. CN A revealed the facility gave all new residents a Wandering Assessment scale risk, and they are all considered to be a high elopement risk if they are ambulatory or diagnosed with Alzheimer's or dementia. An interview in on July 22, 2025, at 03:19pm with ADON A, reflected she was not present when the incident took place. She stated when she was informed of it, she offered to sit with Resident #1 and provide one on one supervision. She arrived at the facility at 12am on June 22, 2025, and relieved a fellow employee who she did not remember the name of the employee. ADON A said she had never known of Resident #1 to elope prior to this situation. She said when she asked Resident #1 why he left the facility, he would not say how he got out of the door. ADON A said when a resident was at high risk of elopement, they are placed on a two-hour check, if their behavior was persistent, they are placed on a one on one or 15min check. ADON A said there was a binder kept at every nurse's station with the residents who are at risk of elopement. She said there was a receptionist at the front of the building from 8:30am to 5pm on the weekdays and a MOD that worked the front for four hours on the weekend. She reported the door has a lock code to enter and exit that was on 24hours a day. Resident #2A record review, of Residents 2's face sheet undated, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #2 was admitted with diagnosis of wedge compression fracture of second lumbar vertebra, Type 2 diabetes, muscle weakness, displaced fracture of base of neck of left femur, vascular dementia and weakness. A record review of Resident #2's quarterly MDS assessment dated [DATE]th, 2025, reflected she had a BIMS score of 4 which indicated severe cognitive impairment. Review of section G revealed Resident #2 required extensive assistance with bed mobility, transfers, eating and toilet use. A record review of Resident #2's care plan dated June 23, 2025, reflected the following focus areas:*Resident #2 was a wander risk without exit seeking behaviors. The goal of the facility was to maintain Resident's #2 safety throughout her next review date. The interventions were to monitor her behavior for exit seeking behaviors every shift and to distract Resident #2 from wandering by offering pleasant diversions, structure activities, food, conversation, television or a book. *Resident #2 was dependent on staff for meeting emotional, intellectual, physical, and social needs. *Resident #had an ADL self-care performance deficit due to a left femur fracture. *Resident #2 had an impaired cognitive function and dementia.No other interventions were put into place such as 2-hour check or 15 minutes if needed. In an attempted interview with Resident #2 on July 23,2025 at 3:23pm. Resident #2 refused to be interviewed. A record review of Resident #2 Wander Risk Scale-V3 dated June 23, 2025, 1:23pm, reflected that her score is a 13, indicating that she a high risk to wander. Resident #3A record review of Resident #3's factsheet undated, reflected that she was a [AGE] year-old female admitted to the facility on [DATE] with a readmission on [DATE]. Resident #3's was admitted with diagnosis of cerebral palsy, aphasia, COVID-19, epilepsy, cognitive communication, quadriplegia, and a conduct disorder. A record review of Residents #3's quarterly MDS assessment dated [DATE], reflected Residents #3's BIMS score was unable to be completed, due to server cognitive impairment. Furter record review of section GG on the MDS reflected the resident had an impairment on both sides of her body and required a wheelchair to get around. The resident required total assistance with bathing, dressing, personal hygiene transfers. A record review of Residents #3's care plan dated June 23, 2025, reflected she was a wanderer without exit seeking behaviors. The goal of the facility was to maintain Resident #3 safety throughout her next review date. The interventions in place are to monitor her behavior for exit seeking behaviors every shift and to distract Resident #3 from wandering by offering pleasant diversions, structure activities, food, conversation, television or a book. As well as maintain visual checks every two hours. The care plan reflected that Resident #3 has impaired cognitive function/dementia or impaired thought processes. No other interventions were put into place such as 2-hour check or 15 minutes if needed. A record review of Resident #3 Wander Risk Scale-V3 dated June 23, 2025, 1:23pm, reflected that her score is a 11, indicating that she a high risk to wander. An interview conducted on July 22, 2025, at 03:49pm with the DON reflected her expectations of staff were to call her when a resident eloped. She said since she arrived on June 30, 2025, her practice has been that once a new resident enters the facility, she personally completes a Wander Risk Assessment. The DON stated if a resident was a high risk of elopement, but showing no behaviors, then she has them on two-hour checks. She stated if the resident's behavior become evident of higher risk of elopement, then the resident was placed on a one on one- or 15-min check. The DON reported currently Resident #2, and Resident #3 were on high risk of elopement. Interventions are currently in place. The interventions include behavior monitoring on every shift for exit seeking behaviors, and distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, or what the residents prefers. DON A stated at this time Resident #3 was labeled as discharged in electronic medical record due to her being out of the facility on a family pass since July 20, 2025. The DON stated she received an in-service on July 22,2025, for wandering. Facility's Wandering and Elopement policy dated March 2022, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. An (IJ) Immediate Jeopardy was identified on July 22, 2025at 08:25pm., due to the above failures. The ADM was notified on July 22, 2025. The ADM was provided with the (IJ) Immediate Jeopardy template on July 22, 2025, at 08:30pm, and a Plan of Removal (POR) was requested.A plan of removal was first submitted by the Regional Nurse on July 22, 2025. The plan of removal was accepted on July 23, 2025, at 03:25pm.Plan of Removal Date Initiated: July 22, 2025The faculty must ensure that each resident received adequate supervision to prevent accidents. The facility failed to ensure Resident #1 did not elope from the facility in February 2025 and again on June 21, 2025. With a change in condition the facility could have prevented elopement.Residents at risk for elopement could be affected by this deficient practice. Action: An Inservice was provided to the DON and Administrator by the Regional Director of Clinical Services regarding missing resident/elopement procedures, resident identification binder, and hourly rounding on those residents identified as high risk. Comprehension will be verified by return verbal summary of the education presented and attendance will be monitored via an Inservice signature log.Person(s) Responsible: RDCSDate: July 22, 2025 Action: An Inservice was provided to direct care staff regarding missing resident/elopement procedures and residents in the elopement identification binder prior to the beginning of their shift. Comprehension will be verified by return verbal summary and attendance will be monitored via an Inservice signature log. Those staff who are PRN or on PTO, LOA, or FMLA will receive the education prior to their next scheduled shift.Person(s) Responsible: DON/DesigneeDate: July 23, 2025 Action: Residents identified to be at high risk will be placed in an elopement identification binder placed at the nursing stations and front desk. The elopement identification binder will contain the resident profile and a picture. Person(s) Responsible: Maintenance Director/DesigneeDate July 22, 2025Action: All licensed nursing staff will be educated prior to the beginning of the next scheduled shift regarding conducting hourly rounds for those residents identified as high risk. Comprehension will be verified by return verbal summary of the education presented and attendance will be documented via an Inservice signature log. Those staff who are PRN or on PTO, LOA, or FMLA will receive the education prior to their next scheduled shift. Person(s) Responsible: Charge NurseDate: July 22, 2025Action: Wandering Risk Assessments will be conducted upon admission, quarterly, or with new wandering behavior. Those identified as high risk will have applicable interventions initiated. Person(s) Responsible: DON/DesigneeDate: July 22, 2025Action: All residents at high risk and listed in the elopement identification binder will be reviewed daily in the morning meeting process and in the weekly We Care Meeting to review for exit seeking behaviors.Person(s) Responsible: DON/DesigneeDate: July 22, 2025 Action: All residents identified as high risk will have all applicable interventions documented on their care plan. Person(s) Responsible: DON/DesigneeDate: July 22, 2025 Action: Signage has been placed on public access door prompting Please check with staff before letting any resident out of the building alone.Person(s) Responsible: ADMDate: July 22, 2025 Action: The RDCS will audit the missing entries report once weekly x 8 weeks to ensure compliance with hourly visual and behavior monitoring checks. The RDCS will randomly select three staff members weekly to ensure compliance within servicing x 8 weeks. The RDCS will attend one weekly We Care Meeting to ensure compliance with weekly monitoring. Person(s) Responsible: RCDSDate: July 22, 2025 Action: A root cause analysis was conducted by the Ad Hoc Committee members. It was determined that the root cause was as follows: Multiple leadership changes have resulted in educational deficiencies for a high turnover staff population regarding the elopement policies, appropriate interventions for those with wander/exit seeking behaviors, and notification of the Admin/DON regarding wandering/exit seeing behaviors. Person(s) Responsible: IDT Date: July 22, 2025Action: An Ad Hoc QAPI was conducted to complete a root cause analysis and review the plan of removal with IDT team and Medical Director. Person(s) Responsible: AdministratorDate: July 22, 2025 Monitoring on July 23, 2025, included the following:Observation made on July 23, 2025, at 09:50am of sign on front for out and inside of facility asking that all visitors and staff check with staff at desk before letting any resident out of the facility alone. Observation made on July 23, 2025, at 10:05am of alarm on 12 exit doors. All alarms functioning properly. Interview and record review on July 23rd, 2025, at 10:23am with ADM revealed he observed maintenance completing emergency door checks that morning. ADM stated the code to the front door changes when it needs to be. ADM Provided a log of signed log's indicating that a member of maintenance had in fact conducted door checks every morning for the last six months. Interviews conducted from July 22, 2025, through July 23, 2025, between 11:30am and 2pm, with LVN B, CNA A, CNA B and ADON B, reflected they had all been in-serviced on July 22, 2025, on wandering. They stated there was a red binder at every nurse's station and in front at the receptionist desk with the high risk of elopement residents. They said they have all been informed that when a resident was at high risk of elopement, they need to have eye's laid on them every hour. LVN B, CNA A, CNA B and ADON B stated that they have no concerns regarding the facility and the supervision of the residents. Interview on July 23, 2025, at 12:07 with CNA C reveled her last in-service was July 23, 2025, on wandering. She said during the in-service she was reminded the binder with high risk for wandering binder was red and was placed at every nurse's station. She said she learned new ways to stop a resident from elopement such as talking to them, making sure someone always has an eye on them or keeping them busy when wandering behavior was evident. Interview on July 23, 2025, at 02:46m ADON B reveled she received her last in-service on wandering July 23, 2025. She said that her definition of eloping was when a resident was attempting to try to get out of the facility. ADON B stated when she sees a resident attempting to elope, she plans to stay with the resident for one and one and do a one. She stated she will then contact the DON and receive further instructions. ADON B said there was a high-risk monitoring binder with the high-risk wanders in the book that was kept at each of the nurse station and the front desk. ADON said some signs of wandering behavior she will look for will include a resident stating that they want to go home over and over, staying near the door, and or appearing anxious.Interview on July 23, 2025, at 02:55pm with RN A reveled she had in serviced all staff on wandering and how to detect wandering behavior in residents. She stated a resident must present signs of elopement once before she expected staff to let her, or the DON know so the resident's behavior can be assessed. Record review on July 23, 2025, at 03:01pm reflected the updated care plan of Resident 2 and Resident 3 and been updated to reflect being checked on every hour as opposed to every two hours. Record review on July 23, 2025, at 3:05pm of QAPI reflected the root cause for residents' elopement was due to multiple leadership changes have resulted in educational deficiencies for a high turnover staff population regarding the elopement policies, appropriate interventions for those with wander/exit seeking behaviors, and notification of the Admin/DON regarding wandering/exit seeing behaviorsThe facility will ensure that residents who exhibit wandering behavior and /or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care.On July 23, 2025, at 03:45pm, the ADM was informed the (IJ)immediate Jeopardy was removed. While the (IJ) Immediate Jeopardy was removed on July 23,2025 the facility remained out of compliance at a scope of isolate and severity level of no actual harm because all staff had not been trained on elopement.Findings included:This was an abbreviated /extended survey, and the sample was increased. Resident #1A record review of Resident #1's face-sheet updated, reflected that he was a [AGE] year-old man admitted to the facility on [DATE], with a readmission on [DATE]. Resident 1 was admitted with diagnosis of Unspecified Dementia, Nontraumatic Intracerebral Hemorrhage, Unsteadiness on feet, Bradycardia, Heart Failure, Allergic Rhinitis, Cerebral Infraction, Vitamin D Deficiency, Benign Neoplasm of colon and Anima. A record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 6 which indicated severe cognitive impairment. Review of section GG- functional abilities indicated Resident #1 required moderate assistance for personal hygiene and was dependent for lower and upper body dressing, showering and toileting. Resident #1 required supervision or touching assistance to roll left and right, sit to lying, and lying to sit. Resident 1 required moderate assistance to sit to stand, chair to bed transfer, toilet transfer and tub/shower transfer. A record review of Resident #1's care plan from March,21,2025 reflected Resident #1 was an elopement risk. The goal was the resident's safety would be maintained through the review date. The Interventions were for staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. All CAN's will document wandering behavior and attempted diversional interventions in behavior log. All CNA's will Monitor resident for elopement attempts and for verbalizations of wanting to go home. A record review of Residents #1's Progress Notes reflected Resident #1 was an elopement risk and had over 21 wandering risk scale assessments completed throughout his stay at the facility. Resident 1 had eloped on March 2, 2022, February 2,2025 and June 21, 2025 while at the facility. A record review, of Residents #1's progress notes dated March 2, 2022 at 02:21pm entered by CNA B stated Appears that pt was let out of the building by someone entering as the door was locked but it was reported to this nurse that resident was outside in the parking lot. Initially he was not seen but he was near the end of the parking lot, looking out over the street. Asked if he was simply enjoying the sunshine he responded, No I'm trying to go home! Brought inside. Vitals assessed. ADON aware. Administrator aware. Phoned and spoke with [Residents #1's] [family member] who will come up to visit although I did make clear there were no injuries. Monitoring will be completed with resident location.A record review of Resident #1 progress notes dated July 22, 2025 at 02:21pm CNA B, reflected that Resident #1 was outside down the street at a stop sign by passerby who called facility to notify staff and also a residents family member from the North side notified staff of resident being outside. Resident brought back into facility by staff and assessed with no injuriesnoted and vitals are 124/64,67,18,98.1. When asked where he was going, he stated to my brother's house. Resident taken to his room and placed into bed. 15-minute checks implemented at this time. DON, Administrator, and RP notified of incident. Plans in place to move resident to secure unit once consent from his daughter. Record review of the Wander Risk Scale assessment dated [DATE] at 06:31am reflected that Resident #1 score was a 9 indicating that Resident #1 is at a high risk to Wander. A telephone interview conducted on July 22,2025 at 3pm with LVN A reflected during shift change she received a call from a community member who had been passing by. A community member told her there was a man out by the stop sign sitting in a wheelchair with the facilities name on it. LVN A stated as she was talking to the community member on the phone, the TD A was approaching her pushing Resident #1. LVN A said she thanked the community member and disconnected the call. LVN A said TD A told her she was leaving from the facility when someone told her a resident was sitting in front of the facility near the stop sign. LVN A stated she asked Resident #1 where he was going and he responded, I was going to my [family member] house. LVN A said she completed a head-to-toe assessment and found no injuries or heat exhaustion. She said she then called RN A to inform her on what happened. LVN A said she also called Resident #1's family member, however she did not answer. LVN A was advised by RN A to put Resident #1 on 15min checks. LVN A said she was given an elopement and abuse and neglect in-service. LVN A stated Resident #1 could have received life threatening injuries from being unsupervised during his elopement. An interview conducted on July 22, 2025, at 03:36pm, with TD A reflected she was leaving for the day when she was told by a resident that a man was in a wheelchair was seen near the stop sign. She said she located the resident and seen that it was Resident #1. TD A said she then approached him and returned him to the south side, which was where his room was located. TD A said she took Resident #1 to LVN A who took Resident #1 to complete a head-to-toe assessment. She said that she has never seen Resident #1 elope before. TD A said she received an in-service the next day about elopement and what to do. She said the facility handled the situation in a timely matter and she had no concerns. An interview and observation on July 22,2025 at 11:57am with CN A reflected LVN A got a call from a community member saying they saw someone in a wheelchair with the facility's name on it. TD A and LVN A went to get the resident and completed assessment and found no injuries, his temperature was fine, and he was not over heated. She said that she instructed LVN A to place Resident # 1 on a one-on-one observation, until he was discharged to a sister facility, the next day around 1pm on June 24, 2025. CN A said LVN A informed her she notified the family. CN A said while she was reviewing residents #1's progress notes she noticed resident #1 has eloped before in February. CN A said she believed the resident was found under the awning in front of the building and brought back inside. She stated she did not know why he was not transferred out of the facility at that time. CN A said she was unable to discuss this with the ADM on site at that time because he was no longer the ADM at the facility. CN A said according to the notes she read after the elopement in February, there was no health concerns were found. She said the building was not equipped with a wonder guard or alarm system due to cost. CN A said the front door had a code that must be entered to exit and enter the building. She said both incidents took place after hours and at that time there was no one monitoring the doors. CN A stated thought Resident #1 may have eloped by a family member(visitor) letting him out. CN A revealed the facility gave all new residents a Wandering Assessment scale risk, and they are all considered to be a high elopement risk if they are ambulatory or diagnosed with Alzheimer's or dementia. An interview in on July 22, 2025, at 03:19pm with ADON A, reflected she was not present when the incident took place. She stated when she was informed of it, she offered to sit with Resident #1 and provide one on one supervision. She arrived at the facility at 12am on June 22, 2025 and relieved a fellow employee who she did not remember the name of the employee. ADON A said she had never known of Resident #1 to elope prior to this situation. She said when she asked Resident #1 why he left the facility, he would not say how he got out of the door. ADON A said when a resident was at high risk of elopement, they are placed on a two-hour check, if their behavior was persistent, they are placed on a one on one or 15min check. ADON A said there was a binder kept at every nurse's station with the residents who are at risk of elopement. She said there was a receptionist at the front of the building from 8:30am to 5pm on the weekdays and a MOD that worked the front for four hours on the weekend. She reported the door has a lock code to enter and exit that was on 24hours a day. Resident #2A record review, of Residents 2's face sheet undated, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #2 was admitted with diagnosis of wedge compression fracture of second lumbar vertebra, Type 2 diabetes, muscle weakness, displaced fracture of base of neck of left femur, vascular dementia and weakness. A record review of Resident #2's quarterly MDS assessment dated [DATE]th, 2025, reflected she had a BIMS score of 4 which indicated severe cognitive impairment. Review of section G revealed Resident #2 required extensive assistance with bed mobility, transfers, eating and toilet use. A record review of Resident #2's care plan dated June 23, 2025, reflected the following focus areas:*Resident #2 was a wander risk without exit seeking behaviors. The goal of the facility was to maintain Resident's #2 safety throughout her next review date. The interventions were to monitor her behavior for exit seeking behaviors every shift and to distract R

Based on interviews and record reviews the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #66) of 1 resident reviewed for significant medication errors. The facility failed to ensure Resident #66 received the prescribed anti-convulsant medication on 6/9/2025 and 6/10/2025. Resident #66 had seizure-like activity, was transferred to the ED, and remained admitted at the hospital for diagnosis of seizure. An Immediate Jeopardy (IJ) situation was identified on 6/12/2025. While the IJ was removed on 6/13/2025, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of serious harm, up to and including death. Findings Include: A record review of Resident #66's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #66 had diagnoses which included cerebral infarction (a condition where brain tissue dies due to lack of blood supply), seizures (temporary disruptions of brain activity, convulsions, loss of consciousness), and nontraumatic intracerebral hemorrhage in brain stem (a serious type of stroke caused by bleeding in the brain stem). A record review of Resident's #66's MDS, dated [DATE], reflected no BIMS score for Resident #66. A record review of Resident #66's Medication Administration Records dated 6/9/2025 and 6/10/2025 reflected Resident #66 missed the scheduled doses of Lacosamide 150 mg tablet on 6/9/2025 at 5:00 PM and 6/10/2024 at 8:00 AM. A record review of Resident #66's facility progress note, dated 6/11/2025 at 5:55 PM, reflected Resident #66 was observed with twitching in her face and jaws and had turned her head to the left. The NP was notified and ordered the transfer to the ED. On 06/13/2025 at 2:40PM a Record Review of the hospital History and Physical signed on 06/13/2025 at 3:24AM was conducted. Diagnoses were listed as Acute on Chronic hypercapnic (too much carbon dioxide in the bloodstream) and hypoxemic (a condition where there is low oxygen in the blood) respiratory failure, Acute metabolic encephalopathy (a brain disorder caused by chemical imbalances in the blood, often stemming from underlying medical conditions or organ dysfunction), Seizure Disorder. Record Review of an additional History and Physical dated 06/12/2025 revealed a reason for admission as Acute Hypercapnic Respiratory Failure. Record review of the anticonvulsant therapy read as follows: Patient has been so far treated for seizure with Keppra and Vimpat (loaded with 1.5g Keppra initially the started on 500mg twice daily (then further loaded with an additional 3.5g Keppra). Keppra was increased to 1.5g twice daily and Vimpat to 200mg twice daily and was placed on EEG (a test that measures and records the electrical activity of the brain. Upon MICU evaluation patient was very somnolent, only grimaced to sternal rub so she was brought to the ICU for acute hypercapnic respiratory failure and encephalopathy due to multiple reasons. Plan from Neurology read as follows: #Metabolic encephalopathy worsening Multifactorial Ongoing seizures, post-ictal state, and seizure medications Hypercapnia No seizure of EEG per Neuro tonight Likely worsened by hypercapnia Continue EEG and AEDs Continue AVAPS for now During an interview on 6/12/2025 at 11:30 AM, the Regional Director of Clinical Services stated Resident #66 was transferred to the ED on 6/11/2025 at 6:30 PM for suspected seizure activity. Upon further investigation, she discovered Resident #66 missed two consecutive doses of Lacosamide 150 mg tablet, an anti-convulsant medication. The first missed dose was 6/9/2025 at 5:00 PM and the second missed dose was on 6/10/2025 at 8:00 AM. During a phone interview on 6/12/2025 at 2:16 PM, RN D stated LVN I processed the original readmission orders for Lacosamide tablets which the facility did not have on hand. The agency nurse entered the wrong medication administration times in the system, and the resident missed the evening dose on Monday. RN D stated on the morning of 6/10/2025 he discovered the tablet form was ordered as opposed to the liquid form of the medication, called the NP to report the discrepancy and asked if the order should be changed to the liquid form. RN D stated the NP returned his call around lunchtime which was too late to administer the morning dose of medication. During an interview on 6/12/2025 at 2:30 PM with RN E, she stated she readmitted the resident on 6/09/2025, upon Resident #66's return from the hospital. RN E stated she entered the first two pages of medication orders and LVN I entered the last two pages of the medications order. Resident #66 should have received the evening dose of Lacosamide on 6/9/2025. The hospital discharge document stated the resident received the last dose of Lacosamide on the morning of 6/9/2025. During an interview on 6/12/2025 at 3:15 PM, the Medical Director stated the missed doses of Lacosamide for Resident #66 could have contributed to Resident #66's seizure like activity. A record review of Resident #66's physicians' order entry for 6/09/2025 reflected an order for Lacosamide Oral Tablet 150 mg one tablet twice daily for seizures entered by LVN A. A record review of Resident #66's hospital Discharge summary, dated [DATE], reflected an order for Lacosamide 150 mg tab by g-tube route two times a day, morning, and bedtime. A record review of the facility's, undated, policy named, 9.3 Medication Administration reflected: 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. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. This was determined to be an Immediate Jeopardy (IJ) on 6/12/2025 at 5:25 PM. The ADM and RDCL were notified. The ADM was provided with the IJ template on 6/12/2025 at 5:51 PM. The following Plan of Removal submitted by the facility was accepted on 6/13/2025 at 12:15 PM. Summary of Details which lead to outcomes: On 6/10/25 an annual re-certification survey was initiated at [NAME] Inn Nursing and Rehabilitation. On 6/12/25 at 6:41 PM the surveyor provided an immediate Jeopardy template notification that Regulatory Service has determined that the condition at the facility constitutes an immediate threat to the residents' health and safety. F760 - The facility failed to keep the residents free from significant medication errors. The facility failed to ensure Resident #1 received the prescribed anti-convulsant medication on 6/9/25 and 6/10/25. Identify residents who could be affected: A total of eleven residents who receive anticonvulsant medications for seizure disorders have the potential to be affected. Identify responsible staff/ what action taken: Start date: 06/12/2025 Completion date: 06/12/2025 Responsible: Regional Director of Clinical Services Action: The Regional Director of Clinical Services provided education to the Assistant Director of Nursing and the Administrator regarding the completion of the admission checklist during the morning meeting process. Beginning on 6/11/25, medication orders will be entered into the EMAR system for all new admissions and readmissions by a member of the nursing leadership team within 4 hours of the resident's arrival from this date forward. During an interview with the ADON on 06/13/2025 at 2:32PM the ADON stated she was trained on the task of needing to enter the admission orders within 4 hours of the resident's arrival for admission to the facility. Start date: 06/11/2025 Completion date: Initial in servicing completed on 6/12/25 and ongoing. Responsible: Assistant Director of Nursing/Designee Action: In-service training provided to all licensed nurses and certified medication aides regarding the process for unavailable seizure medications. If an anticonvulsant medication is unavailable and not in the Stat safe, the nurse is to notify the pharmacy and nursing administration. If a certified medication aide finds an anticonvulsant medication to be unavailable, they are to notify the charge nurse. If a dose is missed, the nurse is to notify the provider. All PRN staff, and those on PTO, LOA, or FMLA, will receive in-service training prior to their next scheduled shift. This training will be provided as part of the new employee orientation for all licensed nurses and certified medication aides. Start date: 6/11/25 Completion Date: 6/12/25 Responsible: Regional Director of Clinical Services Action: An audit was completed for all residents prescribed anticonvulsants for seizure disorders to ensure that medications were available for administration and orders were accurate. No further unavailable medications or transcription errors were found. During record review and interview with the RDCS on 06/13/2025 at 2:07PM, each resident on anticonvulsants was included on the audit list. The RDCS verbally affirmed this audit was completed. Start date: 6/12/25 Completion Date: 6/12/25 Responsible: Regional Director of Clinical Services Action: An audit was completed for residents receiving prescribed anticonvulsants for seizure disorders to ensure there were no additional doses missed. The clinical documentation for the two residents identified in the audit was reviewed, with no documentation of seizure activity noted. During record review and interview with the RDCS on 06/13/2025 at 2:07PM, each resident on anticonvulsants was included on the audit list. The RDCS verbally affirmed this audit was completed. Start Date: 6/12/25 Completion Date: Initiated on 6/12/25 and ongoing. Responsible: Regional Director of Clinical Services/Designee Action: The RDCS/Designee will review the medication administration history for those receiving anticonvulsant medications for seizure disorders three times weekly to ensure no additional missed doses and efficacy of education provided. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Pharmacy Consultant Action: A full MAR to Cart audit has been scheduled for 6/13/25 to ensure medication orders have been transcribed and are correct. Pharmacist observed auditing carts on the afternoon of 06/13/2025. During an interview, the Pharmacist confirmed he had conducted the audts. Start Date: 6/13/25 Completion Date: Initiated on 6/13/25 and ongoing. Responsible: Regional Director of Clinical Services/Designee Action: All new orders will be reviewed during the morning clinical process to ensure accurate transcription and medication availability. Start date: 06/11/25 Completion date: 06/12/25 Responsible: Regional Director of Clinical Services Action: The Medical Director was notified of the medication errors on 6/11/25. The Medical Director was notified that an IJ had been issued on 6/12/25. The Medical Director did not wish to take additional action. Start Date: 06/12/25 Completion Date: 06/12/25 Responsible: Administrator Action: An Ad Hoc QAPI was held to review the plan for the medication error that occurred on 6/11/25. Record Review of the agenda and sign in sheet from the QAPI meeting that was held on 06/11/2025 was conducted. The topic of the missed medications was listed on the agenda. The sign in sheet for the meeting included the signatures of the required attendees. Monitoring of the POR included the following: A record review on 6/13/2025 at 2:46 PM of the in-service sign in sheets reflected 100% of the nurse and CMA employees signatures. In-service training was provided to all licensed nurses and certified medication aides regarding the process for unavailable seizure medications. If an anticonvulsant medication is unavailable and not in the Stat safe, the nurse is to notify the pharmacy and nursing administration. If a certified medication aide finds an anticonvulsant medication to be unavailable, they are to notify the charge nurse. If a dose is missed, the nurse is to notify the provider. All PRN staff, and those on PTO, LOA, or FMLA, will receive inservice training prior to their next scheduled shift. This training will be provided as part of the new employee orientation for all licensed nurses and certified medication aides. During an interview on 6/13/2025 at 2:30 PM, the ADM stated the RDCS completed staff training for the review of the Admissions Checklist during morning meetings. The admission Checklist included a prompt to audit for new orders for anticonvulsant medication orders. During an interview on 6/13/2025 at 2:32 PM, the ADON stated she was trained by the RDCS regarding the review of the Admissions Checklist during daily morning meetings. The Admissions Checklist includes a prompt to audit for new orders for anticonvulsant medication orders. During an interview on 6/13/2025 at 2:36, RN D stated she received training on steps to take when a resident missed a dose of anticonvulsant medication. She stated to whom she would have contacted and what action would have been taken. She stated she would contact the provider to notify of the missed dose and request orders to hold the dose or go ahead and give the medications. During an interview on 6/13/2025 at 3:11 PM, LVN F stated she received training from the RDCS on the steps staff should have taken when the anticonvulsant medications were not available. She stated she would contact the provider to notify of the missed dose and request orders to hold the dose or go ahead and give the medications. An interview attempt was made on 6/13/2025 at 3:19 PM with LVN G. There was no answer and no ability to leave voicemail. During an interview on 6/13/2025 at 4:05 PM, RN E stated he received training from the RDCS on the steps staff should have taken when the anticonvulsant medications were not available. She stated she would contact the provider to notify of the missed dose and request orders to hold the dose or go ahead and give the medications. An interview attempt was made on 6/13/2025 at 4:32 PM with LVN L. A message was left, and a call back was requested. An interview on 6/13/2025 on 4:54, LVN I stated she received training from the RDCS on the process for missed doses of medication. She stated she would contact the provider to notify of the missed dose and request orders to hold the dose or go ahead and give the medications. The ADM and RDCS were informed the Immediate Jeopardy was removed on 6/13/2025 at 6:15 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food storage, food safety, and nutrition services for 1 of 1 kitchen. The facility failed to ensure food items were labeled and/or dated. This failure could place residents at risk foodborne illness by being served expired food. Findings included: Observation on 6/10/2025 at 8:45 AM of the cooler revealed the following: - Hamburger patties in a liquid container was dated 6-03-2025. - Mayonnaise in its original container was dated 6-03-2024. - The juice in a container was not labeled. - Tortillas in a box was dated 10-30-2024, there was no date on the tortillas in the bag. - Tomato soup was dated 5-8-2025. An interview on 6/13/2025 at 9:35 PM, DA B stated everything in the kitchen should be dated and discarded after 3-4 days. DA B stated soup could be kept in the cooler for seven days. DA B said there was a list on the cooler with how many days an item could be in the cooler. DA B stated if residents were served out-of-date food, they could get sick or salmonella poisoning. DA B said if she saw something out of date, she told the DM, and the item were thrown away. Out-of-date items should be discarded. An interview on 6/13/2025 at 9:43 PM, . DA A stated when a leftover food item was placed in the cooler, it should be labeled with what the item was and the date. DA A stated if she saw an item that was out of date, she would notify the DM and throw the item away. DA A stated if residents were served out-of-date food, they could get sick. DA A stated all items in the cooler should be labeled. DA stated everyone on the kitchen is responsible to check for out of date items. DA A stated that all items should be labeled correctly so they know what to use first. DA A stated if food is not labeled or dated residents were served the wrong food or out-of-date food, and residents could get sick. An interview on 6/13/2025 at 9:58 PM, The CK stated prepared food in the refrigerator had a shelf life of 3 to 7 days. The shelf life of food varied depending on the specific item. The CK said there was a list in the cooler that indicated how long each food item could stay. The CK stated it was everyone's responsibility to check for expired products. The CK mentioned when an item was placed in the cooler, it should have a label which indicated what the item was and the date it was placed there. An interview on 6/13/2025 at 10:05 PM with DM revealed if he found out-of-date food in the kitchen, it was discarded. The DM mentioned they were on a tight budget and typically did not have leftovers. He stated prepared food items in the cooler were kept for three to seven days, depending on the item. There was a list on the cooler which indicated how many days an item could remain there. The DM emphasized the importance of communicating with the staff about avoiding out-of-date products in the kitchen. He also noted all food in the cooler should be labeled and dated. He said that if food is not labeled then residents could get the wrong food or out-of-date food. This could lead to foodborne illnesses and residents getting sick. DM stated that his expectations is for everyone in that works in the kitchen to check for out of date items. An interview on 6/13/2025 at 1:05 PM with ADM revealed he expected everything in the kitchen to be labeled and dated. He mentioned if residents consumed food that was past its expiration date, they could get sick. The ADM also stated all kitchen staff were responsible for checking food items for expiration dates. Record review of the facility's food storage policy, reflected the following: Cover, label with name, date stored, and the date it must be used or discarded. We recommend a use-by date, of 3 days after the food was prepared or purchased. Refrigerate leftovers immediately after use. Plastic containers with tight-fitting lids are recommended. Add into evidence a record review of the FDA Food Code applicable to the failures in evidence. The facility must provide each resident 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.

Based on observations, interviews, and record reviews the facility failed to ensure a resident who was unable to conduct activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three of six residents (Residents #8, #9 and #30) reviewed for ADL care. 1. The facility failed to ensure Resident #8 was provided with adequate oral care. 2. The facility failed to ensure Residents #9 and #30 with adequate nail care. These failures could place residents at risk of not receiving care and services to meet their needs. Findings Include: 1. A record review of Resident #9's face sheet reflected a [AGE] year-old male who was re-admitted to the facility on [DATE]. Resident #9 had diagnoses which included: Unspecified Dementia (decline in mental ability to interfere with daily life), Psychotic Disturbance (mental state when one loses touch with reality), Mood Disturbance (disruption of emotional state) and Anxiety (feelings of worry, nervousness, unease). A record review of Resident #9's quarterly MDS. dated 4/22/2025, reflected a BIMS score of 15, which indicated cognition was intact. A record review of Resident #9's care plan, dated 6/3/2025, reflected the following interventions: Personal Hygiene: The resident requires Moderate Assistance by one staff with personal hygiene and oral care. During an interview and observation on 6/10/2025 at 2:27 PM, Resident #9's fingernails revealed a length of more than one half inch past the end of the fingertip. The fingernails were jagged, with sharp edges on more than three fingernails. The fingernails had dark colored debris under the nails. He said, I want them trimmed badly. During an observation on 6/13/25 01:49 PM of Resident #9's fingernails revealed the same condition as previously observed. There was no evidence of nail care and the debris remained under the fingernails. 2. A record review of Resident #8's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included Dysphasia (difficulty or discomfort in swallowing), Quadriplegia (loss of function in all four limbs), Spastic Diplegic Cerebral Palsy (type of Cerebral Palsy that affects the legs, causes stiffness and difficulty moving), Aphasia (inability to swallow), Contracture, Neuromuscular scoliosis (side to side curvature of the spine, affects nerves and muscles), Colostomy (surgery that allows stool to bypass the large intestine) and Acute respiratory failure with Hypoxia (the lungs cannot oxygenate the body). A record review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated cognition was intact. A record review of Resident #8's care plan, dated 5/9/2025, reflected the following interventions: Assess mouth frequently for any signs and symptoms of inflammation. Assist with oral care daily. Keep oral cavity clean at all times to prevent infections. Lubricate lips frequently. Use soft bristle brush or swabs for oral hygiene to prevent breakdown. During an observation and interview on 6/10/2025 at 2:51 PM, 6/11/2025 at 10:42 AM, 6/12/2025 at 4:10 PM and 6/13/2025 at 1:45 PM, Resident #8 revealed bad breath and dry lips. There was a visible thick, white film across the teeth of Resident #8. When asked the last time his teeth were brushed, Resident #8 responded with, Last month. He stated he did not refuse oral care and the facility staff had not initiated oral care. During an interview and observation on 6/13/2025 at 2:30 PM, of Resident #8, revealed his teeth were not brushed and he had foul breath. The resident stated he received a shower on 6/12/2025. During an interview on 6/13/2025 at 3:00 PM, CNA J stated the CNAs were responsible for nail care and it was normally done on shower days. CNA J stated she would cut, file, and clean the nails. She said Resident #8 required complete care as he could not do anything himself. She identified potential negative outcomes for residents who did not receive regular oral care as bad breath and decay. During an interview on 6/13/2025 at 3:15 PM, CNA K stated the CNAs working Hall 500 were responsible for Resident #8's oral care. She stated Resident #8 required total care and staff were trained on how to brush his teeth because he could not have anything by mouth. She identified potential negative outcomes for residents who did not receive regular oral care as decay, gum disease, pneumonia, and bad breath. 3. A record review of Resident #30's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30 had diagnoses which included: End Stage Renal Disease (kidneys lose ability to function), Atherosclerotic Heart Disease (a buildup of fats, cholesterol in/on the artery wall), Type 2 Diabetes (failing to produce insulin) and Spinal Stenosis (narrowing of spinal column, pressure on spinal cord and nerves). A record review of Resident 30's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated cognition was intact. A record review of Resident 30's care plan, dated 5/3/2025, reflected the following interventions: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Personal Hygiene: The resident requires assistance times one. An interview and observation on 6/10/2025 at 2:20 PM of Resident #30, revealed her fingernails were longer than one half inch past the fingertips. The resident stated, They look horrible, referring to her nails. An interview and observation on 6/13/2025 at 4:13 PM of Resident #30, revealed her fingernails were in the same condition as previously observed on 6/10/2025. There was no evidence of nail care performed during the time the survey team was in the facility. Resident #30 stated, Still ridiculous, referring to her fingernails. During an interview on 6/13/2025 at 3:00 PM, CNA J stated the CNAs were responsible for nail care and it was normally done on shower days. CNA J stated she would cut, file, and clean the nails. She identified potential negative outcomes for residents who did not receive regular oral care as bad breath and decay. She identified potential negative outcomes for residents who did not receive routine nail care as infections, scratch themselves or their eyes, they may have feces under their fingernails, and it could make them sick. During an interview on 6/13/2025 at 3:15 PM, CNA K identified potential negative outcomes for residents who did not receive routine nail care as they could have scratched and cut themselves or staff, the debris could have been stool and they could have gotten infections. During an interview on 6/13/2025 at 3:30 PM, the LVN I stated the CNAs provided the nail care unless the resident was diabetic and then a physician would provide the nail care. She identified an acceptable length as right at the fingertip. She stated her expectation for oral care was that it should have been completed twice a day and preferably after every meal. She identified potential negative outcomes for residents who did not receive regular oral care as blocked airways, thrush, bad breath, and decreased hygiene. She identified potential negative outcomes for residents who did not receive routine nail care as injury to skin, infections and bad hygiene. During an interview on 6/13/2025 at 3:47 PM the RDCS stated the CNAs were typically responsible to provide nail care, although any nursing staff could have performed the nail care. She identified an acceptable length as just past the fingertips. She stated her expectation was oral care should have been provided at least once a day or every shift. She identified adverse outcomes for lack of oral care as dental caries and buildup of plaque. She identified adverse outcomes for the lack of nail care as the potential for residents to scratch themselves and infections. A record review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, 2001 MED-PASS, revised March 2018 reflected the following: Policy Statement Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to conduct activities of daily living (ADLs). Residents who are unable to conduct activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. 2. Appropriate care and services will be provided for residents who are unable to conduct ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: 1. Hygiene (bathing, dressing, grooming, and oral care).

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 need of each resident. The facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation at each shift change. This failure could place residents at risk of drug diversions and could result in diminished health and well-being. Findings Include: Record review of the Change of Shift Narcotic Count Sheets for the 500-700 Halls revealed missing documentation for 06/02/2025 6p-6a on-coming and off -going shifts. Record review of the 100-300 Hall count sheet revealed missing documentation for 06/01/2025 6a-6p off-going shift, 06/02/2025 6a-6p on-coming shift, 06/02/2025 6p-6a off-going shift and on-coming shift, and 06/06/2025 6a-6p off-going shift. During an interview with CMA A, on 06/11/2025 at 10:35AM, she stated it was required for the off going and oncoming staff to count narcotic medications and signed the Narcotic Count Sheet. During an interview with CMA B, on 06/11/2025 at 10:52AM, she stated it was required for the off going and oncoming staff to count narcotic meds and signed the Narcotic Count Sheet. During an interview with ADON A, on 06/13/2025 at 11:05AM, she stated it was the expectation the off-going and on-coming shifts counted narcotics and sign the Narcotic Count sheet at each shift change. She also stated staff were trained on this expectation in new employee orientation. ADON A reported she made rounds every morning and audited the Narcotic Count Sheets. If a deficiency was found, the responsible staff was educated. During an interview on 06/13/2025 at 1:40PM with the Regional Director of Clinical Services, she stated it was her expectation the off-going nurse and the on-coming nurse counted the narcotics together at the change of shift. She stated the discovery of the change of shift narcotic count process was not being included in new employee orientation. The Regional Director of Clinical Services stated a negative outcome of not consistently following the narcotic count expectations was a possibility of drug diversion. Record review of the Contracted Pharmacy Policy entitled, Drug Discrepancies, Loss, or Diversion was performed. The Policy stated, The facility must have a system that records receipt, usage, and disposition of all controlled substances in sufficient detail that permits an accurate reconciliation.

Based on observation, interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services. 1. The facility failed to ensure Resident #1 was administered his prescribed and scheduled medications CarBAMazepine (for seizures) , Keppra (anticonvulsant), RisperDAL Oral Risperidone (Antipsychotic) , Venlafaxine (For depression, anxiety, and panic disorder) HYDROcodone-Acetaminophen (for pain), before going for an appointment on 04/15/25 for a painful procedure on his right arm , causing him to be in increased pain on his arm, anxiety, and risked him of seizures and convulsions. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications or could result in worsening or exacerbation of chronic medical conditions. Findings included: Review of Resident #1's face sheet dated 05/09/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including epilepsy, major depressive disorder, conversion disorder with seizures or convulsions, quadriplegia, (paralysis of all the limbs) and hypertension. Review of Resident #1's quarterly MDS assessment, dated 02/05/25, reflected a BIMS score of 0, indicating he had severely impaired cognition. Resident #1 had no difficulty in hearing however the clarity of his speech was poor with absence of spoken words. Review of Resident #1's quarterly care plan dated 01/14/25 reflected: 1. Resident #1 had a communication problem r/t fragile X syndrome (X chromosome that is abnormally susceptible to damage, ) and the relevant intervention was anticipating the needs and meet them in a timely manner. 2. Resident #1 was diagnosed with major depressive disorder, impulse disorder, Epilepsy (seizure) The relevant intervention was administering relevant medications as ordered by physician. 3. Resident #1 had potential for pain r/t Chronic Physical Disability and the interventions were : a) Administering analgesia (pain medication) as per orders. b) Giving PRN pain medication1/2 hour before any treatment or care. c) Notify physician if interventions were unsuccessful or if there was a significant change in the pain from Resident#1's past experience of pain. Review of Resident #1's physician's order reflected: 2. CarBAMazepine Tablet Chewable 100 MG Give 3 tablet via PEG-Tube( A tube inserted into the stomach through the abdominal wall) two times a day for Seizures -Start Date- 12/12/2024. 3. Keppra Oral Solution 100 MG/ML (Levetiracetam) : Give 15 ml by mouth two times a day related to epilepsy, unspecified, not intractable, without status epilepticus -Start Date-12/15/2024. 4. RisperDAL Oral Tablet 1 MG (Risperidone): Give 1 tablet via PEG-Tube two times a day for impulsivity -Start Date- 11/26/2024 1800. 5. Venlafaxine HCl Oral Tablet 25 MG (Venlafaxine HCl) : Give 50 mg via PEG-Tube two times a day related to unspecified intellectual disabilities -Start Date- 11/14/2024 . 6. HYDROcodone-Acetaminophen Oral Solution 7.5-325 MG/15ML (Hydrocodone-Acetaminophen) : Give 15 ml via PEG-Tube three times a day for pain.-Start Date- 04/14/2025 1500 . 7. Acetaminophen Oral Tablet 500 MG (Acetaminophen) : Give 1 tablet via PEG-Tube four times a day for mild pain -Start Date-04/03/2025. Review of Resident #1's MAR of April 25, reflected none of his medications scheduled on 04/15/25 at 9:00am were administered and it was marked as 'OA' (Out on Appointment) . This includes the medications for Seizure, Epilepsy, Behavior, Depression and anxiety and Severe to mild pains. Observation on 05/08/25 at 10:45am revealed Resident #1 was relaxing on a wheelchair with other residents in front of a TV installed at the living room area, in front of the nursing station. He was responding to the investigator's effort to communicate with him, with facial expressions however could not verbalize. He was presented as calm, pleasant and relaxed . During an interview on 05/08/25 at 12:20pm LVN A stated she knew Resident #1 well though she worked only occasionally in the hall where he resides. She stated Resident #1 was nonverbal and his enteral feed and medications were administered via PEG tube. She stated on 4/15/25 she was working with Resident #1 and responsible for medication administration. LVN A said on 04/15/25 at about 7:45am Resident #1 left the facility accompanied by CNA B for a post-surgery procedure at a hospital. She stated Resident #1 had many medications scheduled at 9:00am and since he had to leave the facility at 7:45am, she did not give those medications as it was 15 minutes out of the medication administration time window. She said the pain medication also was included in that. LVN A stated since she had not worked with Resident #1 frequently, she did not know what the appointment was for. LVN A stated since the resident was nonverbal and she used the faces scale to rate his pain and also observed any restlessness, or similar cues. LVN A said , when the resident left the facility, he was in a calm and relaxed mood and was not showing any sign of pain or distress however on his return he was presented as distressed, agitated, and was showing sign of pain. She stated she had given him the PRN pain medication immediately on arrival. All other medications could not be provided as he arrived around noon and was past his morning medication administration time window. She stated she should have asked the NP and administer his medications prior to leaving the facility. She stated medicating him with the prescribed analgesic(pain medication) might have reduced his pain during and after the procedure. She stated all his other medications also was important for him as they were for agitation, seizures, and convulsions. She stated she received an in-service on the importance of premedicating residents with relevant medications prior to they leave the facility for procedures, especially the pain medications. She said it was a learning experience so that she would be cautious to avoid such mistake in the future. During a phone interview on 05/08/25 at 12:35pm the FM of Resident #1 stated on 4/3/2025, Resident #1 received contracted arm surgery on his right arm at a medical center and on 4/15/2025 he was transported, accompanied by CNA B, for a post-surgery follow up appointment. FM stated he also followed the resident to the medical center. He stated during the appointment, the doctor removed the bandages and cleaned up the surgical wound and during the process, the resident appeared to be agitated and difficult to handle. He said Resident #1 acted like he had not received his mood medication or his pain medication before leaving the facility. He stated on the way back to the facility, Resident #1 had hollered and cried the entire drive. FM stated , later in the evening he was informed by the facility that the resident did not have received any of his morning medications in the morning before leaving the facility for the appointment. He stated the facility staff knew that Resident #1 had an appointment on 4/15/2025 and should have administered his medications prior to leaving the facility. During an interview on 05/08/25 at 12:7pm CNA B stated she was the person who accompanied Resident #1 on 04/15/25 in the morning to the medical center for the appointment . She stated Resident #1's FM also had followed them on his vehicle to the medical center. She stated when resident was leaving the facility he was calm and relaxed and was in his usual demeanor indicating he was not in any pain however on return after the procedure on his operated arm, he was presented as agitated and restless as if he was in pain. She stated she tried to calm him down with therapeutic conversation and distraction technique, without any success. CNA B stated they had to wait at the hospital for a while for the procedure to be completed and not sure if they medicated him during the procedure. CNA B stated they returned to the facility on ly by noon on that day due to the delay at the medical center. During a phone interview on 05/08/25 at 1:35pm NP stated she was aware of the incident where Resident #1 went out for a procedure on 04/15/25 without having his morning medications including pain medication as it was a topic of discussion in the clinical meeting on 04/16/25 in the morning. She stated the clinical team in the meeting agreed that any resident who go out on a procedure should be premedicated for pain and also with relevant scheduled medications if any. She stated all the nurses at the facility were educated on the issue immediately after the incident. She stated she visited Resident #1 generally on alternate days and assessed his pain through observing his body language or physical cues like increased heart rate and restlessness. She stated sometimes he was able to smile if he was not in any discomfort. NP stated Resident #1 was on PRN pain medication however scheduled it as regular recently to reduce his discomfort from pain. NP added, this was because, since the resident was nonverbal the accuracy of the pain assessment based on other cues like facial expressions might not be always accurate and there were chances of underestimating his pain. She stated the pain management should be addressed properly to achieve pain reduction among residents. NP stated the nurse should have consulted the MD/NP prior to sending Resident #1 for appointment on 04/15/25, to make available his morning medications earlier than scheduled. During interview on 05/12/25 at 11:45am ADON stated she started working at the facility since March 2025. She stated Resident #1 should have been administered with his morning medication before he left the faciity on [DATE]. She stated the DON at the facility had resigned from her position about a week ago however before she left the DON had discussed the issue of Resident#1's missing medication with the QA team and all the relevant staff were in serviced by her on 04/16/25, the next day after the incident occurred. Record Review of the facility in services revealed on 04/16/25 and 04/18/25 there were in-services conducted on When residents leave for appointments ask if they are in pain. 1) offer to premedicate the resident. 2) Offer to send meds with the resident in the event of painful procedure. 3) Upon return always ask and treat any complaints or signs of pain. Residents have the right to live pain free. Review of the sign in sheet revealed LVN A had attended the in-service with other staff members. Record review of the facility's undated Medication Administration Policy, reflected : Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Record review of the facility's policy Pain-Clinical Protocol revised in October 2022 reflected: 1. The physician and staff will identify individual who have pain or who are at risk of having pain. This includes reviewing known diagnoses and conditions that commonly cause pain .4. The nursing staff will identify any situations or interventions where an increase in resident's pain may be anticipated

Based on observations, interviews, and record review the facility failed to ensure the facility established and maintained an infection prevention program designed to provide a safe environment and to help prevent the transmission of communicable diseases for 2 of 5 residents (Resident #2 and Resident #3) observed for infection control. LVN C failed to disinfect the blood pressure cuff while using it on Residents #2 and Residents #3. This failure could place residents at increased risk of healthcare associated infections. Findings included: Review of resident #2's face sheet dated 05/12/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) , atrial fibrillation(Rapid irregular heartbeat of upper chamber of the heart) , insomnia, major depressive disorder, type 2 diabetes, heart failure and hypertension. Review of resident #2's quarterly MDSs assessment, dated 02/02/25, reflected a BIMS score of 15, indicating he was cognitively intact. Review of resident #2's quarterly care plan, dated 05/08/25, reflected he was at risk for cardiac complications as it relates to his diagnosis of hypertension and relevant intervention was administering anti-hypertensive medications as ordered and obtain blood pressure readings per MD ordered. Review of resident #3's face sheet dated 05/12/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including muscle weakness, cognitive communication deficit, unsteadiness on feet, generalized anxiety disorder, dementia, pain in right knee, and hypertension. Review of resident #3's quarterly MDS assessment, dated 04/08/25, reflected a BIMS score of 15, indicating she was cognitively intact. Review of resident #3's quarterly care plan, dated 03/17/25, reflected she had hypertension and was at risk for complications. The relevant intervention was administering anti-hypertensive medications as ordered and obtain blood pressure readings per MD orders. Observation on 05/12/25 at 10:25 am revealed LVN C was administering medications to the residents in Hall 700. While taking blood pressure of Resident #2 and Resident #3, LVN C had not sanitized the blood pressure cuff before Resident #2 , in between Resident #2 and Resident #3 and after checking blood pressure of Resident #3. During an interview on 05/12/25 at 10:55 am LVN C stated she was an agency nurse and came in as a replacement for a MA who had not turned up to work. She stated she did not sanitize the blood pressure cuff in between residents though she knew it was necessary . She stated since she was not a regular nurse at the facility, she was not sure where the wipes and other sanitizers were kept on the med cart. She stated she did not get any time to ask for the wipes before starting to administer medications to the residents in Hall 700 . She stated sanitizing the blood pressure cuff in between each resident was necessary to ensure infection control by reducing the risk of transferring the germs from one resident to another. LVN C stated she received on going in-services pertaining to infection, abuse and neglect and falls however could not recall any trainings provided specifically for sanitizing medical equipment, including blood pressure cuffs. During an interview on 05/12/25 at 11:30am the ADON stated she started working at the facility as ADON since March 2025. She stated the director of nursing resigned and left the faciity on e week ago. ADON stated she was now in charge of making sure all staff were following hand hygiene, anytime she went through the facility she reminded staff. ADON stated if LVN C had not sanitized the blood pressure cuff in between the residents , it could be an infection control issue as this deficient practice might passed on pathogens to residents through contamination. ADON stated the facility had sufficient stock of wet wipes and sanitizers at any point of time and LVN C could have asked her or the nurse in charge for the wipes if she could not find one . During an interview on 05/12/25 at 2:30pm ADM stated he heard about the deficient infection control practice by LVN C in the morning. He stated it was unfortunate that she did not sanitize the blood pressure cuff in between the residents as it was an infection control concern. He stated the facility policy specifically instructed about the importance of sanitizing that medical equipment are in use on multiple residents on regular basis. He stated he would make sure the staff would be in serviced appropriately. Review of facility Policy Cleaning and disinfection of resident-care items and equipment revised in September 2022 reflected: Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. . 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment)

Based on interview and record review, the facility failed to incorporate the PASRR level II recommendations into a resident's assessment and care planning to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs for one (Resident #1) of three residents reviewed for PASRR (Preadmission Screening Resident Review) services. The facility failed to submit the Nursing Facility Specialized Services for SLP, PT, OT, and a customized wheelchair within 20 business days after the IDT meeting for Resident #1. This failure could place residents at risk of not receiving the needed care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. 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 cerebral palsy (a group of disorders that affect movement and muscle tone or posture), epilepsy (seizures), unspecified intellectual disabilities, dysphagia (difficulty with swallowing), and weakness. Review of Resident #1's quarterly MDS assessment, dated 02/05/25, reflected a BIMS score of 00, indicating he had a severe cognitive impairment. Review of Resident #1's quarterly care plan, revised 10/09/24 reflected he had been identified as having PASRR positive status related to an intellectual disability and/or developmental disability with interventions of providing habilitative OT, PT, and SLP and a CMWC. Review of Resident #1's IDT Care Conference, dated 10/16/24, reflected the following summary: Annual PASSR meeting . Resident/RP has chosen to continue PASRR specialized services PT/OT/ST and Hab Co. Therapy arrange evaluation for CMWC. Review of Resident #1's Habilitation Service Plan, dated 10/23/24, reflected the following: Section 4, Habilitation Coordination Plan: [Resident #1] will receive habilitation coordination while the individual is residing in the nursing facility (NF). In accordance with the requirements in the rule and handbook, the SPT has determined the habilitation coordinator (HC) will meet face-to-face with [Resident #1] List all activities to be coordinated or monitored by the HC, including NF Preadmission Screening and Resident Review (PASRR) support activities. 1 Monitor the specialized services provided to the individual to determine whether progress toward achieving goals and outcome(s) is being made. 2 Facilitate the coordination of the HSP and the NF Comprehensive Care Plan. . Physical Therapy will help [Resident #1] improve his position in his wheelchair. Occupational Therapy will help [Resident #1] with his upper body extremities. Speech Therapy will help [Resident #1] with communicating his needs. Swallowing test in order for him to be able to have pleasure food by month [sic]. CMWC will help [NAME] to be comfortable while sitting in the common area with other individuals. During an interview on 04/10/25 at 9:30 AM, the MDSC stated when a resident who was PASRR positive, the facility scheduled an interdisciplinary team meeting that included the HC. In that meeting they determined what services would benefit the resident. The information gathered in that meeting was entered into the computer system. The NFSS form was completed by the DOR and entered into the computer system. She stated the NFSS for Resident #1 was not accepted multiple times for assorted reasons. She stated she had reached out to her PASRR contact person and to HHSC PASRR support multiple times. During an observation and attempted interview on 04/10/25 at 10:34 AM, revealed Resident #1 sitting in a high-back wheelchair in the day room. He did not respond when spoken to . During an interview on 04/10/25 at 10:40 AM, the MDSC stated the NFSS forms were supposed to be submitted 20 or 21 days after the care plan meeting. She stated she and the DOR received alerts when the NFSS forms were not accepted in the system. During a telephone interview on 04/10/25 at 10:53 AM, the PASRR Program Specialist stated when a resident was admitted and was PASRR positive, an IDT meeting was held, and services were recommended. The facility then had 20 business days to send the NFSS out for approvals. She stated Resident #1's facility did not send the form within 20 business days. She stated that was when she sent out a courtesy email encouraging compliance. She stated if she received no response from that, she then made a complaint to HHSC. She stated if services were approved and a resident went to the hospital, the process would start over once they were readmitted . She stated but the bottom line was Resident #1's trip to the hospital had nothing to do with the facility sending the form within 20 days. During an interview on 04/10/25 at 12:50 PM, the ADM stated he was new to the facility but at is last facility, the SW and MDSC would get started on the PASRR referrals right away after a resident was admitted . His expectations were that they were done timely. He stated a resident could suffer if they did not get the paperwork done and they did not get the services they requested. Review of the facility's PASRR Policy, dated 04/26/16, reflected the following: The facility will initiate the request for specialized services within 20 business days of the IDT meeting, implement Specialized Services therapy within 3 business days after receiving approval from HHSC in the online portal and order CMWC and/or DME within 5 business days of receiving approval from HHSC in the online portal.

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of three residents (Resident # 1) reviewed for misappropriation. The facility failed to prevent a diversion (misappropriation) of Resident #1's Oxycodone 0.5 mg, 30 tablets (opiate narcotic medication); Tramadol 50 mg 30 tablets (a pain medication) received from the pharmacy on 2/7/24 at 4:11 AM and reported missing 2/11/2025 during the day shift. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. Findings include: Record review of Resident # 1's face sheet, printed 2/14/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Sciatica, Right -side (pain that originates along your sciatic nerve), Chronic Pain syndrome (Pain that persists beyond the expected healing time for an injury or illness, often causing significant disruption to daily functioning), Tubulointerstitial nephritis (a kidney disorder that causes inflammation of the kidney tubules and surrounding tissues). Record review of Resident's #1's admission MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #1's physician orders, dated 2/6/2025, revealed order written on 2/6/2025 Oxycodone 0.5 mg 8 hours as needed for moderate or greater pain. Tramadol 50 mg one time daily for pain. Record review of the provider investigation report, dated 2/12/2025, reflected on 2/7/2025 at 4:11 AM the pharmacy delivered 30 (thirty) tablets of Oxycodone 0.5 mg 30 (thirty) and Tramadol 50 mg 30 (thirty) for Resident #1, the packing slip from the pharmacy was signed by RN A as received. The Medication was noticed as missing, four days later. A search of the facility's medication rooms, and medication carts and the medications were not located. The report reflected no injury or harm to the resident as the medication was available in the emergency medication kit and the facility replaced the missing medication after the investigation was completed, the facility notified Hospice, the responsible party, the medical director, and the police. Statements were obtained from staff. The investigation findings confirmed the drug diversion. Record review of the pharmacy packing slip, dated 2/7/2025, reflected Oxycodone 0.5 mg 30 (thirty) and Tramadol 50 mg 30 (thirty) tablets were delivered to the facility and signed as received by RN A Record review of the Business card left by the responding police officer reflected, Case No: P25012257 dated 2/12/2025 . Record review of RN A's statement reflected On Friday 2/7/2025, she received medications including narcotics from pharmacy. The narcotics were for [Resident #1]. When she wanted to put the medication away, she noticed she was not a resident on the northside, and she did not find her at all. She received the medication at approximately 4:00 AM. RN A placed the medication in the narcotics box on her side until day shift arrived including the bag of medications she received. When the day shift nurse arrived, she counted with the day shift LVN A and CMA A. She showed them both narcotics bag and name and asked if the resident was in the facility? CMA A stated she did not know, and she did not think she was still here. LVN A stated she did not know but she will take care of it. She handed off the bag to LVN A and CMA A was there when she handed off the bag to nurse LVN A. She asked if the resident is no longer there, where do they put the medication for returns. She was told to put it in the medication room for returns. She asked if she was sure, and she said yes because she works there regularly. She walked into the medication room with nurse LVN A, showed her where she dropped off the narcotics and looked for a supply for another resident with her. She asked her again was it ok to set the medication down there in the medication room for returns or if there was another place to put it in and she said there is no problem. She stated they exited the medication room, and she exited the facility. She stated the medication was intact in the bag because the bag was unopened but the plastic piece for the name was torn by her earlier to see the piece of paper that had the name of the resident. She stated she exited the facility at 7:53 AM , During a phone interview on 2/14/2025 at 12:55 PM with the local police department desk sergeant, revealed the investigator on the case was not available, a message was left for a return phone call. No return phone call received prior to exit. During an interview with CMA A on 02/13/25 at 1:15 PM revealed she was passing morning med's, and one of the agency nurses stated she had med's for Resident #1. She advised her she no longer had her, but she did not know they moved her on the other side. She told her they were narcotics. She was unsure what to do with them once the resident was no longer there. She stated if the resident passed away, the DON was supposed to count them, but she was unsure what she did with them. If she had someone's med's on the cart and the resident passed away the DON would count them. When Resident #1 was discharged , she went to the hospital and then when she came back, she went to the other side. Resident #1's family member made the decision to have her go to the hospital. The med's were not taken from her cart that day, but she was off and when she came back to work, her med's were gone off her cart. Her son realized she needed long term care, so she came back, and she returned, and she was placed on the other side. She did not know what went on the other side. She was surprised they were getting medication. She was wondering why they were still getting medication for her. All the rest of her medication went over to the south side where she was once, she came back. She stated seems like the pharmacy would have sent them to that side since the rest of her med's were going over there. The agency nurse received the med's and placed them in the med room and locked the room. She stated she was not going to open the envelope (purple bag). The DON asked her if she threw them away. She stated she checked the bag. She stated sometimes they had papers in the bag but that day they were busy. She stated 2/7/2025 was the date of the incident. She worked the night shift. Someone from the pharmacy delivered the medication. They were supposed to check the med's when they first came in, and it was because the pharmacy made mistakes. When the med aids came in in the morning, they put the med's on the cart. She stated a lot of the time the night nurses did not know where the med's went, and she had the wrong medication on her cart. The morning med aides would check them in. When the med's came in at night, they would lock them in the med room until the med aides came in. The nurse would advise them they had med's in the med room, and they got them and placed them where they were supposed to be. During an interview with LVN A on 02/13/25 at 2:18 PM, she stated she was asked about it, but she was not aware of the medication missing. She stated she could not admit she saw the resident's medication. She stated when she came into work, the medication was in the medication room on the counter and the morning med aid put the medication away. She stated when the medication was delivered, they took it to the nurse's station. They took it and placed the medication in the med room. The night nurse or whatever nurse was on duty would sign for it. Only charge nurses, LVN and RNs, could sign for the medications. During an interview with LVN B on 02/13/25 at 3:06 PM, she stated she did not see the medication to give it to her. LVN B knew she could not give it to her because it was not here. It was a PRN medication for her. The oxycodone was not scheduled for her to give to her. She stated the resident did not ask for the medication and that was why she did not know it was not there . During an interview with LVN C on 02/13/25 at 3:20 PM, she stated when the medication was received, she took the sheet, opened the bag, compared it, and gave it to them. She stated she would put it on her cart or give it to the med aid and if it must be refrigerated, she would place it in there. The med aid would put the medication in its proper place . During an interview with the ADM on 02/13/25 at 3:40 PM, she stated she thought the missing medication was in the bag that had been thrown away. She stated all nurses had access to the medication room from 2/7/25 to 2/11/25 . She stated no one saw the medication, and no one admitted having thrown it away. She stated they received in-services on what to do when the med's were received and what to do with them. She stated she placed a sin up in the medication room advising the staff to throw away the purple bags and not to leave them on the counter. She stated when the med's came in, they were supposed to verify and sign what was in the bag. Once the med's were in their possession, they were to secure the med's in their proper places. She stated the medication usually came in about 4:00 AM and about 4:00 PM. She stated there was always 2 nurses in the building. She stated she would be doing an in-service on what to do when there was another nurse on duty and the medication came in. She stated the resident did not have any pain from the med's missing. She stated they contacted the pharmacy and got med's from the e-kit. The pharmacy sent another round of med's for the resident . Record review of Inservice, dated 2/12/2025, reflected all LVN and RNs were in-service on Controlled Substance which included the process for accepting scheduled medications from the pharmacy. Record review of RN A employee file reflected she did not have a file within the facility. RN A was working at the facility through agency. Per the ADM, RN A was not allowed to return to the facility. Record review of the facility's, undated, policy Controlled Substances reflected 3. Controlled substances are counted upon delivery . The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record. Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of three residents (Resident # 1) reviewed for misappropriation. misappropriation of resident property, and exploitation for one of three residents (Resident # 1) reviewed for misappropriation. The facility failed to prevent a diversion (misappropriation) of Resident #1's Oxycodone 0.5 mg, 30 tablets (opiate narcotic medication); Tramadol 50 mg 30 tablets (a pain medication) received from the pharmacy on 2/7/24 at 4:11 AM and reported missing 2/11/2025 during the day shift. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. Findings include: Record review of Resident # 1's face sheet, printed 2/14/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Sciatica, Right -side (pain that originates along your sciatic nerve), Chronic Pain syndrome (Pain that persists beyond the expected healing time for an injury or illness, often causing significant disruption to daily functioning), Tubulointerstitial nephritis (a kidney disorder that causes inflammation of the kidney tubules and surrounding tissues). Record review of Resident's #1's admission MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #1's physician orders, dated 2/6/2025, revealed order written on 2/6/2025 Oxycodone 0.5 mg 8 hours as needed for moderate or greater pain. Tramadol 50 mg one time daily for pain. Record review of the provider investigation report, dated 2/12/2025, reflected on 2/7/2025 at 4:11 AM the pharmacy delivered 30 (thirty) tablets of Oxycodone 0.5 mg 30 (thirty) and Tramadol 50 mg 30 (thirty) for Resident #1, the packing slip from the pharmacy was signed by RN A as received. The Medication was noticed as missing, four days later. A search of the facility's medication rooms, and medication carts and the medications were not located. The report reflected no injury or harm to the resident as the medication was available in the emergency medication kit and the facility replaced the missing medication after the investigation was completed, the facility notified Hospice, the responsible party, the medical director, and the police. Statements were obtained from staff. The investigation findings confirmed the drug diversion. Record review of the pharmacy packing slip, dated 2/7/2025, reflected Oxycodone 0.5 mg 30 (thirty) and Tramadol 50 mg 30 (thirty) tablets were delivered to the facility and signed as received by RN A Record review of the Business card left by the responding police officer reflected, Case No: P25012257 dated 2/12/2025 . Record review of RN A's statement reflected On Friday 2/7/2025, she received medications including narcotics from pharmacy. The narcotics were for [Resident #1]. When she wanted to put the medication away, she noticed she was not a resident on the northside, and she did not find her at all. She received the medication at approximately 4:00 AM. RN A placed the medication in the narcotics box on her side until day shift arrived including the bag of medications she received. When the day shift nurse arrived, she counted with the day shift LVN A and CMA A. She showed them both narcotics bag and name and asked if the resident was in the facility? CMA A stated she did not know, and she did not think she was still here. LVN A stated she did not know but she will take care of it. She handed off the bag to LVN A and CMA A was there when she handed off the bag to nurse LVN A. She asked if the resident is no longer there, where do they put the medication for returns. She was told to put it in the medication room for returns. She asked if she was sure, and she said yes because she works there regularly. She walked into the medication room with nurse LVN A, showed her where she dropped off the narcotics and looked for a supply for another resident with her. She asked her again was it ok to set the medication down there in the medication room for returns or if there was another place to put it in and she said there is no problem. She stated they exited the medication room, and she exited the facility. She stated the medication was intact in the bag because the bag was unopened but the plastic piece for the name was torn by her earlier to see the piece of paper that had the name of the resident. She stated she exited the facility at 7:53 AM , During a phone interview on 2/14/2025 at 12:55 PM with the local police department desk sergeant, revealed the investigator on the case was not available, a message was left for a return phone call. No return phone call received prior to exit. During an interview with CMA A on 02/13/25 at 1:15 PM revealed she was passing morning med's, and one of the agency nurses stated she had med's for Resident #1. She advised her she no longer had her, but she did not know they moved her on the other side. She told her they were narcotics. She was unsure what to do with them once the resident was no longer there. She stated if the resident passed away, the DON was supposed to count them, but she was unsure what she did with them. If she had someone's med's on the cart and the resident passed away the DON would count them. When Resident #1 was discharged , she went to the hospital and then when she came back, she went to the other side. Resident #1's family member made the decision to have her go to the hospital. The med's were not taken from her cart that day, but she was off and when she came back to work, her med's were gone off her cart. Her son realized she needed long term care, so she came back, and she returned, and she was placed on the other side. She did not know what went on the other side. She was surprised they were getting medication. She was wondering why they were still getting medication for her. All the rest of her medication went over to the south side where she was once, she came back. She stated seems like the pharmacy would have sent them to that side since the rest of her med's were going over there. The agency nurse received the med's and placed them in the med room and locked the room. She stated she was not going to open the envelope (purple bag). The DON asked her if she threw them away. She stated she checked the bag. She stated sometimes they had papers in the bag but that day they were busy. She stated 2/7/2025 was the date of the incident. She worked the night shift. Someone from the pharmacy delivered the medication. They were supposed to check the med's when they first came in, and it was because the pharmacy made mistakes. When the med aids came in in the morning, they put the med's on the cart. She stated a lot of the time the night nurses did not know where the med's went, and she had the wrong medication on her cart. The morning med aides would check them in. When the med's came in at night, they would lock them in the med room until the med aides came in. The nurse would advise them they had med's in the med room, and they got them and placed them where they were supposed to be. During an interview with LVN A on 02/13/25 at 2:18 PM, she stated she was asked about it, but she was not aware of the medication missing. She stated she could not admit she saw the resident's medication. She stated when she came into work, the medication was in the medication room on the counter and the morning med aid put the medication away. She stated when the medication was delivered, they took it to the nurse's station. They took it and placed the medication in the med room. The night nurse or whatever nurse was on duty would sign for it. Only charge nurses, LVN and RNs, could sign for the medications. During an interview with LVN B on 02/13/25 at 3:06 PM, she stated she did not see the medication to give it to her. LVN B knew she could not give it to her because it was not here. It was a PRN medication for her. The oxycodone was not scheduled for her to give to her. She stated the resident did not ask for the medication and that was why she did not know it was not there . During an interview with LVN C on 02/13/25 at 3:20 PM, she stated when the medication was received, she took the sheet, opened the bag, compared it, and gave it to them. She stated she would put it on her cart or give it to the med aid and if it must be refrigerated, she would place it in there. The med aid would put the medication in its proper place . During an interview with the ADM on 02/13/25 at 3:40 PM, she stated she thought the missing medication was in the bag that had been thrown away. She stated all nurses had access to the medication room from 2/7/25 to 2/11/25 . She stated no one saw the medication, and no one admitted having thrown it away. She stated they received in-services on what to do when the med's were received and what to do with them. She stated she placed a sin up in the medication room advising the staff to throw away the purple bags and not to leave them on the counter. She stated when the med's came in, they were supposed to verify and sign what was in the bag. Once the med's were in their possession, they were to secure the med's in their proper places. She stated the medication usually came in about 4:00 AM and about 4:00 PM. She stated there was always 2 nurses in the building. She stated she would be doing an in-service on what to do when there was another nurse on duty and the medication came in. She stated the resident did not have any pain from the med's missing. She stated they contacted the pharmacy and got med's from the e-kit. The pharmacy sent another round of med's for the resident . Record review of Inservice, dated 2/12/2025, reflected all LVN and RNs were in-service on Controlled Substance which included the process for accepting scheduled medications from the pharmacy. Record review of RN A employee file reflected she did not have a file within the facility. RN A was working at the facility through agency. Per the ADM, RN A was not allowed to return to the facility. Record review of the facility's, undated, policy Controlled Substances reflected 3. Controlled substances are counted upon delivery . The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record.

Based on observations, interviews, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (Resident # 1 and Resident #9) of 5 Residents reviewed for pressure ulcers. 1. The facility failed to perform wound care to Resident #9's Stage 3 pressure ulcer to right buttock, as ordered, on 01/06/25, 01/09/25, 01/11/25, 01/12/25, 01/14/25, 01/20/25, 1/21/25 and 1/22/25 . Resident #9's wound was infected on 01/16/2025 and got worse from a stage 3 to a stage 4. 2. The facility failed to perform wound care on Resident #9's sacral wound per orders for Resident #9 dated 1/16/2025 until 1/23/2025. Resident #9's wound was infected on 01/16/2025 and got worse from a stage 3 to a stage 4. An Immediate Jeopardy (IJ) was identified on 02/11/25. The template was provided to the facility on [DATE] at 2:30 PM. While the IJ was removed on 02/12/25 at 3:36 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis ( a serious condition in which the body responds improperly to an infection, causing the organs to work poorly), reduced mobility, and a lower quality of life. 3. The facility failed to change a wound vac dressing to Resident #1's Stage 4 pressure ulcer, as ordered, on 01/12/25 and 01/17/25. Findings included: Review of Resident #9's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Cerebral infarction (also known as ischemic stroke, occurs as a disruption of blood floor to the brain due to problems with blood vessels that supply it), non-traumatic intracerebral hemorrhage in the brain stem (focal bleeding from a blood vessel in the brain) Review of Resident #9's admission MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section GG (Functional Abilities) reflected she was dependent on bed mobility and transfers. Section I (Active Diagnoses) reflected diagnoses including aphasia (difficulty using or comprehending language), cardiovascular accident (stroke), chronic lung disease, and other tracheotomy (surgically created hole, also called a stoma in your windpipe) complications. Section M (Skin Conditions) reflected she was at risk for developing pressure ulcers/injuries, had no unhealed pressure ulcers/injuries and no venous or arterial ulcers. Review of Resident #9's Comprehensive Care Plan, initiated 12/28/24 and revised on 01/28/25 reflected it did not address the pressure injury/ulcer ., meaning, Resident #9 was not admitted with pressure injury. Review of Resident #9's skin assessment dated [DATE] reflected the resident had excoriation (wear of the skin often caused by scratching, rubbing, or friction against the skin surface) at right buttock measuring 3 x 6 cm. Review of Resident #9's TAR reflected: Wound Care Consult as indicated, one time only for skin breakdown for 7 Days -Start Date- 12/29/2024. Review of Resident #9's NP's progress notes dated 01/03/2025 reflected: Chief Complaint/Reason for this Visit - wound. New wound to buttocks presents today, stage 3. Wound care referral provided. Stage 3 pressure ulcer: Wound care referral, continue wound care as prescribed. Review of Resident #9's Physician orders dated 01/03/2025 reflected a referral to be seen by wound care doctor. Clean stage 3 to right buttock with normal saline, apply hydrocolloid dressing daily one time a day Supplementary. Key: Drainage: Saturated/Moist/Dry General Appearance: Red/Yellow/Pink/Black/Green/Whit e/Tan/Purple/Brown/Gray Surrounding Skin: Macerated/Reddened/Firm/Normal -Start Date- 01/04/2025 Review of Resident #9's January 2025 MAR/TAR reflected an order dated 01/04/25 and discontinued on 01/20/25, Clean stage 3 to right buttock with normal saline, apply hydrocolloid dressing daily. The dressing change was not documented on 01/06/25, 01/09/25, 01/11/25, 01/12/25, 01/14/25 , and 01/20/25 . It was also reflected there was no wound care order in place for 01/21/25 and 01/22/2025. Review of Resident #9's skin assessment dated [DATE] reflected pressure at right buttocks. Review of Resident #9's clinical records reflected Resident #9 was not seen by the Wound Doctor until 1/16/2025 since the referrals were made on 12/29/2024 and 1/03/2025. Review of Resident #9's Wound Doctor's notes dated 1/16/2025 reflected: LOCATION: Sacro coccyx Extending to Bilateral Buttocks ETIOLOGY: Pressure Injury/Ulcer - Wound Stage: 4 - Pressure Injury PREOPERATIVE INDICATIONS: Necrotic tissue, infected tissue, slough , and drainage SIGNS OF INFECTION: Pain, foul odor, erythema (redness to the skin), and purulent(pus) drainage WOUND DESCRIPTION: UNDERMINING: 2 cm at 12 o'clock EXUDATE: Copious, purulent, and sanguineous PERIWOUND: Erythematous ( redness to the skin due to the accumulation of blood in dilated capillaries) WOUND EDGE: Friable (thin skin) DRESSING USED: Calcium Alginate and Bordered Gauze Review of Resident #9's MAR/TAR for January 2025 reflected Resident #9 was treated with the following antibiotics for wound infection: Doxycycline Hyclate Tablet 100 MG Give 1 tablet via PEG-Tube (a medical device use to provide nutrition and hydration directly to the stomach, also known as G-tube) two times a day for wound infection for 14 Days -Start Date- 01/16/2025 -D/C Date- 01/22/2025. Cipro Oral Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet via G-Tube two times a day for wound infection for 7 Days -Start Date- 01/22/2025. Clindamycin HCl Oral Capsule 300 MG (Clindamycin HCl) Give 2 capsule via G-Tube every 8 hours for wound infection for 7 Days -Start Date- 01/22/2025. Review of Resident #9's TAR reflected orders from Wound Doctor's visit from 01/16/2025 for Resident #9's wounds were not implemented until 1/23/2025. Review of Resident #9's clinical physician orders reflected an order dated 01/22/25 , Clean stage 4 to sacrum with normal saline, apply calcium alginate, then foam adhesive dressing daily. During an observation and interview on 01/27/25 at 10:30 AM, Resident #1 was lying in bed with the head of the bed elevated. The wound vac machine was observed hanging at the bedside. She stated she had a bed sore and was supposed to get wound care on Mondays, Wednesdays, and Fridays but they did not always change the wound vac dressing when they were supposed to. She stated the nurse had just changed the wound vac dressing a short time ago. During an observation and interview on 01/27/25 at 10:41 AM, Resident #9 was observed lying in bed with the head of the bed elevated. Resident was unable to verbalize but family member at bedside confirmed that the resident had a pressure sore on her back side and was dependent on staff for repositioning. The family member stated she had not seen the wound and did not know if it was worsening. During a telephone interview on 01/27/25 at 3:36 PM, the Medical Director stated the nurses should, follow up on wound care. He stated he was familiar with NPWT, usually the settings come from the hospital or wound care doctor. He expected orders to be followed. During an interview on 01/27/25 at 4:00 PM, the DON stated she expected wound vacs to be maintained, and she expected that staff had been trained. She stated she was not sure if there were any competencies for the wound vacs. The DON stated she had been in the building for only 6 days and was not yet familiar with everything. She stated she did not know if agency nurses had been trained on the wound vac. She stated she expected wound care to be completed as ordered and documented. She stated not performing wound care as ordered could lead to infection or delay healing. During an interview on 01/28/25 at 12:04 PM the ADON stated she had observed RN B change a wound vac dressing but she had not received hands-on training on actual wound vac device. She stated it was her expectation that wound care was provided as ordered. If it was not documented, it did not happen. She stated it did not meet her expectations that dressing changes were missed. She stated she had talked with Resident #1's wound care doctor about one missed dressing change. During an interview on 01/30/25 at 12:09 PM, the MDS Nurse stated it was her expectation that all treatments were documented when given. She stated if it was not documented, it did not happen. She stated everything had to be documented to give a picture of what is going on with the resident. She stated documentation was important because the doctor needed to know, if it went to court you needed to know, so you had to document everything. During an interview on 01/30/25 at 12:50 PM, the ADON stated it was her expectation that residents were assessed, and it was documented. She stated regarding wound care, she expected the old dressing was assessed, the wound was assessed, and the resident's response to the treatment was assessed and all of that was documented. She stated wounds should be measured and wound vac settings documented. She stated there needed to be a paper trail to inform the doctor and the insurance of the resident's status. She stated not providing wound care could cause wounds to worsen. During an interview on 01/30/25 at 3:07 PM, LVN E stated it was important to follow the physician orders, such as wound care. She stated treatments were ordered for a reason. She stated wound care was documented when the care was provided. Not providing wound care could cause worsening or more wounds. During an interview on 02/11/2025 at 10:11 am the Wound Doctor stated that he has been seeing Resident #9 for wound care to the sacral wound. He stated he first saw Resident #9 on 1/16/2025, at which point he described the wound as a fairly large sacral wound that was fairly necrotic and draining pus, unstageable ( a pressure ulcer that is cover with necrotic tissue or eschar making it hard to stage or treat), necrotic, once the necrotic tissue was removed over the wound bed, it was immediately a Stage IV pressure ulcer due to the depth of the wound. The Wound Doctor stated, following his assessment of the wound, he started Resident #9 on antibiotics (Doxycycline) for the infection, initially, which was later changed by the primary doctor. The wound Doctor stated, missing wound care can cause problems, like worsening of the wound. The Wound Doctor stated it was his expectation that wound care be done daily as ordered, unless otherwise specified. The Wound Doctor stated Resident #9's comorbidities that might affect wound healing were right hemiparesis, weakness, less mobility, and offloading was a big deal with her wound, less able to feel pain. He also stated nutritional wise, Resident #9 was good. During interview on 2/11/25 at 11:38 am, RN B stated she was ADON for the period in question from 12/28 2024 through 1/23/2025 and made rounds with the Wound Doctor on his visits. She stated the ADON was responsible for monitoring wound progress. She stated it was the expectation that wound care orders be put in the Resident's chart right after the wound Doctor's visit. She stated she did not know why the Wound Doctor was not notified between 1/3/25 to 1/16/25 of the wound consultation for Resident #9. She stated she did not know why the new wound care orders for Resident #9 from the Wound Doctor visit on 1/16/25 were not updated in Resident #9's chart until 1/23/25. She stated that if wound care consult was not given to the Wound Doctor when he was in the building, they would have to wait until the following week as they did not have a way to contact the Wound Doctor between visits. RN B stated if the residents were not seen by the wound doctor timely and the wound care orders were not implement as ordered, the resident's wounds would get worse. RN B stated Resident #9 was not able to move herself from side to side without assistance from staff. RN B stated she worked with Resident #9 on 1/22/2025 but could not state why wound care for Resident #9 was not done on 01/22/2025. Attempts made on 02/11/2025 at 12:37 PM to contact LVN M, the nurse assigned to Resident # 9 on 1/9/2025 but to no avail , a voice message was left. During a phone interview on 02/11/2025 at 12:39 PM, LVN N, the nurse assigned to Resident #9 on 1/21/2025, stated she worked with an agency and only worked 1 shift at the facility. LVN N stated she could not remember Resident #9, but she did a couple of wound cares on the day that she worked at the facility. LVN N stated if she didn't sign or document on the MAR/TAR that means the treatment was not done. During a phone interview on 2/11/2025 at 01:37 PM, LVN A, the nurse assigned to Resident #9 on 01/06/2025, 1/11/2025, 1/12/2025, 01/14/2025 and 1/20/2025, stated she worked with Resident #9, and Resident #9 required daily wound care and the need to be repositioned every two hours. LVN A stated she was responsible for wound care on her shift as a nurse. LVN A stated she performed wound care on Resident #9 on the days she worked with the Resident except for when the Wound Doctor was making his rounds but was unable to recall the dates, she worked with Resident #9 or the dates wound care was completed for the resident. LVN A stated that without documentation of care, it wound suggest the wound care was not done. LVN A stated that providing necessary care to residents and documenting their care was part of quality nursing care and could be neglect if it was not done. Resident #9 was not seen by the Wound Doctor until 1/16/2025 and the Wound Doctor did not visit the facility on 1/20/2025. During an interview on 02/11/2025 at 3:20 PM the Nurse Consultant stated the DON was out sick and she was in place of the DON. she stated that her expectations for physician orders were that they would be implemented and followed. The Nurse Consultant stated wound care orders should be implemented as soon as possible, at the latest, the following morning to enable the resident to receive care ordered by the following morning. The Nurse Consultant stated the Residents could have a negative outcome, such as worsening of a wound, if new orders were not implemented timely. The Nurse Consultant stated that Residents could have negative outcome, such as worsening of a wound, if wound care was not performed as ordered. The Nurse Consultant stated that if a nurse does not document care, then it was not done. Review of the facility's Charting and Documentation policy, revised July 2017, reflected in part, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation: 2. The following information is to be documented in the resident medical record: 2. a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided, b. The name and title of the individual(s) who provided the care, c. The assessment data and/or any unusual findings obtained during the procedure/treatment, d. How the resident tolerated the procedure/treatment, e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol revised April 2018, reflected in part, Assessment and Recognition: 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. The policy did not address providing wound care as ordered. The Administrator was notified on 02/11/2025 at 2:30 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 02/12/2025 at 12:41 PM: Plan of Removal Immediate Jeopardy On 01/27/2025 an abbreviated survey was initiated at the facility. On 02/11/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Date Initiated: 02/11/2025. The notification of Immediate Jeopardy states as follows: F686 - The facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Statement of Deficient Practice: All residents who require wound care could be at risk for potential negative effects. 1. Upon learning the facility failed to ensure residents with pressure ulcers received necessary treatment and services facility had wound physician complete rounds on resident who have consented. All other wound treatments not ref erred or consented to wound care physician will be directed by primary care until otherwise directed by primary physician. Nurse Consultant and Director of Clinical Services have conducted an audit to ensure all wounds identified have a current treatment in place. Responsible Party: DON/ADON, Target date: 2/11/2025 Follow up: Monitor for completion through morning meeting process. 2. Nurse Consultant and Director of Clinical Services provided in- service education to all nursing staff currently on shift regarding following physician ordered wound care and documentation of wound care. Responsible Party: DON/ADON, Target date: 2/11/2025 Follow up: Provide ongoing education to all new hires, agency, prn leave of absence prior to first shift worked and Follow WE CARE meeting process to ensure compliance. 3. All nursing staff will be provided with in-service following physician ordered wound care and documentation of wound care prior to next shift worked, including new hires, PRN, Vacation, Agency and Leave of Absence staff. Responsible Party: DON/ADON or Designee Target date: 2/11/2025 and ongoing Follow-up: Follow WE CARE meeting process to ensure compliance. 4. Identify any new wounds through orders, weekly skin assessments and admission assessments review completed during clinical morning meeting will be referred to primary care physician and wound care physician if ordered by primary care physician. Responsible Party: IDT Team Target date: 2/11/2025 and ongoing Follow-up: Follow WE CARE meeting process to ensure compliance. 5. Wound care physician will be notified via telephone by DON or designee when wound care consultation is ordered. Responsible Party: IDT Team Target date: 2/11/2025 and ongoing Follow-up: Follow WE CARE meeting process to ensure compliance. 6. AD HOC QAPI meeting conducted to discuss plan of correction for compliance. Responsible Party: IDT Team Target date: 2/11/2025 and ongoing Follow-up: Review any compliance issues in QAPI meeting for 3 months 7. Medical Director notified of alleged deficient practice. Responsible Party: Administrator Target date: 2/11/2025 The investigator monitored the Plan of Removal on 02/12/2025 as follows: During interviews conducted on 02/12/2025 between 12:00 noon through 3:30 PM, LVN F, LVN K, RN B, LVN A, LVN L, the MDS Nurse stated they were in-serviced by the ADON and the Administrator on 2/11/2025 and 2/12/2025 prior to their shifts. They stated they were in-serviced on wound care policy, notifying the DON of new wound care orders, implementing new wound care orders immediately after the Wound Doctor's visit. They stated they knew where to find the Wound Doctor's contact number at the nurse's station and in the Resident's chart in Point click Care, the system the facility use to document electronically. They stated they were in-serviced on documenting that treatments were done. They also stated, for new admission current residents, they were in-serviced to ensure skin assessments were done, if there were skin issues, document the color, size, odor and notify the primary care physician, DON and all parties. They stated they were told to follow up with referrals. During an interview on 2/12/2025 at 2:23 PM, the ADON stated she was in-serviced by the Nurse Consultant on 02/11/2025 on the process of new and current residents with wounds, skin assessments weekly as indicated. The ADON stated she was told to get a complete description of the wound, and notify the NP, transcribe orders immediately, communicate with the Wound Doctor if there were referrals, carry out orders from the Wound Doctor immediately. The ADON stated all Residents seen by the wound Doctor had his number in their chart where the nurses can look to contact him. The ADON stated she was to ensure the floor nurses are putting in orders immediately, completing wound care orders as ordered, following up with referrals. The ADON stated she was trained by the Administrator on 2/12/2025 on how to monitor PCC dashboard for missed treatment and follow up with the nurses why the treatments were missed. The ADON stated, she was to ensure after the wound Doctor's visits that all new orders were put in the Resident's charts. She stated the Nurse Consultant rechecked the Wound Doctor's orders from 02/11/2025 to ensure all orders from the Wound Doctor's visit were in the resident's charts. During an interview on 02/12/2025 at 2:54 PM the Administrator stated she was in-serviced by the Nurse Consultant on 02/12/2025 and she was in-servicing nurses at the beginning of their shifts on treatment orders, what to do if they identify new wounds. The Administrator stated the facility already identified all the wounds in the facility, they made sure the new wounds identified by the facility staff were seen by the Wound Doctor on 2/11/2025, made sure there were treatments in place and accurate, was verified by the Nurse Consultant and the Regional Director. The Administrator stated the facility would monitor through their daily morning meeting and the weekly WE Care meeting . The DON stated part of the morning meeting process, they would check the clinical dashboard to make sure treatment had been completed. The Administrator stated the Wound Doctor's contact was in PCC in the Resident's chart. The Administrator stated the DON was responsible to ensure treatments were done and she would designate someone in her absence of the DON. Review of Wound Doctor's visit orders dated 2/11/2025 reflected all new orders were in the Residents charts. Review of facility's in-services reflected in-services were initiated on 02/11/2025 at 5:35 PM with attached documents of: Medication orders, Pressure Ulcers/Skin breakdown-clinical Protocols: Receiving and Transcribing physician orders-Treatment Orders Physician Referrals-Wound assessment and Management Wound treatment documentation-Complete documentation and monitoring Review of facility's Quality Assurance Performance Improvement Committee document reflected QAPI had a meeting on 02/11/2025 to discuss IJ regarding wound care treatment orders. The Administrator was notified on 02/12/2025 at 3:36 PM that the IJ had been removed. While the IJ was removed on 02/12/25 at 3:36 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. 3. Review of Resident #1's face sheet printed on 01/28/25 reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] after an overnight stay in the emergency room . Her diagnoses included pressure ulcer of sacral region (between the buttocks) - stage 4, chronic pain, neuromuscular dysfunction of bladder (lack of bladder control due to a nerve problem), paraplegia (paralysis), and type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar). Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 11 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected she required substantial/maximal assistance with bed mobility. Section M (Skin Conditions) reflected she had an unhealed stage 4 pressure ulcer. Review of Resident #1's current clinical physician orders reflected an order dated 07/29/24, Change wound vac dressing every MWF and as needed. After removing dressing, apply [cleanser] soaked gauze for 3 minutes, apply topical iodine over wound bed, apply adaptic dressing to wound bed then apply wound vac foam at 150mmHg continuous. Apply Eakin ring around peri wound to prevent stool into wound. Use skin prep to protect skin from dressing. Another order dated 07/29/24 reflected, If wound vac is unable to hold a seal or turned off for 2 hours, remove entire dressing and replace with alginate packing. Review of Resident #1's January 2025 MAR and TAR reflected the wound vac dressing was not changed on 01/13/25 and 01/17/25 . Review of Resident #1's comprehensive care plan reflected in part: Problem - Last revised 10/18/24 - The resident has a pressure ulcer stage four to buttocks. NPWT wound vac is in place (continuous 150mm Hg) to promote healing process. Goal - The residents pressure ulcer will show signs of healing and remain free from infection. Interventions - Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. The care plan was not revised to reflect the current order for 125mmHg. Review of Resident #1's Wound Care Progress note, from the wound clinic physician, dated 01/22/25, reflected in part, Resident #1 stated that her wound vac had been changed once weekly. I contacted the ADON at the facility. Resident had a wound vac change that was not done on Friday 01/18/25 but otherwise had her dressing changed 3x/week . Initial sacral wound began April 2022 .She was off NPWT from 06/13/24-07/26/24 . Continue NPWT 125mmHg. During a brief interview on 01/27/25 at 3:30 PM with the ADM, a policy for wound vacs and nursing competencies for wound vacs were requested. A policy for wound vacs was not received prior to exit.

Based on interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #5) of six residents reviewed for pain. The facility failed to provide effective pain management for Resident #5 while she resided at the facility from 01/17/25 - 01/27/25. She had a recently acquired amputation that caused her to be in excruciating pain. The facility did not adjust her pain medication or notify her NP. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/29/25 at 4:04 PM and an IJ template was given. While the IJ was removed on 01/30/25 at 6:15 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Review of Resident #5's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, major depressive disorder, chronic pain, and acquired absence of left leg above the knee. Review of Resident #5's EMR, on 01/29/25, reflected her Admission MDS assessment had not been completed. Review of Resident #5's admission care plan, dated 01/17/25, reflected she had acute pain related to left AKA and sacroiliitis (a painful condition which affects both sacral joints ) with an intervention of monitoring/documenting for side effects of pain medication and notifying the physician if interventions were unsuccessful. Review of Resident #5's physician order, dated 01/17/25, reflected Hydrocodone-Acetaminophen Oral Tablet-325 MG - Give 1 tablet by mouth every 8 hours as needed for pain. Review of Resident #5's MAR , dated January 2025, reflected she was administered the medication (Hydrocodone-Acetaminophen) on the following days with the pain level (numerical) and effectiveness documented (pain level from 1-10): 01/17/25 at 10:36 PM - Pain Level 7 - Ineffective 01/18/25 at 4:30 AM - Pain Level 6 - Effective 01/18/25 at 10:03 PM - Pain Level 10 - Unknown if effective 01/19/25 at 8:40 AM - Pain Level 8 - Ineffective 01/19/25 at 4:40 PM - Pain Level 10 - Effective 01/20/25 at 10:50 PM - Pain Level 7 - Effective 01/21/25 at 11:25 AM - Pain Level 8 - Effective 01/22/25 at 10:15 AM - Pain Level 6 - Effective 01/26/25 at 3:47 AM - Pain Level 8 - Effective 01/26/25 at 5:55 PM - Pain Level 9 - Effective Review of Resident #5's physician order, dated 01/17/25, reflected Tylenol Oral Tablet - 325 MG - Give 2 tablets by mouth every 6 hours as needed for pain. Review of Resident #5's MAR, dated January 2025, reflected she was administered the medication (Tylenol) on the following days with the pain level (numerical) and effectiveness documented: 01/19/25 at 7:18 PM - Pain Level 8 - Effective 01/20/25 at 7:48 AM - Pain Level 4 - Effective 01/21/25 at 2:07 PM - Pain Level 3 - Effective Review of Resident #5's physician order, dated 01/18/25, reflected Buprenorphine Transdermal Patch Weekly 10 MCG/HR - Apply 1 patch transdermally one time a day every 7 day(s) for pain. Review of Resident #5's MAR, dated January 2025, reflected she only received the patch on 01/18/25. Review of an intake reported to HHSC, dated 01/24/25, reflected the following regarding Resident #5: RP and [Resident #5] report that at night when the CNAs [CNA G and CNA H] come in to provide care that they are rough with her and when she tells them she is hurting they will say we are not hurting you. Review of Resident #5's ER paperwork, dated 01/27/25, reflected the following: Reason for Admission: s/p Lt AKA pain . Left AKA stump wrapped, [Resident #5] intolerable of pain and refused exam on leg . . On exam, [Resident #5] has intractable pain . Patient uncomfortable and histrionic on exam per documentation. Left AKA stump with purulent drainage, mild skin necrosis . . [Resident #5] was discharged on the 17th to a skilled nursing facility and had increasing pain in her AKA site. [Resident #5] gets dialyzed Monday Wednesday Friday but apparently missed Friday's dialysis due to the pain . During a telephone interview on 01/29/25 at 1:12 PM, CNA G stated if a resident was complaining of pain, she would tell the nurse. She stated she remembered providing care to Resident #5 (on 01/23/25) and knew she had a fresh amputation so she understood she would be in pain. She stated she was swinging at us (she and CNA H) because of the pain she was in during peri care . She stated RN J knew how much pain she was in because she had gone in and out of the room. She stated she was not sure if RN J gave her medication or what medication could have been given because she was just a CNA and did not know about medications. She stated it took CNA H and herself at least 30 minutes to provide the care due to the amount of pain Resident #5 was in. She stated they were not purposely trying to hurt her but had to get her clean. Review of Resident #5's progress notes, on 01/29/25, reflected no documentation regarding the pain during peri care on 01/23/25 . Pain medication was not administered to Resident #5 until 01/26/25. During a telephone interview on 01/29/25 at 1:34 PM, Resident #5's NP stated she had never expressed pain to her. She stated she would expect nursing staff to notify her if pain was not being managed or if pain medications were not effective. She stated she could have done something about it. She stated Buprenorphine patch orders should be followed. She stated if the order was for every seven days, it should be changed every seven days as it would no longer be effective. She stated a negative outcome of being in uncontrolled pain could be high blood pressure, heavy breathing, or anxiety. She stated Resident #5 was always anxious. During a telephone interview on 01/29/25 at 2:46 PM, Resident #5's RP stated he believed the staff agreed the pain medication was not sufficient while she was at the facility, but they were just following the orders given. He stated her severe pain never subsided the whole time she was at the facility. He stated she recently (01/28/25) had to have a procedure where they put a tube in her wound (incision site) to drain it due to an infection. He stated the infection had been causing her even more pain. An attempt was made to interview RN J on 01/29/25 at 3:04 PM. A returned call was not received prior to exiting. Review of the facility's Pain Policy, Revised October 2022, reflected the following: . The staff will assess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain. . If the resident's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support. The ADM was notified on 01/29/25 at 4:04 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 01/30/25 at 10:47 AM: The notification of Immediate Jeopardy states as follows: F697 The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Statement of Deficient Practice: The facility failed to provide effective pain interventions for Resident #5. CORRECTIVE ACTION: 1. Upon learning of the deficient practice the Regional Director of Clinical Services and Nurse Consultant began a review of residents charts for pain assessment orders . RESPONSIBLE PARTY: RDCS TARGET DATE: 1/29/25 FOLLOW-UP: Monitor for completion through morning meeting process. CORRECTIVE ACTION: 2. DON began inservice education for all nurses currently on shift regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by regimen in place and how to conduct a pain assessment properly. Nursing Administration will complete a second pain assessment on 5 residents twice weekly for 3 months to ensure proper assessment of resident pain and level of nurse proficiency. Regional Director of Clinical Services and Nurse Consultant have conducted a pain assessment on each resident currently in the facility and residents will be continued to be assessed q shift ongoing. No residents have been identified at this time for uncontrolled pain. RESPONSIBLE PARTY: DON TARGET DATE: 1/29/25 FOLLOW-UP: Provide ongoing education to all new hires, agency, prn, leave of absence prior to first shift worked. CORRECTIVE ACTION: 3. All licensed nursing staff will be provided with in-service education on regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by current regimen prior to next shift worked, including new hires, PRN, Vacation, Agency and Leave of Absence staff. RESPONSIBLE PARTY: DON/ADON or Designee. TARGET DATE: 1/29/25 and ongoing. FOLLOW-UP: Review daily staffing to ensure compliance. CORRECTIVE ACTION: 4. Confirm that pain assessment order was placed on the resident chart for all new admissions, readmissions or new complaints RESPONSIBLE PARTY: DON/ADON or Designee TARGET DATE: 1/29/25 and ongoing. FOLLOW-UP: Follow morning meeting process to ensure compliance CORRECTIVE ACTION: 5. Review all residents currently identified for increased or change in pain weekly during WE CARE clinical meeting to confirm ongoing interventions and physician notification. RESPONSIBLE PARTY: IDT Team TARGET DATE: 1/29/25 and ongoing. FOLLOW-UP: Follow WE CARE meeting process to ensure compliance. CORRECTIVE ACTION: 6. AD HOC QAPI meeting conducted to discuss plan of correction for compliance. RESPONSIBLE PARTY: IDT Team TARGET DATE: 1/29/25 FOLLOW-UP: Review any compliance issues in QAPI meetings for 3 months CORRECTIVE ACTION: 7. Medical Director notified of alleged deficient practice. RESPONSIBLE PARTY: Administrator TARGET DATE: 1/29/25 The Investigator monitored the Plan of Removal on 01/30/25 as followed: During interviews conducted on 01/30/25 between 11:13 AM and 6:06 PM, 3 rehab therapists, 2 RNs, 6 LVNs, and 11 CNAs from both shifts stated they were in-serviced on pain. They all stated that if any resident complained of pain during care, they would stop immediately. The CNAs and therapists said they would notify the nurse immediately. The CNAs said they would tell the nurse and give the nurse a written note as a reminder. The nurses stated they would assess the resident every shift and with every complaint of pain. The nurses stated they would provide pain medication and follow up to ensure effectiveness. They stated if the medication was not effective, they would notify the doctor or nurse practitioner. Review of the facility's QAPI agenda, dated 01/29/25, reflected the MD, ADM, DON, ADON , MDS Nurse, SW, and Licensed Nursing Staff were in attendance. Review of an in-serviced entitled Pain, dated 01/29/25, reflected all nursing staff were in-serviced on their pain policy and the following: Monitor for pain every shift. Document pain/pain levels. Complete pain assessment if resident has pain. Provide medication if needed. If resident does not have pain meds notify MD/NP and document in EMR. CNA and Nurse will stop ADL, wound care, etc. and resident must be assessed and medication for pain. Activity resume with medication. Review of the WE CARE documentation form, revised 04/2023, reflected the form identified the procedure for conducting the meeting and the information to be reviewed. The information included pain and how the ADON or designee would review PRN pain medication documentation in [EMR system] for residents taking pain medications consistently. The facility had not had their weekly WE CARE meeting prior to exit. The ADM was notified the IJ was lowered on 01/30/25 at 6:15 PM. However, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure each resident was treated 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, self-determination, recognizing each resident's individuality and failed to protect and promote the rights of the residents for one (Resident #1) of four residents reviewed for rights, in that: The facility failed promote the rights of Resident #1 by not allowing her to choose what diet she was served. Resident #1 had been served a pureed diet since April of 2023 while actively requesting a mechanical soft diet which often left her starving, feeling depressed, inadequate, and feeling less of a person and like a nobody. This deficient practice placed residents at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, unspecified protein-calorie malnutrition, and muscle weakness. Review of Resident #1's quarterly MDS assessment, dated 08/29/23, reflected a BIMS of 11, indicating a moderate cognitive impairment. Review of Resident #1's quarterly care plan, dated 08/04/23, reflected she had potential nutritional problem related to history of poor nutritional intake, diet restrictions, and non-compliance with current diet recommendations (regular diet, pureed texture) with an intervention of RD evaluating and making diet change recommendations PRN. Review of Resident #1's progress notes in her EMR, dated 04/20/23 documented by LVN A, reflected the following: [Resident #1] talked to [LVN A] last week about not wanting to do the thicken liquids and pureed diet. [Resident #1] wanted to talk to the doctor, [LVN A] explained to her that [FM B] is the one to okay that . Review of Resident #1's progress notes in her EMR, dated 04/22/23 documented by LVN A, reflected the following: [Resident #1] noted in the dining room going around trying to eat from other residents' plates. When staff attempts to redirect and educate resident on her diet of pureed and thickened liquid along with the risk of aspiration, [Resident #1] states, I don't care I don't like that baby food I want regular food, if I choke at least I'll be happy. Review of Resident #1's progress notes in her EMR, dated 04/28/23 and documented by the SW, reflected the following: The Ombudsman inquired about changing [Resident #1]'s diet. According to the Ombudsman, [Resident #1] understands the risk and is willing to accept the risks i.e., choking etc. Review of Resident #1's progress notes in her EMR, dated 07/31/23 and documented by LVN A, reflected the following: [Resident #1] was noted at nurses' station eating an oatmeal cream pie. [Resident #1] refused to give [LVN A] the oatmeal cream pie and started eating it faster. Instructed [Resident #1] to slow don and reminded her she should not be eating that type of food. [Resident #1] offered yogurt but refused to give up snack. Review of Resident #1's MD progress note, dated 10/10/23 , reflected the following: Also participated in care plan meeting on 10/11/23 regarding [Resident #1]'s right to be on regular diet instead of pureed; [FM B] insists on dysphagia diet. . Assessment and Plan 1. Dysphagia: [Facility] continues to recommend current duet recommendations. Remains at risk for aspiration PNA due to diet request but she (Resident #1) is able to indicate to me and others her wishes and the risks. I believe [Resident #1] has a right to decide her own treatment including diet texture. 2. Dementia: . retains executive functioning and understanding of current situation and risks of changing to regular diet. Review of Resident #1's progress notes in her EMR, dated 10/11/23, reflected the following: A care plan for [Resident #1] was held on 10/11/23 regarding her desire to eat mechanical soft food even though her orders are for pureed food. Attending: ADM, DON, SW, MDS Nurse, Dietary Manager, and three Ombudsmen. [Resident #1] has orders for pureed foods due to her swallowing issues. [Resident #1] has voiced that she wants to eat mechanical soft foods due to the consistency. The facility's view is that [Resident #1] needs to stay on pureed food for her safety. ADM voiced the facility's concern of [Resident #1] eating mechanical soft food due to the fact it could kill her. [Resident #1] said she understood. [FM B] voiced her strong disagreement with [Resident #1] and that she does not want her on mech soft foods due to the chance of it eventually killing her. Ombudsmen voiced that it was [Resident #1]'s right to eat mechanical soft food if she wanted to. [Resident #1]'s MD voiced that [Resident #1] had the capacity to make the decision to eat mechanical soft foods . ADM asked [Resident #1] if she understood that if she chose to eat mechanical soft food that she could possibly start getting sick more and more and then it could eventually kill her. [Resident #1] stated yes . Review of Resident #1's physician orders on 11/28/23, reflected her diet had been changed to mechanical soft the day prior, 11/27/23. During a telephone call on 11/28/23 at 10:54 AM, the facility Ombudsman stated Resident #1 first made the complaint regarding her diet in April of 2023. She stated Resident #1 told her she could not stand to eat different colored pudding. She stated she made contact with a charge nurse who stated she would put it in her chart to follow up on. She stated in June a care plan meeting was held. She stated the facility MD joined via phone and stated he had interviewed and evaluated Resident #1 and she understood the risks, it was a quality-of-life issue, and she should be allowed to eat the diet she preferred. She stated FM B is passionate about keeping Resident #1 on a pureed diet due to risk of aspiration as she had been diagnosed with pneumonia in the past. She stated the DON told her there was a reason she was on a pureed diet and the Ombudsman informed her it was a resident's rights issue. She stated the DON told her if Resident #1 agreed to be a DNR, she would change her diet. The Ombudsman stated she felt like that was an extremely inappropriate thing to say. She stated her diet was never changed. She stated they had another care plan meeting in October with FM B and the MD on the phone. She stated the MD reaffirmed that Resident #1 had the cognitive function to make the decision. She stated she again reiterated to the DON Resident #1's rights and that the MD had stated she had executive function to make that choice. She stated Resident #1 had been telling her she had been starving and was eating snacks off the snack cart because she was so hungry. During a telephone interview on 11/28/23 at 11:36 AM, Resident #1's MD stated he evaluated her a couple of months ago and yes, she had capacity to make the determination of her diet, she understood the consequences, and he recommended the facility allow her to advance her diet. He stated he was aware how against it FM B was, but it should not be up to her. He stated the facility seemed to think FM B was Resident #1's MPOA and had to listen to her. He stated he communicated his determination to FM B in the care plan meetings and she became irate. He stated he could understand the facility's reluctance as it could be an ethics issue. He stated the resident had a right to make the determination as to what diet she preferred and FM B's preferences should not be taken into account while Resident #1 still has capacity and was clear in her actions. He stated he was not sure why the change in her diet had still not been made. During an interview on 11/28/23 at 11:51 AM, the SW stated they have had several care plans regarding Resident #1 wanting to update her diet to mechanical soft. She stated the ST, ADM, DON, and FM B were against updating her diet. She stated the MD was very clear with the facility about her having the cognitive function to make that decision. She stated she understood Resident #1's FM B wanted her to be around longer, but she still had the right to choose. She stated Resident #1 went to her office all the time begging for snacks because she was starving. She stated if a resident was not getting a diet they wanted, it would be an infringement on their rights. During an observation and interview on 11/28/23 at 12:12 PM, Resident #1 was in the dining room finishing her lunch. Her meal ticket revealed her diet was mechanical soft with thickened liquids with no bread allowed. She stated this was the first day she received a mechanical soft diet. She stated she loved corn bread and rolls and it was ridiculous her meal ticket read no bread. She stated she understood FM B's concerns. She stated she loved FM B and FM B loved her, but it was not her life. She stated she understood what could happen if she ate a mechanical soft diet, I could choke and die! She stated any time she coughed, everyone freaked out that she was choking. She stated she smoked all her life and she had a smoker's cough, and it did not always mean she was choking. She stated she had been going back and forth with the facility for months about her diet and it truly pissed her off. Resident #1 began crying and stated it made her feel like she had no rights, she was inadequate, less of a person, and like a nobody. She stated she did not want to live if she could not eat regular food like she wanted because she was not a baby and wanted to live her life. She stated she had felt so depressed the last few months and was tired of it. During an interview on 11/28/23 at 1:11 PM, the DON stated she started working at the facility at the beginning of June. She stated she was made aware that Resident #1 had been telling the Ombudsman that she wanted to eat regular food, so shortly after she started ST agreed to upgrade her diet to a mechanical soft diet for lunch only . She stated a few days later she was diagnosed with pneumonia, so her diet went back to strictly pureed. She stated Resident #1 had a TBI and did not always make the smartest choices and that was why she could not make her own decisions. She stated Resident #1 would not think of the consequences that may come at a later date. When asked if not letting Resident #1 choose her diet was against her right, she stated there was a fine line between a resident's right and her obligation to keep them safe. She stated she tried to explain to the Ombudsman that yes, she has rights, but if we willingly and knowingly feed her something that could potentially kill her, what would that say about us? We would be letting her harm herself. She stated she could not remember what the MD stated regarding the issue of Resident #1's diet. Review of the facility's Resident's Rights Policy, revised December of 2016, reflected the following: 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 . e. self-determination . p. be informed of, and participate in, his or her care planning and treatment Review of the facility's Diets Offered by the Facility Policy, dated 2018, reflected the following: . 4. If the physician declines the recommendation, the nutrition professional will write the special diet with extensions as ordered. 5. Resident response to special diets will be monitored by the Nutrition and Food Service Manager. If the resident does not accept the special diet, a recommendation will be made to the physician for a change to a more acceptable diet.

Based on observation, interview, and record review the facility failed to provide care that included but not limited to assessing, evaluating, and responding to resident's care needs. The facility failed to assess Resident # 1's G tube and JP drains and provide care needed. This failure placed residents at risk of not getting their care needs assessed and provided by competent nursing staff. An IJ was identified on 6/12/2023. The IL template was provided to the facility on [DATE] at 5:55PM. While the IJ was removed on 6/14/2023 at 5:00PM, the facility remained out of compliance at the scope of actual harm with the potential for more than minimal harm that is not immediate because all staff had not been rained on all corrective systems. Findings included: Review of Resident #1 face sheet reflected that she was a 54- year- old woman, admitted to the facility on [DATE] with a diagnosis of Gastroenteritis ( an internal infection marked by diarrhea, cramping, nausea, vomiting and fever) and Colitis (inflammation in the colon) due to radiation, Gastroparesis, D Urinary Incontinence (Unintentional passing or urine), Hypertensive Retinopathy (retinal vascular damage caused by hypertension), Bilateral Hydroureter ( dilation of the renal pelvis, calyces and ureter), Hydronephrosis (excess fluid in the kidney due to a backup of urine) with ureteral structure, and Acute embolism ( blockage of a pulmonary lung artery) and Thrombosis (serious condition where one or more blood clots form in your blood vessels or heart). Resident # 1 admitted to the facility with 2 JP ([NAME]- [NAME] surgical drains, a closed suction device that collects fluids) drains and bulbs and a G tube (Gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach). Review of Resident # 1 admission MDS dated [DATE], reflected a BIMS score of 15 which indicated Resident # 1 has the cognitive ability to make her wants and needs known. Section G functional status of the MDS reflected Resident # 1 was totally dependent on assistance with bathing, and personal hygiene. Resident # 1 required extensive assistance with brushing teeth, combing hair, and washing face. Resident # 1 required two- person assist with transfers. Review of Resident # 1's care plan dated 5/17/2023, did not reflect or address the care for the G- Tube or JP drains. During an interview on 6/9/2023 at 6:10pm with Resident # 1 at local hospital, revealed she felt like the facility was killing her. She stated her G -Tube and JP drains had been in that condition for weeks, she stated when she would tell the staff that they would say they were going to come back and flush her tubes and dump her drains, but they never came back, and it continued to get worse During an interview on 6/10/ 2023 at 3:13pm with LVN B, revealed she advised the ADON on 6/4/2023 of the condition of the G- Tube and JP drains of Resident # 1. She stated she observed the G Tube to be clogged and dirty with fluid, she stated she was not able to flush the G-Tube at the time due to the condition. During an interview on 6/10/2023 at 3:35pm with the ADON, revealed LVN C advised her on 6/2/2023 of the condition of Resident # 1's G -Tube and JP drains, she stated she was also advised on 6/4/2023 by LVN B of the condition of Resident #1's G-Tube and JP drains. The ADON stated she never saw or assessed the condition of Resident # 1's G Tube or JP drains herself. The ADON stated she sent the referral to the hospital on 6/7/2023. The ADON stated Resident # 1 could have gotten a bacterial, fungal infection or sepsis. In an interview on 6/10/2023 at 3:15PM the DON, stated LVN A advised her that there were maggots, flies, and mold on the G- tube and JP drains for Resident # 1. The DON stated she never assessed Resident # 1's condition or saw the condition of the G- tube or JP drains. The DON stated they had frequently discussed the issue in their morning meetings. The DON stated the nurse's job was for them to monitor the G tube and JP drains and clean them as needed according to the physician's orders. The Don stated this could have caused the resident to get an infection and other bacterial diseases causing more health issues. Record review of hospital records dated 6/9/2023, reflected Resident # 1 was admitted due to concerns with tubes. The report reflected Resident # 1 had feculent material from JP drains. Mold growing on G Tube as well as fruit flies, maggots noted. Stated the resident that this had been going on for some time and that she complained of nausea, abdominal pain for the past two weeks. Records reflected Resident # 1 G-tube and JP drains appeared to have been neglected due to the condition. The record indicated Resident #1 's health conditions were described as having the drains in a bag where it was draining and had a very foul odor. The 2 JP drains and G Tube had not been flushed and cleaned properly over a period. Record Review of the physician's orders: 4/29/2023 - Empty surgical drain to right upper abdomen every shift for wound 4/29/2023- Empty surgical drain to right lower abdomen 5/1/2023- Flush PEG tube with 100ml of H20 once per shift two times a day for G tube 5/31/2023 Flush Each Drains with 5ml of H2O Q-shift evening shift 6/5/2023 Send to hospital IR for replacement of G tube. Review of progress note dated 6/4/2023 by LVN B, reflected Unable to flush due to inability to flush. ADON notified. Resident eating and drinking orally. Record review of progress note dated 6/5/2023 by LVN C, reflected Mold noted to G-tube and dr. notified for further instruction Record review of progress note dated 6/7/2023 by LVN D, reflected G tube, tagged off due to the appearance of mold in G-tube appointment for tomorrow to evaluate. Record review of progress note dated 6/9/2023 by LVN A, reflected Resident # 1 had 2 JP drains to Right lower quadrant of abdomen. Upon entering room to flush JP drain as ordered q shift, drains found in a bag with mold, flies, and fly larva inside. Strong prudent and foul odor. Drains were not flushed due to condition they were found in. Copious (abundant) amounts of prudent drainage. Resident # 1 requested to be sent to ER (emergency room ). 911 notified and Resident # 1 was sent to the hospital. Record review of facility Policies: JP (Jackson Pratt) Drains policy dated March 2019 reflected the following: Empty the bulb every 8 to 12 hours or when half full If a large amount of fluid leaks from around the drain site, use soap and water to clean the area The skin around the drain may become infected. Signs and symptoms of infection include: Cloudy, foul-smelling drainage Abuse/Neglect policy dated Dec. 2016 reflected the following: All residents have the right to be free from abuse/neglect The ADM was notified on 6/12/2023 at 5:55PM that an Immediate Jeopardy had been identified due to the above failure. The IJ template was provided to the ADM on 6/12/2023 at 5:55PM. A Plan of Removal was first submitted by the ADM on 6/12/2023 at 8:15PM. The Plan of removal accepted on 6/13/2023 at 4:33PM. Plan of Removal F600- The facility failed to ensure that the resident was free from Neglect. Impact Statement All residents could be at risk of developing infections and other bacterial diseases such as sepsis and or death from being neglected. 1. Action Item: Current Director of Nursing and Assistant Director of Nursing will be terminated effective 06/13/23. 2. Action Item: Interim DON/Regional Director Clinical Services assessed all residents with JP drains or feeding tubes by 6/13/2023. Orders and care plans reviewed by 6/13/2023. 3. Action Item: Interim DON/Regional Director Clinical Services will in-service licensed nurses on proper assessment, care and monitoring of JP Drains and feeding tubes prior to beginning of next scheduled shift. 4. Action Item: The JP drains and feeding tubes will be identified by nursing during review of pre-admit clinical documentation and new admission review. Orders will be reviewed during morning meeting to ensure assessment measures are included. 5. Action Item: Orders dictating proper assessment care and monitoring of JP Drains and feeding tubes will be obtained from the physician and entered in the resident's chart in Point Click Care. 6. Action Item: Care Plans for all residents with JP drains of feeding tubes have been updated on 7. Action Item: Resident who are admitted with JP drains and or feeding tubes will be assessed and monitored upon admission by interim DON. 8. Action Item: Licensed nursing staff will be educated prior to the beginning of their next shift about conducting weekly skin assessments. 9. Action item: Licensed nursing staff will be educated prior to the beginning of their next shift about documenting on the resident treatment record. 10. Action item: Licensed nursing staff will be educated prior to the beginning of their next shift about proper documentation and notification of residents change of condition. 11. Action Item: All staff will be educated on identifying changes of condition and notification of change of condition utilizing the Interact Stop, Watch, and Change of Condition form prior to the beginning of their next shift. 12. Action Item: All staff will be educated on identifying and prevention of resident neglect prior to the beginning of their next shift. Observation made on 6/14/2023 at 3:00pm of G Tube flush by LVN D, observed using appropriate hand hygiene, staff used gloves in the process. LVN D talked with resident prior to providing the care, Resident was in a pleasant mood, LVN D reviewed the order to ensure the right person and the right amount of fluid was being used to flush the G tube. Observation of the flushing reflected no concerns, no clogs noted during the process LVN D assessed the residents G tube entry site no concerns noted. No redness or irritation observed. Observation made on 6/14/2023 at 3:10PM of PCC documentation by, LVN D observed documenting in PCC the completed task of flushing the residents G tube according to the order and documenting any concerns noted. During an interview on 6/14/2023 at 3:15PM with Resident # 2, stated she was doing fine. Stated staff always check and clean her G tube, she stated she had no concerns at this time. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. During an interview on 6/14/2023 at 3:25PM with Resident # 3, stated he was doing fine, Resident # 3 thanked surveyor for checking on him. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. Resident # 3 G tube appeared to be functioning properly and flowing. During an interview on 6/14/2023 at 3:35PM with Resident # 4, stated she was doing fine. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged, appeared to be flowing properly. During an interview on 6/14/2023 at 3:40PM with Resident # 5, stated she was doing fine. Stated staff check on him all the time. Resident # 5 stated he did not have any concerns at this time. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. During an interview on 6/14/2023 at 2:30PM with LVN D, revealed she worked the 6AM-6PM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. She was able to discuss the procedures when flushing the G tube and the monitoring of the G tube. LVN D stated a G tube and JP drains should be monitored according to the order but believed that it should be monitored more so that any a change in condition or concerns can be noted quickly. LVN D was able to discuss the procedure when reporting suspected abuse/neglect and reported that the Administrator was the abuse/ neglect coordinator. During an interview on 6/14/2023 at 2:40PM with LVN C, revealed she worked the 6AM-6PM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN C was able to discuss when assessing a resident that they should be documenting the output, soiled dressing from either G tube or JP drains, and irritation or infection around the entry site of the tube. LVN C discussed if they G tube is clogged and unable to flush to immediately notify the provider and advise that they are sending the resident to the hospital. LVN C reported the administrator is the abuse/neglect coordinator and stated they contact him immediately if they see or suspect abuse/ neglect. During a phone interview on 6/14/203 at 4:34PM with LVN E revealed, she worked the 6PM-6AM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN E stated when assessing residents with G tubes and JP drains, she goes by the orders. She stated they are assessing for signs of infection, irritation around the entry site, they are assessing the condition of the tubes and if they are functioning properly, they are assessing any changes in the resident's condition. LVN E stated any changes in any of these areas they are documenting in the PCC system and contacting the provider for further instructions. She stated if a resident had to be sent out to the ER, they are notifying the DON, Admin, and the family. LVN E stated the Admin. was the abuse/neglect coordinator and they reported any signs of suspected abuse/neglect immediately. During a phone interview on 6/14/203 at 4:45PM with LVN F revealed, she worked the 6PM-6AM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN F reported they are checking for any changes in the resident's condition. She stated they are checking to ensure that G tube and JP drains are functioning and that they can be flushed and dumped as required according to the orders. LVN F stated any changes in these areas they are documenting in the PCC system and notifying the provider of the changes or concerns noted. She stated the Admin. was the abuse/ neglect coordinator and they are to report any signs of abuse/neglect immediately. During an interview on 6/14/2023 at 5:00PM with Admin. revealed he expected staff to follow the orders that were in place. If there is an emergency the nursing staff was able to contact the provider (NP) on-call line if needed Medline for guidance or should have sent the resident out to the hospital in an emergency. He stated all staff were trained on abuse/ neglect and the protocol if they see or suspect abuse or neglect, stated all contact numbers were located at each nurse's station. During an interview on 6/14/2023 at 3:15PM with interim DON, revealed the facility had no other residents with JP drains and bulbs. She stated there are four residents who have G-tubes, and all residents were assessed, orders and care reviewed. Record review on 6/14/2023 of in-services on Care, Assessment and Monitoring of JP drains and Enteral Feeding Devices reflected 10 nursing staff in-serviced. Record review on 6/14/2023 of PCC regarding resident assessment, orders and care plan reviewed, reflected the four residents identified as having G tubes were reviewed in PCC system. Each resident's care plan had been updated to reflect the care needs for the resident and the G tube, the orders were reviewed for each resident verified to be current and in the PCC system indicating the cleaning needs and frequency of the G tubes. Each resident was assessed and documentation in the PCC system reflected the residents current care needs. Record review of personnel file for DON, reflected the DON was terminated effective 6/13/2023. Record review of personnel file for ADON, reflected the ADON was terminated effective 6/13/2023 6/14/2023- Review of orders residents who currently have G-tube Resident's # 2, # 3, # 4, and #5. All orders have been entered into the Point Click Care system 6/14/2023 review of care plans reflected the care plans were updated 6/14/2023 to care and assessment needs for the following Residents # 2, #3, # 4, and # 5. 6/13/2023 to include proper assessment, care, and monitoring. All new admission residents will have an initial care plan updated to include proper assessment, care, and monitoring. 6/14/2023 Record review reflect the MDS coordinator was in-serviced on comprehensive care plans for residents with JP drains and G tubes 6/14/2023 record review reflect in-service with nursing staff on completion of interim care plans for residents, 8 nursing staff completed this in-service No new admissions at this time, Resident # 2 was admitted on [DATE] and documentation reflected he was assessed for his G tube care and needs. Record review of in-service dated 6/14/2023, reflected 10 nursing staff had been in-serviced on weekly skin assessments for residents. Record review on 6/14/2023 of skin assessments completed for Resident's # 2, # 3, # 4, and #5. Record review of in-service on electronic documentation of treatment provided dated 6/14/2023, reflected 10 nursing staff had completed this training. Record review of in-service of Change in Condition dated 6/14/2023 reflected 8 licensed nursing staff and 9 CNA/CMAs had completed this training. Record review of in-service of Change in Condition documentation utilizing the Stop, Watch, and Change in Condition form dated 6/14/2023 reflected 8 licensed nursing staff and 9 CNA/CMAs had completed this training. Record review of in-service of Abuse/Neglect dated 6/14/2023 reflected all staff had completed this training. An IJ was identified on 6/12/2023. The IJ template was provided to the facility administrator on 6/12/2023 at 5:55PM. While the IJ was removed on 6/14/2023, the facility remained out of compliance at a scope of isolated and a severity level actual harm because all staff had not been trained on effectiveness of corrective systems.

Based on observation, interview, and record review the facility failed to ensure residents were free from Neglect for 1of 5 residents (Resident #1) reviewed. The facility failed to ensure that Resident # 1's G Tube and JP drains were cleaned and flushed according to physician's orders, causing the G tube and JP drains not to function properly. The facility failed to ensure Resident # 1 who had a G tube and JP drains received appropriate care and treatment timely. The tubes and drain were found to be dirty and clogged with mold, gnats, flies, maggots, and fly larvae. As a result, the resident was sent to a local hospital for evaluation and treatment The facility failed to follow the NP order to send the resident to the hospital on 6/5/2023 for interventions and was not sent out until 6/9/2023. This failure placed all residents at risk for Neglect An IJ was identified on 6/12/2023. The IL template was provided to the facility on [DATE] at 5:55PM. While the IJ was removed on 6/14/2023 at 5:00PM, the facility remained out of compliance at the scope of actual harm with the potential for more than minimal harm that is not immediate because all staff had not been rained on all corrective systems. Findings included: Review of Resident #1 face sheet reflected that she was a 54- year- old woman, admitted to the facility on [DATE] with a diagnosis of Gastroenteritis ( an internal infection marked by diarrhea, cramping, nausea, vomiting and fever) and Colitis (inflammation in the colon) due to radiation, Gastroparesis, D Urinary Incontinence (Unintentional passing or urine), Hypertensive Retinopathy (retinal vascular damage caused by hypertension), Bilateral Hydroureter ( dilation of the renal pelvis, calyces and ureter), Hydronephrosis (excess fluid in the kidney due to a backup of urine) with ureteral structure, and Acute embolism ( blockage of a pulmonary lung artery) and Thrombosis (serious condition where one or more blood clots form in your blood vessels or heart). Resident # 1 admitted to the facility with 2 JP ([NAME]- [NAME] surgical drains, a closed suction device that collects fluids) drains and bulbs and a G tube (Gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach). Review of Resident # 1 admission MDS dated [DATE], reflected a BIMS score of 15 which indicated Resident # 1 has the cognitive ability to make her wants and needs known. Section G functional status of the MDS reflected Resident # 1 was totally dependent on assistance with bathing, and personal hygiene. Resident # 1 required extensive assistance with brushing teeth, combing hair, and washing face. Resident # 1 required two- person assist with transfers. Review of Resident # 1's care plan dated 5/17/2023, did not reflect or address the care for the G- Tube or JP drains. Observation on 6/9/2023 at 6:10pm of Resident #1's G-Tube and 2 JP drains at hospital. The G-Tube was observed to be clogged and very dirty with fluid, it did not appear to have not been flushed according to the order. Observation of 2 JP drains and bulbs revealed they were clogged with fluid and dirty. The bulbs were observed on a plastic bag with a foul odor coming from the bag. The bulbs had fluid gathered that was a brownish color, there was a towel wrapped around the bulbs in the bag that was soaked in fluid from the drainage. Record review of hospital records dated 6/9/2023, reflected Resident # 1 was admitted due to concerns with tubes. The report reflected Resident # 1 had feculent material from JP drains. Mold growing on G Tube as well as fruit flies, maggots noted. The record indicated the resident stated this had been going on for some time and that she complained of nausea, abdominal pain for the past two weeks. Records reflected Resident # 1 G-tube and JP drains appeared to have been neglected due to the condition. The records indicated Resident #1 's health conditions were described as having the drains in a bag where it was draining and had a very foul odor. The 2 JP drains and G Tube had not been flushed and cleaned properly over a period. Record Review of the physician's orders: 4/29/2023 - Empty surgical drain to right upper abdomen every shift for wound 4/29/2023- Empty surgical drain to right lower abdomen 5/1/2023- Flush PEG tube with 100ml of H20 once per shift two times a day for G tube 5/31/2023 Flush Each Drains with 5ml of H2O Q-shift evening shift 6/5/2023 Send to hospital IR for replacement of G tube. Review of progress note dated 6/4/2023 by LVN B, reflected Unable to flush due to inability to flush. ADON notified. Resident eating and drinking orally. Record review of progress note dated 6/5/2023 by LVN C, reflected Mold noted to G-tube and dr. notified for further instruction Record review of progress note dated 6/7/2023 by LVN D, reflected G tube, tagged off due to the appearance of mold in G-tube appointment for tomorrow to evaluate. Record review of progress note dated 6/9/2023 by LVN A, reflected Resident # 1 had 2 JP drains to Right lower quadrant of abdomen. Upon entering room to flush JP drain as ordered q shift, drains found in a bag with mold, flies, and fly larva inside. Strong prudent and foul odor. Drains were not flushed due to condition they were found in. Copious (abundant) amounts of prudent drainage. Resident # 1 requested to be sent to ER (emergency room ). 911 notified and Resident # 1 was sent to the hospital. Recordd review of TAR (treatment adminsitration record) dated 6/1/2023 -6/9/2023, reflected for the order to Flush the PEG tube with 100ml once per shift reflected the tube was not flushed on 6/3/2023, 6/6/2023, and 6/9/2023 Empty surgical drain to upper right abdomen and lower right abdomen every shift reflected not dumped 6/3/2023, 6/6/2023, and 6/9/2023, and Flush each drain with 5ml of H2O Qshift in evening- not completed 6/3, 6/9 Review of Admission record to facility dated 5/2/2023, reflected Resident # 1 admitted to the facility with G tube and JP drains in place, Facility Physical exam dated 5/2/2023, reflected Gastrointestinal: Abdomen soft , Non-tender, Normative BS, Drain x 2 abdomen, G tube L abdomen, no concerns noted with G tube or JP drains upon admission to facility. During an interview on 6/9/2023 at 6:10pm with Resident # 1 at the hospital, revealed she felt like the facility was killing her. She stated her G -Tube and JP drains had been in that condition for weeks, she stated when she would tell the staff that they would say they were going to come back and flush her tubes and dump her drains, but they never came back, and it continued to get worse. She stated the smell was bad, so she stopped going to therapy the last three days due to not wanting others to smell her bag. Resident # 1 stated she would ask the facility for bags for the JP drains. She stated she wrapped the towel around the drains, but the towel got soaked from the drainage and was smelling also. Resident # 1 stated she felt sick to her stomach and that she had pain in her abdomen area. During an interview on 6/12/2023 at 8:10am LVN A stated she worked at the facility on 6/8/2023 the 6pm to 6am shift. She stated when she came on shift, the nurse going off advised her that Resident # 1 had a G-Tube and 2 JP drains. She stated when she assessed Resident # 1 and entered the room there was a very foul odor. She stated the two JP drains were in a transparent plastic bag, filled with flies/Larva, and discharge from the drains. She stated the G-Tube was clogged and filled with fluid and had appeared to have not been flushed over a period of time. LVN A stated she immediately knew the resident needed to be sent out to the hospital, she stated she could not risk flushing the G Tube line and those fluids get flushed into the resident's system. LVN A stated Resident # 1 reported that she had been telling the facility for about two weeks. She stated the JP drains and G tube had been in that condition for about two weeks. She stated Resident # 1 stated she was relieved that she was sending her to the hospital. During an interview on 6/10/2023 at 3:06pm with the DON, revealed that she was made aware Resident # 1 was sent to the ER the morning of 6/9/2023. The DON stated LVN A advised her that there were maggots, flies, and mold on the G- tube and JP drains for Resident # 1. The DON stated she never assessed Resident # 1's condition or saw the condition of the G- tube or JP drains. The DON stated they had problems with the odor since the resident admitted to the facility stated it was a rotten smell and it continued to get worse. The DON stated they had frequently discussed the issue in their morning meetings. The DON stated the nurse's job was for them to monitor the G tube and JP drains and clean them as needed according to the physician's orders. She stated the JP drains were draining dying flesh (caused from cancer) from the Resident # 1's body causing the odor. The DON stated they were working on trying to get Resident # 1 a referral to the hospital. During an interview on 6/10/ 2023 at 3:13pm with LVN B, revealed she advised the ADON on 6/4/2023 of the condition of the G- Tube and JP drains of Resident # 1. She stated she observed the G Tube to be clogged and dirty with fluid, she stated she was not able to flush the G-Tube at the time due to the condition. LVN B stated the ADON advised her that they were trying to get a consult with the NP. During an interview on 6/10/2023 at 3:35pm with the ADON, revealed LVN C advised her on 6/2/2023 of the condition of Resident # 1's G -Tube and JP drains. She stated she was also advised on 6/4/2023 by LVN B of the condition of Resident #1's G-Tube and JP drains. The ADON stated to her understanding the G Tube and drains were flushed and dumped. She stated once she was notified, they were trying to get Resident # 1 a consult with the NP. The ADON stated the NP assessed Resident # 1 on 6/5/2023 and stated she completed an order for Resident # 1 to be sent out to the hospital (IR) intervention radiology to have the G -Tube and JP drains replaced. The ADON stated she never saw or assessed the condition of Resident # 1's G Tube or JP drains herself. The ADON stated she sent the referral to the hospital on 6/7/2023. The ADON stated Resident # 1 could have gotten a bacterial, fungal infection or sepsis. Interview on 6/12/2023 at 12:30pm with the ADM, stated he was not aware that a resident had been sent out until 6/9/2023 in their morning meeting. He stated he never received a call about anyone being sent out to the hospital. He stated with Resident # 1 they were waiting for the hospital to get the right tubes and bulbs that fit so they could send her to back to the hospital to have them replaced. The ADM stated until they were able to get Resident # 1 an appointment scheduled the nursing staff were expected to follow the orders that were in place for the care of the G- tube and JP drains. Interview on 6/12/2023 at 2:12pm the NP, stated she assessed Resident # 1 on 6/5/2023. She stated she only assessed the G- tube because that's what staff reported was a problem. She observed the G -tube to have some residue around the entry site and it was clogged. She stated there did not appear to be mold when she observed the G tube, however she felt that it needed to be removed or changed since Resident # 1 was not using it at the time. She stated after she assessed Resident # 1, she completed an order for Resident # 1 to go to hospital (IR) to have the G -tube replaced, she stated usually they can get them in the next day. She stated the facility did not call and tell her that they had a problem getting Resident # 1 sent to the hospital, because if that was the case Resident # 1 needed to be sent to the emergency room . She stated she expected Resident # 1 to have been seen the next day at the hospital. The NP stated the Resident # 1 should have gone to the hospital before Friday 6/9/2023 with the condition of the G tube. The NP stated the facility never reached out to her or any of their on-call staff to indicate that there were any issues getting the Resident #1 seen at the hospital. She stated she believed that someone dropped the ball along the way and that is why it took that long for Resident # 1 to be sent out to the hospital. The resident could have developed an irritation, infection, and other bacterial diseases. Record review of facility Policies: JP (Jackson Pratt) Drains policy dated March 2019 reflected the following: Empty the bulb every 8 to 12 hours or when half full If a large amount of fluid leaks from around the drain site, use soap and water to clean the area The skin around the drain may become infected. Signs and symptoms of infection include: Cloudy, foul-smelling drainage Abuse/Neglect policy dated Dec. 2016 reflected the following: Residents have the right to be free from abuse/neglect The ADM was notified on 6/12/2023 at 5:55PM that an Immediate Jeopardy had been identified due to the above failure. The IJ template was provided to the ADM on 6/12/2023 at 5:55PM. A Plan of Removal was first submitted by the ADM on 6/12/2023 at 8:15PM. The Plan of removal accepted on 6/13/2023 at 4:33PM. Plan of Removal F600- The facility failed to ensure that the resident was free from Neglect. Impact Statement All residents could be at risk of developing infections and other bacterial diseases such as sepsis and or death from being neglected. 1. Action Item: Current Director of Nursing and Assistant Director of Nursing will be terminated effective 06/13/23. 2. Action Item: Interim DON/Regional Director Clinical Services assessed all residents with JP drains or feeding tubes by 6/13/2023. Orders and care plans reviewed by 6/13/2023. 3. Action Item: Interim DON/Regional Director Clinical Services will in-service licensed nurses on proper assessment, care and monitoring of JP Drains and feeding tubes prior to beginning of next scheduled shift. 4. Action Item: The JP drains and feeding tubes will be identified by nursing during review of pre-admit clinical documentation and new admission review. Orders will be reviewed during morning meeting to ensure assessment measures are included. 5. Action Item: Orders dictating proper assessment care and monitoring of JP Drains and feeding tubes will be obtained from the physician and entered in the resident's chart in Point Click Care. 6. Action Item: Care Plans for all residents with JP drains of feeding tubes have been updated on 7. Action Item: Resident who are admitted with JP drains and or feeding tubes will be assessed and monitored upon admission by interim DON. 8. Action Item: Licensed nursing staff will be educated prior to the beginning of their next shift about conducting weekly skin assessments. 9. Action item: Licensed nursing staff will be educated prior to the beginning of their next shift about documenting on the resident treatment record. 10. Action item: Licensed nursing staff will be educated prior to the beginning of their next shift about proper documentation and notification of residents change of condition. 11. Action Item: All staff will be educated on identifying changes of condition and notification of change of condition utilizing the Interact Stop, Watch, and Change of Condition form prior to the beginning of their next shift. 12. Action Item: All staff will be educated on identifying and prevention of resident neglect prior to the beginning of their next shift. Observation made on 6/14/2023 at 3:00pm of G Tube flush by LVN D, observed using appropriate hand hygiene, staff used gloves in the process. LVN D talked with resident prior to providing the care, Resident was in a pleasant mood, LVN D reviewed the order to ensure the right person and the right amount of fluid was being used to flush the G tube. Observation of the flushing reflected no concerns, no clogs noted during the process LVN D assessed the residents G tube entry site no concerns noted. No redness or irritation observed. Observation made on 6/14/2023 at 3:10PM of PCC documentation by, LVN D observed documenting in PCC the completed task of flushing the residents G tube according to the order and documenting any concerns noted. During an interview on 6/14/2023 at 3:15PM with Resident # 2, stated she was doing fine. Stated staff always check and clean her G tube, she stated she had no concerns at this time. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. During an interview on 6/14/2023 at 3:25PM with Resident # 3, stated he was doing fine, Resident # 3 thanked surveyor for checking on him. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. Resident # 3 G tube appeared to be functioning properly and flowing. During an interview on 6/14/2023 at 3:35PM with Resident # 4, stated she was doing fine. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged, appeared to be flowing properly. During an interview on 6/14/2023 at 3:40PM with Resident # 5, stated she was doing fine. Stated staff check on him all the time. Resident # 5 stated he did not have any concerns at this time. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. During an interview on 6/14/2023 at 2:30PM with LVN D, revealed she worked the 6AM-6PM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. She was able to discuss the procedures when flushing the G tube and the monitoring of the G tube. LVN D stated a G tube and JP drains should be monitored according to the order but believed that it should be monitored more so that any a change in condition or concerns can be noted quickly. LVN D was able to discuss the procedure when reporting suspected abuse/neglect and reported that the Administrator was the abuse/ neglect coordinator. During an interview on 6/14/2023 at 2:40PM with LVN C, revealed she worked the 6AM-6PM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN C was able to discuss when assessing a resident that they should be documenting the output, soiled dressing from either G tube or JP drains, and irritation or infection around the entry site of the tube. LVN C discussed if they G tube is clogged and unable to flush to immediately notify the provider and advise that they are sending the resident to the hospital. LVN C reported the administrator is the abuse/neglect coordinator and stated they contact him immediately if they see or suspect abuse/ neglect. During a phone interview on 6/14/203 at 4:34PM with LVN E revealed, she worked the 6PM-6AM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN E stated when assessing residents with G tubes and JP drains, she goes by the orders. She stated they are assessing for signs of infection, irritation around the entry site, they are assessing the condition of the tubes and if they are functioning properly, they are assessing any changes in the resident's condition. LVN E stated any changes in any of these areas they are documenting in the PCC system and contacting the provider for further instructions. She stated if a resident had to be sent out to the ER, they are notifying the DON, Admin, and the family. LVN E stated the Admin. was the abuse/neglect coordinator and they reported any signs of suspected abuse/neglect immediately. During a phone interview on 6/14/203 at 4:45PM with LVN F revealed, she worked the 6PM-6AM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN F reported they are checking for any changes in the resident's condition. She stated they are checking to ensure that G tube and JP drains are functioning and that they can be flushed and dumped as required according to the orders. LVN F stated any changes in these areas they are documenting in the PCC system and notifying the provider of the changes or concerns noted. She stated the Admin. was the abuse/ neglect coordinator and they are to report any signs of abuse/neglect immediately. During an interview on 6/14/2023 at 5:00PM with Admin. revealed he expected staff to follow the orders that were in place. If there is an emergency the nursing staff was able to contact the provider (NP) on-call line if needed Medline for guidance or should have sent the resident out to the hospital in an emergency. He stated all staff were trained on abuse/ neglect and the protocol if they see or suspect abuse or neglect, stated all contact numbers were located at each nurse's station. During an interview on 6/14/2023 at 3:15PM with interim DON, revealed the facility had no other residents with JP drains and bulbs. She stated there are four residents who have G-tubes, and all residents were assessed, orders and care reviewed. Record review on 6/14/2023 of in-services on Care, Assessment and Monitoring of JP drains and Enteral Feeding Devices reflected 10 nursing staff in-serviced. Record review on 6/14/2023 of PCC regarding resident assessment, orders and care plan reviewed, reflected the four residents identified as having G tubes were reviewed in PCC system. Each resident's care plan had been updated to reflect the care needs for the resident and the G tube, the orders were reviewed for each resident verified to be current and in the PCC system indicating the cleaning needs and frequency of the G tubes. Each resident was assessed and documentation in the PCC system reflected the residents current care needs. Record review of personnel file for DON, reflected the DON was terminated effective 6/13/2023. Record review of personnel file for ADON, reflected the ADON was terminated effective 6/13/2023 6/14/2023- Review of orders residents who currently have G-tube Resident's # 2, # 3, # 4, and #5. All orders have been entered into the Point Click Care system 6/14/2023 review of care plans reflected the care plans were updated 6/14/2023 to care and assessment needs for the following Residents # 2, #3, # 4, and # 5. 6/13/2023 to include proper assessment, care, and monitoring. All new admission residents will have an initial care plan updated to include proper assessment, care, and monitoring. 6/14/2023 Record review reflect the MDS coordinator was in-serviced on comprehensive care plans for residents with JP drains and G tubes 6/14/2023 record review reflect in-service with nursing staff on completion of interim care plans for residents, 8 nursing staff completed this in-service No new admissions at this time, Resident # 2 was admitted on [DATE] and documentation reflected he was assessed for his G tube care and needs. Record review of in-service dated 6/14/2023, reflected 10 nursing staff had been in-serviced on weekly skin assessments for residents. Record review on 6/14/2023 of skin assessments completed for Resident's # 2, # 3, # 4, and #5. Record review of in-service on electronic documentation of treatment provided dated 6/14/2023, reflected 10 nursing staff had completed this training. Record review of in-service of Change in Condition dated 6/14/2023 reflected 8 licensed nursing staff and 9 CNA/CMAs had completed this training. Record review of in-service of Change in Condition documentation utilizing the Stop, Watch, and Change in Condition form dated 6/14/2023 reflected 8 licensed nursing staff and 9 CNA/CMAs had completed this training. Record review of in-service of Abuse/Neglect dated 6/14/2023 reflected all staff had completed this training. An IJ was identified on 6/12/2023. The IJ template was provided to the facility administrator on 6/12/2023 at 5:55PM. While the IJ was removed on 6/14/2023, the facility remained out of compliance at a scope of isolated and a severity level actual harm because all staff had not been trained on effectiveness of corrective systems.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the 18 residents and 23 staff members in the facility that contracted the COVID-19 virus. The facility failed to ensure staff were trained on the cleaning, disinfecting and sanitization of the COVID unit, staff were provided a sterile area to don and doff their PPE, staff stored PPE correctly and appropriately cleaned reusable PPE and staff were provided hand sanitizer in the screening area as well as the designated COVID unit. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 6/10/2020. While the IJ was lowered on 6/17/2020, the facility remained out of compliance at a level of actual harm with a scope identified as pattern. This failure could place residents at risk for the transmission of COVID-19 and death. Findings Include: During an observation on 6/3/20 at 4:00 pm on the COVID unit (400 hall) revealed that no housekeeping staff was on the COVID unit. During an interview on 6/3/20 at 4:00 pm LVN D and CNA A, who stated they had not received training on cleaning the residents' rooms but were cleaning after the use something on the unit or if they touch something in the residents' room. Both LVN D and CNA A stated there was not a designated housekeeping staff member assigned to the COVID unit and that they were given cleaning supplies by the administrator and the DON and told to clean the COVID unit themselves. During an interview on 6/3/20 at 3:00 pm with the DON and Administrator who stated they both felt it was okay for the nursing staff on the COVID unit to be responsible for the cleaning of the unit. The DON stated that she had trained the nursing staff on how to clean high touch areas but had not in-service the staff on deep cleaning or anything like that. The DON stated that she did not have plans to add a housekeeping staff member on the COVID unit at this time. The DON acknowledged that no housekeeping staff had been scheduled for the COVID unit since it had opened on 6/1/20. During an interview on 6/3/20 at 3:00 pm, Administrator stated that he was shorted staffed in the housekeeping department and was going to contact the housekeeping agency to get more staff. The administrator stated that several of the housekeeping staff had tested positive at the facility. During an interview on 6/4/20 a 2:00 pm, Administrator stated that he had hired a housekeeping staff member for the COVID unit. Review of Resident # 4's face sheet dated 6/9/20 reflected a [AGE] year-old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of resident # 4's MDS dated [DATE] reflected a BIMS score of 10, which indicated moderate cognitive deficient with daily decision making. Review of the resident # 4's care plan dated 5/28/20 reflected the resident required the assistance of 1 for bathing, transferring, dressing, eating, and toileting. The resident is at risk for falls related to generalized weakness and decreased cognitive status. Observation on 6/9/20 at 3:00 pm, revealed Resident #4 was lying face down in bed wearing a brief. The room had a urine odor, and trash was on the floor. Resident # 4's toilet had a brown ring and no liner was observed in the trash can. During an interview with CNA A on 6/9/20 at 3:30 pm, CNA A stated she was not sure about the cleaning schedule or what the housekeeping staff cleaned before leaving for the day. CNA A stated the housekeeping staff was on the Unit today, but she was not sure what time and she was not sure why resident # 4's room had trash on the floor or why the toilet appeared not to be clean. Review of Resident #1's facesheet reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnosis, which included COVID-19, [MEDICAL CONDITION], muscle weakness, and hypertension. Review of the Resident #1's, MDS, dated [DATE], reflected a BIMS score of 7, which indicated the resident had a severe cognitive impairment. Review of the Resident #1's care plan, dated 5/29/20, reflected the resident was at risk for falls related to impaired functional mobility and required the assistance of 2 for transfers as well as a wheelchair for mobility. The resident was at risk for skin impairment related to bowel and bladder incontinence and required assistance with toileting as well as every two hours peri-care. During an observation on 6/9/20 at 3:15 pm of the resident # 1's room, revealed trash and food on the floor. The resident's toilet was stained with a brown substance on the raiser and toilet bowl. The resident's wheelchair had staining as well of a brown substance was on the wheelchair seat. During an interview on 6/9/2020 at 3:30 p.m., CNA A stated she was not aware of the Resident #1's room having trash on the floor and the CNA stated that the resident had periods of incontinence. The CNA said it was important to keep the residents' rooms clean to prevent cross-contamination and create a better atmosphere for the residents. CNA A stated she was not sure if the housekeeping staff had cleaned the resident's bathrooms, and she was not aware of where the cleaning supplies were kept, which the housekeeping staff used to clean. CNA A stated there was not a schedule for cleaning the resident's wheelchairs on the COVID unit. Review of the residents most recent Minimum Date Set (MDS) assessment dated [DATE], revealed Resident #5 cognition was moderately impaired and required assistance of 1 for medication administration. During an observation on 06/09/20 at 4:00 pm of Resident #5's room revealed trash on the floor and a dried brown substance on the toilet seat and brown staining in the toilet bowel. A whole pill and some trash were found lying on the floor beside the trash can. During an interview on 6/9/20 at 4:00 pm, LVN D stated the resident's rooms to be clean and for the floors to not have trash on the floor. The LVN stated it was important keep the resident's rooms clean to prevent cross-contamination/infection. During an interview on 6/9/2020 at 5:00 p.m., DON stated she expected the resident rooms to be cleaned and that nursing staff were responsible to clean when needed after the housekeeping staff leaves for the day. During an interview on 6/9/20 at 3:00 pm with LVN D who stated that she was not aware that the clean room of the COVID unit was dirty and stated that she thought the housekeeping staff had left around 11 or 12 o clock but was not sure and that the housekeeping staff started cleaning the COVID unit at 8am. The LVN D stated she was not sure what had been cleaned and what needed to be cleaned on the COVID unit. During an interview on 6/10/20 at 3:00 pm with housekeeping staff who stated that he has been working three or four hours a day due to a schedule conflict with his family, but he stated that he cleaned the clean room of the COVID unit and was not sure why it was dirty. Housekeeping staff stated that he cleans all areas of the COVID unit daily before he leaves for the day. During an interview on 6/10/20 at 4:00 pm, housekeeping supervisor stated that she expects all areas of the COVID unit to be cleaned prior to the housekeeping leaving for the day. Housekeeping supervisor stated that the housekeeping staff should communicate with the charge nurse before leaving for the day. Housekeeping supervisor stated that currently there is no one in charge of ensuring the COVID unit is clean prior to the housekeeping staff leaving for the day but that she would coordinate with her immediate supervisor about this issue. Review of facility's policy, titled Quality of Life, dated May 2017, reflected that team members are responsible for keeping the residents' rooms a clean, sanitary and orderly. Review of in-service, given by the DON, dated 6/2/20, reflected communication was important between departments and that housekeeping and nursing staff should collaborate to keep the resident's rooms clean. During a review of the CDC recommendations titled Covid-19 cleaning and disinfecting your facility dated 2019 which states that facilities should 1. Practice more frequent cleaning of frequently high touch areas including tables, doorknobs, light switches, handles, desks, toilets, faucets, and sinks. 2. Educate staff members about the cleaning and disinfecting of high touch areas. https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html During an observation on 6/10/20 at 2:50 pm, revealed that CNA B failed to perform hand hygiene and perform hand hygiene three times after exiting/entering the doffing room and entering into the hallway of the COVID unit (400 hall). CNA B was also wearing above the knee shorts with his legs exposed while working on the COVID unit. Observation on 6/10/20 at 2:50 pm, on the COVID-19 Unit, revealed no PPE (personal protective equipment stations) readily available on the Unit. Observation revealed all PPE supplies were kept in an empty room in the end of the hallway. Nursing staff was observed taking off a medical gown before leaving a resident's room but going to the supply room next to the entrance of the Unit, wearing only their uniform. Interview on 6/10/20 at 3:00 pm, CNA B stated he had not been trained on how to don/doff PPE and or that he was supposed to wear long pants. CNA B stated the facility did not have pants that he could wear for the remainder of his shift. CNA B said he was not aware that he did not perform hygiene or change his gloves on 3 consecutive occurrences. CNA B stated he was not aware he was required to wear gloves in the hallway of the COVID unit (400 hall) stating, no one told me. CNA B stated it was important to both perform hand hygiene and don clean gloves when entering the COVID unit from the doffing room to decrease the risk for contracting COVID-19. Interview on 6/10/20 3:15 pm, LVN E stated had not received training on how to clean and disinfect the COVID Unit. LVN E stated no one told her that she would not be wearing a reusable protective suit prior to her shift so she just brought scrub pants because of the frequency of changing policies in regards to PPE on the COVID unit. LVN E stated she had not been trained on donning/doffing PPE, but she heard from other staff that there was a video about PPE sent by email. LVN E said she had not watched the training video and did not receive the video in her email. about donning and doffing PPE. LVN E stated she does not clean after housekeeping leaves unless she sees something that is dirty. LVN E stated she does not communicate with housekeeping staff before they go and has not been trained on how to clean the resident's rooms. LVN E stated she does wipe down items that are used during patient care with bleach wipes and was not advised by the housekeeping staff to do additional cleaning of the COVID-19 Unit. In an interview on 6/9/2020 at 4:00 p.m., LVN E stated that she reused a protective suit and disinfects the suit after each shift and leaves it outside hanging. LVN E stated that she would get new protective suit if the personal protective suit gets ripped or stained. The LVN E stated she does not don/doff in pairs to ensure compliance. LVN stated that she only wears a protective suit and does not put on a disposable gown in between caring for residents. During an interview on 6/11/20 at 4:45pm with the administrator stated that he would get pants for CNA B right away. On 6/15/20 at 10:00 pm during an interview with RN H and LVN D as well as CNA C whom stated that they were not aware of what cleaning solution they should use to sanitize high touch surfaces on the Unit including the type of cleaning solution and the location of the cleaning solution (Virex) they should use. RN H, LVN D, and CNA C three of the staff members were not sure what they should use to disinfect high-touch areas as well as the location of the Virex cleaner. All three staff members did not know the dwell time for Virex cleaning solution. The RN H and LVN D both stated they did not get a report from the off-going shift day shift regarding the cleaning schedule of the Unit or the location of the vacuum and or Bissel rolling sweeper was kept. The LVN D, RN H, and CAN C were not aware of food and trash on the floor in two of the resident's rooms (as well as fecal staining on the Resident #1's toilet seat. During an interview with the housekeeping supervisor on 6/10/20 at 2:40 pm the housekeeping manager stated that she expects the housekeeping cart to be cleaned after each shift and placed on the clean side in preparation for the next shift. The housekeeping supervisor stated that before housekeeping staff leave they should empty all the trash and discard any unused undated cleaning solution. The housekeeping manager stated she expects housekeeping staff on the covid-19 hall to be screened before and after each shift for elevated temperature and covid-19 signs and symptoms. The housekeeping manager also stated she expected floors to be cleaned and high touch areas should be cleaned every two hours and the housekeeping staff should communicate with the nurse before leaving to continue every two hours cleaning and as needed. During an interview with an infection control practitioner on 6/3/20 at 4:00 pm with DSHS (who conducted an infection control assessment of the facility on 6/3/20 and 6/11/2) recommended that since the facility had many resident rooms with carpet, it was recommended, based on CDC guidelines, that the facility staff use vacuums with an approved HEPPA filter in the carpeted areas of the facility. The infection control practitioner stated that by using a broom to sweep the carpets the staff would be stirring dust and infectious particulates into the air which could increase the risk for staff and residents to become infected with COVID-19. According to the CDC dated 2019 health care facilities should conduct training with health care personnel to prevent the spread of infectious agents. This training should include when to use PPE, when is PPE necessary, how to don/doff PPE in a manner to prevent self-contamination, how to disinfect PPE, and the limitations of PPE. Staff should have practiced the appropriate use of PPE prior to caring for a patient including the contamination of clothing, skin, and the environment during the process of equipment removal. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.htm During an observation on 6/9/20 at 2;00 pm revealed the area of the COVID unit used for symptom screening revealed no hand sanitizer was present. During an interview on 6/9/20 at 2:30 pm with LVN A who stated that she was not aware that there was no hand available at both the screening station as well as the clean room of the COVID-1Unit. LVN A stated that should put some hand gel in both areas. During an observation on 6/10/20 at 2:50 pm revealed that hand sanitizer was available in the screening section of the COVID unit. During an interview on 6/10/20 at 10:00 am, DON stated that the hand sanitizer would be put by the front door in the COVID unit where the employee. During an observation on the COVID-19 revealed that the housekeeping cart contained a broom while no vacuum was present. During and observation on 6/9/20 at 4:00 pm and 6/10/20 at 2pm revealed that the doffing room was also being used as a breakroom and the soap dispenser was broken and a bag of soap was lying on the side of the sink in the doffing room. During an interview on 6/9/20 at 2:17 pm with the charge nurse LVN D who stated that she uses the doffing room to take her breaks and eat her lunch. LVN D stated that she takes off her mask and googles when she enters the doffing room and sets them down on a table before eating and then she reapplies her mask and googles after eating and taking breaks. The LVN D stated that she discards her N95 mask and sanitizes her face shield with bleach wipes after the end of her shift. During an interview on 6/10/20 at 3:15 pm with the charge nurse working on the COVID-1Unit- LVN E stated that she uses the doffing room as a breakroom and when taking a break to eat her lunch, she either pulls her mask off halfway, leaving it hanging on her ear or she just disposes of the mask and dons a new N95 mask. LVN E stated that unused N95 masks are kept in the doffing room. During an observation on 6/10/20 at 4:00 pm LVN E and CNA B were witnessed moving a refrigeration, microwave as well as tables to an empty resident room. During an interview on 6/10/20 at 4:00 pm with LVN E who stated that she was just told by the DON to move these items to an empty breakroom and use the empty resident room as a breakroom. During an observation on 6/11/20 at 4:30 pm revealed that the soap dispenser in the doffing room was fixed and attached to wall in the restroom and paper bags were available in the breakroom to store N95 masks. During an observation on 6/12/20 at 2:00 pm which reflected that reusable protective suits were hanging outside the COVID unit with a commercial sprayer bottle. Bedside tables were also sitting outside next to the entrance. During an observation on 6/12/20 at 4:00 pm revealed that face shields with staff names were hanging on the wall in the dirty doffing room uncovered. During an observation on 6/12/20 at 6:30 pm, LVN E was observed outside the COVID unit without a mask or face shield spraying her reusable protective suit. LVN sprayed the front of her suit but failed to spray the back of her suit. Also, LVN E failed to wear facial protection when using the sprayer, thus increasing her risk for contracting COVID-19. During an interview on 6/12/20 at 6:40 pm, LVN E stated she was not aware she did not spray the back of her reusable protective suit and was not aware that she increased her risk for contracting COVID-19. LVN E stated it was important to wear proper PPE in order to prevent cross-contamination. During an record review of the facilities Tyvek suit cleaning log which reflected that from 6/12/20 to 6/15 only 6 people had signed off that they had disinfected their reusable protective suit, no sign off was found for 6/14/20. On the COVID unit (400 hall) 8 staff members were scheduled. During an interview with an infection control practitioner with DSHS on 6/4/20 at 4:00 pm (Texas Department of Health Services) (who conducted an infection control assessment of the facility on 6/3/20 and 6/11/2) who stated that she recommended the facility should separate the breakroom from the doffing room and adequate table space for facility staff to eat meals. These recommendations were sent to the administrator on 6/7/20 however, the facility did not change the location of the breakroom to an empty room until 6/10/20 at 4pm even though there were multiple empty rooms. According to the Texas Health and Human Services long term care procedure guide dated 2020 which states that PPE should be readily accessible where resident care is provided. https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/long-term-care/covid-response-plan-alf.pdf During an observation on 6/9/20 at 2:00 pm revealed that the housekeeping cart was in the doffing had wet cleaning rags in a bag hanging on the side of the cart. A mopping bucket had soaked cleaning cloths still present. No housekeeping staff were working on the COVID unit. During an interview with on 6/9/20 at 5:00 pm with the housekeeping supervisor who stated that she expected the housekeeping staff to dispose of unused cleaning rags and unused and used cleaning solution at the end of their shift. The housekeeping supervisor stated that the housekeeping staff are expected to report to the nursing staff about the cleaning schedule before leaving for their shift. During an interview on 6/10/20 at 11:00 am with the housekeeping staff on the COVID unit who stated that the housekeeping cart should be cleaned and unused as well as used cleaning clothes as well as cleaning solution should be discarded after the end of the shift. The housekeeping staff stated it was important to keep the housekeeping cart clean to prevent cross-contamination. The Administrator was notified on 06/10/2020 at 11:35 a.m. an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to administrator on 6/10/2020. The facility's first Plan of Removal (POR) was submitted by the administrator on 6/11/2020 at 3:00 p.m. The following POR was accepted by the survey team on 6/11/2020 at 5:39 p.m. Actions taken and plan included: Vitals signs and full body assessment will be scheduled three times a day and PRN. This will be added to the MAR and monitored by Director of Nurses and Regional Nurse daily to verify no changes in condition. In-servicing initiated on 6/10/20 to be completed by Director of Nurses no later than 6/12/2020. Administrator to ensure this is completed. Direct care staff to be in-serviced to check for food and fecal matter on wheelchairs after each meal and a wheelchair cleaning schedule is being created by Director of Nurses. Wheelchairs were cleaned on 6/10/20 since the observation above and the wheelchair cleaning schedule has been implemented. Extra bags will be left on unit by housekeeping personnel. An additional Housekeeper was added to work specifically on the COVID Unit and additional Management support was added to monitor the Non-COVID area; The COVID Unit Housekeeper will check out with the charge nurse prior to leaving; Multiple trash liners to be left in each trash can to replaced as needed; Entire facility was sprayed with the Electrostatic Sprayer on 6/8 and additional deep clean of the COVID Unit to be done on 6/11. In-servicing initiated on 6/10/20 to be completed by Director of Nurses no later than 6/12/2020. Charge nurse will monitor each shift and report to administrator. Administrator to ensure this is completed. PPE in-servicing and return demonstration forms have been already issued to COVID unit staff and will be completed by 6/11/20, 6:00 pm. Housekeeping position was added to the COVID unit 6/4 and is scheduled for 7-3 daily. Nursing staff will be in-serviced on essential remedial picking up and disinfection of incidents when housekeeping personnel are not present. Scheduled in-services for all HCSG Staff to include Infection Control, 5 & 7 Step Cleaning Procedures, COVID-19 Isolation Room/Unit Cleaning, HTP Cleaning Checklist, COVID-19 Checklist for Environmental Services. In-servicing initiated on 6/10/20 to be completed by Director of Nurses no later than 6/12/2020. Administrator will monitor daily to ensure this is completed. An extra can for trash been added to the clean room, cricket removed. Protective suits will be hung/stored outside by the employee that wore it on hangars after disinfection until ready for use the next time that employee reports for duty. A cleaning log has been created/implemented for staff to sign and date to show disinfection of suits after use. In-servicing on PPE storage initiated on 6/10/20 to be completed by Director of Nurses no later than 6/12/2020. Charge nurse will monitor each shift. Administrator to ensure this is completed. Pump hand sanitizer has already been added to the screening location. Charge nurse will monitor each shift. In-servicing on hand sanitizing prior to entering COVID-19 unit initiated on 6/10/20 to be completed by Director of Nurses no later than 6/12/2020. Administrator to ensure this is completed. Stocking a Housekeeping Cart in-service to be completed by 6/11/20; manual sweepers added to the COVID Unit and 1 vacuum with a HEPA filter; toilet bowl brush added to the cart on 6/10; Housekeeping supervisor will monitor daily. Administrator to ensure completion. Supplies were removed and relocated to a different room on the unit on 6/10. Paper bags to be labeled individually by staff members for storing facemasks while on break. Soap placed in working dispenser. In-servicing on mask storage initiated on 6/10/20 to be completed by Director of Nurses no later than 6/12/2020. Administrator to ensure this is completed. Restructuring of the breakroom and supplies from the doffing room into separate rooms on the COVID-19 Unit was executed by nursing and rehab staff assigned to the unit. Facility has elected to return to jumpsuit PPE for COVID unit. This staff member changed clothes and will not be in that attire again on the hall unless in jumpsuit PPE. PPE training to include disinfecting strategy of jumpsuit(s). PPE Competency Validation to be completed with all Housekeeping staff; In-service on How to properly don and doff PPE. In-servicing on hand hygiene and PPE disinfecting initiated on 6/10/20 to be completed by Director of Nurses no later than 6/12/2020. Administrator to ensure this is completed. Staff nurse will ensure all residents are physically watched to ensure swallowing of pills. Nurse will dispose of any pill that becomes contaminated. New High Security Carts have been ordered to be delivered by 6/19/20; A dedicated housekeeping cart was moved to the COVID Unit to be able to store chemical properly and use 1 rag per resident room and to have the chemical sprayed on the rag prior to cleaning an area and then discarded in the double bag on the housekeeping cart; In-service COVID-19 Isolation Room/Unit Cleaning (June 11th) Administrative staff being trained as well on above-mentioned issues by Regional Nurse, initiated on 6/11/20 and completed no later than 6/12/20. Restructuring of the breakroom and supplies from the doffing room into separate rooms on the COVID-19 Unit was executed by nursing and rehab staff assigned to the unit. Additional Info: Entire building was sprayed with an Electrostatic Sprayer on 6/8 and one will be placed in the facility to be used at least once a week. Housekeeping staff in-serviced on electrostatic sprayer on 6/11/20. 6/15/2020 Revision: Based on new guidance, the facility has opted to utilize disposable gowns without the use of the jumpsuit (bunny suit) for PPE in the COVID unit. Training on gown PPE has already been started and will be finished by end of day 6/16/20. Surveyor Team Monitoring: During an observation on 6/12/20 at 2:00 pm individual bedside tables (4) were brought into the COVID unit by the housekeeping staff and were being used to store PPE. During an interview with the DON on 6/12/20 at 4:15 pm who stated that she was setting up designated PPE stations throughout the COVID hall to make it more accessible for the nursing staff to access PPE. During an observation on 6/10/20 at 2:50 pm The clean room of the COVID-19-unit floors were clean, and a trash can was accessible as well as no used PPE in this room and a trash can was found in the bathroom. During an observation on 6/10/20 at 3:00 pm the COVID unit revealed that the resident bathrooms were clean, and the housekeeping staff had a bathroom brush available on his housekeeping cart. During an interview on 6/10/20 at 4:15 pm housekeeping staff on the COVID-1Unit stated that he uses a broom to sweep the floor and does not have a vacuum available to clean the floors and a bathroom brush to clean the toilets. During an observation on 6/10/20 at 4:30 pm revealed the housekeeping manager was witnessed taking a vacuum with a heppa filter to the COVID unit. During an observation on 6/11/20 revealed both a Bissel sweeper as well as a vacuum were present on the COVID unit in the doffing room. On 6/10/20 at 11:00 am during an observation revealed that a bathroom brush was present on the housekeeping cart. During an interview on 6/11/20 at 3:00 pm, LVN E stated she would assess each resident on the COVID-19 Unit two times on her shift (day shift) and once on the night shift. The LVN stated that she had been in serviced on conducting comprehensive assessments on residents who are COVID-19 positive three times in a 24-hour period. The LVN stated that it was important to increase comprehensive assessments in residents who were infected with COVID-19 in order to identify changes and treat new symptoms. During an observation on 6/11/20 at 3:00 pm revealed that signs were posted indicated the need for comprehensive assessments to be conducted on residents who were infected with COVID-19. Interview on 6/11/20 at 3:15 p.m., DON stated that she would implement a facility-wide policy to conduct three times a day comprehensive assessment on residents who were suspected and or confirmed to be infected with COVID-19. The DON stated it was important to increase assessments on those who are suspected of or confirmed to have COVID-19 symptoms to identify changes in these residents and provide care. During an interview with the DON on 6/12/20 at 2:00 pm, stated that she has inserviced nursing staff on monitoring residents both positive and presumptive positive for covid-19. The DON stated that she expects nursing staff to monitor residents vital signs three times a day and to increase the frequency of monitoring vital signs if the residents condition changes. During a record review on 6/12/20 reflected that the nursing staff had been inserviced by the DON to increase frequency of monitoring vital for residents both probable and positive for COVID-19 to three times a day. During a record review of the facility in service on 6/12/20 at 2 pm on hand, hygiene reflected that facility staff was in-service on hand hygiene. During a record review on 6/12/20 at 2pm which reflected that staff were inserviced on communication between housekeeping and nursing staff and how to properly clean the COVID unit. 6/12/20 2:30 pm The LVN A stated that she knew she was expected to clean the Unit three times a day and was responsible for the cleaning of the Unit once housekeeping left. The LVN stated that she does communicate with housekeeping before they left for the day. During a record review of the facility Inservice record on 6/15/20 at 6pm reflected that staff were in serviced on how to disinfect Tyvek garment/storage of PPE as well as a requirement to sign off on a log book after each use. The in service also stated that staff was required to watch a don/doff PPE video. During a record review on 6/15/20 at 6pm which reflected that nursing staff were inserviced on conducting vital signs. The inservice stated that staff are to monitor vital signs twice on the day shift and once on the night shift. The night shift is responsible to complete skilled nursing charting. During a record review of the facilities Inservice on 6/15/20 at 6pm on the medication administration as well as medication storage reflected staff were in serviced. During an observation on 6/16/20 at 10pm reflected that staff were using disposable gowns and were changing gowns after each use. During a record review of the facilities Inservice record reflected on 6/16/20 at 10pm, facility staff was in service on how to properly don/doff reusable medical gowns. On 6/16/20 10:20 pm during an interview with LVN F, RN H and CNA C who stated they were aware of how to disinfect the Unit and were given an in-service as well as an update about how to disinfect high touch areas of the COVID-19 Unit prior to the start of their shift. LVN F, RN H, and CNA C stated that they knew where the Bissel sweeper as well as the vacuum was located. Administrator was n (TRUNCATED)

Based on observation, interview, and record review the facility failed to implement policies and procedures that prohibit neglect for 1 of 4 residents reviewed for high risk for falls (Resident #1). Resident #1 fell from his bed on Monday 2/23/15, the facility failed to consult with the Nurse Practitioner (NP) for further instruction, when an x-ray that was ordered was not obtained. Resident #1 was sent to the emergency room (ER) on Tuesday 2/24/15 for [MEDICAL CONDITION] activity; it was identified that the resident had comminuted fractures of the right arm and right leg that would require surgical intervention. This deficient practice contributed to actual harm for one of one resident (Resident #1) and could affect 36 additional residents with risk for falls resulting in a decline and potential delay in rehabilitation. Findings Include: Review of Resident #1 ' s face sheet revealed an [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Fall Risk assessment dated [DATE] reflected a total score of 24 (score of 10 or above represents high risk). Review of Resident #1 ' s admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 5 (00-07 Severe Impairment); Resident #1 requires extensive assistance of two staff with transfers, is incontinent of bowel and bladder, and has a history of falls. Review of Resident #1 ' s Care Plan dated 2/11/15 revealed: High Risk for Falls-Has had a fall since admission and has an unsteady gait. Review of a facility incident report dated 2/23/15 at 3:30 PM revealed Resident #1 wiggled out of bed onto his floor mat, then scooted across the floor toward the bath room. The resident stated later in the evening his right arm was sore. X-ray order obtained-unable to schedule due to weather situation. No apparent injury. Temperature 98.9 degrees Fahrenheit; Pulse 103; Respirations 21; Blood Pressure 146/82; Oxygen Saturation 94; alert/follows commands. NP and daughter notified at 5:00 PM. No other recent incidents for this resident could be found. Review of Resident #1 ' s Telephone Orders revealed the following: 2/11/15 Scoop mattress to bed; floor mats to floor on each side of the bed; bed in lowest position possible at all times. 2/22/15 Discontinue [MEDICATION NAME] (works by stopping the formation of substances that cause clots) due to high risk for falls. 2/23/15 X-ray of right arm due to pain. 2/24/15 Send to the local emergency room for [MEDICAL CONDITION] activity and AMS (Altered Mental Status). Review of Nurses ' Notes dated 2/23/14 reflected the following: 2:00 PM-Resident remains on Medicare charting [MEDICAL CONDITION]([MEDICAL CONDITION]/stroke) Patient currently resting in bed. No distress noted. Breathing even and unlabored. No report of pain at this time. Safety measures in place. 5:30 PM-Resident noted on mat beside bed by another resident ' s family member. Resident was observed by this nurse sitting on the floor on the mat. Urine was all around resident and on the floor. Resident assisted back into his wheel chair and cleaned up. Vital signs: bp 146/82, pulse 103, temperature 98.9 degrees Fahrenheit, respirations 21. Resident does not complain of pain, but is holding right arm. X-ray ordered for right arm to rule out injury. Will continue to monitor. No time:-X-ray unable to treat resident due to weather conditions. Resident not complaining of pain. Will reschedule for tomorrow. Observation on 2/26/15 at 8:30 AM at a local hospital revealed Resident #1 was lying in a hospital bed with the head of bed up 30 degrees and intravenous fluids running into his left arm. Observation of his right arm revealed purple bruising from his arm pit to his inner elbow approximately 4 inches at the widest area. There was deep purple bruising to right groin area, his right leg was rotated outward and he flinched and grimaced when the foot was moved. He had TED hose and a compression device to his legs. The nurse stated he had refused pain medication since admission. He was responsive. Review of the ER History and Physical dated 2/24/15 for Resident #1 revealed in part: Chief Complaint of [MEDICAL CONDITION]. Patient has a history of past [MEDICAL CONDITION] in January undergoing rehabilitation at the facility without previous history of [MEDICAL CONDITION] brought by EMS due to report of [MEDICAL CONDITION] activity when the nurse was trying to assist him in transferring from bed to wheel chair and trying to dress him. She reports " rhythmical movements toward the body for a few seconds which he never did before " ...and looked more confused than usual. On arrival to the ER, patient was noted to have UTI (urinary tract infection) on UA, Acute Kidney Injury ... with swelling in right arm and right hip and was found to have right humerus fracture and right femur fracture. Orthopedics was consulted and patient was admitted ... Radiology Review: multiple imaging with right comminuted fracture (a crushed bone) of the proximal humerus (long arm bone closest to the shoulder) and comminuted [MEDICAL CONDITION] femur (Long leg bone closest to the hip). In a phone interview on 2/26/15 at 10:30 AM, when asked about the incident with Resident #1, Primary Care Physician (PCP) stated, " Yes, I am aware of the incident, but my Nurse Pratitioner (NP) was the one that witnessed the incident. I will have her call you. " Interview on 2/26/15 at 11:10 AM the NP for Resident #1 stated she is usually in the building Monday through Friday from 8 AM -5 PM' but she usually sees residents on halls 300 and 400. There were two other NPs that assisted her with residents on halls 100 and 200. She stated she did not witness an incident with Resident #1. She thought they (the facility) called her on Monday (2/23/15) for an order for [REDACTED]. The NP stated she did not get a call that the x-ray was not obtained. She expected to go in Tuesday morning and review the x-ray, but Resident #1 had already been transferred to the hospital. The NP stated LVN A called her on 2/23/15 at 7:53 AM (time verified on her cell phone)that Resident #1 looked like he was having some type of [MEDICAL CONDITION] activity and the family wanted him sent out. The NP stated she asked the nurse if she was sure it was not a TIA ([MEDICAL CONDITION]-a stroke that comes and goes quickly/mini stroke) since the resident had a stroke in January. The NP stated she lets the family ultimately make the decision to send the resident out or not. When asked what was her expectation if a resident complained of limb pain, she stated, " I would expect them to get a portable x-ray. I would have sent the resident out to the emergency room if the portable x-ray could not get here. " The NP also stated, " I still gave them an order for [REDACTED]. Interview on 2/26/15 at 11:45 AM Resident #5 (witness to the fall) stated Resident #1 was standing on top of his bed (in the room across the hall). Resident #5 mentioned it to his wife and they heard " cupong ". Then the resident was on the floor. His wife ran across the hall and yelled "man down". Three staff came running and went into the room. Telephone interview on 2/26/15 at 3:00 PM LVN A stated that when Resident #1 fell (on Monday 2/23/15) he was kind of holding his right arm, but not complaining of pain. When he fell , he had a puddle of urine on the floor where he was sitting. He did not have any pain. He was just sitting on the mat. She was calling the NP for a chest x-ray on another resident and asked to x-ray Resident #1 ' s right arm also. LVN A stated she should probably have called the doctor when the x-rays could not be done. The resident did not complain of pain. She stated that on Tuesday morning, Resident #1 was shaking all over and dazed and she had never seen him act like that before. LVN stated he was sent to the ER for [MEDICAL CONDITION] activity and Altered Mental Status (AMS). She stated that later on Tuesday she got two calls from the ER. The first doctor asked her about Resident #1 ' s usual mental status, how much assistance he needed, did he walk, things like that. The second call was from an orthopedic doctor. He asked if Resident #1 had a fall, then the same type things the other doctor asked. The LVN stated that she told both of them that he had a fall. Then the orthopedic doctor said he had a UTI (urinary tract infection). Interview on 2/26/15 at 3:20 PM CNA C stated she, LVN A, and CNA D ran to Resident #1 ' s room on 2/23/15 when he fell . They put the gait belt around him and he got right up and stood on his feet. His head was toward the door and his feet were toward the bathroom when they found him. Where he was sitting there was urine. He wanted to go to the rest room. He stood up holding onto the bar in the rest room while they cleaned him. He helped change his own shirt and lifted his legs to put on pants. They took him out to the TV room and he held his feet up while being pushed in the wheel chair. Telephone interview on 2/26/15 at 3:40 PM with CNA D revealed she did Resident #1 ' s care on Monday evening (2/23/15). He already had his pajama top on so she just changed his brief and put him to bed. He ate dinner in the dining room, and then went to the TV room for a while. He was no different. He didn ' t favor one side or the other. She didn ' t notice any bruising (but she didn ' t look under the pajama top that he had on all day). She put the gait belt on; he stood right up and went from the wheel chair to bed. Interview on 2/26/15 at 2:20 PM CNA E stated she cared for Resident #1 on Tuesday (2/24/15, the day he went out to the ER). The CNA would ask him ' yes/no ' questions and he was appropriate with his responses. He had no complaints of pain and transferred with one assist. On Tuesday morning he was kind of in a daze. He wanted to keep his top on so she put his pants on without looking under his shirt. He was no different than usual, no guarding the right arm, no bruising observed. When she went to transfer him she put the gait belt around him and the resident said he was ready, but when she went to stand him for transfer he went dead weight. She put him in the wheel chair and went for the nurse. Interview on 2/26/15 at 4:40 PM with the ADON revealed she had not seen Resident #1. He had already gone out Tuesday morning before she got there. She hadn ' t seen him on Monday because she was busy on the South Hall. She did not know if the NP was notified that the x-ray was not done. She stated she would have expected the nurse to notify the NP. She stated that the x-ray was never done at the facility. Interview on 2/26/15 at 8:00 AM Resident #1's son stated that Resident #1 never complained of pain from this injury and never complained of pain with anything before. The resident handles high levels of pain. Review of the facility's undated policy Titled 'Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property' included in part: Each resident has the right to be free from mistreatment, neglect and misappropriation of property... Therefore the facility has developed operational policies and procedures for screening and training employees for the protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, involuntary seclusion, exploitation, and misappropriation of property. The facility ' s purpose is to assure that the facility is doing all that is within their control to prevent occurrences ... The interim DON stated there were 37 residents at risk for falls.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect for one (1) of four (4) residents (Resident #1) reviewed for high risk for falls. Resident #1 fell from his bed on Monday 2/23/15, the facility failed to consult with the Nurse Practitioner (NP) for further instruction, when an ordered x-ray was not obtained. Resident #1 was sent to the emergency room (ER) on Tuesday 2/24/15 for [MEDICAL CONDITION] activity; it was identified that the resident had comminuted fractures of the right arm and right leg that would require surgical intervention. This deficient practice contributed to actual harm for one of one resident (Resident #1) and could affect 36 additional residents with risk for falls resulting in a decline and potential delay in rehabilitation. Findings Include: Review of the facility's undated policy Titled 'Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property' included in part: Each resident has the right to be free from mistreatment, neglect and misappropriation of property... Therefore the facility has developed operational policies and procedures for screening and training employees for the protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, involuntary seclusion, exploitation, and misappropriation of property. The facility ' s purpose is to assure that the facility is doing all that is within their control to prevent occurrences ... Review of Resident #1 ' s face sheet revealed an [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Fall Risk assessment dated [DATE] reflected a total score of 24 (score of 10 or above represents high risk). Review of Resident #1 ' s admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 5 (00-07 Severe Impairment); Resident #1 requires extensive assistance of two staff with transfers, is incontinent of bowel and bladder, and has a history of falls. Review of Resident #1 ' s Care Plan dated 2/11/15 revealed: High Risk for Falls-Has had a fall since admission and has an unsteady gait. Review of a facility incident report dated 2/23/15 at 3:30 PM revealed Resident #1 wiggled out of bed onto his floor mat, then scooted across the floor toward the bath room. The resident stated later in the evening his right arm was sore. X-ray order obtained-unable to schedule due to weather situation. No apparent injury. Temperature 98.9 degrees Fahrenheit; Pulse 103; Respirations 21; Blood Pressure 146/82; Oxygen Saturation 94; alert/follows commands. NP and daughter notified at 5:00 PM. No other recent incidents for this resident could be found. Review of Resident #1 ' s Telephone Orders revealed the following: 2/11/15 Scoop mattress to bed; floor mats to floor on each side of the bed; bed in lowest position possible at all times. 2/22/15 Discontinue [MEDICATION NAME] (works by stopping the formation of substances that cause clots) due to high risk for falls. 2/23/15 X-ray of right arm due to pain. 2/24/15 Send to the local emergency room for [MEDICAL CONDITION] activity and Altered Mental Status (AMS). Review of Nurses ' Notes dated 2/23/14 reflected the following: 2:00 PM-Resident remains on Medicare charting [MEDICAL CONDITION]([MEDICAL CONDITION]/stroke) Patient currently resting in bed. No distress noted. Breathing even and unlabored. No report of pain at this time. Safety measures in place. 5:30 PM-Resident noted on mat beside bed by another resident ' s family member. Resident was observed by this nurse sitting on the floor on the mat. Urine was all around resident and on the floor. Resident assisted back into his wheel chair and cleaned up. Vital signs: bp 146/82, pulse 103, temperature 98.9 degrees Fahrenheit, respirations 21. Resident does not complain of pain, but is holding right arm. X-ray ordered for right arm to rule out injury. Will continue to monitor. No time:-X-ray unable to treat resident due to weather conditions. Resident not complaining of pain. Will reschedule for tomorrow. Interview on 2/26/15 at 11:45 AM Resident #5 (witness to the fall) stated Resident #1 was standing on top of his bed (in the room across the hall). Resident #5 mentioned it to his wife and they heard " cupong ". Then the resident was on the floor. His wife ran across the hall and yelled "man down". Three staff came running and went into the room. Observation on 2/26/15 at 8:30 AM at a local hospital revealed Resident #1 was lying in a hospital bed with the head of bed up 30 degrees and intravenous fluids running into his left arm. Observation of his right arm revealed purple bruising from his arm pit to his inner elbow approximately 4 inches at the widest area. There was deep purple bruising to right groin area, his right leg was rotated outward and he flinched and grimaced when the foot was moved. He had TED hose and a compression device to his legs. The nurse stated he had refused pain medication since admission. He was responsive. Review of the ER History and Physical dated 2/24/15 for Resident #1 revealed in part: Chief Complaint of [MEDICAL CONDITION]. Patient has a history of past [MEDICAL CONDITION] in January undergoing rehabilitation at the facility without previous history of [MEDICAL CONDITION] brought by EMS due to report of [MEDICAL CONDITION] activity when the nurse was trying to assist him in transferring from bed to wheel chair and trying to dress him. She reports " rhythmical movements toward the body for a few seconds which he never did before " ...and looked more confused than usual. On arrival to the ER, patient was noted to have UTI (urinary tract infection) on UA, Acute Kidney Injury ... with swelling in right arm and right hip and was found to have right humerus fracture and right femur fracture. Orthopedics was consulted and patient was admitted ... Radiology Review: multiple imaging with right comminuted fracture (a crushed bone) of the proximal humerus (long arm bone closest to the shoulder) and comminuted [MEDICAL CONDITION] femur (Long leg bone closest to the hip). In a phone interview on 2/26/15 at 10:30 AM, when asked about the incident with Resident #1, Primary Care Physician (PCP) stated, " Yes, I am aware of the incident, but my Nurse Pratitioner (NP) was the one that witnessed the incident. I will have her call you. " Interview on 2/26/15 at 11:10 AM the NP for Resident #1 stated she is usually in the building Monday through Friday from 8 AM -5 PM' but she usually sees residents on halls 300 and 400. There were two other NPs that assisted her with residents on halls 100 and 200. She stated she did not witness an incident with Resident #1. She thought they (the facility) called her on Monday (2/23/15) for an order for [REDACTED]. The NP stated she did not get a call that the x-ray was not obtained. She expected to go in Tuesday morning and review the x-ray, but Resident #1 had already been transferred to the hospital. The NP stated LVN A called her on 2/23/15 at 7:53 AM (time verified on her cell phone)that Resident #1 looked like he was having some type of [MEDICAL CONDITION] activity and the family wanted him sent out. The NP stated she asked the nurse if she was sure it was not a TIA ([MEDICAL CONDITION]-a stroke that comes and goes quickly/mini stroke) since the resident had a stroke in January. The NP stated she lets the family ultimately make the decision to send the resident out or not. When asked what was her expectation if a resident complained of limb pain, she stated, " I would expect them to get a portable x-ray. I would have sent the resident out to the emergency room if the portable x-ray could not get here. " The NP also stated, " I still gave them an order for [REDACTED]. Telephone interview on 2/26/15 at 3:00 PM LVN A stated that when Resident #1 fell (on Monday 2/23/15) he was kind of holding his right arm, but not complaining of pain. When he fell , he had a puddle of urine on the floor where he was sitting. He did not have any pain. He was just sitting on the mat. She was calling the NP for a chest x-ray on another resident and asked to x-ray Resident #1 ' s right arm also. LVN A stated she should probably have called the doctor when the x-rays could not be done. The resident did not complain of pain. She stated that on Tuesday morning, Resident #1 was shaking all over and dazed and she had never seen him act like that before. LVN stated he was sent to the ER for [MEDICAL CONDITION] activity and Altered Mental Status (AMS). She stated that later on Tuesday she got two calls from the ER. The first doctor asked her about Resident #1 ' s usual mental status, how much assistance he needed, did he walk, things like that. The second call was from an orthopedic doctor. He asked if Resident #1 had a fall, then the same type things the other doctor asked. The LVN stated that she told both of them that he had a fall. Then the orthopedic doctor said he had a UTI (urinary tract infection). Interview on 2/26/15 at 3:20 PM CNA C stated she, LVN A, and CNA D ran to Resident #1 ' s room on 2/23/15 when he fell . They put the gait belt around him and he got right up and stood on his feet. His head was toward the door and his feet were toward the bathroom when they found him. Where he was sitting there was urine. He wanted to go to the rest room. He stood up holding onto the bar in the rest room while they cleaned him. He helped change his own shirt and lifted his legs to put on pants. They took him out to the TV room and he held his feet up while being pushed in the wheel chair. Telephone interview on 2/26/15 at 3:40 PM with CNA D revealed she did Resident #1 ' s care on Monday evening (2/23/15). He already had his pajama top on so she just changed his brief and put him to bed. He ate dinner in the dining room, and then went to the TV room for a while. He was no different. He didn ' t favor one side or the other. She didn ' t notice any bruising (but she didn ' t look under the pajama top that he had on all day). She put the gait belt on; he stood right up and went from the wheel chair to bed. Interview on 2/26/15 at 2:20 PM CNA E stated she cared for Resident #1 on Tuesday (2/24/15, the day he went out to the ER). The CNA would ask him ' yes/no ' questions and he was appropriate with his responses. He had no complaints of pain and transferred with one assist. On Tuesday morning he was kind of in a daze. He wanted to keep his top on so she put his pants on without looking under his shirt. He was no different than usual, no guarding the right arm, no bruising observed. When she went to transfer him she put the gait belt around him and the resident said he was ready, but when she went to stand him for transfer he went dead weight. She put him in the wheel chair and went for the nurse. Interview on 2/26/15 at 8:00 AM Resident #1's son stated that Resident #1 never complained of pain from this injury and never complained of pain with anything before. The resident handles high levels of pain. Interview on 2/26/15 at 4:40 PM with the ADON revealed she had not seen Resident #1. He had already gone out Tuesday morning before she got there. She hadn ' t seen him on Monday because she was busy on the South Hall. She did not know if the NP was notified that the x-ray was not done. She stated she would have expected the nurse to notify the NP. She stated that the x-ray was never done at the facility. The interim DON stated there were 37 residents at risk for falls.

Based on observation, interview and record reviews the facility failed to ensure that one (1) of seven (7) residents reviewed for falls (Resident #2) received adequate supervision and assistive devices to prevent falls with injury. Resident #2 was at risk for falls, extensive assist, had a [DIAGNOSES REDACTED]. She was left alone on the commode, transferred herself and had an unwitnessed fall in her room resulting in a hospital visit on 03/20/14 and a femur fracture. This deficient practice could place the 30 residents identified as a fall risk at risk of not receiving proper supervision, care and services to prevent falls with injury. Findings include: Review of Resident #2 ' s facesheet reflected a [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s most recent Quarterly Minimum Data Set ((MDS) dated [DATE] reflected: Section C: Cognitive Patterns - C0500: Brief Interview for Mental Status (BIMS): 7 (00-07 Severe Impairment) Section G: Functional Status - G0110B1: Transfer: self-performance: 3. Extensive Assistance - G0110B2: Transfer: support provided: 2. One person physical assist. - G0110C1: Walk in room: self-performance. 3. Extensive Assistance - G0110C2: Walk in room: support provided 2. One person physical assist - G0110I1: Toilet use: self-performance. 3. Extensive Assistance - G0110I2: Toilet use: support provided. 2. One person physical assist Section H: Bladder and Bowel - H0300: Urinary continence. 1. Occasionally incontinent - H0400: Bowel continence. 0. Always continent Section J: Health Conditions - J1800: Falls since admit/reentry/prior asmt: any falls. 1. Yes - J1900A: Falls since admit/reentry/prior asmt: no injury. 2. Two or more - J1900B: Falls since admit/reentry/prior asmt: injury (not major). 2. One Review of Resident #2 ' s Comprehensive Care Plan dated 03/12/14 reflected: - Problem: Requires assistance for all Activities of Daily Living (ADLSs) with approaches to transfer on strong side, resident is impulsive, tab alert (a device with a pull-string magnetically attached with a garment clip so when a resident attempts to stand from their chair or bed, the pull-string magnet is pulled away from the alarm causing the alarm to sound, alerting a caregiver) on resident at all times, low bed with mat at bedside, anticipate resident needs due to severe dementia, and redirect resident with ADLs. - Problem: Resident has the potential for falls related to decline in ADLs and cognitive impairment with approaches to assist with ambulation and transfers, remind to ask for assist for all ambulation, monitor for changes in condition that may warrant increased supervision/assistance, low bed with mat, and tab alarm on at all times. - Problem: Resident has moderate cognitive impairments and may require assistance with decision making with approaches to anticipate needs, explain all procedures when addressing resident, and allow resident adequate time to respond to questions and commands. Review of Resident #2 ' s Fall Risk assessment dated [DATE] reflected a total score of 16 (score of 10 or above represents high risk). Review of the facility ' s Incident/Accident Report dated 03/20/14 reflected that Resident #2 had an unobserved fall at 7:25 pm. She was found on the floor on her stomach next to roommate ' s bed; her vitals were not able to be obtained due to her yelling and crying out. Resident #2 was transported to the emergency room via Emergency Medical Services (EMS). Review of the Hospital Admission History and Physical dated 03/20/14 reflected Resident #2 experienced a traumatic fall earlier that day at the nursing home with no reported loss of consciousness. She has a past medical history of [REDACTED]. It further reflected that Resident #2 has hearing loss and is clearly confused to some degree. Review of the facility ' s Provider Investigation Report dated 03/21/14 reflected that Resident #2 had an unobserved fall at 7:25 pm on 03/20/14. She was found on the floor on her stomach next to roommate ' s bed. She was on the commode and transferred herself without assistance. Resident #2 was transported to the emergency room and diagnosed with [REDACTED].#2 usually transfers via wheelchair and one person assist. She was assisted to the bathroom by charge nurse to have a bowel movement (BM). An alarm went off on another resident so the nurse went to check the alarm and told a Certified Nurse Aide (CNA), who was in a different room helping another resident, to assist Resident #2 in the bathroom. When the CNA got there, Resident #2 was found on the floor. During an interview on 04/07/14 at 3:20 pm, CNA D stated Registered Nurse (RN) E told her that Resident #2 was in her bathroom on the toilet having a BM and to give her five minutes to finish and then to assist her. CNA D then stated that she was in another resident ' s room helping that resident when RN E told her this so it took her a few minutes to get to Resident #2 ' s room. When she got there, Resident #2 was on the floor on her stomach next to the roommate ' s bed. She further stated Resident #2 is confused, has a history of falls, has a bed alarm, and can sometimes make her needs known. She then stated they never leave Resident #2 on the toilet alone and she knew she was a fall risk so she knew she had to hurry to finish up what she was doing to go help Resident #2 in the bathroom. During a phone interview on 04/07/14 at 3:40 pm, RN E stated she assisted Resident #2 to the toilet to have a BM, she then heard an alarm go off in another room so she left Resident #2 alone on the commode to go answer the alarm. She then stated she told CNA D to help Resident #2 when she was done. RN E then stated she knew Resident #2 was a fall risk and had a history of [REDACTED]. During an interview on 04/08/14 at 10:10 am, the Director of Nursing (DON) stated that she was in the building when Resident #2 fell . She then stated RN E assisted Resident #2 onto the toilet to have a BM, she then heard an alarm in another room so she left to answer it and told CNA D to assist Resident #2 when she was done. When CNA D got to Resident #2 ' s room, CNA D found Resident #2 on the floor on her stomach next to her roommate ' s bed. When asked if it was ok to leave Resident #2 on the toilet alone, she stated RN E should not have left Resident #2 on the toilet. During an interview on 04/08/14 at 10:25 am, the Nurse Practitioner (NP) stated that staff were toileting Resident #2, left her, and when they came back, she was found on the floor. When asked if it was ok to leave Resident #2 on the toilet alone, she stated that she didn ' t think they usually do that and she ' s not sure they should have left Resident #2 alone on the toilet alone. During an interview on 04/08/14 at 11:45 am, the Regional Minimum Data Set (MDS) Coordinator stated if a resident is a one person, extensive assist, staff must always help the resident with some sort of lifting. When asked if it is ever ok to leave a resident who is a one person, extensive assist, has a history of falls, is impulsive, and has dementia alone on the commode in the bathroom, she stated " I would think not. " The Regional MDS Coordinator further stated she would especially not leave a resident who has dementia alone on the commode. Observation on 04/08/14 at 12:40 pm revealed Resident #2 lying in her bed in her room. Her bed was approximately two to two and a half feet off the ground and no mat was at her bedside. During an interview on 04/08/14 at 12:45 pm, Assistant Director of Nursing (ADON) A stated that Resident #2 did have a fall with a fracture a few weeks ago. When asked about Resident #2 ' s low bed and mat at bedside that she was care planned for because she was a fall risk, ADON A stated she would show the surveyor in Resident #2's room. ADON A then stated Resident #2 was not in a low bed and did not know where the mat was that was supposed to be at her bedside. She further stated that she would have to find out about that. When asked to show the surveyor Resident #2 ' s tab alarm, ADON A could not find it and then stated maybe she just has it when she is up out of bed. During an interview on 04/08/14 at 1:05 pm, the DON stated they are going to discontinue the tab alarm, the low bed, and the mat because Resident #2 does not move around and she does not need them. She then stated Resident #2 was a big fall risk before her femur fracture and she was always trying to get up so she needed the low bed and fall mat then because she was always trying to get up unassisted. When asked if a resident with a fall history like Resident #2 should have been left alone on the commode, the DON stated no. The DON then stated the most current Care Plan was the one dated 03/12/14 in her chart and she was going to write a telephone order to discontinue the alarm, low bed, and mat right then. Review of the facility ' s undated Fall Management Process reflected a successful fall management requires a thorough clinical assessment of residents who fall (or have a history of falls) and their environment. Staff will help identify ways to modify some of the risk factor s for falls, as well as identifying ways to adjust the patient ' s environment to minimize the risk of injury due to falls. It further reflected to assess the resident ' s level of ADL dependence and to see if the resident is receiving ADL assistance needed for bathing, toileting, dressing, grooming, and meals. Review of the facility ' s 802 dated 04/08/14 reflected 30 residents at risk for falls.

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibit neglect for one (1) of eight (8) residents reviewed for abuse and neglect (Resident #2). Resident #2 was at risk for falls, had a [DIAGNOSES REDACTED]. She was left alone on the commode, transferred herself and had an unwitnessed fall in her room resulting in a hospital visit on 03/20/14 and a femur fracture. This deficient practice could place the 30 residents at risk for falls at risk of neglect due to not receiving proper care and services to prevent falls and injury. Findings include: Review of the facility ' s undated Abuse and Neglect Policy reflected neglect to be defined as an injury, harm, or death of a resident due to the facility's failure to provide services, treatment or care to a resident. If any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been or maybe adversely affected by abuse or neglect caused by another person is to report the abuse or neglect immediately and the facility must determine if neglect occurred. Review of Resident #2 ' s facesheet reflected a [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s most recent Quarterly Minimum Data Set ((MDS) dated [DATE] reflected: Section C: Cognitive Patterns - C0500: Brief Interview for Mental Status (BIMS): 7 (00-07 Severe Impairment) Section G: Functional Status - G0110B1: Transfer: self-performance: 3. Extensive Assistance - G0110B2: Transfer: support provided: 2. One person physical assist. - G0110C1: Walk in room: self-performance. 3. Extensive Assistance - G0110C2: Walk in room: support provided 2. One person physical assist - G0110I1: Toilet use: self-performance. 3. Extensive Assistance - G0110I2: Toilet use: support provided. 2. One person physical assist Section H: Bladder and Bowel - H0300: Urinary continence. 1. Occasionally incontinent - H0400: Bowel continence. 0. Always continent Section J: Health Conditions - J1800: Falls since admit/reentry/prior asmt: any falls. 1. Yes - J1900A: Falls since admit/reentry/prior asmt: no injury. 2. Two or more - J1900B: Falls since admit/reentry/prior asmt: injury (not major). 2. One Review of Resident #2 ' s Comprehensive Care Plan dated 03/12/14 reflected: - Problem: Requires assistance for all Activities of Daily Living (ADLSs) with approaches to transfer on strong side, resident is impulsive, tab alert (a device with a pull-string magnetically attached with a garment clip so when a resident attempts to stand from their chair or bed, the pull-string magnet is pulled away from the alarm causing the alarm to sound, alerting a caregiver) on resident at all times, low bed with mat at bedside, anticipate resident needs due to severe dementia, and redirect resident with ADLs. - Problem: Resident has the potential for falls related to decline in ADLs and cognitive impairment with approaches to assist with ambulation and transfers, remind to ask for assist for all ambulation, monitor for changes in condition that may warrant increased supervision/assistance, low bed with mat, and tab alarm on at all times. - Problem: Resident has moderate cognitive impairments and may require assistance with decision making with approaches to anticipate needs, explain all procedures when addressing resident, and allow resident adequate time to respond to questions and commands. Review of Resident #2 ' s Fall Risk assessment dated [DATE] reflected a total score of 16 (score of 10 or above represents high risk). Review of the facility ' s Incident/Accident Report dated 03/20/14 reflected that Resident #2 had an unobserved fall at 7:25 pm. She was found on the floor on her stomach next to roommate ' s bed; her vitals were not able to be obtained due to her yelling and crying out. Resident #2 was transported to the emergency room via Emergency Medical Services (EMS). Review of the Hospital Admission History and Physical dated 03/20/14 reflected Resident #2 experienced a traumatic fall earlier that day at the nursing home with no reported loss of consciousness. She has a past medical history of [REDACTED]. It further reflected that Resident #2 has hearing loss and is clearly confused to some degree. Review of the facility ' s Provider Investigation Report dated 03/21/14 reflected that Resident #2 had an unobserved fall at 7:25 pm on 03/20/14. She was found on the floor on her stomach next to roommate ' s bed. She was on the commode and transferred herself without assistance. Resident #2 was transported to the emergency room and diagnosed with [REDACTED].#2 usually transfers via wheelchair and one person assist. She was assisted to the bathroom by charge nurse to have a bowel movement (BM). An alarm went off on another resident so the nurse went to check the alarm and told a Certified Nurse Aide (CNA), who was in a different room helping another resident, to assist Resident #2 in the bathroom. When the CNA got there, Resident #2 was found on the floor. During an interview on 04/07/14 at 3:20 pm, CNA D stated Registered Nurse (RN) E told her that Resident #2 was in her bathroom on the toilet having a BM and to give her five minutes to finish and then to assist her. CNA D then stated that she was in another resident ' s room helping that resident when RN E told her this so it took her a few minutes to get to Resident #2 ' s room. When she got there, Resident #2 was on the floor on her stomach next to the roommate ' s bed. She further stated Resident #2 is confused, has a history of falls, has a bed alarm, and can sometimes make her needs known. She then stated they never leave Resident #2 on the toilet alone and she knew she was a fall risk so she knew she had to hurry to finish up what she was doing to go help Resident #2 in the bathroom. During a phone interview on 04/07/14 at 3:40 pm, RN E stated she assisted Resident #2 to the toilet to have a BM, she then heard an alarm go off in another room so she left Resident #2 alone on the commode to go answer the alarm. She then stated she told CNA D to help Resident #2 when she was done. RN E then stated she knew Resident #2 was a fall risk and had a history of [REDACTED]. During an interview on 04/08/14 at 10:10 am, the Director of Nursing (DON) stated that she was in the building when Resident #2 fell . She then stated Registered Nurse (RN) E assisted Resident #2 onto the toilet to have a BM, she then heard an alarm in another room so she left to answer it and told CNA D to assist Resident #2 when she was done. When CNA D got to Resident #2 ' s room, CNA D found Resident #2 on the floor on her stomach next to her roommate ' s bed. When asked if it was ok to leave Resident #2 on the toilet alone, she stated RN E probably should not have left Resident #2 on the toilet. During an interview on 04/08/14 at 10:25 am, the Nurse Practitioner (NP) stated that staff were toileting Resident #2, left her, and when they came back, she was found on the floor. When asked if it was ok to leave Resident #2 on the toilet alone, she stated that she didn ' t think they usually do that and she ' s not sure they should have left Resident #2 alone on the toilet alone. During an interview on 04/08/14 at 11:45 am, the Regional MDS Coordinator stated if a resident is a one person, extensive assist, staff must always help the resident with some sort of lifting. When asked if it is ever ok to leave a resident who is a one person, extensive assist, has a history of falls, is impulsive, and has dementia alone on the commode in the bathroom, she stated " I would think not. " The Regional MDS Coordinator further stated she would especially not leave a resident who has dementia alone on the commode. Observation on 04/08/14 at 12:40 pm revealed Resident #2 lying in her bed in her room. Her bed was approximately two to two and a half feet off the ground and no mat was at her bedside. During an interview on 04/08/14 at 12:45 pm, Assistant Director of Nursing (ADON) A stated that Resident #2 did have a fall with a fracture a few weeks ago. When asked about Resident #2 's low bed and mat at bedside that she was care planned for because she was a fall risk, ADON A stated she would show the surveyor in Resident #2's room. ADON A then stated Resident #2 was not in a low bed and did not know where the mat was that was supposed to be at her bedside. She further stated that she would have to find out about that. When asked to show the surveyor Resident #2 ' s tab alarm, ADON A could not find it and then stated maybe she just has it when she is up out of bed. During an interview on 04/08/14 at 1:05 pm, the DON stated they are going to discontinue the tab alarm, the low bed, and the mat because Resident #2 does not move around and she does not need them. She then stated Resident #2 was a big fall risk before her femur fracture and she was always trying to get up so she needed the low bed and fall mat then because she was always trying to get up unassisted. When asked if a resident with a fall history like Resident #2 should have been left alone on the commode, the DON stated no. The DON then stated the most current Care Plan was the one dated 03/12/14 in her chart and she was going to write a telephone order to discontinue the alarm, low bed, and mat right then. Review of the facility ' s undated Fall Management Process reflected a successful fall management requires a thorough clinical assessment of residents who fall (or have a history of falls) and their environment. Staff will help identify ways to modify some of the risk factor s for falls, as well as identifying ways to adjust the patient ' s environment to minimize the risk of injury due to falls. It further reflected to assess the resident ' s level of ADL dependence and to see if the resident is receiving ADL assistance needed for bathing, toileting, dressing, grooming, and meals. Review of the facility ' s 802 dated 04/08/14 reflected 30 residents at risk for falls.

Based on observation, interview, and record review, the facility failed to implement policies and procedures that prohibit neglect for one (1) of eight (8) residents reviewed for abuse and neglect (Resident #2). Resident #2 was at risk for falls, extensive assist, had a [DIAGNOSES REDACTED]. She was left alone on the commode, transferred herself and had an unwitnessed fall in her room resulting in a visit to the hospital on [DATE] and femur fracture. This deficient practice could place 30 residents at risk for falls at risk of neglect due to not receiving proper care and services to prevent falls and injury. Findings include: Review of Resident #2 ' s facesheet reflected a [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s most recent Quarterly Minimum Data Set ((MDS) dated [DATE] reflected: Section C: Cognitive Patterns - C0500: Brief Interview for Mental Status (BIMS): 7 (00-07 Severe Impairment) Section G: Functional Status - G0110B1: Transfer: self-performance: 3. Extensive Assistance - G0110B2: Transfer: support provided: 2. One person physical assist. - G0110C1: Walk in room: self-performance. 3. Extensive Assistance - G0110C2: Walk in room: support provided 2. One person physical assist - G0110I1: Toilet use: self-performance. 3. Extensive Assistance - G0110I2: Toilet use: support provided. 2. One person physical assist Section H: Bladder and Bowel - H0300: Urinary continence. 1. Occasionally incontinent - H0400: Bowel continence. 0. Always continent Section J: Health Conditions - J1800: Falls since admit/reentry/prior asmt: any falls. 1. Yes - J1900A: Falls since admit/reentry/prior asmt: no injury. 2. Two or more - J1900B: Falls since admit/reentry/prior asmt: injury (not major). 2. One Review of Resident #2 ' s Comprehensive Care Plan dated 03/12/14 reflected: - Problem: Requires assistance for all Activities of Daily Living (ADLSs) with approaches to transfer on strong side, resident is impulsive, tab alert (a device with a pull-string magnetically attached with a garment clip so when a resident attempts to stand from their chair or bed, the pull-string magnet is pulled away from the alarm causing the alarm to sound, alerting a caregiver) on resident at all times, low bed with mat at bedside, anticipate resident needs due to severe dementia, and redirect resident with ADLs. - Problem: Resident has the potential for falls related to decline in ADLs and cognitive impairment with approaches to assist with ambulation and transfers, remind to ask for assist for all ambulation, monitor for changes in condition that may warrant increased supervision/assistance, low bed with mat, and tab alarm on at all times. - Problem: Resident has moderate cognitive impairments and may require assistance with decision making with approaches to anticipate needs, explain all procedures when addressing resident, and allow resident adequate time to respond to questions and commands. Review of Resident #2 ' s Fall Risk assessment dated [DATE] reflected a total score of 16 (score of 10 or above represents high risk). Review of the facility ' s Incident/Accident Report dated 03/20/14 reflected that Resident #2 had an unobserved fall at 7:25 pm. She was found on the floor on her stomach next to roommate ' s bed; her vitals were not able to be obtained due to her yelling and crying out. Resident #2 was transported to the emergency room via Emergency Medical Services (EMS). Review of the Hospital Admission History and Physical dated 03/20/14 reflected Resident #2 experienced a traumatic fall earlier that day at the nursing home with no reported loss of consciousness. She has a past medical history of [REDACTED]. It further reflected that Resident #2 has hearing loss and is clearly confused to some degree. Review of the facility ' s Provider Investigation Report dated 03/21/14 reflected that Resident #2 had an unobserved fall at 7:25 pm on 03/20/14. She was found on the floor on her stomach next to roommate ' s bed. She was on the commode and transferred herself without assistance. Resident #2 was transported to the emergency room and diagnosed with [REDACTED].#2 usually transfers via wheelchair and one person assist. She was assisted to the bathroom by charge nurse to have a bowel movement (BM). An alarm went off on another resident so the nurse went to check the alarm and told a Certified Nurse Aide (CNA), who was in a different room helping another resident, to assist Resident #2 in the bathroom. When the CNA got there, Resident #2 was found on the floor. During an interview on 04/07/14 at 3:20 pm, CNA D stated RN E told her that Resident #2 was in her bathroom on the toilet having a BM and to give her five minutes to finish and then to assist her. CNA D then stated that she was in another resident ' s room helping that resident when RN E told her this so it took her a few minutes to get to Resident #2 ' s room. When she got there, Resident #2 was on the floor on her stomach next to the roommate ' s bed. She further stated Resident #2 is confused, has a history of falls, has a bed alarm, and can sometimes make her needs known. She then stated they never leave Resident #2 on the toilet alone and she knew she was a fall risk so she knew she had to hurry to finish up what she was doing to go help Resident #2 in the bathroom. During a phone interview on 04/07/14 at 3:40 pm, RN E stated she assisted Resident #2 to the toilet to have a BM, she then heard an alarm go off in another room so she left Resident #2 alone on the commode to go answer the alarm. She then stated she told CNA D to help Resident #2 when she was done. RN E then stated she knew Resident #2 was a fall risk and had a history of [REDACTED]. During an interview on 04/08/14 at 10:10 am, the Director of Nursing (DON) stated that she was in the building when Resident #2 fell . She then stated Registered Nurse (RN) E assisted Resident #2 onto the toilet to have a BM, she then heard an alarm in another room so she left to answer it and told CNA D to assist Resident #2 when she was done. When CNA D got to Resident #2 ' s room, CNA D found Resident #2 on the floor on her stomach next to her roommate ' s bed. When asked if it was ok to leave Resident #2 on the toilet alone, she stated RN E probably should not have left Resident #2 on the toilet. During an interview on 04/08/14 at 10:25 am, the Nurse Practitioner (NP) stated that staff were toileting Resident #2, left her, and when they came back, she was found on the floor. When asked if it was ok to leave Resident #2 on the toilet alone, she stated that she didn ' t think they usually do that and she ' s not sure they should have left Resident #2 alone on the toilet alone. During an interview on 04/08/14 at 11:45 am, the Regional Minimum Data Set (MDS) Coordinator stated if a resident is a one person, extensive assist, staff must always help the resident with some sort of lifting. When asked if it is ever ok to leave a resident who is a one person, extensive assist, has a history of falls, is impulsive, and has dementia alone on the commode in the bathroom, she stated " I would think not. " The Regional MDS Coordinator further stated she would especially not leave a resident who has dementia alone on the commode. Observation on 04/08/14 at 12:40 pm revealed Resident #2 lying in her bed in her room. Her bed was approximately two to two and a half feet off the ground and no mat was at her bedside. During an interview on 04/08/14 at 12:45 pm, Assistant Director of Nursing (ADON) A stated that Resident #2 did have a fall with a fracture a few weeks ago. When asked about Resident #2 ' s low bed and mat at bedside that she was care planned for because she was a fall risk, ADON A stated she would show the surveyor in Resident #2's room. ADON A then stated Resident #2 was not in a low bed and did not know where the mat was that was supposed to be at her bedside. She further stated that she would have to find out about that. When asked to show the surveyor Resident #2 ' s tab alarm, ADON A could not find it and then stated maybe she just has it when she is up out of bed. During an interview on 04/08/14 at 1:05 pm, the DON stated they are going to discontinue the tab alarm, the low bed, and the mat because Resident #2 does not move around and she does not need them. She then stated Resident #2 was a big fall risk before her femur fracture and she was always trying to get up so she needed the low bed and fall mat then because she was always trying to get up unassisted. When asked if a resident with a fall history like Resident #2 should have been left alone on the commode, the DON stated no. The DON then stated the most current Care Plan was the one dated 03/12/14 in her chart and she was going to write a telephone order to discontinue the alarm, low bed, and mat right then. Review of the facility ' s undated Fall Management Process reflected a successful fall management requires a thorough clinical assessment of residents who fall (or have a history of falls) and their environment. Staff will help identify ways to modify some of the risk factor s for falls, as well as identifying ways to adjust the patient ' s environment to minimize the risk of injury due to falls. It further reflected to assess the resident ' s level of ADL dependence and to see if the resident is receiving ADL assistance needed for bathing, toileting, dressing, grooming, and meals. Review of the facility ' s undated Abuse and Neglect Policy reflected neglect to be defined as an injury, harm, or death of a resident due to the facility's failure to provide services, treatment or care to a resident. If any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been or maybe adversely affected by abuse or neglect caused by another person is to report the abuse or neglect immediately and the facility must determine if neglect occurred. Review of the facility ' s 802 dated 04/08/14 reflected 30 residents at risk for falls.